THE HEALTH

CONSEQUENCES

OF SMOKING
FOR WOMEN

a report of the Surgeon General

u
ne DEPARTMENT OF HEALTH AND HUMAN SERVICES
as Health Service
One of the Assistant Secretary for Health
‘ce On Smoking and Health

ree
THE SECRETARY OF HEALTH, EODUCATION, AND WELFARE

WASHINGTON. D.C.20201

 

The Honorable Thomas P. O'Neill,Jr.
Speaker of the House of Representatives
Washington, D.C. 20515

Dear Mr. Speaker:

I hereby submit the 12th annual report that the
Department of Health, Education, and Welfare (DHEW) has
prepared for Congress as required by the Public Health
Cigarette Smoking Act of 1969, Public Law 91-222, and its
predecessor, the Federal Cigarette Labeling and Advertising
Act. This report is one of the most alarming in the series.

It clearly establishes that women smokers face the same
risks as men smokers of lung cancer, heart disease, lung
disease and other consequences. Perhaps more disheartening
is the harm which mothers' smoking causes to their unborn
babies and infants.

The report is not all bad news. It presents recent
data showing that women are turning away from smoking in
response to the warnings of government, voluntary agencies
and physicians, The precipitate rise in women's deaths from
lung cancer and chronic lung disease demand that this trend
away from cigarettes be accelerated. Our scientists expect
that by 1983, the lung cancer death rate will exceed that of
any other type of cancer among women,

Citizens of our free society may decide for themselves
whether to smoke cigarettes. The health consequences of
this decision make it imperative for their government to
assure that the decision is an informed one. This series
Of reports is one way in which DHEW is striving to meet
this critical responsibility.

Neer

Patricia Roberts Harris
PREFACE

This report is more than a factual review of the health conse-
quences of smoking for women. It is a document which chal-
lenges our society and, in particular, our medical and public
health communities.

This report points out that the first signs of an epidemic of
smoking-related disease among women are now appearing. Be-
cause women’s cigarette use did not become widespread until
the onset of World War II, those women with the greatest inten-
sity of smoking are now only in their thirties, forties, and fifties.
As these women grow older, and continue to smoke, their bur-
den of smoking-related disease will grow larger. Cigarette smok-
ing now contributes to one-fifth of the newly diagnosed cases of
cancer and one-quarter of all cancer deaths among women—
more cancer and more cancer deaths among women than can be
attributed to any other known agent. Within three years, the
lung cancer death rate is expected to surpass that for breast
cancer. A similar epidemic of chronic obstructive lung disease
among women has also begun.

Four main themes emerge from this report to guide future
public health efforts.

First, women are not immune to the damaging effects of
smoking already documented for men. The apparently lower
susceptibility to smoking-related diseases among women smok-
ers is an illusion reflecting the fact that women lagged one-
quarter century behind men in their widespread use of cigar-
ettes.

Second, cigarette smoking is a major threat to the outcome of
pregnancy and well-being of the newborn baby.

Third, women may not start smoking, continue to smoke, quit
smoking, or fail to quit smoking for precisely the same reasons
as men. Unless future research clarifies these differences, we
will find it difficult to prevent initiation or to promote cessation
of cigarette smoking among women.

Fourth, the reduction of cigarette smoking is the keystone in
our nation’s long term strategy to promote a healthy lifestyle
for women and men of all races and ethnic groups.

The Fallacy of Women’s Immunity

All of the major prospective studies of smoking and mortality
have reached consistent conclusions. Death rates from coronary
heart disease, chronic lung disease, lung cancer, and overall
mortality rates are significantly increased among both women
and men smokers. These risks increase with the amount
smoked, duration of smoking, depth of inhalation, and the “tar”

Vv
and nicotine delivery of the cigarette smoked.

In these studies, conducted during the past three decades,
relative mortality risks among female smokers appeared to be
less than those of male smokers. It is now clear, however, that
these studies were comparing the death rates of a generation of
established, lifelong male smokers with a generation of women
who had not yet taken up smoking with full intensity. Even
those older women who reported smoking a large number of
cigarettes per day had not smoked cigarettes in the same way as
their male counterparts. Now that the cigarette smoking char-
acteristics of women and men are becoming increasingly simi-
lar, their relative risks of smoking-related illness will become
increasingly similar.

This fallacy of women’s apparent immunity is clearly illus-
trated by differences in the timing of the growth in lung cancer
among men and women in this century. Lung cancer deaths
among males began to increase during the 1930s, as those men
who had converted from other forms of tobacco to cigarette
smoking before the turn of the century gradually accumulated
decades of inhaled tobacco exposure. By the time of the first
retrospective studies of smoking and lung cancer in 1950, two
entire generations of men had already become lifelong cigarette
smokers. Relatively few women from these generations smoked
cigarettes, and even fewer had smoked cigarettes since their
adolescence. Those young women who had taken up smoking
intensively during World War II were only in their twenties and
thirties. In 1950, women accounted for less than one in twelve
deaths from lung cancer.

Thereafter, the age adjusted lung cancer death rate among
women accelerated, and the male predominance in lung cancer
declined. Lung cancer surpassed uterine cervical cancer as a
cause of death in women. By 1968, as the findings of many large
population prospective studies were being published, women
accounted for one-sixth of all lung cancer deaths. These studies
found that women cigarette smokers had 2.5 to 5 times greater
death rates from lung cancer than women nonsmokers. By 1979,
women accounted for fully one-fourth of all lung cancer deaths.
Over the next few years, women cigarette smokers’ risk of lung
cancer death will approach 8 to 12 times that of women
nonsmokers, the same relative risk as that of men.

Lung cancer has four main histological types: epidermoid,
small cell, adenocarcinoma, and large cell carcinoma, As several
studies have shown, the incidence of each of these types of lung
cancer displays a clear relationship to cigarette smoking among
both men and women. Epidermoid and small cell lung cancer
appear to be more prominent among men, while adenocar-

vl
cinoma of the lung now appears to be more prominent among
women.

