The Health Consequences of SMOKING A PUBLIC HEALTH SERVICE REVIEW : 1967 U.S. DEPARTMENT OF HEALTH, EDUCATION, AND WELFARE i,`. -, ' Public Health Service Public Health Service Publication No. 1696 For sale by the 6uperluten~t of Dommsl t+3, us. oo- t RintiIlE omce we&bgton, D.C. 204W - Wee 60 -ta The Federal Cigarette Labeling and Advertising Act of 1965 (Pub- lic Law 89-92) requires that the Secretary of Health, Education, and Welfare submit regular reports to the Congress on the health conse- quences of smoking, together with any legislative recommendations he may wish to make. This 1967 Surgeon General's Report was pr&tred to provide the Secretary and the public with a review of the research findings which have taken place in smoking and health in the approximately 3% years which have elapsed since the Surgeon General's Advisory Committee issued its monumental 1964 report. Part I of this document was in- cluded as part of the Secretary's 1967 Report which he sent to Congress in July 196'7. Part II, which provides detailed discussions of the re- lationship of smoking to specific diseases, is issued here for the first time. The 1967 report represents a review of more than 2,000 research studies published since the 1964 report. These additional studies con- firm and strengthen the conclusion of the Surgeon General's Advisory Committee that: "Cigtlrette smoking is a health hazard of sutllcient importance in the United States to warrant appropriate remedial action." In a separate section of this report, acknowledgments have been made for the help of numerous scientists both within and outside the Public Health Service, who participated in the preparation of this report. These include the 10 distinguished scientists who made up the Surgeon General's 1964 Advisory Committee, all of whom were kind enough to review part I of the 1967 report before its publication. A special word of thanks is due Leonard M. Schuman, M.D., one of the 1964 committee members, who advised the staff in the final editing of the entire document. SURGEON GENERAL. Table of Contents Part I. Current Information on the Health Consequences of Smolring-_------------------------------------- Introduction__------------------------------- Smoking and Overall Mortality- _ _ _ __ __ _ __ _ _ _ _ _ Some Oeneral Considerations- _ _ _ _ _ ___ ___ __ Smoking and Overall Morbidity-- _ __ __ _ _ _ _ _ _ _ _ _ Smoking and Cardiovascular Diseases,,- _ _ _ _ _ _ _ _ Smotig and Chronic B~onchopulmonary Dis- eases (Non-neoplastic) _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ Smoking and Cancer--- _ _ _ _ _ __ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ Other Conditiona and Areas of Research- _ _ _ _ _ _ _ Cited References----- -----I------------------ II. Technical Reports on the Relationship of Smoking to Specific Disease Categories- _ _ _ __ __ _ __ _ _ _ __ _ _ _ _ _ _ Chapter 1. Smoking and Cardiovascular Diseases- 2. Smoking and Chronic Bronchopul- monary Diseases (Non-neoplastic) _ 3. Smoking and Cancer- _ _ __ __ __ _ __ _ __ 4. Other Conditions and Areas of Re- search-------------------------- 1 3 7 11 19 25 29 33 39 41 43 45 87 125 179 V Acknowledgments Responsible for the preparation of this report was the National Clearinghouse for Smoking and Health, Daniel Horn, Ph. D., director. Staff director for this report was Albert C. Kolbye, Jr., M.D., M.P.H., LL.B. The professional staff has had the assistance and advice of a number of experts in the scientific and technical fields in and outside govern- ment. The staff gratefully acknowledges their contributions, often made at considerable sacrifice of time from their own professional duties. Although space does not permit a listing of all those who have participated in this project, the staff wishes to express appreciation for their cooperation and help. Special thanks are due the following: hNAHT1, FBAITC~S R., D.V.M, PH. D.