A Report of the Surgeon General - 2001
United States. Public Health Service. Office of the Surgeon General.
Centers for Disease Control and Prevention (U.S.)
National Center for Chronic Disease Prevention and Health Promotion (U.S.)
United States. Office on Smoking and Health.

Rockville, MD : U.S. Dept. of Health and Human Services,
Public Health Service, Office of the Surgeon General;
Washington, D.C.:
For sale by the Supt. of Doc., U.S. G.P.O., / 2001.

Women and girls in the United States are in the throes of an epidemic of tobacco-related diseases. Over time, the once-wide gender gap in smoking-and its health consequences-has narrowed considerably. Cigarette smoking was rare among women in the early part of this century, increased until the 1960s, and finally began to decline in the mid-1970s. During the past decade, however, reductions in smoking prevalence among adult women were minor, and tobacco use among teens increased markedly. By the late 1990s, more than one in five adult women was a regular smoker, and about 30 percent of high school senior girls reported having smoked within the past 30 days. Many of the tobacco-related diseases that have manifested today are the result of the cumulative effects of smoking initiated several decades ago. Unless we succeed in further curbing tobacco use among women and girls, the health effects of tobacco use will remain great for the foreseeable future.

This report reviews in detail what we know about smoking-related diseases among women, and documents that the toll of smoking on women's health is wide-ranging and staggering. Like their male counterparts who smoke, women smokers are at increased risk of cancer, cardiovascular disease, and pulmonary disease, but women also experience unique risks related to menstrual and reproductive function. In the face of so many strides that were made during the twentieth century to improve health outcomes for women, including enormous declines in maternal mortality, heart disease, and cervical cancer, to name but a few, it is tragic that an entirely preventable factor continues to claim so many women's lives.

Through its detailed examination of smoking patterns by demographic and other characteristics, this report confirms that it is often women who are more socioeconomically disadvantaged and girls who perform less well academically who are most likely to smoke in our society today. For example, the smoking prevalence in 1998 among women with 9 to 11 years of education was almost three times higher than that among women who had 16 or more years of education. Once a mark of sophistication among women in the social forefront, then adopted by middle-class women, smoking has increasingly become an addiction borne by women with the least resources in our society. The long history of tobacco marketing targeted to women is also chronicled here. The positive imagery in cigarette advertisements is greatly at odds with the negative health consequences suffered by so many women who smoke.

The importance of vigilance in our efforts to prevent initiation of smoking by girls and to promote cessation among female smokers of all ages is underscored by this report. To be successful, we know that a multipronged approach is necessary, including antitobacco media campaigns, increases in tobacco prices, promotion of nonsmoking in public places, curbs on tobacco advertising and promotion, enforcement of legislation to reduce youth's access to tobacco products, and effective tobacco use treatment programs. Women who smoke represent diverse subgroups of the population with unique issues and needs. An important subgroup is pregnant women, among whom smoking has declined in recent years but remains significant. Efforts to assist quitting among pregnant women (and their partners) can greatly impact not only their health but that of their infants and children. We must dramatically accelerate declines in smoking among both women and girls. Exciting models of new tobacco control programs in states show that this can be done. In Florida, where the Tobacco Pilot Program was begun in 1998, the prevalence of current smoking among middle school girls declined from 18.1 percent in 1998 to 10.9 percent in 2000-a 40-percent decline in just two years.

The challenge facing this Nation now is to establish effective tobacco control programs in every state and nationwide. No one who reads this report can help but recognize that combating smoking and the forces that promote it deserves to be among our very highest priorities for women's health.

Jeffrey P. Koplan, M. D., M.P.H.
Director
Centers for Disease Control and Prevention
and
Administrator
Agency for Toxic Substances and Disease Registry

from the Surgeon General,
U.S. Department of Health and Human Services

Two decades have passed since the first Surgeon General's report on women and smoking was published in 1980. That report pointed out the first signs of an epidemic of smoking-related disease among women. This report documents that the epidemic became full-blown.

Cigarette smoking is the leading cause of preventable death in the United States, and women's share of tobacco-related disease has risen dramatically over the past half century. The point is underscored by the 600-percent increase since 1950 in women's death rates for lung cancer, a disease that is primarily attributable to smoking. Lung cancer accounted for only 3 percent of all female cancer deaths in 1950, whereas in 2000 it accounted for an estimated 25 percent. Already in 1987, lung cancer had surpassed breast cancer as the leading cause of cancer death in U.S. women, and in 2000 nearly 27,000 more women died of lung cancer (67,600) than breast cancer (40,800). In fact, more women are estimated to have died of lung cancer in the year 2000 than of cancers of the breast, uterus, and ovary combined. Of course, lung cancer is but one of the many diseases for which risk is greater among smokers than nonsmokers.

Despite these facts, 22.0 percent of U.S. adult women smoked in 1998. Moreover, between 1992 and 1997, the percentage of high school senior girls who reported smoking within the past 30 days increased from 26.1 percent to 35.2 percent before declining to 29.7 percent in 2000.

Since the first Surgeon General's report on women and smoking in 1980, thousands of studies have expanded both our knowledge of the effects of smoking on women's health and our understanding of the myriad factors that influence smoking initiation, maintenance, and cessation. The need for an updated compendium on women and smoking is great, and this report addresses that need.

Ironically, in the face of the overwhelmingly negative health effects of smoking, tobacco marketing has always used positive imagery and has attempted to capitalize on issues important to women and to exploit the women's movement. The same tobacco brand that for so long featured the slogan "You've come a long way, baby" more recently launched an advertising campaign with the theme "Find your voice." Tobacco advertisements suggest that women who smoke are liberated, sexually attractive, athletic, fun loving, and slim, whereas in reality women who smoke are often nicotine dependent, physically unhealthy, socioeconomically disadvantaged, or depressed. Tobacco companies also have tried to ingratiate themselves with women's causes, providing funding for women's sports, for women's professional organizations, and for anti-domestic violence programs and other issues of salience to women, not to mention providing huge sums in advertising revenues to women's magazines. Perhaps such support has contributed to the fact that women's lung cancer does not have a voice, in contrast to breast cancer, which has such a well-developed and effective advocacy community.