The recent acceleration of lung cancer incidence among
women has in fact been more rapid than the corresponding
growth of lung cancer among men in the 1930s. Again, this dif-
ference in the initial rate of acceleration of lung cancer inci-
dence does not refute the demonstrated causal relation between
cigarette smoking and lung cancer among both sexes. Instead,
differences in the rate of increase of lung cancer incidence may
reflect changes in the carcinogenic properties of cigarette
smoke, the style of cigarette smoking, or the interaction of
cigarette smoking with other environmental hazards. It is
noteworthy that those men who died of lung cancer in the 1930s
came from a generation that had gradually converted to
cigarettes from other, non-inhaled forms of tobacco. By con-
trast, the first regular tobacco users among women were almost
exclusively cigarette smokers.

The 1979 Report on Smoking and Health documented numer-
ous instances where cigarette smoking adds to the hazards of
the workplace environment among men. Among women, this
report reveals two such occupational exposures— asbestos and
cotton dust— which have been clearly demonstrated to interact
with cigarette smoking. The fact that evidence is limited among
women does not imply that women are protected from the
dangerous interactions of smoking and occupational exposures.

Pregnancy, Infant Health, and Reproduction

Scientific studies encompassing various races and ethnic
groups, cultures and countries, involving hundreds of
thousands of pregnancies, have shown that cigarette smoking
during pregnancy significantly affects the unborn fetus and the
newborn baby. These damaging effects have been repeatedly
shown to operate independently of all other factors that influ-
ence the outcome of pregnancy. The effects are increased by
heavier smoking and are reduced if a woman stops smoking
during pregnancy.

Numerous toxic substances in cigarette smoke, such as
nicotine and hydrogen cyanide, cross the placenta to affect the
fetus directly. The carbon monoxide from cigarette smoke is
transported into the fetal blood and deprives the growing baby
of oxygen. Fetal growth is directly retarded. The resulting re-
duction in fetal weight and size has many unfortunate conse-
quences. Women who smoke cigarettes during pregnancy have
more spontaneous abortions, and a greater incidence of bleed-
ing during pregnancy, premature and prolonged rupture of am-

vil
niotic membranes, abruptio placentae and placenta previa.
Women who smoke cigarettes during pregnancy have more fetal
and neonatal deaths than nonsmoking pregnant women. A rela-
tion between maternal smoking and Sudden Infant Death Syn-
drome has now been established.

The direct harmful effects of smoking on the fetus have long
term consequences. Children of mothers who smoked during
pregnancy lag measurably in physical growth; there may also
be effects on behavior and cognitive development. The extent
of these deficiencies increases with the number of cigaret-
tes smoked.

The damaging effects of maternal smoking on infants are not
restricted to pregnancy. Nicotine, a known poison, is found in
the breast milk of smoking mothers. Children whose parents
smoke cigarettes have more respiratory infections and more
hospitalizations in the first year of life.

Women who smoke cigarettes have more than three times the
risk of dying of stroke due to subarachnoid hemorrhage, and as
much as two times the risk of dying of heart attack in compari-
son to nonsmoking women. The use of oral contraceptives in
addition to smoking, however, causes a markedly increased risk,
including a 22-fold increase in the risk of subarachnoid hemor-
rhagic stroke and a 20-fold increase in heart attack in heavy
smokers.

Why Do Women Smoke?

Cigarette consumption in this country is now declining. An-
nual per capita consumption has decreased from 4,258 in 1965 to
an estimated 3,900 in 1979. From 1965 to 1979, the proportion of
adult male cigarette smokers declined from 51 to 37 percent. Not
only have millions of men quit smoking, but the rate of initia-
tion of smoking among adolescent males has now slowed.

From 1965 to 1976, the proportion of adult women cigarette
smokers remained virtually unchanged at 32 to 33 percent.
Since 1976, however, the proportion of adult women cigarette
smokers appears to have declined to 28 percent. Although adult
women are now beginning to quit smoking at rates comparable
to adult men, the rate of initiation of smoking among younger
women has not declined.

This report documents numerous differences by sex in the
perceived role of cigarette smoking, in attitudes toward health
and lifestyle, and in methods of coping with stress, anger, and
boredom. Yet the significance of these differences, and their
relation to differences in smoking patterns, remains poorly un-
derstood.

vill
Although it is frequently observed that women in organized
smoking cessation programs have more severe withdrawal
symptoms and lower rates of successful quitting than men,
these observations have not been systematically confirmed for
the general population. In the past, women may have attempted
to quit or succeeded in quitting smoking less frequently than
men. The recent decline in the proportion of women smokers,
however, suggests that women’s attempted and successful quit-
ting rates have now increased.

Although weight gain is a frequently cited consequence of
quitting smoking, the association of weight gain with cessation
of smoking has not been the subject of sufficient scrutiny. Con-
trolled studies with careful measurement on representative
populations of women do not exist. The impact of the fear of
weight gain after quitting has not been adequately examined. If
weight gain does result from cessation of smoking, its exact
mechanism must be determined.

Even more problematic are marked differences by sex in the
distribution of smoking prevalence by occupation. Men with ad-
vanced education and professional occupations have taken the
lead in quitting smoking, but women in administrative and
managerial positions have relatively high smoking prevalence
rates. Although 20 percent or fewer male physicians smoke, the
proportions of cigarette smokers among women health profes-
sionals, especially nurses and psychologists, remain disturb-
ingly high.

Recent changes in smoking prevalence among black women
and men have paralleled those of the general population. From
1965 to 1979, the proportion of black women cigarette smokers
declined from 34 to 29 percent, while the proportion of black men
smokers declined from 61 to 42 percent. However, differences by
race in the onset, maintenance, and cessation of smoking have
not been adequately explored. Little is known about cigarette
smoking among other ethnic and minority groups.

