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The Health Consequences of Smoking for Women A Report of the Surgeon General - Part 1 of 4
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THE HEALTH
CONSEQUENCES
OF SMOKING
FOR WOMEN
a report of the Surgeon General
U.S. DEPARTMENT OF HEALTH! EDUCATIONANO WELFARE
Public Health Servide
Office of'the Assistant Secretary for, Health
Office on Smoking andiHealth
V
the lowest yield cigarettes are more or less likely to attempt
to quit, or to succeed in quitting, than smokers of
conventionall filtertip or nonfilter cigarettes. The extent to
which the act of switching to a lower "tarn cigarette may
serve as a substitutee for quitting may differ among wom en
and men.
PUBLIC HEALTH RESPONSIBILITIES
This report, which includes data compiled by individuals from
both inside and outside the Government, has confirmed in
every way thejudge:nent of the World Health Organization,
that there cann no longer be any doubt among informed people
that cigarette smoking is a major and removable cause of ill
health and premature death. Eachh individual woman must make her own decision
about this significant health issue. Secretary Harris has
noted that the role of the Government, and all responsible
health professionals, is to assure that this decision Is an
infonnedd one. In issuing this report, we hope to help the
public health community accomplish this purpose.
Julius B. Richmond, M.D.
Assistant Secretary for
Health and Surgeon General
0
viii
PREFACE
This report is more than a factual review of the health
consequences of smoking for women. It is a document which
challenges our society and, In particular, our medical and
public health communities.
This report points out that the first signs of an
epidemic of s;noking-related disease among women are now
appearing.. Because women's cigarette use did not become
widespread until the onset' of YyorldWar II, those women with
the greatest intensity of smoking are now only in their
thirties, forties, and fifties. As these women grow older, and
continue to smoke, their burden of smoking-related disease
will grow larger. Cigarette smoking now contributes to one-
fifth of the newly diagnosed cases of cancer and one-quarter
of all cancer deaths among women--more cancer and more
cancer deaths among women than can be attributed to any
other knownn agent. Within three years, the lung cancer death
rate is expected to surpass that for breast cancer. A similar
epidemic of chronic obstructive lung disease among women has
also begun.
Four main themes emerge from this report to guide
future public health efforts.
First, women are not immune to the damaging effects
of smoking already documented for men. The apparently lower
susceptibility to smoking related diseases among women
smokers is an illusion reflecting the fact that women lagged
one-quarter century behind menn in their widespread use of
cigarettes.
Second, cigarette sm oking is a major threat to the
outcome of pregnancy and well-being of the newborn baby.
Third, women may not start smoking, continue to
smoke, quit smoking, or fail to quit sm oking for precisely the
sam e reasons as men. Unless future research clarifies these
differences, we will find it difficult to prevent initiation or
to promote cessation of cigarette smoking among women.
Fourth, thereduetione of cigarette sm oking. is the
keystone in our nation's long termn strategy to promote a
healthy lifestyle for wo men and men of all races and ethnic
groups.
}MC SCCREiMNT OiN ~ H.CGVG..TIONIND W[LI/:Xr
WwCNIN6TON. DC.COio~i
The Honorable Thomas P. O'Neill,Jr.
Speaker of the House of Representatives
Washingtonj D.C. 20515
Dear Mr. Speaker:
I hereby submit the 12th annual report that the
Department of Health, Education, and Welfare (DHEW)has
prepared for Congress as required by the Public Health
Cigarette Smoking Act of.1969,Public Law 91i-222, and its
predecessor, the Federal Cigarette Labeling and Advertising
Act. This report is one of the most alarming in the series.
It.clearly establishes that women smokers face the same
risks as men smokers of lung cancer, heart disease, lung
disease and other consequences. Perhaps more disheartening
is the harm.which mothers' smoking.causes to their unborn
babies and infants.
The report is not all bad news. It presents recentt
data showing that women are turning away from smoking in
response to the warnings of government, voluntary agencies
and physicians. The precipitate rise in women's deaths from
lung cancer and chronic lung disease demand that this trend
away from cigarettes be.accelerated.. Our scientists expect
that by 1983, the lung cancer death rate will exceed that of
any other type of cancer among women.
