The Health Consequences of Smoking
Executive Summary
This report of the Surgeon General on the health This approach separates the classification of the effects of smoking returns to the topic of active smok- evidence concerning causality from the implications ing and disease, the focus of the first Surgeon General’s of that determination. In particular, the magnitude of report published in 1964 (U.S. Department of Health, the effect in the population, the attributable risk, is Education, and Welfare [USDHEW] 1964). The first considered under “implications” of the causal deter- report established a model of comprehensive evidence mination. For example, there might be sufficient evi- evaluation for the 27 reports that have followed: for dence to classify smoking as a cause of two diseases those on the adverse health effects of smoking, the but the number of attributable cases would depend evidence has been evaluated using guidelines for as- on the frequency of the disease in the population and sessing causality of smoking with disease. Using this the effects of other causal factors. model, every report on health has found that smoking This report covers active smoking only. Passive causes many diseases and other adverse effects. Re- smoking was the focus of the 1986 Surgeon General’s peatedly, the reports have concluded that smoking is report and subsequent reports by other entities the single greatest cause of avoidable morbidity and (USDHHS 1986; U.S. Environmental Protection Agen- mortality in the United States. cy [EPA] 1992; California EPA 1997; International Agen- Of the Surgeon General’s reports published since cy for Research on Cancer [IARC] 2002). The health 1964, only a few have comprehensively documented effects of pipes and cigars, also not within the scope of and updated the evidence on active smoking and dis- this report, are covered in another report (NCI 1998). ease. The 1979 report (USDHEW 1979) provided a In preparing this report, the literature review broad array of information, and the 1990 report on approach was necessarily selective. For conditions for smoking cessation (U.S. Department of Health and which a causal conclusion had been previously Human Services [USDHHS] 1990) also investigated reached, there was no attempt to cover all relevant lit- major diseases caused by smoking. Other volumes erature, but rather to review the conclusions from pre- published during the 1980s focused on specific groups vious Surgeon General’s reports and focus on impor- of diseases caused by smoking (USDHHS 1982, 1983, tant new studies for that topic. The enormous scope 1984), and the 2001 report was devoted to women and of the evidence precludes such detailed reviews. For smoking (USDHHS 2001). Because there has not been conditions for which a causal conclusion had not been a recent systematic review of the full sweep of the previously reached, a comprehensive search strategy evidence, the topic of active smoking and health was was developed. Search strategies included reviewing considered an appropriate focus for this latest report. previous Surgeon General’s reports on smoking, pub- Researchers have continued to identify new adverse lications originating from the largest observational effects of active smoking in their ongoing efforts to studies, and reference lists from important publica- investigate the health effects of smoking. Lengthy tions; consulting with content experts; and conduct- follow-ups are now available for thousands of partici- ing focused literature searches on specific topics. For pants in long-term cohort (follow-up) studies (National this report, studies through 2000 were reviewed. Cancer Institute [NCI] 1997). In addition, conclusions from prior reports con- This report also updates the methodology for cerning smoking as a cause of a particular disease have evaluating evidence that the 1964 report initiated. been updated and are presented in this new format Although that model has proved to be effective, this based on the evidence evaluated in this report (Table report establishes a uniformity of language concern- 1.1). Remarkably, this report identifies a substantial ing causality of associations so as to bring greater speci- number of diseases found to be caused by smoking ficity to the findings of the report. Beginning with this that were not previously causally associated with report, conclusions concerning causality of association smoking: cancers of the stomach, uterine cervix, will be placed into one of four categories with regard pancreas, and kidney; acute myeloid leukemia; pneu- to strength of the evidence: (1) sufficient to infer a monia; abdominal aortic aneurysm; cataract; and causal relationship, (2) suggestive but not sufficient to periodontitis. The report also concludes that smoking infer a causal relationship, (3) inadequate to infer the generally diminishes the health of smokers. presence or absence of a causal relationship, or (4) sug- gestive of no causal relationship.
Executive Summary 1 Surgeon General’s Report
Table 1.1 Diseases and other adverse health effects for which smoking is identified as a cause in the current Surgeon General’s report Disease Highest level conclusion from previous Conclusion from the 2004 Surgeon Surgeon General’s reports (year) General’s report Cancer
Bladder cancer “Smoking is a cause of bladder cancer; “The evidence is sufficient to infer a cessation reduces risk by about 50 percent causal relationship between smoking after only a few years, in comparison with and. . .bladder cancer.” continued smoking.” (1990, p. 10)
Cervical cancer “Smoking has been consistently associated “The evidence is sufficient to infer a with an increased risk for cervical cancer.” causal relationship between smoking (2001, p. 224) and cervical cancer.”
Esophageal cancer “Cigarette smoking is a major cause of “The evidence is sufficient to infer a esophageal cancer in the United States.” causal relationship between smoking (1982, p. 7) and cancers of the esophagus.”
Kidney cancer “Cigarette smoking is a contributory factor “The evidence is sufficient to infer a in the development of kidney cancer in the causal relationship between smoking United States. The term ‘contributory and renal cell, [and] renal pelvis. . . factor’ by no means excludes the possibil- cancers.” ity of a causal role for smoking in cancers of this site.” (1982, p. 7)
Laryngeal cancer “Cigarette smoking is causally associated “The evidence is sufficient to infer a with cancer of the lung, larynx, oral cavity, causal relationship between smoking and esophagus in women as well as in and cancer of the larynx.” men. . . .” (1980, p. 126)
Leukemia “Leukemia has recently been implicated “The evidence is sufficient to infer a as a smoking-related disease. . .but this causal relationship between smoking observation has not been consistent.” and acute myeloid leukemia.” (1990, p. 176)
Lung cancer “Additional epidemiological, pathological, “The evidence is sufficient to infer a and experimental data not only confirm the causal relationship between smoking conclusion of the Surgeon General’s 1964 and lung cancer.” Report regarding lung cancer in men but strengthen the causal relationship of smoking to lung cancer in women.” (1967, p. 36)
Oral cancer “Cigarette smoking is a major cause of “The evidence is sufficient to infer a cancers of the oral cavity in the United causal relationship between smoking States.” (1982, p. 6) and cancers of the oral cavity and pharynx.”
