1989 Surgeon General Report: Reducing the Health Consequences of Smoking

Chapter 1

HISTORICAL PERSPECTIVE, OVERVIEW, AND CONCLUSIONS 

• Contents
• Historical Perspective
• Highlights of Conclusions and Findings
•      Major Conclusions
•      Key New Findings
• Overview

Contents

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Historical Perspective

Each of the last five Surgeons General of the U.S. Public Health Service (PHS) has identified cigarette smoking as one of this Nation’s most significant sources of death and disease. Today, more than one of every six American deaths is the result of cigarette smoking. Smoking is responsible for an estimated 30 percent of all cancer deaths, including 87 percent of lung cancer, the leading cause of cancer mortality; 21 percent of deaths from coronary heart disease; 18 percent of stroke deaths; and 82 percent of deaths from chronic obstructive pulmonary disease. Other forms of tobacco use, including pipe and cigar smoking and use of smokeless tobacco, are also associated with significantly elevated risks of disease and death (US DHEW 1979a; US DHHS 1986b).

Although the health hazards of tobacco use have been suspected for almost 400 years, the first reported clinical impressions of a relationship between tobacco and disease date from the 18th century, when tobacco use was associated with lip cancer (US DHEW 1979a) and nasal cancer (US DHHS 1986b). However, true scientific under-standing of the health effects of tobacco has been achieved only in the present century. Broders (1920) published an article in the Journal of the American Medical Association linking tobacco use to lip cancer, and 8 years later, Lombard and Doering (1928) published an article in the New England Journal of Medicine noting that heavy smoking was more common among cancer patients than among control groups. Later, Pearl (1938) observed in the journal Science that heavy smokers had a shorter life expectancy than nonsmokers.

During the 1930s the Nation’s increasing rate of lung cancer and other diseases prompted the initiation of epidemiologic and laboratory studies of the relationship between tobacco use and disease. In the late 1940s and early 1950s a number of retrospective epidemiologic studies, published by Wynder and Graham (1950) and by other investigators, provided scientific evidence strongly linking smoking to lung cancer. This association was soon thereafter supported by the emerging early findings of major prospective (cohort) mortality studies, including the work of Doll and Hill (1954, 1956) in Great Britain and Hammond and Horn (1958a, 1958b) in the United States. The strength and consistency of these results, combined with evidence from laboratory and autopsy studies, led a national scientific study group to conclude in 1957 that the relationship between smoking and lung cancer was causal (Study Group on Smoking and Health 1957).

On July 12 of that year, U.S. Surgeon General Leroy Burney issued a statement declaring that "The Public Health Service feels the weight of the evidence is increasingly pointing in one direction; that excessive smoking is one of the causative factors in lung cancer" (US PHS 1964). Two years later, in 1959, Surgeon General Burney said that "The weight of evidence at present implicates smoking as the principal factor in the increased incidence of lung cancer" (Burney 1959).

Increases in chronic diseases in other parts of the world led health authorities in other countries to examine the relationship between tobacco and disease, particularly in Europe and Scandinavia. In 1957, the British Medical Research Council reported that a major part of the increase in lung cancer was attributable to smoking (British Medical Research Council 1957). Later, the Royal College of Physicians (1962) issued a landmark document on smoking and health that concluded that "Cigarette smoking is the most likely cause of the recent world-wide increase in deaths from lung cancer. . . is an important predisposing cause of the development of chronic bronchitis. . . probably increases the risk of dying from coronary heart disease...has an adverse effect on healing of [gastric and duodenal] ulcers . . .[and] may be a contributing factor in cancer of the mouth, pharynx, esophagus, and bladder."

On June 1, 1961, the presidents of the American Cancer Society, the American Public Health Association, the American Heart Association, and the National Tuberculosis Association (now the American Lung Association) urged President John F. Kennedy to establish a commission to study the health consequences of smoking. Representatives of these organizations met with Surgeon General Luther L. Terry in January 1962 to reiterate their call for action. In April, the Surgeon General presented a detailed proposal for an advisory group to reevaluate the position adopted by the Public Health Service in 1959. In calling for the advisory group, Dr. Terry cited new research on the adverse health effects of tobacco, a request from the Federal Trade Commission for guidance on policy regarding the labeling and advertising of tobacco products, and the findings in the new report of the Royal College of Physicians.

