The Health Benefits
of
SMOKING CESSATION

 

 

a report of the
Surgeon General

1990

Pos U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES

Public Health Service

Centers for Disease Control

Center for Chronic Disease Prevention and Health Promotion CENTERS FOA DISEASE CONTROL
Office on Smoking and Health

Rockville, Maryland 20857

 
Suggested Citation

U.S. Department of Health and Human Services. The Health Benefits of Smok-
meg Cessation. US. Department of Health and Human Services, Public Health
Service, Centers for Disease Control. Center for Chronic Disease Prevention

Health Promotion, Office on Smoking and Health. DHHS Publication No.
(CDC) 90-8416, 1990.

und
THE SECRETARY OF HEALTH AND HUMAN SERVICES
WASHINGTON. OC 20701

SEP 13 1990

 

The Honorable Thomas S. Foley

Speaker of the House of
Representatives

Washington, D.C. 20515

Dear Mr. Speaker:

It is my pleasure to transmit to the Congress the 1990 Surgeon General's
Report on the health consequences of smoking as mandated by Section 8(a) of
the Public Health Cigarette Smoking Act of 1969 (Pub. L. 91-222). The report
was prepared by the Centers for Disease Control's Office on Smoking and Health.

This report, entitled The Health Benefits of Smoking Cessation, examines how
an individual's risk of smoking-related diseases declines after quitting
smoking. The evidence is overwhelming that smoking cessation has major and
immediate health benefits for men and women of all ages. Smoking cessation
increases overall life expectancy and reduces the risk of lung cancer, other
cancers, heart attack, stroke, and chronic lung disease such as emphysema.

The health benefits of smoking cessation far exceed any risks from the average
5-pound weight gain or any adverse psychological effects that may follow
quitting.

Cigarette smoking is the most important preventable cause of death in our
society. It is responsible for approximately 390,000 deaths each year in the
United States, or more than one of every six deaths. We must do all we can to
prevent young people from taking up this deadly addiction, and we must help
smokers quit. Given the enormous benefits of smoking cessation, and the fact
that good smoking cessation programs Can achieve abstinence rates of 20 to 40
percent at one-year followup, these programs are likely to be extremely
cost-effective compared with other preventive or curative services.
Therefore, I would encourage health insurers to provide payment for smoking
cessation treatments that are shown to be effective. At a minimum, the
treatment of nicotine addiction should be considered as favorably by
third-party payors as treatment of alcoholism and illicit drug addiction.

This report should help convince all smokers of the compelling need to quit
smoking.

Sincerely,
x . ys J
Chu AW pete

Louis W. Sullivan, M.D.
Secretary

Enclosure
THE SECRETARY OF HEALTH AND HUMAN SERVICES
WASHINGTON, D& 20201

SEP 13 1996

 

The Honorable Dan Quayle
President of the Senate
Washington, D.C. 20515

Dear Mr. President:

It is my pleasure to transmit to the Congress the 1990 Surgeon General's
Report on the health consequences of smoking as mandated by Section &(a) of
the Public Health Cigarette Smoking Act of 1969 (Pub. L. 91-222). The report
was prepared by the Centers for Disease Control's Office on Smoking and Health.

This report, entitled The Health Benefits of Smoking Cessation, examines how
an individual's risk of smoking-related diseases declines after quitting
smoking. The evidence is overwhelming that smoking cessation has major and
immediate health benefits for men and women of all ages. Smoking cessation
increases overall life expectancy and reduces the risk of lung cancer, other
cancers, heart attack, stroke, and chronic lung disease such as emphysema.

The health benefits of smoking cessation far exceed any risks from the average
S-pound weight gain or any adverse psychological effects that may follow
quitting.

Cigarette smoking is the most important preventable cause of death in our
society. It is responsible for approximately 390,000 deaths each year in the
United States, or more than one of every six deaths. We must do all we can to
Prevent young people from taking up this deadly addiction, and we must help
smokers quit. Given the enormous benefits of smoking cessation, and the fact
that good smoking cessation programs can achieve abstinence rates of 20 to 40
Percent at one-year followup, these programs are likely to be extremely
cost-effective compared with other preventive or curative services.
Therefore, I would encourage health insurers to provide payment for smoking
cessation treatments that are shown to be effective. At a minimum, the
treatment of nicotine addiction should be considered as favorably by
third-party payors as treatment of alcoholism and illicit drug addiction.

This report should help convince all smokers of the compelling need to quit
smoking.

Sincerely,
aw of
Chg AY (ether tae

Louis W. Sullivan, M.D.
Secretary

Enclosure
FOREWORD

More than 38 million Americans have quit smoking cigarettes. and nearly half of all
living adults who ever smoked have quit. Unfortunately, some 50 million Americans
continue to smoke cigarettes, despite the many health education programs and anti-
smoking campaigns that have been conducted during the past quarter century, despite
the declining social acceptability of smoking, and despite the consequences of smoking
to their health. , .

Twenty previous reports of the Surgeon General have reviewed the health effects of
smoking. Scientific data are now available on the consequences of smoking cessation
for most smoking-related diseases. Previous reports have considered some of these
data. but this Report is the first to provide a comprehensive and unified review of this

* topic.
The major conclusions of this volume are:

1. Smoking cessation has major and immediate health benefits for men and women
of all ages. Benefits apply to persons with and without smoking-related disease.

2. Former smokers live longer than continuing smokers. For example, persons
who quit smoking before age 50 have one-half the risk of dying in the next 15
years compared with continuing smokers.

3. Smoking cessation decreases the risk of lung cancer, other cancers, heart attack,
stroke, and chronic lung disease.

4. Women who stop smoking before pregnancy or during the first 3 to 4 months
of pregnancy reduce their risk of having a low birthweight baby to that of
women who never smoked.

5. The health benefits of smoking cessation far exceed any risks from the average
5-pound (2.3-kg) weight gain or any adverse psychological effects that may
follow quitting.

With the long-standing evidence that smoking is extremely harmful to health and the
mounting evidence that smoking cessation confers major health benefits, we remain
faced with the task of developing effective strategies to curtail the use of tobacco, Two
broad categories of intervention are available: prevention of smoking initiation among
youth and smoking cessation. Resources for tobacco control are limited. and
policymakers must decide how best to allocate those resources to smoking prevention
and cessation.

The goal of public health is to intervene as early as possible to prevent disease,
disability, and premature death. From that standpoint. prevention of smoking initiation
should be a major priority. More than 3.000 teenagers become regular smokers each
day in the United States. Because of the strength of nicotine addiction. some have
argued that public health efforts should focus on smoking prevention rather than
smoking cessation. However. this need not be an “either-or” situation.

Public health practitioners have categorized interventions into primary, secondary,
and tertiary prevention. Primary prevention generally refers to the elimination of risk
factors for disease in asymptomatic persons. Secondary prevention is defined as the
early detection and treatment of disease. and is practiced using tools such as Pap smears
and blood pressure screening. Tertiary prevention consists of measures to reduce
impairment, disability. and suffering in people with existing disease.

Smoking cessation falls under the category of primary prevention as does the
prevention of smoking initiation. Smoking cessation meets the definition of primary
prevention by reducing the risk of morbidity and premature mortality in asymptomatic
people. In addition, parents who quit smoking reduce or eliminate the risk of passive-
smoking-related disease among their children and reduce the probability that their
children will become smokers. Thus, there should be no debate about the need for
smoking prevention versus cessation—both are important.

Public awareness of the health effects of smoking has increased substantially through
the years. Nevertheless, important gaps in public knowledge still exist. Some smokers
may have failed to quit because of a lack of appreciation of the health hazards of
smoking and the benefits of quitting. In the 1987 National Health Interview Survey of
Cancer Epidemiology and Control. respondents were asked whether smoking increases
the risk of various diseases (lung cancer. cancer of the mouth and throat, heart disease.
emphysema, and chronic bronchitis) and whether smoking cessation reduces the risk.
Thirty to forty percent of smokers either did not believe that smoking increases these
risks or did not believe that cessation reduces these risks. These proportions correspond
to 15 to 20 million smokers in the United States. Clearly. our efforts to educate the
public on the health hazards of smoking and the benefits of quitting are not yet complete.

As we continue and intensify our efforts to inform the public of these findings, we
must make available smoking cessation programs and services to those who need them.
Although 90 percent of former smokers quit without using smoking cessation programs.
counseling. or nicotine gum. smokers who do need this assistance should have it
available. We endorse the view expressed in the Preface to the 1988 Surgeon General’s
Report that treatment of nicotine addiction should be considered at least as favorably
by third-party payors as treatment of alcoholism and illicit drug addiction. Good
smoking cessation treatments can achieve abstinence rates of 20 to 40 percent at I-year
followup. Those success rates. combined with the enormous health benefits of smoking
cessation, would likely make payment for some smoking cessation treatments cost-
beneficial. For example. research by the Centers for Disease Control suggests that a
smoking cessation program offered to all pregnant smokers could save $5 for every
dollar spent by preventing low birthweight-associated neonatal intensive care and
long-term care.
This Report should galvanize the health community to stress repeatedly at every
opportunity the value of smoking cessation to the 50 million Americans who continue
to smoke.

James O. Mason. M.D., Dr.P.H. William L. Roper. M.D.

Assistant Secretary for Health Director
Public Health Service Centers for Disease Control

i
PREFACE

This Report of the Surgeon General is the 21st Report of the U.S. Public Health
Service on the health consequences of smoking and the first issued during my tenure
as Surgeon General. Whereas previous reports have focused on the health effects of
smoking, this Report is devoted to the benefits of smoking cessation.

