The Health
Consequences

Of Smoking

 

CANCER

 

a report of the
Surgeon General

1982

=
Z U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES
a Public Health Service
%, Office on Smoking and Heaith
in Rockville, Maryland 20857
dag

 

For sale by the Superintendent of Documents, U.S. Government Printing Office

Washington, D.C. 20402
WASHINGTON DC 2920°

: Wi THE SECRETARY OF HEALTM AND HUMAN SEAVICES

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

Dear Mr. Speaker:

I hereby submit to you the 1982 Report on the
Health Consequences of Smoking, prepared in accordance
with the Public Health Cigarette Smoking Act of 1969
and its predecessor, the Federal Cigarette Labeling
and Advertising Act. This is the first report in the
series to focus on a single disease entity--cancer.

Scientists inside and outside of Government have
evaluated tne evidence presented in this report. It
joins this Department's previous reports on smoking
and health in making publicly availabie information
about one of the major health risks of smoking. These
reports reflect the important responsibility of
Government to inform its citizens in order that they
can make a considered decision about whether to smoke.

Sincerely,

Uppbadd Laahe

Richard S. Schweiker
Secretary
 

THE SECRETARY OF HEALTH AND HUMAN SERVICES
WASHINGTON, O¢ 20201

The Honorable George Bush
President of the Senate
Washington, D. C. 20510

Dear Mr. President:

I hereby submit to you the 1982 Report on the Health
Consequences of Smoking, prepared in accordance with the
Public Health Cigarette Smoking Act of 1969 and its prede-
cessor, the Federal Cigarette Labeling and Advertising Act.
This is the first report in the series to focus on a single
disease entity--cancer.

Scientists inside and outside of Government have
evaluated the evidence presented in this report. It joins
this Department's previous reports on smoking and health in
making publicly available information about one of the major
health risks of smoking. These reports reflect the important
responsibility of Government to inform its citizens in order
that they can make a considered decision about whether to
smoke.

Sincerely,

Yabudl lunbe

Schweiker
Secretary
FOREWORD

The 1982 report on The Health Consequences of Smoking presents
a comprehensive evaluation of the relationship between cigarette
smoking and cancer.”

Since 1937, cancer has been the second most important cause of
death in the United States and will account for an estimated 430,000
deaths this year. Surveys have shown that Americans fear dying of
cancer more than any other disease. We have yet to observe,
however, a decline in the cancer mortality rate as is currently
occurring for other chronic diseases, such as the 30 percent decline
in the cardiovascular disease mortality rate and the 50 percent
decline in the cerebrovascular disease mortality rate observed over
the last three decades. The mortality rate for cancer has changed
little over two decades, and that change has been a small, but
measurable, increase. This increase in mortality has occurred in the
face of remarkable improvements in survival rates for some cancer
sites through earlier or better diagnosis and treatment. Unfortunate-
ly. however, these advances have failed to counter the remarkable
increases in mortality from smoking-related cancers, many of which
have a poor prognosis for long-term survival or cures.

The Public Health Significance of this Report

Cigarette smoking is the major single cause of cancer
mortality in the United States. Tobacco’s contribution to all
cancer deaths is estimated to be 30 percent. This means we can
expect that 129,000 Americans will die of cancer this year because of
the higher overall cancer death rates that exist among smokers as
compared with nonsmokers. Cigarette smokers have total cancer
death rates two times greater than do nonsmokers. Heavy smokers
have a three to four times greater excess risk of cancer mortality. If
large numbers of our population did not smoke, the cancer death
rate in this country could be reduced, and instead of the small but
continued increase in the total cancer death rate, there could be a
substantial decline. There is no single action an individual can take
to reduce the risk of cancer more effectively than quitting smoking,
particularly cigarettes.
Cigarette smoking is a major cause of cancers of the lung, larynx,
oral cavity, and esophagus, and is a contributory factor for the
development of cancers of the bladder, pancreas, and kidney. The
term contributory factor by no means excludes the possibility of a
causal role for smoking in cancer of these sites.