Adolescent Smoking

The health consequences of smoking evolve over a lifetime.
Evidence continues to accumulate, for example, that cigarette
smoking produces measurable lung changes in adolescence and
young adulthood. Young cigarette smokers of both sexes show
more evidence of small airway dysfunction, and a higher preva-
lence of cough, wheezing, phlegm production, and other respira-
tory symptoms. The health damage due to cigarette smoking
increases when an individual begins regular smoking earlier in
life. Yet, as this report documents, the average age of onset of

ix
regular smoking among women has continuously declined dur-
ing the last 50 years, and continues to decline.

According to a recent survey by the National Institute of
Education, cigarette smoking among adolescent girls now ex-
ceeds that among adolescent boys. In the 17-19 year age group,
there are almost 5 female cigarette smokers for every 4 male
cigarette smokers. The causes of this inversion are far from
clear. We do not yet understand the signal events in the initia-
tion of smoking among young women. It is possible that parents
set examples concerning lifestyle, health attitude, and risk-
taking much earlier in childhood. The beginning of junior high
school or entrance into the work force may be equally critical
events. We do not know enough about an adolescent’s sense of
competence and self-mastery, and how these roles differ among
women and men. Although smoking patterns among girls corre-
late with parental, peer and sibling smoking habits, educational
level, type of school curriculum, academic performance,
socioeconomic status, and other forms of substance abuse, the
practical significance of these empirical correlations is unclear.

Women and the Changing Cigarette

As this report documents, the proportion of men and women
smokers using brands with lowered “tar” and nicotine con-
tinues to grow. Adolescents of both sexes have followed this
trend, to the point where nonfilter cigarettes are relatively rare
among young adults.

Although the preponderance of scientific evidence continues
to suggest that cigarettes with lower “tar” and nicotine are less
hazardous, four serious warnings are in order.

First, the reported “tar” and nicotine deliveries of cigarettes
are standardized machine measurements. They do not neces-
sarily represent the smoker’s actual intake of these substances.
Evidence is now mounting that individuals who switch to
cigarettes with lowered “tar” and nicotine inhale more deeply,
smoke a greater proportion of their cigarettes, and in some
cases smoke more cigarettes.

Second, “tar” and nicotine are not the only dangerous chemi-
cal components of cigarette smoke. Many conventional filter
cigarettes, in fact, may deliver more carbon monoxide than non-
filter cigarettes.

Third, it has not been established that lower ‘tar’ and
nicotine cigarettes have less harmful effects on the unborn
fetus and baby; on women and men at high risk for developing
coronary heart disease, such as those with elevated cholesterol
or high blood pressure; or on workers with adverse occupational

x
exposures. It has not been established that switching to a lower
“tar” and nicotine cigarette has any salutary effect on indi-
viduals who already have smoking-related illnesses, such as
coronary heart disease, chronic bronchitis, and emphysema.

Fourth, even the lowest yield cigarettes present health
hazards for both women and men that are very much higher
than smoking no cigarettes at all.

The single most effective way for both women and men smok-
ers to reduce the hazards associated with cigarettes is to quit
smoking.

As this report demonstrates, little is known about the effects
of these product changes on the initiation, maintenance and
cessation of smoking, particularly among women. It has not
been determined whether the availability of cigarettes with
lowered “tar” and nicotine has made it easier for young women
to experiment with and become addicted to cigarettes. It is not
known whether smokers of the lowest yield cigarettes are more
or less likely to attempt to quit, or to succeed in quitting, than
smokers of conventional filtertip or nonfilter cigarettes. The
extent to which the act of switching to a lower “tar” cigarette
serves as a substitute for quitting may differ among women
and men.

Public Health Responsibilities

This report, which includes data compiled by individuals from
both inside and outside the Government, has confirmed in every
way the judgement of the World Health Organization that there
ean no longer be any doubt among informed people that
cigarette smoking is a major and removable cause of ill health
and premature death.

Each individual woman must make her own decision about
this significant health issue. Secretary Harris has noted that
the role of the Government, and all responsible health profes-
sionals, is to assure that this decision is an informed one. In
issuing this report, we hope to help the public heaith community
accomplish this purpose.

Julius B. Richmond, M.D.
Assistant Secretary for Health and
Surgeon General

xi
ACKNOWLEDGEMENTS

This report was prepared by agencies of the U.S. Department
of Health, Education, and Welfare under the general editorship
of the Office on Smoking and Health, John M. Pinney, Director.
Consulting scientific editors were David M. Burns, M.D., As-
sistant Clinical Professor of Medicine, Pulmonary Division,
University of California at San Diego, San Diego, California, and
John H. Holbrook, M.D., Associate Professor of Internal
Medicine, University of Utah Medical School, Salt Lake City,
Utan. Contributing scientific editors were Joanne Luoto, M.D.,
M.P.H., Medical Officer, Office on Smoking and Health,
Rockville, Maryland, and Kelley L. Phillips, M.D., M.P.H., Ex-
pert Consultant, Office on Smoking and Health, Rockville,
Maryland.

Introduction and Summary
Office on Smoking and Health

Patterns of Cigarette Smoking

Office on Smoking and Health

Jeffrey E. Harris, M.D., Ph.D., Associate Professor, Depart-
ment of Economics, Massachusetts Institute of Technology,
Cambridge, Massachusetts; Clinical Associate, Medical Serv-
ices, Massachusetts General Hospital, Boston, Mas-
sachusetts.

Mortality

National Heart, Lung, and Blood Institute

Eugene Rogot, M.A., Division of Heart and Vascular Diseases,
National Heart, Lung, and Blood Institute, National Insti-
tutes of Health, Bethesda, Maryland.

Thomas J. Thom, Division of Heart and Vascular Diseases,
National Heart, Lung. and Blood Institute, National Insti-
tutes of Health, Bethesda, Maryland.

Morbidity

National Center for Health Statistics

Ronald W. Wilson, M.A., Chief, Health Status and Demo-
graphic Analysis Branch, Division of Analysis, National Cen-
ter for Health Statistics, Hyattsville, Maryland.

