Chapter 1
Overview — The Health Consequences of Smoking

Source:

1975 Report, Overview — The Health Consequences of Smoking,
pages 1 - 8.
OVERVIEW — HEALTH CONSEQUENCES OF SMOKING

The statement, ‘Warning: The Surgeon General Has Determined
That Cigarette Smoking fs Dangerous to Your Health,”’ has been
required by law on cigarette packaging since 1970 as a part of the
Public Health Cigarette Smoking Act of 1969. This Act was a
response by the U.S. Congress to the scientific information on the
health consequences of cigarette smoking summarized in reports then
available (the Surgeon General’s Report of 1964 and the subsequent
1967, 1968, and 1969 PHS Health Consequences of Smoking). This
Act was passed because a series of important questions concerning
cigarette smoking and health had been answered.

The following discussion summarizes the basic questions, the
methodology used to determine the answers, and the answers

themselves.

The initial question to be answered concerning the health
consequences of smoking was “Are there any harmful health effects
of smoking cigarettes?” The answer to this question was provided in
two ways. First, it was demonstrated that some diseases occurred
more frequently in smokers than in nonsmokers. Second, a causal
relationship was established between smoking and these diseases.

Concern about the possible health effects of smoking started
when scientists began looking for an explanation to account for the
rapidly increasing death rate from lung cancer. The early retrospec-
tive studies showed a link between lung cancer and smoking. The
first prospective studies, however, found that only one-eighth of the
excess overall mortality found among smokers could be accounted
for by lung cancer; the rest was largely due to coronary heart disease,
chronic respiratory disease, and other forms of cancer. They also
found that the effect on overall mortality was largely confined to
cigarette smokers rather than the users of other forms of tobacco.

However, demonstrating an association by statistical probability
is not enough to establish the causal nature of a relationship.
Determining that the association between smoking and excess death
rates is cause and effect was a judgment made after a number of
criteria had been met, no one of which by itself is sufficient to make
this judgment. These criteria as listed in the Surgcon General’s

3
Advisory Committee Report (1964) were the consistency, Strength,
specificity, temporal relationship, and coherence of the association.

In addition, convincing theories about the mechanisms whereby
smoking contributes to the various diseases responsible for the excess
mortality among cigarette smokers were developed from the evidence
on the biochemical, cytologic, pathologic, and pathophysiologic
effects of cigarette smoking, thereby providing the necessary support
for the decision that the relationship was causal.

The most important specific health consequence of cigarette
smoking in terms of the number of people affected is the
development of premature coronary heart disease (CHD). Both
Prospective and retrospective studies clearly established that cigarette
smokers have a greater risk of death due to CHD and have a higher
prevalence of CHD than nonsmokers. Long-term. followup of healthy
populations has confirmed that a Cigarette smoker is more likely to
have a myocardial infarction and to die from CHD than a

nonsmoker. Cigarette smoking has been shown to be one of the

elevated senim cholesterol). Autopsy studies have shown that
persons who smoked cigarettes have more severe coronary athero-
sclerosis than persons who did not smoke. Physiologic studies and
animal experiments have indicated several mechanisms whereby these
effects can take place.

cancer than smokers of nonfilter cigarettes, but the risk remains well
above that for nonsmokers. The risk of developing cancer of the
larynx, pharynx, oral cavity, esophagus, Pancreas, and urinary
bladder. was also found to be significantly higher in cigarette smokers

than in nonsmokers. Pipe and cigar smokers were found to have
Pharynx, larynx, and esophagus when compared to nonsmokers.

Fewer Pipe and cigar smokers than cigarette smokers report that they
inhale. As a result lungs of pipe and cigar smokers receive much less

4
exposure to smoke than the lungs of cigarette smokers. This is
probably the primary reason for the lower incidence of cancer of the
lung for pipe and cigar smokers compared to cigarette smokers.

Women have had far lower rates of lung cancer than men. This
has been attributed to the fact that fewer women than men smoke
and the fact that women smokers generally select filter and low tar
and nicotine cigarettes. However, the percentage of women smokers
in the United States has increased steadily in the last 30 years, and
since 1955 the death rates from lung cancer in women have increased
proportionately more rapidly than the rates for men, reflecting this
increased proportion of women smokers.

The tar from cigarette smoke has been found to induce
malignant changes in the skin and respiratory tract of experimental
animals, and a number of specific chemical compounds contained in
cigarette smoke were established as potent carcinogens or co-carcino-
gens. Malignant changes including carcinoma in situ were found in
the larynx and in the sputum exfoliative cytology. of experimental
animals exposed to cigarette smoke.

