Th e
Health Consequences
of Smoking

A Report of the Surgeon General: 1971

U.S. DEPARTMENT OF HEALTH, EDUCATION, AND WELFARE
             Public Health Service


For sale by the Superintendent of Documents, U.S. Government Printing OI%x
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This report is a comprehensive review of more than 20 years
of research into the problem of smoking and health. This re-
search has been carried on under the sponsorship of many groups
in this country and abroad, including governments, universities,
private research institutions, voluntary health agencies, and the
tobacco industry.

Seven years ago, an advisory committee to the Surgeon General
concluded that cigarette smoking is a serious hazard to health and
is related to illness and death from lung cancer, chronic broncho-
pulmonary disease, cardiovascular disease and other diseases. In
the intervening years, a great deal of new research has been com-
pleted.  This has resulted in a growing understanding of the bio-
mechanisms whereby cigarette smoking adversely affects the hu-
`man organism and contributes to the development of serious
illness.

It is encouraging that cigarette consumption in this country is
declining.  If this decline can be maintained, it will result in better
health for our population and in fewer deaths among those of our
@tizens who are in their most productive years of life.

JESSE L. STEINFELD, M.D.,
       Surgeon General.


Acknowledgments

The National Clearinghouse for Smoking and Health, Daniel
Horn, Ph.D., Director, was responsible for the preparation of this
report. Daniel P. Asnes, M.D., was consulting editor.  Staff direc-
tor for the report was David G. Cook, 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.-Chief, Pulmonary Disease Section, University
of Louisville School of Medicine, Louisville, Ky.
AKTHONISEN, NICHOLAS, R., M.D.-Ph. D.--Associate Professor, Department
of Experimental Medicine, McGill University, Montreal, Quebec, Canada.
AUERBXH, OSCAR, M.D.-Senior Medical Investigator, VA Hospital, East
Orange, N.J.

AYRES, STEPHEN M., M.D.-Director, Saint Vincent's Hospital and Medical
Center of New York, Cardiopulmonary Laboratory, New York, N.Y.
BAKER, CARL, M.l).-Director, National Cancer Institute, National Institutes
of Health, Bethesda, Md.

BELLET, SAMUEL, M.D.-Director, Division of Cardiology, Philadelphia General
Hospital, Philadelphia, Pa.

BI~`G, RICHARD J., M.D.-Professor, of Medicine, California Institute of Tech-
nology, Pasadena, Calif.

BOCK, FRED G., Ph. D.-Ijirector, Orchard Park Laboratories, Roswell Park
Memorial Institute, Orchard Park, N.Y.
BOREN, HOLLIS, M.D.-Professor of Medicine, Marquette School of Medicine,
Wood VA Hospital, Milwaukee, Wis.

BOUTWELL, ROSWELL Ii., M.D.-Professor of Oncology, McArdle Laboratory
for Cancer Research, University of Wisconsin, Madison, Wis.
COOPER, THEODORE, MD-1 iirector, National Heart Institute, National In-
stitutes of Health, Bethesda, Md.

CORNFIELD, JEROME-Research Professor of Biostatistics, University of Pitts-
burgh Graduate School of Public Health, Riostatistics Project, Bethesda, Md.
EARL, CHRISTOPHER J., M.L).-National Hospital, London, England.
EPSTEIX, FREDERICK H., M.D-Professor of Epidemiology, University of
Michigan, School of Public Health, Ann Arbor, Mich.
FALK, HANS L., Ph. I).--.Associate Ijirector for Laboratory Research, National
Institute of Environmental Health Sciences, Research Triangle Park, N. C.
FERRIS, BENJAMIN G., JR.. M.I).-Professor, Department of Physiology, Har-
vard School of Public Health, Boston, Mass.


FITZPATRICK, MARK J., M.D., M.P.H.-Obstetrician, Perinatal Biology and In-
fant Mortality, National Institute of Child Health and Human Development,
National Institute of Child Health and Human Development, National In-
stitutes of Health, Bethesda, Md.

FRAZIER, TODD M.-Assistant Director, Harvard Center for Community Health
and Medical Care, Harvard &ho01 of Public Health, Boston, Mass.
GOLDSMITH, JOHN R., M.D.-Head, Environmental Epidemiology Unit, Cali-
fornia State Department of Public Health, Berkeley, Calif.
HANNA, MICHAEL G., JR., Ph. D.-Biology Division, Oak Ridge National Lab-
oratory, Oak Ridge, Tenn.

HIGGINS, IAN T. T., M.D., M.R.C.P.-Professor, Department of Epidemiology,
University of Michigan Schclol of Public Health, Ann Arbor, Mich.
HOFFMANN, DIETRICH, Ph. D.-Division of Environmental Toxicology, Ameri-
can Health Foundation, New York, N.Y.
ISRAEL, ROBERT A.-Director, Division of Vital Statistics, National Center for
Health Statistics, U.S.P.H.S., U.S. Department. of Health, Education and
Welfare, Rockville, Md.

