The Surgeon General's 1990 Report on the Health Benefits of Smoking Cessation Executive Summary - 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-II) 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 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 returns 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 intermittent 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 like 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 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 1 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. I am pleased that a coalition 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 for a strong smoking cessation campaign targeting older Americans: (1) 7 million smokers are aged 60 or older; and (2) smoking is a major risk 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 condition, 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 smoking. Smoking cessation reduces the risk of respiratory infections such as pneumonia, which are often the immediate causes of death in patients with an underlying 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 outcome 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 statistic 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 consumption without quitting may have little or no benefit for birthweight. Of the women who quit smoking during pregnancy, 70 percent resume smoking within 1 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. Benefits for Infants and Children

As a pediatrician, I 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 ear 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 1 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 risk by eliminating most or all of the exposure.

If parents are unwilling to quit smoking for their own sake, I 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 1 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, difficulty 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 and programs, nicotine replacement, exercise, stress management, and dietary counseling can help smokers cope with these symptoms until they abate, after which favorable psychological 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 example, 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 warnings 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.

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 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., M.S.

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 MexicoRonald 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, MarylandNeil E. Grunberg, Ph.D., Professor, Department of Medical Psychology, Uniformed Services University of the Health Sciences, Bethesda, MarylandJudith 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 Community Medicine, University of California at San Francisco, School of Medi cine, 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, Massachu setts

More than 100 individuals from Government, academic, and private institutions contributed to the preparation of The Health Benefits of Smoking Cessation. Space constraints prevent acknowledging these authors, reviewers and staff in this Executive Summary. Their names are listed, however, in the "Acknowledgments" section of the full Report.

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