U.S. DEPARTMENT OF HEALTH, EDUCATION, AND WELFARE Public Health Service Health Services and Mental Health Administration Th e Health Consequences of Smoking January 1973 U.S. DEPARTMENT OF HEALTH, EDUCATION, AND WELFARE Public Health Service For sale by the Sqwintendent of Documents U.S. Government. Printing Office, Washington. D.C. 20102 Priw $1.85 domestic postpaid or $1.60 GPO Rookstow Stock Number 17'2&00064 Preface This report is the seventh in a series issued by the Public Health Service reviewing and assessing the scientific evidence linking ciga- rette smoking to disease and premature deat.11. The current report reiterates, strengthens, and extends the findings in earlier reports that cigarette smoking is a major health problem in the United States. The evidence has broadened dramatically in recent years. A Public Hea1t.h Service assessment of evidence available in 1050 was largely focused on the relationship of cigarette smoking and lung cancer. The first formal report on this subject in 1964 found that cigarette smoking was not, only a major cause of lung cancer and chronic bronchitis, but was associat.ed with illness and death from chronic hronchopulmonary disease, cardiovascular disease, and other diseases. The 1973 report confirms all these relationships and adds new evidence in other areas as well. The evidence in the chapter on preg- nancy strongly indicates a causal relationship between cigarette smoking during pregnancy and lower infant, birth weight. and a strong, probably causal, association between cigarette smoking and higher late fetal and neonatal mortality. Also reported is the convergence of other evidence which suggests that, cigarette smoking during pregnancy interacts with other risk factors to increase the risk of an unfavorable outcome of pregnancy for certain women more than others. For the first time in this series of reports, a separate chapter is (lcroted to pipe and cigar smoking and the health hazards involved. lt~clnded is an assessment of the health implications of the new small +ars which look like cigarettes. 41 final chapter, new to the reports. concerns cigarette smoking and "starcise performance. A review of a number of fitness tests comparing >tliokers to nonsmokers indicates that cigarette smoking imp,airs exer- "in performance for many types of athletic events and activit.ies in- l'Olving maximal work rapacity. The interrelationships of smoking and health are no less complex tc)cl:iy than they were reported to be in the 1964 report. But, since (ll:lt;irne we have greatlv broadened our knowledge and understanding `If +he problem. The curient report svmbolizes this progress. . . . 111 Table of Contents PREFACE___-_~-_______-___-~~~---~-~~_-~--~_~__---~__ TABLE OF CONTENTS.. _ - - _ _ _ _ - _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ - PREPARATION OF THE REPORT AND ACKNOWL- EDGMENTS______-_-___-__-__--______--____________ Chapter 1. Cardiovascular Diseases- _ _ _ _ - _ - _ _ _ _ _ _ _ - _ _ __ _ _ _ Chapter 2. Nonneoplastic Bronchopulmonary Diseases- _ _ _ _ _ _ Chapters. Cancer--------..-- ____-______ - -______________ Chapterk Pregnancy----___________________________---- Chapter 5. Peptic Ulcer Disease-------- ____ --_- ____ ----_- Chapter 6. Pipe and Cigar Smoking--_----_-_--_-----_---- Chapter 7. Exercise Performance-----_-------------- _____ - l~DEX_______-__-------------------------------------- Page . . . 111 V vii . . . xln 33 65 99 153 167 239 251 Preparation of the Repot-t and Acknowledgments "Smoking and Health. Report of the Advisory Committee to the Surgeon General of the Public Health Service," subsequently referred to as the "Surgeon General's Report,`? was published in 1964. The National Clearinghouse for Smoking and Health, established in 1965, has the responsibility for the continuous monitoring, compilation, and review of the world's medical literature which bears upon the health consequences of smoking. As called for by Public Law 89-92, the following three reviews of the medical literature on the health conse- quences of smoking, which had come to the attention of the Clearing- house since the original "Surgeon General's Report," were sent to the Congress : 1. "The Health Consequences of Smoking, ,4 Public Health Service Review : 1967" (submitted July 1967). 