2 Executive Summary The Health Consequences of Smoking
Table 1.1 Continued Disease Highest level conclusion from previous Conclusion from the 2004 Surgeon Surgeon General’s reports (year) General’s report Pancreatic cancer “Smoking cessation reduces the risk of “The evidence is sufficient to infer a pancreatic cancer, compared with contin- causal relationship between smoking ued smoking, although this reduction in and pancreatic cancer.” risk may only be measurable after 10 years of abstinence.” (1990, p. 10)
Stomach cancer “Data on smoking and cancer of the “The evidence is sufficient to infer a stomach. . .are unclear.” (2001, p. 231) causal relationship between smoking and gastric cancers.”
Cardiovascular diseases
Abdominal aortic “Death from rupture of an atherosclerotic “The evidence is sufficient to infer aneurysm abdominal aneurysm is more common in a causal relationship between cigarette smokers than in nonsmokers.” smoking and abdominal aortic (1983, p. 195) aneurysm.”
Atherosclerosis “Cigarette smoking is the most powerful “The evidence is sufficient to infer a risk factor predisposing to atherosclerotic causal relationship between smoking peripheral vascular disease.” (1983, p. 8) and subclinical atherosclerosis.”
Cerebrovascular “Cigarette smoking is a major cause of “The evidence is sufficient to infer a disease cerebrovascular disease (stroke), the causal relationship between smoking third leading cause of death in the United and stroke.” States.” (1989, p. 12)
Coronary heart “In summary, for the purposes of preven- “The evidence is sufficient to infer a disease tive medicine, it can be concluded that causal relationship between smoking smoking is causally related to coronary and coronary heart disease.” heart disease for both men and women in the United States.” (1979, p. 1-15)
Respiratory diseases
Chronic obstruc- “Cigarette smoking is the most important “The evidence is sufficient to infer a tive pulmonary of the causes of chronic bronchitis in the causal relationship between active disease United States, and increases the risk smoking and chronic obstructive of dying from chronic bronchitis.” pulmonary disease morbidity and (1964, p. 302) mortality.”
Pneumonia “Smoking cessation reduces rates of “The evidence is sufficient to infer a respiratory symptoms such as cough, causal relationship between smoking sputum production, and wheezing, and and acute respiratory illnesses, includ- respiratory infections such as bronchitis ing pneumonia, in persons without and pneumonia, compared with continued underlying smoking-related chronic smoking.” (1990, p. 11) obstructive lung disease.”
Executive Summary 3 Surgeon General’s Report
Table 1.1 Continued Disease Highest level conclusion from previous Conclusion from the 2004 Surgeon Surgeon General’s reports (year) General’s report Respiratory effects “In utero exposure to maternal smoking is “The evidence is sufficient to infer in utero associated with reduced lung function a causal relationship between maternal among infants. . . .” (2001, p. 14) smoking during pregnancy and a reduction of lung function in infants.”
Respiratory effects “Cigarette smoking during childhood and “The evidence is sufficient to infer in childhood and adolescence produces significant health a causal relationship between active adolescence problems among young people, including smoking and impaired lung growth cough and phlegm production, an during childhood and adolescence.” increased number and severity of respiratory illnesses, decreased physical “The evidence is sufficient to infer fitness, an unfavorable lipid profile, and a causal relationship between active potential retardation in the rate of lung smoking and the early onset of lung growth and the level of maximum lung function decline during late adoles- function.” (1994, p. 41) cence and early adulthood. “
“The evidence is sufficient to infer a causal relationship between active smoking and respiratory symptoms in children and adolescents, including coughing, phlegm, wheezing, and dyspnea.”
“The evidence is sufficient to infer a causal relationship between active smoking and asthma-related symptoms (i.e., wheezing) in childhood and adolescence.”
Respiratory effects “Cigarette smoking accelerates the “The evidence is sufficient to infer in adulthood age-related decline in lung function that a causal relationship between active occurs among never smokers. With smoking in adulthood and a premature sustained abstinence from smoking, the onset of and an accelerated age-related rate of decline in pulmonary function decline in lung function.” among former smokers returns to that of never smokers.“ (1990, p. 11) “The evidence is sufficient to infer a causal relationship between sustained cessation from smoking and a return of the rate of decline in pulmonary function to that of persons who had never smoked.”
4 Executive Summary The Health Consequences of Smoking
Table 1.1 Continued Disease Highest level conclusion from previous Conclusion from the 2004 Surgeon Surgeon General’s reports (year) General’s report Other respiratory “Smoking cessation reduces rates of “The evidence is sufficient to infer effects respiratory symptoms such as cough, a causal relationship between active sputum production, and wheezing, smoking and all major respiratory and respiratory infections such as symptoms among adults, including bronchitis and pneumonia, compared coughing, phlegm, wheezing, and with continued smoking.” (1990, p. 11) dyspnea.”
“The evidence is sufficient to infer a causal relationship between active smoking and poor asthma control.”
Reproductive effects
Fetal death “The risk for perinatal mortality—both “The evidence is sufficient to infer and stillbirths stillbirth and neonatal deaths—and the a causal relationship between sudden risk for sudden infant death syndrome infant death syndrome and maternal (SIDS) are increased among the offspring smoking during and after pregnancy.” of women who smoke during preg- nancy.” (2001, p. 307)
Fertility “Women who smoke have increased “The evidence is sufficient to infer risks for conception delay and for both a causal relationship between smoking primary and secondary infertility.” and reduced fertility in women.” (2001, p. 307)
Low birth weight “Infants born to women who smoke “The evidence is sufficient to infer during pregnancy have a lower a causal relationship between maternal average birth weight. . .than. . .infants active smoking and fetal growth restric- born to women who do not smoke.” tion and low birth weight.” (2001, p. 307)
Pregnancy “Smoking during pregnancy is associated “The evidence is sufficient to infer complications with increased risks for preterm prema- a casual relationship between maternal ture rupture of membranes, abruptio active smoking and premature rupture placentae, and placenta previa, and with of the membranes, placenta previa, and a modest increase in risk for preterm placental abruption.” delivery.” (2001, p. 307) “The evidence is sufficient to infer a causal relationship between maternal active smoking and preterm delivery and shortened gestation.”
