TABLE 7.—Estimated relative risks for current and former cigarette smokers,
females aged 35 years or more, 4-year (1982-86) followup of
American Cancer Society 50-State study (CPS-II)

 

 

Underlying cause Current Former
of death smokers" smokers"
All causes 1.90 b 1,32 b
(1.82-1.98) (1.27-1.37)
CHD, age 235 (410-414)° 1.78 1,31
(1.62-1.97) (1.19-1.44)
CHD, age 35-649 (410-414) 3.00 1.43
(2.50-3.59) (1.15-1.77)
CHD, age 265 (410-414) 1.60 1.29
(1.42-1.80) (1.16-1.43)
Other Heart Disease* (390-398, 1.69 1.16
401-405, 415-417, 420-429) (1.44-1.99) (1.00-1.34)
Cerebrosvascular Lesions, age 235 1.84 1.06
(430-438) (1.56-2.16) (0.88-1.27)
Cerebrovascular Lesions, age 35-64 4.80 1.41
(430-438) (3.52-6.54) (0.94—2.13)
Cerebrovascular Lesions, age 265 1.47 1.01
(430-438) (1.19-1.81) (0.83-1.24)
Other Circulatory Disease’ (440-448) 3.00 1,34
(2.20-4.08) (0.95-1.90)
COPD (490-492,496) 10.47 7.04
(7.78-14.09) (5.33-9.30)

Other Respiratory Disease® 2.18 1.38
(010-012,480-489 493) (1.60-2.97) (1.04-1.84)

Cancer, Lip, Oral Cavity, Pharynx 5.59 2.88
(140-149) (3.15~9.91) (1.57-5.26)
Cancer, Esophagus (150) 10.25 3.16
(4.94-21.27) (1.45-6.85)
Cancer, Pancreas (157) 2.33 1.78
(1.77-3.08) (1.37-2.30)
Cancer, Larynx (161) 17.78 11.88
(3.45-91.74) (2.46-57.34)
Cancer, Lung (162) 11,94 4.69
(9.99-14.26) (3.86-5.70)
Cancer, Cervix Uteri (180) 2.14 1.94
(1.06-4.30) (0.97-3.87)
Cancer, Kidney (189) 1.41 1.16
(0.86—2.30) (0.72-1.87)
Cancer, Bladder, Other Urinary Organs (188) 2.58 1,85
(1.31-5.08) (1.00-3.42)

 

NOTE: Preliminary estimates, based upon 2,418,909 woman-years of exposure among female subjects who never
smoked regularly, or who smoked only cigarettes, present or past. Relative risks, estimated with respect to women
who never smoked regularly, have been directly standardized to the age distribution of all woman-years of exposure.
sRefers to cigarette smoking status at enrollment (September 1982).

‘Numbers in parentheses are 95-percent confidence intervals, computed on the assumption that the logarithm of
relative risk was normally distributed.

All disease codes refer to International Classification of Diseases, Ninth Revision.
When an age range is given, it refers to the age at enrollment in 1982.

includes Hypertensive Heart Disease (401-404).

Includes Aortic Aneurysm, Non-Syphilitic, and General Arteriosclerosis (440-441).
"Includes Influenza and Pneumonia (480-487).

SOURCE: Unpublished tabulations, American Cancer Society.

151
tween Cigarette use and risk of stroke. They also noted a slight increase in risk among
former cigarette smokers, especially for the first 2 years after cessation. The prelimi-
nary results from CPS-II, reported in Tables 6 and 7, further support a causal role for
cigarette smoking in stroke.

The preliminary results of CPS-II also show significantly higher relative risks for
cancers of the lip, oral cavity and pharynx, esophagus, and lung, as compared with CPS-
I. The computed relative risk for lung cancer death has increased to 22 in men and 12
in women. While the relative risks for COPD death have not changed significantly
among men, there is a trend toward increasing risk among women. The available data
from CPS-II do not permit identification of specific mortality risks for hypertensive
heart disease, aortic aneurysm, and influenza and pneumonia, as in CPS-I. However,
among broader categories of cardiovascular and nonneoplastic respiratory disease, in-
creased risks are likewise found in CPS-II.

Endocrine and Sex-Related Cancers in Women

A protective effect of smoking on cancer of the endometrium has been suggested in
a recent case-control study (Lesko et al. 1985). For CPS-I, the relative risk for cancers
of the uterine corpus (ICD-7 Codes 172-174) among current smokers was 0.94 (95-per-
cent confidence interval, 0.57 to 1.53). Preliminary results for CPS-II suggest a reduced
relative risk for endometrial cancer (ICD-9 Code 182).

Recent data on a possible protective effect of smoking for breast cancer have been
contradictory (See Chapter 2; Rosenberg et al. 1984). For CPS-I, the relative risk for
breast cancer (ICD-7 Code 170) among current smokers was 0.88 (95-percent con-
fidence interval, 0.77 to 1.01), while the relative risk among former smokers was 1.20
(95-percent confidence interval, 1.15 to 1.35). Preliminary data from CPS-II have
likewise been contradictory.

An increased risk of cervical cancer among cigarette smokers has been reported in
case-control studies (LaVecchia et al. 1986; Nischan, Ebeling, Schindler 1988). For
CPS-I, the relative risk for cervical cancer (ICD-7 Code 171) was 1.10 (95-percent con-
fidence interval, 0.83 to 1.47). Data from CPS-II show a twofold increase in cervical
cancer mortality among current smokers (relative risk 2.14, 95-percent confidence in-
terval 1.06 to 4.30).

Summary

The relative risks for current smokers for selected comparable disease categories
causally related to smoking in CPS-I and CPS-II are summarized and listed side by side
in Table 8. These comparisons show substantial increases in the risk of death due to
smoking for most of the disease categories listed between the years 1959 and 1965 and
1982 and 1986. Statistically significant increases in relative risks occurred in those dis-
ease categories for which 95-percent confidence limits around the estimated relative
risks do not overlap between CPS-I and CPS-II. Compared with men during this period,
women experienced greater increases in the relative risks of cerebrovascular lesions
(ages 35 to 64 years), COPD, laryngeal cancer, and lung cancer.

152
TABLE 8.—Summary of estimated relative risks for current cigarette smokers,
major disease categories causally related to cigarettes, males and
females aged 35 years and older, CPS-I (1959-65) and CPS-II

 

 

 

(1982-86)
Underlying cause : Males Females
of death” CPS-I CPS-II CPS-I CPS-II
CHD, age 235 1.83 1.94 1.40 1.78°
CHD, age 35-64 2.25 2.81° 1.81 3.00°
Cerebrovascular Lesions, 1.37 2.24° 1.19 1.84°
age 235
Cerebrovascular Lesions, 1.79 - 3.67° 1.92 430°
age 35-64
COPD 8.81 9.65 5.89 10.47
Cancer, Lip, Oral Cavity, 6.33 27.48 1.96 5.59
and Pharynx
Cancer, Esophagus 3.62 7.60 1.94 10.25°
Cancer, Pancreas 2.34 2.14 , 1.39 2.33
Cancer, Larynx 10.00 _ 10.48 3.81 17.78
Cancer, Lung 11.35 22.36 2.69 11.94?

 

"See Tables 4-7 for International Classification of Disease codes.
*95-percent confidence intervals do not overlap between CPS-I and CPS-IL
SOURCE: Tables 4-7.

Smoking-Attributable Mortality in the United States, 1965 and 1985

Table 9 reports the attributable risks a from cigarette smoking during the year 1965.
Ten causes of death are considered: CHD, COPD, cerebrovascular disease, and can-
cers of seven sites. The computations are based upon the age-adjusted relative risks
reported in CPS-I and the prevalence rates reported in the 1965 NHIS. For men, the
age-adjusted relative risks among present and past cigarette smokers with a history of
pipe or cigar use were slightly lower than those for present and past smokers of ciga-
rettes exclusively. While the latter are reported for comparison in Table 4, the former
were used in the attributable risk computations. In 1965, as shown in Figure 2, about
two-thirds of men with a history of regular cigarette smoking were also exposed to pipe
or cigar smoke. (As noted in Note b of Table 10 below, the use of relative risks derived
from the death rates of men who smoked cigarettes exclusively resulted in about a 5-
percent increase in attributable deaths for 1965.) For women, the computation of at-
tributable risks in 1965 did not distinguish between current and former smokers.