Although the Healthy People 2000 objective of reducing the prevalence of current smoking among U.S. adult men and women to 15 percent is unlikely to be met, we should emphasize that nearly 80 percent of adult women in this country choose not to smoke. Nonsmoking is now by far the accepted norm. If the recommendations in this and previous reports were fully implemented, the Healthy People 2010 objective to reduce the rate of tobacco use among girls and women in the country by more than 50 percent could be met.

Hopeful signs now exist that the lung cancer epidemic may have peaked among U.S. women. As this report goes to press, encouraging news comes from a report issued by the Centers for Disease Control and Prevention based on data from California and from the National Cancer Institute. In California, which has been at the forefront of tobacco control activities and where smoking prevalence has declined more rapidly than in the rest of the country, the lung cancer incidence rate among women has actually declined in recent years. Another report from California found that 33,300 fewer heart disease deaths occurred in the state between 1989 and 1997 among women and men combined than would have been expected during that time had earlier trends in heart disease mortality relative to the rest of the United States continued. California was the first state to implement a comprehensive statewide tobacco control program funded by a cigarette surtax that began in 1989. Today all states have enormous monetary settlement payments from the state lawsuits with the tobacco industry to recover the cost of smoking-related disease; unfortunately, few states have used these new resources to make the level of investments in the proven tobacco control strategies that could reduce the disease and death rates related to smoking.

Women in the United States and a number of other developed countries are less likely to be smokers than was the case 30 years ago. However, just the opposite trend is feared for women in many other parts of the world, particularly women in developing countries where smoking prevalence has traditionally been low but where the tobacco industry now recognizes tremendous market potential and is aggressively pursuing females. Thwarting increases in the use of tobacco among women around the world represents one of the greatest public health opportunities of our time.

David Satcher, M.D., Ph.D.
Surgeon General

This report was prepared by the U.S. Department of Health and Human Services under the general direction of the Centers for Disease Control and Prevention, National Center for Chronic Disease Prevention and Health Promotion, Office on Smoking and Health.

David Satcher, M.D., Ph.D.,

Surgeon General,

Office of Public Health and Science,

Office of the Secretary,

Washington, D.C.

Jeffrey P. Koplan, M.D., M.P.H.,

Director,

Centers for Disease Control and Prevention,

Atlanta, Georgia.

James S. Marks, M.D., M.P.H.,

Director,

National Center for Chronic Disease Prevention and Health Promotion,

Centers for Disease Control and Prevention,

Atlanta, Georgia.

Lawrence W. Green, Dr.P.H.,

Acting Director,

Office on Smoking and Health,

National Center for Chronic Disease Prevention and Health Promotion,

Centers for Disease Control and Prevention,

Atlanta, Georgia.

Nicole Lurie, M.D., M.S.P.H.,

Principal Deputy Assistant Secretary for Health,

Office of Public Health and Science,

Office of the Secretary,

Washington, D.C.

Beverly L. Malone, Ph.D., R.N., F.A.A.N.,

Deputy Assistant Secretary for Health,

Office of Public Health and Science,

Office of the Secretary,

Washington, D.C.

Arthur Lawrence, Ph.D., R.Ph.,

Assistant Surgeon General,

U.S. Public Health Service and Deputy Assistant Secretary for Health (Operations),

Office of Public Health and Science,

Office of the Secretary,

Washington, D.C.

Kenneth Moritsugu, M.D., M.P.H.,

Deputy Surgeon General,

U.S. Public Health Service,

Office of the Surgeon General,

Office of the Secretary,

Washington, D.C.

Allan S. Noonan, M.D., M.P.H., CAPT,

Senior Advisor,

U.S. Public Health Service,

Office of the Surgeon General,

Office of the Secretary,

Washington, D.C.

Special thanks to

Michael P. Eriksen, Sc.D.,

Centers for Disease Control and Prevention Assignee to the World Health Organization,

Geneva, Switzerland.

Elizabeth Majestic, M.P.H.,

Associate Director for Planning, Evaluation, and Legislation,

National Center for Chronic Disease Prevention and Health Promotion,

Centers for Disease Control and Prevention,

Atlanta, Georgia.

Terry F. Pechacek, Ph.D.,

Associate Director for Science,

Office on Smoking and Health,

National Center for Chronic Disease Prevention and Health Promotion,

Centers for Disease Control and Prevention,

Atlanta, Georgia.

The editors of the report were

Virginia L. Ernster, Ph.D.,

Senior Scientific Editor, Professor and Vice Chair,

Department of Epidemiology and Biostatistics and Associate Director for Epidemiology, Prevention, and Control,

UCSF Comprehensive Cancer Center,

University of California,

San Francisco, California.

Gayle Lloyd, M.A.,

Managing Editor, Office on Smoking and Health,

National Center for Chronic Disease Prevention and Health Promotion,

Centers for Disease Control and Prevention,

Atlanta, Georgia.

Leslie A. Norman,

Managing Editor,

Office on Smoking and Health,

National Center for Chronic Disease Prevention and Health Promotion,

Centers for Disease Control and Prevention,

Atlanta, Georgia.

Anne McCarthy,

Technical Editor,

Consultant to Palladian Partners, Inc.,

Silver Spring, Maryland.

Audrey L. Pinto,

Technical Medical Writer and Editor,

Consultant to Palladian Partners, Inc.,

Silver Spring, Maryland.

Contributing editors were

David G. Altman, Ph.D.,

Professor, Department of Public Health Sciences,

Wake Forest University School of Medicine,

Winston-Salem, North Carolina.

John A. Baron, M.D.,

Professor, Department of Medicine and Community and Family Medicine,

Dartmouth Medical School,

Hanover, New Hampshire.

Ellen R. Gritz, Ph.D.,

Professor and Chair, Frank T. McGraw Memorial Chair in the Study of Cancer, Department of Behavioral Science,

The University of Texas,

M. D. Anderson Cancer Center,

Houston, Texas.