The public health impact of smoking is enormous. As documented in the 1989
Surgeon General's Report. an estimated 390.000 Americans die each year from diseases
caused by smoking. This toll includes 115.000 deaths from heart disease: 106,000 from
lung cancer, 31,600 from other cancers: 57,000 from chronic obstructive pulmonary
disease, 27,500 from stroke: and 52.900 from other conditions related to smoking.
More than one of every six deaths in the United States are caused by smoking. For
more than a decade the Public Health Service has identified cigarette smoking as the
most important preventable cause of death in our society.

It is clear, then, that the elimination of smoking would yield substantial benefits for
public health. What are the benefits. however, for the individual smoker who quits? A
large body of evidence has accumulated to address that question and derives from cohort
and case-control studies, cross-sectional surveys, and clinical trials. In studies of the
health effects of smoking cessation, persons classified as former smokers may include
some current smokers; this misclassification is likely to cause an underestimation of
the health benefits of quitting. Taken together. the evidence clearly indicates that
smoking cessation has major and immediate health benefits for men and women of all
ages.

Overall Benefits of Smoking Cessation

People who quit smoking live longer than those who continue to smoke. To what
extent is a smoker’s risk of premature death reduced after quitting smoking? The
answer depends on several factors, including the number of years of smoking, the
number of cigarettes smoked per day, and the presence or absence of disease at the time
of quitting. Data from the American Cancer Society’s Cancer Prevention Study II
(CPS-If) were analyzed in this Report to estimate the risk of premature death in
ex-smokers versus current smokers. These data show, for example, that persons who
quit smoking before age 50 have one-half the risk of dying in the next 15 years compared
with continuing smokers.

Smoking cessation increases life expectancy because it reduces the risk of dying from
specific smoking-related diseases. One such disease is lung cancer, the most common
cause of cancer death in both men and women. The risk of dying from lung cancer is

Vv
22 times higher among male smokers and 12 times higher among female smokers
compared with people who have never smoked. The risk of lung cancer declines steadily
in people who quit smoking: after 10 years of abstinence, the risk of lung cancer is about
30 to 50 percent of the risk for continuing smokers. Smoking cessation also reduces
the risk of cancers of the larynx, oral cavity, esophagus, pancreas. and urinary bladder.

Coronary heart disease (CHD) is the leading cause of death in the United States.
Smokers have about twice the risk of dying from CHD compared with lifetime
nonsmokers. This excess risk is reduced by about half among ex-smokers after only 1
year of smoking abstinence and declines gradually thereafter. After 15 years of
abstinence the risk of CHD is similar to that of persons who have never smoked.

Compared with lifetime nonsmokers. smokers have about twice the risk of dying from
stroke, the third leading cause of death in the United States. After quitting smoking.
the risk of stroke returns to the level of people who have never smoked: in some studies
this reduction in risk has occurred within 5 years. but in others as long as 15 years of
abstinence were required.

Cigarette smoking is the major cause of chronic obstructive pulmonary disease
(COPD), the fifth leading cause of death in the United States. Smoking increases the
risk of COPD by accelerating the age-related decline in lung function. With sustained
abstinence from smoking, the rate of decline in lung function among former smokers
retums to that of never smokers, thus reducing the risk of developing COPD.

Influenza and pneumonia represent the sixth leading cause of death in the United
States. Cigarette smoking increases the risk of respiratory infections such as influenza.
pneumonia. and bronchitis. and smoking cessation reduces the risk.

Cigarette smoking is a major cause of peripheral artery occlusive disease. This
condition causes substantial mortality and morbidity: complications may include inter-
mittent claudication, tissue ischemia and gangrene. and ultimately. loss of limb.
Smoking cessation substantially reduces the risk of peripheral artery occlusive disease
compared with continued smoking.

The mortality rate from abdominal aortic aneurysm is two to five times higher in
current smokers than in never smokers. Former smokers have half the excess risk of
dying from this condition relative to current smokers,

About 20 million Americans currently have. or have had. an ulcer of the stomach or
duodenum. Smokers have an increased risk of developing gastric or duodenal ulcers.
and this increased risk is reduced by quitting smoking.

Benefits at All Ages

According to a 1989 Gallup survey, the proportion of smokers who say they would
hike to give up smoking is lower for smokers aged 50 and older (57 percent) than for
smokers aged 18-29 (68 percent) and 30-49 (67 percent). Older smokers may be less
motivated to quit smoking because the highly motivated may have quit already at
younger ages. leaving a relatively “hard-core” group of older smokers. But many
long-term smokers may lack motivation to quit for other reasons. Some may believe
they are no longer at risk of smoking-related diseases because they have already
survived smoking for many years. Others may believe that any damage that may have

vi
been caused by smoking is irreversible after decades of smoking. For similar reasons.
many physicians may be less likely to counsel their older patients to quit.

CPS-II data were used to estimate the effects of quitting smoking at various ages on
the cumulative risk of death during a fixed interval after cessation. The results show
that the benefits of cessation extend to quitting at older ages. For example. a healthy
man aged 60-64 who smokes | pack of cigarettes or more per day reduces his risk of
dying during the next 15 years by 10 percent if he quits smoking.

These findings support the recommendations of the Surgeon General's 1988
Workshop on Health Promotion and Aging for the development and dissemination of
smoking cessation messages and interventions to older persons. [am pleased that a
coalttion of organizations and agencies is now working toward implementation of those
recommendations, including the Centers for Disease Control: the National Cancer
Institute: the National Heart. Lung, and Blood Institute: the Administration on Aging:
the Department of Veterans Affairs: the Office of Disease Prevention and Health
Promotion: the American Association of Retired Persons: and the Fox Chase Cancer
Center. The major message of this campaign will be that it is never too late to quit
smoking.

Two facts point to the urgent need fora strong smoking cessation campaign largeting
older Americans: (1) 7 million smokers are aged 60 or older: and (2) smoking is a major
tisk factor for 6 of the 14 leading causes of death among those aged 60 and older, and
is a complicating factor for 3 others.

Benefits for Smokers with Existing Disease

Many smokers who have already developed smoking-related disease or symptoms
may be less motivated to quit because of a belief that the damage is already done. For
the same reason, physicians may be less motivated to advise these patients to quit.
However, the evidence reviewed in this Report shows that smoking cessation yields
important health benefits to those who already suffer from smoking-related illness.

Among persons with diagnosed CHD, smoking cessation markedly reduces the risk
of recurrent heart attack and cardiovascular death. In many studies. this reduction in
risk has been 50 percent or more. Smoking cessation is the most important intervention
in the management of peripheral artery occlusive disease: for patients with this condi-
lion, quitting smoking improves exercise tolerance, reduces the risk of amputation after
peripheral artery surgery, and increases overall survival. Patients with gastric and
duodenal ulcers who stop smoking improve their clinical course relative to smokers
who continue to smoke. Although the benefits of smoking cessation among stroke
Patients have not been studied. it is reasonable to assume that quitting smoking reduces
the risk of recurrent stroke just as it reduces the risk of recurrence of other cardiovascular
events.

Even smokers who have already developed cancer may benefit from smoking
cessation. A few studies have shown that persons who stopped smoking after diagnosis
of cancer had a reduced risk of acquiring a second primary cancer compared with
persons who continued to smoke. Although relevant data are sparse, longer survival
might be expected among smokers with cancer or other serious illnesses if they stop

vin
smoking. Smoking cessation reduces the risk of respiratory infections such as
pneumonia, which are often the immediate causes of death in patients with an under-
lying chronic disease.

The important role of health care providers in counseling patients to quit smoking is
well recognized. Health care providers should give smoking cessation advice and
assistance to all patients who smoke, including those with existing illness,

Benefits for the Fetus

Maternal smoking is associated with several complications of pregnancy including
abruptio placentae, placenta previa, bleeding during pregnancy. premature and
prolonged rupture of the membranes. and preterm delivery. Maternal smoking retards
fetal growth, causes an average reduction in birthweight of 200 g. and doubles the risk
of having a low birthweight baby. Studies have shown a 25- to 50-percent higher rate
of fetal and infant deaths among women who smoke during pregnancy compared with
those who do not.

Women who stop smoking before becoming pregnant have infants of the same
birthweight as those born to women who have never smoked. The same benefit accrues
to women who quit smoking in the first 3 to 4 months of pregnancy and who remain
abstinent throughout the remainder of pregnancy. Women who quit smoking at later
stages of pregnancy, up to the 30th week of gestation. have infants with higher
birthweight than do women who smoke throughout pregnancy.

Smoking is probably the most important modifiable cause of poor pregnancy cutcome
among women in the United States. Recent estimates suggest that the elimination of
smoking during pregnancy could prevent about 5 percent of perinatal deaths. about 20
percent of low birthweight births, and about 8 percent of preterm deliveries in the United
States. In groups with a high prevalence of smoking (e.g.. women who have not
completed high school}, the elimination of smoking during pregnancy could prevent
about 10 percent of perinatal deaths. about 35 percent of low birthweight births, and
about 15 percent of preterm deliveries.

The prevalence of smoking during pregnancy has declined over time but remains
unacceptably high. Approximately 30 percent of U.S. women who are cigarette
smokers quit after recognition of pregnancy. and others quit later in pregnancy.
However, about 25 percent of pregnant women in the United States smoke throughout
pregnancy. A shocking stitistic is that half of pregnant women who have not completed
high school smoke throughout pregnancy. Many women who do not quit smoking
during pregnancy reduce their daily cigarette consumption: however, reduced con-
sumption without quitting may have little or no benefit for birthweight. Of the women
who quit smoking during pregnancy. 70 percent resume smoking within | year of
delivery.

Initiatives have been launched in the public and private sectors to reduce smoking
during pregnancy. These programs should be expanded. and less educated pregnant
women should be a special target of these efforts. Strategies need to be developed to
address the problem of relapse after delivery.