Lung Cancer

Lung cancer, first correlated with smoking over 50 years ago, is
the single largest contributor to the total cancer death rate. Lung
cancer alone accounts for fully 25 percent of all cancer deaths in this
country; it is estimated that 85 percent of lung cancer cases are due
to cigarette smoking. Overall, smokers are 10 times more likely to
die from lung cancer than are nonsmokers. Heavy smokers are 15 to
25 times more at risk than nonsmokers. The total number of lung
cancer deaths in the United States increased from 18,313 in 1950 to
90,828 in 1977. The lung cancer death rate for women is currently
rising faster than the lung cancer death rate for men, a fact that
reflects the later adoption of smoking by large numbers of women.
The lung cancer death rate for women will soon surpass that of
breast cancer (perhaps as early as next year), currently the leading
cause of cancer mortality in women. This remarkable increase in
lung cancer mortality for women mimics that observed among men
some 30 years ago. However, since the early 1960s, large numbers of
men have given up cigarette smoking or have not begun to smoke,
whereas only recently has the prevalence of cigarette smoking by
women started to decline. These differences in patterns of smoking
have a decided effect on lung cancer mortality trends in this country,
with a decline in lung cancer mortality already apparent for younger
men. These differences will clearly affect future lung cancer
mortality experience by sex in the United States. The American
Cancer Society estimates there will be 111,000 lung cancer-related
deaths in 1982, of which 80,000 will be in men and 31,000 in women.

The 5-year survival rate for cancer of the lung is less than 10
percent. This rate has not changed in 20 years. Early diagnosis and
treatment do not appreciably alter this dismal survival rate—the
best preventive measure a smoker can take to reduce the risk of lung
cancer is to quit smoking, and for a nonsmoker, to not take up the
habit.

Larynx and Oral Cavity Cancer

Laryngeal and oral cancers will strike an estimated 40,000
individuals and will be responsible for approximately 13,000 deaths
this year in the United States. These sites have 5-year survival rates
of 60 and 40 percent, respectively. An estimated 50 to 70 percent of

vi
oral and laryngeal cancer deaths are associated with smoking. These
cancers are strongly associated with the use of cigars and pipes in
addition to cigarettes. All carry approximately the same excess
relative risk of at least fivefold. The use of alcohol in conjunction
with smoking acts synergistically to greatly increase the risk of these
cancers.

Esophageal Cancer

This year, 8,300 deaths due to cancer of the esophagus are
expected. Cancer of the esophagus has one of the poorest survival
rates of all cancers—only about 4 percent of esophageal cancer
patients live 5 years after diagnosis and most die within 6 months.
Cigarette smoking is estimated to be a factor in over half of
esophageal cancer deaths. Smokers have mortality ratios approxi-
mately 4 to 5 times higher than nonsmokers. The use of alcohol has a
synergistic interaction with smoking that greatly increases this risk.

Bladder and Kidney Cancers

Over 50,000 Americans are expected to develop bladder and
kidney cancer this year. Bladder and kidney cancers will be
responsible for a total of 20,000 deaths this year. The 5-year survival
rates are approximately 50 to 60 percent. Various investigators have
estimated that between 30 and 40 percent of bladder cancers are
smoking related, with slightly higher estimates for males than for
females.

Pancreatic Cancer

Approximately 24,000 people will develop cancer of the pancreas
this year, and there will be an estimated 22,000 deaths. Like cancers
of the lung and esophagus, cancer of the pancreas is often fatal, with
a 5-year survival of less than 3 percent. While few estimates are
available as to the proportion of these deaths attributable to
smoking, it would appear to be about 30 percent. Pancreatic cancer

appears to be increasing at a more rapid rate than most other cancer
sites.

Stomach and Uterine Cervix Cancer

A link between smoking and stomach cancer and cancer of the
uterine cervix is noted. However, no judgment can be reached on the
significance of any association, because of insufficient data.

vii
Involuntary Smoking and Lung Cancer

In recent months, the popular press has generated interest in the
controversy of whether passive or involuntary smoking causes lung
cancer in nonsmokers. Three epidemiological studies examined this
issue in the past year. Evidence from two of the studies demon-
strated a statistically significant correlation between involuntary
smoking and lung cancer risk in nonsmoking wives of husbands who
smoked. A third noted a positive association, but it was not
statistically significant. While the nature of this association is
unresolved, it does raise the concern that involuntary smoking may
pose a carcinogenic risk to the nonsmoker. Any health risk resulting
from involuntary smoke exposure is a serious public health concern
because of the large numbers of nonsmokers in the population who
are potentially exposed. Therefore, for the purpose of preventive
medicine, prudence dictates that nonsmokers avoid exposure to
second-hand tobacco smoke to the extent possible.