On July 27, 1962, following consultations between the White House and the Public Health Service, the Surgeon General held a meeting to define the work of an expert advisory group and to identify candidates for the committee. Meeting with the Surgeon General were representatives of the American Cancer Society, the American College of Chest Physicians, the American Heart Association, the American Medical Association, the Tobacco Institute, the Food and Drug Administration, the National Tuberculosis Association, the Federal Trade Commission, and the President’s Office of Science and Technology. The group agreed on a list of more than 150 scientists and physicians. Each of the organizations had the right to veto any of the names on the list for any reason. Persons who had taken a public position on smoking and health were not considered for inclusion on the advisory committee.

Dr. Terry selected 10 individuals from the list to serve on the Surgeon General’s Advisory Committee on Smoking and Health: Stanhope Bayne-Jones, M.D., LL.D., former Dean, Yale School of Medicine; Walter J. Burdette, M.D., Ph.D., University of Utah; William G. Cochrane, M.A., Harvard University; Emmanuel Farber, M.D.,Ph.D., University of Pittsburgh; Louis F. Fieser, Ph.D., Harvard University; Jacob Furth, M.D., Columbia University; John B. Hickam, M.D., Indiana University; Charles LeMaistre, M.D., University of Texas; Leonard M. Schuman, M.D., University of Minnesota; and Maurice H. Seevers, M.D., Ph.D., University of Michigan.

The Advisory Committee held nine meetings from November 1962 through December 1963, during which they reviewed all the available data from animal laboratory experiments, clinical and autopsy studies, and retrospective and prospective epidemiologic studies. The Committee had access to over 7,000 publications pertaining to smoking and health, including more than 3,000 articles reporting research findings published after 1950. In evaluating evidence linking smoking to disease, the Commit-tee restricted judgments of a causal relationship to those associations for which the evidence was (1) consistent, (2) strong, (3) specific, (4) supportive of appropriate temporal relationships, and (5) coherent (US PHS 1964).

The final Report of the Advisory Committee was released on January 11, 1964 (US PHS 1964). It concluded that "Cigarette smoking is causally related to lung cancer in men; the magnitude of the effect of cigarette smoking far outweighs all other factors. The data for women, though less extensive, point in the same direction . . . . The risk of developing lung cancer increases with duration of smoking and the number of cigarettes smoked per day, and is diminished by discontinuing smoking."

The Report also concluded that pipe smoking is causally related to lip cancer, that cigarette smoking is causally related to laryngeal cancer in men, and that "Cigarette smoking is the most important of the causes of chronic bronchitis." The Advisory Committee identified significant associations between smoking and cancer of the esophagus, cancer of the urinary bladder, coronary artery disease, emphysema, peptic ulcer disease, and low-birthweight babies, but it did not consider the available data to be sufficient to label these associations causal.

The Committee found that male cigarette smokers had a 70-percent excess mortality rate over men who had never smoked and that female smokers also had an elevated mortality rate, although less than that of males. The Advisory Committee concluded that "Cigarette smoking is a health hazard of sufficient importance in the United States to warrant appropriate remedial action."

"Remedial action" was initiated immediately after publication of the Advisory Committee’s Report, when the Federal Trade Commission (FTC) proposed that cigarette packs and advertisements bear warning labels and that strict limitations be placed on the content of cigarette advertising. With passage of the Federal Cigarette Labeling and Advertising Act of 1965 (Public Law 89-92; amended in April 1970 by Public Law 91-222), Congress preempted the FTC’s recommendation: beginning in 1966, a congressionally mandated health warning appeared on all cigarette packs but not on advertisements.

The Act also required the Secretary of Health, Education, and Welfare to submit an-annual reports to Congress on the health consequences of smoking, together with legislative recommendations, beginning no later than mid-1967. New reports of the Surgeon General on smoking and health were issued in each calendar year beginning in 1967, except for 1970, 1976, 1977, and 1987. (In 1976, a volume of selected chapters from the 1971-75 Reports was published. The report issued in 1978 was a joint Report for the years 1977 and 1978.) Thus, the present volume, commemorating the 25th anniversary of the 1964 Report, is the 20th Report in the series. In addition, in 1986, PHS issued a report on the health consequences of using smokeless tobacco (US DHHS 1986b). Table 1 identifies the previous reports and highlights their coverage.

The reports published since the 1964 Report have confirmed the scientific judgment of the Advisory Committee and have extended its findings. The evidence available today has reinforced the Advisory Committee’s judgments of causality; converted most of its "significant associations" into causal relationships, adhering to the strict criteria described in the first Report; confirmed causal associations for relationships not contemplated in the 1964 Report (e.g., the health hazards of involuntary smoking (US DHHS 1986a)); and identified additional disease associations. 

