The Health Consequences of Smoking THE CHANGING CIGARETTE areport of the Surgeon General z U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES 3 Public Health Service My, Olfice on Smoking and Health For sale by the Superintendent of Documents, U.S. Government Printing Office, Washington, D.C. 20402 THE SECRETARY OF HEALTH AND HUMAN SERVICES WASHINGTON. 2.6. 20201 The Honorable Thomas P. O'Neill, Jr. Speaker of the House of Representatives Washington, D. C. 20515 Dear Mr. Speaker: I hereby submit to you the Health Consequences of Smoking—- The Changing Cigarette. This report is in response to two Congressional requirements. The Public Health Cigarette Smoking Act of 1969 calls upon this Department to issue annual reports on the health consequences of smoking and to submit legislative recommendations. Section 403 of the Health Services and Centers Amendments of 1978 asks for a “study or studies of (1) the relative health risks associated with smoking cigarettes of varying levels of tar, nicotine, and carbon monoxide; and (2) the health risks associated with smoking cigarettes containing any substances commonly added to commercially manufactured cigarettes.” . In preparing this report, the scientists and scientific agencies of this Department have reviewed all current scientific evidence and have concluded that the search for less hazardous cigarettes has not yielded a product which can be considered “safe.” The person who changes to a cigarette with lower measured yields may reduce certain hazards of smoking, but the benefits will be small compared to the benefits of quitting entirely. The most important conclusion of this report is that government and the private community alike must intensify their efforts to remind the public of the hazards of smoking and to assist those who do smoke to quit. We must step up our programs to persuade young people not to take up the habit in the first place. This report also notes that we mist continue to monitor the changing cigarette to insure that when new cigarette products appear they do not bring with them new hazards to health. Throughout this report the need to know about substances added to clgarettes is stated repeatedly. At present, there is no mechanism by which government or the scientific community can require disclosure of these additives, which must obviously be a firet step in assessing their health effects. This needs to be corrected by voluntary action or, if necessary, by legislation. On a number of occasions previous Secretaries of this Department have called for new and stronger health warnings, the establishment of maximum levels of “tar"“ and nicotine and the disclosure of more information about cigarette products. This 1981 report establishes the need to move forward on these recommendations. In particular, I believe the manufacturers should list yields of "tar", nicotine and other hazardous components on their packages and in their advertising with appropriate explanatory information on the health significance of these measurements. This would be a minimum first step in giving cigarette consumers full and adequate information about the products they are buying. incerely : a Ix Me Patricia Roberts Harris Enclosure PREFACE This is the fourteenth report on the health consequences of smoking which the Public Health Service has issued since 1964 and the third to be issued during my term as Surgeon General. By Congressional directive it considers the relative health effects of cigarettes with varying levels of “tar” and nicotine and the relative health effects of cigarette additives. At the present time, a third of all smokers, some 18 million persons, are smoking cigarettes with measured yields of less than 15 mg “tar,” and this number is increasing by approximately 5 percent per year. Most of these persons have changed to lower yield cigarettes in the expectation that this will somehow reduce the hazards of their smoking. It is in the interest of these persons, and in the public interest, to know to what extent these expectations are justified. In 1966, the Public Health Service held that “The preponderance of scientific evidence strongly suggests that the lower the tar and nicotine content