Vill
Benefits for Infants and Children

As a pediatrician. | am particularly concerned about the effects of parental smoking
on infants and children. Evidence reviewed in the 1986 Surgeon General's Report. The
Health Consequences of Involuntary Smoking. indicates that the children of parents
who smoke, compared with the children of nonsmoking parents. have an increased
frequency of respiratory infections such as pneumonia and bronchitis. Many studies
have found a dose-response relationship between respiratory illness in children and
their level of tobacco smoke exposure.

Several studies have shown that children exposed to tobacco smoke in the home are
more likely to develop acute otitis media and persistent middle ear effusions. Middle
eur disease imposes a substantial burden on the health care system. Otitis media is the
most frequent diagnosis made by physicians who care for children. The myringotomy-
and-tube procedure, used to treat otitis media in more than | million American children
each year, is the most common minor surgical operation performed under general
anesthesia.

The impact of smoking cessation during or after pregnancy on these associations has
not been studied. However. the dose-response relationship between parental smoking
and frequency of childhood respiratory infections suggests that smoking cessation
during pregnancy and abstinence after delivery would eliminate most or all of the excess
tisk by eliminating most or all of the exposure.

If parents are unwilling to quit smoking for their own sake. ] would urge them to quit
for the sake of their children. Passive-smoking-induced infections in infants and young
children can cause serious and even fatal illness. Moreover, children whose parents
smoke are much more likely to become smokers themselves.

Smoking Cessation and Weight Gain

The fear of postcessation weight gain may discourage many smokers from trying to
quit. The fear or occurrence of weight gain may precipitate relapse among many of
those who already have quit. In the 1986 Adult Use of Tobacco Survey. current smokers
who had tried to quit were asked to judge the importance of several possible reasons
for their return to smoking. Twenty-seven percent reported that “actual weight gain”
was a “very important” or “somewhat important” reason why they resumed smoking:
22 percent said that “the possibility of gaining weight” was an important reason for
their relapse. Forty-seven percent of current smokers and 48 percent of former smokers
agreed with the statement that “smoking helps control weight.”

Fifteen studies involving a total of 20,000 persons were reviewed in this Report to
determine the likelihood of gaining weight and the average weight gain after quitting.
Although four-fifths of smokers who quit gained weight after cessation, the average
weight gain was only 5 pounds (2.3 kg). The average weight gain among subjects who
continued to smoke was | pound. Thus, smoking cessation produces a 4-pound greater
weight gain than that associated with continued smoking. This weight gain poses a
minimal health risk. Moreover, evidence Suggests that this small weight gain is
accompanied by favorable changes in lipid profiles and in body fat distribution.
Smoking cessation programs and messages should emphasize that weight gain after
quitting is small on average.

Not only is the average postcessation weight gain small, but the risk of large weight
gain after quitting is extremely low. Less than 4 percent of those who quit smoking
gain more than 20 pounds. Nevertheless. special advice and assistance should be
available to the rare person who does gain considerable weight after quitting. For these
individuals, the health benefits of cessation still occur, and weight control programs
rather than smoking relapse should be implemented.

Increases in food intake and decreases in resting energy expenditure are largely
responsible for postcessation weight gain. Thus, dietary advice and exercise should be
helpful in preventing or reducing postcessation weight gain. Unfortunately, minor
weight control modifications to smoking cessation programs do not generally yield
beneficial effects in terms of reducing weight gain or increasing cessation rates. A few
studies have investigated pharmacologic approaches to postcessation weight control:
preliminary results are encouraging but more research is needed. High priority should
be given to the development and evaluation of effective weight control programs that
can be targeted in a cost-effective manner to those at greatest need of assistance.

Psychological and Behavioral Consequences of Smoking Cessation

Nicotine withdrawal symptoms include anxiety. irritability, frustration, anger. dif-
ficulty concentrating. increased appetite. and urges to smoke. With the possible
exception of urges to smoke and increased appetite. these effects soon disappear.
Nicotine withdrawal peaks in the first 1 to 2 days following cessation and subsides
rapidly during the following weeks. With long-term abstinence. former smokers are
likely to enjoy favorable psychological changes such as enhanced self-esteem and
increased sense of self-control.

Although most nicotine withdrawal symptoms are short-lived, they often exert a
strong influence on smokers’ ability to quit and maintain abstinence. Nicotine
withdrawal may discourage many smokers from trying to quit and may precipitate
relapse among those who have recently quit. In the 1986 Adult Use of Tobacco Survey.
39 percent of current smokers reported that irritability was a “very important” or
“somewhat important” reason why they resumed smoking after a previous quit attempt.

Smokers and ex-smokers should be counseled that adverse psychological effects of
smoking subside rapidly over time. Smoking cessation materials und programs,
nicotine replacement. exercise. stress management. and dietary counseling can help
smokers cope with these symptoms until they abate. after which favorable psychologi-
cal changes are likely to occur.

Support for a Causal Association Between Smoking and Disease

Tens of thousands of studies have documented the associations between cigarette
smoking and a large number of serious diseases. It is safe to say that smoking represents
the most extensively documented cause of disease ever investigated in the history of
biomedical research.
Previous Surgeon General's reports. in particular the landmark 1964 Report of the
Surgeon General’s Advisory Committee on Smoking and Health and the 1982 Surgeon
General's Report on smoking and cancer, examined these associations with respect to
the epidemiologic criteria for causality. These criteria include the consistency. strength.
specificity, coherence, and temporal relationship of the association. Based on these
criteria, previous reports have recognized a causal association between smoking and
cancers of the lung. larynx, esophagus. and oral cavity: heart disease: stroke: peripheral
artery occlusive disease: chronic obstructive pulmonary disease: and intrauterine
growth retardation. This Surgeon General's Report is the first to conclude that the
evidence is now sufficient to identify cigarette smoking as a cause of cancer of the
urinary bladder: the 1982 Report concluded that cigarette smoking is a contributing
factor in the development of bladder cancer.

The causal nature of most of these associations was well established long before
publication of this Report. Nevertheless. it is worth noting that the findings of this
Report add even more weight to the evidence that these associations are causal. The
criterion of coherence requires that descriptive epidemiologic findings on disease
occurrence correlate with measures of exposure to the suspected agent. Coherence
would predict that the increased risk of disease associated with an exposure would
diminish or disappear after cessation of exposure. As this Report shows in great detail.
the risks of most smoking-related diseases decrease after cessation and with increasing
duration of abstinence.

Evidence on the risk of disease after smoking cessation is especially important for
the understanding of smoking-and-disease associations of unclear causality. For ex-
ample, cigarette smoking is associated with cancer of the uterine cervix. but this
association is potentially confounded by unidentified factors (in particular by a sexually
transmitted etiologic agent). The evidence reviewed in this Report indicates that former
smokers experience a lower risk of cervical cancer than current smokers, even after
adjusting for the social correlates of smoking and risk of sexually acquired infections.
This diminution of risk after smoking cessation supports the hypothesis that smoking
is a contributing cause of cervical cancer.

Conclusion

The Comprehensive Smoking Education Act of 1984 (Public Law 98-474) requires
the rotation of four health warnings on cigarette packages and advertisements. One of
those wamings reads, “SURGEON GENERAL'S WARNING: Quitting Smoking
Now Greatly Reduces Serious Risks to Your Health.” The evidence reviewed in this
Report confirms and expands that advice.

The health benefits of quitting smoking are immediate and substantial. They far
exceed any risks from the average 5-pound weight gain or any adverse psychological
effects that may follow quitting. The benefits extend to men and women, to the young
and the old, to those who are sick and to those who are well. Smoking cessation
represents the single most important step that smokers can take to enhance the length
and quality of their lives.

xi
Public opinion polls tell us that most smokers want to quit. This Report provides
smokers with new and more powerful motivation to give up this self-destructive
behavior.

Antonia C. Novello. M.D.. M.P.H.
Surgeon General

xu
ACKNOWLEDGMENTS

This Report was prepared by the Department of Health and Human Services under
the general editorship of the Office on Smoking and Health, Ronald M. Davis. M.D.,
Director. The Managing Editor was Susan A. Hawk. Ed.M.. MLS.

The scientific editors of the Report were:

Jonathan M. Samet. M.D. (Senior Scientific Editor), Professor of Medicine and Chief,
Pulmonary Division, Department of Medicine and the New Mexico Tumor Registry,
Cancer Center, University of New Mexico, Albuquerque, New Mexico

Ronald M. Davis, M.D., Director. Office on Smoking and Health, Center for Chronic
Disease Prevention and Health Promotion (CCDPHP), Centers for Disease Control
(CDC), Rockville, Maryland

Neil E. Grunberg, Ph.D., Professor, Department of Medical Psychology. Uniformed
Services University of the Health Sciences, Bethesda, Maryland

Judith K. Ockene, Ph.D., Professor of Medicine, and Director, Division of Preventive
and Behavioral Medicine, Department of Medicine, University of Massachusetts
Medical School, Worcester, Massachusetts

Diana B. Petitti, M.D., M.P.H., Associate Professor, Department of Family and Com-
munity Medicine, University of California at San Francisco, School of Medicine, San
Francisco, California

Walter C. Willett, M.D.. Dr.P.H., Professor of Epidemiology and Nutrition, Harvard
School of Public Health, and The Channing Laboratory, Department of Medicine.
Harvard Medical School and Brigham and Women’s Hospital. Boston, Mas-
sachusetts

The following individuals prepared draft chapters or portions of the Report:

Robert Anda. M.D., Epidemiologist, Office of Surveillance and Analysis, CCDPHP.
CDC, Atlanta, Georgia

John Baron, M.D., Associate Professor of Medicine, Department of Medicine.
Dartmouth Medical School, Hanover, New Hampshire