Cardiovascular Diseases

National Heart, Lung, and Blood Institute

G. C. McMillan, M.D., Ph.D., Associate Director for Etiology of
Arteriosclerosis and Hypertension, Division of Heart and
Vascular Diseases, National Heart, Lung, and Blood Insti-
tute, National Institutes of Health, Bethesda, Maryland.

xill
Cancer

National Cancer Institute

Jesse L. Steinfeld, M.D., Dean, School of Medicine, Medical
College of Virginia, Virginia Commonwealth University,
Richmond, Virginia.

Non-Neoplastic Bronchopulmonary Diseases

National] Heart, Lung, and Blood Institute

Richard A. Bordow, M.D., Associate Director of Respiratory
Medicine, Brookside Hospital, San Pablo, California.

Claude J. M. Lenfant, M.D., Director, Division of Lung Dis-
eases, National Heart, Lung, and Blood Institute, National
Institutes of Health, Bethesda, Maryland.

Barbara Marzetta Liu, S.M., Division of Lung Diseases, Na-
tional Heart, Lung, and Blood Institute, National Institutes
of Health, Bethesda, Maryland.

Eric R. Jurrus, Ph.D., Division of Lung Diseases, National
Heart, Lung, and Blood Institute, National Institutes of
Health, Bethesda, Maryland.

Interaction Between Smoking and Occupational Exposures
National Institute of Occupational Safety and Health
Jeanne M. Stellman, Ph.D., Associate Professor, Columbia
University, School of Public Health, New York, New York.
Steven D. Stellman, Ph.D., Assistant Vice-President for
Epidemiology, American Cancer Society, New York, New
York.

Pregnancy and Infant Health

National Institute of Child Health and Human Development
Eileen G. Hasselmeyer, Ph.D., R.N., Associate Director for
Scientific Review, National Institute of Child Health and
Human Development, National Institutes of Health,
Bethesda, Maryland.

Mary B. Meyer, Sc.M., Associate Professor of Epidemiology,
Johns Hopkins University, School of Hygiene and Public
Health, Baltimore, Maryland.

Lawrence D. Longo, M.D., Professor of Physiology and of
Obstetrics and Gynecology, Loma Linda University School of
Medicine, Loma Linda, California.

Donald R. Mattison, M.D., Medical Officer, Pregnancy Re-
search Branch, National Institute of Child Health and
Human Development, National Institutes of Health,
Bethesda, Maryland.

Peptic Ulcer Disease

National Institute of Arthritis, Metabolism and Digestive

Diseases
Travis E. Solomon, M.D., Ph.D., Center for Uleer Research

X1V
and Education, Veterans Administration Wadsworth Medical
Center, and University of California, Los Angeles School of
Medicine, Los Angeles, California.

Janet D. Elashoff, Ph.D., Center for Uleer Research and Edu-
cation, Veterans Administration Wadsworth Medical Center
and University of California, Los Angeles School of Medicine,
Los Angeles, California.

Interactions of Smoking with Drugs, Food Constituents, and
Responses to Diagnostic Tests

Food and Drug Administration

Cheryl Fossum Graham, M.D., Division of Drug Experience,
Office of Biometrics and Epidemiology, Bureau of Drugs,
Food and Drug Administration, Rockville, Maryland.

Psychosocial and Behavioral Aspects of Smoking in Women
National Institute on Drug Abuse and National Institute of
Child Health and Human Development

Initiation

Ellen R. Gritz, Ph.D., Research Psychologist, Veterans Ad-
ministration Medical Center, Brentwood, and Associate Re-
search Psychologist, Department of Psychiatry and
Biobehavioral Sciences, School of Medicine, University of
California, Los Angeles, California.

Ann F. Brunswick, Ph.D., Senior Research Associate (Public
Health, Sociomedical Sciences), Center for Sociocultural Re-
search on Drug Use, Columbia University, New York, New
York.

Maintenance and Cessation

Karen L. Bierman, M.A., Department of Psychology, Univer-
sity of California, Los Angeles, California.

Ellen R. Gritz, Ph.D., Research Psychologist, Veterans Ad-
ministration Medical Center, Brentwood, and Associate Re-
search Psychologist, Department of Psychiatry and
Biobehavioral Sciences, School of Medicine, University of
California, Los Angeles, California.

The editors acknowledge with gratitude the many distin-
guished scientists, physicians, and others who assisted in the
preparation of this report by coordinating manuscript prepara-
tion, contributing critical reviews of the manuscripts or helping
in other ways.

Elvin E. Adams, M.D., M.P.H., Chairman, Texas Interagency

Council on Smoking and Health, Practicing Internal

Medicine, Fort Worth, Texas.

Josephine D. Arasteh, Ph.D., Health Scientist Administrator,
Xv
Human Learning and Behavior Branch, Center for Research
for Mothers and Children, National Institute of Child Health
and Human Development, National Institutes of Health,
Bethesda, Maryland.

Lester Breslow, M.D., M.P.H., Dean, School of Public Health,
University of California at Los Angeles, Los Angeles, Califor-
nia.

A. Sonia Buist, M.D., Associate Professor of Medicine and
Physiology, University of Oregon Health Sciences Center,
Portland, Oregon.

David M. Burns, M.D., Assistant Clinical Professor of
Medicine, Pulmonary Division, University of California at
San Diego, San Diego, California.

Thomas C. Chalmers, M.D., President and Dean, Mount Sinai
Medical Center, New York, New York.

Florence L. Denmark, Ph.D., Professor of Psychology, Hunter
College of the City University of New York, and President of
the American Psychological Association, New York, New
York.

Robert M. Donaldson, Jr., M.D., Chief, Medical Services,
Westhaven Veterans Hospital, and Vice-Chairman, Depart-
ment of Internal Medicine, Yale University School of
Medicine, New Haven, Connecticut.

Joseph T. Doyle, M.D., Professor of Medicine and Head, Divi-
sion of Cardiology of the Department of Medicine, Albany
Medical College of Union University, Albany, New York.
Elizabeth M. Earley, Ph.D., Chief, Section of Cytogenetics,
Division of Pathology, Bureau of Biologics, Food and Drug
Administration, Rockville, Maryland.