Nonmalignant respiratory disease is a third area of smoking-
induced morbidity and mortality. Cigarette smokers have been
shown to have more frequent minor respiratory infections, miss more
days from work due to respiratory iliness, and report symptoms of
cough and sputum production more frequently than nonsmokers.
Retrospective and prospective studies with long-term followup have
found that cigarette smoking is the primary factor in the develop-
ment of chronic bronchitis and emphysema in the United States.
Cigarette smokers have also been found to be more likely to have
abnormalities of pulmonary function and have higher death rates
from respiratory diseases than nonsmokers. Data from autopsy
studies have shown that cigarette smokers were more likely to have
the macroscopic changes of emphysema, and that these changes are
closely related to the number of cigarettes smoked per day. Mucous
cell hyperplasia has been found more often in cigarette smokers.
Cigarette smoke also inhibits the ciliary motion responsible for

cleansing the respiratory tract.

An additional area of health concern has been the effect of
cigarette smoking during pregnancy. Mothers who smoke cigarettes
during the last two trimesters of their pregnancy have been found to
have babies with a lower average birth weight than nonsmoking
mothers. In addition cigarette smoking mothers had a higher risk of
having a stillborn child, and their infants had higher late fetal and

5
neonatal death rates. There are some data to show that these risks
due to cigarette smoking are even greater in women who have a high
risk pregnancy for other reasons. These effects may occur because
carbon monoxide passes freely across the placenta and is readily
bound by fetal hemoglobin, thereby decreasing the oxygen carrying
capacity of fetal blood.

Having established that cigarette smoking is a significant causal
factor in a number of serious disease processes, two additional
questions became important. They are “Can the health consequences
to the individual be averted by stopping smoking or by changing the
cigarette,”’ and “What are the overall public health consequences of
cessation and of the changes made in cigarettes?”

The first question is the simpler of the two to answer. In the
individual, cessation of cigarette smoking results in a rapid decline of
the carbon monoxide level in the blood over the first 12 hours.
Symptoms of cough, sputum production, and shortness of breath
usually improve over the next few weeks. A woman who stops
smoking by the fourth month of her pregnancy has no increased risk
of stillbirth or perinatal death in her infant related to smoking. The
deterioration in pulmonary function tests that occurs in some
smokers becomes less rapid than that of continuing smokers. The
death rates from ischemic heart disease, chronic bronchitis, and
emphysema also become less than those of the continuing smoker.
The risk of developing cancer of the lung, larynx, and oral cavity
declines relative to the continuing smoker in the first few years after
cessation and 10 to 15 years after stopping smoking approximates
that of nonsmokers. A smoker who switches to filter cigarettes and
has smoked them for 10 years or longer has a lower risk of
developing lung cancer than a smoker who continues to smoke
nonfilter cigarettes. The risk to a filter cigarette smoker, however,
still remains well above that of a nonsmoker.

The public health benefits of cessation are more difficult to
determine than the effects of cessation on the individual. Just as
Cause-specific death rates have reflected the effect of cigarette
smoking on certain diseases, they should also reflect any substantial
benefits to be gained by cessation or reduction in cigarette smoking.
Several factors combined to produce a reduction in per capita dosage
of tobacco exposure in the United States for the years 1966-1970.
First, per capita consumption of cigarettes declined from 4,287
cigarettes per person in 1966 to 3,985 in 1970. Second, during this
period there was a slow but significant decrease in the average tar and
nicotine content of cigarettes as well as a decrease in the amount of

6
tobacco contained in the average cigarette. The decline in per capita
consumption during those years occurred in the face of a substantial
increase in the proportion of young women becoming smokers as
compared to women of previous generations and ‘so reflected
predominantly a decrease in cigarette consumption by men.

Since 1970, although the per capita consumption of cigarettes
has increased, the average levels of tar and nicotine have continued to
decline, making it more difficult to predict what has happened to per

capita dosage.

Examination of cause-specific death rates for the period of this
declining per capita consumption reveals that there was a downturn
in the male death rate from ischemic heart disease beginning in 1966
which reversed the upward trend that had occurred over the previous
two decades. This decline in the death rate from ischemic heart
disease has not occurred in women.

The male death rate from chronic bronchitis has also been
declining since 1967, and the male death rate for emphysema has
declined since 1968 when it was first recorded as a separate category.
Female death rates for these two diseases have not shown these

trends.

Despite the impressive coincidences of the decline in deatn rates
among males occurring at the same time that there was a decline in
per capita cigarette consumption, it is impossible to be certain of the
exact cause of the decline in the death rates. These diseases are
influenced by a variety of factors in addition to cigarette smoking
such as blood pressure and air pollution. Some of these factors have
also been subject to major control efforts which may have
contributed to the decline in the death rates. In addition, there have
been therapeutic advances in the treatment of these problems which

may also have helped lower the death rates.