Tim Byers. M.D.. M.P.H., Chief. Epidemiology Branch, Division of Nutrition.
CCDPHP, CDC, Atlanta, Georgia

Arden G. Christen, D.D.S., M.S.D., M.A., Chairman, Professor, Department of Preven-
tive and Community Dentistry, Indiana University School of Dentistry, Indianapolis.
Indiana

Graham Colditz, Dr.P.H., Assistant Professor of Medicine. Harvard School of Public
Health, and the Channing Laboratory, Department of Medicine, Harvard Medical
School and Brigham and Women’s Hospital. Boston. Massachusetts

SHI
Carlo C. DiCiemente, Ph.D., Associate Professor. Department of Psychology, Univer-
sity of Houston, Houston, Texas

Douglas W. Dockery, Sc.D.. Associate Professor, Department of Environmental
Health, Environmental Epidemiology Program. Harvard School of Public Health,
Boston, Massachusetts

Gary A. Giovino, Ph.D., Acting Chief, Epidemiology Branch, Office on Smoking and
Health, CCDPHP, CDC, Rockville. Maryland

Deborah Grady, M.D.. Assistant Professor, Departments of Epidemiology and
Medicine, University of California at San Francisco, School of Medicine. San
Francisco, California

Neil E. Grunberg, Ph.D., Professor, Department of Medical Psychology. Uniformed
Services University of the Health Sciences, Bethesda, Maryland

John R. Hughes. M.D., Associate Professor, Human Behavioral Pharmacology
Laboratory, Departments of Psychiatry. Psychology, and Family Practice. University
of Vermont. Burlington, Vermont

Robert W. Jeffery, Ph.D., Professor, Division of Epidemiology, School of Public
Health, University of Minnesota, Minneapolis, Minnesota

LTC James W. Kikendall, M.D.. Assistant Chief, Gastroenterology Section. Walter
Reed Army Medical Center, Washington, D.C.

Robert Klesges. Ph.D., Associate Professor, Department of Psychology, Memphis State
University, Memphis, Tennessee

Lynn Kozlowski, Ph.D.. Head, Behavioral Tobacco Research, Socio-behavioral Re-
search Department, Addiction Research Foundation. Toronto, Ontario, Canada

Stephen Marcus, Ph.D., Epidemiologist. Office on Smoking and Health. CCDPHP.,
CDC, Rockville, Maryland

James L. McDonald, Jr.. Ph.D.. Assistant Chairman. Professor, Department of Preven-
tive and Community Dentistry. Indiana University School of Dentistry, Indianapolis.
Indiana

Sherry L. Mills, M.D.. M.P.H.. Medical Officer, Office on Smoking and Health.
CCDPHP. CDC, Rockville. Maryland

Judith K. Ockene, Ph.D.. Professor of Medicine. and Director, Division of Preventive
and Behavioral Medicine. Department of Medicine. University of Massachusetts
Medical School. Worcester, Massachusetts

Carole Tracy Orleans. Ph.D., Director. Smoking Cessation Services. Fox Chase Cancer
Center, Cheltenham, Pennsylvania

Diana B. Petitti, M.D... M.P.H.. Associate Protessor, Department of Family and Com-
munity Medicine, University of California at San Francisco. School of Medicine, San
Francisco, California

John P. Pierce. Ph.D.. Associate Professor. Director. Population Studies and Cancer
Prevention, Tobacco Control Project. University of California, San Diego Cancer
Center, San Diego, California

Paul R. Pomrehn, Ph.D.. M.S.. Associate Professor. Department of Preventive
Medicine and Environmental Health, University of lowa College of Medicine. lowa
City, lowa

James O. Prochaska. Ph.D., Professor. Director, Cancer Prevention Research Unit.
Department of Psychology. University of Rhode Island. Kingston. Rhode Island

xiv
Barbara Rimer. Dr.P.H.. Director, Behavioral Research. Fox Chase Cancer Center.
Philadelphia, Pennsylvania

Mary Ann Salmon, Ph.D., Research Specialist. School of Social Work. C.A.R.E.S..
University of North Carolina. Chapel Hill. North Carolina

Jonathan M. Samet. M.D. (Senior Scientific Editor). Professor of Medicine and Chief.
Pulmonary Division, Department of Medicine and the New Mexico Tumor Registry,
Cancer Center, University of New Mexico. Albuquerque. New Mexico

David Savitz, Ph.D.. Associate Professor, Department of Epidemiology. School of
Public Health. University of North Carolina. Chapel Hill. North Carolina

Charles B. Sherman, M.D.. Director. Pulmonary Division. Miriam Hospital.
Providence, Rhode Island

Meir Stampter. M.D.. Dr.P.H.. Associate Professor of Epidemiology. Harvard School
of Public Health, and The Channing Laboratory. Department of Medicine. Harvard
Medical School and Brigham and Women’s Hospital. Boston, Massachusetts

Wayne F. Velicier. Ph.D.. Professor, Co-Director, Cancer Prevention Research Unit.
Department of Psychology. University of Rhode Island. Kingston, Rhode Island

Thomas Vogt. Ph.D., Principle Investigator, Center for Health Research, Portland.
Oregon

Scott T. Weiss. M.D., Associate Professor. Harvard School of Public Health, and The
Channing Laboratory. Department of Medicine. Harvard Medical School and
Brigham and Women’s Hospital. Boston. Massachusetts

Anna H. Wu-Williams, Ph.D.. Associate Professor. Department of Preventive
Medicine. University of Southern California, Los Angeles. California

The editors acknowledge with gratitude the following distinguished scientists,
physicians, and others who lent their support in the development of this Report by
coordinating manuscript preparation, contributing critical reviews, or aSSISUNG In
other ways. In particular, the editors express appreciation to the American Cancer
Society for making available data from its Cancer Prevention Study IT.

David B. Abrams, Ph.D.. Director, Division of Behavioral Medicine. The Miriam
Hospital, Associate Professor, Psychiatry and Human Behavior, Brown University
Program in Medicine, Providence, Rhode Island

Duane Alexander, M.D., Director, National Institute of Child Health and Human
Development. National Institutes of Health, Bethesda, Maryland

David Bates, M.D.. FRCP, FRCPC. FACP. FRSC, Professor Emeritus of Medicine.
Department of Health Care. University of British Columbia, Vancouver. British
Columbia

James S. Benson, Acting Commissioner. Food and Drug Administration, Rockville.
Maryland

Trudy S. Berkowitz, Ph.D., Associate Professor, Department of Obstetrics. Gynecol-
ogy, and Reproductive Science. Mount Sinai School of Medicine, New York. New
York

Ruth Bonita, M.P.H., Ph.D., Masonic Senior Research Fellow. Geriatric Unit, Univer-
sity of Auckland, Auckland 9. New Zealand

XV
Lester Breslow, M.D..M.P.H.. Professor of Public Health and Director, Health Services
Research, Division of Cancer Control, Jonsson Comprehensive Cancer Center,
University of California, Los Angeles. Los Angeles. California

Samuel Broder, M.D., Director, National Cancer Institute, National Institutes of Health,
Bethesda, Maryland

David Burns, M.D.. Associate Professor, Pulmonary Division, Division of Pulmonary
Medicine and Critical Care. University of California at San Diego Medical Center,
San Diego, California

Benjamin Burrows, M.D.. Director, Division of Respiratory Sciences, University of
Arizona Health Sciences Center, University of Arizona School of Medicine, Tucson,
Arizona

Jane Cauley, Dr.P.H., Assistant Professor of Epidemiology, Department of Epidemiol-
ogy. University of Pittsburgh, Pittsburgh, Pennsylvania

Gregory N. Connolly, D.M.D., M.P.H.. Director, Office on Nonsmoking and Health.
Massachusetts Department of Public Health, Boston, Massachusetts

Thomas M. Cooper, D.D.S.. Professor. University of Kentucky Medical Center. Col-
lege of Dentistry, Lexington, Kentucky

Stephen Corbin, D.D.S., M.P.H.. Policy Analyst, Disease Prevention, Center for
Preventive Services (CPS), CDC. Bethesda, Maryland

K. Michael Cummings. Ph.D., M.P.H.. Cancer Control and Epidemiology, Roswell
Park Cancer Institute, Buffalo, New York

Joseph W. Cullen, Ph.D., Director. AMC Cancer Research Center, Denver, Colorado

Sir Richard Doll, ICRF Cancer Studies Unit. Oxford. United Kingdom

Virginia Ernster, Ph.D.. Professor of Epidemiology. Department of Epidemiology and
Intemational Health, University of Califomia, San Francisco, San Francisco.
California

Jonathan E. Fielding, M.D.. M.P.H., Vice President and Health Director. Johnson and
Johnson Health Management. Inc., Santa Monica. California

Gary D. Friedman, M.D.. M.S.. Division of Research, Kaiser Permanente Medical Care
Program. Northern California Region. Oakland. California

William Foege. M.D.. Executive Director, The Carter Center of Emory University.
Atlanta, Georgia

Lawrence J. Furman, D.D.S.. M.P.H.. Chief, Dental Disease Prevention Activity. CPS,
CDC, Atlanta, Georgia

Lawrence Garfinkel. Vice President for Epidemiology and Statistics. Director of Cancer
Prevention, American Cancer Society, Inc.. New York, New York

Barbara A. Gilchrest, M.D.. Professor and Chairman, Department of Dermatology.
Boston University Medical Center. Boston, Massachusetts

Frederick K. Goodwin. M.D.. Administrator. Alcohol. Drug Abuse, and Mental Health
Administration, Rockville. Maryland