KELLER, ANDREW Z., D.M.D., M.P.H.-Chief, Research in Geographic Epide-
miology, Veterans Administration Central Office, Washington, D.C.
KIRSNER, JOSEPH, M.D.-Professor of Medicine, University of Chicago School
of Medicine, Chicago, Ill.

KNOX, DAVID L., M.D.-Associate Professor, The Wilmer Ophthalmological
Institute, The Johns Hopkins University School of Medicine, Baltimore, Md.
KOLBYE, ALBERT C., JR., M.D., J.D.-Deputy Director, Bureau of Foods, Food
and Drug Administration, U.S. Department of Health, Education and Wel-
fare, Washington D.C.

KOTIN, PAUL, M.D.-Director, National Institute of Environmental Health
Sciences, Research Triangle Park, North Carolina.
KRUMHOLZ, RICHARD A., M.D.--Director, Institute of Respiratory Diseases,
Kettering Medical Center, Kettering, Ohio.
LIEBOW, AVERILL A., M.D.-Professor and Chairman, Department of Path-
ology, University of California at San Diego, La Jolla, Calif.
LILIENFELD, ABRAHAM, M.D.--Professor and Chairman, Department of
Chronic Diseases, Johns Hopkins School of Hygiene and Public Health,
Baltimore, Md.

MACMAHON, BRIAN, M.D.-Professor of Epidemiology, Harvard University
School of Public Health, Boston, Mass.
MCLEAN, Ross, M.D.-Medical Consultant, Regional Medical Program of
Texas, Austin, Tex.

MCMILLAN, GARDNER C., M.I).--Chief, Arteriosclerotic Disease Branch, Na-
tional Heart and Lung Institute, National Institutes of Health, Bethesda, Md.
MITCHELL, ROGER S., M.I).-Director, University of Colorado Medical Center,
Webb-Waring Institute for Medical Research, Denver, Colo.
MURPHY, EDMOND A., M.D., SC. D.-Associate Professor of Medicine and Bio-
statistics, The Johns Hopkins Hospital, Baltimore, Md.
PAFFENBARGER, RALPH S., JR., M.D.-Chief, Bureau of Adult Health and
Chronic Diseases, California State Department of Public Health, Berkeley,
Calif.

PETERS, JOHN M., M.D.-Associate Professor of Occupational Medicine, Har-
vard University School of Public Health, Boston, Mass .
PETERSON, WILLIAM F., M.D.--Chairman, Department of Obstetrics and
Gynecology, Washington Hospital Center, Washington, D.C.
PETTY, THOMAS L., M.D-Associate Professor of Medicine, University of
Colorado Medical Center, Denver, Colo.

vi


SAFFIOTTI, UMBERTO, M.D.--Associate Scientific Director for Carcinogenesis
Etiology, National Cancer Institute, National Institutes of Health, Beth-
esda, Md.

SCHUMAN, LEONARD M., M.D.-Professor and Head, Division of Epidemiology,
University of Minnesota School of Public Health, Minneapolis, Minn.
SHIIMKIK, MICHAEL B., M.D.-Coordinator, Regional Medical Program, Uni-
versity of California at San Diego, La Jolla, Calif.
STAMLER, JEREMIAH, M.D.-Executive Director, Chicago Board of Health,
Health Research Foundation, Chicago, 111.
UNDERWOOD, PAUL B., JR., M.D.--Associate Professor, Department of Ob-
stetrics and Gynecology, University of South Carolina Medical School,
Charleston, S.C.

VAN DUUREN, BENJAMIN L., M.D.-Professor of Environmental Medicine, In-
stitute of Environmental Medicine, New York University Medical Center,
New York, N.Y.

VICTOR, MAURICE, M.D.-Professor of Neurology, Department of Neurology,
Case Western Reserve, Cleveland, Ohio.
WYNDER, ERNEST L., M.D-President and Medical Director, American Health
Foundation, New York, N.Y.

The following professional staff of the National Clearinghouse
for Smoking and Health contributed to the preparation of this re-
port: John H. Holbrook, M.D., Richard W. White, Robert S. Hutch-
ings, Elaine Bratic, Annabel W. Hecht, Richard H. Amacher,
Donald R. Shopland and Jennie M. Jennings.
Special thanks are due Nancy S. Johnston, Kathryn Carlysle,
Mary E. Dement, and Mildred H. Ritchie.

vii


           Contents

                                       Page
PREFACE . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .     ...
                                                        111

ACKNOWLEDGMENTS   . . . . . . . . . . . . . . . . . . . . . . . . . . . .      v
Chapter 1. Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . .     1
Chapter 2. Cardiovascular Diseases . . . . . . . . . . . . . . . . . . .    15
Chapter 3. Chronic Obstructive Bronchopulmonary
       Disease . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .   135
Chapter 4. Cancer . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .   231
Chapter 5. Pregnancy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .   385
Chapter 6. Peptic Ulcer . . . . . . . . . . . . . . . . . . . . . . . . . . . . .   419
Chapter 7. Tobacco Amblyopia . . . . . . . . . . . . . . . . . . . . . . .   431