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1989 Surgeon General Report: Reducing the Health Consequences of Smoking
Introduction
The Honorable Jim Wright
Speaker of the House
of Representatives
Washington, D.C. 20515
Dear Mr. Speaker:
It is my pleasure to transmit to the Congress the 1989 Surgeon General’s
Report on the health consequences of smoking, as mandated by Section
8(a) of the Public Health Cigarette Smoking Act of 1969. The report
was prepared by the Centers for Disease Control’s Office on Smoking
and Health.
This report, entitled Reducing the Health Consequences of
Smoking 25 Years of Progress, examines the fundamental developments
over the past quarter century in smoking prevalence and in mortality
caused by smoking. It highlights important gains in preventing smoking
and smoking-related disease, reviews changes in programs and
policies designed to reduce smoking, and emphasizes sources of
continuing concern and remaining challenges.
During the past 25 years,
smoking behavior has changed dramatically. Nearly half of all living
adults who ever smoked have quit. The prevalence of smoking has
declined steadily, with a particularly impressive decline among men.
Smoking prevalence among men decreased from 50 percent in 1965 to 32
percent in 1987. As a result, lung cancer mortality rates among men
are now leveling off after many decades of consistent increase.
Despite this progress, the prevalence of smoking remains higher among
blacks, blue-collar workers, and less-educated persons, than in the
overall population. Smoking among high school seniors leveled off from
1981 through 1987 after previous years of decline.
In 1985, the last year for which estimates are available, approximately
390,000 Americans died as the result of past and current smoking.
This represents more than one of every six deaths in the United
States. Smoking remains the single most important preventable cause
of death in our society.
To maintain our momentum toward a smoke-free
society, we must focus our efforts on preventing smoking initiation
and encouraging smoking cessation among high-risk populations.
Increased public information activities,
smoking prevention and cessation programs, and policies that encourage
nonsmoking behavior should be pursued. Unless we meet this challenge
successfully, smoking-related mortality will remain high well into
the 21st Century.
Sincerely,
Otis R. Bowen, M.D.
Secretary
Enclosure
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The Honorable George Bush
President of the Senate
Washington, D.C. 20515
Dear Mr. President:
It is my pleasure to transmit to the Congress the 1989 Surgeon
General’s Report on the health consequences of smoking, as mandated by Section 8(a) of the Public Health Cigarette Smoking Act of 1969. The
report was prepared by the Centers for Disease Control’s Office on Smoking and Health.
This report, entitled Reducing the Health Consequences of Smoking:
25 Years of Progress, examines the fundamental developments over the past quarter century in smoking prevalence and in mortality caused by
smoking. It highlights important gains in preventing smoking and smoking-related
disease, reviews changes in programs and policies designed to reduce smoking, and emphasizes sources of continuing concern
and remaining challenges.
During the past 25 years, smoking behavior has changed
dramatically. Nearly half of all living adults who ever smoked have quit. The prevalence of smoking has declined steadily, with a
particularly impressive decline among men. Smoking prevalence among men decreased from 50 percent in 1965 to 32 percent in 1987. As a result,
lung cancer mortality rates among men are now leveling off after many decades of consistent increase. Despite this progress, the prevalence of
smoking remains higher among blacks, blue-collar workers, and less-educated persons, than in the overall population. Smoking among
high school seniors leveled off from 1981 through 1987 after previous years of decline.
In 1985, the last year for which estimates are available,
approximately 390,000 Americans died as the result of past and current smoking. This represents more than one of every six deaths in the United
States. Smoking remains the single most important preventable cause of death in our society.
To maintain our momentum toward a smoke-free society, we must focus
our efforts on preventing smoking initiation and encouraging smoking cessation among high-risk populations. Increased public information
activities, smoking prevention and cessation programs, and policies that encourage nonsmoking behavior should be pursued. Unless we meet this
challenge successfully, smoking-related mortality will remain high well into the 21st Century.
Sincerely,
Otis R. Bowen, M.D.