Citizens off our free society may decide for themselves
whether to smoke cigarettes. The health consequences of
thi~sdecision make it imperative for their government to
assure that the decision is an informed one. This- series
of reports is one way in which DHEW is striving to meet
this critical responsibility..
m~,
~ /J --~
Patricia Roberts Harris
cancer than women nonsmokers. By 1979, womem accounted
for fully one-fourthof all lung cancer deaths.. Over the next
few years, womem cigarette smokers' risk of lung cancer death
will approach, 8 to 12 times that of women nonsmokers, the
same relative risk as that of men.
Lung cancer has four main histological types:
epidermoid, small cel.l, adenocarcinoma, and large cell
carcinoma. As several studies have shown, the incidence of
each of these types of lung cancer displays a clear
relationship to cigarette smoking amongboth men and women.
Epider:noid and small cell lung cancer appear to be more
prominent among men, while adenocarcinoma of the lung now
appears to be more prominent among women.
The recent acceleration of lung cancer incidence among
women has in fact beenmore rapid than the corresponding
growth of lung cancer among men in the 1930s. Again, this
difference in the initial rate of acceleration of lung cancer
incidencedoes not refute the demonstrated causal relation
between cigarette smoking and lungg cancer among both sexes.
Instead, differences in the rate of increase of lung cancer
incidencemay reflect changes in the carcinogenic properties
of cigarette smoke, thee style of cigarette sm oking, or the
interaction of cigarette smoking with other environmental
hazards. It is noteworthy that those :menwho died of lung
cancer in the 1930s came from a generation that had
gradually converted to cigarettes from other, non-inhaled
forms of tobacco. By contrast, the first regular tobacco
users am ono women weree almost exclusively cigarette sm okers.
The 1979 Report on Smoking and Health documented
numerous instances where cigarette smoking adds to the
hazard's of the workplace envinonmentt among men. Among,
women, this report reveals two such occupational exposures--
asbestos and cotton dust- -which have been clearly
demonstrated to interact with cigarette snoking.The fact
that evidence is limited among women does not imply that
women are protected from the dangerous interactions of
smoking and occupational exposures.
PREGNANCY, INFANT HEALTH, AND REPRODUCTION'
Scientific studies encompassing various races and ethnic
groups, cultures and countries, involving hundreds of thousands
of pregnancies, have shown that cigarette smoking during
pregnancy significantly affects the unborn fetus and the
iii
`
women and men have paralleled those of the general
population. From 1965 to 1979, the proportion of black
women cigarette smokers declined from 34 to 29 percent,
while the proportion of black men smokers declined from 61
to 42 percent. However, differences by race in the onset,
maintenance, and cessation of smoking have not been
adequately explored6 Little Is known about cigarette smoking
among other ethnic and minority groups.
ADOLESCENT 5;9flKNNG
The health consequences of smoking evolve over a lifetime.
Evidence continues to accumulate, for example, that cigarette
smoking produces measurable lung changes even In childhood
and young adulthood. Young cigarette smokers of both sexes
show more evidenceofe small airway dysfunction, and a higher
prevalence of cough, wheezing, phlegm production, and', other
respiratory symptoms. The health damage due to cigarette
smokingg increases when an individual' begins regular smoking
earlier in life. Yet,, as this report documents, the average
age of onset of regular smoking among women has
continuously declined during the last 50 years, and continues
to decline. .
According to a recent survey by the National Institute
of Education, cigarette smoking among adolescent girls now
exceeds that among adolescent boys. In the: 17-19 year age
group, there are almost 5 fe:rtalecigarette smokers for every
4 m ale cigarette sm okers. The causes of this inversion are
far fromn clear. We do nott yet understand the signal events
in the Initiation of smoking among young women. It is
possible that parents set examples concerning lifestyle, healthh
attitude, and risk-taking much earlier in childhood. The
beginning of junior high school or entrance into the work
force may be equally critical events. We do not know enough
about an adolescent's sense of competence and self-m astery,
and how these roles differ among women and men. Although
smoking patterns am onggirls correlate withi parental, peer andd
sibling sm oking habits, educational level, type of schootl
curriculum, academic performance, socioeconomic status, and:
other forms of substance abuse, the practical significance of
these empirical correlations is unclear.:
VI
ACKNOWLEDGEMENTS
This report was prepared by agencies of the U.S.