Executive Summary 5 Surgeon General’s Report
Table 1.1 Continued Disease Highest level conclusion from previous Conclusion from the 2004 Surgeon Surgeon General’s reports (year) General’s report Other effects
Cataract “Women who smoke have an increased “The evidence is sufficient to infer risk for cataract.” (2001, p. 331) a causal relationship between smoking and nuclear cataract.”
Diminished health “Relationships between smoking and “The evidence is sufficient to infer status/morbidity cough or phlegm are strong and consistent; a causal relationship between smoking they have been amply documented and are and diminished health status that may judged to be causal. . . .” (1984, p. 47) be manifest as increased absenteeism from work and increased use of “Consideration of evidence from many medical care services.” different studies has led to the conclusion that cigarette smoking is the overwhelm- “The evidence is sufficient to infer ingly most important cause of cough, a causal relationship between smoking sputum, chronic bronchitis, and mucus and increased risks for adverse surgical hypersecretion.” (1984, p. 48) outcomes related to wound healing and respiratory complications.”
Hip fractures “Women who currently smoke have an “The evidence is sufficient to infer increased risk for hip fracture compared a causal relationship between smoking with women who do not smoke.” and hip fractures.” (2001, p. 321)
Low bone density “Postmenopausal women who currently “In postmenopausal women, the smoke have lower bone density than do evidence is sufficient to infer a causal women who do not smoke.” (2001, p. 321) relationship between smoking and low bone density.”
Peptic ulcer “The relationship between cigarette “The evidence is sufficient to infer disease smoking and death rates from peptic a causal relationship between smoking ulcer, especially gastric ulcer, is confirmed. and peptic ulcer disease in persons In addition, morbidity data suggest a who are Helicobacter pylori positive.” similar relationship exists with the preva- lence of reported disease from this cause.” (1967, p. 40)
Sources: U.S. Department of Health, Education, and Welfare 1964, 1967, 1979; U.S. Department of Health and Human Services 1980, 1982, 1983, 1984, 1989, 1990, 1994, 2001.
6 Executive Summary The Health Consequences of Smoking
Despite the many prior reports on the topic and by the editors on the basis of the experts’ comments. the high level of public knowledge in the United States Subsequently, the report was reviewed by various in- of the adverse effects of smoking in general, tobacco stitutes and agencies within USDHHS. use remains the leading preventable cause of disease Publication lags, even short ones, prevent an up- and death in the United States, causing approximately to-the-minute inclusion of all recently published ar- 440,000 deaths each year and costing approximately ticles and data. Therefore, by the time the public reads $157 billion in annual health-related economic losses this report, there may be additional published studies (see Chapter 7, “The Disease Impact of Cigarette or data. To provide published information as current Smoking and Benefits of Reducing Smoking”). Nation- as possible, this report includes an appendix of more ally, smoking results in more than 5.6 million years of recent studies that represent major additions to the potential life lost each year. Although the rates of smok- literature. ing continue to decline, an estimated 46.2 million This report is also accompanied by a companion adults in the United States still smoked cigarettes in database of key evidence that is accessible through the 2001 (Centers for Disease Control and Prevention Internet (see http://www.cdc.gov/tobacco). The data- [CDC] 2003a). In 2000, 70 percent of those who smoked base includes a uniform description of the studies and wanted to quit (CDC 2002b). An increasingly disturb- results on the risks of smoking that were presented in ing picture of widespread organ damage in active a format compatible with abstraction into standard- smokers is emerging, likely reflecting the systemic ized tables. Readers of the report may access these data distribution of tobacco smoke components and their for additional analyses, tables, or figures. The Office high level of toxicity. Thus, active smokers are at higher on Smoking and Health at CDC intends to maintain risk for cataract, cancer of the cervix, pneumonia, and this database and will periodically update its contents reduced health status generally. as new reports are published. This new information should be an impetus for even more vigorous programs to reduce and prevent smoking. Smokers need to be aware that smoking car- Organization of the Report ries far greater risks than the most widely known haz- This report covers major groups of the many dis- ards. Health care providers should also use the new eases associated with smoking: cancers, cardiovascu- evidence to counsel their patients. For example, oph- lar diseases, respiratory diseases, reproductive effects, thalmologists may want to warn patients about the and other adverse health consequences. Chapter 1 increased risk of cataract in smokers, and geriatricians includes a discussion of the concept of causation and should counsel their patients who smoke, even the introduces new concepts of causality that are used oldest, to quit. This report shows that smokers who throughout this report. Chapter 2 discusses each of the quit can lower their risk for smoking-caused diseases main sites of cancer and their relationship to smok- and improve their health status generally. Those who ing. Cardiovascular diseases, including atherosclero- never start can avoid the predictable burden of dis- sis, coronary heart disease, stroke, and abdominal ease and lost life expectancy that results from a life- aortic aneurysm are the focus of Chapter 3, which time of smoking. begins with an extensive review of newer findings on the mechanisms by which smoking causes this group Preparation of the Report of very common diseases. Chapter 4 includes both acute respiratory diseases associated with smoking and This report of the Surgeon General was prepared the chronic respiratory diseases long known to be by the Office on Smoking and Health, National Cen- caused by smoking, including accelerated loss of lung ter for Chronic Disease Prevention and Health Promo- function with aging. The full scope of adverse repro- tion, CDC, USDHHS. Initial chapters were written by ductive effects caused by smoking in both men and 19 experts who were selected because of their exper- women is covered in Chapter 5. Chapter 6 discusses tise and familiarity with the topics covered in this other specific effects of smoking on the eyes, the bones, report. Their various contributions were summarized and oral health, along with evidence on more general into six major chapters that were then reviewed by adverse effects related to health status overall. Chap- more than 60 peer reviewers. The entire manuscript ter 7 updates prior estimates of the burden of diseases was then sent to more than 20 scientists and experts, caused by smoking. Finally, Chapter 8 discusses “A who reviewed it for its scientific integrity. After each Vision for the Future” outlining broad strategies and review cycle was completed, the drafts were revised courses of action for tobacco control in the future.