Secretary
Enclosure
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Twenty-five years have elapsed since publication of the landmark report
of the Surgeon General’s Advisory Committee on Smoking and Health. By any
measure, these 25 years have witnessed dramatic changes in attitudes toward
and use of tobacco in the United States. The health consequences of tobacco
use will be with us for many years to come, but those consequences have been
greatly reduced by the social revolution that has occurred during this
period with regard to smoking.
Since 1964, substantial changes have occurred
in scientific knowledge of the health hazards of smoking, in the impact of
smoking on mortality, in public knowledge of the dangers of smoking, in the
prevalence of smoking and using other forms of tobacco, in the availability
of programs to help smokers quit, and in the number of policies that
encourage nonsmoking behavior and protect nonsmokers from exposure to
environmental tobacco smoke. These changes and other significant
developments, as well as the overall impact of the Nation’s antismoking
activities, are reviewed in detail in the individual chapters of this
Report. Based on this review, five major conclusions of the entire Report
were reached. 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. The conclusions are:
- 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.
- 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.
- 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.
- 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.
- 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.
The last 25 years have witnessed phenomenal changes in the way Americans
think about tobacco use. More people now than ever before consider smoking
to be outsidethe social norm. Antismoking programs and policies have
contributed to this change. This shift in societal attitudes is almost
certain to generate additional efforts to further limit the use of tobacco.
Almost half of all living Americans who ever smoked have quit. This is
especially remarkable when one takes into account the powerful media images
enticing people to smoke and the powerfully addictive nature of nicotine. As
the downward trends in smoking behavior continue, we can expect to see a
decline in the number of premature deaths and avoidable morbidity due to
smoking.
For now, however, we must recognize that continued tobacco exposure in
the population will cause a great deal of human suffering for many decades.
Thus, we must not rest upon the laurels of the past quarter century. As long
as children and adolescents continue to find reasons to use tobacco,
replacements will be recruited for at least some of the smokers who quit or
who die prematurely. If current trends continue, these replacements will be
found disproportionately among minority groups, among the less educated,
among the most economically disadvantaged, and among women.
We must look back on the last 25 years of change in order to look forward
to our tasks for the future. Surely those tasks include expanding
educational efforts for the young and old alike, restrictions against minors’
access to tobacco, support for cessation activities, and restrictions
against smoking in worksites, restaurants, transportation vehicles, and
other public places.
The Public Health Service is dedicated to continuing the legacy of the
1964 Report. We hope this 25th Anniversary Report will stimulate new
commitment to action by public health officials, civic leaders, educators,
scientists, and the public at large on the problem of tobacco use,
especially among children, adolescents, and high-risk groups.
Robert E. Windom, M.D.
Assistant Secretary for Health
Public Health Service
James O. Mason, M.D., Dr.P.H.
Director
Centers for Disease Control
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Exactly 25 years ago, on January 11, 1964, Luther L. Terry, M.D., Surgeon
General
of the U.S. Public Health Service, released the report of the Surgeon
General’s Advisory
Committee on Smoking and Health. That landmark document, now referred to
as the first Surgeon General’s Report on Smoking and Health, was
America’s first widely
publicized official recognition that cigarette smoking is a cause of
cancer and other
serious diseases.
On the basis of more than 7,000 articles relating to smoking and disease
already available
at that time in the biomedical literature, the Advisory Committee
concluded that
cigarette smoking is a cause of lung cancer and laryngeal cancer in men,
a probable
cause of lung cancer in women, and the most important cause of chronic
bronchitis.
The Committee stated that "Cigarette smoking is a health hazard of
sufficient importance
in the United States to warrant appropriate remedial action."
What would constitute "appropriate remedial action" was left
unspecified. But the
release of the report was the first in a series of steps, still being
taken 25 years later, to
diminish the impact of tobacco use on the health of the American people.
This 1989 Report, the 20th in a series of Surgeon General’s Reports on
the Health
Consequences of Smoking, spells out the dramatic progress that has been
achieved in
the past quarter century against one of our deadliest risks.
The circumstances surrounding the release of the first report in 1964 are
worth
remembering. The date chosen was a Saturday morning, to guard against a
precipitous
reaction on Wall Street. An auditorium in the State Department was
selected because
its security could be assuredit had been the site for press conferences
of the late President
John F. Kennedy, whose assassination had occurred less than 2 months
earlier.