2. "The Health Consequences of Smoking, 1968 Supplement to the 1967 PHS Review" (submit,ted July 1968). 3. "The Health Consequences of Smoking, 1969 Supplement to the 1967 PHS Review" (submitted July 1969). Public Law 91-222 was signed into law on April 1, 1970, and called for an M-month interval between the 1969 supplement and the next report. During t,his period, a comprehensive review of all of the medi'- ~1 literature available to the Clearinghouse relating to the health consequences of smoking was undertaken, with an emphasis upon the most recent additions to the literature. The product of this review was : "The Health Consequences of Smoking, ,4 Report of the Surgeon General: 1971," submitted to the Congress in January of 1971. Sub- wqnently, a review of the medical literature in the field, which had r"ll~e to the attention of the Clearinghouse since the publication of the 1~1 report, was published as? "The Health Consequences of Smoking, -1 Report of the Surgeon General: 1972," submitted in January of I!,??. vii Every report published since the original "Surgeon General's Re- port" has contained a review of the medical literature relevant to the association between smoking and cardiovascular disease, nonneoplastic bronchopulmonary disease, and cancer. Several of the reports in- cluded reviews of the relationship between smoking and peptic ulcer disease (1967,1971,1972) and cigarette smoking and pregnancy (1967, 1969, 1971, 1972). Other topics relating to the use of tobacco have received special emphasis in single reports : 1. Tobacco Amblyopia (1971 Report). 2. Allergy (1972 Report). 3. Public Exposure to Air Pollution From Tobacco Smoke (1972 Report). 4. Harmful Constituents of Cigarette Smoke (1972 Report). 5. Noncancerous Oral Disease (1969 Report). The present document, "The Health Consequences of Smoking: 1973," includes reviews of the relationships between smoking and cardiovascular disease, broachopulmonary disease, cancer, and peptic ulcer disease which are based upon medical liter&ture which has become available to the Clearinghouse since the publication of the 1972 report. It also includes special reviews of the health consequences of pipe and cigar smoking and of the relationship between cigarette smoking and the outcomes of pregnancy. The material in these two latter chaptersreflects a comprehensive review of the pertinent world medical literature which has come to the attention of the Clearing- house since the publication of the original "Surgeon General's Re- port," including material which has be&me available since the 1972 report. The final chapter in t.his year's report is a review of the rela- tionship between. smoking and exercise performance, an area not covered previously in any report. With the exception of "Chapter 4, Pregnancy," each chapter is orga- nized in a: similar fashion. The introduction to each chapter is a sum- mary of t.he work reviewed in previous reports. The summary of each chapter encompasses only the work which has most recently become available to the Clearinghouse. The pregnancy chapter is organized into separate sections according to several different dutcomes of preg- nancy. Each section includes a brief review of previously reported work and contains its own separate summary, in place of an.overaIl summary for the entire chapter. Viii The preparation of this report was accomplished in the following fashion : 1. The continuous monitoring and compilation of the medical liter- ature on the health consequences of smoking was accomplished through several mechanisms. (a) An inform&on science corporation is on contract to extract articles on smoking and health from the medical literature of the world. This organization provides a semimonthly ac- cessions list with abstracts and copies of the various articles. Translations are called for as needed. Articles are classified according to subject and filed by a series of code words and phrases. (6) The Kational Library of Medicine, through the Medlars system, sends the National Clearinghouse for Smoking and Health a monthly listing of articles in the smoking and health area. These are reviewed, and articles not identified by the information science corporation are ordered. (c) Staff members review current medical literature and identify pertinent articles. 