-Chief, Virology and Rickettaiologs Branch, Extramural Program, National Institute of Allergy and Infectious Dra~aesq National Institutes of Health, Bethesda, Md. AMES, BBUCE N., M.D.-Laboratory of Molecular Biology, National Institutes of Health, Bethesda, Md. hEaD, WILLTAM P., M.D.-Medical consultant, Stroke Section, Heart Disease Control Pro&m, National Center for Chronic Disease Control, U.S.P.H.S., Arlington, Va. Aunns~on, Oecq M.D.-Senior medical investigator, Veterans Administration Hospital, East Orange, N. J. AXEUOD, DA=, M.D.-Medical consultant, Laboratory of Biology of Viruses, National Institutes of Health, Bethesda, Md. Am, Srnr~nrv M., M.D.-Dire&or, Cardiopulmonary Laboratory, Saint Vin- cent's Hospital and Medical Center of New York, New York, N.Y. AYEW, W= R., M.D.-Medical of&X& Heart Disease Control Program, Na- tional Center for Chronic Disease Control, U.S.P.H.S., Arlington, Va. Bmena, JOHH J., M.D.-Head, Department of Otolaryngology, Evanston Hos- pital, Evanston, Ill. BEBENDES, Hews, W., M.D.-Chief, National Institute of Neurological Diseases and Blindness, Perinatal Research Branch, National Institutes of Health, Bethesda, Md. Bnao, Connon W;-`Statistician, Operational Studies Section, Cancer Control Pro- gram, National Center for Chronic Disease Control, U.S.P.H.S., Arlington, Va. Bsa~~nna, Ronmw, M.D.-Director, oface of Director of Research, National Heart Institute, National Institutes of Health, Bethesda, Md. BIBG, RIO- J., MD-Professor and chairman, Department of Medicine, Wayne State University, Detroit, Mich. BLEBE, STIJA~~ R, MD.-Medical consultant, Heart Disease Control Program, National Center for Chronic Disease Control, U.S.P.H.S., Arlington, Va. VII BOBEN, HOUS, M.D.-Clinical investigator, Veterans A-Uin Hospital, Denver, 62010. CABBO& BENJAMIN E.-Biometric Bknch, National Cancer Institute, National Inetitutea of Health, Bethesda, Md, CHADWICK, DONALD IL, M.D.-Director, National Center for Chronic Dkaae Control, U.S.P.H.S., Arlington, Va. DE LA PUEITTIZ, Joema L.+hief, statistical methods, Cancer Control Program, National Center for Chronic Disease Control, lJ.S.P.&S.. Arlington, Va. DEYKIIT, DAXIZL, M.D.-Assistant proteseor of medicine, Harvard Medical Scholl, Boston, Masf3. DOBBS, GEOFCO~ M.D.-Aesociate chief. Dlvlalon of Sclentitl~ Ophio~, Eweral Trade Commission, Washington, D.C. DOYLE, JO~EPE, M.D.-Dir&or, Cardiovascular Health Center, Albany Medical College, Union University, Albany, N.Y. ~ETMAH, NICOLAS J., M.D.-Profmr emerlhm of obatetrl~ Johns Hopldna Hoepital, Woman's Clinic, Baltlmore, Md. EPSTEIN, ~lcBIC!K H., M.D.--f-r, University of Mlcbigan School of Pt&llc Health, Department of Epidemiology, Ann Arhor, AXich. P~ELZOE, 8. PAUL, Jr., M.D.-Deputy chief, Heart Dlaeaae Control w Na- tional Center for Chronic Disease Control, U.S.P.ES., Arllngbn, Va EVANS, B~BEBT, Ph. D.-Department of sodology, University of Wisconein, Madison, Wis. FALK, HANS L., Ph. D.-Associate scientifk dlreetor for carcinogenesb, National Cancer InstLtute, Natlonal Institutes of Health, Bethesda, Md. Fmurxs, BEXJAMI~J G., Jr., M.D.-Professor, Deperbnent of Physiology, Harvard School of F'ubllc Health, Harvard University, Boston, Masc. Fox, BE~R~BD H., Ph. D.-Acting Chief, Experimental -Branch,Injnry Control Program, National Center for Urban and Industrial Health, U.S.P.H.S., Arlington, Va. Fox, SAHUEL M., III.,. M.D.Ahlef, Heart Disease Control Program, National Center for Chronic Disease Control, U.S.P.ES.. ArRqbn, Va. GIITLESOHN, ALLAN, Ph. D.-Professor, Johns Hopkins gob001 of P&c Health and Hygiene, Johns Hopkins University, Baltimore, Md GOLD, B~XALD J.