The first two copies of the 387-page, brown-covered Report were hand
delivered to
the West Wing of the White House at 7:30 on that Saturday morning. At
9:00, accredited
press representatives were admitted to the auditorium and "locked
in," without
access to telephones. Surgeon General Terry and his Advisory Committee
took their
seats on the platform. The Report was distributed and reporters were
allowed 90
minutes to read it. Questions were answered by Dr. Terry and his
Committee members.
Finally, the doors were opened and the news was spread. For several days,
the
Report furnished newspaper headlines across the country and lead stories
on television
newscasts. Later it was ranked among the top news stories of 1964.
During the quarter century that has elapsed since that Report, individual
citizens,
private organizations, public agencies, and elected officials have
tirelessly pursued the
Advisory Committee’s call for "appropriate remedial action."
Early on, the U.S. Congress
adopted the Federal Cigarette Labeling and Advertising Act of 1965 and
the Public Health Cigarette Smoking Act of 1969. These laws required a
health warning on cigarette packages, banned cigarette advertising in the
broadcast media, and called for an annual report on the health consequences
of smoking.
In 1964, the Public Health Service established a small unit
called the National Clearinghouse for Smoking and Health (NCSH). Through the
years, the Clearinghouse and its successor organization, the Office on
Smoking and Health, have been responsible for the 20 reports on the health
consequences of smoking previously mentioned, eight of which have been
issued during my tenure as Surgeon General. In close cooperation with
voluntary health organizations, the Public Health Service has supported highly successful school and community programs on smoking and health, has
disseminated research findings related to tobacco use, and has ensured the
continued public visibility of antismoking messages.
Throughout this period,
tremendous changes have occurred. As detailed in this Report, we have
witnessed expansion in scientific knowledge of the health hazards of
smoking, growing public knowledge of the dangers of smoking, increased
availability of programs to prevent young people from starting to smoke and
to help smokers quit, and widespread adoption of policies that discourage
the use of tobacco.
Most important, these developments have changed the way
in which our society views smoking. In the 1940s and 1950s, smoking was
chic; now, increasingly, it is shunned. Movie stars, sports heroes, and
other celebrities used to appear in cigarette advertisements. Today, actors,
athletes, public figures, and political candidates are rarely seen smoking.
The ashtray is following the spittoon into oblivion.
Within this evolving
social milieu, the population has been giving up smoking in increasing
numbers. Nearly half of all living adults who ever smoked have quit. The
most impressive decline in smoking has occurred among men. Smoking
prevalence among men has fallen from 50 percent in 1965 to 32 percent in
1987. These changes represent nothing less than a revolution in behavior.
The antismoking campaign has been a major public health success. Those who
have participated in this campaign can take tremendous pride in the progress
that has been made.
The analysis in this Report shows that in the absence of
the campaign, there would have been 91 million American smokers (15 to 84
years of age) in 1985 instead of 56 million. As a result of decisions to
quit smoking or not to start, an estimated 789,000 smoking-related deaths
were avoided or postponed between 1964 and 1985. Furthermore, these
decisions will result in the avoidance or postponement of an estimated 2.1
million smoking-related deaths between 1986 and the year 2000.
This
achievement has few parallels in the history of public health. It was
accomplished despite the addictive nature of tobacco and the powerful
economic forces promoting its use.
The Remaining Challenges
Despite this achievement, smoking will continue as the leading cause of
preventable, premature death for many years to come, even if all smokers
were to quit today. Smoking cessation is clearly beneficial in reducing the
risk of dying from smoking-related diseases. However, for some diseases,
such as lung cancer and emphysema, quitting may not reduce the risk to the
level of a lifetime nonsmoker even after many years of abstinence. This
residual health risk is one reason why approximately 390,000 Americans died
in 1985 as the result of smoking, even after two decades of declining
smoking rates.
The critical message here is that progress in curtailing
smoking must continue, and ideally accelerate, to enable us to turn
smoking-related mortality around. Otherwise, the disease impact of smoking
will remain high well into the 21st century.