Bernard H. Ellis, Jr., Program Director for Smoking and Oc-
cupational Activities, Office of Cancer Communications, Na-
tional Cancer Institute, National Institutes of Health,
Bethesda, Maryland.

Diane Fink, M.D., Associate Director, National Cancer Insti-
tute, and Coordinator, Smoking, Cancer, and Health Program,
National Institutes of Health, Bethesda, Maryland.

Harold E. Fox, M.D., Associate Professor of Clinical Obstetrics
and Gynecology, Department of Obstetrics and Gynecology,
College of Physicians and Surgeons, Columbia University,
and Medical Director, Western and Upper Manhattan
Perinatal Network, New York, New York.

Joseph H. Gainer, D.V.M., Veterinary Medical Officer, Divi-
sion of Veterinary Medical Research, Bureau of Veterinary
Medicine, Food and Drug Administration, Beltsville, Mary-
land.

Stanley N. Gershoff, Ph.D., Director, Nutrition Institute and

XVI
Chairman, Graduate Department of Nutrition, Tufts Univer-
sity, Medford, Massachusetts.

Mary E. Guinan, M.D., Clinical Research Investigator, Clini-
cal Studies Section, Venereal Disease Control Division, Cen-
ter for Disease Control, Atlanta, Georgia.

Sharon M. Hall, Ph.D., Assistant Professor in Residence, Uni-
versity of California at San Francisco, Langley Porter Psy-
chiatric Institute, San Francisco, California.

Jane Halpern, M.D., Assistant Secretary for Policy Evalua-
tion and Research, Office of Health and Disability, United
States Department of Labor, Washington, D.C.

Beatrix A. Hamburg, M.D., Senior Research Psychiatrist,
Laboratory of Developmental Psychology, National Institute
of Mental Health, National Institutes of Health, Bethesda,
Maryland.

Virginia G. Harris, M.D., Director, Maternal and Child Health,
Onondaga County Health Department, Syracuse, New York.
John H. Holbrook, M.D., Associate Professor of Internal
Medicine, University of Utah Medical School, Salt Lake City,
Utah.

L. Stanley James, M.D., Professor of Pediatrics, and of Obstet-
rics and Gynecology, and Director, Division of Perinatal
Medicine, College of Physicians and Surgeons, Columbia Uni-
versity, New York, New York.

Hershel Jick, M.D., Boston Collaborative Drug Surveillance
Program, Boston University Medical Center, Waltham, Mas-
sachusetts.

Reese T. Jones, M.D., Professor of Psychiatry, Department of
Psychiatry, University of California at San Francisco,
Langley Porter Psychiatric Institute, San Francisco,
California.

Philip Kimbel, M.D., Chairman, Department of Medicine,
Graduate Hospital, Philadelphia, Pennsylvania.

Jan W. Kuzma, Ph.D., Chairman and Professor of Biostatis-
tics, Department of Biostatistics and Epidemiology, Loma
Linda University, Loma Linda, California.

Abraham Lilienfeld, M.D., M.P.H., D.Se., University Distin-
guished Service Professor, Johns Hopkins School of Hygiene
and Public Health, Baltimore, Maryland.

Harold A. Menkes, M.D., Associate Professor of Medicine and
Environmental Health Sciences, Department of Medicine,
Johns Hopkins University, Baltimore, Maryland.

Kenneth Moser, M.D., Professor of Medicine and Director,
Pulmonary Division, University of California at San Diego,
San Diego, California.

Mariquita Mullan, B.S.N., M.P.H., Special Assistant to the Di-

XV11
rector, National Institute of Occupational Safety and Health,
Center for Disease Control, Rockville, Maryland.

Janyce E. Notopoulos, Program Analyst, Office of Planning
and Evaluation, National Institute of Child Health and
Human Development, National Institutes of Health,
Bethesda, Maryland.

Albert Oberman, M.D., Director, Division of Preventive
Medicine, University of Alabama in Birmingham Medical
Center, Birmingham, Alabama.

Ralph S. Paffenbarger, M.D., D.R.P.H., Professor of
Epidemiology, Stanford University, School of Medicine, Stan-
ford, California, and Adjunct Professor of Epidemiology at the
University of California, School of Public Health, Berkeley,
California.

Richard Peto, M.D., Radcliff Clinic, Oxford University, Ox-
ford, England.

Malcolm C. Pike, Ph.D., Professor, Community and Family
Medicine, School of Medicine, University of Southern Califor-
nia at Los Angeles, Los Angeles, California.

Ovide F. Pomerleau, Ph.D., Professor of Psychology and Psy-
chiatry, University of Connecticut, School of Medicine, Far-
mington, Connecticut.

Phill H. Price, M.D., Medical Officer, Metabolic Products
Branch, Division of Metabolism and Endocrine Drugs,
Bureau of Drugs, Food and Drug Administration, Rockville,
Maryland.

Dorothy P. Rice, Director, National Center for Health Statis-
tics, Office of the Assistant Secretary for Health, Hyattsville,
Maryland.

Anthony Robbins, M.D., Director, National Institute of Occu-
pational Safety and Health, Center for Disease Control,
Rockville, Maryland.

Judith B. Rooks, C.N.M., M.P.H., M.S., Office of the Assistant
Secretary for Health, Washington, D.C.

Harold P. Roth, M.D., Associate Director for Digestive Dis-
eases and Nutrition, National Institute of Arthritis,
Metabolism, and Digestive Diseases, National Institutes of
Health, Bethesda, Maryland.

Philip Sapir, Special Assistant to the Director for Behavioral
and Social Sciences and Chief, Human Learning and Behavior
Branch, Center for Research for Mothers and Children, Na-
tional Institute of Child Health and Human Development,
National Institutes of Health, Bethesda, Maryland.

Marvin A. Schniederman, Ph.D., Associate Director for Sci-
ence Policy, National Cancer Institute, National Institutes of
Health, Bethesda, Maryland.

xvii
Irving J. Selikoff, M.D., Professor of Community Medicine and
Professor of Medicine, and Director of Environmental Sci-
ences Laboratory, Mount Sinai Medical Center, New York,
New York.