Corinne G. Husten, M.D., M.P.H.,

Chief, Epidemiology Branch,

Office on Smoking and Health,

National Center for Chronic Disease Prevention and Health Promotion,

Centers for Disease Control and Prevention,

Atlanta, Georgia.

Richard B. Rothenberg, M.D., M.P.H.,

Professor, Department of Family and Preventive Medicine,

Emory University School of Medicine,

Atlanta, Georgia.

Beti Thompson, Ph.D.,

Member, Fred Hutchinson Cancer Research Center,

Seattle, Washington.

Contributing authors were

David G. Altman, Ph.D.,

Professor, Department of Public Health Sciences,

Wake Forest University School of Medicine,

Winston-Salem, North Carolina.

Amanda Amos, Ph.D.,

Senior Lecturer in Health Promotion, Public Health Sciences,

Department of Community Health Sciences,

University of Edinburgh Medical School,

Edinburgh, United Kingdom.

John A. Baron, M.D.,

Professor, Department of Medicine and Community and Family Medicine,

Dartmouth Medical School,

Hanover, New Hampshire.

Neal Benowitz, M.D.,

Professor of Medicine, Psychiatry, and Biopharmaceutical Sciences,

University of California,

and Chief, Clinical Pharmacology,

San Francisco General Hospital,

San Francisco, California.

Lois Biener, Ph.D.,

Senior Research Fellow, Center for Survey Research,

University of Massachusetts,

Boston, Massachusetts.

William J. Blot, Ph.D.,

Chief Executive Officer,

International Epidemiology Institute, Ltd.,

Rockville, Maryland.

Edward J. Boyko, M.D., M.P.H.,

Professor of Medicine, University of Washington and

Director, Epidemiologic Research and Information Center,

Veterans Affairs Puget Sound Health Care System,

Seattle, Washington.

Louise A. Brinton, Ph.D.,

Chief, Environmental Epidemiology Branch,

National Cancer Institute,

Bethesda, Maryland.

David N. Burns, M.D., M.P.H.,

Medical Officer, Pediatric, Adolescent, and Maternal AIDS Branch,

Center for Research for Mothers and Children,

National Institute of Child Health and Human Development,

Bethesda, Maryland.

Graham A. Colditz, M.D., Dr.P.H.,

Professor of Medicine, Channing Laboratory, School of Medicine,

Harvard University,

Boston, Massachusetts.

David B. Coultas, M.D.,

Professor of Internal Medicine and Chief, Division of Epidemiology and Preventive Medicine,

School of Medicine,

University of New Mexico,

Albuquerque, New Mexico.

Alyssa N. Easton, Ph.D., M.P.H.,

Epidemiologist, Office on Smoking and Health,

National Center for Chronic Disease Prevention and Health Promotion,

Centers for Disease Control and Prevention,

Atlanta, Georgia.

Brenda Eskenazi, Ph.D.,

Professor of Maternal and Child Health and Epidemiology Director,

Center for Children's Environmental Health Research,

School of Public Health,

University of California,

Berkeley, California.

Edwin B. Fisher, Ph.D.,

Professor of Psychology, Medicine, and Pediatrics and

Head, Division of Health Behavior Research,

Departments of Medicine and Pediatrics,

Washington University,

St. Louis, Missouri.

Brian R. Flay, D.Phil.,

Director, Health Research and Policy Centers,

Chicago, Illinois.

Brian S. Flynn, Sc.D.,

Research Professor and Director, Office of Health Promotion Research,

College of Medicine,

University of Vermont,

Burlington, Vermont.

Elizabeth T. Fontham, Dr.P.H.,

Professor and Chairman, Department of Public Health and Preventive Medicine,

Louisiana State University Health Science Center,

New Orleans, Louisiana.

Elizabeth A. Gilpin, M.S.,

Clinical Professor of Biostatistics and Director, Biostatistics Shared Resource,

University of California at San Diego Cancer Center,

La Jolla, California.

Deborah Grady, M.D.,

Professor and Vice Chair, Department of Epidemiology and Biostatistics and Department of Medicine,

University of California,

San Francisco, California.

Andrew Grandinetti, Ph.D.,

Assistant Researcher, Pacific Biomedical Research Center,

University of Hawaii at Manoa,

Honolulu, Hawaii.

Sharon M. Hall, Ph.D.,

Professor and Vice-Chair, Psychiatry, Department of Psychiatry,

University of California,

San Francisco, California.

Dorothy Hatsukami, Ph.D.,

Professor, Department of Psychiatry,

University of Minnesota,

Minneapolis, Minnesota.

S. Jane Henley, M.S.P.H.,

Epidemiologist, Department of Epidemiology and Surveillance Research,

American Cancer Society,

Atlanta, Georgia.

Frank B. Hu, M.D., Ph.D.,

Assistant Professor, Department of Nutrition,

Harvard School of Public Health,

Boston, Massachusetts.

Corinne G. Husten, M.D., M.P.H.,

Chief, Epidemiology Branch, Office on Smoking and Health,

National Center for Chronic Disease Prevention and Health Promotion,

Centers for Disease Control and Prevention,

Atlanta, Georgia.

Nancy J. Kaufman, R.N., M.S.,

Vice President, The Robert Wood Johnson Foundation,

Princeton, New Jersey.

Ichiro Kawachi, M.D., Ph.D.,

Assistant Professor of Medicine, Channing Laboratory, School of Medicine and

Associate Professor of Health and Social Behavior,

School of Public Health,

Harvard University,

Boston, Massachusetts.

Robert C. Klesges, Ph.D.,

Executive Director, University of Memphis Center for Community Health,

University of Memphis,

Memphis, Tennessee.

Edward Lichtenstein, Ph.D.,

Senior Research Scientist, Oregon Research Institute,

Eugene, Oregon.

Alan D. Lopez, Ph.D.,

Epidemiologist, Prevention, Advocacy and Promotion,

Programme on Substance Abuse,

World Health Organization,

Geneva, Switzerland.

Everly Macario, M.S., Ed.M.,

Associate Professor, Department of Health and Social Behavior,

Harvard School of Public Health,

Boston, Massachusetts.

