Th e Health Consequences of SMOKING 1969 SUPPLEMENT TO THE 1967 Public He&h Service Review U.S. DEPARTMENT OF HEALTH, EDUCATION, AND WELFARE Public Health Service 1969 Supplement to Public Health Service Publication No. 1696-2 Library of Congress Catalog No. 6840025 For sala by the Superht8ndent of Document% U.S. Oommme nt Prblting omw Washington. D.C. 2041X2 - Prka 60 cents Foreword This is the third report required by Section 5 (d) (1) of the Federal Cigarette Labeling and Advertising Act, which directs the Secretary of Health, Education, and Welfare to submit annual reports to the Congress on tihe health, consequences of smoking. The preceding two reports were The Health Comepnces of Smoking, A Public Hedth Service Review: 1967 and The Hedth Consequences of Smking, 1968 Supplement to the 2967 Public Eealth Service Review. The present Supplement was submitted to the Congress on July 29, 1969. iii Acknowledgments The National Clearinghouse for Smoking and Health, Daniel Horn, Ph. D., Director, was responsible for the preparation of this report ; Albert C. Kolbye, Jr., M.D., M.P.H., LL.B., was consulting editor. Staff director for the report was Daniel P. Asnes, M.D. The professional staff has had the assistance and advice of a number of experts in the scientific and technical fields, both in and outside of the Government. Their contributions are gratefully acknowledged. Special thanks are due the following : ANDERSON, WILLIAM H., M..D.-Associate professor of medicine, UniVersitY of Louisville, School of Medicine, Louisville, Ky. AUEBBACH, Osc~n, M.D.-Senior medical investigator, Veterans Administration Hospital, East Orange, N. J. AVIADO, DOMINIX M., M.D.-Professor of pharmacology, Department of Pharma- cology, School of Medicine, University of Pennsylvania, Philadelphia, Pa. Arass, STEPHEN M., M.D.-Director, Cardiopulmonary Laboratory, Saint Vin- cent's Hospital and Medical Center of New York, New York, N.Y. BATES, DAVY, V., MD.-Cha~lrman, Department of Physiology, McGill UniVeIFdty, Montreal, Quebec, Canada. BELLET, SAMUEL, M.D.-Director, Division of Cardiology, Philadelphia General Hospital, Philadelphia, Pa. Brno, RICHARD J., M.D.-Professor and chairman, Department of Medicine, Wayne State University, Detroit, Mich. BL~MQUIST, EDWARD T., M.D.-Chief, Chronic Respiratory Disease Control Pro- gram, Health Services and Mental Health Administration, U.S.P.H.S., Arling- ton, Va. BOCK, F'mm G., Ph. D.-Director, Orchard Park Laboratories, Roswell Park Memorial Institute, Orchard Park, N.Y. BOREN, HOLLIB, M.D.-Chief of pulmonary disease, Professor of medicine, Mar- quette School of Medicine, Wood VA Center, Milwaukee, Wis. BOUTWELL, ROEWELL K., M.D.-Professor of oncology, McArdle Laboratory for. Cancer Research, University of Wisconsin, Madison, Wis. Coo~ns, THEODOBE, M.D.-Director, National Heart Institute, National Institutes of Health, Bethesda, Md. COBNFIEL.D, Jrmobx-Biostatistics Project, Bethesda, Md. DE LA PUENTE, Jossrn-Chief, Program Studies Section, Kidney Disease Control Program, Health Services and Me&al Health Administration, U.S.P.H.S., Arlington, Va. EASTMAN, NICHOLSON J., M.D.-Professor emeritus of obstetrics, Johns Hopkins Hospital, Baltimore, Md. ELIOT, ROBEBT S., M.D.-Associate professor of medicine, Division of Cardiology, College of Medicine, University of Florida, Gainesville, Fla. V Ennrco~~, KENNGTH M., M.D.-Director, National Cancer Institute, National In- stitutes of Health, Bethesda, Md. EPSTEIN, FBEDEBICR H., M.D.-Professor of epidemiology, Department of Epi- demiology, University of Michigan, School of Public Health, Ann Arbor, Mich. FALK, HANS L., Ph. D.-Associate director for laboratory research, National Institute of Environmental Health Sciences, Research Triangle Park, N.C. FEBBIS, BENJA~~IN G., Jr., M.D.-Professor. Department of Physiology. Harvard School of Public Health, Harvard University, Boston, Mass. Fox, SAMUEL M., III, M.D.-Chief, Heart Disease and Stroke Control Program, Health Services and Mental Health Administration, U.S.P.H.S., Arlington, Va. FRAZIER, TODD M.-Assistant director, Harvard Center for Community Health and Medical Care, Harvard School of Public Health, Ro.ston, Mass. HASS, GEORCJE M., M.D.-Chairman, Division of Pathology, Presbyterian-St. Luke's Hospital, Chicago, Ill. HIGGINS, IAN T. T., M.D., M.R.C.P.-Professor, Department of Epidemiology, University of Michigan, School of Public Health, Ann Arbor, Mich. HOFFMANN, DIETRICH, Ph. D.-. 4ssociate member, Environmental Carcinogenesis, Sloan-Kettering Institute for Cancer Research, New York, N.Y. KELLEB, ANDBEW Z., D.M.D., M.P.H.-Chief, Research in Geographic Epidemi- ology Research Service, Veterans Administration Central Office, Department of Medicine and Surgery. Washington, D.C. *KERSHBAUM, ALFRED, M.D.-Assistant Chief, Division of Cardiology, Philadel- phia General Hospital, Philadelphia, Pa. (Dr. Kershbaum, who contributed to this and previous reports, died suddenly in March 1969.) KOTIN, PAUL, M.D.