153
TABLE 9.—Estimated attributable risks for 10 selected causes of death from
cigarette smoking, males and females, United States, 1965

 

 

Males" b
Cause of death (Se) ar
CHD, age 35-64 42 26
(40-45)° (23-30)
CHD, age 265 ll 3.3
(9-14) (2.1-5.1)
COPD 84 67
(79-88) (57-76)
Cancer of lip, oral cavity, and pharynx 74 27
(59-85) (12-51)
Cancer of larynx 84 47
(61-94) (8-90)
Cancer of esophagus 57 14
(36-76) (6-29)
Cancer of lung 86 40
(82-88) (31-50)
Cancer of pancreas 41 14
(30-53) (6-30)
Cancer of bladder 53 36
(39-66) (20-56)
Cancer of kidney 36 17
(19-56) (5-42)
Cerebrovascular disease, age 35-64 28 28
(21-36) (22-33)
Cerebrovascular disease, age 265 2.0 1.3
(0.6-6.6) (0.2-6.5)

 

“For males, computations based on prevalence rates in Table 2 and relative risks for male current and former cigarette
smokers, with or without a history of pipe and cigar smoking, derived from CPS-1.

"For females, attributable risks computed from prevalence rates in Table 2 and relative risks for all female smokers,
past and present, in Table 5,

“Numbers in parentheses are 95-percent confidence intervals.

In 1965, as Table 9 reveals, cigarette smoking was responsible for 42 percent of CHD
deaths among younger men and 26 percent of deaths among younger women. For
COPD deaths at all ages, the smoking-attributable risks were 84 percent for men and
67 percent for women. For lung cancer, the respective attributable risks were 86 per-
cent and 40 percent for men and women. With the exception of deaths from stroke
among younger persons, attributable risks were markedly higher for men.

Table 10 reports the corresponding smoking-attributable deaths, A, during the year
1965. Attributable deaths were computed by multiplying the attributable risk percent-
ages in Table 9 by the corresponding cause-specific death rates among persons aged 20

154
TABLE 10.—Estimated deaths (in thousands) attributable to cigarette smoking,
10 selected causes, males and females, United States, 1965

 

 

Cause of death Males Females
CHD, age <65 51 9.5
(48-54)? (8.2-10.8)
CHD, age 265 25 6.0
(20-30) (3.9-9.4)
COPD 16 2.3
(15-17) (2.0-2.7)
Cancer of lip, oral cavity, and pharynx 3.6 0.4
(2.9-4.2) (0.2-0.8)
Cancer of larynx 1.9 O14
(1.42.2) (0.02-0.3)
Cancer of esophagus 2.4 0.1
(1.5-3.2) (0.2-0.8)
Cancer of lung 35 3.1
(34-36) (2.4-3.8)
Cancer of pancreas 3.8 0.9
(2.8-4.9) (0.4—2.0)
Cancer of bladder 3.0 1.0
(2.2-3.7) (0.5-1.5)
Cancer of kidney 1.2 0.3
(0.7-1.9) (0.1-1.8)
Cerebrovascular disease, age <65 5.5 AT
(4.2-7.2) (3.8-5.6)
Cerebrovascular disease, age 265 1.5 1.0
(0.4-4.8) (0.2-5.9)
Ten causes 150° 30
(143-157) (26-34)

 

NOTE: Computed from Table 9 and tabulations of deaths at ages 20 years or more by cause for 1965 (NCHS 1967).

Sums may not equal totals because of rounding.
*Numbers in parentheses are 95-percent confidence intervals.

>When the attributable risk estimates given in Note a of Table 9 were used, the total attributable deaths for males were
158,000 (95-percent confidence interval, 151,000 to 166,000). Approximately two-thirds of the 8,000 additional deaths

were from CHD.

years or more. For the 10 causes combined, cigarette smoking was responsible for

150,000 deaths among men and 30,000 deaths among women in 1965.

Among men, CHD deaths made up 51 percent of smoking-attributable mortality for
the 10 causes combined. This proportion is consistent with the estimate of 45 percent
reported by the 1964 Advisory Committee to the Surgeon General for excess mortality
from all causes (US PHS 1964). Similarly, lung cancer accounted for 23 percent of the
smoking-attributable mortality for the 10 causes combined—again consistent with the

155
1964 Report’s estimate of 16 percent of deaths from all causes. Among women, CHD
deaths made up 52 percent and lung cancer 10 percent of the smoking-attributable mor-
tality from the 10 causes combined.

Table 11 shows the estimated attributable risks a from cigarette smoking for the year
1985. For comparability with the 1965 calculations, the same 10 causes of death are
considered. The computations are based upon the relative risks reported in CPS-II and
the prevalence rates reported in the 1985 NHIS. For men, the computations employed
the relative risks for past and present smokers of cigarettes exclusively, as shown in
Table 6. As Figure 2 indicates, the proportion of male smokers who used other forms

TABLE 11.—Estimated attributable risks for 10 selected causes of death from
cigarette smoking, males and females, United States, 1985

 

 

Males Females
Cause of death (%) (%)
CHD, age <65 45 ; 4)
(40-50) (34-48)
CHD, age 265 21 12
(17-26) (9-15)
COPD 84 79
(78-88) © (73-83)
Cancer of lip, oral cavity, and pharynx 92 61
(79-97) (45-76)
Cancer of larynx 81 87
(57-93) (56-97)
Cancer of esophagus 78 75
(62-89) (57-87)
Cancer of lung 90 79
(88-92) (75-82)
Cancer of pancreas 29 34
(18-43) (25-44)
Cancer of bladder 47 37
(31-63) (18-61)
Cancer of kidney 48 12
(32-64) (3-43)
Cerebrovascular disease, age <65 51 Rp)
(36-65) (45-65)
Cerebrovascular disease, age 265 24 6
(16-35) (2-14)

 

NOTE: Computed from Tables 2, 6, and 7. For adult men under 65, the proportions of current and former cigarette
smokers in 1985 were, respectively, 34.7 and 25.8 percent. For men 65 or older, the prevalences of current and former
cigarette smoking were, respectively, 19.4 and 51.1 percent. For adult women under 65, the corresponding proportions
were 30.1 and 16.5 percent; for adult women 65 or older, 12.6 and 19.6 percent.

“Numbers in parentheses are 95-percent confidence intervals.

156
of tobacco was too small to affect significantly the results for 1985. For women, rela-
tive risks for current and former cigarette smokers were employed (Table 7).

Comparison of Tables 9 and 11 reveals significant increases in attributable risk from
1965-85. In 1985, smoking accounted for 21 percent of CHD deaths in older men,
compared with 11 percent in 1965. The attributable risks for cancers of the lip, oral
cavity and pharynx, esophagus, and lung increased significantly.

Changes in the attributable risk estimates for women are even more striking. Among
younger women, smoking now accounts for an estimated 41 percent of CHD deaths
and an estimated 55 percent of lethal strokes, compared with 26 and 28 percent, respec-
tively, in 1965. Among women of all ages, 79 percent of lung cancers are attributable
to cigarette use (see Table 11).

Overall, smoking accounted for 86.7 percent of all lung cancer deaths (95-percent
confidence interval 84.9 to 88.4), 81.8 percent of all COPD deaths (95-percent con-
fidence interval 78.3 to 85.3), and 21.5 percent of all CHD deaths (95-percent con-
fidence interval 19.4 to 23.4). In addition, smoking accounted for 18.0 percent of all
stroke deaths (95-percent confidence interval 14.2 to 22.9).