Accompanying the growth and dissemination of scientific knowledge has been in-creased public understanding of the hazards of smoking, reflected in decreases in smoking prevalence and, in recent years, the intensification of public and private measures to discourage smoking. A quarter century after publication of the first Report, smoking remains the leading cause of preventable premature death in our society, but per capita cigarette consumption is declining annually, and analyses of consumption and disease trends augur eventual decreases in smoking’s toll.

Given these changes, the remaining toll of tobacco-related disease, and the Surgeon General’s objective of a smoke-free society by the year 2000 (Koop 1984), Surgeon General C. Everett Koop devotes this 25th anniversary edition of the Surgeon General’s Report to an assessment of progress against smoking in the quarter century since the first Report was published.

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Highlights of Conclusions and Findings

As the present Report documents, knowledge of the health consequences of smoking has expanded dramatically since 1964, and programs and policies to combat the hazards of smoking have proliferated. The essential chapter-specific conclusions relating to these and other topics of this Report are presented at the end of each chapter and are reproduced in the final Section of this introductory Chapter. The major conclusions of the entire Report, immediately following, address fundamental developments over the past quarter century in smoking prevalence and in mortality caused by smoking. The first two conclusions highlight important gains in preventing smoking and smoking- related disease in the United States. The last three conclusions emphasize sources of continuing concern and remaining challenges.

1. The prevalence of smoking among adults decreased from 40 percent in 1965 to 29 percent in 1987. Nearly half of all living adults who ever smoked have quit.

2. Between 1964 and 1985, approximately three-quarters of a million smoking-related deaths were avoided or postponed as a result of decisions to quit smoking or not to start. Each of these avoided or postponed deaths represented an average gain in life expectancy of two decades.

3. The prevalence of smoking remains higher among blacks, blue-collar workers, and less educated persons than in the overall population. The decline in smoking has been substantially slower among women than among men.

4. Smoking begins primarily during childhood and adolescence. The age of initiation has fallen over time, particularly among females. Smoking among high school seniors leveled off from 1980 through 1987 after previous years of decline.

5. Smoking is responsible for more than one of every six deaths in the United States. Smoking remains the single most important preventable cause of death in our society. 

Key New Findings

While this Report is designed to provide a retrospective view of smoking and health over the past 25 years, several findings never previously documented in a report of the Surgeon General emerged during the process of reviewing and analyzing the voluminous materials consulted for the study. Discussed in detail throughout the Report, key new findings include the following:

• Cigarette smoking is a major cause of cerebrovascular disease (stroke), the third leading cause of death in the United States.
• By 1986, lung cancer caught up with breast cancer as the leading cause of cancer death in women. Women smokers’ relative risk of lung cancer has increased by a factor of more than four since the early 1960s and is now comparable to the relative risk identified for men in that earlier period. Gender differences in smoking behavior are disappearing; consistent with this, gender differences in the relative risks of and mortality from smoking-related diseases are narrowing.
• Cigarette smoking is associated with cancer of the uterine cervix.
• To date, 43 chemicals in tobacco smoke have been determined to be carcinogenic.
• In 1985, approximately 390,000 deaths were attributable to cigarette smoking. This figure is greater than other recent estimates of smoking-attributable mortality, reflecting the use of higher relative risks of smoking-related diseases for women and, especially in the case of lung cancer, for men. These higher relative risks were derived from the largest and most recent prospective study of smoking and disease, conducted by the American Cancer Society.
• Disparities in smoking prevalence, quitting, and initiation between groups with the highest and lowest levels of educational attainment are substantial and have been increasing. Educational attainment appears to be the best single sociodemographic predictor of smoking.
• There is growing recognition that prevention and cessation interventions need to target specific populations with a high smoking prevalence or at high risk of smoking-related disease. These populations include minority groups, pregnant women, military personnel, high school dropouts, blue-collar workers, un-employed persons, and heavy smokers.
• One-quarter of high school seniors who have ever smoked had their first cigarette by sixth grade, one-half by eighth grade. Associated with knowledge of this fact is a growing consensus that smoking prevention education needs to begin in elementary school.
• Whereas past smoking control efforts targeting children and adolescents focused exclusively on prevention of smoking, the smoking control community has identified the need to develop cessation programs for children and adolescents addicted to nicotine.
• As of mid-1988, more than 320 local communities had adopted laws or regulations restricting smoking in public places. This compares with a total of about 90 as of the end of 1985, a more than threefold increase in 3 years. The number of new State laws restricting smoking in public places in 1987 exceeded the number passed in any preceding year.
• A growing body of evidence on the role of economic incentives in influencing health behavior has contributed to increased interest in and use of such incentives to discourage use of tobacco products. These include excise taxation of tobacco products, workplace financial incentives, and insurance premium differentials for smokers and nonsmokers.
• In marked contrast to the trends in virtually all other areas of smoking control policy, the number of legal restrictions on children’s access to tobacco products has decreased over the past quarter century. Studies indicate that vendor compliance with minimum-age-of-purchase laws is the exception rather than the rule.
• The marketing of a variety of alternative nicotine delivery systems has heightened concern within the public health community about the future of nicotine addiction. The most prominent development in this regard was the 1988 test marketing by a major cigarette producer of a nicotine delivery device having the external appearance of a cigarette and being promoted as "the cleaner smoke."
• While over 50 million Americans continue to smoke, more than 90 million would be smoking in the absence of the changes in the smoking-and-health environment that have occurred since 1964.
• Quitting and noninitiation of smoking between 1964 and 1985, encouraged by changes in that environment, have been or will be associated with the postponement or avoidance of almost 3 million smoking-related deaths. That figure reflects the three-quarters of a million deaths noted in conclusion 2 above, and an additional 2.1 million deaths estimated to be postponed or avoided between 1986 and the year 2000.