of cigarette smoke, the less harmful would be the effect.” In 1979, the Public Health Service confirmed this statement, citing new evidence, but was more cautious. “In presenting information to the public,” I wrote in the Preface to the 1979 Report, “three caveats are in order: consumers should be advised to consider not only levels of tar and nicotine but also (when the evidence becomes available) levels of other tobacco smoke constituents, including carbon monoxide. They should be warned that, in shifting to a less hazardous cigarette, they may in fact increase their hazard if they begin smoking more cigarettes or inhaling more deeply. And, most of all, they should be cautioned that even the lowest yield of cigarettes presents health hazards very much higher than would be encountered if they smoked no cigarettes at all, and that the single most effective way to reduce the hazards associated with smoking is to quit.” In this 1981 Report, the Public Health Service has reviewed the question again and in far greater depth than before. Overall, our judgment is unchanged from that of 1966 and 1979: smokers who are unwilling or as yet unable to quit are well advised to switch to cigarettes yielding less “tar” and nicotine, provided they do not increase their smoking or change their smoking in other ways. But our v new review raises new questions and suggests an even more cautious approach to the issue. Here are the basic findings of this Report: 1. There is no safe cigarette and no safe level of consumption. 2. Smoking cigarettes with lower yields of “tar” and nicotine reduces the risk of lung cancer and, to some extent, improves the smoker's chance for longer life, provided there is no compensatory increase in the amount smoked. However, the benefits are minimal in comparison with giving up cigarettes entirely. The single most effective way to reduce hazards of smoking continues to be that of quitting entirely. 8. It is not clear what reductions in risk may occur in the case of diseases other than lung cancer. The evidence in the case of cardiovascular disease is too limited to warrant a conclusion, nor is there enough information on which to base a judgment in the case of chronic obstructive lung disease. In the case of smoking’s effects on the fetus and newborn, there is no evidence that changing to a lower “tar” and nicotine cigarette has any effect at all on reducing risk. 4. Carbon monoxide has been impugned as a harmful constituent of cigarette smoke. There is no evidence available, however, that permits a determination of changes in the risk of diseases due to variations in carbon monoxide levels. 5. Smokers may increase the number of cigarettes they smoke and inhale more deeply when they switch to lower yield cigarettes. Compensatory behavior may negate any advantage of the lower yield product or even increase the health risk. 6. The “tar” and nicotine yields obtained by present testing methods do not correspond to the dosages that the individual smokers receive: in some cases they may seriously underestimate these dosages. 7. A final question is unresolved, whether the new cigarettes being produced today introduce new risks through their design, filtering mechanisms, tobacco ingredients, or additives. The chief concern is additives. The Public Health Service has been unable to assess the relative risks of cigarette additives because information was not available from manufacturers as to what these additives are. In evaluating the public health significance of the finding of reduced risk of lung cancer, it is important to recognize that the largest component of excess mortality caused by smoking is cardiovascular disease deaths. There is not sufficient evidence to conclude that use of lower “tar” and nicotine cigarettes causes any reduction in this burden. The same is true of the other major diseases caused by cigarette smoking, most notably chronic obstructive lung disease and adverse effects on pregnancy. vi These findings raise important questions of public policy. Some appear to be easily resolved. It should be possible to work out procedures so that cigarette manufacturers can disclose the additives they use while still protecting their