Table 12 reports estimated smoking-attributable deaths for the 10 causes during
1985. Total deaths have increased to 231,000 for men and 106,000 for women. As op-
posed to 1965, CHD in men now accounts for only one-third of the smoking-attributable
mortality from the 10 causes combined. The proportion of these attributable deaths due
to lung cancer has increased to one-third. Likewise, among women, smoking-at-
tributable CHD fatalities now account for one-third of the 10-cause total; the relative
importance of smoking-induced cancer fatalities has also increased.

The total 10-cause smoking-attributable mortality for 1985 was 337,000 deaths, com-
pared with 183,000 in 1965. A portion of the observed 1965-85 increase, however,
was the result of population growth. In addition, there were increases in the proportion
of elderly persons who would be more at risk for smoking-induced death. For men and
women, respectively, Figures 10 and 11 show the results of a correction for population
increase and population aging. In each figure, three quantities are shown for each of
four categories of smoking-attributable mortality: CHD deaths under age 65; CHD
deaths age 65 years or more: COPD deaths; and lung cancer deaths. The first quan-
lity is the estimated smoking-attributable deaths for 1965. The second bar shows smok-
ing-attributable deaths for 1985. The third bar shows the estimated 1985 smoking-at-
tributable deaths if the U.S. populations at each age had remained at 1965 levels. The
latter quantities were computed as aD, where a is the attributable risk given in Table
li and D’ isa population-corrected estimate of 1985 U.S. deaths. The latter quantity
was computed by multiplying 1985 age-specific death rates by the populations at risk
in 1965.

Figures 10 and 11 show that population growth and aging cannot explain the chan-
ges in smoking-attributable mortality between 1965 and 1985. In particular, the marked
increases in smoking-attributable deaths from lung cancer and COPD in women are
systematic consequences of the American woman's adoption of lifelong cigarette
smoking, from teenage years onward.

For men, population-corrected deaths due to smoking in 1985 were 165,000, com-
pared with 150,000 in 1965. For women, population-corrected deaths due to smoking

157
TABLE 12.—Estimated deaths (in thousands) attributable to cigarette smoking,
10 selected causes, males and females, United States, 1985

 

 

Cause of death Males Females
CHD, age <65 34 11
(30-38)" (9-12)
CHD, age 265 44 26
(36-54) (20-34)
COPD , 37 20
(35-39) (18-21)
Cancer of lip, oral cavity, and pharynx S.1 1.6
(4.4.5.4) (1.2-2.0)
Cancer of larynx 2.3 0.6
(1.6-2.7) (0.4-0.7)
Cancer of esophagus 5.0 1.6
(4.0-5.7) (1.3-1.9)
Cancer of lung 76 30
(74-77) (29-32)
Cancer of pancreas 3.3 3.4
(2.1-5.0) (2.8-5.1)
Cancer of bladder : 3410 Ld
(2.1-4.2) (0.6-1.9)
Cancer of kidney 2.6 0.4
(1.8-3.5) (0.1-1.5)
Cerebrovascular disease, age <65 5.5 5.2
(3.9-7.0) (4.3-6.2)
Cerebrovascular disease, age 265 12 48
. (8-17) (1.9-11.4)
Ten causes 231 106
(220-242) (98-115)

 

NOTE: Computed from Table 11 and unpublished tabulations of deaths at ages 20 years or more by cause from
NCHS, 1985. Sum of individual causes may not equal totals because of rounding.
“Numbers in parentheses are 95-percent confidence intervals.

in 1985 were 67,000, compared with 30,000 in 1965. Even if the population had
remained entirely stable during 1965 through 1985, the lethality of cigarette use in
American women would have doubled.

Among men, the total of 231,000 smoking-induced deaths in 1985 represented 41
percent of total deaths from the 10 causes combined and 22 percent of all deaths among
persons aged 20 years or more. Among women, the total of 106,000 smoking-induced
deaths represented 25 percent of deaths from the 10 causes combined and 11 percent
of deaths from all deaths among persons aged 20 years or more.

The computations in Tables 10 and 12 have omitted other causes of death that are
likely to be attributable to cigarette use. If the relative risks given in Tables 6 and 7 for

158
8s 8 6 8 8 38 8

SMOKING ATTRIBUTABLE DEATHS (1000s)

  

0 CHO 85+ COLD Ca Lung

FIGURE 10.—Estimated cigarette-smoking-attributable deaths from CHD,
COPD, and lung cancer, males aged 20 years or more, United
States, 1965 and 1985

NOTE: For the bars marked 1985", the estimated smoking-attributable deaths in 1985 have been corrected for population
increases during 1965-85.

  
  

FEMALES

SRRBBSRE

4 T3

SMOKING ATTRIBUTABLE DEATHS ¢ 1000s)
@

    
   

CHO <85 CHD 65+ COLD Ca Lung
FIGURE 11.—Estimated cigarette-smoking-attributable deaths from CHD,
COPD, and lung cancer, females aged 20 years or more, United

States, 1965 and 1985
NOTE: For the bars marked 1985”, the estimated smoking-attributable deaths in 1985 have been corrected for population
increases during 1965-85.

159
the broader categories of cardiovascular and nonneoplastic respiratory disease are ap-
plied to deaths from hypertensive heart disease, arteriosclerosis, aortic aneurysm, and
influenza and pneumonia, then smoking-attributable deaths would increase to 256,000
among men and 126,000 among women. Inclusion of deaths among newborns and in-
fants due to smoking during pregnancy would add an additional 2,500 to the total (CDC
1987b; McIntosh 1984; Kleinman et al. 1988); this does not include fetal loss due to
smoking (Stein et al. 1981). Inclusion of lung cancer deaths among nonsmokers due
to environmental tobacco smoke (NRC 1986) would add 3,800 and inclusion of deaths
from cigarette-caused fires (Hall 1987) would add 1,700 to total attributable deaths. In-
clusion of deaths due to cervical cancer caused by smoking would add 1,500. Includ-
ing these additional causes of death, the smoking-attributable mortality in 1985 is then
estimated to be approximately 390,000. Recent studies have also noted increased risks
among smokers for hepatic cancer (Trichopoulos et al. 1987), penile cancer (Hellberg
et al. 1987), leukemia (Kinlen and Rogot 1988), and anal cancer (Daling et al. 1987),
Among all persons at risk during 1985, an estimated 52 million were also cigarette
smokers in 1965. The remaining 42 million were new cigarette smokers. In 1985, only
about 4,400 deaths occurred among the latter group, which consists of persons in their
teens, twenties, and thirties. Thus, 99 percent of deaths attributable to cigarette use in
1985 occurred among people who started smoking in 1965 or earlier. The vast majority
of these people started smoking before the release of the 1964 Surgeon General’s Report

TABLE 13.—Estimated risks of various activities

 

Annual fatalities

 

per | million
Activity or cause exposed persons
Active smoking 7,000"
Alcohol 541
Accident 275
Disease 266
Motor vehicles 187
Alcohol-involved 95
Non-alcohol-involved 92
Work 113
Swimming 22
Passive smoking? 19
All other air pollutants? 6
Football 6
Electrocution 2
Lightning 0.5
DES in cattlefeed 0.3
Bee sting 0:2
Basketball 0.02

 

NOTE: Activities are not mutually exclusive: there are overlaps between categories. Differences in fatalities do not
imply proportionate differences in years of life lost.

“Number of deaths per million smokers who began smoking before 1965.

°Cancer deaths only.

SOURCE: Active smoking, CPS-II; NHISs 1965, 1985: U.S. Bureau of the Census (1974, 1986). Other activities or
causes, U.S. President (1987).

160
and before the 1965 Federal Cigarette Labeling and Advertising Act. For this group,
the annual smoking-attributable fatality rate is about 7 deaths per 1,000 at risk, or about
7,000 deaths per 1 million persons. As shown in the Economic Report of the President
(U.S. President 1987), this rate far exceeds the rates for other risks of death (Table 13).

10.

