The Health Consequences of SMOKING 1968 SUPPLEMENT TO THE 1967 Public Health Service Review U.S. DEPARTMENT OF HEALTH, EDUCATION, AND WELFARE Public Health Service 1968 Supplement to Public Health Service Publication No. 1696 Library of Congress Catalog No. 68-60025 For sale by the Supexintendent of Documents. U.S. Govanmrnt Printing Office Wadingcon. D.C. 20402 - Price 55 cents Foreword Section 5 (d) (1) of Public JAW 80-02, the Federal Cigarette Label- ing and Advertising Xct, requires the Secretary of Health, Educa- t.ion, and Welfare to submit an annual report to the Congress "concerning (A) current information on the health consequences of smoking and ( 1%) such ~e~onlnlentlntiolls for legislation as he nlxy deem npproprintc." This 1068 Supplement to the 1067 Public Health Service review, "The Health Consequenws of Slnoking", was prepill+ed for the Secretary pursuant to this section. The Secretary's report was delivered to the Congress ou July 1, 1068. It is printed below. The information presented in the accompanying report, "The Health Con- sequences of Smoking, 1968 Supplement," confirms or strengthens the conclu- sions of two previous studies published by this Department-the 1964 Report of the Surgeon General's Adrisory Committee on Smoking and Health, and the 1965 Report on the Health Consequences of Smoking. These conclusions are that smoking is a serious health hazard in this country, one which is bringing about much unnecessary disease and death within our population. In the words of the 1964 Report, adequate remedial action is re- quired. In my opinion, the remedial action taken until now has not been adequate. I therefore recommend : 1. The warning statement required by the Federal Cigarette Labeling and Adrertising Act should be strengthened. This Department would support the wording recommended last year by the Federal Trade Commission, or a suitable paraphrase of the wording.* 2. This warning should be required to be placed not only on the cigarette package but on cigarette rending machines and in all advertisements. 3. Levels of "tar" and nicot.ine in cigarette smoke should be published on cigarette packages, on rigarette vending marhines, and in all advertisements. Authorization is also needed to make it possible to add other harmful agents to this listing. 4. Appropriations should be made to the Federal Trade Commission to permit the Commission to test all cigarette brands on a quarterly basis for "tar" and nicotine and other harmful agents in cigarette smoke. Secretary. o The wording recommended by the Federal Trade Commission (Report to Congress, June 36, 1967) was "Warning: Cigarette Smoking is Dangerous to Health and May Cause Death from Cancer and Other Diseases." iii Preface The following pages provide a review of current information on the hea.lth conseqwnces of smoking. as will be seen, the evidence attesting to the harmful effect of smoking on health has continued to mount during t.he past. year, with new research findings confirming the clini- WI, eI;l)ermlenka~, and epidemiological relationships I)etween tobacco smoking and many forms of illness related to it. The convergence of research findings continues without. substantial negat.i\-e scie.ntific evidence. Sew considerations are presented concerning some bio- mechanism in\-ol\-et1 in the pnthogenesis of cardiovascular and bron- cl~opulnionnry diseases. This 1968 Supplemcnt;tl Report reviews the recent research literature on cardiovascular disease, chronic broncllopulmonary disease and can- cer that has become a.vailablc since TAe Henlt?