S. I. Shibko, Ph.D., Chief, Contaminants and Natural Toxic-
ants Branch, Division of Toxicology, Bureau of Foods, Food
and Drug Administration, Washington, D.C.

Jeremiah Stamler, M.D., Chairman, Department of Commu-
nity Health and Preventive Medicine, Northwestern Univer-
sity Medical School, Chicago, Tllinois.

John E. Vanderveen, Ph.D., Director, Division of Nutrition,
Bureau of Foods, Food and Drug Administration,
Washington, D.C.

Eve Weinblatt, Assistant Director for Research, Department
of Research and Statistics, Health Insurance Plan of Greater
New York, New York, New York.

Samuel S. C. Yen, M.D., Professor and Chairman, Department
of Reproductive Medicine, University of California, San Di-
ego, LaJolla, California.

The editors also acknowledge the help of the following staff
who among others assisted in the preparation of the report.

John L. Bagrosky, Associate Director for Program Opera-
tions, Office on Smoking and Health, Rockville, Maryland.
Jacqueline O. Blandford, Clerk-Typist, Office on Smoking and
Health, Rockville, Maryland.

Betty Budd, Secretary, Office on Smoking and Health,
Rockville, Maryland.

John F. Hardesty, Jr., Public Information Officer, Office on
Smoking and Health, Rockville, Maryland.

Patricia E. Healy, Technical Information Clerk, Office on
Smoking and Health, Rockville, Maryland.

Robert S. Hutchings, Associate Director for Information and
Program Development, Office on Smoking and Health,
Rockville, Maryland.

Margaret E. Ketterman, Secretary, Office on Smoking and
Health, Rockville, Maryland.

Richard A. Lasco, Ph.D., Bureau of Health Education, Center
for Disease Control, Atlanta, Georgia.

Joanne Luoto, M.D., M.P.H., Medical Officer, Office on Smok-
ing and Health, Rockville, Maryland.

Judith L,. Mullaney, M.L.S., Technical Information Specialist,
Office on Smoking and Health, Rockville, Maryland.

Marjorie L. Olson, Secretary, Office on Smoking and Health,
Rockville, Maryland.

xix
Kelley L. Phillips, M.D., M.P.H., Expert Consultant, Office on
Smoking and Health, Rockville, Maryland.

David L. Pitts, Public Health Advisor, Operations Branch,
Nutrition Division, Bureau of Smallpox Eradication, Center
for Disease Control, Atlanta, Georgia.

Donald R. Shopland, Technical Information Officer, Office on
Smoking and Health, Rockville, Maryland.

Linda R. Spiegelman, Administrative Assistant, Office on
Smoking and Health, Rockville, Maryland.

Carol M. Sussman, Technical Publication Writer/Editor, Of-
fice on Smoking and Health, Rockville, Maryland.

Ronald G. Thomas, Public Health Analyst, Office on Smoking
and Health, Rockville, Maryland.

Selwyn M. Waingrow, Public Health Analyst, Office on Smok-
ing and Health, Rockville, Maryland.

Ann E. Wessel, Public Health Analyst, Office on Smoking and
Health, Rockville, Maryland.

Carole L. Winn, Assistant Chief, Clinical Chemistry Stand-
ardization Section, Clinical Chemistry Division, Metabolic
Biochemistry Branch, Bureau of Laboratories, Center for
Disease Control, Atlanta, Georgia.

xx
TABLE OF CONTENTS

 

 

 

INTRODUCTION AND SUMMARY ..........5 se eeeeeee 1
PARTI
PATTERNS OF CIGARETTE SMOKING ................ 15
Introduction .... 0. ccc ccc ec eee eee eee en tenes 17
The Rise of Cigarette Smoking: 1900-1950 ........... 17
The Emergence of Filtertip Cigarettes: 1951-1963 .. 21
Increasing Public Health Awareness: 1964-1979 ..... 21
Exposure to Cigarette Smoking Among
Successive Birth Cohorts ......... ccc eee eee ees 28
Cigarette Smoking Among Young Women ........... 33
SuUMMary ... cee cee ccc eee eee eee eee ee tee tenes 36
References oo. cc cece ccc cece eee ee eee en een eens 39
PART II
BIOMEDICAL ASPECTS OF SMOKING
MORTALITY ...... 0... ccc ccc ence een eee eee nneaes 44
Introduction and Background ............. 000. eecaee 45
Mortality TrendS .......... cece cece eee ee ence nee 45
Epidemiological Studies ........ cece eee ee ees 46
The American Cancer Society
25-State Study ......... cc cece ee eee cece e eens 47
The Swedish Study ......... ccc eee ee ee eee eens 51
The Canadian Veterans Study ................06. 51
Japanese Study of 29 Health Districts ........... 51
The British Doctors Study ............... eee eens 51
The Framingham Heart Study ..............0065 52
The British-Norwegian
Migrant Study ....... ccc ccc e ec eee eee eee ences 52
Overall Mortality for Females—Cigarette Smokers
Versus Nonsmokers.......--- ee eee eee ere eens 53
Mortality Ratios .......... ccc cece ee ccc eee eens 53
Amount Smoked and Age ........ cece eee eee eee ees 54
Duration of Smoking ........... ccc eee eee ees 57
Age Began Smoking ......... 0... ec eee eee ee re eees 58
Inhalation ......... 00. c ccc cee ee teeter tenes 59
“Tar” and Nicotine Content of
Cigarettes ooo ccc ccc ccc ccc cece ee eee ene eee eee 59