Robert O. Greer, Jr.. D.D.S.. Sc.D., Professorand Chairman. Division of Oral Pathology
and Oncology. Department of Diagnostic and Biological Sciences. School of Den-
listry, University of Colorado Health Sciences Center. Boulder. Colorado

Ellen Gritz. Ph.D. Director. Division of Cancer Control. Jonsson Comprehensive
Cancer Center, University of California, Los Angeles. Los Angeles. Califormia

XV1
Nancy J. Haley. Ph.D.. Associate Chief. Division of Nutrition and Endocrinology.
American Health Foundation, Valhalla, New York

Sharon M. Hall. Ph.D., Professor of Medical Psychology. Department of Psychiatry.
University of California, San Francisco, San Francisco Veterans Administration
Medical Center, San Francisco, California

Robert Harmon. M.D., Administrator, Health Resources and Services Administration,
Rockville. Maryland

Jetfrey E. Harris. M.D.. Ph.D.. Associate Professor, Department of Economics, Mas-
sachusetts Institute of Technology. Cambridge. Massachusetts, Clinical Associate.
Medical Services. Massachusetts General Hospital. Boston. Massachusetts

Norman O. Harris, D.D.S., M.S.. University of Texas Health Science Center. San
Antonio, Texas

Jack Henningfield. Ph.D.. Chief, Clinical Pharmacology Branch, National Institute on
Drug Abuse Addiction Research Center, National Institutes of Health, Baltimore.
Maryland

Robert A. Hiatt. M.D.. Ph.D.. Senior Epidemiologist. Division of Research. Kaiser
Permanente Medical Care Program, Oakland California

Millicent Higgins. M.D.. Associate Director, Epidemiology and Biometry Program.
Division of Epidemiology and Clinical Applications, National Heart. Lung. and
Blood Institute, National Institutes of Health, Bethesda. Maryland

Carol Hogue. Ph.D., M.P.H.. Director, Division of Reproductive Health. CCDPHP.
CDC, Atlanta, Georgia

John Holbrook, M.D., Professor of Internal Medicine. Department of Internal Medicine.
University of Utah School of Medicine, Salt Lake City, Utah

Richard Hunt, M.D., Division of Gastroenterology. McMaster University Medical
Center, Hamilton, Ontario, Canada

Dwight Janerich, D.D.S.. M.P.H.. Professor of Epidemiology. Department of
Epidemiology and Public Health, Yale University School of Medicine, New Haven.
Connecticut

William Kannel, M.D.. Professor of Medicine, Department of Preventive Medicine.
Boston University School of Medicine, Boston, Massachusetts

LTC James W. Kikendall, M.D., Assistant Chief, Gastroenterology Section. Walter
Reed Army Medical Center, Washington, D.C.

Dushanka V. Kleinman, D.D.S.. M.Sc.D., Section Chief, National Institute on Dental
Research, National Institutes of Health, Bethesda, Maryland

C. Everett Koop, M.D., Sc.D., U.S. Surgeon General, 1981-89, Bethesda, Maryland

Jeffrey P. Koplan, M.D., M.P.H., Director, CCDPHP, CDC, Atlanta, Georgia

Lewis H. Kuller, M.D., Dr.P.H., Professor and Chairperson, Department of Epidemiol-
ogy, University of Pittsburgh Graduate School of Public Health, Pittsburgh. Pennsyl-
vania

Charles L. LeMaistre, M.D., President, The University of Texas M.D. Anderson Cancer
Center, Houston, Texas

Claude Lenfant, M.D.. Director, National Heart, Lung, and Blood Institute, National
Institutes of Health, Bethesda, Maryland

Richard J. Levine, M.D.. M.S., M.P.H., Chief Epidemiologist, Chemical Industry
Institute of Toxicology, Research Triangle Park, North Carolina

XVH
Edward Lichtenstein, Ph.D., Research Scientist. Oregon Research Institute. Eugene,
Oregon

Jay H. Lubin, Ph.D.. National Cancer Institute. National Institutes of Health, Rockville,
Maryland

Alfred C. Marcus, Ph.D., Director. Community Research and Applications. AMC
Cancer Research Center. Denver. Colorado

Denis M. McCarthy, M.D., M.Sc.. Chief, Division of Gastroenterology. University of
New Mexico. Department of Medicine. Veterans Administration Medical Center,
Albuquerque. New Mexico

J. Michael! McGinnis, M.D.. Deputy Assistant Secretary for Health, Disease Prevention
and Health Promotion, Department of Health Human Services, Washington. D.C.

Sonja M. McKinlay, Ph.D.. M.Sc., M.A.. B.A., ASA. APHA, AER. SCt. Biometrics
Society, Institute of Mathematical Statistics, International Menopause Society.
American Association for the Advancement of Science, President, New England
Research Institute. Inc.. Watertown, Massachusetts

Robert E. Mecklenberg. D.D.S.. M.P.H.. Potomac. Maryland

L. Joseph Melton. HI. M.D.. Head. Section of Clinical Epidemiology. Department of
Health Sciences Research. Mayo Clinic and Foundation, Rochester. Minnesota

Anthony Miller, B.A., M.B.B., M.R.C.P.. M.F.C.M., F.R.C.P.C.. Professor. Depart-
ment of Preventive Medicine and Biostatistics. University of Toronto. Toronto,
Ontario, Canada

Gregory Morosco, Ph.D.. M.P.H.. Chief. Health Education Branch and Coordinator.
Smoking Education Program, National Heart. Lung. and Blood Institute. National
Institutes of Health, Bethesda. Maryland

Richard L. Naeye, M.D., Professor and Chairman. Department of Pathology. Pennsyl-
vania State University School of Medicine. Hershey, Pennsylvania

Thomas A. Pearson, M.D.. M.P.H., Ph.D.. Director, Mary Imogene Bussett Research
Institute, Cooperstown. New York, Professor of Public Health in Medicine. Columbia
University, New York. New York

Terry Pechacek, Ph.D.. Acting Chief. Smoking. Tobacco, and Cancer Branch, National
Cancer Institute, National Institutes of Health. Bethesda. Maryland

Michael G. Perri, Ph.D.. Professor and Deputy Chairman. Psychology Department.
Fairleigh Dickinson University. Teaneck. New Jersey

Richard Peto. FRS. ICRF Cancer Studies Unit. Oxford. United Kingdom

John M. Pinney. Executive Director. Institute for the Study of Smoking Behavior and
Policy. John F. Kennedy School of Government. Harvard University. Cambridge.
Massachusetts

William F. Raub, Ph.D.. Acting Director. National Institutes of Health. Bethesda.
Maryland

Patrick L. Remington. M.D.. Bureau of Community Health Prevention. Wisconsin
Division of Health. Madison, Wisconsin

Everett R. Rhoades. M.D.. Director. Indian Health Service. Rockville. Maryland

Julius Richmond. M.D.. John D. MacArthur Professor of Health Policy. Emeritus.
Division of Health Policy. Research, and Education, Harvard University, Boston,
Massachusetts

XVill
William A. Robinson, M.D.. M.P.H.. Director. Office of Minority Health. Department
of Health and Human Services. Washington, D.C.

William L. Roper. M.D., M.P.H., Director, CDC, Atlanta. Georgia

Richard B. Rothenberg. M.D.. Assistant Director for Science. CCDPHP. CDC. Atlanta,
Georgia

Thomas C. Schelling. Ph.D.. Director. Institute for the Study of Smoking Behavior and
Policy, Lucius N. Littauer Professor of Political Economy, Harvard University.
Cambridge. Massachusetts

Marc B. Schenker, M.D.. M.P.H.. Associate Professor and Division Chief, Occupation-
al and Environmental Medicine, University of California, Davis. Davis. California

David Schottenteld. M.D.. Professor and Chairman. Department of Epidemiology.
University of Michigan School of Public Health, Ann Arbor. Michigan

Kathleen L. Schroeder, D.D.S., M.Sc.. Assistant Professor. Section of Oral Biology.
The Ohio State University College of Dentistry. Columbus, Ohio

Mary J. Sexton, Ph.D., M.P.H.. Professor, Department of Epidemiology and Preventive
Medicine. University of Maryland School of Medicine. Baltimore. Maryland

Saul Shiffman, Ph.D.. Associate Professor, Department of Psychology. University of
Pittsburgh, Pittsburgh. Pennsylvania

Donald Shopland. Smoking. Tobacco, and Cancer Branch. National Cancer Institute,
National Institutes of Health, Bethesda. Maryland

Amnon Sonnenberg, M.D., Associate Professor, Gastroenterology Section, Medical
College of Wisconsin, Veterans Administration Medical Center, Milwaukee. Wis-
consin

Frank E. Speizer. M.D., Professor of Medicine, Harvard Medical School, Professor of
Environmental Epidemiology. Harvard School of Public Health. Co-Director, The
Channing Laboratory, Department of Medicine, Brigham and Women’s Hospital.
Boston, Massachusetts

Jesse Steinfeld, M.D., San Diego, California

Steven D. Steliman, Ph.D., Assistant Commissioner, New York City Department of
Health, New York, New York

Ira B. Tager, M.D., M.P.H., Associate Professor of Medicine and Epidemiology and
Biostatistics, University of California. San Francisco, Veterans Administration Medi-
cal Center, San Francisco, San Francisco. California

Kenneth Warner, Ph.D., Senior Fellow, Institute of Gerontology. University of
Michigan, Ann Arbor, Michigan

Jonathan S. Weiss. M.D., Assistant Professor of Dermatology. Section of Dermatology.
Emory Clinic, Atlanta, Georgia

Noel S. Weiss, M.D., Dr.P.H., Professor and Chairman. Department of Epidemiology.
University of Washington, Seattle, Washington

Gail R. Wilensky, Ph.D.. Administrator. Health Care Financing Administration.
Washington, DC