-Director, National Institute of Environmental Health Sciences, Research Triangle Park, N.C. KIIUMHOLZ, RICHAU.~ A., M.D.-Director, Institute of Respiratory Diseases, Kettering Medical Center, Kettering, Ohio. LEIXHTENBEROER, CECILE, Ph. D.-Head. Department of Cytochemistry, Swiss Institute for Experimental Cancer Research, Lausanne, Switzerland. LEIJCHTENBEXGEB, RUDOLF, M.D.-Profeswr, Swiss Institute for Experimental Cancer Research, Lausanne, Switzerland. Lmsow, AVERILL A., M.D.-Professor and chairman, Department of Pathology, University of California. San Diego. La Jolla, Calif. LILIENFPZD, ABB~HAX, M.D.-Professor and chairman, Department of Chronic Diseases, Johns Hopkins School of Hygiene and Public Health, B,altimore, Md. LYOIV, HARLEY W., D.D.S., Ph. D.-Secretary, Council on Dental Research, American Dental Association, Chicago, Ill. MACMAHON, BEIAN, M.D.-Professor of epidemiology; Harvard University School of Public Health, Boston, Mass. MCLEAN, Ross, M.D.-Professor of medicine (pulmonary disease), Emory Uni- versity, School of Medicine, Atlanta, Ga. Mrro~n;r, ROGER S., M.D.-Director, Webb-Waring Institute for Medical Re- search, University of Colorado Medical Center, Denver, Colo. MUBPHY, EDMOND A., M.D., SC. D.-Associate professor of medicine, The Johns Hopkins Hospital, Baltimore, Md. PAFFE~EAEGE~, RALPH S., Jr., M.D.-Chief, Bureau of Adult Health and Chronic Diseases, Department of Public Health, Berkeley, Callf. PETEESOB, WILIZAM F., M.D.-Chief, Obstetrics and Gynecology Service, USAF Hospital Andrew& MSHCB, Andrews Air Force Base, Washington, D.C. *Deceasea Vi PETTY, THOMAS L., M.D.-Assistant professor of medicine, University of &do- rado Medical Center, Denver, Cola. ROCHMIS, PAUL G., M.D.-Heart Diseamse and Stroke Control Program, Health Services and Mental Health Administration, U.S.P.H.S., Arlington, Va. Ross, WILLIAM L., M.D.-Chief, Cancer Control Program, Health Services and Mental Health Administr.ation, U.S.P.H.S., Arlington, Va. S~~p~cvrr~, UMBEBTO, M.D.-Associate scientific director for carcinogenesis, etiology, National Cancer Institute, National Institutes of Health, Bethesda, Md. SCHACHTER, JOSEPH-Statistician, Adult Heart Activities, Heart Disease and Stroke Control Program, Health Services and Mental Health Administration, U.S.P.H.S., Arlington, Va. SCHUMAN, LEONARII M., M.D.-Professor of epidemiology, University of Min- nesota, School of Public Health, Minneapolis, Minn. SHIMKIN, MICHAEL B., M.D.-Director, Regional Medical Programs, University of California at San Diego, La *Jolla, Calif. SILVERMAN, SOLS, Jr., D.D.S.-Professor of oral biology, School of Dentistry, University of California, San Francisco, Calif. SMITH, LOWEL.L C., D.D.S.-Chief, Preventive Services Section, Community Pro- grams Branch, Division of Dental Health, U.S.P.H.S., Bethesda, Md. STAMLEB, JEREMIAH, M.D.-Executive director, Chicago Health Research Foun- dation, Chicago, Ill. STDMAN, RUSSELL L., D. &.--Head, Smoke Investigations, Tobacco Laboratory, U.S. Department of Agriculture, Philadelphia, Pa. TIECKE, RICHARD W., D.D.S.-Director, Research Institute, American Dental Association, Chicago, Ill. TOBIN, CHABLES E., Ph. D.-Professor of human biology, University of Colorado School of Dentistry, Denver, 0010. TYLER, WALTZB S., D.V.M., Ph. D.-Professor and chairman, Department of Anat- omy, School of Veterinary Medicine, University of California, Davis, Calif. UNDERWOOD, PAUL, M.D.-Assbstant professor of obstetrics and gynecology, De- partment of Obstetrics and Gynecology, University of South Carolina Medical School, Charleston, S.C. VAN DWREN, BENJAMIN L., M.D.-Associate professor, New York University Medical Center, Institute of Environmental Health, New York, N.Y. WEIB, JOHN M.-Director, Bureau of Dental Health Education, American Dental Association, Chicago, Ill. WYNDEB, EBNE~T L., M.D.-Associate member, Sloan-Kettering Institute for Cancer Research, New York, N.Y. The following professional staff of the National Clearinghouse for Smoking ,and Health contributed to the preparation of this report: Louis Nemser, M.D., David V. Sharpe, M.D., Dorothy E. Green, Ph. D., Richard Eisinger, Robert S. Hutchings, Emil Corwin, and Richard W. White. Special thanks are due Jennie M. Jennings, Mildred H. Ritchie, and Donald R. Shopland. vii Table of Contents Foreword-__-_------------------------------------------ Acknowledgments_--_----------------------------------- Part 1. Current Information on the Health Consequences of Smoking: Summary of the Report ____ _ ___ _ _ -_ _ _ _ Part 2. Technical Reports on the Relationship of Smoking to Specific Disease Categories---------------------- Chapter 1. Smoking and Cardiovascular Dis- eases ______ -_--- ________________ Chapter 2. Smoking and Chronic Obstructive Bronchopulmonary Disease------- Chapter 3. Smoking and Cancer------- ________ Chapter 4. Effects of Smoking on Pregnancy---- Chapter 5. Smoking and Noncancerous Oral Dis- ease_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ PW iii V 1 7 9 35 53 75 83 iX