Conclusions

Lung cancer death rates increased two- to fourfold among older male smokers
over the two decades between the American Cancer Society’s two Cancer Preven-
tion Studies (CPS-I, 1959-65, and CPS-II, 1982-86). Lung cancer death rates for
younger male smokers fell about 30 to 40 percent during this period.

Lung cancer death rates increased four- to sevenfold among female smokers aged
45 years or older in CPS-II compared with CPS-I, while lung cancer death rates
among younger women declined 35 to 55 percent.

The two-decade interval witnessed a two- to threefold increase in death rates from
chronic obstructive pulmonary disease (COPD) in female smokers aged 55 years
or older.

There was no change in the age-adjusted death rates for lung cancer and COPD
between CPS-I and CPS-II among men and women who never smoked regularly.
Overall death rates from coronary heart disease (CHD) declined substantially be-
tween CPS-I and CPS-II. The decline in CHD mortality among nonsmokers,
however, was notably greater than among current cigarette smokers.

In CPS-II, the relative risks of death from cerebrovascular lesions were 3.7 and
4.8 for men and women smokers under age 65. Increased risks of stroke were also
observed among older smokers and former smokers. Along with the recently
reported results of other studies, these findings strongly support a causal role for
cigarette smoking in thromboembolic and hemorrhagic stroke.

In 1985, smoking accounted for 87 percent of lung cancer deaths, 82 percent of
COPD deaths, 21 percent of CHD deaths, and 18 percent of stroke deaths. Among
men and women less than 65 years of age, smoking accounted for more than 40
percent of CHD deaths.

The large increase in smoking-attributable mortality among American women be-
tween 1965 and 1985 was a direct consequence of their adoption of lifelong
cigarette smoking, especially from their teenage years onward.

In 1985, 99 percent of smoking-attributable deaths occurred among people who
started smoking before the 1964 Surgeon General’s Report. For this group, the
annual smoking-attributable fatality rate is about 7,000 deaths per | million per-
sons at risk.

For 10 causes of death, a total of 337,000 deaths were attributable to smoking in
1985. These represented 22 percent of al] deaths among men and 11 percent
among women. If other cardiovascular, neoplastic, and respiratory causes of
death were included—as well as deaths among newborns and infants resulting
from maternal smoking, deaths from cigarette-caused residential fires, and lung
cancer deaths among nonsmokers due to environmental tobacco smoke—the total
smoking-attributable mortality was about 390,000 in 1985.

161
References

ABBOTT, R.D., YIN, Y., REED, D.M., YANO, K. Risk of stroke in male cigarette smokers,
New England Journal of Medicine 315(12):717-720, September 18, 1986.

ALDERSON, M.R., LEE, P.N., WANG, R. Risks of lung cancer, chronic bronchitis, ischaemic
heart disease, and stroke in relation to type of cigarette smoked. Journal of Epidemiology and
Community Health 39(4):286-293, December 1985.

AMERICAN CANCER SOCIETY. Unpublished tabulations.

ANDERSON, S., AUQUIER, A., HAUCK, W.W., OAKES, D., VANDAELE, W., WEIS-
BERG, HI. Statistical Methods for Comparative Studies. New York: John Wiley and Sons,
1980.

BLACK, B., LILIENFELD, D.E. Epidemiological proof in toxic tort litigation. Fordham Law
Review 52:732-785, 1984. ;

BOND, V.P. The cancer risk attributable to radiation exposure: Some practical problems.
Health Physics 40:108-111, January 1981.

BOTKIN, J.R. The fire-safe cigarette. Journal of the American Medical Association 260(2):
226-229, July 8, 1988.

BRACKBILL, R., FRAZIER, T., SHILLING, S. Smoking characteristics of us workers, 1978—
1980, American Journal of Industrial Medicine 13:5-41, 1988.

BROWN, C.C., KESSLER, L.G. Projections of lung cancer mortality in the United States:
1985-2025. Journal of the National Cancer Institute 80(1):43—51, March 2, 1988.

CASTELLI, W.P., DAWBER, T.R., FEINLEIB, M., GARRISON, R.J., MCNAMARA, P.M.,
KANNEL, W.B. The filter cigarette and coronary heart disease: The Framingham Study.
Lancet 2(8238):109-113, July 18, 1981.

CENTERS FOR DISEASE CONTROL. Cigarette smoking in the United States, 1986. Mor-
bidity and Mortality Weekly Report 36(35):581-585, September 11, 1987a.

CENTERS FOR DISEASE CONTROL. Smoking-attributable mortality and years of potential
_life lost—United States, 1984. Morbidity and Mortality Weekly Report 36(42):693-697, Oc-
tober 30, 1987b.

COLDITZ, G.A., BONITA, R., STAMPFER, M.J., WILLETT, W.C., ROSNER, B., SPEIZER,
F.E., HENNEKENS, C.H. Cigarette smoking and risk of stroke in middle-aged women. New
England Journal of Medicine 318(15):937-941, April 14, 1988.

CONSUMER PRODUCT SAFETY COMMISSION. Toward a Less Fire-Prone Ci igarette:
Final Report of the Technical Study Group on Cigarette and Little Cigar Fire Safety. Con-
sumer Product Safety Commission, October 1987.

CORNFIELD, J. A method of estimating comparative rates from clinical data. Applications to
cancer of the lung, breast, and cervix. Journal of the National Cancer Institute 11:1269-1275,
1951.

COX, L.A. JR. Statistical issues in the estimation of assigned shares for carcinogenesis liability.
Risk Analysis 7(1):71-80, 1987.

CURRENT POPULATION SURVEY. Unpublished tabulations, 1985.

DALING, J.R., WEISS, N.S., HISLOP, T.G., MADEN, C., COATES, R.J., SHERMAN, K.I.,
ASHLEY, R.L., BEAGRIE, M., RYAN, J.A., COREY, L. Sexual practices, sexually trans-
mitted diseases, and the incidence of anal cancer. New England Journal of Medicine 317(16):
973-977, October 15, 1987.

DEANFIELD, J., WRIGHT, C., KRIKLER, S., RIBEIRO, P., FOX, K. Cigarette smoking and
the treatment of angina with propranolol, atenolol, and nifedipine. New England Journal of
Medicine 310(15):951-954, April 12, 1984.

162
DOLL, R., GRAY, R., HAFNER, B., PETO, R. Mortality in relation to smoking: 22 years’ ob-
servations on female British doctors. British Medical Journal 280(6219):967-971, April 5,
1980.

DOLL, R., HILL, A.B. Lung cancer and other causes of death in relation to smoking. A second
report on the mortality of British doctors. British Medical Journal 2:1071-1081, November
10, 1956.

DOLL, R., HILL, A.B. Mortality in relation to smoking: Ten years’ observations of British
doctors. British Medical Journal 1:1399-1410, May 30, 1964; 1460-1467, June 6, 1964.
DOLL, R., HILL, A.B. Mortality of British doctors in relation to smoking: Observations on
coronary thrombosis. In: Haenszel, W. (ed.) Epidemiological Approaches to the Study of
Cancer and Other Chronic Diseases, NCI Monograph 19. U.S. Department of Health, Educa-
tion, and Welfare, Public Health Service, National Cancer Institute, January 1966, pp. 205—

268.

DOLL, R., PETO, R. Mortality in relation to smoking: 20 years’ observations on male British
doctors. British Medical Journal 2:1525-1536, December 25, 1976.

DOLL, R., PETO, R. Cigarette smoking and bronchial carcinoma: Dose and time relationships
among regular and lifelong non-smokers. Journal of Epidemiology and Community Health
32(4):302-—313, December 1978.

DOLL, R., PETO, R. The causes of cancer: Quantitative estimates of avoidable risks of can-
cer in the United States today. Journal of the National Cancer Institute 66(6):1191—1308,
June 1981.

DORN, H.F. Tobacco consumption and mortality from cancer and other diseases. Public Health
Reports 74(7):581-593, July 1959.