Executive Summary 7 Surgeon General’s Report
Major Conclusions
Forty years after the first Surgeon General’s 2. Quitting smoking has immediate as well as long- report in 1964, the list of diseases and other adverse term benefits, reducing risks for diseases caused effects caused by smoking continues to expand. Epi- by smoking and improving health in general. demiologic studies are providing a comprehensive assessment of the risks faced by smokers who continue 3. Smoking cigarettes with lower machine-measured to smoke across their life spans. Laboratory research yields of tar and nicotine provides no clear ben- now reveals how smoking causes disease at the mo- efit to health. lecular and cellular levels. Fortunately for former smokers, studies show that the substantial risks of 4. The list of diseases caused by smoking has been smoking can be reduced by successfully quitting at any expanded to include abdominal aortic aneurysm, age. The evidence reviewed in this and prior reports acute myeloid leukemia, cataract, cervical cancer, of the Surgeon General leads to the following major kidney cancer, pancreatic cancer, pneumonia, pe- conclusions: riodontitis, and stomach cancer.
1. Smoking harms nearly every organ of the body, causing many diseases and reducing the health of smokers in general.
Chapter Conclusions
Chapter 2. Cancer 5. Even after many years of not smoking, the risk of lung cancer in former smokers remains higher than Lung Cancer in persons who have never smoked. 1. The evidence is sufficient to infer a causal relation- ship between smoking and lung cancer. 6. Lung cancer incidence and mortality rates in men are now declining, reflecting past patterns of ciga- 2. Smoking causes genetic changes in cells of the lung rette use, while rates in women are still rising. that ultimately lead to the development of lung cancer. Laryngeal Cancer 7. The evidence is sufficient to infer a causal relation- 3. Although characteristics of cigarettes have ship between smoking and cancer of the larynx. changed during the last 50 years and yields of tar and nicotine have declined substantially, as as- 8. Together, smoking and alcohol cause most cases sessed by the Federal Trade Commission’s test of laryngeal cancer in the United States. protocol, the risk of lung cancer in smokers has not declined. Oral Cavity and Pharyngeal Cancers 4. Adenocarcinoma has now become the most com- 9. The evidence is sufficient to infer a causal relation- mon type of lung cancer in smokers. The basis for ship between smoking and cancers of the oral cav- this shift is unclear but may reflect changes in the ity and pharynx. carcinogens in cigarette smoke.
8 Executive Summary The Health Consequences of Smoking
Esophageal Cancer Prostate Cancer 10. The evidence is sufficient to infer a causal rela- 20. The evidence is suggestive of no causal relation- tionship between smoking and cancers of the ship between smoking and risk for prostate esophagus. cancer.
11. The evidence is sufficient to infer a causal relation- 21. The evidence for mortality, although not consis- ship between smoking and both squamous cell tent across all studies, suggests a higher mortality carcinoma and adenocarcinoma of the esophagus. rate from prostate cancer in smokers than in non- smokers. Pancreatic Cancer Acute Leukemia 12. The evidence is sufficient to infer a causal relation- ship between smoking and pancreatic cancer. 22. The evidence is sufficient to infer a causal rela- tionship between smoking and acute myeloid Bladder and Kidney Cancers leukemia. 13. The evidence is sufficient to infer a causal relation- 23. The risk for acute myeloid leukemia increases with ship between smoking and renal cell, renal pelvis, the number of cigarettes smoked and with dura- and bladder cancers. tion of smoking. Cervical Cancer Liver Cancer 14. The evidence is sufficient to infer a causal relation- 24. The evidence is suggestive but not sufficient to ship between smoking and cervical cancer. infer a causal relationship between smoking and liver cancer. Ovarian Cancer 15. The evidence is inadequate to infer the presence Adult Brain Cancer or absence of a causal relationship between smok- 25. The evidence is suggestive of no causal relation- ing and ovarian cancer. ship between smoking cigarettes and brain cancer in men and women. Endometrial Cancer 16. The evidence is sufficient to infer that current Breast Cancer smoking reduces the risk of endometrial cancer in 26. The evidence is suggestive of no causal relation- postmenopausal women. ship between active smoking and breast cancer. Stomach Cancer 27. Subgroups of women cannot yet be reliably iden- 17. The evidence is sufficient to infer a causal relation- tified who are at an increased risk of breast cancer ship between smoking and gastric cancers. because of smoking, compared with the general population of women. 18. The evidence is suggestive but not sufficient to infer a causal relationship between smoking and 28. Whether women who are at a very high risk of noncardia gastric cancers, in particular by modi- breast cancer because of mutations in BRCA1 or fying the persistence and/or the pathogenicity of BRCA2 genes can lower their risks by smoking has Helicobacter pylori infections. not been established.
Colorectal Cancer Chapter 3. Cardiovascular Diseases 19. The evidence is suggestive but not sufficient to infer a causal relationship between smoking and Smoking and Subclinical Atherosclerosis colorectal adenomatous polyps and colorectal 1. The evidence is sufficient to infer a causal rela- cancer. tionship between smoking and subclinical atherosclerosis.