Judith Mackay, MBE, FRCP (Edin), FRCP (Lon), FHKAM,

Director, Asian Consultancy on Tobacco Control,

Hong Kong, China.

Nejma Macklai,

Epidemiologist, Tobacco-Free Initiative,

World Health Organization,

Geneva, Switzerland.

Ann M. Malarcher, Ph.D.,

Epidemiologist, Division of Chronic Disease Control and Community Intervention,

National Center for Chronic Disease Prevention and Health Promotion,

Centers for Disease Control and Prevention,

Atlanta, Georgia.

Ruth E. Malone, R.N., Ph.D.,

Assistant Professor of Nursing and Health Policy,

Institute for Health Policy Studies and Department of Physiological Nursing,

University of California,

San Francisco, California.

Joseph K. McLaughlin, Ph.D.,

President, International Epidemiology Institute, Ltd.,

Rockville, Maryland.

Deborah L. McLellan, M.H.S.,

Assistant Director, Center for Community Based Research,

Division of Population Sciences,

Dana-Farber Cancer Institute,

Boston, Massachusetts.

Robert K. Merritt, M.A.,

Health Scientist, Division of Reproductive Health,

National Center for Chronic Disease Prevention and Health Promotion,

Centers for Disease Control and Prevention,

Atlanta, Georgia.

Sherry L. Mills, M.D., M.P.H.,

Chief, Applied Sociocultural Research Branch,

Behavioral Research Program,

Division of Cancer Control and Population Studies,

National Cancer Institute,

Bethesda, Maryland.

Micah H. Milton, M.P.H.,

Behavioral Scientist, Office on Smoking and Health,

National Center for Chronic Disease Prevention and Health Promotion,

Centers for Disease Control and Prevention,

Atlanta, Georgia.

Heidi L. Miracle-McMahill, M.S.P.H.,

Epidemiologist, Department of Epidemiology and Surveillance Research,

American Cancer Society,

Atlanta, Georgia.

Patricia Dolan Mullen, Dr.P.H.,

Professor of Behavioral Sciences and Health Education and Training Director,

Center for Health Promotion and Prevention Research,

University of Texas Science Center at Houston School of Public Health,

Houston, Texas.

Judith K. Ockene, Ph.D.,

Professor of Medicine and Chief, Division of Preventive and Behavioral Medicine,

Department of Medicine,

University of Massachusetts Medical School,

Worcester, Massachusetts.

C. Tracy Orleans, Ph.D.,

Senior Scientist, The Robert Wood Johnson Foundation,

Princeton, New Jersey.

Kathyrn Osann, Ph.D., M.P.H.,

Associate Adjunct Professor, Division of Hematology and Oncology,

Department of Medicine,

College of Medicine,

University of California,

Irvine, California.

John Petraitis, Ph.D.,

Associate Professor, Department of Psychology,

University of Alaska,

Anchorage, Alaska.

Phyllis Pirie, Ph.D.,

Professor, Division of Epidemiology,

School of Public Health,

University of Minnesota,

Minneapolis, Minnesota.

Richard W. Pollay, Ph.D.,

Professor of Marketing and Curator, History of Advertising Archives,

Faculty of Commerce,

University of British Columbia,

Vancouver, British Columbia, Canada.

Cynthia S. Pomerleau, Ph.D.,

Senior Associate Research Scientist and Director, Nicotine Research Laboratory,

Department of Psychiatry,

University of Michigan,

Ann Arbor, Michigan.

Alex V. Prokhorov, M.D., Ph.D.,

Associate Professor, Department of Behavioral Science,

The University of Texas,

M.D. Anderson Cancer Center,

Houston, Texas.

Herbert H. Severson, Ph.D.,

Senior Research Scientist, Oregon Research Institute and Associate Professor of Counseling Psychology,

College of Education,

University of Oregon,

Eugene, Oregon.

Dana M. Shelton, M.P.H.,

Assistant Director for Policy, Planning, and External Relations, Division of STD Prevention,

National Center for HIV, STD, and TB Prevention,

Centers for Disease Control and Prevention,

Atlanta, Georgia.

Laura Solomon, Ph.D.,

Research Professor, Department of Psychology,

University of Vermont,

Burlington, Vermont.

Glorian Sorensen, Ph.D., M.P.H.,

Director, Community Based Research,

Division of Cancer, Epidemiology, and Control,

Dana-Farber Cancer Institute and Professor of Health and Social Behavior,

Department of Health and Social Behavior,

Harvard School of Public Health,

Boston, Massachusetts.

Margaret Spitz, M.D.,

Chairman, Department of Epidemiology,

The University of Texas,

M.D. Anderson Cancer Center,

Houston, Texas.

Beti Thompson, Ph.D.,

Member, Fred Hutchinson Cancer Research Center,

Seattle, Washington.

Michael J. Thun, M.D.,

Vice President, Epidemiology and Surveillance Research,

American Cancer Society,

Atlanta, Georgia.

Suzanne Tyas, Ph.D.,

Postdoctoral Fellow, Centre on Aging,

University of Manitoba,

Winnipeg, Manitoba, Canada.

Kenneth D. Ward, Ph.D.,

Assistant Professor, University of Memphis Prevention Center,

Memphis, Tennessee.

Elisabete Weiderpass, M.D., M.Sc., Ph.D.,

Associate Professor, Department of Medical Epidemiology,

Karolinska Institutet,

Stockholm, Sweden.

Gayle Windham, Ph.D.,

Senior Epidemiologist, Division of Environmental and Occupational Disease Control,

California Department of Health Services,

Oakland, California.

Anna H. Wu, Ph.D.,

Professor, Keck School of Medicine,

Department of Preventive Medicine,

Norris Comprehensive Cancer Center,

University of Southern California,

Los Angeles, California.

Reviewers were

Duane Alexander, M.D.,

Director, National Institute of Child Health and Human Development,

National Institutes of Health,

Bethesda, Maryland.

Robert Barbieri, M.D.,

Chairman, Department of Obstetrics and Gynecology,

Brigham and Women's Hospital,

Boston, Massachusetts.