legitimate interest in trade secrets; an effort to accomplish this is now underway. It should also be possible to develop better methodologies to measure smoke constituents, although no machine will ever be able to duplicate human smoking behavior exactly. And longitudinal surveys are now being carried on in an effort to monitor smoking behavior, and to help answer some of the behavioral questions raised in this Report. Other questions pose greater difficulty. A common thread running through the sections of the Report is that too much reliance in the past has been placed on the nonselective measure of “tar” as a measure of risk to the neglect of other constituents and approaches to risk assessment. Additional epidemiologic and bioassay work is required, as is a better definition of the fundamental mechanisms of smoking- related disease. Further study is necessary to examine the addictive nature of smoking and its impact on initiation, maintenance, and cessation, especially in light of the recent statement of the National Drug Abuse Advisory Council that cigarette smoking is addictive. These questions cannot be answered quickly or without expenditure of scientific resources. The questions raised by this Report suggest action in both the public and private sector. In the research community, a research plan is needed to enable us to monitor the changing cigarette and to answer the many research questions put forth in this Report, with special emphasis on the issues of initiation and cessation. New measures and markers of relative toxicity are needed to supplement “tar” and nicotine. As stated, a voluntary disclosure and testing program needs to be developed with cigarette manufacturers to assess the relative health risks of cigarette additives and to protect against new hazards. In the regulatory area, this Report suggests the need to increase the public’s access to information about the product it buys. Advertise- ments and packages alike should display yield figures more prominent- ly, including measures of carbon monoxide and possibly other hazard- ous ingredients. Marketing terms such as “low-low” and “ultra-low” need to be standardized. In the area of public information and education, much more needs to be done both by the Government and by private health and educational agencies. The overriding objective must be to persuade young people not to take up smoking and to encourage present smokers to quit. Smokers of the lower yield cigarettes should be warned not to begin smoking more cigarettes or inhaling more deeply. Pregnant women should be cautioned that lower yield cigarettes are not an alternative to quitting. vii Since 1964, when the first Public Health Service Report was issued, smoking has declined in the United States from 40.3 percent of the population to 32.5 percent. Per capita consumption of cigarettes is now at the lowest level since 1957. There is less smoking by boys than in many years, and smoking by girls has declined from the higher levels of the mid-1970s. This is a tribute to the educational efforts of our teachers, of our health professionals, and of our educational and health agencies. There is every reason to hope and believe these trends will continue. Yet 54 million Americans continue to smoke, unwilling or unable to quit. This population is at extra risk of lung cancer, heart disease, chronic lung disease, and other diseases; it is a population with a life expectancy months and years less than the population of nonsmokers. The evidence presented in this Report shows that there is no “safe” cigarette available to these smokers, but that some cigarettes may be less hazardous than others, reducing the risks of smoking in a limited and selective fashion. Julius B. Richmond, M.D. Assistant Secretary for Health and Surgeon General January 12, 1981 viii ACKNOWLEDGEMENTS This Report was prepared by the Department of Health and Human Services under the general editorship of the Office on Smoking and Health, John M. Pirtney, Director. Medical Staff Director for the Report was Joanne Luoto, M.D., M.P.H. Managing Editor was Donald R. Shopland. Consulting scientific editors were David M. Burns, M.D., Ellen R. Gritz, Ph.D., Jeffrey