Deborah Winn, Ph.D., Deputy Director, Division of Health Interview Statistics. Na-
uonal Center for Health Statistics, CDC, Hyattsville. Maryland

Philip A. Wolf, M.D.. Professor of Neurology, Department of Neurology. Boston
University School of Medicine. Boston, Massachusetts

Ernst L. Wynder. M.D.. President. American Health Foundation, New York. New York

XIX
The editors also acknowledge the contributions of the following staff members anid

others who assisted in the preparation of this Report:

Carmen Aguirre, Secretary, Office on Smoking and Health. CCDPHP. CDC. Rock ille.
Maryland

Andrea Anderson. Student Intern. Office on Smoking and Health. CCDPHP. CDC.
Rockville. Maryland

Margaret Anglin. Secretary. Office on Smoking and Health. CCDPHP. CDC. Rock.
ville. Maryland

Cathy Amey. Graphic Artist. The Circle. Inc.. McLean, Virginia

John Artis, Courier. The Circle, Ine.. McLean. Virginia

Michele Asrael, Conference Coordinator. The Circle. Inc.. MeLean. Virginia

John L. Bagrosky. Associate Director for Program Operations, Office on Smoking and
Health. CCDPHP. CDC, Rockville. Maryland

Sonia Balakirsky. Secretary. Office on Smoking and Health. CCDPHP. CDC. Rock-
ville. Maryland

Barbara Barnes. Administrative Assistant. The Circle. Inc.. MeLean. Virginia

Carol A. Bean. Ph.D.. Acting Managing Editor. Artemis Technologies. Ine.
Springfield. Virginia

Marissa A. Bernstein. Editor. The Circle. Ine. McLean. Virginia

Em Ria Briscoe. Conference Coordinator. The Circle. Inc.. McLean. Virginia

Karen Broder, Public Information Specialist. Office on Smoking and Health. CCDPHP.
CDC, Rockville. Maryland

Barbara M. Brown. Editorial Assistant. Office on Smoking and Health. Rockville.
Maryland

Catherine E. Burckhardt. Public Information Specialist. Office on Smoking and Health,
CCDPHP. CDC. Rockville. Maryland

Lee Chapell. Courier, The Circle. Inc.. McLean. Virginia

Won Choi, Research Assistant. Office on Smoking and Health, CCDPHP. CDC.
Rockville. Maryland

Trish Davidson. Student Intern. Office on Smoking and Health. CCDPHP. CDC.
Rockville. Maryland

Susan E. Day. Secretary. Office on Smoking and Health, CCDPHP, CDC. Rockville.
Maryland

Karen M. Deasy. Associate Director for Policy. Office on Smoking and Health.
CCDPHP. CDC, Rockville. Maryland

June Dow, Public Health Service Congressional Reports Coordinator, Oftice of Health
Planning and Evaluation, Office of the Assistant Secretary for Health. Washington.
D.C.

Joanna Ebling. Word Processing Specialist. The Circle. Inc.. McLean. Virginia

Pam Edwards. System Administrator. MSA. Inc.. Rockville. Maryland

Rita Elliott, Technical Editor, New Mexico Tumor Registry. Uni ersity of New
Mexico. Albuquerygue. New Mexico

Seth Emont. Ph.D.. Epidemic Intelligence Service Officer. Office on Smoking and
Health. CCDPHP. CDC. Rockville. Maryland

XX
Sharon K. Faupel, Staff Assistant, Office on Smoking and Health. CCDPHP. CDC,
Rockville, Maryland

Leanna Fernando, Administrative Assistant, New Mexico Tumor Registry, University
of New Mexico, Albuquerque, New Mexico

David Fry. Editor, The Circle, Inc., McLean, Virginia

Lynn Funkhauser, Word Processing Specialist, The Circle, Inc.. McLean, Virginia

Amy Garson, Student Intern, Office on Smoking and Health, CCDPHP. CDC. Rock-
ville, Maryland

Mary Graber, Secretary, University of California at San Francisco, School of Medicine.
Department of Family and Community Medicine, San Francisco, California

Gwen Harvey, Program Analyst, CCDPHP, CDC, Atlanta. Georgia

Patricia Healy, Technical Information Specialist, Office on Smoking and Health,
CCDPHP, CDC, Rockville, Maryland

Phyllis E. Hechtman, Editorial Assistant, The Circle. Inc.. McLean, Virginia

Timothy K. Hensley, Technical Publications Writer-Editor, Office on Smoking and
Health, CCDPHP, CDC, Rockville. Maryland

Julian Hudson, Courier, The Circle, Inc.. McLean. Virginia

Beth Jacobsen, Student Intern, Office on Smoking and Health. CCDPHP. CDC,
Rockville, Maryland

Renee Kolbe, Program Specialist. Office on Smoking and Health, CCDPHP, CDC,
Rockville, Maryland

Matt Kreuter, Public Information Specialist, Office on Smoking and Health, CCDPHP,
CDC, Rockville, Maryland

Peggy Lytton, Editor, The Circle, Inc., McLean, Virginia

Diana Lord, Research Psychologist, Department of Medical Psychology, Uniformed
Services University of the Health Sciences, Bethesda. Maryland

Daniel F. McLaughlin, Editor, The Circle, Inc., McLean. Virginia

Jackie L. Meador, Desktop Publishing/Word Processing Specialist, The Circle, Inc.,
McLean, Virginia

Elaine Medoff-McGovern, Medical Secretary, Division of Preventive and Behavioral
Medicine, Department of Medicine, University of Massachusetts Medical School.
Worcester, Massachusetts

Nancy A. Miltenberger, M.A., Production Editor, The Circle. Inc., McLean. Virginia

Rebecca Mosher, Staff Assistant, New Mexico Tumor Registry, University of New
Mexico, Albuquerque, New Mexico

Millie R. Naquin, Research Assistant, Office on Smoking and Health, CCDPHP, CDC.
Rockville, Maryland

Thomas E. Novotny, M.D., Chief, Program Services Activity, Office on Smoking and
Health, CCDPHP, CDC, Rockville, Maryland

Cathie M. O'Donnell, Project Director, The Circle, Inc., McLean. Virginia

Christine Pappas, Editorial Research Assistant, The Channing Laboratory, Harvard
School of Public Health, Boston, Massachusetts

Stacey M. Parcover, Secretary, Office on Smoking and Health, CCDPHP, CDC,
Rockville, Maryland

Lida Peterson, Computer Systems Manager. The Circle. Inc., McLean, Virginia

XXI
Renate J. Phillips. Graphic Artist. Desktop Publishing Designer, The Circle. Inc..
McLean. Virginia

Margaret E. Pickerel. Public Information and Publications Specialist. Office on Smok-
ing and Health, CCDPHP. CDC. Rockville. Maryland

Elizabeth Precup, Student Intern. Office on Smoking and Health. CCDPHP, CDC.
Rockville. Maryland

Cary R. Prince, Editor. The Circle. Inc.. McLean. Virginia

Dick Ray. Director of Computer Services. The Circle. Inc.. McLean. Virginia

Nancy J. Rhodes, Editor. The Circle. Inc.. McLean. Virginia

Rose Mary Romano. Chief. Public Information Branch, Office on Smoking and Health,
CCDPHP, CDC. Rockville. Maryland

Lisa Phelps. Computer Systems Analyst. The Circle. Inc.. McLean. Virginia

Sel Semler. Secretary. Office on Smoking and Health. CCDPHP. CDC. Rockville.
Maryland

James Sliwa. Student Intern, Office on Smoking and Health. CCDPHP. CDC. Rock-
ville. Maryland

Mattie Smith, Secretary. CCDPHP. CDC. Rockville. Maryland

Linda R. Spiegelman. Administrative Officer. Office on Smoking and Health.
CCDPHP. CDC. Rockville, Maryland

Traion C. Stallings, Project Secretary. The Circle. Inc.. McLean. Virginta

Sophia Stewart. Student Intern. Office on Smoking and Health. CCDPHP. CDC.
Rockville. Maryland

Daniel R. Tisch. Director of Publications. The Circle. Ine.. McLean. Virginia

Anne Trontell, M.D., Epidemic Intelligence Service Officer. Office on Smoking and
Health. CCDPHP. CDC. Rockville. Maryland

Karen Tyler. Conference Coordinator, The Circle. Inc.. McLean. Virginia

Godfrey R. Vaz. M.D., Student Intern. Office on Smoking and Health. CCDPHP. CDC,
Rockville. Maryland

Susan Von Braunsberg. Information Specialist. The Cirele. Inc.. McLean. Virginia

Elyse Watson, Administrative Assistant. New Mexico Tumor Registry. University of
New Mexico, Albuquerque, New Mexico

Michael F. White. Associate Director for Program Development. CCDPHP. CDC.
Rockville. Maryland

Charles Wiggins. M.S.P.HL. Epidemiologist. New Mexico Tumor Registry. University
of New Mexico. Albuquerque. New Mexico

Louise G. Wiseman. Technical Information Specialist, Office on Smoking and Health,
CCDPHP. CDC. Rockville, Mary hind

Rebecca B. Wolf, Program Analyst. Office of Program Planning and Evaluation. CDC.
Atlanta, Georgia

S. Tanner Wray. Technica! Information Specialist. Office on Smoking and Health,
CCDPHP. CDC. Rockville. Maryland

XX
TABLE OF CONTENTS

 

 

 

 

 

 

 

 

 