GALAN, K.M., DELIGONUL, U., KERN, M.J., CHAITMAN, B.R., VANDORMAEL, M.G.
Increased frequency of restenosis in patients continuing to smoke cigarettes after percutaneous
transluminal coronary angioplasty. American Journal of Cardiology 61:260-263, 1988.

GARFINKEL, L. Cancer mortality in nonsmokers: Prospective study by the American Cancer
Society. Journal of the National Cancer Institute 65(5):1169-1173, November 1980a.

GARFINKEL, L. Cardiovascular mortality and cigarette smoking. In: Ramstrom, L.M. (ed.)
The Smoking Epidemic. A Matter of Worldwide Concern. Proceedings of The Fourth Worid
Conference on Smoking and Health. Stockholm: Almqvist and Wiksell International, 1980b,
pp. 41-44.

GARFINKEL, L. Time trends in lung cancer mortality among nonsmokers and a note on pas-
sive smoking. Journal of the National Cancer Institute 66(6):1061—1066, June 1981.

GARFINKEL, L. Selection, follow-up and analysis in the American Cancer Society prospec-
tive studies. In: Garfinkel, L., Ochs, O., Mushinski, M. (eds.) Selection, Follow-up, and
Analysis in Prospective Studies: A Workshop, NCI Monograph 67. National Cancer Institute.
NIH Publication No. 85-2713, 1985, pp. 49-52.

GARFINKEL, L., STELLMAN, S.D. Smoking and lung cancer in women. Cancer Research
48(23):6951-6955, December 1, 1988.

GOLDBAUM, G.M., KENDRICK, J.S., HOGELIN, G.C., GENTRY, E.M., BEHAVIORAL
RISK FACTORS SURVEYS GROUP. The relative impact of smoking and oral contracep-
tive use on women in the United States. Journal of the American Medical Association
258(10): 1339-1342, September 11, 1987.

HAENSZEL, W., SHIMKIN, M.B., MILLER, H.P., MILMORE, B.K., CONOVER, A.G.
Tobacco Smoking Patterns in the United States, Public Health Monograph 45. U.S. Public
Health Service, 1956.

HALL, LR. JR. Expected Changes in Fire Damages From Reducing Cigarette Ignition Propen-
sity. Quincy, Massachusetts: National Fire Protection Association, Fire Analysis Division,
1987.

163
HAMMOND, E.C. Smoking in relation to physical complaints. Archives of Environmental
Health 3:146-164, August 1961.

HAMMOND, E.C. Some preliminary findings on physical complaints froma prospective study
of 1,064,004 men and women. American Journal of Public Health 54(1):11-23, January
1964a.

HAMMOND, E.C. Smoking in relation to mortality and morbidity. Findings in the first thirty-
four months of follow-up in a prospective study started in 1959. Journal of the National Can-
cer Institute 32(5):1161-1188, May 1964b.

HAMMOND, E.c. Smoking in relation to the death rates of one million men and women. In:
Haenszel, W. (ed.) Epidemiological Approaches to the Study of Cancer and Other Chronic
Diseases, NCI Monograph 19. U.S. Department of Health, Education, and Welfare, Public
Health Service, National Cancer Institute, January 1966, pp. 127-204.

HAMMOND, E.C. Quantitative relationship between cigarette smoking and death rates. In:
Wynder, E.L. (ed.) Toward a Less Harmful Cigarette, NCI Monograph 28. U.S. Public
Health Service, National Cancer Institute, June 1968, pp. 3-8.

HAMMOND, E.C. Life expectancy of American men in relation to their smoking habits. Jour-
nal of the National Cancer Institute 43(4):951-962, October 1969.

HAMMOND, E.C. Smoking habits and air pollution in relation to lung cancer. In: Lee, D.H.K.
(ed.) Environmental Factors in Respiratory Disease. New York: Academic Press, 1972.
HAMMOND, E.C., GARFINKEL, L. Smoking habits of men and women. Journal of the Na-

tional Cancer Institute 27(2):419-442, August 1961.

HAMMOND, E.C., GARFINKEL, L. Changes in cigarette smoking. Journal of the National
Cancer Institute 33(1):49-64, July 1964. ;

HAMMOND, E.C.,GARFINKEL, L. The influence of health on smoking habits. In: Haenszel,
W. (ed.) Epidemiological Approaches to the S tudy of Cancer and Other Chronic Diseases,
NCI Monograph 19. U.S. Department of Health, Education, and Welfare, Public Health Ser-
vice, National Cancer Institute, January 1966, pp. 269-285.

HAMMOND, E.C., GARFINKEL, L. Changes in cigarette smoking 1959-1965. American
Journal of Public Health 58(1):30-45, January 1968.

HAMMOND, E.C., GARFINKEL, L. Coronary heart disease, stroke, and aortic aneurysm.
Factors in etiology. Archives of Environmental Health 19:167-182, August 1969.

HAMMOND, E.C., GARFINKEL, L. Aspirin and coronary heart disease: Findings of a
Prospective study. British Medical Journal 2:269-271, May 3, 1975.

HAMMOND, E.C., GARFINKEL, L., SEIDMAN, H., LEW, E.A. “Tar” and nicotine content
of cigarette smoke in relation to death rates. Environmental Research 12(3):263—-274, Decem-
ber 1976.

HAMMOND, E.C., HORN, D. The relationship between human smoking habits and death rates.
A follow-up study of 187,766 men. Journal of the American Medical Association 155:1316~
1328, August 7, 1954.

HAMMOND, E.C., SEIDMAN, H. Smoking and cancer in the United States. Preventive
Medicine 9(2):169-173, March 1980.

HARRIS, J.E. Cigarette smoking among successive birth cohorts of men and women in the
United States during 1900-80. Journal of the National Cancer Institute 71(3):473-479, Sep-
tember 1983.

HAVLIK,R.J., FEINLEIB, M. (eds.} Proceedings of the Conference onthe Decline inC. oronary
Heart Disease Mortality. U.S. Department of Health, Education, and Welfare, National In-
stitutes of Health. DHEW Publication No. (NIH) 79-1610, 1979.

HAWTHORNE, V.M., FRY, J.S. Smoking and health: The association between smoking be-
haviour, total mortality, and cardiorespiratory disease in west central Scotland. Journal of
Epidemiology and Community Health 32:260-266, 1978.

164
HELLBERG, D., VALENTIN, J., EKLUND, T., STAFFAN, N. Penile cancer: Is there an
epidemiological role for smoking and sexual behaviour? British M edical Journal 295(6609):
1306-1308, November 21, 1987.

INTERNATIONAL CLASSIFICATION OF DISEASES. /nternational Classification of Dis-
eases, Seventh Revision (ICD-7).

INTERNATIONAL CLASSIFICATION OF DISEASES. International Classification of Dis-
eases, Ninth Revision (ICD-9). U.S. Department of Health and Human Services, Public
Health Service, Health Care Financing Administration. DHHS Publication No. (PHS) 80-
1260, September 1980.

KAHN, H.A. The Dom study of smoking and mortality among U.S. veterans: Report on eight
and one-half years of observation. In: Haenszel, W. (ed.) Epidemiological Approaches to
the Study of Cancer and Other Chronic Diseases, NCI Monograph 19. U.S. Department of
Health, Education, and Welfare, Public Health Service, National Cancer Institute, January
1966, pp. 1-125.

KAUFMAN, D.W., HELMRICH, S.P., ROSENBERG, L., MIETTINEN, O.S., SHAPIRO, S.
Nicotine and carbon monoxide content of cigarette smoke and the risk of myocardial infarc-
tion in young men. New England Journal of Medicine 308(8):409-413, February 24, 1983.

KINLEN, L.J., ROGOT, E. Leukaemia and smoking habits among United States veterans.
British Medical Journal 297(6649):657-659, September 10, 1988.