-Statistician, Operational Stndies Section, Cancer Control Pro- gram, Na,tional Center for Chronic Disease Control, U.S.P.HB., kiington. Va. H~SZEL, WILLIAM M.-Chief, Biometry Branch, National Cancer Institute, National Institutes of Health, Bethesda, bfd mm, Max, Ph. D.-Assistant chief, Biometrics Besear& Branch, National Instktntea of Health, Bethesda, Md. HAMMOXD, E. Cm, SC. D.-Vice president., epidemiology and statistical IX+ sea&b American Cancer Society, New York, N.Y. HA~ELL, WILLIAM L, Ph. D.-Physical activity consultant, Heart Disease Con- trol Program, National Center for Chronic Disease Control, U.S.P.H.S., Arllng- ton, Va. HAYES, RICHAR.D, D.D.S.-Assistant to the chief, cancer detection. Cancer Control Program, National Center for Chronic Disease Control, U.S.P.H.S., Arllnq- ton, Va. HEIXZELXAN, F&D, Ph. D.--Research peyeholagbt, Heart Disease Control Pro- gram, Natfonal Center for Chronic Disease tints& U.S.P.ES.. Arlington, Va. HESS. CATHERINE B., M.D.-Assistant to the chief, Cancer Control Program, Na- tional Center for Chronic Disease Control, U.SS,H.S., Arlington, Va. HIGQINS, I. I. T., M.D.-Professor, University of Michigan School of Pnhllc Health, Department of Epidemiology, Ann Arbor, Mlch. HO~FXAX~, D~TEICJH, M.D.-Associate member, environmental carcinogenesis, Sloan-Kettering Inatltute for Cancer Research, New York, N.Y. IMBODEN, C. &, Jr., M.D.-Chief, (&ronic Re8piratory Disease Control Frogram, National Center for Chronic Dleease `Control, US.P.Hd., tilington, Va. IBXBANT, Ar.aan~ P.-Uhief, Epidemiology and SurveilMnce Branch, Injury Control Program, National Center for Urban and Industrial Health, U.W.P.H.S., Arlington, Va. KANNEL, WISXJAM B., M.D.-Associate medical director, National Heart Institute, Harvard Medical School, Boeton, Ma&a KENNEB, HAIEZS, M.D.-Medical c&k&ant, Heart Ditveaae Dontrol Program, National Center for Chronic Disease Control, U.S.P.H.S., Arllngton, Va. KOOLBYE, SUBAX~AE M+Sclentiat, Chevy Chase, Md. Korxx, Pam, M.D.-Director, National Environmental Health Sciences Center, Research Triangle Par& N.C. Krkmox& Dw E.-Statl&ician, Biometrics Section. Natlonal Heart Institute, National Institutes of Health, Beth&a, Md. LANDAU, EMANUEL, Ph. D.-Statistical advisor, OlIlce of the Director, National Center for Air `Pollution Control, U.S.~P.ES., Washington, D.C. LEQAT~B, Mmvrxv S., M.D.-Chief, Cell Biology Branch, Division of Nutrition, Food and Drug Adminletration, Washington, D.C. LEMAISTBE, CHABLKS A., M.D.-Vice chancellor of health affaire, Otllce of the Chancellor, University of !kxas, Austin, Tex. LILXEHFELD, ABMHAY, M.D.-Professor, Johns Hopkins School of Hygiene and Public Health, Baltimore, Md. LONOIN, Hmwwr, M.D.-O&X of associate director for collaborative studies, National Heart Institute, National Institutes of Health, Bethesda, Md. LOUDON, R. G., M.D.-Profeeeor, Department of Internal Medicine, University of Texas, Da&la. Ta. MABIAND, Rx- ,E., Ph. D.-Injury Control Program, National Center for Urban and Industrial Health, U.S.P.H.S., Arlington, Va. MoL~Ax, Roes, M.D.-Pro-C-r of medicine (pulmonary disease), Emory Uni- versity, School of Medicine, Atlanta, Ga. MOBBISON, BAYA~~ H., Ph. D.-Ofllce of the Director, National Cancer Institute, National Institutes of Health, Bethesda, Md. MOUNT, FBANK W., M.D.-Deputy chief, Ohronic Respiratory Disease Control Program, U.S~P.HS., Arlington Va. MUBPHY, EDYOND A., M.D.-Associate professor, University of Colorado Medical Center, medicine and biostatietics, Denver, Cola. PETQLBorv, WILLXAX `F., M.D.--chief, Obstetrics and Uynecolopy Service, USAF Ho&al Andrews, MSHCB, Andrewa Air Force Basf?, Washington, D.C. PETTY, THOMAS L., M.D.-Assistant professor of medicine, University of Colo- rado Medical Oenter, Denver, Colo. Romxe, Moxrox-chief, program evaluation and project design, Heart Disease Control `Program,