E. Harris, M.D., Ph.D., and John H. Holbrook, M.D. The following individuals participated in working groups at the June 1980 conference on Research Needs on Low-Yield Cigarettes. Except where otherwise indicated, the working group chairperson also au- thored the corresponding working group report and was responsible for incorporating comments from other members of the group. Pharmacology and Toxicology Fred G. Bock, Ph.D. (Chairman), Director, Orchard Park Laboratories, Roswell Park Memorial Institute, Orchard Park, New York S. P. Battista, Ph.D., Senior Staff Pharmacologist, Arthur D. Little, Inc., Cambridge, Massachusetts James F. Chaplin, Ph.D., Director, Oxford Tobacco Research Laborato- ry, Oxford, North Carolina 0. T. Chortyk, Ph.D., Chief, Tobacco and Health Laboratory, Richard Russell Research Center, Athens, Georgia Louis Diamond, Ph.D., Professor and Director of the Pharmacodynam- ies and Toxicology Division, College of Pharmacy, University of Kentucky, Lexington, Kentucky M. R. Guerin, Ph.D., Section Head, Bio-Organic Analysis Section, Analytical Chemistry Division, Oak Ridge National Laboratory, Oak Ridge, Tennessee Jeffrey E. Harris, M.D., Ph.D., Associate Professor, Department of Economics, Massachusetts Institute of Technology, Cambridge, Massachusetts Dietrich Hoffmann, Ph.D., Chief, Division of Environmental Carcino- genesis and Associate Director of Naylor-Dana Institute, American Health Foundation, Valhalla, New York Harold C. Pillsbury, B.S., Technical Director, Federal Trade Commis- sion, Tobacco Research Laboratory, Washington, D.C. ix W.S. Rickert, Ph.D., Department of Statistics, University of Waterloo, Waterloo, Ontario, Canada T. C. Tso, Ph.D., Chief, Tobacco Laboratory, U.S. Department of Agriculture, Beltsville, Maryland Cancer Jesse L. Steinfeld, M.D. (Chairman), Dean of the School of Medicine, Medical College of Virginia, Richmond, Virginia Lawrence Garfinkel, M.A., Vice President for Epidemiology and Statistics, American Cancer Society, Inc., New York, New York Michael Kunze, M.D., Professor of Social Medicine, Institute of Hygiene, University of Vienna, Vienna, Austria William Lijinsky, Ph.D., Director, Chemical Carcinogenesis Program, Litton Bionetics, Frederick Cancer Research Center, Frederick, Maryland Donald H. Luecke, M.D., Chief of Special Programs Branch, Division of Cancer Cause and Prevention, National Cancer Institute, Bethesda, Maryland Marvin A. Schneiderman, Ph.D., Bethesda, Maryland William D. Terry, M.D., Acting Director, Division of Cancer Control and Rehabilitation, National Cancer Institute, Bethesda, Maryland Elizabeth Weisburger, Ph.D., Chief of Laboratory for Carcinogenesis Metabolism Branch, Carcinogenesis Intramural Program, Division of Cancer Cause and Prevention, National Cancer Institute, Bethesda, Maryland Ernst L. Wynder, M.D., President, American Health Foundation, New York, New York Dietrich Hoffmann, Ph.D. (Special Consultant), Chief, Division of Environmental Carcinogenesis and Associate Director of Naylor- Dana Institute, American Health Foundation, Valhalla, New York Cardiovascular Diseases William P. Castelli, M.D. (Chairman), Medical Director, Framingham Heart Study, Framingham, Massachusetts Poul Astrup, M.D., Professor of Clinical Chemistry, University of Copenhagen, Copenhagen, Denmark Manning Feinleib, M.D., Dr.P.H., Associate Director for Epidemiology and Biometry, National Heart, Lung, and Blood Institute, Bethesda, Maryland William Friedewald, M.D., Associate Director, Clinical Applications and Prevention Program, National Heart, Lung, and Blood Institute, Bethesda, Maryland Robert S. Gordon, Jr., M.D., Special Assistant to the Director, National Institutes of Health, Bethesda, Maryland William R. Harlan, M.D., Professor and Chairman, Department of Postgraduate Medicine, University of Michigan, Ann Arbor, Michi- gan Richard J. Havlik, M.D., M.P.H., Chief, Clinical and Genetics Epide- miology Section, National Heart, Lung, and Blood Institute, Bethes- da, Maryland John H. Holbrook, M.D., Associate Professor of Internal Medicine, University of Utah, Salt Lake City, Utah Stephen B. Hulley, M.D., M.P.H., University of California, School of Medicine, San Francisco, California Henry