Glen Bennett, M.P.H.,

Coordinator, Advanced Technologies Applications in Health Education,

Office of Prevention, Education, and Control,

National Heart, Lung, and Blood Institute,

National Institutes of Health,

Bethesda, Maryland.

Michelle Bloch, M.D., Ph.D.,

Medical Officer, Tobacco Control Research Branch,

Division of Cancer Control and Population Sciences,

National Cancer Institute,

National Institutes of Health,

Rockville, Maryland.

Gilbert J. Botvin, Ph.D.,

Professor and Director, Institute for Prevention Research,

Department of Public Health,

Cornell University Medical College,

New York, New York.

Michael B. Bracken, Ph.D.,

Professor and Head, Division of Chronic Disease Epidemiology,

Department of Epidemiology and Public Health,

Yale University School of Medicine,

New Haven, Connecticut.

David M. Burns, M.D.,

Professor of Medicine, Tobacco Control Policies Project,

University of California,

San Diego, California.

Olivia Carter-Pokras, Ph.D.,

Director, Division of Policy and Data,

Office of Minority Health,

Rockville, Maryland.

Jane A. Cauley, Dr.P.H.,

Associate Professor, Department of Epidemiology,

University of Pittsburgh,

Pittsburgh, Pennsylvania.

Sven Cnattingius, M.D., Ph.D.,

Professor, Department of Medical Epidemiology,

Karolinska Institutet,

Stockholm, Sweden.

Daniel W. Cramer, M.D., Sc.D.,

Professor of Obstetrics, Gynecology, and Reproductive Biology,

Harvard University Medical School,

Boston, Massachusetts.

Byron L. Cryer, M.D.,

Associate Professor of Medicine,

University of Texas Southwestern Medical Center,

Veterans Affairs Medical Center,

Dallas, Texas.

K. Michael Cummings, Ph.D., M.P.H.,

Chairman and Senior Scientist, Department of Cancer Prevention,

Epidemiology, and Biostatistics,

Roswell Park Cancer Institute,

Buffalo, New York.

Susan Curry, Ph.D.,

Director, Center for Health Studies,

Group Health Cooperative,

Seattle, Washington.

Ronald M. Davis, M.D.,

Director, Center for Health Promotion and Disease Prevention,

Henry Ford Health System,

Detroit, Michigan.

Andrew K. Diehl, M.D., M.Sc.,

Professor and Chief, Division of General Medicine,

Department of Medicine,

University of Texas Health Science Center,

San Antonio, Texas.

Jeffrey L. Fellows, Ph.D.,

Health Economist, Office on Smoking and Health,

National Center for Chronic Disease Prevention and Health Promotion,

Centers for Disease Control and Prevention,

Atlanta, Georgia.

David Felson, M.D., M.P.H.,

Professor of Medicine and Public Health, The Arthritis Center,

School of Medicine,

Boston University,

Boston, Massachusetts.

Roberta G. Ferrence, Ph.D.,

Director, Ontario Tobacco Research Unit,

University of Toronto,

Toronto, Ontario, Canada.

Frederick L. Ferris III, M.D.,

Director, Division of Epidemiology and Clinical Research,

Clinical Director, National Eye Institute,

National Institutes of Health,

Bethesda, Maryland.

Gary A. Giovino, Ph.D., M.S.,

Senior Research Scientist, Department of Cancer Prevention, Epidemiology, and Biostatistics,

Roswell Park Cancer Institute,

Buffalo, New York.

Alexander H. Glassman, M.D.,

Professor of Clinical Psychiatry, Department of Psychiatry,

College of Physicians and Surgeons,

Columbia University,

New York, New York.

Thomas J. Glynn, Ph.D.,

Director, Cancer Science and Trends,

American Cancer Society,

Washington, D.C.

Amy Borenstein Graves, Ph.D., M.P.H.,

Associate Professor, Department of Epidemiology and Biostatistics,

College of Public Health,

University of South Florida,

Tampa, Florida.

Lorraine Greaves, Ph.D.,

Executive Director, British Columbia Centre of Excellence for Women's Health,

British Columbia Women's Hospital,

Vancouver, British Columbia, Canada.

Betty Lee Hawks, M.A.,

Special Assistant to the Director, Office of Minority Health,

U.S. Department of Health and Human Services,

Rockville, Maryland.

Jack E. Henningfield, Ph.D.,

Associate Professor, Department of Psychiatry and Behavioral Sciences,

The Johns Hopkins University School of Medicine,

Bethesda, Maryland.

Marc C. Hochberg, M.D., M.P.H.,

Professor of Medicine and Epidemiology and Preventive Medicine,

University of Maryland School of Medicine,

Baltimore, Maryland.

John R. Hughes, M.D.,

Professor, Human Behavioral Pharmacology Laboratory,

Department of Psychiatry,

University of Vermont,

Burlington, Vermont.

Wanda K. Jones, Dr.P.H.,

Deputy Assistant Secretary for Health (Women's Health),

Office on Women's Health,

Washington, D.C.

Donald Kadunce, M.D.,

Assistant Professor, Department of Dermatology,

University of Utah,

Salt Lake City, Utah.

Denise Kandel, Ph.D.,

Professor of Public Health in Psychiatry, Department of Psychiatry,

College of Physicians and Surgeons of Columbia University and

Chief, Department on the Epidemiology of Substance Abuse,

New York State Psychiatric Institute,

New York, New York.

Ichiro Kawachi, M.D., Ph.D.,

Assistant Professor of Medicine, Channing Laboratory,

School of Medicine and Associate Professor of Health and Social Behavior,

School of Public Health,

Harvard University,

Boston, Massachusetts.

Kay-Tee Khaw,

Professor, Clinical Gerontology Unit,

University of Cambridge,

Cambridge, United Kingdom.

Douglas P. Kiel, M.D., M.P.H.,

Director for Medical Research, Hebrew Rehabilitation Center for Aged,

Research and Training Institute and

Associate Professor, Division on Aging,

Harvard Medical School,

Boston, Massachusetts.