2. The first drafts of the individual chapters were sent to reviewers for criticism and comment with respect to the articles reviewed, articles not included, and conclusions. The drafts were then re- vised until they met wit.h the general approval of the reviewers. The final drafts were reviewed as a whole by the Director of the National Clearinghouse for Smoking and Health, the Director of the National Cancer Institute, the Director of the National Heart and Lung Institute, the Director of the National Institute of Environmental Health Sciences, the Surgeon General, and by additional experts both within and outside of the Public Health c ervice. $ Acknowledgments `l%e Sational Clearinghouse for Smoking and Healt.h, Daniel Horn. 1%. I)., Director, was respousible for the preparation of this report. ~~rllica'l Staff D' lrector .for the report was Elvin E. Adams, M.D., ~~ssist:mt AIedical Staff Director was H. Stephen Williams, 3s.D. con- Sillting editors were Daniel P. Asnes. M.D., David G. Cook. M.D., and *`Otlll EI. Holbrook, M.D. `I%? professional staff has had the assistance and aclvice of a number `If (`~prrts ill the scientific aucl technical fields, both in ant1 outside the ix Government. Their contributions are gratefully acknowledged. Special thanks are due the following : ANDERSON, WILLIAM H., M.D.-Chief, Pulmonary Section, School of Medicine, University of Louisville, Louisville, Ky. AUERBACH, OSCAR, M.D.-Senior Medical Investigator, Veteraus Administration Hospital, East Orange, N.J. AYRES, STEPHEN M., M.D.-Director, Cardiopulmonary LaboratorS, Saint Vincent's Hospital and Medical Center of New York, New York, N.Y. BOCK, FRED G., Ph. D.-Director, Orchard Park Laboratories, Roswell Park Memorial Institute, Orchard Park, N.Y. BOREN, HOLLIS G., M.D.-Medical Investigator, Veterans Administration Hos- pital, Tampa, Fla. BOUTWELL, ROSWELL K., M.D.-Professor of Oncology, McArdle Laboratory for Cancer Research, University of Wisconsin, Madison, Wis. BROSS, IBWIN, M.D.-Director of Biostatistics, Roswell Park Memorial Institute, Buffalo, S.Y. COOPER, TIIEODOBE, M.D.-Director, National Heart and Lung Institute, National Institutes of Health, Bethesda, Md. EPSTEIN, FREDERICK H., M.D.-Director and Professor of Epidemiology, School of Public Health, University of Michigan, Ann Arbor, Mich. FALK, HANS L., Ph. D.-Associate Director for Program, National Institute of Environmental Health Sciences, Research Triangle Park, N.C. FERRIS, BENJAMIN G., Jr., M.D.-Professor of Environmental Health and Safety, School of Public Health, Harvard University, Boston, Mass. FRAZIER, TODD M.-Assistant Director, Harvard Center for Community Health anif Medical Care, School of Public Health, Harvard University, Boston, Mass. E'RESTON, JAXES, M.D.-Associate Professor of Medicine, Head, Division of Gastroenterology. University of Utah Medical School, Salt Lake City, Utah. GOLDSLUTH, JOHN R., M.D.-Head, &vironmental Epidemiology- Unit, Bureau of Occupational Health and Environmental Epidemiology, California State De- partment of Public Health, Berkeley, Calif. GORI, GIO BATTA, M.D.-Associate Scientific Dix%ctor for Program, Division of Cancer Cause and Prevention, National Cancer Institute, Bethesda, Md. HIGOINS. 1.4~ T. T., M.D.-Professor of Epidemiology, School of Public Health, University of Michigan, Ann Arbor, Mich.. HOFFMAN?, DIETBICH, Ph. D.