KLEBBA, A.J. Comparability of mortality statistics for the seventh and eighth revisions of the
International Classification of Diseases, United States. Vital and Health Statistics, Series 2,
No. 66. U.S. Department of Health, Education, and Welfare. DHEW Publication No. (HRA)
76-1340, October 1975.

KLEBBA, A.J. Mortality from diseases associated with smoking: United States, 1960-77.
Vital and Health Statistics, Series 20, No. 17. U.S. Department of Health and Human Ser-
vices. DHHS Publication No. (PHS) 82-1854, January 1982.

KLEBBA, A.J., SCOTT, J.H. Estimates of selected comparability ratios based on dual coding
of 1976 death certificates by the eighth and ninth revisions of the International Classification
of Diseases. Monthly Vital Statistics Report From the National Center for Health Statistics
28(11):1-19, February 29, 1980.

KLEBBA, J. Personal communication to J. Harris, June 1988.

KLEINMAN, J.C., PIERRE, M.B. JR., MADANS, J.H., LAND, G.H., SCHRAMM, W.F. The
effects of maternal smoking on fetal and infant mortality. American Journal of Epidemiol-
ogy 127(2):274-282, 1988.

LAVECCHIA, C., FRANCESCHI, S., DECARLI, A., FASOLI, M., GENTILE, A., TOGNONI,
G. Cigarette smoking and the risk of cervical neoplasia. American Journal of Epidemiology
123(1):22-29, January 1986.

LEE, P.N., GARFINKEL, L. Mortality and type of cigarette smoked. Journal of Epidemiology
and Community Health 35(1):16-22, March 1981.

LESKO, S.M., ROSENBERG, L., KAUFMAN, D.W., HELMRICH, S.P., MILLER, D.R.,
STROM, B., SCHOTTENFELD, D., ROSENSHEIN, N.B., KNAPP, R.C., LEWIS, J.,
SHAPIRO, S. Cigarette smoking and the risk of endometrial cancer. New England Journal
of Medicine 313(10):593-596, 1985.

LEVIN, M.L. The occurrence of lung cancer in man. Acta-Unio Internationalis Contra
Cancrum 9:531-541, 1953.

LEW, E.A.,GARFINKEL, L. Mortality at ages 65 and over in a middle-class population. Trans-
actions of the Society of Actuaries 36:257-308, 1984.

LEW, E.A., GARFINKEL, L. Differences in mortality and longevity by sex, smoking habits
and health status. Transactions of the Society of Actuaries 39:19-36, 1988.

165
LILIENFELD, D.E., GUNDERSON, P.D. The “missing cases” of pleural malignant meso-
thelioma in Minnesota, 1979-81: Preliminary report. Public Health Reports 101(4): 395~
399, July-August 1986.

LILIENFELD, A.M., LILIENFELD, D.E. Foundations of Epidemiology, Second Edition. New
York: Oxford University Press, 1980.

LUBIN, J.H., BLOT, W.J., BERRINO, F., FLAMANT, R., GILLIS, C.R., KUNZE, M.,
SCHMAHL, D., VISCO, D. Modifying risk of developing lung cancer by changing habits
of cigarette smoking. British Medical Journal 288(6435):1953-1956, June 30, 1984.

LUBIN, J.H., BOICE, J.D. JR. Estimating radon-induced lung cancer inthe U.S. Working paper,
1988.

MACMAHON, B., PUGH, T.F. Epidemiology. Principles and Methods. Boston: Little, Brown |
and Company, 1970.

MASSEY, M.M., BOYD, G., MATTSON, M., FEINLEIB, M.R. Inventory of surveys on smok-
ing. Public Health Reports 102(4):430-438, July-August 1987.

MCFARLANE, M.J., FEINSTEIN, A.R., WELLS, C.K. Necropsy evidence of detection bias
in the diagnosis of lung cancer. Archives of Internal Medicine 146(9):1695-1698, Septem-
ber 1986.

MCINTOSH, I.D. Smoking and pregnancy: Attributable risks and public health implications.
Canadian Journal of Public Health 75(2):141-148, March-April 1984.

MIETTINEN, O.S. Proportion of disease caused or prevented by a given exposure, trait or inter-
vention, American Journal of Epidemiology 99(5):325-332, 1974.

NATIONAL CENTER FOR HEALTH STATISTICS. Vital Statistics of the United States 1965.
Volume 2—Mortality, Part A. U.S. Department of Health, Education, and Welfare, Public
Health Service, National Center for Health Statistics, 1967.

NATIONAL CENTER FOR HEALTH STATISTICS. Unpublished tabulations, 1985.

NATIONAL CENTER FOR HEALTH STATISTICS. Health, United States, 1986. U.S.
Department of Health and Human Services, Public Health Service, National Center for Health
Statistics. DHHS Publication No. (PHS) 87-1232, December 1986.

NATIONAL HEALTH INTERVIEW SURVEY. Unpublished tabulations, 1965.

NATIONAL HEALTH INTERVIEW SURVEY. Unpublished tabulations, 1985.

NATIONAL RESEARCH COUNCIL. Assigned Share for Radiation as a Cause of Cancer.
Review of Radioepidemiologic Tables Assigning Probabilities of Causation. Washington,
D.C.: National Academy Press, 1984. :

NATIONAL RESEARCH COUNCIL. Environmental Tobacco Smoke. Measuring Exposures
and Assessing Health Effects. Washington, D.C.: National Academy Press, 1986.

NATIONAL RESEARCH COUNCIL. Health Risks of Radon and Other Internally Deposited
Alpha-Emitters. BEIR IV. Washington, D.C.: National Academy Press, 1988.

NISCHAN, P., EBELING, K., SCHINDLER, C. Smoking and invasive cervical cancer risk.
Results from a case~control study. American Journal of Epidemiology 128(1):74-77, July
1988.

NOVOTNY, T.E., WARNER, K.E., KENDRICK, J.S., REMINGTON, PL. Smoking by blacks
and whites: Socioeconomic and demographic differences. American Journal of Public
Health 78(9):1187-1189, September 1988.

OFTEDAL, P., MAGNUS, K., HVINDEN, T. On the probability of radiation being the cause
of leukaemia. (Letter.) British Journal of Radiology 41:711-712, 1968.

PEARL, R. Tobacco smoking and longevity. Science 87(2253):216-217, March 4, 1938.

PETO, R. Influence of dose and duration of smoking on lung cancer rates. In: Zaridze, D.G.,

Peto, R. (eds.) Tobacco: A Major International Health Hazard. Lyon, France: Internation-
al Agency for Research on Cancer, 1986, pp. 23-33.

166
RAVENHOLT, R.T. Cigarette smoking: Magnitude of the hazard. (Letter.) American Jour-
nal of Public Health 54(11):1923-1926, November 1964.

RAVENHOLT, R.T. Addiction mortality in the United States, 1980: Tobacco, alcohol, and
other substances. Population and Development Review 10(4):697-724, December 1984.

RICE, D.P., HODGSON, T.A., SINSHEIMER, P., BROWNER, W., KOPSTEIN, A.N. The
economic costs of the health effects of smoking, 1984. Milbank Quarterly 64(4):489-547,
1986.

ROGOT, E. Smoking and mortality among U.S. veterans. Journal of Chronic Diseases 27:189—
203, 1974.

ROGOT, E., MURRAY, J.L. Smoking and causes of death among U.S. veterans: 16 years of
observation. Public Health Reports 95(3):213-222, May-June 1980.

ROSENBERG, L., KAUFMAN, D.W., HELMRICH, S.P., SHAPIRO, S. The risk of myocar-
dial infarction after quitting smoking in men under 55 years of age. New England Journal of
Medicine 313(24):1511-1514, December 12, 1985.

ROSENBERG, L., SCHWINGL, P.J., KAUFMAN, D.W., MILLER, D.R., HELMRICH, S.P.,
STOLLEY, P.D., SCHOTTENFELD, D., SHAPIRO, S. Breast cancer and cigarette smok-
ing. New England Journal of Medicine 310:92-94, January 12, 1984.