Just maintaining the current
rate of progress is a challenge. Compared with non-smokers, smokers are
disproportionately found in groups that are harder to reach, and this
disparity may increase over time. Greater effort and resources will need to
be devoted to achieve equivalent reductions in smoking among those whose
behavior has survived strong, countervailing social pressures.
Today, thanks
to the remarkable progress of the past 25 years, we can dare to envision a
smoke-free society. Indeed it can be said that the social tide is flowing
toward that bold objective. To maintain momentum, we need to direct special
attention to the following groups within our society:
Children and Adolescents
As a pediatric surgeon, and now as Surgeon General, I have dedicated my
career to protecting the health of children. In the case of smoking, children
and adolescents hold the key to progress toward curbing tobacco use in future
generations.
If the adult rate of smoking were to continue at the present
level, the impact of smoking on the future health and welfare of today’s
children would be enormous. Research has shown that one-fourth or more of all
regular cigarette smokers die of smoking-related diseases. If 20 million of
the 70 million children now living in the United States smoke cigarettes as
adults (about 29 percent), then at least 5 million of them will die of
smoking-related diseases. This figure should alarm anyone who is concerned
with the future health of today’s children.
Two additional factors make
smoking among young people a preeminent public health concern: (1) the age of
initiation of smoking, and (2) nicotine addiction. As this Report shows,
four-fifths of smokers born since 1935 started smoking before age 21. The
proportion of smokers who begin smoking during adolescence has been increasing
over time, particularly among women.
In the Teenage Smoking Survey conducted by the Department of Health,
Education, and Welfare in 1979, respondents were asked, "What would you
say is the possibility that five years from now you will be a cigarette
smoker?" Among smokers, half answered "definitely not" or
"probably not." This response suggests that many children and
adolescents are unaware of, or underestimate, the addictive nature of smoking.
The predecessor to this volume, The Health Consequences of Smoking:
Nicotine Addiction, provided a comprehensive review of the evidence that
cigarettes and other forms of tobacco are addicting and that nicotine is the
drug in tobacco that causes addiction. These two factors refute the argument
that smoking is a matter of free choice. Most smokers start smoking as
teenagers and then become addicted. By the time smokers
become adults, when they would be expected to have greater appreciation of
the health
effects of smoking, many have difficulty quitting. Today, 80 percent of
smokers say
they would like to quit; two-thirds of smokers have made at least one
serious attempt
to quit. Characteristically, people quit smoking several times before
becoming permanent
ex-smokers.
The prevalence of daily smoking among high school seniors leveled off from
1981
through 1987, at about 20 percent, after previous years of decline. Each
day, more than
3,000 American teenagers start smoking. If we can substantially reduce this
number,
we will soon achieve a major impact on smoking prevalence among adults.
Although
research efforts in prevention are increasing, prevention programs are not
yet reaching
large numbers of young people. The public health community should pay at
least as
much attention to the prevention of smoking among teenagers as it now pays
to smoking
cessation among adults. Comprehensive school health education,
incorporating
tobacco use prevention, should be provided in every school throughout the
country. Women
Since release of the first Surgeon General’s Report, the prevalence of
smoking among
women has declined much more slowly than among men. If current trends
continue,
smoking rates will be about equal among men and women in the mid-1990s,
after which
women may smoke at a higher rate than men. The public health impact of this trend is already being seen. Lung cancer
mortality
rates are increasing steadily among women, and estimates by the American
Cancer
Society indicate that this disease has now overtaken breast cancer as the
number one
cause of cancer death among women. Smoking during pregnancy poses special
risks
to the developing fetus and is an important cause of low birthweight and
infant mortality.
Smoking and oral contraceptive use interact to increase dramatically the
risk of
cardiovascular disease. Women’s organizations and women’s magazines
have paid
scant attention to these issues.
The key to addressing this problem is the prevention of smoking among
female
adolescents. The disparity in smoking prevalence between men and women is
primarily
a reflection of differences in smoking initiation. Smoking initiation has
declined
much more slowly among females than among males. This difference is due, in
large
part, to increasing initiation rates among less educated young women. Among
high
school seniors, the prevalence of daily smoking has been higher among
females than
among males each year since 1977. In summary, women, and especially female adolescents not planning higher
education,
are an important target group for prevention activities. Minorities
Smoking rates are higher in certain racial and ethnic minority groups, many
of which
already suffer from a disproportionate share of risk factors and illness.