~ Conxeprtewcs of Xm.ok- ing, A Public Health Sercice Recieza: 1967 was published. This publication in turn was a review of the research literature which had al)l)enrecl in the 31/s years since the Surgeon General's Advisory Corn- mittee issuecl its monumental report in 19&L The current research findings should be consi'dered in the perspeotire of the resea.rch evi- dence previously presented in t.he 1964 and 1967 reports. Problems created by oigarette smoking hare made t,his a difficult health issue. Effective preventive programs must be created if we are to meet smoking's grave challenge to human health successfully and reduce t:he burden of suffering and economic loss involved. Swgeon General. Acknowledgments The National Clearinghouse for Smoking and Health, Daniel Horn, Ph. D., Director, was responsible for the preparation of this report; Albert C. Rolbye, Jr., KD., M.P.H., LLX, n-as senior editor and David 0. Wember, M.D., was st,aff director. The professional staff of t.he National Clearinghouse for Smoking and Health owes a debt of gratitude to the many expe&s in the scien- t,ific and technical fields, both in and outside of the government who have provided much advice and assistance. Their contributions are gratefully acknowledged. Special thanks are due the following: AUERBACH, OSCAR, M.D.-Senior medical investigator, Veterans Administration Howital, East Orange, N. J. ATRES, STEPIIEN RI., M.D.-Director, Cardiopulmonary Laboratory, Saint Vin- cent's Hospital and Medical Center of New York, Sew York, N.Y. BELLET, SAXLXL, M.D.-Director, Division of Cardiology, Philadelphia General Hospital, Philadelphia, Pa. BINQ, RICHARD J., M.D.-Professor and chairman, Department of Medicine, Wayne State University, Detroit, Mich. BOCK, FRED G., Ph. D.-Director, Orchard Park Laboratories, Roswell Park JIeruorial Institute, Orchard Park, N. Y. BOERTK, ROBERT, Ph. D., XD.-National Heart Institute, Sational Institutes of Health, Bethesda, Md. BORES, HOLLIS, M.D.-Clinical investigator, Veterans Administration Hospital, Denver, Cola. BRAUR'WALD, EUGENE, M.D.-Department of Medicine, University of Oalifornia at San Diego, San Diego, Calif. BIK-GNFIPTI, IDA L.-Health educator, Adult Heart-Preventive Programs Sec- tion, Heart Disease and Stroke Control Program, Sational Center for Chronic Disease Control, U.S.P.H.S., Arlington, Va. C~XADWICK, DOXALD R., JI.D.-Director, Sational Center for Chronic Disease Control, U.S.P.H.S., Arlington, Va. CHANCE, BXITTON, Ph. D., SC. D.-Director, Johnson Research Foundation, Chair- man, Department of Biophysics and Physical Biochemistry, School of Illedi- tine, University of Pennsylvania, Philadelphia, Pa. COOPER. THEODORE, M.D.--Director, Sational Heart Institute, National Institutes of Health, Bethesda, Nd. DOYLE, JOSEPH T., U.D.-Professor of medicine, Albany Medical College, Albany, N.Y. EUERER, FaEn-Statistician, Biometric Research Branch, Sational Heart Insti- tute, Sation8.1 Institumtes of Health, Bethesda, Jfd. ELIOT, ROBERT S., M.D.-Assc&ate professor of medicine, Department of Jledi- tine, Division of Cardiology, College of afedicine, University of Florida, Gainesville, Fla. Vi EXDICOTT, KESSETH ;\I., M.D.-Director, Sational Cancer Institute, Sational Institutes of Health, Bethesda, Nd. EPSTEIS, FREDERICK H., l\l.D.