Barbara Eden Kobrin Klein, M.D., M.P.H.,

Professor, Department of Ophthalmology and Visual Sciences,

Department of Preventive Medicine,

School of Medicine,

University of Wisconsin,

Madison, Wisconsin.

Lewis H. Kuller, M.D., Dr.P.H.,

University Professor of Public Health and Professor and Chair, Department of Epidemiology,

Graduate School of Public Health,

University of Pittsburgh,

Pittsburgh, Pennsylvania.

John H. Kurata, Ph.D., M.P.H.,

Chief, Chronic Disease Epidemiology Section,

California Department of Health Services,

Sacramento, California.

Carlo La Vecchia, M.D.,

Laboratory of Epidemiology,

Mario Negri Institute for Pharmacological Research and University of Milan,

Milan, Italy.

Darwin R. Labarthe, M.D., Ph.D.,

James W. Rockwell Professor of Public Health, School of Public Health,

The University of Texas-Houston,

Health Science Center,

Houston, Texas.

Harry A. Lando, Ph.D.,

Professor, Division of Epidemiology,

School of Public Health,

University of Minnesota,

Minneapolis, Minnesota.

Douglas S. Lloyd, M.D., M.P.H.,

HRSASenior Scholar, Association of Schools of Public Health,

Washington, D.C.

Richard Logan, B.Sc., MBChB, M.Sc., MFPHM, FRCP, FRCPE,

Professor of Clinical Epidemiology, Division of Public Health and Epidemiology,

University of Nottingham,

Queens Medical Centre,

Nottingham, England.

Alexander H. Glassman, M.D.,

Professor of Clinical Psychiatry, Department of Psychiatry,

College of Physicians and Surgeons,

Columbia University,

New York, New York.

Thomas J. Glynn, Ph.D.,

Director, Cancer Science and Trends,

American Cancer Society,

Washington, D.C.

Amy Borenstein Graves, Ph.D., M.P.H.,

Associate Professor, Department of Epidemiology and Biostatistics,

College of Public Health,

University of South Florida,

Tampa, Florida.

Lorraine Greaves, Ph.D.,

Executive Director, British Columbia Centre of Excellence for Women's Health,

British Columbia Women's Hospital,

Vancouver, British Columbia, Canada.

Betty Lee Hawks, M.A.,

Special Assistant to the Director, Office of Minority Health,

U.S. Department of Health and Human Services,

Rockville, Maryland.

Jack E. Henningfield, Ph.D.,

Associate Professor, Department of Psychiatry and Behavioral Sciences,

The Johns Hopkins University School of Medicine,

Bethesda, Maryland.

Marc C. Hochberg, M.D., M.P.H.,

Professor of Medicine and Epidemiology and Preventive Medicine,

University of Maryland School of Medicine,

Baltimore, Maryland.

John R. Hughes, M.D.,

Professor, Human Behavioral Pharmacology Laboratory,

Department of Psychiatry,

University of Vermont,

Burlington, Vermont.

Wanda K. Jones, Dr.P.H.,

Deputy Assistant Secretary for Health (Women's Health), Office on Women's Health,

Washington, D.C.

Donald Kadunce, M.D.,

Assistant Professor, Department of Dermatology,

University of Utah,

Salt Lake City, Utah.

Denise Kandel, Ph.D.,

Professor of Public Health in Psychiatry, Department of Psychiatry,

College of Physicians and Surgeons of Columbia University and

Chief, Department on the Epidemiology of Substance Abuse,

New York State Psychiatric Institute,

New York, New York.

Ichiro Kawachi, M.D., Ph.D.,

Assistant Professor of Medicine, Channing Laboratory,

School of Medicine and

Associate Professor of Health and Social Behavior, School of Public Health,

Harvard University,

Boston, Massachusetts.

Kay-Tee Khaw,

Professor, Clinical Gerontology Unit,

University of Cambridge,

Cambridge, United Kingdom.

Douglas P. Kiel, M.D., M.P.H.,

Director for Medical Research, Hebrew Rehabilitation Center for Aged,

Research and Training Institute and

Associate Professor, Division on Aging,

Harvard Medical School,

Boston, Massachusetts.

Barbara Eden Kobrin Klein, M.D., M.P.H.,

Professor, Department of Ophthalmology and Visual Sciences,

Department of Preventive Medicine,

School of Medicine,

University of Wisconsin,

Madison, Wisconsin.

Lewis H. Kuller, M.D., Dr.P.H.,

University Professor of Public Health and Professor and Chair, Department of Epidemiology,

Graduate School of Public Health,

University of Pittsburgh,

Pittsburgh, Pennsylvania.

John H. Kurata, Ph.D., M.P.H.,

Chief, Chronic Disease Epidemiology Section,

California Department of Health Services,

Sacramento, California.

Carlo La Vecchia, M.D.,

Laboratory of Epidemiology,

Mario Negri Institute for Pharmacological Research and University of Milan,

Milan, Italy.

Darwin R. Labarthe, M.D., Ph.D.,

James W. Rockwell Professor of Public Health, School of Public Health,

The University of Texas-Houston,

Health Science Center,

Houston, Texas.

Harry A. Lando, Ph.D.,

Professor, Division of Epidemiology,

School of Public Health,

University of Minnesota,

Minneapolis, Minnesota.

Douglas S. Lloyd, M.D., M.P.H.,

HRSASenior Scholar, Association of Schools of Public Health,

Washington, D.C.

Richard Logan, B.Sc., MBChB, M.Sc., MFPHM, FRCP, FRCPE,

Professor of Clinical Epidemiology, Division of Public Health and Epidemiology,

University of Nottingham,

Queens Medical Centre,

Nottingham, England.

Marc Manley, M.D., M.P.H.,

Special Assistant for Tobacco Policy, National Cancer Institute,

National Institutes of Health,

Rockville, Maryland.

Sonja M. McKinlay, Ph.D.,

President, New England Research Institutes, Inc.,

Watertown, Massachusetts.

Robin Mermelstein, Ph.D.,

Deputy Director, Health Research and Policy Centers and Department of Psychology,

University of Illinois,

Chicago, Illinois.