Lower Tar Cigarettes

This report also notes that smokers who use filtered or lower tar
cigarettes have statistically lower death rates from lung cancer than
do cigarette smokers who use nonfiltered or higher tar brands. This
reduced risk was also noted for laryngeal cancer. However, cancer
death rates for smokers of lower tar cigarettes were still significantly
higher than those noted for nonsmokers.

Cessation of Smoking

Since cigarette smoking is a cause of many cancers, encouraging
data about céssation are presented in this Report. Quitting smoking
reduces one’s cancer risk substantially, compared with the continu-
ing smoker, even after many years of cigarette smoking. The more
years one is off cigarettes, the greater the reduction in excess cancer
risk. Fifteen years after quitting cigarette smoking, the former
smoker’s lung cancer risk, for example, is reduced close to that
observed in nonsmokers. This same reduction in cancer risk is
observed for the other cancer sites associated with smoking.

Part V of this Report contains a review of cessation research
among adults and adolescents. In summary, many promising tech-
niques are available to smokers who have been unable to quit on
their own. It is nonetheless interesting to note that the vast majority
of former smokers, probably close to 95 percent, quit on their own,
without the aid of formal smoking cessation programs.

As a physician, I encourage all health care providers, particularly
other physicians, to counsel cigarette smokers to quit and to give
them as much support as possible. As this Report notes, a few

vill
minutes’ discussion with patients about their smoking behavior can
have a decisive impact on whether they quit smoking or continue the
habit.

Trends in Smoking Prevalence

I am encouraged by the recent decline in cigarette smoking rates
in this country. Today, only one-third of adults smoke, a decline from
42 percent in 1965. Teenage smoking, particularly among adolescent
girls, also appears to be declining.

While these figures are encouraging, there are still 53 million
cigarette smokers in this country—about the same number of
smokers as 20 years ago.

Furthermore, while per capita use of cigarettes has declined to its
lowest level since 1957, there has been a substantial increase in the
consumption of chewing tobacco and snuff, particularly among the
young. What impact the use of these products will have on future
cancer mortality is unclear; knowledge of the type and extent of the
health effects of these tobacco products is limited. Current evidence
indicates, however, that their use is not without risk. Studies
conducted in this country and others have demonstrated an in-
creased risk for oral cancer and other noncancerous oral diseases.

Educational Efforts

This Department is committed to continuing the programs of
education and information for all our citizenry regarding the adverse
health consequences of smoking. There is no more important aspect
of this than the health education of our young, to convince them not
to start smoking, or to quit the habit before it becomes difficult to
break.

This problem cannot be left solely to government to solve. I call
upon the rest of the health care community, the voluntary health
agencies, and our schools to increase their efforts to control one of
this country’s most pressing health problems. Reducing smoking will
reduce the devastating toll that cancer, as well as other smoking-
related diseases, exacts on this Nation’s health.

Edward N. Brandt, Jr., M.D.
Assistant Secretary for Health

ix
PREFACE

In July 1957, Dr. Leroy E. Burney issued the Public Health
Service’s first statement on cigarette smoking: it identified smoking
as a cause of lung cancer. Each succeeding Surgeon General has had
occasion to issue additional and stronger warnings. These have
linked smoking with lung cancer, with heart disease, with chronic
lung disease, with other cancers, and with increases in overall
mortality.

With this 1982 statement on cigarette smoking and cancer, I am
joining my distinguished predecessors, Drs. Burney, Luther Terry,
William Stewart, Jesse Steinfeld, and Julius Richmond. Cigarette
smoking, as this Report again makes clear, is the chief, single,
avoidable cause of death in our society and the most important
public health issue of our time.

Over the years, 14 reports on the health consequences of smoking
have been prepared by the Public Health Service under the Federal
Cigarette Labelling and Advertising Act and its successor, the Public
Health Cigarette Smoking Act of 1969. These reports have contrib-
uted greatly to public understanding of the hazards that cigarette
smoking poses to the health of this Nation.

In contrast with previous Public Health Service reports on
smoking and health, the present document examines the relation-
ship between smoking and a single category of disease, cancer. The
relationships between smoking and lung cancer, as well as cancer of
other sites, are carefully examined. This should not distract atten-
tion from the fact that smoking is related to many diseases,
including cardiovascular disease, which exacts a greater tol] than
does cancer in disease and death. Cancer, however, was the first
disease to be linked with tobacco use, and its association with
smoking has been the subject of the most intense research: Much of
the research within the past few years has not previously been
examined in the detail presented here.