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Overview

Coverage of the Report

As the major conclusions and new findings suggest, progress against smoking is necessarily measured in several dimensions. Ultimately, the most important measure is the burden of mortality, morbidity, and disability associated with smoking. Secondarily, changes in the prevalence of smoking and its distribution among sociodemographic groups foretell the future course of smoking-related disease. Behavioral changes in turn reflect a myriad of social and psychological influences that have evolved over the past 25 years. These include public knowledge of smoking hazards and attitudes toward the behavior; availability and effectiveness of smoking prevention and cessation programs; and adoption of smoking-related social policies, often reflections of public attitudes and opinions. At the heart of all these phenomena is the substantial and expanding body of scientific knowledge about the health consequences of smoking.

The 1989 Report examines changes in each of these dimensions over the past quarter century. The Report includes a Foreword by the Assistant Secretary for Health and the Director of the Centers for Disease Control, a Preface by the Surgeon General of the U.S. Public Health Service, and the following chapters: Chapter 1. Historical Perspective, Overview, and Conclusions 
Chapter 2. Advances in Knowledge of the Health Consequences of Smoking
Chapter 3. Changes in Smoking-Attributable Mortality
Chapter 4. Trends in Public Beliefs, Attitudes, and Opinions About Smoking
Chapter 5. Changes in Smoking Behavior and Knowledge About Determinants
Chapter 6. Smoking Prevention, Cessation, and Advocacy Activities
Chapter 7. Smoking Control Policies
Chapter 8. Changes in the Smoking-and-Health Environment: Behavioral and Health Consequences
A key to abbreviations used throughout the Report is found at the end of the volume.

Analysis of changes in scientific-medical understanding follows the core tradition of the Surgeon General’s Report series. Chapter 2 summarizes current knowledge of the health consequences of smoking and examines how it has advanced, both qualitatively and quantitatively, beyond that reflected in the original Surgeon General’s Report. The Chapter also summarizes knowledge of the physicochemical nature of tobacco smoke.

Chapter 3 examines the ultimate population impact of smoking-disease relationships in its review of changes in smoking-attributable mortality. The patterns of mortality have changed in predictable ways, reflecting variations in the rates and sociodemographic distribution of smoking prevalence (the subject of much of Chapter 5). In particular, smoking-attributable mortality in women has increased dramatically, the predictable consequence of the rapid growth in smoking by women in the middle decades of the century. Shifts in sociodemographic patterns of smoking, with greater prevalence now found among blue-collar workers and some minorities than among the white-collar population, presage a continuing disproportionate burden of illness for the Nation’s poor and minority populations.

One element of the decision of whether or not to smoke is personal understanding of the dangers involved. Chapter 4 reviews changes in public knowledge since 1964. The most basic findings from scientific research on the health consequences of smoking have been conveyed to and accepted by the American public, at least at a generalized level. Nevertheless, survey research reveals important gaps in public understanding of the hazards of smoking. Smokers report less understanding of the basic consequences of smoking than do nonsmokers; furthermore, smokers often do not internalize, or personalize, the hazards they acknowledge as applying to smokers in general. In addition, knowledge of smoking-and-health facts beyond the most basic information is not possessed by significant numbers of Americans. Thus, a substantial educational task remains.