C. McGill, M.D., Professor, Department of Pathology, Universi- ty of Texas Health Science Center, San Antonio, Texas Gardner C. McMillan, M.D., Associate Director for Etiology, Arterio- sclerosis and Hypertension, Division of Heart and Vascular Disease, National Heart, Lung, and Blood Institute, Bethesda, Maryland Douglas R. Rosing, M.D., Senior Investigator, Cardiology Branch, National Heart, Lung, and Blood Institute, Bethesda, Maryland Nicholas J. Wald, M.D., I.C.R.S., Cancer Epidemiology and Clinical Trials Unit, Radcliffe Infirmary, Oxford, England William J. Zukel, M.D., Associate Director for Program Coordination and Planning, Division of Heart and Vascular Diseases, National Heart, Lung, and Blood Institute, Bethesda, Maryland Chronic Obstructive Lung Disease Philip Kimbel, M.D. (Chairman), Chairman, Department of Medicine, The Graduate Hospital, Philadelphia, Pennsylvania A. Sonia Buist, M.D., Associate Professor, Department of Physiology, School of Medicine, University of Oregon, Portland, Oregon David M. Burns, M.D., Pulmonary Division, University Hospital, San Diego, California Jeffrey M. Drazen, M.D., Assistant Professor of Medicine, Harvard Medical School, Peter Bent Brigham Hospital, Boston, Massachu- setts Eric R. Jurrus, Ph.D., Health Scientist Administrator, Airways Dis- eases Branch, Division of Lung Diseases, National Heart, Lung, and Blood Institute, Bethesda, Maryland James F. Morris, M.D., Chief, Pulmonary Disease Section, Veterans Administration Medical Center, Portland, Oregon Clifford H. Patrick, Ph.D., Chief, Prevention, Education, and Manpow- er Branch, Division of Lung Diseases, National Heart, Lung, and Blood Institute, Bethesda, Maryland Diana Petitti, M.D., Department of Medical Methods Research, Kaiser Permanente Medical Care Program, Oakland, California Pregnancy and Infant Health Lawrence D. Longo, M.D. (Chairman), Professor of Physiology and Perinatal Biology, Professor of Obstetrics and Gynecology, School of Medicine, Loma Linda University, Loma Linda, California Heinz W. Berendes, M.D., M.H.S., Director, Epidemiology and Biome- try Research Program, National Institute of Child Health and Human Development, Bethesda, Maryland xi William A. Blane, M.D., Professor of Pathology, Head, Division of Developmental Pathology, College of Physicians and Surgeons, Columbia University, New York, New York Alfred W. Brann, M.D., Professor, Department of Pediatrics, Director, Division of Neonatal-Perinatal Medicine, Emory University School of Medicine, Atlanta, Georgia Charlotte S. Catz, M.D., Head, Pregnancy and Perinatology Section, Clinical Nutrition and Early Development Branch, Center for Research for Mothers and Children, National Institute of Child Health and Human Development, Bethesda, Maryland Eileen G. Hasselmeyer, Ph.D., Associate Director for Scientific Review, National Institute of Child Health and Human Development, Bethesda, Maryland Mary B. Meyer, Se.M., Associate Professor, Department of Epidemiolo- gy, School of Hygiene and Public Health, The Johns Hopkins University, Baltimore, Maryland David Rush, M.D., Ph.D., Associate Professor of Public Health (Epidemiology) and Pediatrics, Faculty of Medicine, School of Public Health, Columbia University, New York, New York Zena Stein, M.D., Professor of Public Health (Epidemiology), Sergiev- ski Center at Columbia University, New York, New York Behavioral Aspects Charles R. Schuster, Ph.D. (Chairman), Departments of Psychiatry and Pharmacological and Physiological Sciences, Pritzker School of Medicine, University of Chicago, Chicago, Illinois Lynn T. Kozlowski, Ph.D. (Author), Scientist, Clinical Institute of the Addiction Research Foundation, Toronto, Ontario, Canada Roland R. Griffiths, Ph.D., Associate Professor of Behavioral Biology, School of Medicine, The Johns Hopkins University, Baltimore, Maryland Ellen R. Gritz, Ph.D., Associate Research Psychologist, Department of Psychiatry and Pharmacology, University of California at Los Angeles; Research Psychologist, Veterans Administration Medical Center, Brentwood, Los Angeles, California Murray E. Jarvik, M.D., Ph.D., Professor of Psychiatry and Pharmacol- ogy, University of California at Los Angeles; Chief, Psychopharma- cology