In particular,
smoking prevalence has been consistently higher among black men than among
white
men (41 and 31 percent, respectively, in 1987). In addition, the limited
data available
show higher rates of smoking among Hispanic men than among white men. Trends in smoking initiation, prevalence, and quitting among blacks and
whites show
similar rates of change from 1974 to 1985. Thus, the gap in smoking
prevalence between
blacks and whites is not widening. However, to reduce the gap in smoking
between
blacks and whites, prevention efforts must focus on blacks more
successfully.
The public health community is only now beginning to address this
problem. The urgency
of the situation is greater because cigarette companies are increasingly
targeting
their marketing efforts at blacks and Hispanics. Blue-Collar Workers
The prevalence of smoking has been consistently higher among blue-collar
workers
than among white-collar workers. In 1985, 40 percent of blue-collar
workers smoked
compared with 28 percent of white-collar workers. Again, blue-collar
workers are a
major target of cigarette company advertising and promotional campaigns.
Worksite
smoking cessation programs, employee incentive programs, and policies
banning or
restricting smoking at the workplace are effective strategies to reach
this group. Toward a Smoke-Free Future
Because the general health risks of smoking are well known, because
smoking is
banned or restricted in a growing number of public places and worksites,
and because
smoking is losing its social acceptability, the overall prevalence of
smoking in our
society is likely to continue to decline. The progress we have achieved
during the past
quarter century is impressive. Equally impressive, however, are the challenges we face. During the next
quarter
century and beyond, progress will be slow, and smoking-related mortality
will remain
high, unless the health community more effectively reaches children and
adolescents,
women, minorities, and blue-collar workers. Organizations that represent
these groups
can contribute substantially to the antismoking movement. In large part,
the future
health of these populations will depend on the degree to which schools,
educators,
parents’ organizations, women’s groups, minority organizations,
employers, and
employee unions join the campaign for a smoke-free society. Here in the
United States,
such a society is an attainable long-term goal. Unfortunately, the looming epidemic of smoking and smoking-related
disease in
developing countries does not encourage similar optimism. According to
the World
Health Organization, increases in cigarette consumption between 1971 and
1981 exceeded
population growth in all developing regions: by 77 percent in Africa, and
by
30 percent in Asia and Latin America. The topic of tobacco and health internationally, although critically
important, especially
for developing nations, is beyond the scope of this Report. I can only
hope that the lessons we have learned in the United States, as detailed in
this Report, will help other countries take the necessary steps to avoid the
devastation caused by use of tobacco.
C. Everett Koop, M.D., Sc.D.
Surgeon General
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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 Editors were Susan A. Hawk, Ed.M., M.S.,
and Thomas E. Novotny, M.D., Office on Smoking and Health.
The scientific editors of the Report were:
Kenneth E. Warner, Ph.D. (Senior Scientific Editor), Professor,
Department of Public Health Policy and Administration, School of Public
Health, University of Michigan, Ann Arbor, Michigan
Ronald M. Davis, M.D., Director, Office on Smoking and Health, Center for
Chronic Disease Prevention and Health Promotion, Centers for Disease
Control, Rockville, Maryland
John H. Holbrook, M.D., Professor of Internal Medicine, Department of
Internal Medicine, University Hospital, Salt Lake City, Utah
Thomas E. Novotny, M.D., Medical Epidemiologist, Office on Smoking and
Health, Center for Chronic Disease Prevention and Health Promotion, Centers
for Disease Control, Rockville, Maryland
Judith K. Ockene, Ph.D., Associate Professor of Medicine, and Director,
Division of Preventive and Behavioral Medicine, Department of Medicine,
University of Massachusetts Medical School, Worcester, Massachusetts
Nancy A. Rigotti, M.D., Associate Director, Institute for the Study of
Smoking Behavior and Policy, John F. Kennedy School of Government, Harvard
University, Cambridge, Massachusetts, Instructor in Medicine, Harvard
Medical School, Boston, Massachusetts
The following individuals prepared draft chapters or portions of the
Report.