Department of Health, Education and Welfare under the general
editorship of the Office on Smoking and Health, John M.
Pinney, Director. Consulting scientific editors were David M.
Burns, Assistant Clinical Professor, Pulmonary Division,
University of California at San Diego, San Diego, California
and John H. Holbrook, M.D., Assistant Professor of Internal
Medicine, University of Utah Medical School, Salt Lake City,
Utah.
Introduction and Summary
Office on Smoking and Health
Patterns of Cigarette Smoking
Office on Smoking and Health .
Jeffrey E. Harris, M.D., Ph.D., Assistant Professor,
Department of Economics, Masasachusetts Institute of
Technology, Cambridge, Massachusetts; Clinical
Associate, Medical Services, Massachusetts General
Hospital, Boston, Massachusetts. ..
Overall Mortality ..
National Heart, Lung, and Blood Institute
Eugene Rogot, Division of Heart and Vascular
Diseases, National Heart, Lung, and Blood Institute,
National Institutes of Health, Bethesda, Maryland;
Thomas J. Thom, Division of Heart and Vascular
Diseases, National Heart, Lung and Blood Institute,
National Institutes of Health, Bethesda, Maryland
Morbidity
National, . Center for Health Statistics
Ronald W. Wilson, M.A., Chief, Health Status and
Demographic Analysis Branch, Division of Analysis,
National Center for Health Statistics, Hyattsvllle,
Maryland.
Cardiovascular Diseases
National. Heart, Lung, and Blood Institute.
G.C. McMillan, M.D., Ph.D., Associate Director for
Etiology of Arteriosclerosis and Hypertension,,
Division of Heart and Vascular Diseases, National.
Heart, Lung, and Blood Institute, National Institutes
of Health, Bethesda, Maryland.
xi
Cancer
National Cancer Institute . .
Jesse L. Steinfeldy M.D., Dean, Medical College of
Virginia, Richmond, Virginia. Non-Neoplastic Rronchopulmonary niseases
National Heart, Lung, and Riood.Institute , Richard A. Rordow,M.D., Associate Research
' Physiologist, University of California at San niego,
San Diego, California; Claude J.M. Lenfant, M.n.,
Director, Division of Lung Disease,. National Heart,
Lung, and Rlood Institute, National Lnstitutes of
Health,Rethesda, Maryland
Earbara Marzetta Liu, Division of Lung Disease,
-National Heart, Lung, and Rlood Institote, National
Institutes of Health, Rethesda, Maryland Eric R. Jurrus, Division of Lung Disease, National
..Heart, Lung, and Blood Institute, National Institutes
of Health, Bethesda, Maryland,
Interaction Between Smokingm and r)ccupational
Exposures - - - -
National Institute of Occupational Safety and Health
.. Jeanne M. Steelman, Ph.D., American Health
-"Foundation,New York, New York. ' Steven D. Stetlman, Chief, Division 'of Health &
'Toxicology, A merican Health Foundation, New York,
New York' - -
Pregnancy and Infant. Health - National Institute of Child Health and Human
Development - Eileen. G. Hasselmeyer, Ph.D., R.N., Associate
Director for Scientific Revie w, National Institute of
Child Health and Human Development,National
Institutes of Health, -Rethesda Maryland.
M ary R. Meyer, M.Sc., Associate Professor of
Epidemiology, Johns Hopkins University School of
Hygiene and Public Health, Raltimore, Maryland.