Although significant gaps remain, it is also clear that the public has a much better appreciation of the hazards of smoking than it did 25 years ago. Associated with the growing acceptance of smoking as a health hazard for the smoker, and more recently as a hazard for nonsmokers, is a growing public desire to restrict smoking in public places to protect the rights of nonsmokers to breathe clean air. Opinions about smoking and the appropriate role of smoking control are also considered in Chapter 4.

The relationship between knowledge and opinion change, on the one hand, and subsequent behavior change, on the other, is quite complex. Nevertheless, substantial smoking behavior change has occurred since issuance of the first Surgeon General’s Report and has often followed shifts in beliefs and opinions about smoking. The many dimensions of such behavior change are explored in Chapter 5. Part I of the Chapter examines empirical evidence on behavior change across a number of smoking behaviors and across the major sociodemographic groups. Several previous reports of the Surgeon General have included consideration of these trends (US DHEW1979a;US DHHS 1980a, 1983, 1985, 1988). Part II of Chapter 5 reviews the evolution of understanding of smoking behaviors and their determinants. The 1979 Surgeon General’s Report devoted several chapters to the psychological and social determinants of smoking (US DHEW 1979a). Most recently, the phenomenon of nicotine addiction was reviewed thoroughly by the Surgeon General (US DHHS 1988).

Changes in public attitudes toward smoking and in the prevalence of smoking are reflected in the rapid expansion in the 1980s of State and local laws and workplace policies restricting smoking. The Nation’s growing nonsmoking ethos is also reflected in more attention to both voluntary and regulatory measures intended to prevent the initiation of tobacco use or to assist smokers to quit. The number of smoking-cessation techniques and programs has expanded. Smoking policy discussions today concern such diverse activities as excise taxation, restriction of advertising and promotion of tobacco products, limitation of children’s access to tobacco products, and regulation of the newly emerging nicotine-based products collectively referred to as "alternative nicotine delivery systems."

Chapters 6 and 7 examine developments over the past quarter century in voluntary programmatic efforts and public policies directed at smoking control, respectively. Chapter 6 describes separately programs directed at smoking prevention and cessation, and highlights the work of the major voluntary health associations. The Chapter reviews such diverse efforts as comprehensive school health education curricula and antismoking public service announcements on the broadcast media. Chapter 6 concludes with a brief overview of advocacy and lobbying activities related to smoking and health. Advocacy activities are purely voluntary in nature, yet most have been directed at promoting smoking control policies, particularly in recent years. As such, a discussion of advocacy serves as a logical transition between the focus of Chapter 6 on voluntary efforts to combat smoking and concentration in Chapter 7 on policy measures.

Coverage of developments in smoking control policies in Chapter 7 has few precedents in prior reports of the Surgeon General, despite the first Report’s call for "appropriate remedial action" a quarter of a century ago (US PHS 1964). The major exception was the substantial attention accorded workplace and Government smoking restriction policies in the 1986 Report (US DHHS 1986a). Otherwise, the report series’ principal references to policy have come in the form of legislative recommendations to the Congress. Yet, as noted above, policies intended to diminish smoking and its disease burden have become increasingly common in both the public and private sectors. Thus, as part of the history of smoking and health, and as a determinant of progress against smoking, smoking-related policy is examined in detail in this 25th anniversary Report. Coverage of policy in Chapter 7 includes documentation of trends in specific policies, analogous to the coverage afforded smoking restrictions in the 1986 Report. Policies are grouped into three categories: policies pertaining to information and education (Part I), economic incentives (Part II), and direct restrictions (Part III). Where possible, discussion includes examination of scientific understanding of specific policy effects. Such understanding derives from a growing and increasingly sophisticated body of empirical social science research.

Collectively, the program and policy efforts discussed in Chapters 6 and 7, combined with changing public knowledge and social norms, have encouraged tens of millions of Americans not to smoke. As examined in Chapter 8, this behavioral change can be credited with the avoidance of many hundreds of thousands of premature deaths and the associated saving of millions of life-years. Chapter 8 reviews these and other findings on the behavioral and health consequences of changes in the Nation’s smoking-and- health environment. 

Conclusions pertaining to the findings of each of the Report’s chapters are reviewed in the final Section of this introductory Chapter. 