Elvin E. Adams, M.D., M.P.H., Associate Director, Health Department,
General Conference of Seventh-Day Adventists, Washington, D.C.
Gregory N. Connolly, D.M.D., M.P.H., Director, Office for Nonsmoking and
Health, Massachusetts Department of Public Health, Boston, Massachusetts
K. Michael Cummings, Ph.D., M.P.H., Director, Smoking Control Program,
Roswell Park Memorial Institute, Buffalo, New York
Ronald M. Davis, M.D., Director, Office on Smoking and Health, Center for
Chronic Disease Prevention and Health Promotion, Centers for Disease
Control, Rockville, Maryland
Joseph R. DiFranza, M.D., Director of Research, Fitchburg Family Practice
Residency Program, University of Massachusetts Medical Center, Fitchburg,
Massachusetts
Michael P. Eriksen, Sc.D., Director, Behavioral Research Program,
Department of Cancer Prevention and Control, The University of Texas M.D.
Anderson Cancer Center, Houston, Texas
David P. Fan, Ph.D., Professor of Genetics and Cell Biology, University
of Minnesota, St. Paul, Minnesota
Michael C. Fiore, M.D., M.P.H., Assistant Professor, Department of
Medicine, Center for Health Sciences, University of Wisconsin, Madison,
Wisconsin
Edwin B. Fisher, Jr., Ph.D., Associate Professor of Psychology, Director,
Center for Health Behavior Research, Washington University, St. Louis,
Missouri
Jeffrey E. Harris, M.D., Ph.D., Visiting Associate Professor, Department
of Biostatistics, Harvard School of Public Health, Boston, Massachusetts;
Clinical Associate, Medical Services, Massachusetts General Hospital,
Boston, Massachusetts; Associate Professor of Economics, Massachusetts
Institute of Technology, Cambridge, Massachusetts
Jan L. Hitchcock, Ph.D., Associate Director, Institute for the Study of
Smoking Behavior and Policy, John F. Kennedy School of Government, Harvard
University, Cambridge, Massachusetts
Thomas A. Hodgson, Ph.D., Chief Economist, Office of Analysis and
Epidemiology, National Center for Health Statistics, Hyattsville, Maryland
Dietrich Hoffmann, Ph.D., Associate Director, Naylor Dana Institute for
Disease Prevention, American Health Foundation, Valhalla, New York
Ilse Hoffmann, Research Coordinator, Naylor Dana Institute for Disease
Prevention, American Health Foundation, Valhalla, New York
Juliette S. Kendrick, M.D., Deputy Chief, Pregnancy Epidemiology Branch,
Division of Reproductive Health, Center for Chronic Disease Prevention and
Health Promotion, Centers for Disease Control, Atlanta, Georgia
Lewis H. Kuller, M.D., Dr.P.H., Professor and Chairperson, Department of
Epidemiology, Graduate School of Public Health, University of Pittsburgh,
Pittsburgh, Pennsylvania
Eugene M. Lewit, Ph.D., Associate Professor, Departments of Medicine and
Preventive Medicine and Community Health, Office of Primary Health Care
Education, UMDNJ-New Jersey Medical School, Newark, New Jersey
Edward Lichtenstein, Ph.D., Research Scientist, Oregon Research
Institute; Professor of Psychology, University of Oregon, Eugene, Oregon
Thomas E. Novotny, M.D., Medical Epidemiologist, Office on Smoking and
Health, Center for Chronic Disease Prevention and Health Promotion, Centers
for Disease Control, Rockville, Maryland
Judith K. Ockene, Ph.D., Associate Professor of Medicine, and Director,
Division of Preventive and Behavioral Medicine, Department of Medicine,
University of Massachusetts Medical School, Worcester, Massachusetts
Chris Leo Pashos, M.P.P., Project Coordinator, Institute for the Study of
Smoking Behavior and Policy, John F. Kennedy School of Government, Harvard
University, Cambridge, Massachusetts
Richard Peto, M.A., M.Sc., ICRF Cancer Studies Unit, Radcliffe Infirmary,
Oxford, England
John P. Pierce, M.Sc., Ph.D., Chief, Epidemiology Branch, Office on
Smoking and Health, Center for Chronic Disease Prevention and Health