As in previous years, this Report has been prepared with the aid
and critical review of experts from within and outside the Govern-
ment. On behalf of the Public Health Service, I express here my
respect for their expertise and gratitude for their help.

C. Everett Koop, M.D.
Surgeon General
xl
ACKNOWLEDGEMENTS

This Report was prepared by the Department of Health and
Human Services under the general editorship of the Office on
Smoking and Health, Joanne Luoto, M.D., M.P.H., Acting Director.
Managing Editor was Donald R. Shopland, Technical Information
Officer, Office on Smoking and Health.

Consulting scientific editors were David M. Burns, M.D., Assistant
Professor of Medicine, Pulmonary Division, University of California
at San Diego, San Diego, California; John H. Holbrook, M.D.,
Associate Professor of Internal Medicine, University of Utah Medi-
cal School, Salt Lake City, Utah; and Ellen R. Gritz, Ph.D., Director,
Macomber-Murphy Cancer Prevention Program, Division of Cancer
Control, Jonsson Comprehensive Cancer Center, University of
California at Los Angeles, Los Angeles, California.

The editors wish to acknowledge the assistance of the National
Cancer Institute, particularly the Clinical Epidemiology Branch, for
making available the computer-generated three dimensional graphs
of cancer mortality, and the National Center for Health Statistics,
for making available the cancer mortality data extracted from the
publication by A. Joan Klebba, Mortality From Diseases Associated
with Smoking, United States, 1960 to 1977.

The following individuals authored sections within the Parts of the
Report as indicated:

PartI. Introduction and Conclusions
Office on Smoking and Health

Part ll. Biomedical Evidence for Determining Causality

Richard A. Bordow, M.D., Associate Director of Respiratory Medi-
cine, Brookside Hospital, San Pablo, California; and Assistant
Clinical Professor of Medicine, University of California at San
Francisco, San Francisco, California

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

Part III. Mechanisms of Carcinogenesis

Dietrich Hoffmann, Ph.D., Associate Director, Naylor Dana Institute
for Disease Prevention, American Health Foundation, Valhalla,
New York

xiii
Ilse Hoffmann, Research Coordinator, Naylor Dana Institute for
Disease Prevention, American Health Foundation, Valhalla, New
York

Stanley E. Shackney, M.D., Head, Section of Cellular Kinetics.
Clinical Pharmacology Branch, Division of Cancer Treatment.
National Cancer Institute, Bethesda, Maryland

Elizabeth K. Weisburger, Ph.D., Assistant Director for Chemica]
Carcinogenesis, Division of Cancer Control and Prevention, Na-
tional Cancer Institute, Bethesda, Maryland

Part IV. Involuntary Smoking and Lung Cancer

Aristide Y. Apostolides, D.V.M., M.P.H., Associate Professor of
Epidemiology, Department of Preventive Medicine and Biometry,
Uniformed Services University of the Health Sciences, Depart-
ment of Defense, Bethesda, Maryland

Michael D. Lebowitz, Ph.D., Professor of Internal Medicine, College
of Medicine, the University of Arizona Health Sciences Center,
Tucson, Arizona

Part V. Cessation of Smoking

E. B. Fisher, Jr., Ph.D., Associate Professor of Psychology, Associate
Director of the Washington University Diabetes Research and
Training Center, Washington University in St. Louis, St. Louis,
Missouri

Ellen R. Gritz, Ph.D., Director, Macomber-Murphy Cancer Preven-
tion Program, Division of Cancer Control, Jonsson Comprehensive
Cancer Center, University of California at Los Angeles, Los
Angeles, California; Associate Research Psychologist, Department
of Psychiatry and Biobehavioral Sciences, School of Medicine,
Neuropsychiatric Institute, University of California, Los Angeles,
California; and Research Psychologist, Veterans Administration
Medical Center, Brentwood, Los Angeles, California

C. Anderson Johnson, Ph.D., Associate Professor and Director,
Health Behavior Research Institute, University of Southern
California, Los Angeles, California

The editors acknowledge with gratitude the following distin-
guished scientists, physicians, and others who lent their support in
the development of this Report by coordinating manuscript prepara-
tion, contributing critical reviews of the manuscript, or assisting in
other ways.