Executive Summary 9 Surgeon General’s Report
Smoking and Coronary Heart Disease 6. The evidence is suggestive but not sufficient to infer a causal relationship between maternal smok- 2. The evidence is sufficient to infer a causal relation- ing during pregnancy and an increased risk for im- ship between smoking and coronary heart disease. paired lung function in childhood and adulthood. 3. The evidence suggests only a weak relationship 7. Active smoking causes injurious biologic processes between the type of cigarette smoked and coro- (i.e., oxidant stress, inflammation, and a protease- nary heart disease risk. antiprotease imbalance) that result in airway and alveolar injury. This injury, if sustained, ultimately Smoking and Cerebrovascular Disease leads to the development of chronic obstructive 4. The evidence is sufficient to infer a causal relation- pulmonary disease. ship between smoking and stroke. 8. The evidence is sufficient to infer a causal relation- Smoking and Abdominal Aortic Aneurysm ship between active smoking and impaired lung growth during childhood and adolescence. 5. The evidence is sufficient to infer a causal relation- ship between smoking and abdominal aortic 9. The evidence is sufficient to infer a causal relation- aneurysm. ship between active smoking and the early onset of lung function decline during late adolescence Chapter 4. Respiratory Diseases and early adulthood. Acute Respiratory Illnesses 10. The evidence is sufficient to infer a causal relation- ship between active smoking in adulthood and a 1. The evidence is sufficient to infer a causal relation- premature onset of and an accelerated age-related ship between smoking and acute respiratory ill- decline in lung function. nesses, including pneumonia, in persons without underlying smoking-related chronic obstructive 11. The evidence is sufficient to infer a causal relation- lung disease. ship between sustained cessation from smoking and a return of the rate of decline in pulmonary 2. The evidence is suggestive but not sufficient to function to that of persons who had never smoked. infer a causal relationship between smoking and acute respiratory infections among persons 12. The evidence is sufficient to infer a causal relation- with preexisting chronic obstructive pulmonary ship between active smoking and respiratory disease. symptoms in children and adolescents, including coughing, phlegm, wheezing, and dyspnea. 3. In persons with asthma, the evidence is inadequate to infer the presence or absence of a causal rela- 13. The evidence is sufficient to infer a causal relation- tionship between smoking and acute asthma ship between active smoking and asthma-related exacerbation. symptoms (i.e., wheezing) in childhood and adolescence. Chronic Respiratory Diseases 4. The evidence is sufficient to infer a causal relation- 14. The evidence is inadequate to infer the presence ship between maternal smoking during pregnancy or absence of a causal relationship between active and a reduction of lung function in infants. smoking and physician-diagnosed asthma in childhood and adolescence. 5. The evidence is suggestive but not sufficient to infer a causal relationship between maternal smok- 15. The evidence is suggestive but not sufficient to ing during pregnancy and an increase in the fre- infer a causal relationship between active smok- quency of lower respiratory tract illnesses during ing and a poorer prognosis for children and ado- infancy. lescents with asthma.
10 Executive Summary The Health Consequences of Smoking
16. The evidence is sufficient to infer a causal rela- 2. The evidence is sufficient to infer a causal relation- tionship between active smoking and all major ship between smoking and reduced fertility in respiratory symptoms among adults, including women. coughing, phlegm, wheezing, and dyspnea. Pregnancy and Pregnancy Outcomes 17. The evidence is inadequate to infer the presence 3. The evidence is suggestive but not sufficient to or absence of a causal relationship between active infer a causal relationship between maternal ac- smoking and asthma in adults. tive smoking and ectopic pregnancy. 18. The evidence is suggestive but not sufficient to 4. The evidence is suggestive but not sufficient to infer a causal relationship between active smok- infer a causal relationship between maternal ac- ing and increased nonspecific bronchial hyper- tive smoking and spontaneous abortion. responsiveness. 5. The evidence is sufficient to infer a causal rela- 19. The evidence is sufficient to infer a causal relation- tionship between maternal active smoking and ship between active smoking and poor asthma premature rupture of the membranes, placenta control. previa, and placental abruption. 20. The evidence is sufficient to infer a causal relation- 6. The evidence is sufficient to infer a causal rela- ship between active smoking and chronic obstruc- tionship between maternal active smoking and a tive pulmonary disease morbidity and mortality. reduced risk for preeclampsia. 21. The evidence is suggestive but not sufficient to 7. The evidence is sufficient to infer a causal relation- infer a causal relationship between lower machine- ship between maternal active smoking and measured cigarette tar and a lower risk for cough preterm delivery and shortened gestation. and mucus hypersecretion. 8. The evidence is sufficient to infer a causal relation- 22. The evidence is inadequate to infer the presence ship between maternal active smoking and fetal or absence of a causal relationship between a lower growth restriction and low birth weight. cigarette tar content and reductions in forced ex- piratory volume in one second decline rates. Congenital Malformations, Infant Mortality, and Child Physical and Cognitive Development 23. The evidence is inadequate to infer the presence or absence of a causal relationship between a lower 9. The evidence is inadequate to infer the presence cigarette tar content and reductions in chronic ob- or absence of a causal relationship between ma- structive pulmonary disease-related mortality. ternal smoking and congenital malformations in general. 24. The evidence is inadequate to infer the presence or absence of a causal relationship between active 10. The evidence is suggestive but not sufficient to smoking and idiopathic pulmonary fibrosis. infer a causal relationship between maternal smok- ing and oral clefts.
Chapter 5. Reproductive Effects 11. The evidence is sufficient to infer a causal relation- ship between sudden infant death syndrome and Fertility maternal smoking during and after pregnancy. 1. The evidence is inadequate to infer the presence or absence of a causal relationship between active 12. The evidence is inadequate to infer the presence smoking and sperm quality. or absence of a causal relationship between ma- ternal smoking and physical growth and neuro- cognitive development of children.
Executive Summary 11 Surgeon General’s Report
Chapter 6. Other Effects Eye Diseases Diminished Health Status 12. The evidence is sufficient to infer a causal relation- ship between smoking and nuclear cataract. 1. The evidence is sufficient to infer a causal relation- ship between smoking and diminished health 13. The evidence is suggestive but not sufficient to status that may manifest as increased absenteeism infer that smoking cessation reduces the risk of from work and increased use of medical care nuclear opacity. services. 14. The evidence is suggestive but not sufficient to 2. The evidence is sufficient to infer a causal relation- infer a causal relationship between current and ship between smoking and increased risks for ad- past smoking, especially heavy smoking, with risk verse surgical outcomes related to wound healing of exudative (neovascular) age-related macular and respiratory complications. degeneration.