SARACCI, R. The interactions of tobacco smoking and other agents in cancer etiology.
Epidemiologic Reviews 9:175-193, 1987.

SCHOENBORN, C.A., BENSON, V. Relationships between smoking and other unhealthy
habits: United States, 1985. Advance Data From Vital and Health Statistics of the National
Center for Health Statistics 154:1-8, May 27, 1988.

SHULTZ, J.M. SAMMEC. Smoking-Attributable Mortality, Morbidity, and Economic Costs.
Computer Software and Documentation. Minnesota Department of Health, Center for Non-
smoking and Health, 1986. .

SLONE, D., SHAPIRO, S., ROSENBERG, L., KAUFMAN, D., HARTZ, S.C., ROSSI, A-C.,
STOLLEY, P.D., MIETTINEN, O.S. Relation of cigarette smoking to myocardial infarction
in young women. New England Journal of Medicine 298(23):1273—1276, June 8, 1978.

STEIN, Z., KLINE, J., LEVIN, B., SUSSER, M., WARBURTON, D. Epidemiologic studies
of environmental exposures in human reproduction. In: Berg, G.G., Maillie, H.D. (eds.)
Measurement of Risks. New York: Plenum Press, 1981, pp. 163-183.

STELLMAN, S.D. Cigarette yield and cancer risk: Evidence from case-control and prospec-
tive studies. In: Zaridze, D.G., Peto, R. (eds.) Tobacco: A Major International Health
Hazard. Lyon, France: International Agency for Research on Cancer, 1986a, pp. 197-209.

STELLMAN, S.D. Influence of cigarette yield on risk of coronary heart disease and chronic
obstructive pulmonary disease. In: Zaridze, D.G., Peto, R. (eds.) Tobacco: A Major Inter-
national Health Hazard. Lyon, France: International Agency for Research on Cancer, 1986b,
pp. 237-~249.

STELLMAN, S.D., BOFFETTA, P., GARFINKEL, L. Smoking habits of 800,000 American
men and women in relation to their occupations. American Journal of Industrial Medicine
13:43-58, 1988.

STELLMAN, S.D., GARFINKEL, L. Smoking habits and tar levels in a new American Can-
cer Society prospective study of 1.2 million men and women. Journal of the National Can-
cer Institute 76(6): 1057-1063, June 1986.

STERLING, T.D., WEINKAM, J.J. Errors in estimates of smoking-related deaths derived from
nonsmoker mortality. Risk Analysis 7(4):463-475, 1987.

TRICHOPOULOS, D., DAY, N.E., KAKLAMANI, E., TZONOU, A., MUNOZ, N., ZAVIT-
SANOS, X., KOUMANTAKI, Y., TRICHOPOULOU, A. Hepatitis B virus, tobacco smok-
ing and ethanol consumption in the etiology of hepatocellular carcinoma. International Jour-
nal of Cancer 39(1):45—49, January 1987.

167
U.S. BUREAU OF THE CENSUS. Estimates of the Population of the United States, by Age,
Sex, and Race: April 1, 1960 to July 1, 1973. Current Population Reports, Series P-25, No.
519. U.S. Bureau of the Census, April 1974.

U.S. BUREAU OF THE CENSUS. Estimates of the Population of the United States, by Age,
Sex, and Race: 1980 to 1985. Current Population Reports, Series P-25, No. 985. U.S. Bureau
of the Census, April 1986.

U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES. The Health C. onsequences of
Smoking for Women. A Report of the Surgeon General. U.S. Department of Health and
Human Services, Public Health Service, Office of the Assistant Secretary for Health, Office
on Smoking and Health, 1980.

U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES. The Health C. onsequences of
Smoking. The Changing Cigarette: A Report of the Surgeon General. U.S. Department of
Health and Human Services, Public Health Service, Office of the Assistant Secretary for
Health, Office on Smoking and Health. DHHS Publication No. (PHS) 81-50156, 1981.

U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES. The Health Consequences of
Smoking: Cancer. A Report of the Surgeon General. U.S. Department of Health and Human
Services, Public Health Service, Office on Smoking and Health. DHHS Publication No.
(PHS) 82-50179, 1982.

U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES. The HealthC onsequences of
Smoking: Cardiovascular Disease. A Report of the Surgeon General. U.S. Department of
Health and Human Services, Public Health Service, Office on Smoking and Health. DHHS
Publication No. (PHS) 84-50204, 1983.

U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES. The HealthC onsequences of
Smoking: Chronic Obstructive Lung Disease. A Report of the Surgeon General. U.S. Depart-
ment of Health and Human Services, Public Health Service, Office on Smoking and Health.
DHHS Publication No. (PHS) 84-50205, 1984.

U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES. The Health C. onsequences of
Smoking: Cancer and Chronic Lung Disease in the Workplace. A Report of the Surgeon
General. U.S. Department of Health and Human Services, Public Health Service, Office on
Smoking and Health. DHHS Publication No. (PHS) 85-50207, 1985.

U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES. The HealthC. onsequences of
Involuntary Smoking. A Report of the Surgeon General. U.S. Department of Health and
Human Services, Public Health Service, Centers for Disease Control. DHHS Publication No.
(CDC) 87-8398, 1986.

U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES. The Health Consequences of
Smoking: Nicotine Addiction. A Report of the Surgeon General, 1988. U.S. Department of
Health and Human Services, Public Health Service, Centers for Disease Control, Center for
Health Promotion and Education, Office on Smoking and Health. DHHS Publication No.
(CDC) 88-8406, 1988a.

U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES. Health, United States, 1987.
U.S. Department of Health and Human Services, Public Health Service, Centers for Disease
Control, National Center for Health Statistics. DHHS Publication No. (PHS) 88-1232, March
1988b.

U.S. DEPARTMENT OF HEALTH, EDUCATION, AND WELFARE. Smoking and Health.
A Report of the Surgeon General. U.S. Department of Health, Education, and Welfare, Public
Health Service, Office of the Assistant Secretary for Health, Office on Smoking and Health.
DHEW Publication No. (PHS) 79-50066, 1979.

U.S. OFFICE OF TECHNOLOGY ASSESSMENT. Smoking-Related Deaths and Financial

Costs. Health Program, Office of Technology Assessment, U.S. Congress, September 1985.

168
U.S. PRESIDENT. Economic Report of the President. Transmitted to the Congress January
1987. Washington, D.C., 1987.

U.S. PUBLIC HEALTH SERVICE. Smoking and Health. Report of the Advisory Committee
to the Surgeon General of the Public Health Service. U.S. Department of Health, Education,
and Welfare, Public Health Service, Center for Disease Control. PHS Publication No. 1103,
1964.

WALTER, S.D. The estimation and interpretation of attributable risk in health research.
Biometrics 32:829-849, December 1976.

WHYTE, H.M. The relative importance of the major risk factors in atherosclerotic and other
diseases. Australian and New Zealand Journal of Medicine 6(5):387-393, October 1976.
WILCOX, H.B., SCHOENBERG, J.B., MASON, T.J., BILL, J.S.. STEMHAGEN, A. Smok-
ing and lung cancer: Risk as function of cigarette tar content. Preventive Medicine 17(3):263-

272, March 1988.

WILLETT, W.C., GREEN, A., STAMPFER, M.J., SPEIZER, F.E., COLDITZ, G.A., ROSNER,
B., MONSON, R.R., STASON, W., HENNEKENS, C.H. Relative and absolute excess risks
of coronary heart disease among women who smoke cigarettes. New England Journal of
Medicine 317(21):1303-1309, November 19, 1987.

WILLIAMSON, D.F., FORMAN, M.R., BRADSTOCK, M.K., GENTRY, E., BINKIN, N.J.
Behavioral Risk Factor Survey results for cigarette smoking and other health-risk behaviors
among U.S. women, 1981-1983. (Abstract.) In: Epidemic Intelligence Service 35th Annual
Conference. U.S. Department of Health and Human Services, Public Health Service, 1986.