A decline in male death rates from lung cancer should also
follow the decline in per capita consumption. This rate would not be
influenced as much by changes in other etiologic factors or changes in
therapy because cigarette smoking causes from 85 to 90 percent of
all lung cancer and there have been no major improvments in survival
due to changes in therapy. With lung cancer, however, two
additional considerations must be kept in mind. A decline in death
rates from lung cancer would be expected to lag several years behind
a decline in per capita consumption. In addition, the decline in
consumption and switch to low tar and nicotine cigarettes occurred

7
predominantly in the younger age groups where death rates from
lung cancer are low. For these reasons, it is necessary to look at lung
cancer death rates by age group rather than total lung cancer death
rates. The lung cancer rates by age groups for 197] suggest a decline
in the lung cancer rates for the younger males (under 45), but the
confidence limits on these trends at present remain wide enough
that it is impossible to say whether this is a real decline or merely
a leveling off. The national health statistics broken down by 5-year
age groups are currently available only through 1971. The data by
age group from a few more years will be necessary to determine
whether the changes in smoking behavior which have taken place
have reversed the trend of the preceding 40 years of continually
increasing lung cancer rates in men. In 1971, the last year for
which detailed mortality statistics are available, the accumulated
exposure to cigarettes reached its peak among men bor between
1915 and 1919, a group then in their early 50’s. Cumulative
exposure has continued to decline with each successive 5-year birth
cohort born since then. The trends of the last few years offer some
hope that the peak of the “lung cancer epidemic,” as some have
termed this phenomenon, may have been reached with this group
and that future years will show a slow but consistent decline.
Chapter 2
Cardiovascular Diseases
Part f
Part I

Sources:

Part 1-— 1971 Raport, Chapter 2, pages 15 - 174.
Part 11 — 1975 Revort, Chapter 1, pages 9 - 38.
Chapter 2
Cardiovascular Diseases

Part I
Contenis

Introduction

  

The Effect of Cessation 9 i Cigarette Smoking on Coronary «

 

 
 
 
  
 
 
 

 

Heart Disease
The Constitutional Hypothesis AG
Autopsy Studies Relating (Smoking, | Atherosclerosis, and | ~
Sudden CHD Death 48
Experimental Studies Concerning the - ‘Relationship of |
Coronary Heart Disease and Smoking .....2222.20 2080, 52
Cardiovascular Effects of Cigarette Smoke and
Nicotine ......, TE 2: Deane .

Coronary Blood Flow °. 2/0/8034 -ha3iaubr sot! 3 5

Cardiovascular Effects of Carbon Monoxide . Bae

Effects of Smoking on the Formation of Atherosclerotic ae
Lesions .....0 200. ives ies. we hee pg 59

The Effect of Smoking on Serum Lipid Levels
The Effect of Smoking on Thrombosis .. abl
Other Areas of Investigation. erreres
Cerebrovascular Disease <.°. need. SEO A A: os al ob
Nonsyphilitic Aortic Aneurysm . we LE Hon
Peripheral Arteriosclerosis we ah
Experimental Evidence.”
Thromboangiitis Obliterans .”
Summary and Conclusions ae, i

  
 
 
 
‘Coronary Heart Disease ..........-......2........ 70

Cerebrovascular Disease ............0.0.0-20...... 71

Nonsyphilitic Aortic Aneurysm .................... 71

Peripheral Vascular Disease ......2......0.2.02... 71

References.....020..... ws s SURE eee eeee see cee eee eee 71
FIGURES

1. National Cooperative Pooling Project, Inter-Society Com-
..° mission for Heart Disease Resources 2000 vse etiecrey 19

  

a Risk of coronary heart disease “(2 years) according to.
. a ~ cigarette smoking habit and presence of “predisposing
. factors” (men 30-59 at entry). Framingham Heart
AStudy 00 ISLA cenee 20
3. Estimated coronary heart disease death ratios i in a 17-51
year follow-up, and frequencies of paired combinations
of six high-risk characteristics in n college, for all ages
atdeath 1.0.0.0... 0... bebe aces wa lee we wheel... 21
4. Relationship between smoking status and serum choles-
~ terol level at initial examination, and incidence of clin-
ical coronary heart disease in men originally age 40-59
’. free of definite CHD. Peoples Gas Light and Coke
Company Study, 1958-1962...... “nee be tec eee aeeee _ 39
5. Average annual incidence of first myocardial infarction a
among men in relation to overall physical activity, —
class, and smoking habits _(age- adjusted | rates per

1,000) . rpeiitiertyechscnuy tigen tts feu -

: “LIST OF TABLES» .
- (A indicates tables located i in Appendix at end of Chapter) ort an 5°