Loss of Bone Mass and the Risk of Fractures 15. The evidence is suggestive but not sufficient to 3. The evidence is inadequate to infer the presence infer a causal relationship between smoking and or absence of a causal relationship between smok- atrophic age-related macular degeneration. ing and reduced bone density before menopause in women and in younger men. 16. The evidence is suggestive of no causal relation- ship between smoking and the onset or progres- 4. In postmenopausal women, the evidence is suffi- sion of retinopathy in persons with diabetes. cient to infer a causal relationship between smok- ing and low bone density. 17. The evidence is inadequate to infer the presence or absence of a causal relationship between smok- 5. In older men, the evidence is suggestive but not ing and glaucoma. sufficient to infer a causal relationship between smoking and low bone density. 18. The evidence is suggestive but not sufficient to infer a causal relationship between ophthalmopa- 6. The evidence is sufficient to infer a causal relation- thy associated with Graves’ disease and smoking. ship between smoking and hip fractures. Peptic Ulcer Disease 7. The evidence is inadequate to infer the presence 19. The evidence is sufficient to infer a causal relation- or absence of a causal relationship between smok- ship between smoking and peptic ulcer disease in ing and fractures at sites other than the hip. persons who are Helicobacter pylori positive.
Dental Diseases 20. The evidence is inadequate to infer the presence 8. The evidence is sufficient to infer a causal relation- or absence of a causal relationship between smok- ship between smoking and periodontitis. ing and peptic ulcer disease in nonsteroidal anti- inflammatory drug users or in those who are 9. The evidence is inadequate to infer the presence Helicobacter pylori negative. or absence of a causal relationship between smok- ing and coronal dental caries. 21. The evidence is suggestive but not sufficient to infer a causal relationship between smoking and 10. The evidence is suggestive but not sufficient to risk of peptic ulcer complications, although this infer a causal relationship between smoking and effect might be restricted to nonusers of non- root-surface caries. steroidal anti-inflammatory drugs.
Erectile Dysfunction 22. The evidence is inadequate to infer the presence or absence of a causal relationship between 11. The evidence is suggestive but not sufficient to smoking and the treatment and recurrence of infer a causal relationship between smoking and Helicobacter pylori-negative ulcers. erectile dysfunction.
12 Executive Summary The Health Consequences of Smoking
Chapter 7. The Impact of Smoking on 3. Meeting the Healthy People 2010 goals for current Disease and the Benefits of Smoking smoking prevalence reductions to 12 percent Reduction among persons aged 18 years and older and to 16 percent among youth aged 14 through 17 years will 1. There have been more than 12 million premature prevent an additional 7.1 million premature deaths deaths attributable to smoking since the first pub- after 2010. Without substantially stronger national lished Surgeon General’s report on smoking and and state efforts, it is unlikely that this health goal health in 1964. Smoking remains the leading pre- can be achieved. However, even with more mod- ventable cause of premature death in the United est reductions in tobacco use, significant additional States. reductions in premature death can be expected.
2. The burden of smoking attributable mortality will 4. During 1995–1999, estimated annual smoking at- remain at current levels for several decades. Com- tributable economic costs in the United States were prehensive programs that reflect the best available $157.7 billion, including $75.5 billion for direct science on tobacco use prevention and smoking medical care (adults), $81.9 billion for lost produc- cessation have the potential to reduce the adverse tivity, and $366 million for neonatal care. In 2001, impact of smoking on population health. states alone spent an estimated $12 billion treat- ing smoking attributable diseases.
A Vision for the Future
This report of the Surgeon General on the health USDHEW 1964) was a landmark and pivotal event in effects of smoking returns to the topic of the first Sur- the history of public health. By that time, there was a geon General’s report on active smoking and disease. rapidly accumulating amount of evidence on the dan- This current report discusses many diseases associated gers of smoking, and it was inevitable that action with smoking including cancer, cardiovascular dis- would follow the publication of a comprehensive ex- eases, respiratory diseases, reproductive effects, and pert report with the powerful conclusion that smok- other adverse health consequences, and also updates ing causes disease. Since 1964, there has been a broad prior estimates of the burden of diseases caused by societal shift in the acceptability of tobacco use and in smoking. the public’s knowledge about the accompanying health The courses of action highlighted below are po- risks. In 1963, per capita annual adult consumption in tential next steps presented by the Surgeon General. the United States peaked at 4,345 cigarettes, a figure Given his role as the nation’s spokesman on matters that included both smokers and nonsmokers (Giovino of public health, these recommendations represent a et al. 1994). By 2002, per capita annual consumption in vision for the future built on information available to- this country had declined to 1,979 cigarettes, the low- day. They do not constitute formal policy statements, est level since before the start of World War II (U.S. but are intended to inform and guide policymakers, Department of Agriculture 2003). In 1964, the major- public health professionals, professional and advocacy ity of men smoked and an increasing number of organizations, researchers, and most important, the women were becoming smokers. Today, there are more American people, to ensure that efforts to prevent and former smokers than current smokers, and each year control tobacco use are proportionate to the harmful over half of all daily smokers try to quit (CDC 2003a). effects it causes. In 1964, smoking a cigarette was viewed as a “rite of passage” by almost all adolescents. Today, only about half of all high school seniors have ever smoked a ciga- Tremendous Progress Since 1964 rette and less than one in four is a current smoker, the lowest level since researchers started monitoring smok- The publication of the first Surgeon General’s ing rates among high school seniors in the mid-1970s report on smoking and health in January of 1964 (U.S. (University of Michigan 2003).