Linda D. Meyers, Ph.D.,

Deputy Director, Office of Disease Prevention and Health Promotion,

Washington, D.C.

Kenneth Moritsugu, M.D., M.P.H.,

Deputy Surgeon General, U.S. Public Health Service,

Office of the Surgeon General,

Office of the Secretary,

Washington, D.C.

Polly A. Newcomb, Ph.D., M.P.H.,

Member, Fred Hutchinson Cancer Research Center,

Seattle, Washington, and

Senior Scientist,

University of Wisconsin,

Madison, Wisconsin.

Patrick O'Malley, Ph.D.,

Research Scientist, Institute for Social Research,

University of Michigan,

Ann Arbor, Michigan.

Regina Otero-Sabogal, Ph.D.,

Associate Adjunct Professor, Institute for Health and Aging,

University of California,

San Francisco, California.

Nancy S. Padian, Ph.D.,

Co-Director, Center for Reproductive Health Research and Policy and

Professor, Department of Obstetrics, Gynecology, and Reproductive Sciences,

University of California,

San Francisco, California.

Julie R. Palmer, Sc.D.,

Associate Professor, Slone Epidemiology Unit,

Boston University School of Medicine,

Brookline, Massachusetts.

Donald Maxwell Parkin, M.D.,

Chief, Unit of Descriptive Epidemiology,

International Agency for Research on Cancer,

Lyon, France.

Terry F. Pechacek, Ph.D.,

Associate Director for Science, Office on Smoking and Health,

National Center for Chronic Disease Prevention and Health Promotion,

Centers for Disease Control and Prevention,

Atlanta, Georgia.

Linda L. Pederson, Ph.D.,

Visiting Scientist, Office on Smoking and Health,

National Center for Chronic Disease Prevention and Health Promotion,

Centers for Disease Control and Prevention,

Atlanta, Georgia.

Cheryl L. Perry, Ph.D.,

Professor, Division of Epidemiology,

School of Public Health,

University of Minnesota,

Minneapolis, Minnesota.

Göran Pershagen, M.D., Ph.D.,

Professor, Institute of Environmental Medicine,

Karolinska Institutet,

Stockholm, Sweden.

Richard Peto, FRS,

Professor, University of Oxford,

Clinical Trial Service Unit,

Radcliffe Infirmary,

Oxford, England.

Diana B. Pettiti, M.D., M.P.H.,

Director, Department of Research and Evaluation,

Kaiser Permanente of Southern California,

Pasadena, California.

John Pierce, Ph.D.,

Professor, Cancer Prevention and Control,

University of California at San Diego,

La Jolla, California.

Vivian Pinn, M.D.,

Associate Director for Research on Women's Health,

National Institutes of Health,

Bethesda, Maryland.

Ovide Pomerleau, Ph.D.,

Director, Behavioral Medicine Program,

Department of Psychiatry,

University of Michigan School of Medicine,

Ann Arbor, Michigan.

Patrick L. Remington, M.D., M.P.H.,

Associate Professor, Department of Preventive Medicine,

University of Wisconsin Medical School,

Madison, Wisconsin.

Nancy A. Rigotti, M.D.,

Director, Tobacco Treatment and Research Center,

Massachusetts General Hospital and

Associate Professor of Medicine,

Harvard Medical School,

Boston, Massachusetts.

Barbara K. Rimer, Dr.P.H.,

Director, Division of Cancer Control and Population Sciences,

National Cancer Institute,

National Institutes of Health,

Rockville, Maryland.

Thomas Rohan, M.D.,

Professor and Chairman, Department of Epidemiology and Social Medicine,

Albert Einstein College of Medicine,

Bronx, New York.

Elaine Ron, Ph.D.,

Chief, Radiation Epidemiology Branch,

National Cancer Institute,

National Institutes of Health,

Bethesda, Maryland.

Lynn Rosenberg, Sc.D.,

Associate Director, Slone Epidemiology Unit,

Brookline, Massachusetts, and

Professor, School of Public Health,

Boston University,

Boston, Massachusetts.

Michael J. Rosenberg, M.D., M.P.H.,

President, Health Decisions, Inc.,

Chapel Hill, North Carolina.

Rosemary Rosso, J.D.,

Senior Attorney, Division of Advertising Practices,

Federal Trade Commission,

Washington, D.C.

Richard B. Rothenberg, M.D., M.P.H.,

Professor, Department of Family and Preventive Medicine,

Emory University School of Medicine,

Atlanta, Georgia.

Jonathan M. Samet, M.D., M.S.,

Professor and Chairman, Department of Epidemiology,

School of Hygiene and Public Health,

The Johns Hopkins University,

Baltimore, Maryland.

Ulonda Shamwell, M.S.W.,

Associate Administrator for Women's Services,

Substance Abuse and Mental Health Services Administration,

Rockville, Maryland.

Donald R. Shopland,

Coordinator, Smoking and Tobacco Control Program,

National Cancer Institute,

National Institutes of Health,

Rockville, Maryland.

Nelson K. Steenland, Ph.D.,

Senior Epidemiologist, Division of Surveillance, Hazard Evaluations, and Field Studies,

National Institute for Occupational Safety and Health,

Centers for Disease Control and Prevention,

Cincinnati, Ohio.

Robert S. Stern, M.D.,

Carl J. Herzog Professor of Dermatology,

Harvard Medical School at Beth Israel Deaconess Medical Center,

Boston, Massachusetts.

Scott L. Tomar, D.M.D., Dr.P.H.,

Epidemiologist, Division of Oral Health,

National Center for Chronic Disease Prevention and Health Promotion,

Centers for Disease Control and Prevention,

Atlanta, Georgia.

Dimitrios Trichopoulos, M.D.,

Vincent L. Gregory Professor of Cancer Prevention and Professor of Epidemiology,

School of Public Health,

Harvard University,

Boston, Massachusetts.

Jaylan Turkkan, Ph.D.,

Chief, Behavioral Sciences Research Branch,

National Institute on Drug Abuse,

National Institutes of Health,

Rockville, Maryland.