Elvin E. Adams, M.D., M.P.H., P.A., Huguley Medical Arts Clinic,
Fort Worth, Texas

Sam P. Battista, Ph.D., Senior Staff Pharmacologist, Arthur D.
Little, Inc., Cambridge, Massachusetts

Fred G. Bock, Ph.D., Director, Orchard Park Laboratories, Roswell
Park Memorial Institute, Buffalo, New York

xiv
Vincent T. DeVita, M.D., Director, National Cancer Institute,
Bethesda, Maryland

Hans L. Falk, Ph.D., Associate Director, Health Hazard Assessment,
National Institute of Environmental Health Sciences, Research
Triangle Park, North Carolina

William Foege, M.D., Director, Centers for Disease Control, Atlanta,
Georgia

Robert A. Goyer, M.D., Deputy Director, National Institute of
Environmental Health Sciences, Research Triangle Park, North
Carolina

Dorothy E. Green, Ph.D., Consulting Research Psychologist, Arling-
ton, Virginia

Michael R. Guerin, Ph.D., Section Head, Bio-Organic Analysis
Section, Analytical Chemistry Division, Oak Ridge National
Laboratory, Oak Ridge, Tennessee

Sharon M. Hall, Ph.D., Associate Professor, Langley Porter Psychiat-
ric Institute, University of California at San Francisco, San
Francisco, California

Jeffrey E. Harris, M.D., Ph.D., Associate Professor, Department of
Economics, Massachusetts Institute of Technology, Cambridge,
Massachusetts

Arthur Hull Hayes, Jr., M.D., Commissioner, Food and Drug
Administration, Rockville, Maryland

Maureen M. Henderson, M.D., Professor of Medicine and Epidemiol-
ogy, School of Public Health and Community Medicine, University
of Washington, Seattle, Washington

Harry A. Lando, Ph.D., Professor, Department of Psychology, Iowa
State University, Ames, Iowa

Alex Langmuir, M.D., Chilmark, Massachusetts

Edward Lichtenstein, Ph.D., Department of Psychology, University
of Oregon and Oregon Research Institute, Eugene, Oregon

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

Anthony B. Miller, M.D., Director, Epidemiology Unit, National
Cancer Institute of Canada, University of Toronto, Ontario,
Canada

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

Richard Peto, M.A., M.Sc., I.C.R.S., Reader in Cancer Studies Unit,
Nuffield Department of Clinical Medicine, Radcliffe Infirmary,
Oxford, England

Richard D. Remington, Ph.D., Dean, School of Public Health,
University of Michigan, Ann Arbor, Michigan

XV

377-310 O - 82 - 2
Dorothy P. Rice, Director, National Center for Health Statistics,
Hyattsville, Maryland

David Schottenfeld, M.D., Chief of Epidemiology and Preventive
Medicine, Director of Cancer Control, Memorial Sloan-Kettering
Cancer Center, New York, New York; and Professor of Public
Health, Cornell University Medical College, New York, New York

Marvin A. Schneiderman, Ph.D., Bethesda, Maryland

Irving J. Selikoff, M.D., Professor of Community Medicine and
Medicine, and Director, Environmental Sciences Laboratory, Mt.
Sinai School of Medicine, City University of New York, New York,
New York

Saul Shiffman, Ph.D., Assistant Professor, Department of Psycholo-
gy, College of Social and Behavioral Sciences, University of South
Florida, Tampa, Florida

Michael B. Shimkin, M.D., Professor Emeritus, Department of
Community and Family Medicine, School of Medicine, University
of California at San Diego, La Jolla, California

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

The editors also acknowledge the contributions of the following
staff members and others who assisted in the preparation of the
Report.

Erica W. Adams, Copy Editor, Clearinghouse Services Division,

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
Richard J. Bast, Medical Translation Consultant, Clearinghouse
. Services Division, Informatics Incorporated, Rockville, Maryland
Jacqueline O. Blandford, Secretary, Office on Smoking and Health,

Rockville, Maryland
Marsha Clay, Clerk-Typist, Office on Smoking and Health, Rockville,

Maryland
Melissa R. Colbert, Applications Manager, Publishing Services

Division, Informatics Incorporated, Riverdale, Maryland
Karen M. Cox, Technical Information Specialist, Office on Smoking

and Health, Rockville, Maryland
Joanna B. Crichton, Copy Editor, Information and Technology