Unit, Veterans Administration Medical Center, Brentwood, Los Angeles, California Chris-Ellyn Johanson, Ph.D., Research Associate (Associate Professor), Department of Psychiatry, University of Chicago, Chicago, Illinois Sandra Levy, Ph.D., Acting Chief, Behavioral Medicine Branch, Division of Resources, Centers, and Community Activities, National Cancer Institute, Bethesda, Maryland Margaret E. Mattson, Ph.D., Program Scientist, Behavioral Medicine Branch, Division of Heart and Vascular Diseases, National Heart, Lung, and Blood Institute, Bethesda, Maryland xii David M. Monsees, Ph.D., Program Director for State and Evaluation Projects, Behavioral Medicine Branch, Division of Resources, Cen- ters, and Community Activities, National Cancer Institute, Silver Spring, Maryland > Edward J. Roccella, Ph.D., Deputy Branch Chief, Health Education Branch, Office of Prevention, Education and Control, National Heart, Lung, and Blood Institute, Bethesda, Maryland Michael Russell, M.D., Institute of Psychiatry, Maudsley Hospital, London, England The editors acknowledge with gratitude the many distinguished scientists, physicians, and others who lent their support in the preparation of this Report by coordinating manuscript preparation, contributing critical reviews of the manuscript, or assisting in other ways. Henry Blackburn, M.D., Professor and Director, Laboratory of Physio- logical Hygiene, School of Public Health, University of Minnesota, Minneapolis, Minnesota Lester Breslow, M.D., M.P.H., Dean, School of Public Health, Center for the Health Sciences, University of California, Los Angeles, California Benjamin Burrows, M.D., Director, Division of Respiratory Sciences, Arizona Health Sciences Center, Tucson, Arizona : Vincent T. DeVita, M.D., Director, National Cancer Institute, Bethes- da, Maryland Donald §. Fredrickson, M.D., Director, National Institutes of Health, Bethesda, Maryland Maureen Henderson, M.D., Associate Vice President for Health Sciences, University of Washington, Seattle, Washington Norman Kretchmer, M.D., Ph.D., Director, National Institute of Child Health and Human Development, Bethesda, Maryland Robert I. Levy, M.D., Director, National Heart, Lung, and Blood Institute, Bethesda, Maryland Abraham Lillienfeld, M.D., M.P.H., D.S.C., University Distinguished Service Professor, Department of Epidemiology, School of Hygiene and Public Health, The Johns Hopkins University, Baltimore, Maryland Kenneth Moser, M.D., Director, Pulmonary Division, University Hospi- tal, San Diego, California R. L. Naeye, M.D., Professor and Chairman, Department of Pathology, M.S. Hershey Medical Center, Hershey, Pennsylvania Richard Peto, M.A., M.S.C., I.C.R.S., Regius Assessor of Medicine, Radcliffe Infirmary, Oxford, England William Pollin, M.D., Director, National Institute on Drug Abuse, Rockville, Maryland xiii Richard D. Remington, Ph.D., Dean, School of Public Health, Universi- ty of Michigan, Ann Arbor, Michigan Robert Resnick, M.D., Associate Professor, Department of Reproduc- tive Medicine, Medical Center, University of California, San Diego, California Dorothy P. Rice, Director, National Center for Health Statistics, Hyattsville, Maryland Marvin A. Sackner, M.D., Chairman, Department of Medicine, Mt. Sinai Medical Center, Miami Beach, Florida Irving J. Selikoff, M.D., Professor of Community Medicine, Professor of Medicine, Mt. Sinai School of Medicine, City University of New York, New York, New York Jeremiah Stamler, M.D., Chairman, Department of Community Health and Preventive Medicine, Northwestern University Medical School, Chicago, Illinois Ronald W. Wilson, M.A., Chief, Health Status and Demographic Analysis Branch, Division of Analysis, National Center for Health Statistics, Hyattsville, Maryland The editors also acknowledge the contributions of the following staff and others who assisted in the preparation of the Report. Erica W. Adams, Copy Editor, Informatics Incorporated, Rockville, Maryland Richard H. Amacher, Director, Clearinghouse Projects Department, Informatics Incorporated, Rockville, Maryland John L. Bagrosky, Associate Director for Program Operations, Office on Smoking and Health, Rockville, Maryland Jacqueline