Foreword 20.2... ccc cee eecceeeveeeeee eee cette tet teeeece red
cr
Acknow ledgments cect ee eevee ee Se teev eve eesereeerveceees XH
Listof Tables ........ eves eeees vee eee ecreeebeeeterteteveseenee, XX¥
List of Figures eee eee te eee tenet en es XXXi
1. Introduction, Overview, and Conclusions ..........0 00000000 cee eee ee |
2. Assessing Smoking Cessation and Its Health Consequences See e eee ee 17
3. Smoking C Cessation and Overall Mortality a and Morbidity Dees ee eset eee 71
4, Smoking Cessation and Respiratory Cancers... eevee eee eee eee. 103
5 Smoking Cessation and Nonrespiratory Cancers oo... cece cece cece. 143
6. Smoking Cessation and Cardiovascular Disease . boc eveeteeeeeees “oo. 187
7, ~ Smoking C Cessation and Nonmalignant Respiratory Diseases ............ 275
8. Smoking Cessation and Reproduction | voce vesaees bocce tt eveeeres.. 367
9. Smoking, Smoking Cessation, and Other Nonmalignant | Diseases ........ 425
10. ‘Smoking Cessation and Body Weight C Change Le eeeee Settee verre. 469
dl. Ps Psychological and Behavioral Consequences and Correlates of
Smoking Cessation ......0. 0000000 ccc cece ccc e ese c eee ceceeeees 517
Volume Appendix. . National Trends in Smoking Cessation ................ 579
Glossary 6... n cece ete cen te teeteceeeee, 617
Index oe eee cee cscs cetevteveeeveee. bebe tec veces 619

XxHl
LIST OF TABLES

 

Chapter 2
Table 1. Measures of false reports of not smoking from studies using
nicotine and cotinine as a marker. 2.0.00 000.0. cece cence. 38
Table 2. Measures of false reports from studies using CO asa marker... 2... 4}
Table 3. Examples of potential methodologic problems in Investigating
the health consequences of smoking cessation. .................0..00-.. 47
Chapter 3

Table 1. Summary of longitudinal studies of overall mortality ratios
relative to never smokers among male current and former smokers
according to duration of abstinence (when reported) ..................... 76

Table 2. Overall mortality ratios among current and former smokers,
relative to never smokers, by sex and duration of abstinence at date of
enrollment, ACS CPS-H oo. ccc cence cee cece eee. 78

Table 3. Estimated probability of dying in the next 16.5-year interval for

quitting at various ages compared with never smoking and continuing

to smoke. by amount smoked and sex .. 00.0000... 0c cece ee eee eee. 83
Table 4. Summary of overall mortality ratios in intervention studies in

which smoking cessation was acomponent ....................0.-.2-.. 84

Table 5. Summary of studies of medical care utilization among smokers
and former smokers 0... cece cece cence eeee, 88

Table 6. Relation of smoking cessation to various measures of general

health status .....0.0..00, ee cece eee tee eens 90
Table 7. Age- and sex-specific mortality rates among never smokers.

continuing smokers, and former smokers by amount smoked and

duration of abstinence at time of enrollment for subjects in ACS

CPS-II study who did not have a history of cancer. heart disease, or

stroke and were not sick at enrollment 20.00.0000... 00000 ccc cece eeeeen. 95

Table 8. Estimated probability of dying in the next 16.5-year interval
(95% Cl) for quitting at various ages compared with never smoking
and continuing to smoke, by amount smoked and sex..................-.. 97

WAN
Chapter 4 7

Table |. Histologic changes (%) in bronchial epithelium by smoking

StAtUS 2 eee eae 109
Table 2. Relative risks of lung cancer among never, former, and current

smokers in selected epidemiologic studies ..............-...0000.000-. Hit
Table 3. Lung cancer mortality ratios among never, current, and former

smokers by number of years since stopped smoking (relative to never

smokers), prospective studies 2.0... ee eee eee eee 112
Table 4. Relative risks of lung cancer among former smokers, by

number of years since stopped smoking. and current smokers, from

selected case-control studies... 0... eee ee 11s
Table 5. Relative risks of lung cancer among never, current, and former

smokers, by number of years since stopping smoking and histologic

0 0 119
Table 6. Relative risks of lung cancer among never, former, and current

smokers by types of tobacco products smoked .. 00.0... 0 eee ee eee 120
Table 7. Standard mortality ratios of lung cancer among former smokers

in ACS CPS-I] (relative to never smokers) by years of smoking

abstinence, daily cigarette consumption at time of cessation, and

 

history of chronic disease 2.00... eee ees 130
Table 8. Histologic changes in laryngeal epithelium by smoking status ...... 132
Table 9. Relative risks of laryngeal cancer by smoking status .............. 133

Chapter 5
Table 1. Studies of oral cancer and smoking cessation 2.6.0.0... 00s 148
Table 2. Studies of esophageal cancer that have examined the effect of

sMOkKing CESSAHON 6 eee eee 153
Table 3. Studies of cancer of the pancreas and smoking cessation .......... 156
Table 4. Studies of bladder cancer and smoking cessation ............2055 160
Table 5. Bladder cancer risk according to smoking dose. duration of

smoking, and smoking status 2.0. eee 165
Table 6. Studies of cervical cancer and smoking cessation ............505- 167
Table 7. Studies of breast cancer and smoking cessation .............--05- 170

Table 8. Studies of cancer at selected sites that have examined the effect
of smoking cessation... ee nee 173

XXV1
Chapter 6

 

Table 1. Case—control studies of CHD risk among former smokers ......... 20!
Table 2. Cohort studies of CHD risk among former smokers .............. 206
Table 3. Estimated probability of dying from ischemic heart disease in

the next 16.5-year interval (95% Cl) for quitting at various ages

compared with never smoking and continuing to smoke. by amount

smoked and Sexo... eet eee e ees 216
Table 4. Intervention trials of smoking cessation and CHD risk ............ 225
Table 5. Studies of the effect of smoking cessation on persons with

diagnosed CHD «0... ccc eect eect ee eens 231
Table 6. Studies of smoking cessation and risk of death due to aortic

ANEUTYSM 6 cee eee ete teen eens 242
Table 7. Case-control studies of smoking cessation and risk of stroke ....... 247
Table 8. Prospective cohort studies of smoking cessation and risk of

SS C0) 253

Chapter 7

Table 1. Percentages of subjects in cross-sectional studies with

respiratory symptoms. by cigarette smoking status and gender............ 289
Table 2. Percentages of subjects in cross-sectional surveys with

respiratory symptoms by smoking and occupational exposure status ....... 297
Table 3. Change (%) in presence of respiratory symptoms, longitudinal

studies, by cigarette smoking status .........0.0..00.0 0.0000 c cece even eeee 300
Table 4. Percentage of subjects with respiratory symptoms by smoking

status, 1961 and 1971, in a cohort of middle-aged, rural Finns ............ 305
Table 5. Age-standardized mortality ratios for influenza and pneumonia

for current and former smokers compared with never smokers ............ 309
Table 6. Association between cigarette smoking status and FEV} levels

in selected cross-sectional studies of adult populations ................-. 31i
Table 7. Spirometric studies of participants in smoking cessation

PFOgTaMs «6. cee teen eee n eas 320
Table 8. Studies of closing volume (CV/VC%), closing capacity

(CC/TLC%), and slope of alveolar plateau (SBN2/L) among

participants in smoking cessation programs ................-...-20004. 324
Table 9. Population-based longitudinal studies of annual decline in

pulmonary function 0.0.2.6. ee cee cece eee eevee 330
Table 10. Decline of FEV) (mL/yr) in subjects in the Copenhagen City

Heart Study 2.0... ccc cece eee eee 337
Table 11. Mortality attributable to COPD, United States, 1986............. 342

XAME
Table 12. Prospective studies of COPD mortality in relation to cigarette
SMOKING StAtUs eee etc e eee ene ns
Table 13. Standardized mortality ratios for COPD among current and
former smokers broken down by yeurs of abstinence .....0000..0..0.00.

Chapter 8

Table 1. Possible mechanisms for effect of smoking on pregnancy and

pregnancy outcome ... 0.0000. 0 2 ete eee,
Table 2. Summary of studies of fertility among smokers and former

SMOKES oo nee entree teen ne es
Table 3. Summary of studies of perinatal and neonatal mortality in

smokers and nonsmokers during pregnancy ........... 000.00 .0000000
Table 4. Estimated relative risk of fetal plus infant mortality for maternal

smoking in several birthweight groups, adjusting for maternal marital

status, education, age. and parity 22.0... cee eee
Table 5. Summary of studies of perinatal mortality in smokers

throughout pregnancy, smokers who quit in the early months of

pregnancy, and nonsmokers during pregnancy ............000...0000.,
Table 6. Summary of studies of mean birthweight. by smoking status 20.2...
Table 7. Summary of.nonexperimental studies of smoking cessation

after conception. mean increase (+) or decrease (—) in birthweight (g)

according to timing of cessation... 0... ce eee
Table 8. Summary of nonexperimental studies of relative risk of low

birthweight for smoking cessation after conception ..........000 00.0...
Table 9. Summary of birthweight outcome in randomized trials of

smoking cessation in pregnancy 2.0... eee eee

Table 10. Smoking and smoking cessation during pregnancy. summary

of results of two surveys of national probability samples .........0....... .

Table 11. Patterns of smoking cessation during pregnancy among

selected populations 2.00. es :

Table 12. Summary of studies that estimated relative risk of various
pregnancy outcomes for smoking based on a “synthesis” of the
literature, and attributable risk percent based on several estimates of
the prevalence of smoking during pregnancy ...........0.0.0..0 000002 ee ee

Table 13. Summary of studies reporting relationship of cigarette

smoking and age at natural menopause .........0 000.0 .

Table 14. Summary of studies of age of natural menopause among

former smokers ... 000000000 ccc cece eee cence eben teenies 3

Table 15. Sexual performance among male former smokers .........0.0.....

Table 16. Sperm quality among smokers and nonsmokers ................