1. Sudden death and acute mortality with first major.

  

coronary episodes ..0ish.levSccsves: paver 19
2. Coronary heart disease mortality ratios related to
smoking—prospective studies’. pidge. Pig 89 .22
3. Sudden death from coronary heart aie related to ~. '
smoking . vee cee bees SACI ee Voi ee6r 3. A 26
4. Coronary heart disease morbidity | as Ebene to 65567}
smoking. 2.02... see eee ee cere eee ee tene : Sis en,28,
5. Coronary heart disease morbidity as yelated to smok- | fer “ J
ing—-angina pectoris—prospective studies V2.7 yd 33
A6. Coronary heart disease morbidity | and mortality— en
-r .. yetrospective studies ....0.0..00 0000270. ” aE Bg
A7. Differences in serum lipids between smokers and non- eg
0000) ) 6 REEL oT Og

ry

we
LIST OF TABLES (CONT.)
(A indicates tables located in Appendix at end of Chapury

Page

A 8. ‘Blood pressure differences between smokers and non- 7
smokers 2... cos Sa ee ee a ese oles Net. oa dae 99
, 9. Death rates from coronary heart disease, by systolic fAS
- blood pressure: ILWU mortality study, 1951-1961 38

10. Death rates from coronary heart disease, by diastolic (51:5

°*i blood pressure: ILWU mortality study, 1951-1961 _ 38
11. Death rates from coronary heart disease, among hy-. ay,

 

- 12. Death rates from coronary heart disease among men‘
without abnormalities related to cardiopulmonary -
‘diseases by weight classification in 1951: ILWU .
mortality study, 1951-1961. - arrin tometer dsr Al

13. Death rates from coronary heart disease, by electro- :
cardiographic findings in 1951: ILWU mortality
Study, 1951-1961... 1.0.0... ce eee eee eee eee 41
14, 1958 status with respect to heart rate, blood pressure,
cigarette smoking, and ten-year mortality rates, by
cause (1,329 men originally age 40-59 and free of
definite coronary heart disease) Peoples Gas Com-
pany Study, 1958-1968............+-+ e+e eeee 41
15. The effect of the cessation of cigarette smoking on the ,
incidence of CHD .......--.. 2 0c e eee eee etre 42
16. Annual probability of death from coronary heart dis-
ease, in current and discontinued smokers, by age,
maximum amount smoked, and age started smoking 42

Al7. Incidence of new coronary heart disease by smoking

category and behavior type for men 39-49 years

Of AGE Lecce eee ee eee erent terre reetttes “101
A18. Incidence of new coronary heart disease by smoking
category and behavior type for men 50-58 years se
“of age .....- Jicicsceeee+-+-ss eee ao obead —102
19. Autopsy studies of atherosclerosis cece cee eens a 49
A 20. Experiments concerning the effects of smoking and
nicotine on animal cardiovascular function ...... ~ 103
A 21. Experiments concerning the effects of smoking and
_ nicotine on the cardiovascular system of humans. 109
A22. Experiments concerning the effect of nicotine or
smoking on catecholamine levels ...-.--- aeseceee +115
‘A 23. Experiments concerning the atherogenic effect of ;
nicotine administration. ......---e-ereeree eres “116

15
LIST OF TABLES (CONT.)

(A indicates tales located in Appendix at end of Chapter)
Page

24. Experiments concerning the atherogenic effect of
carbon monoxide exposure and hypoxia . 60

425. Experiments coricerning the effect of smoking and
nicotine upon blood lipids (Human Studies) +. bootde 119
A 25a. Experiments concerning the effect of smoking and’ E08
nicotine upon blood lipids (Animal Studies) ..: <4% _ 123
4 26. Experiments concerning the effect ‘of. carbon amon- $e &
oxide exposure upon blood lipids. a out vr 2-125
4 27. Smoking and thrombosis ..02°22: ;
28. Deaths from cerebrovascular. “disease. related to. Gare
smoking. ossiece. ol fas eer 2 TS ete wa 64
29. Deaths from nonsyphilitic aortic aneurysm related to

 
 

 

 

A 30. Experiments concerning the effect. of. ‘Ricotine. and. j pe
smoking upon the > peripheral vascular system .. 4;
1 POG 260L

 

   
 
     
        
  
      
    
 
  

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INTRODUCTION

Coronary Heart Disease (CHD) cuts short the lives of many
men in the Western World in their prime productive years. More
Americans die from heart disease than from any other disease. In
1967, in this country, a total of 345,154 men and 227,999 women
were classified as dying of arteriosclerotic heart disease (ASHD)
(196), a. category which consists largely of what is commonly
called CHD. During the years, from 1950 to 1967, the age-adjusted
' death rate from ASHD increased 15.1 percent (196, 197).

‘Besides the many deaths attributed to CHD, much morbidity
results from this disease, The National Health Examination Sur- -
vey of 1960-1962 estimated that 3.1 million American adults, ages
18 to 79, had definite CHD and 2.4 million had suspect CHD,
together representing about 5 percent of the population. It was
further estimated that of Americans under age 65, almost 1.8 mil-
lion had definite CHD and 1.6 million had suspect CHD (195).