Promotion, Centers for Disease Control, Rockville, Maryland
John M. Pinney, Executive Director, Institute for the Study of Smoking
Behavior and Policy, John F. Kennedy School of Government, Harvard
University, Cambridge, Massachusetts
Edward T. Popper, M.B.A., D.B.A., Associate Professor of Marketing,
Bryant College, Smithfield, Rhode Island
Patrick L. Remington, M.D., M.P.H., Medical Epidemiologist, Bureau of
Community Health and Prevention, Wisconsin Division of Health, Madison,
Wisconsin
Nancy A. Rigotti, M.D., Associate Director, Institute for the Study of
Smoking Behavior and Policy, John F. Kennedy School of Government, Harvard
University, Cambridge, Massachusetts, and Instructor in Medicine, Harvard
Medical School, Boston, Massachusetts
Jonathan M. Samet, M.D., Professor of Medicine, Department of Medicine,
Chief, Pulmonary Division, University of New Mexico, Albuquerque, New Mexico
Russell C. Sciandra, M.A., Associate Director, Smoking Control Program,
Roswell Park Memorial Institute, Buffalo, New York
Carol Anne Soltanek, M.D., Resident, Southwestern Michigan Area Health
Education Center, Kalamazoo, Michigan
Michael A. Stoto, Ph.D., Senior Staff Officer, Institute of Medicine,
National Academy of Sciences, Washington, D.C.
Owen T. Thomberry, Ph.D., Director, Division of Health Interview
Statistics, National Center for Health Statistics, Centers for Disease
Control, Hyattsville, Maryland
Kenneth E. Warner, Ph.D., Professor, Department of Public Health Policy
and Administration, School of Public Health, University of Michigan, Ann
Arbor, Michigan
The editors acknowledge with gratitude the following distinguished
scientists, physicians, and others who lent their support in the
development of this Report by coordinating manuscript preparation,
contributing critical reviews, or assisting in other ways.
Elvin E. Adams, M.D., M.P.H., Associate Director, Health Department,
General Conference of Seventh-Day Adventists, Washington, D.C.
Charles Althafer, M.P.H., Assistant Director for Health Promotion and
Risk Appraisal, Office of Program Planning and Evaluation, National
Institute for Occupational Safety and Health, Centers for Disease Control,
Atlanta, Georgia
Lynn M. Artz, M.D., M.P.H., Senior Policy Advisor, Office of Disease
Prevention and Health Promotion, Office of the Assistant Secretary for
Health, Washington, D.C.
Donald A. Berreth, Director, Office of Public Affairs, Centers for
Disease Control, Atlanta, Georgia
Gayle M. Boyd, Ph.D., Program Director, Smoking, Tobacco and Cancer
Program, Division of Cancer Prevention and Control, National Cancer
Institute, Bethesda, Maryland
Allan Brandt, Ph.D., Department of Social Medicine and Health Policy,
Harvard Medical School, Boston, Massachusetts
Lester Breslow, M.D., M.P.H., Professor, School of Public Health, and
Director, Health Services Research, Jonsson Comprehensive Cancer Center,
University of California, Los Angeles, Los Angeles, California
Clarice Brown, M.S., Data Analyst, Office of Prevention, Education, and
Control, National Heart, Lung, and Blood Institute, Bethesda, Maryland
David P. Brown, M.D., Deputy Director, Division of Surveillance, Hazard
Evaluations, and Field Studies, National Institute for Occupational Safety
and Health, Centers for Disease Control, Atlanta, Georgia
Martin Brown, Ph.D., Surveillance and Operations Research Branch,
Division of Cancer Prevention and Control, National Cancer Institute,
Bethesda, Maryland
David M. Burns, M.D., Associate Professor of Medicine, Division of
Pulmonary and Critical Care Medicine, University of California, San Diego
Medical Center, San Diego, California
Dee Burton, Ph.D., Assistant Professor, Prevention Research Center,
School of Public Health, University of Illinois at Chicago, Chicago,
Illinois