Transfer Department, Informatics Incorporated, Rockville, Mary-

land
Denise M. Cross, Data Entry Manager, Publishing Services Division,

Informatics Incorporated, Riverdale, Maryland
Martha E. Davis, Technical Ilustrator, Informatics Incorporated,

Rockville, Maryland

XVi
Stephanie D. DeVoe, Data Entry Operator, Clearinghouse Services
Division, Informatics Incorporated, Rockville, Maryland

Andrea L. Dykstra, Senior Technical Editor, Biospherics Incorporat-
ed, Rockville, Maryland

Susan H. Fenton, Table Coder, Publishing Services Division, Infor-
matics Incorporated, Riverdale, Maryland

Judy Fernandes, Writer-Editor, Office on Smoking and Health,
Rockville, Maryland

Sandy Gibson, Copy Editor and Indexer, Clearinghouse Projects
Department, Informatics Incorporated, Rockville, Maryland

Wendy S. Goldin, Secretary, Information and Technology Transfer
Department, Informatics Incorporated, Rockville, Maryland

Rebecca C. Harmon, Manager, Graphics Unit, Clearinghouse Ser-
vices Division, Informatics Incorporated, Rockville, Maryland

Reginald V. Hawkins, M.P.H., Public Health Analyst, Office on
Smoking and Health, Rockville, Maryland

Douglas Hayes, Applications Manager, Informatiori Processing Ser-
vices Division, Informatics Incorporated, Riverdale, Maryland

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

Leslie J. Headlee, Information Specialist, Clearinghouse Projects
Department, Informatics Incorporated, Rockville, Maryland

Shirley K. Hickman, Data Entry Operator, Clearinghouse Services
Division, Informatics Incorporated, Rockville, Maryland

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

Lisa A. Katz, Graphic Artist, Clearinghouse Services Division,
Informatics Incorporated, Rockville, Maryland

Margaret E. Ketterman, Public Information and Publications Assis-
tant, Office on Smoking and Health, Rockville, Maryland

John J. Kourilo, Senior Information Analyst, Clearinghouse Services
Division, Informatics Incorporated, Rockville, Maryland

Julie Kurz, Graphic Artist, Clearinghouse Services Division, Infor-
matics Incorporated, Rockville, Maryland

William R. Lynn, Program Operations Technical Assistance Officer,
Office on Smoking and Health, Rockville, Maryland

Marilynn H. Meinke, Copy Editor, Clearinghouse Projects Depart-
ment, Informatics Incorporated, Rockville, Maryland

Jacquelene Mudrock, Technical Illustrator, Informatics Incorporat-
ed, Rockville, Maryland

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

Douglas F. Pepin, Statistical Analyst, Clearinghouse Projects De-
partment, Informatics Incorporated, Rockville, Maryland

xvil
Raymond K. Poole, Production Coordinator, Clearinghouse Projects
Department, Informatics Incorporated, Rockville, Maryland

Roberta A. Roeder, Secretary, Clearinghouse Projects Department,
Informatics Incorporated, Rockville, Maryland

Linda R. Sexton, Information Specialist, Clearinghouse Projects
Department, Informatics Incorporated, Rockville, Maryland

Carol A. Sherrer, Technical Consultant, 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

Selwyn Waingrow, Public Health Analyst, Office on Smoking and
Health, Rockville, Maryland

Aileen L. Walsh, Secretary, Clearinghouse Projects Department,
Informatics Incorporated, Rockville, Maryland

Melissa L. Yorks, M.L.S., Technical Information Specialist, Office on
Smoking and Health, Rockville, Maryland

XViii
TABLE OF CONTENTS

 

 

 

 

 

 

 

 

 

Foreword ....... ceueuuueeeeeceeeeeeseeeseseeeeerrssatetettreteteseeeces v
Preface ........ cic cece eee eee ene ener xi
Acknowledgements ................ 000 ccee cence eee n eee e etna e ees xili
1. Introduction and Conclusions.................ccc see eeee ee ee es 1
2. Biomedical Evidence for Determining Causality....... 13
3. Mechanisms of Carcinogenesis .................6.0 cece 171
4. Involuntary Smoking and Lung Cancer................. 237
5. Cessation of Smoking ..................0:ccceeee cece ene e eee ees 255
INde@X 0.2.0... c cece ee eee cece eect ee eee e eee ene renee e eee e ence enna e es 305

xix