- There are several manifestations of CHD, all related in part to
the basic process of severe atherosclerosis, a disease of arteries in
which fatty materials (lipids) accumulate in the form of plaques
in the walls of medium and large arteries. This process, as it occurs
in the coronary arteries, leads to stiffening of the wall and narrow-
ing of the lumen which, when severe, result in a diminution in the:
blood supply to the cardiac muscle. Angina pectoris, a major mani-
festation of CHD, results from diminution in blood supply relative
to the needs of the myocardium. If the blood supply to a portion
of the myocardium is completely obstructed, due for example to the
formation of a thrombus at the site of atherosclerotic narrowing,
necrosis or death of a portion of heart muscle may occur.-This
occurrence is known as a myocardial infarction. In many cases, a
disturbance of cardiac rhythm occurs at the time of thrombosis,
and the patient may die immediately. It is estimated that approxi-
mately 25 percent of patients suffering coronary artery occlusion
die within the first three hours following the occlusion (table 1)
(88). Not infrequently, sudden death occurs in patients with severe
coronary atherosclerosis but without a demonstrable arterial occlu-
sion. In these cases, it is thought that the meager blood flow to a
portion of the myocardium becomes so diminished with respect to
cardiac needs as to lead to a fatal arrhythmia, as well as to, per-
haps, a myocardial infarction.

gyl7
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GARETTE SMOKING(S) AT ENTRY—WITH CONTROL Of SERUM CHOLESTEROL (C) AND DIASTOLIC BLOOD PRESSURE (H)—-AND TEN YEAR INCIDENCE
oo ino MORTALITY RATER 7,594 WHITE MALES AGE 30-59 AT ENTRY, POOLING PROJECT /

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RATE bet 2) i © FIRST MAJOR -, RATE - _ ALL CHD DEATHS”. 2”
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$2" PER 1000779 *__ PER 1,000 . ~
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“iC NUMBER 28). 97 SD 2 al
(Ree OF EVENTS Och OS Se an .
“ Qo NUMBER 1,249° 01a Sy! OT 984 595
OF MEN” : i ot :

 

— moe eae oo Dee EEE a ‘
ui Natlonal Cooperative Pooling Project; smoking status at entry and 10-year age-adjusted rates per 1,000 men for first major coronary event (Incting nonfatal MI,
gs fatal MI, and sudden death due to CHD) and any coronary death. U.S. white males age 30-59 at entry. All rates age-adjusted by 10-year age groups to the U.S,
S white male Fopuiaton 1960, Graphs present rates for noncigaratte vs, cigarette smokers at entry with simultaneous control of blood pressure and serum cho-

  
  

lesterol level. For this latter anatysis, the following cutting points were used:
iu .. (a) Cigarette smoking S$ —any use at entry

     
  

“e want i (y) Serum cholesterol: Co 250 mg/d. we 7 : hoy PR ee oy
ay Spt (¢) Diastolic blood pressure H ~— = 90 mm. Hg. Slo me Ry fh 2 2

‘ rent ee Te Ry “ct
= SOURCE: Inter-Soclety Commission for Heart Disease Resources. National Cooperative Pooling Project Data (88).
SIP.

. cholesterol level.
(a) Cigarette smoking—S-any use at entry
(b) Serum cholesterol—C-2250 mg./dl.

~”(e) Diastolic blood Pressure—H-290 mm, Hg.

   
 

..Floure 1—National Cooperative. Pooling Project; smoking status at entry and 10-year age-adjusted rates per 1,000 men for
¥ first major coronary event (includes nonfatal MI, fatal MI, and sudden death due to CHD) and any coronary death. U.S.
white males age 30-59 at entry. All rates age-adjusted by 10 year age groups to the U.S. white male population 1960, .
- Graphs present rates for noncigarette vs, cigarette smokers at entry with simultaneous control of blood pressure and serum
For this latter analysis, the following cutting points were used:

 

! TABLE i Sudden death and acute mortality ‘pith firat major’ coronary “episodes ©’ me

 

* Author, year, «

    

Proportion per ;

 

 

  

5. within 8 hours of onset -

 

28 Association, “. Ten-year - ae

‘data from the Albany civil servant, Chicago

Number and mot - is Number « 1,000 events .
country, - typeof. Data - : wus of { (ascaleulatedon . -
“3 . reference cca, Population . collection « . Event “et events =} the basis of age- “> Comment
: ” " be i adjusted rates) me
am * Pooling , ;, 1,694 males. Medical exam- All first major coronary a \- vee Data from the Poollng Project, Council on
hie Project, ~ ‘ty Males 30-59 inationand episodes, nonfatal and fatal, 60h oT. * Epidemiology, American Heart Association,
< American’ o7. yearsofage. | follow-up. , Budden death (death 4 ‘Ro a national cooperative project for pooling
. Heart a atentry, - 2H

” of acute illness) ae?
All acute deaths with
first episodes.