-Professor of epidemiology. Department of Epidemiology, University of Michigan, School of Public Health, Ann Arbor, Mich. FALK, HANK L., Ph. D.-Associate scientific director for carcinogenesis etiology, National Cancer Institute, National Institutes of Health, Bethesda Md. FARIIEIL, EJIMAXUEL, M.D., Ph. D.-Profesrjor and chairman, Department of Pathology, University of Pittsburgh. Pittsburgh, Pa. FERRIS, BENJAMIN G., Jr., M.D.-Professor, Del)artment of Physiology, Harvard School of Public Health, Harvard University, Boston. Mass. Fox, SAXUEL M., III, M.D.-Chief, Heart Disease and Stroke Control Program, Sational Center for Chronic Disease Control, U.S.P.H.S., Arlington, \`a. E'ICEDERICKSOS, DOXALD S., JI.D.--Chief, Laboratory of Jlolewlar rJi.sease, Na- ational Heart Institute, Sational Institutes of Health, Bethesda, Jld. FROL~, ARTHUR H., M.D.-Heart Disease and Stroke Control Program, Sational Center for C?hronic Disease Control, U.S.P.H.S., Applied Physiology Labora- tory, Georgetown rniversity, Washington, D.C. GELLER. Hawlx--Chief. Operational Studies Section, Canwr Control Program. National Center for Chronic Disease Control, U.S.P.H.S., Arlington, Va. GITTLESOHN, ALLAS, Ph. D.-Johns Hopkins University, School of Public Health, Baltimore, Md. G~DnJARx.4SOS, SIG>%UNDUR, Ph. D.-Department of l\ledicine, \\T'aylle State University, Detroit, Xch. HA>~JIOND, E. CWLER, SC. D.-Vice president, epidemiology and statistical re- search, American Cancer Society, Sew York, S.Y. HESS, CATHERINE B., M.D.-Assistant to the chief, Oancer Control Program, Sational @enter for Chronic Disease Control, U.S.P.H.S., Arlington, Va. HIGGISS, I.T.T., XD., JI.R.C.P.-Professor, Department of Epidemiology, rni- rersity of Michigan, School of Public Health, Ann Arbor, Nich. HOFFJ~AXX, DIETRICH, Ph. D.-Associate member, Environmental Carcinogene- sis, Sloan-Kettering Institute for Cancer Research, New York, S.Y. IMBODEN, CLARENCE A., Jr., M.D.-Division of Regional hIedica1 Programs, Sa- tional Institutes of Health, Bethesda, Md. ISHII, KAREO, M.D.-Chief, Serology Division, National Cancer Center, Research Institute, Tokyo, Japan. KANSEL, WILLIAX B., M.D.-Medical director, Heart Disease Epidemlolo~ Study, National Heart Institute, National Institutes of Health, Framingham, Mass. KELLER, ANDREW 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. KESNER, HARRIS N., XL).--Jledical consultant, Heart Disease and Stroke Con- trol Program, Sational Ceutrr for Chronic Disease Control, TI.S.P.H.S., Arling- ton, Va. KERSHBUA~K, ALFRED, M.D.-Assistant chief, Division of Cardiology, Philadelphia General Hospital, Philadelphia, Pa. KOTIN, PAUL, M.D.-Director, Division of Environmental Health Sciences, U.S. P.H.S., Research Triangle Park, S.C. KRLXHOLZ, RICHARD A., M.D.-Director, Medical Chest Department and Pul- monary Function Laboratory, Charles F. Kettering Jlrmorial Hospital, Ketter- ing, Ohio. LILIENFELD, ABRAHAII, M.D.-Professor and chairman, Department of Chronic Diseases, Johns Hopkins School of Hygiene and Public Health, Baltimore, ;\Id. vii MCLEAN, Ross, M.D.--Professor of medicine (pnlmonar~ disease), Emory Uni- versity, School of Medicine, Atlanta, Ga. MCXILLAN, GARUSER C., JI.D.--Sational Heart Institute, Sational Institutes of Health, Bethesda, Md. MEPER, JOHN S., M.D.-Professor and Chairman, Department of Il'eurology, College of Medicine, \Va~ne State l:niversity, Detroit, Jlich. MOOBE, GEORGE E., M.D.-Director, Rosaell Park Memorial Institute, Buffalo, N.Y. MOUKT, FRAXK W., M.D.