Executive Summary 13 Surgeon General’s Report
In 1964, smoking was permitted almost every- (CDC 2003a). Equally disturbing, the rates of smok- where, and even the U.S. Public Health Service had ing among some racial and ethnic minority popula- logo ashtrays on its conference tables. Today, second- tions and among less educated Americans remain high hand tobacco smoke is widely accepted as a public (CDC 2003a). Although the percentage of high school health hazard and levels of exposure among nonsmok- seniors who are current smokers has been reduced ers have declined dramatically over the last decade. from 36.5 percent in 1997 to 24.4 percent in 2003, the In fact, there is an unprecedented level of activity to trends in youth smoking over the last few years indi- achieve clean indoor air quality at both the local and cate that the rate of decline is slowing appreci- state levels. More communities and states are consid- ably (CDC 2003d; University of Michigan 2003). ering and adopting laws that are even more compre- Although the level of secondhand tobacco smoke that hensive in the range of venues they cover. The 1964 nonsmokers are exposed to has declined significantly Surgeon General’s report on smoking and health in the last decade, the decline has been greater among started this country on an epic process of change to- adults than among children, who are largely exposed ward a society free of tobacco-related disease and at home. Currently, levels of exposure to this known death. Yet many challenges remain. human carcinogen are more than twice as high among nonsmoking children than among nonsmoking adults (CDC 2003c). Finally, while the knowledge that smok- The Need for a Sustained Effort ing can adversely affect health has become widespread among the general public, the grave health risks re- Smoking remains the leading preventable cause main poorly understood. of disease and death in the United States, resulting in In recognition of the need to enhance public un- more than 440,000 premature deaths each year (CDC derstanding of these health consequences of smoking, 2002a; see also Chapter 7, “The Impact of Smoking on this Surgeon General’s report introduces a “Public Disease and the Benefits of Smoking Reduction”). In Summary” that will serve as the foundation of a con- 1964, the list of diseases known to be caused by smok- tinuing effort to disseminate the findings of this re- ing was short: chronic bronchitis and cancers of the port more widely and comprehensively at the national, lung and larynx (USDHEW 1964). Each subsequent community, and local levels (among individuals and Surgeon General’s report has expanded the under- families). In 1964, the conclusion that smoking causes standing of the magnitude of the health consequences lung cancer was major news; today, it is widely ac- of tobacco use. According to this 2004 report, the num- cepted. Unfortunately for many people, the multiple ber of diseases caused by smoking has continued to ways in which smoking damages almost every organ increase. The list is now so long, this report concludes of the human body are not well understood. that smoking harms nearly every organ of the body To help educators, the media, and health profes- and causes generally poorer health. For this reason, sionals more fully understand the scientific basis for the burden of tobacco use on the physical and eco- all of the conclusions in this Surgeon General’s report, nomic health of this country remains staggering. Since a companion database of the more than 1,600 articles the release of the 1964 Surgeon General’s report on cited in this report will be available for the first time smoking and health, more than 12 million Americans on the Internet at
14 Executive Summary The Health Consequences of Smoking
The Need for a Comprehensive Approach places, and the perception by some that the problem has been solved. Additionally, funding levels for many The 2000 Surgeon General’s report, Reducing effective state and national counter-advertising Tobacco Use, provided a detailed framework for com- campaigns were recently reduced. We know enough prehensive tobacco use prevention and control efforts: to take action. As in many areas of public health, there educational, clinical, regulatory, economic, and social is a need to improve the dissemination, adoption, and approaches (USDHHS 2000). That report noted that implementation of effective, evidence-based interven- “…our recent lack of progress in tobacco control is at- tions, and to continue to investigate new methods to tributable more to the failure to implement proven prevent and reduce tobacco use. strategies than it is to a lack of knowledge about what to do” (USDHHS 2000, p. 436). A comprehensive ap- proach—one that optimizes synergy from a mix of Continuing to Build the educational, clinical, regulatory, economic, and social Scientific Foundation strategies—has emerged as the guiding principle for effective efforts to reduce tobacco use. Progress in tobacco control always has been built There is a very strong scientific base to guide upon a foundation of conclusive scientific knowledge. these sustained efforts. In addition to recent Surgeon Each of the previous 27 Surgeon General’s reports on General’s reports, the Community Preventive Services smoking and health has contributed to this ever- Task Force, the U.S. Public Health Service, and other enlarging foundation not only about the health professional bodies have reviewed the efficacy of consequences of tobacco use, but also about effective specific strategies (Fiore et al. 2000; American Journal of strategies to prevent tobacco use among youth, to help Preventive Medicine 2001). Additionally, CDC’s Best current tobacco users quit, and to protect nonsmok- Practices for Comprehensive Tobacco Control Programs pro- ers from exposure to secondhand tobacco smoke. vides a broad framework for comprehensive statewide Progress in tobacco control always has been built upon tobacco control programs (CDC 1999). Recent analy- a foundation of conclusive scientific knowledge. Each ses of evidence from these state programs conclude of the previous 27 Surgeon General’s reports on smok- that the magnitude and rate of change in smoking ing and health, as well as numerous other publications, behaviors are significantly related to the level and have contributed to this ever-enlarging foundation of continuity of investments in comprehensive program data. These reports include information about the efforts (Farrelly et al. 2003; Stillman et al. 2003). The health consequences of tobacco use, effective strate- results from these programs indicate that reducing gies to prevent tobacco use among young people and youth initiation rates, promoting smoking cessation, to help current tobacco users quit, and approaches to and increasing protections for nonsmokers from sec- protect nonsmokers from exposure to secondhand to- ondhand tobacco smoke exposure necessitate chang- bacco smoke (Fiore et al. 1996, 2000; NCI 1999, 2001). ing many facets of the social and policy environments. Nevertheless, there are scientific questions remaining Thus, Best Practices provides effective guidance for ef- to be addressed on the adverse health effects of tobacco forts at the state level, but a comprehensive national use, methods for the efficient surveillance of the tobacco control effort requires strategies that go be- tobacco-related epidemic, strategies to eliminate yond guidance to the states. Based on the evidence tobacco-related disparities, and innovative approaches reviewed in Reducing Tobacco Use (USDHHS 2000), a for the prevention of tobacco use and treatment of comprehensive national effort should involve a broad nicotine addiction. mix of strategies. That report also noted that some of One major topic in need of more research is to the program and policy changes needed within these complete the understanding of the mechanisms by strategies can be most effectively addressed at the na- which tobacco-related diseases are caused. A greater tional level. understanding of these causal mechanisms should There is a need for a continuing and sustained have implications for disease prevention that extend national tobacco use prevention and control effort. to agents other than smoking. This report reviews Many factors encourage tobacco use in this country: the association between smoking and cancer, the positive imagery of smoking in movies and in the cardiovascular diseases, respiratory diseases, repro- popular culture, the billions of dollars spent by the ductive effects, and other health consequences, and tobacco industry to advertise and promote cigarettes defines a variety of specific research questions and (e.g., $11.2 billion in 2001 [Federal Trade Commission issues related to the biologic mechanisms by which the 2003]), acceptance of secondhand smoke in public multiple toxic agents in tobacco products and tobacco