By all accounts, the 1964 Report of the Surgeon General’s Advisory Committee is a landmark document in the history of public health and a seminal contribution to the Nation’s efforts to understand and combat tobacco-related morbidity and mortality. The present Report chronicles progress against smoking in the intervening 25 years, demonstrating an extraordinary array of advances in knowledge, changes in norms and behavior, and effects on the health of the American people. By any reasonable measure, the burden of smoking remains enormous; but the legacy of the 1964 Report is a society that has made impressive strides toward ridding itself of this most prevent-able source of disease, disability, and death.

1990 Health Objectives for the Nation

In 1979, PHS released the first Surgeon General’s Report on Health Promotion and Disease Prevention (US DHEW 1979b). The Report identified 15 priority areas, including smoking, in which significant health gains could be expected in the 1980s, with appropriate actions. Subsequently, working with health experts from both the private and public sectors, the PHS established 226 specific health objectives for the Nation (US DHHS 1980b). Seventeen of these pertain directly to cigarette smoking (Table 2). Many others relate to smoking as well, because they address the prevention of heart disease, cancer, burn injuries, and other smoking-related disease problems. In 1986, the PHS published a midcourse assessment of progress toward achieving the 226 objectives (US DHHS 1986c). One of the goals of the present Report is to offer additional insight in this assessment as it relates to the 17 smoking objectives. This is discussed in the relevant chapters. PHS is currently developing national health goals for the year 2000, again working with organizations and individuals in the private and public sectors. The reduction of tobacco use is one of 21 priority areas in which objectives are being formulated. PHS intends to publish the objectives in 1990.

Limitations of Coverage

Despite the broad scope of this Report, certain limitations have had to be placed on coverage. Two in particular are worthy of mention here:

(1) The Report focuses primarily, but not exclusively, on cigarette smoking, reflecting its dominance among forms of tobacco use, in terms of both prevalence and disease impact. This focus also reflects the desire to represent the principal interest of the 1964 Advisory Committee in this 25th anniversary Report. Pipe and cigar smoking are much less prevalent than cigarette smoking but also carry significant health risks (US DHEW 1979a). Growing use of smokeless tobacco products (snuff and chewing tobacco), primarily by adolescent males, has focused national attention on the prevalence and health consequences of using these tobacco products (Connolly et al. 1986). This subject was recently reviewed thoroughly by an advisory committee to the Surgeon General (US DHHS 1986b) and in a National Cancer Institute monograph (Boyd and Darbey, in press).

(2) The Report concentrates on smoking in the United States. Both within the United States and around the world, there is growing concern about the spread of smoking, particularly in the world’s poorer countries. While per capita cigarette consumption is stable or falling in most developed nations, it is rising in Third World counties. Rates of smoking-related chronic diseases are also increasing rapidly, to the point that tobacco is expected to soon become the leading cause of premature, preventable mortality in the Third World, as it is at present in the developed world (Aoki, Hisamichi, Tominaga 1988).

Concentration of this Report on smoking in the United States is no reflection on the relative importance of the international situation. Rather, it results from the principal objective of reviewing where this Nation has come in its efforts to control smoking-related disease since the 1964 report of the Surgeon General’s Advisory Committee. The Public Health Service hopes that this review, like its predecessors, will prove to be of value to scientists, health professionals, and public health officials in countries throughout the world.

This Report was developed by the Office on Smoking and Health (OSH), Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control, Public Health Service of the U.S. Department of Health and Human Services, as part of the Department’s responsibility, under Public Law 91-222, to report new and current in-formation on smoking and health to the U.S. Congress.

The scientific content of this Report was produced through the efforts of more than 130 scientists in the fields of medicine, the biological and social sciences, public health, and policy analysis. Manuscripts for the Report, constituting drafts of chapters or sections of chapters, were prepared by 33 scientists selected for their expertise in the specific content areas. An editorial team including the Director of OSH, a medical epidemiologist from OSH, and four non-Federal experts edited and consolidated the individual manuscripts into chapters. These draft chapters were subjected to an intensive outside peer review, with each chapter reviewed by 5 to 12 individuals knowledge-able about the chapter’s subject matter. Incorporating the reviewers’ comments, the editors revised the chapters and assembled a draft of the complete Report. The draft Report was then submitted to 25 distinguished scientists for their review and comment on the entirety of its contents. Simultaneously, the draft Report was submitted to 9 institutes and agencies within the U.S. Public Health Service for their review. Comments from the senior scientific reviewers and the agencies were then used to prepare the final draft of the Report, which was then reviewed by the Offices of the Assistant Secretary for Health and the Secretary, Department of Health and Human Services.

Chapter Conclusions

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