O. Blandford, Secretary, Office on Smoking and Health, Rockville, Maryland Tina K. Brubaker, Information Specialist, Clearinghouse Projects Department, Informatics Incorporated, Rockville, Maryland Betty Budd, Administrative Clerk, Office on Smoking and Health, Rockville, Maryland Marsha Clay, Clerk-Typist, Office on Smoking and Health, Rockville, Maryland Martha E. Davis, Technical Illustrator, Informatics Incorporated, Rockville, Maryland Wesley Dean, Clerk-Typist, Office on Smoking and Health, Rockville, Maryland Stephanie D. DeVoe, Data Entry Operator, Informatics Incorporated, Rockville, Maryland Steve A. Fairbairn, Applications Manager, Information Processing Services Division, Informatics Incorporated, Rockville, Maryland Rose M. Gerondakis, Secretary, Office on Smoking and Health, Rockville, Maryland xiv John F. Hardesty, Jr., Public Information Officer, Office on Smoking and Health, Rockville, Maryland Rebecca C. Harmon, Manager, Graphics Unit, Informatics Incorporat- ed, Rockville, Maryland Reginald V. Hawkins, M.P.H., Public Health Analyst, Office on Smoking and Health, Rockville, Maryland Patricia E. Healy, Technical Information Clerk, Office on Smoking and Health, Rockville, Maryland Linda Herold, Information Specialist, Clearinghouse Projects Depart- ment, Informatics Incorporated, Rockville, Maryland Shirley K. Hickman, Lead Data Entry Operator, Informatics Incorpo- rated, Rockville, Maryland Cindi M. Holgash, Secretary, Clearinghouse Projects Department, Informatics Incorporated, Rockville, Maryland Robert S. Hutchings, Associate Director for Information and Program Development, Office on Smoking and Health, Rockville, Maryland Barbara Hyde, Editor, Biospherics, Incorporated, Rockville, Maryland Lisa A. Katz, Graphic Artist, Informatics Incorporated, Rockville, Maryland Margaret E. Ketterman, Public Information and Publications Assis- tant, Office on Smoking and Health, Rockville, Maryland Julie Kurz, Graphic Artist, Informatics Incorporated, Rockville, Mary- land C. Yvonne Lee, Statistician, Informatics Incorporated, Rockville, Maryland William R. Lynn, Public Health Analyst, Office on Smoking and Health, Rockville, Maryland Jacquelene Mudrock, Technical Illustrator, Informatics Incorporated, 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 Raymond K. Poole, Production Coordinator, Clearinghouse Projects Department, Informatics Incorporated, Rockville, Maryland Karen Robinson, Clerk-Typist, Office on Smoking and Health, Rock- ville, Maryland Roberta A. Roeder, Secretary, Informatics Incorporated, Rockville, Maryland Matthew J. Schudel, Editor, Biospherics, Incorporated, Rockville, Maryland Valsala Sekhar, Data Entry Operator, Informatics Incorporated, Rockville, Maryland Linda R. Sexton, Information Specialist, Clearinghouse Projects Department, Informatics Incorporated, Rockville, Maryland Scott Smith, Editor, Biospherics, Incorporated, Rockville, Maryland Linda Spiegelman, Administrative Officer, Office on Smoking and Health, Rockville, Maryland Sol Su, Sc.D., Statistician, Office on Smoking and Health, Rockville, Maryland Carol M. Sussman, Writer-Editor, Office on Smoking and Health, Rockville, Maryland Selwyn Waingrow, Public Health Analyst, Office on Smoking and Health, Rockville, Maryland Melissa L. Yorks, M.L.S., Technical Information Specialist, Office on Smoking and Health, Rockville, Maryland xvi TABLE OF CONTENTS Acknowledgements ............:ccscsecnseescneeneeeseneneesensenerenes ix 1. Introduction, Summary, and Research Recommendations ...........ccscsceeeenceceseeeeseneneneeereseeeees 1 2. Pharmacology and Toxicology .............cssessseescerenereees 27 B. Caner .......cccecssceceererec sree eens eee e enon nena eens eens tena ee ee eens 75 4. Cardiovascular Diseases ...............cssecsnenenseeeeneesenees 111 5. Chronic Obstructive Lung Disease .............:---eseeeeees 131 6. Pregnancy and Infant Health..................:eseeeeeeeeees 153 7. Behavioral Aspects...........:.ceccsceeceseeeneesrensereeseees 173 8. Lower “Tar” and Nicotine Cigarettes: Product Choice ANG Use.........ccccescecececceneeenneeesneneceeeeneneneeeeneeses ees 198 Index ........0cceceeeececceceeeeeeencesseceaeeenereeneseeaeseaereeeseees 239 xvii