WYNDER, E.L., STELLMAN, S.D. Impact of long-term filter cigarette usage on lung and
larynx cancer risk: A case-control study. Journal of the National Cancer Institute 62(3):471-
477, March 1979.

169
CHAPTER 4

TRENDS IN PUBLIC BELIEFS,
ATTITUDES, AND OPINIONS
ABOUT SMOKING

171
CONTENTS

 

 

Introduction .. 0... cece ee teen eee beet enna een nes 175
Data SOUrceS 0... 0 cece ee eee teen eee entrees 175
Issues in Comparing Surveys... 6.0.62 cece eee teen eens 177

Trends in Public Beliefs About the Health Effects of Smoking ..........----- 179
OVErVIEW 2. cece ee eee teen ence teense nent etn 179
Is Cigarette Smoking Harmful to Smokers in General? ............ ae 179

Heavy Versus Light Smoking .......:-..++-- ene ene e eens 181
Tar Yield 0.0.20... cee cece cece eee err rere Le. 183
Duration of Smoking ......... 0. 0c eee c ee teeters 185
Does Cigarette Smoking Cause: .... 0.0... 000s eee eee Deke eee 185
Lung Cancer? 6.6... cee cece eet nen enn ns 185
Heart Disease? ....... 0.0 cece eee ee eee eens 188

Chronic Obstructive Pulmonary Disease? ......-. Lecce cease 188 .
Other Cancers? 20... cc ccc ee ee eee e ene 195
What Are the Special Health Risks for Women? .......---++-+++5+5 195
Effects of Smoking on Pregnancy Outcome .........- toes 197

Risk of Cardiovascular Disease Among Smokers

Who Use Oral Contraceptives ©. ..-- 6 eee e eee cere nee 197
Other Health Risks Related to Tobacco Use ........--+ see eee veees 200
Involuntary (Passive) Smoking «2... 06... 0+ eee e ete e eens 200
Is Smoking an Addiction? ...:.. cece tence nee eee eeeeee 200
Interaction Between Smoking and Other Exposures ......-....-- 202
Smokeless Tobacco .........-+-+-0055 Lecce eet ee teens 202
Personal Health Risks for Smokers .........0 0200 e ee tee tee eee tees 202
How Harmful Is Smoking? 2.0.0... 6 60 eee eee eet eter e eens 204
Absolute Risk 2.0.0.0... 0c cece eee cee ee teen tenn nenes 206
Relative Risk ... 0.00.0 ccc eee cee tent e enn nneees 206
Attributable Risk and Smoking- Attributable Mortality ...........+-- 206
Comparative Risk ....... 0000s cece terete ene tent en nes 207
Knowledge Among Adolescents About the Health Risks of Smoking .......- 212
General Health Effects ......... 002 cee cece e eee ene een e renee 212
Personalized Risk 22.0... 00. c ee cece tee tee eet ee enn ee eens 215
Comparative Risk 22.02... 6-000 e cece ete eee teeter ents 215
Addiction .... cece cece cece eee tenet eee nent nee 216
Smokeless Tobacco Use ....... 00 ce eee eee teen teen eres 217
Constituents of Tobacco Smoke... 0.0... 0 eee eee ete tenets 217
Health Benefits of Smoking Cessation .......--.-. see e eee e eee e eens 219
DiscusSiON .... ccc ccc tee eeeee  ee ee ee eee eee ee eee ene rena 219
Current Gaps in Public Beliefs About the Health Effects of Smoking .. 219
Factors Interfering With Changes in Knowledge ......---+--+-+++: 222
The 1990 Health Objectives for the Nation .......... +--+ sees reese 223

173
 

 

 

 

 

 

 

Trends in Public Attitudes About Smoking and Smokers ................... 224
Involuntary Smoking as an Ammoyance ....... 00... cece eee cee eee. 224
Nonsmokers’ Rights... 0... eee eeeeeeeee cece 224
Actions When Smokers Light UP occ cece e cece eee. 227
Opinions of Teenagers 2.0.2... eee eee eee! 227

Trends in Public Opinion About Smoking Policies ........................ 230
Overview ooo eee cee etter entree! 230

Background ...... 2.00... e cece cece cece. 230
Limitations of the Surveys in Assessing Public Opinion
About Smoking Policies ©... 0.2... cece eee ee. 230
Restrictions on Smoking ...... 20.00... o kee e ce ceee cece 230
General... cece cee eee! 230
Public Places... 02. ceee eee. 232
Workplace... 6.6 ee cece cence. 232
Airplanes 2.0.2.0 cece eee ee cece 232
Restaurants... eee cece eee! 235
Other Places 62. cece cece. 235
Restrictions on the Sale and Distribution of Cigarettes 2......0.00.0....., 235
Complete Ban on Sales... 000.0... ce cece cece. 235
Limiting Sales to Minors 2.2.0.2... 235
Banning Free Samples ....... 0.00.00... cece eee eee 239
Policies Pertaining to Information and Education........................ 239
Restricting or Prohibiting Tobacco Advertising ................0.. 239
Waming Labels for Cigarettes... 2.2.2.0... ooo cece cee. 241
Economic Policies... 2... cece cee eee cee el 241
Taxation 0c ccc ce cece cece 241
Hiring 2... cece cece cece 241

Conclusions ..... 6... eiceeeer se pre eeT 244

Appendix 2... ii eeeeessssre ers re enn 246

References... 0. esses eres serene 254

174
Introduction

This Chapter analyzes trends in public beliefs, attitudes, and opinions about smok-
ing. It is divided into three sections. The first describes trends in public beliefs regard-
ing the health effects of smoking, the second describes trends in public attitudes about
smokers and smoking, and the third describes trends in public opinion about smoking
policies.

At the outset, it is important to define and clarify the important terms used in this
Chapter. Terms such as knowledge, awareness, opinions, beliefs, and attitudes have
commonsense meanings to the lay person, but more complex meanings to the social
scientist. For example, Allport (1935) reviewed many definitions of attitude and con-
structed his own comprehensive definition: “An attitude is a mental or neural state of
readiness, organized through experience, exerting a directive or dynamic influence
upon the individual’s response to all objects and situations with which it is related.”
Entire books have been devoted to the science of defining and measuring public at-
titudes, opinions, and beliefs (e.g., Oskamp 1977).

For sections two and three of this Chapter, which deal with attitudes and opinions,
the commonplace understanding of these terms will suffice. For the first section,
however, which covers beliefs about health effects, a more careful approach is war-
ranted. This Section generally follows the construct described by Fishbein (1977),
which embraces three levels of belief:

1. Level 1 (awareness): A person may believe that “the Surgeon General has deter-

mined that cigarette smoking is dangerous to health.”

2. Level 2 (general acceptance): A person may believe that “cigarette smoking is

dangerous to health.”

3. Level 3 (personalized acceptance): A person may believe that “my cigarette

smoking is dangerous to my health.”

Most of the survey data presented in the first section address Level 2 beliefs. At
times, the term public knowledge is used to refer to public beliefs (Level 2 beliefs at
the population level). There are few data regarding Level 1 beliefs; consequently, use
of the terms awareness and public awareness is generally avoided. Data pertinent to
Level 3 beliefs are available from a few surveys in three forms: (1) questions asking
whether smoking “is harmful to your health”; (2) questions asking whether respondents
are “concerned” about the effects of smoking on their health; and (3) questions asking
whether respondents believe that they are less likely, as likely, or more likely than other
people to be adversely affected by smoking. These levels of beliefs are discussed in
more depth later in this Chapter.

Data Sources

The information presented in this Chapter is derived from three principal sources:

1. Nationally representative surveys conducted by the U.S. Public Health Service
from 1964-87, including the Adult Use of Tobacco Surveys (AUTSs) (1964,
1966, 1970, 1975, 1986) and the National Health Interview Surveys (NHISs)
(1985, 1987). The NHIS questions were part of the Health Promotion and Dis-

175