“1970,
U.S.A.
4 (38), r

  

-experience. |

   

 

“ ce Bounce, Inter-Soclety Commission for Heart Disease Resources (88),
is pe i Representative references include: lor 95, 148, 177) and others lsted ag

te a 6a-6k fn Inter-Society Commission ‘or Heart Disease Resources report,
Cg

 
 

Le

 

Peoples Gas Co., Chicago Western Electric
Co., Framingham Community, Los Angeles
civil servant, Minneapolis-St. Paul busincas
} = ‘ men, and other prospective epidemiologie
: studies of adult cardiovascular disease in the
United States.

   

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CIGARETTE SMOKING: 2° 0 vss)
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MORBIOITY RATIO

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_ ANY ONE

PREDISPOSING FACTORS (CHOLESTEROL * 250, HYPERTENSION, DIABETES)
*SIGNIFICANTLY DIFFERENT FROM “NONSMOKER™ P<.05 . moi 3

?

 

Ficure 2—Risk of coronary heart disease (12 years) according to cigarette
smoking habit and presence of PL factors” (men 30-59 at takes
Framingham Heart Study. : | . Be, :
Source: Kannel, W. B., et al. (94). i. ee _ s s

. a) oo. oe : Do

   

Numerous epidemiological studies have indicated that cigarette
smokers have increased mortality ratios for CHD; that is, cigarette
smokers show significantly increased death rates compared with
nonsmokers (table 2). The risk incurred by cigarette smoking in-
creases with increasing dosage and, as measured by mortality _
ratios, is more marked for men in the younger age groups, under
age 60, although the absolute increment in death rates experienced
by smokers over that of nonsmokers continues to increase with
increasing age. Table 2 lists the mortality ratios found in the major _
studies. Certain of these studies, including those at Framingham, ©
_ Massachusetts, the Health Insurance Plan of New York City
(HIP), and at Tecumseh, Michigan, have analyzed morbidity as
well as mortality from CHD and have indicated that the risk of
developing fatal and nonfatal CHD is greater among cigarette
smokers than among nonsmokers (tables 3 and 4). Conflicting
evidence has been published concerning the relationship of ciga-
rette smoking and the incidence of angina pectoris. While some

20
 

 

 
 
    

 

  

 

 

   

 

 

 

   

 

 

 

 

 

 

 

 

 

 

 

 

 

 

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0 i ot .
Cigarettes, —A nes eanci29 A Height<68
3] Parent deed —B S*dYC Sys. BP 2304. —B «YC Pavan dead
tab gett . pts : 7 :
: 1A - a 19
: 4 . 76 1.3 124
1.0 [307 } 2? | 02 1000 149
2 99 232
_ was || 52 || 402 1 {189 ]] a
1071 1119 | | 294
0
A- AF AS AE AR AP AR AE
B— e— B+ B+ s— e— 8+ Be " B-* a

: , PRESENCE (+) OR ABSENCE (—) OF CHARACTERISTICS (A or B)
~ -- —- Top numbers in bars are CHD decedents with paired combinations of characteristics; bottoms aumbers,

 

: ~ 5 ate subjects with combinations. . Bhi Me Lote on Dit
as xX OF ar OF a res
eR Beng BRE

Ficure 3—Estimated coronary heart disease death ratios in a 17-51 year -
follow-up, and frequencies of paired combinations of six high-risk charac-
_ teristics in college, for all ages at death. eT RGek Sage tee stp s inf)

_ Source: Paffenbarger, R 8., et al. (146).

  

    
Tas_e 2.—Coronary heart disease mortality
(Actual number of deaths
: {SM = Smokers

 

 

 

  

 

 

   

 

   

 

 

 
 
    

 

 

   

  
 
 
 

 

 

    

 

Author, a oo. son :
country, Noe a Cigarettes /day t
reference population sone ;

Hammond 187,783 Questin- Pay Bast Ns ....../5£1.00 (709)
and white males naireand «- ---- pov All smokers .1.70 (3361) *(p<0.001)
- Horn, in @ states - follow-up vt - (192) + .
~ 1958, * 50-69 years of death . (864) © As. :
- U.S.A. of age. ““ eertificate,  _ (604) - . fe)
= + (77,78). eas op tt 3 (118) ‘|
Doyle . 2282 males, Detailed - 10 ce 98 NS ...025...1.00 (20) a
_ etal, 1. Fram | |! medical 25: te Allamokers .2.40 (73) 8
1964, «|. ingham, °-.examina- =? {ote <20 ....2-5.2.00 (17) 1 otk
USA. |: 3062yearms tion and : a 7 20 .. oo
(54). cof age. follow-up. PB op cl pd 20-2... 3.80 !
hae 1,913 males, wah Chips Sec woken. *
Albany, ages fet
29-55 years oe ma ee fo
of age. Meee aa ooh
Doll and Approuzi- Question- 10 1,376 NS ......-- 1.00 : .
Hid, mately naire and : Allsmokers .1.35 : *
1964, 41,000 }. follow-up aa 1-14 ....1.29 . og Z
Great male British of death Cobra 18-24 ....1.27 fo.
Britain physicians. certificate. ae «>26 ..2....-1-43 02 0;
(50). : Pe : .
Btrobel 3,149 male —- Question- 9 162 NS ........ 1.00 oo
and Gsell Swiss phy- naire and : pon: : fear “