XXVIU

343

346

372

375

377

378

379
382

384

385

388
Table 17. Estimated relative risk of azoospermia or oligospermia among

smokers versus nonsmokers or never smokers......................

Table 18. Sperm quality among former smokers ......................

Chapter 9

Table I. Percentage of healed duodenal ulcers among smoking and

nonsmoking patients... 0... ccc cece cece eeee
Table 2. Results of statistical analysis of pooled data from Table | .......

Table 3. Recurrences of duodenal ulcer in smokers and nonsmokers in

Climical trials 00. ccc ccc ccc cec elec ee.

Table 4. Recurrences of gastric ulcer in smokers and nonsmokers in

Clinical trials oo. cc ccc cece cece e ec eee,

Table 6. Summary of case-control studies of smoking and fractures ......

Table 7. Summary of cohort studies of smoking and fractures ...........

 

Chapter 10

Table 1. Summary of prospective studies on smoking and body weight ....

Table 2. Details of prospective studies in which change in weight

relative to continuing smokers was reported .................-0-00-.

Table 3. Mortality ratios for all ages combined in relation to the death

rate of those 90-109% of average weight ................0..00.00-.

Table 4. Mortality ratios for all ages combined according to smoking

status in relation to those 90-109% of average age ...................

Chapter 1]

Table 1. Diagnostic categorization and criteria for nicotine

withdrawal—Nicotine-induced organic mental disorder ...............

Table 2. Prospective studies of quitting-related changes in mood,
anxiety, stress reactivity, perceived stress, self-image, and

psychological well-being .....0. 000000000 c cece ccc eee eee.

Table 3. Summary of data from 1985 NHIS, behaviors of never, former.

and current smokers aged 20 and older ..............-.00--00-022..

Table 4. Summary of data from 1987 NHIS, behaviors of never. former.

and current smokers aged 18 and older .......................-....

Table 5. Summary of data from 1987 BRFSS, behaviors of former

smokers and current smokers aged 18 andolder .....................

.. 408

.. 434

548

549

550

XXIX
Table 6. Summary of data from 1987 BRFSS. behaviors of former
smokers aged 18 and older by duration of abstinence .................., 552

Table 7. Percent distribution of persons aged [8 and older by tobacco
product and use status. according to gender and cigarette smoking

status, United States. L987 0. eee eee. SST
Table 8. Physician visits and medical tests within the past year among
AARP members aged 50 and older. by smoking status .. 20. ..........00.. 563
Volume Appendix

Table |. Quit ratio in selected States, by age group and gender—BRFSS.

a 586
Table 2. Cigarette smoking continuum by year. percentage of ever

cigarette smokers. by NHISs, United States, 1978-87, adults aged 20

and older 2.0... cnet tenet need 589
Table 3. Trends in quit ratio (% ) (percentage of ever cigarette smokers

who are former cigarette smokers). by age and by education. NHISs.

United States, 1965-87. adults aged 20 and older... 0.00 0.002....00000. 592
Table 4. Effect of adjusting for use of other tobacco products on quit

ratio (percentage of ever cigarette smokers who are former cigarette

smokers), 1987, NHIS, United States 20.000. eee 594
Table 5. Selected measures of quitting activity (%), NHISs, United

States, adults aged 20 and older 2... 62 ee tees 600
Table 6. Percentage of those intending to smoke in 5 years. by gender,

AUTSs, United States. 1964-86. current smokers aged 21 and older ....... 609

Table 7. Percentage who report having ever received advice to quit from
a doctor, by smoking status and gender. United States, 1964-87, adults
aged 21 andolder «0.2.00... eee 610

XXX
LIST OF FIGURES

 

 

Chapter 2
Figure 1. Cyclical model of the stages of change ......................... 23
Figure 2, Hypothetical examples of disease incidence rates for current,
former, and never smokers, by age... 2.0... ee eee ee ee ees SS
Chapter 3

Figure |. Compared with never smokers, relative risk of mortality in

current and former smokers aged 50-54. 60-64. and 70-74 at

enrollment, by amount smoked and duration of abstinence ................ 8]
Figure 2. Estimated probability of dying in the next 16.5-yr interval for

quitting at ages 55-59 compared with never smoking and continuing to

smoke, DY SEX eee eee etn e eens 98
Chapter 4
Figure |. Risk of lung cancer by number of cigarettes smoked per day
before quitting. number of years of abstinence. sex, and histologic types ... 121

Figure 2. Relative risk of lung cancer among ex-smokers compared with
continuing smokers as a function of time since stopped smoking,
estimated trom logistic regression model, pattern adjusted for smoking
duration compared with pattern unadjusted for duration ................. 123
Figure 3. Incidence of bronchial carcinoma among continuing cigarette
smokers in relation to age and duration of smoking and among never
smokers in relation to age, double logarithmic scale .......00..00.00.0... 127

Chapter 6
Figure 1. Hypothetical effects of smoking cessation on risk of CHD if
mechanisms are predominantly rapidly reversible ..................0005 198
Figure 2. Estimated relative risk of MI after quitting smoking among
men under age 55, adjusted forage 2.0... cee ee 204

Figure 3. Mortality ratios due to coronary artery diseases; rates for men

who have stopped smoking are compared with those for men who

never smoked and those for men still smoking in 1952...........2........ 214
Figure 4. Mortality ratios for all cardiovascular diseases and CHD. by

daily cigarette consumption. US Veterans Study. 1954-69... 0.200002... 219
Figure 5. Mortality ratio for current and former cigarette smokers by

years of smoking cessation, US Veterans Study, 1954-69 ............... 220

XXX
Figure 6. Effect of smoking cessation on survival among men with
documented coronary atherosclerosis; pooled survival among quitters
(N=1.490) and continuers (N=2.675) 00.00.0000 cc ce cece eee eee ee ee 238

Figure 7. Mortality ratios for stroke for current smokers and ex-smokers
compared with never smokers, by daily cigarette consumption, US
Veterans Study, 1954-69 00... ce cee cee cece eens 252

Figure 8. Survival free of stroke in cigarette smokers. never smokers,
and former smokers, aged 60, using Cox proportional hazard

regression model, among men and women ........... 0.00000 eee eee e, 259
Chapter 7
Figure 1. Nonproportional Venn Diagram of the interrelationship among
chronic bronchitis, emphysema, asthma, and airways obstruction ......... 280
Figure 2. Theoretical curves depicting varying rates of decline of FEV; ..... 281

Figure 3. Hypothesized mechanisms by which airway
hyperresponsiveness may be associated with developing or established
COPD without necessarily being a preexisting risk factor ............... 284

Figure 4. Symptom ratio (number of observed symptoms to number of
possible symptoms) in nonmodifiers, modifiers, and quitters at each
test period: symptoms are cough, sputum production. wheezing. and

shortness of breath 2... e, 287
Figure 5. Prevalence of cough and phlegm by smoking group ............. 293
Figure 6. Prevalence of dyspnea by smoking group ...................... 295

Figure 7. Sex-specific mean height-adjusted FEV) residuals versus

pack-years for current and ex-smokers, and distributions of number of

subjects by pack-years. 0. cette eee nen 317
Figure 8. Mean values FVC and FEV}. expressed as a percentage of

predicted values, in 15 quitters and 42 smokers during 30 months after

2 smoking cessation clinics 2.0.2.2 322

Figure 9. Mean values for the ratio of CV/VC. of CC/TLC, and slope for

phase III of the single breath N2 test (N2/L). expressed as a percentage

of predicted values in 15 quitters and 42 smokers during 30 months

after 2 smoking cessation clinics 2.00... 0.2 eee eee es 326
Figure 10. Percent-predicted diffusing capacity (%pDL) by pack-years

of smoking, current smokers and former smokers, in a study of adults

in Tucson. AZ oo cnt en eee e teen need 329

Figure 11. Mean AFEV| values in never smokers, consistent

ex-smokers, subjects who quit smoking during followup, and

consistent smokers in several age groups .............. 000000222004 334
Figure 12. Effects of quitting smoking during followup among men aged

XXXIi
Chapter 8

Figure 1. Perinatal, neonatal. and fetal mortality rates by birthweight in

 

singleton white males, 1980 22.0.2. 2022 ee eee 380
Chapter 11
Figure |. Performance on a meter (ie., visual) vigilance task.

Performance on the continuous clock task, a visual vigilance task ........ 527
Figure 2. Self-reported withdrawal discomfort among abstinent smokers .... 53]
Figure 3. Drinking relative to smoking status for men, 1983 NHIS ......... 558
Figure 4. Drinking relative to smoking status for women, 1983 NHIS ....... 559

Appendix
Figure 1. Trends in the quit ratio. United States, 1965-87. by gender........ 590
Figure 2. Trends in the quit ratio, United States, 1965-87. by race .......... 59]
Figure 3. Flow chart of quitting history, attempts lasting longer than 1
year, NHEFS 2.0.0... etter as 597
Figure 4. Estimated duration of abstinence on first 1-year or longer quit
attempt, product—limit method, N=3,363 2.0.0.0... e cee 598

Figure 5. Percentage of ever smokers who never tried to quit. by
education, United States, 1974-87 20.0... ce 601

Figure 6. Percentage of persons smoking at 12 months prior to the
survey interview who quit for at least 1 day during those 12 months,

United States, 1978-80, 1987, by education 2.0.2... ee eee 602
Figure 7. Percentage of ever smokers who had been abstinent for less

than | year, United States. 1966-87, by education ......0.............. 603
Figure 8. Percentage of ever smokers who had been abstinent for 1-4

years, United States. 1966-87. by education ..........0 0.0.0.0 0.000 604
Figure 9. Percentage of ever smokers who had been abstinent for 5 years

or more, United States, 1966-87, by education ....................0... 605

Awad