-Chief, Division of Environmental Carcinogenesis. American Health Foundation, New York, N.Y. KELLEK, ANDREW Z., D.Y.D.-Chief, Research in Geographic Epidemiology, Vet- erans Administration Central Office, Washington, D.C. KIRSSER, JOSEPH B., M.D., Ph. D.-Chief of Staff and Deputy Dean for Medical Affairs, The Pritzker School of Medicine, University of Chicago Hospitals and Clinics, Chicago, Ill. KOLBYE, ALBERT C., Jr., M.D. J.D.-Deputy Director, Bureau of Foods, Food and Drug Administration. U.S. Department of Health, Education, and Welfare, Washington, D.C. KR~UAOIZ, RIUIARD A., M.D.-Medical Director, Institute of Respiratory Dis- eases, Ketteriug aledical (`enter, Kettering, Ohio. LILIEKFELD, ABR~HA~~, M.D.-Professor and Chairman, Department 0P Epidem- iology, School of Hygiene and Public Health, The Johns Hopkins University, Baltimore, Md. M\Ic.~.E.\s, Ross, JI.D.iProfessor of Medicine, Bowman Gras School of Medicine, Wake Forest University, Winston-Salem, N.C. x ~loMmr.~K, GABDNEX C., M.D.-Chief, Arteriosclerotic Disease Branch, National Heart and Lung Institute, Sational Institutes of Health, Bethesda, Md. ,\IACMAHON, BRIAN, M.D.-Professor of Epidemiology, School of Public Health, Harvard University, Boston, Mass. NEPEB, MABY B., M.S.-Assistant Professor of Epidemiology, The Johns Hopkins University, Baltimore, Md. JIITCHELL, R~~EB S., M.D.-Chief of Staff, Veterans Administration Hospital, Denver, Colo. MIUBPHY, EDMOND A., M.D., SC. D.-Associate Professor of Medicine and Bio- statistics, The Johns Hopkins Hospital, Baltimore, Md. SETTESHEIM, PAUL, M.D.-Group Leader, Respiratory Carcinogenesis, Biology Division, Oak Ridge Sational Laboratory, Oak Ridge, Term. PAFFENBABOER, RALPH S., Jr., M.D.-Chief Epidemiology Section. Bureau Of Adult Health and Chronic Diseases, California State Department of Public Health, Berkeley. Calif. P~EBSON, WILLL~X F., M.D.--Chairman, Department of Obstetrics and Gyne- cology, Washington Hospital Center, Washington, D.C. F'ETTY, THOMAS I,., M.D.-Associate Professor of Medicine and Head, Division of Pulmonary Diseases, University of Colorado Medical Center, Denver, Cola. RALL, DAVID P.. M.D.-Director, Sational Institute of Environmental Health Sciences, Research Triangle Park, N.C. RAUBCHEIL, FRANK J., M.D.-Director, National Cancer Institute, Sational Insti- tutes of Health, Bethesda, Md. REINKK, WILLIAM A. Ph. D.-Professor, Department of International Health, The Johns Hopkins University. Baltimore, Md. REXZEXTI, ATTILIO D., Jr., M.D.-Professor of Medicine, Pulmonary Disease Division, University of Utah Medical Center. Salt Lake City, Utah. ROBINS, MoBToN-Chief of Study, Design, and Analysis Staff, Regional Medical Programs Service, Health Services and Mental Health Administration, Rock- ville, Md. SWFI~TTI, UMBEBTO. M.D.-Associate Scientific Director for Carcinogenesis, Division of Cancer Cause and Prevention, National Cancer Institute, National Institutes of Health, Bethesda, Md. SOtruMAN, LEONARD M., M.D.-Professor and Head, Division of Epidemiology, School of Public Health, University of Minnesota, Minneapolis, Minn. StttSIKIN, MICHAEL B., M.D.-Professor of Community Medicine and Oncology and Coordinator, Regional Medical Program, University of California at San Blego, La Jolla, Calif. sTp-\~~LER, JEREMIAH, M.D.-Professor and Chairman, Department of Community Health and Preventive Medicine, Northwestern University, Chicago, Ill. \`AS DUIJREN, BENJAMIN L., M.D.-Professor of Environmental Medicine, Insti- tute of Environmental Medicine, New York University Medical Center, New York, N.Y. n'rKoKa, EBXEST L., M.D.-President, American Health Foundation, New York, S.P. The following additional staff members of the National Clearinghouse for stlloking and Health contributed to the preparation of this report: Richard H. -i*bacher, Marjorie L. Brigham, Emil Corwin. Lillian Davis, Gertrude P. Herrin, k'Il)frt S. Hutchings, Jennie 31. Jennings, Sancy S. Johnston, Dan Semzer, `*il(lrcd Ritchie, James A. Robertson, Donald R. Shopland, and Kathleen H. smith. xi