1965 sicians. follow-up ean 1.4, 37200 2 ..--- 21,48 7"
Switzer- of death "320 2.22216 °
land BG certificate. : :
(180). : fon - ae LoS

- Best, Approxi- Question- 2,000 NS ......-. 1.00

1966 mately ~. naire and i= + Allsmokers .1.60 (1380)
Canada 78,000 follow-up ~S10 2..22...1.686 (337)

(25). male Cana- of death : 1.58 (766)
dian. certificate. 1.78 (217) =
veterans, 0°" + be eeppret

Kahn U.S. male Question- 8% 10,890 NS ........ 1.00 (2997) .
1966 veterans naire and . Allsmokers .1.74 (4150)
U.S.A. 2,265,674 “follow-up 2. 0 89 (489 OP

(93). person , ofdesth fh 10-20 ......1.78 (2102) 1°

. ; : . “years. . _ -- certificate. & 21-39 - 1225-184 (1292) z
Peery St peer ye e898 “2.00 (266) _ 3,
Hirayama, 265,118 Trained in- NS ........1.00 (17) +s -

1967, Japanese | terviewers (69) wale
Japan adultsover — and follow- . 9 *

(84). age 40, up of death

‘ ~. * ‘certificate.
Kannel 5,127 males = Medical ex- 12 62 NS ..0..2..1.00 (27)

etal, and females amination -- 8  gMs20 1.2.20 (25); (><0.05)

1968, age 30-59. and Coa - an _ vs
U.S.A. POatd og gd follow-up. :

(%). : fA ae mie yt

 

 

2 Unless otherwise specified, disparities between the total number of deaths :
and the som of the individual smoking categories are due to the exchosion

  

of either occasional, miscellaneous, mixed, or ex-emokers. ‘ :

_ gis
22
ratios related to smoking—prospective studies
shown in parentheses}*

NS = Nonamokers}

 

 

 

 

 

- ., : _ oe a . . mi
Cigars, pipes _ ° SO A ge variation : 7 3us =" Comments :
oie aad sb le : a. a

Cigarea UP  SOSb |. BSD 60-45 65-48 toad bevel
NS. .1,00 ONS ool lees. 1.00 (90) 1.00 (142) 1.00 (204) 1.00 (273). we

SM. .1.28 (420). Allsmokers 1.93 (765) 1.85 (962) 1.66 (921) 1.41 (718) |,

Pipes 10 88 (386) 1.88 (50) 1.7 (49) 1.27 (68) |
NS..1.00 ~ "10-20 +2.00 (213) 2.04 (258) 1.91 (235) 1.58 (158)
SM..1.03 (312) >20 > 2.51 (203) 2.47 (199) 1.92 (129) 1.86 (78) 3

 

odie bs +

    

 

 

     

 

   

 

 

 

  

 

 

    

 

: : Data apply
. . oe . ae only to males
~ aged 40-49
- 7 and free
. oy ,_ of CHD at
. entry. NS
: " inelude pipe,
Soot ee an eet erm se ete wens cmmene ss mers 7 ~.. Clgar and
, - “"-* ex-amokers,
SS-45 -, 65-84 65-85 ff se
> 1.00 1.00 . °
1.40 1.71 mo . .
1.73 12700 t ane
1.92 1.58 oa
NS. .1,00 Ltr .
BM. 1.45 Ss wee - us
Cigara . . 30-49 50-69 70 and over
NS. .1,00 NS .... 1.00 1.00
8M..0.98 (16)  <10 . 1.66 (220) 1.71 (99)
Pipes 10-20 ......- 1.45 (115) 1.67 (557) 1,29 (94)
N8. .1.00 >20 ...-.... 1.85 (65) 1.76 (184) 1.73 (28)
SM..0.96 (95) . .
Cigars mo, : or a:
NB. .1.00 ob east t ,
3M..1.06 (623), 4 . whew
Pipes Be Ld . dsr DASARI PE oe
NB. .1.00 Dele EMS os TD fa tet 18:
3M. .1.08 (3868) . 2 a ye ee
eee . ee ae ~ ere - a Prelimin-

           
 
 
 

 

 

 

 

 