XXi
CommentS ..ccccceccecec eter reece reese een e eases eee ees 61

Summary ..ceee cece cece e cece eee e eee esse ce cere e es 61
References ...ceeeeee rere renee ene rene erase reser ees 62
MORBIDITY ....-e eee e sere reer eee rete ere eee ees 65
Days Lost from Work .....---s+ eee srer settee 67
Limitation of Activity ......e cere ere reer eretteeeeres 68
Cigarette Smoking and Occupation ....-.++.seeeeeeee 69
Summary ..cce eee eee e rere eee e ects seen see esses sees 70
ReferenceS .cccecec cece ener rene nese ener rere cere ees 715
CARDIOVASCULAR DISEASES  .....-- eee ee errr teers V7
Introduction .....ceee eee e reer ee eee teen tena n neers es 79
Mortality Rates  ......e eee ee cree erent eens reeset es 79
Atherosclerosis ......eeecce tree reer reeneee rer eereees 84
Risk FactorS ...ccee cece cece eee tenn renee een reeeers 86
The Effect of Smoking .....--.eeeee ener errr ee eer tenes 86
Atherosclerosis ...cceeeee reece tenner neers eneaes 86
Coronary Heart Disease ....-.--e seer eee e recente 88

Cessation of Smoking and “Tar”
and Nicotine Content of

Cigarettes ...... cece eee eee ene e reer eee n ees 92
Angina PectoriS ......ssseee errr reer eer erer snes? 93
Cerebrovascular Disease .......eeeeeerrereerccces 93
Arteriosclerotic Peripheral
Vascular Disease... ee cece cence eee ener eenees 95
Aortic AN@ULySM .. se eee eee enter teen terete 96
Hypertension .....-.eseeee cree reser erence ecetees 96
Venous Thrombosis ......ccereeee eect cenreeness 97
High-Density Lipoprotein .....-.+++sesereerereees 98
Oral Contraceptive Use, Smoking, and
Cardiovascular Disease ....-..eeee errr er eeeertres 98
Carbon Monoxide ........eeee ener e eee eter rene erences 101
Comment ..cceec cece eee etree tenner eens enee nes aes 101
Summary ..cccecece cece eee eet eee eres seen sees sees 102
References ...cccccese cece cece nese ener eres sees enes ees 103
CANCER vce ccc eee eee e teen e renee een eeeeeer ener nesses 107
Introduction ...... cece eee e eee eee renee ete eee ents 109
LUNG cece eee cee eee eee een enn eter n teen eres eee e es 111
Geographic Differences .......++-+erereereseteces 116
Smoking Patterns Among Women ...-.+--++--++++ 117
Cessation of Smoking .....----.eeeee ec eeee eer eee 120
Experimental Carcinogensi§S ...-..eeeeee ee ee renee 121
LarynX oo. eee eee e ener ee eees ence eee eeeenaeeeenee 121
(0 7) 122
Esophagus .......eeeceee sree cree ee er eee r eer eeese reese 123

XXli
Urinary Bladder ........... eee e eee e eee rece e ence enees 125

Kidney ccc cece eee ener eee eee ee nee ence eees 125
PAncreaS i.e ee ccc cece ete cee ce ee eee eee eee ee eens 126
SUMMALY 2... cece eee eee e een enna tees 126
References ... cece ccc c cece eee e eee eee eee eee eee enenes 127

Non-neoplastic Bronchopulmonary

DiSCaASCS co cece ccc cece ce eee ee ee eee ene teeta en ean 133
Introduction ..... cece cece eee eee eee nee eee eees 135
DefinitionS . oo. c ccc cece eee ee cee tenner en eens 1385
Smoking and Respiratory Mortality ............+.5+- 137
Smoking and the Epidemiology and

Pathology of Cold 21... . cc cece erence rene ee eee eees 141
Smoking and Respiratory Morbidity ..........-..-+.- 146
Smoking and Pulmonary Function ..........+...0ee 156

Smoking and “Early” Functional
Abnormalities ....... cece cece eee ene 157
Smoking and Ventilatory Function ............-- 160
Summary ........ cece cece e eee een eet e eee e anaes 163
ReferenceS 2... cc cc cec ccc s cece cence nent een eee renee eees 1638
Interaction Between Smoking and

Occupational Exposures .........e reece teen eee 169
Smoking Patterns in Women ...........:seeee ere eeeee 172
Patterns of Employment .........ce eee ee cece eens 175
The Reproductive Role .......--- esse eee rece ee eeeeee 177
Specific Interactions Between Occupational

Exposure and Smoking .......-- ee see eee e ener eens 179
ASDOEStOS 2. cece cece cece rece eee e er een eee ene eens 179
Cotton Dust ..... ccc eee cee ence teen eens 181

Summary ..... ccc eee eee cece renee eee ee nnnenenes 186
ReferenceS oo. cece ccc cece ete e ee tee eee eee nent e ee enes 187
PREGNANCY AND INFANT HEALTH ...........-000e- 189
Introduction ...... ccc cee cee eee eee eee e nee eee e eens 191
Smoking, Birth Weight, and Fetal Growth ........... 191
Placental Ratios .......:cee cee cece tener e erence 194
Gestation and Fetal Growth ............ ee eeeeee 195
Long-Term Growth and Development ............ 196
Role of Maternal Weight Gain ..........-.. 5 eee 202
Smoking, Fetal and Infant Mortality,

and Morbidity  ......... cece eee e eee cree ne eee enee 206
Spontaneous Abortion ........cee reece ee ete eens 206
Congential Malformations ..........-sesee eee ees 207
Perinatal Mortality ........ 0... cece cece e nee e nee 211
Cause of Death oo... ccc cece eee eens 214

Complications of Pregnancy and Labor .............. 214
Preeclampsia ..... cece eee cere eee nee teen e eee zie
Preterm Delivery, Pregnancy
Complications, and Perinatal