-Acting chief, Chronic Respiratory Disease Control Program, Sational Center for Chronic Disease Control, U.Y.P.H.S., Arlington, \`a. XURPHY, ED~IOND A., M.D., SC. D.-Associate professor, University of Colorado Medical Center, Medicine and Biostatistics, Denver, Colo. ~`ADEL, JAY A.. JI.D.-Carclioras~nlar Research Institute, University of California JIedical Center, San Francisco, Calif. PAYSE. GERALI) H., M.D.--Chief, Adult Heart-Preventive Programs Section, Heart Disease and Stroke Control Program, Kational Center for Chronic Disease C'ont rol, T.S.l'.H.S., Arlington, \`a. PETERSON, WILLIAM F., AID-Chief, Obstetrics and Gyneco1og.v Service. USAF Hospital, Andrews Air Force Base, Washington, D.C. PETTY, THOMAS L., M.D.-Assistant professor of medicine, University of Colorado Medical Center, Denver, Colo. PTRI, PRITPBL S., M.D.-Department of Medicine, Wayne State University Medical School, Detroit, Mich. QIIISLAS, CARROL B., M.D.-Deputy chief, Heart Disease and Stroke Control Pro- gram, Sationnl Center for Chronic Disease Control, U.P.P.H.S., Arlington, Va. ROBIXS, MoRTos-chief, Program Statistics and Analysis Section, Heart Disease and Stroke Control Program, Sational Center for Chronic Disease Control, U.S.P.H.S., Arlington, Va. Ross, WILLIAX L., JI.D.-Chief. Cancer Control Program, Sational Center for Chronic Disease Control, U.S.P.H.S.. Arlington, Ya. SCHACHTER, JOSEPH-Statistician, Adnlt Heart Activities, Heart Disease nud Stroke Control Program, Sational Center for Chronic Disease Control, U.S. P.H.S., Arlington, Ta. SVHL?~~AS, LEOSARD JI., JI.D.-Professor of epidemiology, l'nirewity of Minne- sota, School of Public Health, Minneapolis, Minn. STAJILER, JEREYIAII. JI.D.--(`hiwgo Board of Health. Health Research Founda- tion, Chicago, Ill. THOX, T~osras .J.--St;ltirtic,iatl, Program Stntistirs and Analysis Section, Heart Disease and Stroke Control Program, Sntional Center for Chronic Disease Control, lV.S.I'.H.S.. Arlington, Tn. \YEsT~-RA. Enwrs E., M.D.-Heart Disease and Stroke Control Program, Sational Center for (`hronie Disease Control, l~.S.l'.H.S., Chief, .$lrplied I'h~siolog~ Laboratory. Georgetown Vnirrrsitr, Washingtou, D.C. IVYSUER. ERSEST I,., Jl.D.-Asweiate member, Sloan-Kettering Institute for Cancer Research. Sew York. S.T. %T~(EI.. WII.I.IAN a., M.D.--1seist:int Director for Collahorntive Stndies. Sational Heart Institute, Sational Institutes of Health, Bethesda, Md. The following professional staff of the Sational Clearinpl~ouse for Smoking ant1 IIenlth contributed to the preparation of this report: Selwp 31. Wniqyon-, Dorothy E. Green, Ph. D., Robert S. Hutchings, Ric.hnrd 11'. White, Emil (`orwin, and Robert F. Clarke, Ph. D. Special thanks are due Jennie 31. ,Jennings and Donald R. Sllopland. . . . VIII Foreword_-----______________________---_--------------- Preface-------__-___-----_-________-------------------- Acknowledgments _________ -_- ____________ ---_--__----_-_ Part I. Current Information on the Health Consequences of Smoking__----_-_-_-___--------------_------- Highlights of the Report- -__--___-- __________ Smoking and Overall Mortality- - _ _ _ - _ _ _ _ _ - - _ - Part II. Technical Reports on the Relationship of Smoking to Specific Disease Categories ___________ -------_--_ Chapter 1. Smoking and Cardiovascular Diseases- Chapter 2. Smoking and Chronic Bronchopul- monary Diseases (Non-neoplastic) _ _ Chapter 3. Smoking and Cancer- __ - - - _ _ _ _ _ _ _ _ _ Page . . . 111 V vi 1 3 5 11 13 63 87 ix