Lawrence D. Longo, M.D., Professor of Physiology and
.Obstertrics and Gynecology, Loma Linda University
School of Medicine, Loma Linda, California
Donald R. M attison, M.D., Senior Investigator,
Pregnancy Research Pranch, National Institute of
Child Health and Humam. Development, National
Institutes of Health, Bethesda, Maryland.
xii
Peptic Ulcer
National Institute of Arthritis, Metabolism and
Digestive Diseases - -
Travis E. Solomon, M.D., Ph.D., Center for Ulcer
Research and Education, VA Wadsworth Medical Center
and UCLA School of Medicine, Los Angeles, California
Janet Elashoff, Ph.D., Center for Ulcer Research and
Education, VA Wadsworth Medical Center and UCLA
School of Medicine, Los Angeles, California.
Interactiuns of Smoking with Drugs, Food
Constituents and Responses to Diagnostic Tests
Cheryl Fossum Graham, M.D., Division of Drug
Experience, Office of Biom etrics and Epidemiology,
Bureau of Drugs, Food and Drug Administration.
Psychosocial and Behavioral Aspects of Smokingg
in. Women - Initiation, Maintenance, and Cessation
'
Ellen P.. Gritz, Ph.D., Research Psychologist,
Veterans Administration Medical Center, Brentwood,
California and Associate Research. Psychologist,
Department of Psychiatry and Behavioral Sciences,
School of Medicine, University of California, Los
Angeles, California. . -
Ann Brunswick, Ph.D., Senior Research. Associate(Sociom edical Sciences), Center for Sociocultural
Research on Drug Use, School of Public Health,
Columbia University, New York, New York. ..
Karen L. Bierman, M.A., Department of Psychology,
University of California, Los Angeles, California.
The editors acknowledge with gratitude the many
distinguished scientists, physicians, and others who
assisted in the preparation of this report by coor-
dinating manuscript preparation, contributing criti-
cal reviews of the manuscripts or helping in other
ways.
Elvin A. Adams, M.D., M.P.H., Practicing Internal
M edicine, Fort Worth, Texas.
Josephine D. Arasteh, Ph.D., Health Scientist
Administrator, Human Learning and Behavior Rranch,
Center for Research for Mothers and Children,
National Institute of Child Health and Human
THE FALLACY OF WOMEN'S IMMUNITY
All of the major prospective studies off smoking and mortality
have reached consistent conclusions.. Deathrates from
coronary heart disease, chronic lung disease, Iung.cancer, and
overall mortality rates are significantly increased among both
women and men smokers. The.serisks increase with the
amount smoked, durationn of smoking, depth of inhalation, and
the "tar" and nicotine delivery of the cigarette smoked.
. In these studies, conducted during the past three
decades, relative mortality risks among female smokers
appeared to be less than those of male smokers. It is now
clear, ho wever, that these studies were comparing the death.rates of a generation of established,
lifelong male sm okerswith a generation of womenn who had not yet taken up smokingg
with full~ intensity. Even those older wom en who reported
smoking a large number of cigarettes per day had not smoked
cigarettes im the same way as their male counterparts. Now
that the cigarette sm oking characteristics of wom en and men
are becoming increasingly simflar, their relative risks of
smoking-related illness will become increasingly similar.
This fallacy of women's apparent immunity is clearly
illustrated' by differences in the timing of the growth in lung
cancer among men and women in this century. _Lung cancer
deaths among males began to increase during the 1930s,as
those aten who had converted from other forms of tobacco to
cigarette smokingg before the turn of the century gradually
accumulated decades of inhaled tobacco exposure. .. By the
tim e of the first retrospective studies of smoking and lung
cancer in 1950, two entire generations of men had already
become lifelong cigarette smokers.. Relatively few womenn
from these generations smoked cigarettes, and even fewer had'd
smokedd cigarettes since their adolescence. Those young
women who had'd taken up smoking intensively during World War
II were only in their twenties and thirties. In 1950, women
accounted for less than one in twelve deaths from~ lung
cancer.
- Thereafter, the age adjusted lung cancer death rate
among women accelerated, and the male predominance in lung
cancer declined. Lung cancer surpassed uterine cervical
cancer as a cause of death in women. By 1968, as the
findings of many large population prospectivee studies were
being published, women accounted for one-sixth of all lung
cancer deaths. These studies found that women cigarette
smokers had 2.5 to 5 ti:nes greater deatNrates from lung