Mortality by Gestation .........ee eee e eee ener 217
Long-Term Morbidity and Mortality .....-..--.+++++: 221
Sudden Infant Death Syndrome ...........++.+-- 225
Mechanisms ......cce cece c eee e ee ete eee eee een e eens 226
Experimental Studies .........se eee eee reenter ees 229
Tobacco Smoke ........ once e ee cee cece ence neres 229
Nicotine ... cc cece cee cee eee cee eee ene e en enenaes 229
Carbon Monoxide ....... see c cee eee cece ee eneeees 231
Polycyclic Aromatic Hydrocarbons ...........+-+-- 233
Other Components ......-.. eee cece eee eeeee 234
Fertility 0.0... cee cece cee eee eee nen een eeees 235
Smoking and Reproduction in Women ........-.- 235
Smoking and Age of Menopause .....-...+++++-+- 236
Smoking and Reproduction in Men ..........-.+- 236
Fertilization and Conceptus
Transport .... cece cece ee eee ene een eee eenens 237
SUMMALY ... ee cece eee e erect eee eens een eee 238
ReferenceS 1... cece cee cee cee eee ee tenner eeeeneeees 239
PEPTIC ULCER DISEASE _ ..... cee cece cece ee eee eees 251
Summary 2... cee eee ce eee eee eee tenes 254
ReferenceS oe ccevccccecc crete ccc en een ee eee eeeeenenes 254

INTERACTIONS OF SMOKING WITH DRUGS,
FOOD CONSTITUENTS, AND RESPONSES

 

TO DIAGNOSTIC TESTS 2... ce eee cnet e eee 259
Women Smokers and Nonsmokers and
Drug Consumption Patterns .........+.e sees eee ees 259
Altered Clinical Response to Drug Therapy
by Smokers as Compared to Nonsmokers .........: 261
Oral Contraceptives and Smoking .....+--..-+++eeees 262
Alterations in Normal Clinical Laboratory
Values in Women Smokers ......... 0c cece eeeeeeeecs 263
The Influence of Smoking on the
Nutritional Needs of Women .........0.. cece ee eeeee 264
Summary ....--. sec ce cece eee erect ence eee eee eeneee 265
ReferenCeS .cecceccccccecccee cece cee eeeeeeeeeeeerens 265
PART III
PSYCHOSOCIAL AND BEHAVIORAL ASPECTS
OF SMOKING IN WOMEN ........--. cee cee eee eee ceees 269
Introduction oo... ccc cece cece eee eee rere eens 271

XXIV
Initiation of Smoking in Adolescent Girls ............ 271

Concepts of Adolescent Behavior ...............6. 272
Prevalence and Patterns of
Adolescent Cigarette Use ......... 0. eee eee eee 278
Prevalence ..... cc ec ccc eee eee e ees 273
Age at Initiation of Smoking ................ 275
Number of Cigarettes Smoked ............... 277
Type of Cigarette Smoked ..................-. 278
Smoking Cessation ........... ccc eee eee eee 278
Smoking Prevalence and Ethnicity .......... 280
Alcohol and Marihuana Use ................. 280

Demographic and Psychosocial
Correlates of Smoking in

Adolescence oo... ccc cece ccc c eee e eee enes 281
Socioeconomic Influences ..............-0005- 281
Family Patterns ........... cece eee eee eee eens 282
Smoking Among Parents and Siblings ....... 282
Peer Group Influence ............. 0.00 cee eee 284
Scholastic Achievement and Aspirations ..... 285
Dynamic/Personality Factors ................ 286
Prediction of Future Smoking Behavior ..... 288

Prevention of Smoking and
Considerations for Future

Research  .... eee ccc cece eee eee eee eens 290

Prevention of the Initiation of
Smoking ......... eee eee ee eee eee ees 290
Research Goals ........ cee cee cee ee eee ences 291
Maintenance of Smoking Behavior ..............505 293
Patterns of Cigarette Smoking ...............0005 293
Smoking Prevalence and Ethnicity .......... 296

Pharmacological Effects of

Smoking ...... cece cece ee eee eee ence seen 297
Nicotine 1... cece cee eee cee ee ee eee enone 297
Peripheral Effects ............ cece eee ences 297
Central Effects ...... 0... cc cece eee cee eens 298

A Possible Role for Nicotine in
Smoking Maintenance .............seeeeee 298
Differences in Nicotine Metabolism .......... 300
Smoking and Stimulation Effects ................ 300
Smoking Cessation ....... 2. ee cece cece eet ee cee e ees 302
Demographics ......... cece eee ence ee een e ees 303
AGO Lice c eee cece eee cence ene nee enes 303
Education ..... cece ccc c ccc eee eee teen eens 303
INCOME 2. eee ect cere tee tee e ee eee 304
Occupation ..... eee eee ee ee eens 304
Psychology of Changing Smoking Habits......... 305
Treatment StudieS ......cc cece cece eee cette ences 306

The Smoking Withdrawal Syndrome ...........-. 315
Smoking and Weight Control .........+-e+eeeeees 315
Treatment Recommendations .........s-e eee eees 319
Conclusions ...cccc cece cece eect eect e eee eeeeeeees 321
Dissemination of Information About Smoking ....... 321
Health Attitudes and Behaviors .........++++.++- 321
Sources of Information ........cce eee eee e eee eeee 322
Health Care ProviderS ........cceeeeeeeeeeees 322
EducatorS ccc c cece cece ee ere eee ee eee eeeees 324
Peer Group... sce ccc eee eee eet e ee eneens 324
Family ...c cece cece ee eee cece een e ener eneeee 325
Media: Television, Radio, Film,
Newspapers, MagazineS ..-...seeeeeeeeeeee 325
Advertising ........cc cece eee eter cern eennees 325
The Failure to Disseminate
Information ....c cece cece eee ee eee reece eeenes 327
Stress at Work ..... ccc cece cece erect entree eee eeeness 327
Smoking Habits of Health Professionals ............. 329
Physicians ...... cece cece een ee eee recent ennnees 329
Psychologists .......cseceee eee renee ee eeeene eens 332
NurseS c.ccccccccc ccc cc cece eee ee renee ene eeeneens 333
The Pregnant Smoker—A Special Target ...........- 336
Sources of Information .......c cece cece eee eres 336
Physician Advice «6... cece ee eee eee eee e ne eeee 337
Prevalence of Smoking and Quitting
During Pregnancy ........- ss eee eee ener eee e cies 340
Psychosocial Factors in Quitting ............+-+- 344
Recommendations ........ceccee cece eee ene ceees 845
SuUMMAry oo cece cece cee eee eee nee e nent eee n ees 346
References ..ccscccc cece ence ec ee terete eee ee eee ennees 347