Executive Summary 15 Surgeon General’s Report smoke cause specific adverse health outcomes. For lung infections, visual loss due to cataracts, and oth- example, the lung remains the primary site for elevated ers). More research emphasis needs to be placed on tobacco-related cancer risk; however, during the past the broad health consequences of smoking—namely, 40 years, the type of lung cancer caused by smoking how smoking has a negative impact on many aspects has changed for reasons still unknown. Similarly, as of the body at the same time, and how these multiple the evidence that smoking damages the heart and cir- adverse health effects combine to produce an overall culatory system and is a primary preventable cause of reduced quality of life and greater health care costs heart disease and stroke continues to expand, impor- prior to causing premature death. Recently, prelimi- tant research questions remain about how smoking nary estimates indicated that for every premature interacts with other cardiovascular risk factors and death caused each year by smoking, there were at least accelerates the atherosclerotic disease process. With 20 smokers living with a smoking-related disease (CDC respect to these and the other research questions, the 2003b). public health message remains the same: smoking This report highlights the diversity of the health greatly increases the risk of many adverse health ef- effects caused by smoking, and how dramatically fects. Therefore, never start smoking or quit as soon smoking affects the risk of the leading causes of death as possible. in this country (e.g., cancer, heart disease, respiratory For several organ sites, there is a need for more disease). These findings emphasize that tobacco pre- evidence regarding the possible causal role of smok- vention and control should be key elements in a na- ing on cancer risk (see Chapter 2, “Cancer”). For pros- tional prevention strategy for all of these major causes tate and colorectal cancers, the evidence is suggestive of death. Additionally, there is great disparity in but not sufficient to determine a possible causal rela- tobacco-related disease and death among populations tionship. For breast cancer, even though there is no and the need to address the research gaps that exist evidence overall for a causal role of smoking, on a ge- for many special populations. Research is needed not netic basis some evidence suggests that some women only on disease outcome but also on the development may be at an increased risk if they smoke. For other of more effective strategies to reach and involve high sites such as the liver, confounding exposures to other risk populations (e.g., race/ethnicity, low income, low risk factors have made the evaluation of the risk of education, the unemployed, blue-collar and service smoking very complex, but this report finds the evi- workers, and heavily addicted smokers). dence to be suggestive of causation. There should be Finally, more research is needed on how chang- further research on those sites where the evidence is ing tobacco products, as well as pharmaceutical prod- suggestive but not yet sufficient to warrant a causal ucts, have affected and could continue to affect health. conclusion. As this new evidence emerges it will be In this report, one major conclusion finds that ciga- evaluated using the causal criteria and standardized rettes with lower machine-measured yields of tar and language applied in the Surgeon General’s reports to nicotine (i.e., low-tar/nicotine cigarettes) have not pro- express the strength of the evidence bearing on cau- duced a lower risk of smoking-related diseases. Yet sality for all adverse health effects of smoking. As new there are rapidly growing numbers of modified tobacco evidence emerges with respect to the research ques- products characterized as Potentially Reduced Expo- tions raised in this report, the individual chapter con- sure Products (PREPs) (Institute of Medicine 2001). clusions in this report will be re-evaluated. Research has demonstrated that with the expectation Chapter 6, “Other Effects,” of this report con- of reducing risk, many smokers switched to low cludes that, overall, smokers are less healthy than non- machine-measured tar/nicotine cigarettes, and may smokers. Most often the risks of smoking are discussed thus have been deterred from quitting (National with respect to a specific cancer, to heart disease, or to Cancer Institute 2001). Therefore, it is critically impor- respiratory disease risk. Unfortunately, because smok- tant that the health risks of the emerging PREPs be ing is such a powerful cause of disease, most smokers evaluated comprehensively and quickly to avoid a rep- suffer from adverse health effects in many parts of their lication of that unfortunate low-tar/nicotine cigarette bodies at once. Additionally, before a death from one experience. Research on the biologic mechanisms by of the diseases caused by smoking, which is often quite which the multiple toxic agents in tobacco products premature, many smokers live for years with a dimin- and tobacco smoke cause specific adverse health out- ished quality of life from the burden of chronic and comes can help establish an important scientific disabling health effects (e.g., reduced breathing capac- foundation for evaluating the potential health effects ity, poor heart functioning, greater susceptibility to of PREPs. Similarly, the public health and policy
16 Executive Summary The Health Consequences of Smoking implications of changes in manufactured cigarettes, control efforts worldwide are commensurate with the other tobacco-containing products, and pharmaceuti- harm caused by tobacco use. At the start of the last cal products will require the continued attention of century, lung cancer was a very rare disease. Now lung public health researchers and policymakers. cancer is the leading cause of cancer deaths in both men and women in this country (see Chapter 2, “Can- cer”; USDHHS 2001). Our success in reducing tobacco Tobacco Control in the New Millennium use during the last 40 years has led to a reversal in the epidemic of lung cancer among men; nationwide, rates As the world enters this new millennium, it is of lung cancer deaths among men have declined since faced with many new public health challenges even the early 1990s (Weir et al. 2003). In California, where as many of the old risks to good health remain. Dur- there has been a comprehensive tobacco control pro- ing the last 40 years, people have become increasingly gram in place since 1989, reductions in rates of tobacco- more aware of the adverse health consequences of related disease and deaths already have been observed tobacco use. Currently, tobacco use is the leading cause (CDC 2000; Fichtenberg and Glantz 2000; Scott et al. of preventable illness and death in this nation, in the 2003). If we apply what we know works, we can make majority of other high-income nations, and increas- lung cancer a rare disease again by the end of this ingly in low- and middle-income nations. Unfortu- century! nately, the high rates of tobacco-related illnesses and deaths will continue until tobacco prevention and
Executive Summary 17 Surgeon General’s Report
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18 Executive Summary The Health Consequences of Smoking
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Executive Summary 19 Surgeon General’s Report
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20 Executive Summary