K. M. Venkat Narayan, M.D.,

Chief, Epidemiology Section,

Epidemiology and Statistics Branch,

Division of Diabetes Translation,

National Center for Chronic Disease Prevention and Health Promotion,

Centers for Disease Control and Prevention,

Atlanta, Georgia.

Ingrid Waldron, Ph.D.,

Professor of Biology, Department of Biology,

University of Pennsylvania,

Philadelphia, Pennsylvania.

Kenneth E. Warner, Ph.D.,

Richard D. Remington Collegiate Professor of Public Health,

Department of Health Management and Policy,

School of Public Health,

University of Michigan and Director,

University of Michigan Tobacco Research Network,

Ann Arbor, Michigan.

Walter C. Willett, M.D., Dr.P.H.,

Professor of Epidemiology and Nutrition and

Chair, Department of Nutrition,

Harvard School of Public Health,

Boston, Massachusetts.

Gayle Windham, Ph.D.,

Senior Epidemiologist, Division of Environmental and Occupational Disease Control,

California Department of Health Services,

Oakland, California.

Warren Winkelstein, Jr., M.D., M.P.H.,

Professor Emeritus of Epidemiology,

Division of Public Health, Biology, and Epidemiology,

School of Public Health,

University of California,

Berkeley, California.

Anna H. Wu, Ph.D.,

Professor, Keck School of Medicine,

Department of Preventive Medicine,

Norris Comprehensive Cancer Center,

University of Southern California,

Los Angeles, California.

Mitchell R. Zeller, J.D.,

Director, Office of Tobacco Programs,

Food and Drug Administration,

Rockville, Maryland.

Other contributors were

Kathleen Adams, Ph.D.,

Associate Professor, Rollins School of Public Health,

Emory University and

Health Economist, Division of Reproductive Health,

National Center for Chronic Disease Prevention and Health Promotion,

Centers for Disease Control and Prevention,

Atlanta, Georgia.

Harmony Allison, M.P.H.,

Visiting Fellow, Office on Smoking and Health,

National Center for Chronic Disease Prevention and Health Promotion,

Centers for Disease Control and Prevention,

Atlanta, Georgia.

Felicia M. Barlow,

Project Coordinator, Palladian Partners, Inc.,

Silver Spring, Maryland.

Trudy Barnes,

Project Coordinator, Palladian Partners, Inc.,

Silver Spring, Maryland.

Lara Boeck,

Proofreader, Palladian Partners, Inc.,

Silver Spring, Maryland.

Alison Brown,

Graphic Artist, Palladian Partners, Inc.,

Silver Spring, Maryland.

Tavian K. Cardwell,

Graphic Artist, Palladian Partners, Inc.,

Silver Spring, Maryland.

Christine Choy,

Administrative Assistant, Department of Epidemiology and Biostatistics,

University of California,

San Francisco, California.

Robyn Ertwine,

Indexer, Palladian Partners, Inc.,

Silver Spring, Maryland.

Luis G. Escobedo, M.D., M.P.H.,

Border Health Epidemiologist, New Mexico Border Health Office,

New Mexico Department of Health,

Las Cruces, New Mexico.

Wanda Foster,

Word Processing Specialist, Palladian Partners, Inc.,

Silver Spring, Maryland.

Sarah Gregory,

Acting Managing Editor, Office on Smoking and Health,

National Center for Chronic Disease Prevention and Health Promotion,

Centers for Disease Control and Prevention,

Atlanta, Georgia.

Barbara H. Hebb,

Project Manager, SAIC,

Oak Ridge, Tennessee.

Elizabeth L. Hess, E.L.S.,

Senior Technical Editor, Palladian Partners, Inc.,

Silver Spring, Maryland.

Lynn Hughley,

Lead Graphic Artist, TRW, Inc.,

Atlanta, Georgia.

Yun Chen W. Lin, M.P.H.,

Technical Information Specialist, Office on Smoking and Health,

National Center for Chronic Disease Prevention and Health Promotion,

Centers for Disease Control and Prevention,

Atlanta, Georgia.

William T. Marx, M.L.I.S.,

Technical Information Specialist, Office on Smoking and Health,

National Center for Chronic Disease Prevention and Health Promotion,

Centers for Disease Control and Prevention,

Atlanta, Georgia.

Richard Mayeux, M.D., M.S.E.,

Gertrude H. Sergievsky Professor of Neurology, Psychiatry, and Public Health (Epidemiology),

Gertrude H. Sergievsky Center,

Columbia University,

New York, New York.

Maribet McCarty, R.N., M.P.H.,

Technical Information Specialist, The Orkand Corporation,

Atlanta, Georgia.

Cathy L. Melvin, Ph.D., M.P.H.,

Chief, Program Services and Development Branch,

Division of Reproductive Health,

National Center for Chronic Disease Prevention and Health Promotion,

Centers for Disease Control and Prevention,

Atlanta, Georgia.

Donald J. Sharp, M.D.,

Medical Epidemiologist, Office on Smoking and Health,

National Center for Chronic Disease Prevention and Health Promotion,

Centers for Disease Control and Prevention,

Atlanta, Georgia.

Cate Timmerman,

Co-President, Palladian Partners, Inc.,

Silver Spring, Maryland.

Angela Trosclair, M.S.,

Statistician, TRW, Inc.,

Atlanta, Georgia.

Lynne Wilcox, M.D., M.P.H.,

Director, Division of Reproductive Health,

National Center for Chronic Disease Prevention and Health Promotion,

Centers for Disease Control and Prevention,

Atlanta, Georgia.

Peggy E. Williams, M.S.,

Writer-Editor, Analytical Sciences, Inc.,

Marietta, Georgia.

Trevor A. Woollery, Ph.D.,

Health Economist, Office on Smoking and Health,

National Center for Chronic Disease Prevention and Health Promotion,

Centers for Disease Control and Prevention,

Atlanta, Georgia.

Derek Yach, M.D.,

Program Manager, Tobacco-Free Initiative,

World Health Organization,

Geneva, Switzerland.