. . * Sash fite+ ~~ ayy report, 7
zp” values specified only for those provided by authors. ite ; oy ar ~
: z Ge ane oe foe ao at ab ads my

 

wee Bot

  

   

Aft Sele gc inh Oe aatsiz to,

 
TABLE 2.—Coronary heart disease mortality ratios
(Actual number of deaths
{SM = Smokers

 

 

 

  

 

 
  
 
   

Author,
year, | Number and y Follow- Number . tee
eoantry, typeof Data “ep - of or Clgarcties/day
reference population collection (years) deaths [ woe ee eae
Hammond 358,534 _ Question- ; 5 at B19
and mates <)"*-netreangd 2°37 oNS
Garfinkel, 445,878 ‘follow-up * " [1
1969, females “7 of death : 15S kz 3 ba ct “10-19
age 40-79 ‘enka AG gag "18

  
 
 
  

spate
tee he ge
eet ars

aye.

 

 

7 certificate.
boo

    

 

x? aera
Laiyotes fa8S Sao
ays pny

      
 

 

 

 

 

 

 

 

  
   

 

 

 

    
   
   
 

 

 

  

  
 
 

  
    

Paffenbsar- 50,000 male Baseline 17-51 1,146 NS
ger and _ former . interview  —.,----matehed 3M (885) {p<0.01)
Wing stodents. and exam- tVicwith +--+, .

1969 ination and eo: 2992 °°. te vere cao
U.S.A. _ follow-up [*Seontrola > --9- - Gt
(4) by death ave cab, oe
certificate, “a °

Paffenbar- 3,263 male Initial multi. 16 ~ 21 NSand<20 2.00 (137) oe
geretal, longshore phasic SM>20 ....2.08 (15a) (S900)
1970, men 85-64 screening i. . ne
U.B.A, years of and follow- .

(164). age. up of death
certificate,

Taylor - 2,571 male —s Interviews B 74600 ONS C...L...1.00 (4) ea
etal, railroad and regular ae S20 NOT (20) es
1970, . employees follow-up itis te PRO ce, 3.60 (22) “3
U.S.A. 40-59 years os exam- | ; faye eed
(143). of age at ination, |: vie

entry. °

Weir and $8,153 Call-  Question- BS 1,718 NS .........1.00
Dunn, fornia male naire and oC Allsmokers .1.60
1970, workers follow-up +10 2.0.....1.89
U.B.AL 85-64 years of death 20 2... 1.67
(905). of age at certificate, >80 .....0.. La

entry.

Pooling 1,427 white Medieslex- 10 = 289 NS ......... 1.00 (27) ~
Project, males amination (84)

American 30-59 years and . (86)

Heart of age at follow-up. (68)

Associe- entry, 9 -—---— :

ton, °

1970, . ’

U.B.A. : Le

(se). ar - -

 

 

 

1 Unless otherwise specified, dis
Gnd the sum of the individus]
of ether Occasfqnal, miscellaneous, mix

24

amoking

parities between the tots! number of deathe

categories are due to the exclusion
ed, or ex-smokers.

“>

 

Fare

 
related to smoking—prospective atudies (cont.)

shown in parentheses}I ces“ *

 

 

 

NS = Nonsmokers] --~ ~* - ~ 7
til ve Coat. aes mw. PTRSdE .
Cigars, pipes _ Age variation — woe _ - Comments

 

PBN tt tegen Males ~- sos E"" *Based on
oe 40-09 970-79 "69 deaths.
- 1.00 "Loo -. i

1.48 ‘aye
: “1.820 -— Bal”
+ 2.40 1.91 1.49
2.79 1.79 LAT

Females pT ern
1.00 1.00 1.00
1.15 1.04 0.76
237 1.79 0.98
2.68 . 2.08 1.27 woe

3.13 202 ke ee

   

   
  
 
     

 

“10-19
20-30
__.. D4

 

ween me Ob SESE SSBB em

   

 

   

 

NS ...,.....1.00 1.00. 1.00
: (p<0.01)
SM ...... 180 (88) 1. 60 (163) ‘120 (134)
5 ; : gre? : 7Y

  

 

_85-09 _..- NS includes

  

~~ ee SESE 45-56 55-84

 

   

. NS . - 1.00 1.00 17 1,00 ters 2> pipes and
Mood x10 . 2.05 hap. La: tat heselgars at
‘ tee +20 3.17 166 > 126 -tishity BM incladés |
- +++ ©3830 . 3.83 $660 ix C186 - rock 4 ex-smokers.-

re $18 AZ ee AZ at ae
eae All ......- 5. 6.24 295 | 1856 . 2 124 aes es

 

 

 

- 1.00 (27) So LE ra fate a - tad

 

   

~ lg go (aay aR rs
_. - ‘ : 4

  
 
 

 

 

ot att arew- * ‘eeitiss pasty, eek
oe ab acy our wre 5 hal tae neds, 2a a