Frank J. Chaloupka, Ph.D., Assistant Professor, Department of Economics,
College of Business Administration, University of Illinois at Chicago,
Chicago, Illinois
Paul D. Cleary, Ph.D., Department of Health Care Policy and The Division
on Aging, Harvard Medical School, Boston, Massachusetts
Alexander Cohen, Ph.D., Deputy Director, Division of Biomedical and
Behavioral Science, National Institute for Occupational Safety and Health,
Centers for Disease Control, Atlanta, Georgia
Joel B. Cohen, Ph.D., Distinguished Service Professor and Director,
Center for Consumer Research, University of Florida, Gainesville, Florida
Michael J. Cowell, F.S.A., Vice President and Corporate Actuary, UNUM
Life Insurance Company, Portland, Maine
Joseph W. Cullen, Ph.D., Deputy Director, Division of Cancer Prevention
and Control, National Cancer Institute, Coordinator for the National Cancer
Institute’s Smoking, Tobacco and Cancer Program, Bethesda, Maryland
Sir Richard Doll, Emeritus Professor of Medicine, University of Oxford,
Acting Director, Imperial Cancer Research Fund, Cancer Epidemiology and
Clinical Trials Unit, Oxford, England
J. David Erickson, D.D.S., Ph.D., Chief, Birth Defects and Genetic
Diseases Branch, Division of Birth Defects and Developmental Disabilities,
Center for Environmental Health and Injury Control, Centers for Disease
Control, Atlanta, Georgia
Michael P. Eriksen, Sc.D., Director, Behavioral Research Program,
Department of Cancer Prevention and Control, University of Texas M.D.
Anderson Cancer Center, Houston. Texas
Donald A. Berreth, Director, Office of Public Affairs, Centers for
Disease Control, Atlanta, Georgia
Gayle M. Boyd, Ph.D., Program Director, Smoking, Tobacco and Cancer
Program, Division of Cancer Prevention and Control, National Cancer
Institute, Bethesda, Maryland
Allan Brandt, Ph.D., Department of Social Medicine and Health Policy,
Harvard Medical School, Boston, Massachusetts
Lester Breslow, M.D., M.P.H., Professor, School of Public Health, and
Director, Health Services Research, Jonsson Comprehensive Cancer Center,
University of California, Los Angeles, Los Angeles, California
Clarice Brown, M.S., Data Analyst, Office of Prevention, Education, and
Control, National Heart, Lung, and Blood Institute, Bethesda, Maryland
David P. Brown, M.D., Deputy Director, Division of Surveillance, Hazard
Evaluations, and Field Studies, National Institute for Occupational Safety
and Health, Centers for Disease Control, Atlanta, Georgia
Martin Brown, Ph.D., Surveillance and Operations Research Branch,
Division of Cancer Prevention and Control, National Cancer Institute,
Bethesda, Maryland
David M. Burns, M.D., Associate Professor of Medicine, Division of
Pulmonary and Critical Care Medicine, University of California, San Diego
Medical Center, San Diego, California
Dee Burton, Ph.D., Assistant Professor, Prevention Research Center,
School of Public Health, University of Illinois at Chicago, Chicago,
Illinois
Frank J. Chaloupka, Ph.D., Assistant Professor, Department of Economics,
College of Business Administration, University of Illinois at Chicago,
Chicago, Illinois
Paul D. Cleary, Ph.D., Department of Health Care Policy and The Division
on Aging,Harvard Medical School, Boston, Massachusetts
Alexander Cohen, Ph.D., Deputy Director, Division of Biomedical and
Behavioral Science, National Institute for Occupational Safety and Health,
Centers for Disease Control, Atlanta, Georgia
Joel B. Cohen, Ph.D., Distinguished Service Professor and Director,
Center for Consumer Research, University of Florida, Gainesville, Florida
Michael J. Cowell, F.S.A., Vice President and Corporate Actuary, UNUM
Life Insurance Company, Portland, Maine
Joseph W. Cullen, Ph.D., Deputy Director, Division of Cancer Prevention
and Control, National Cancer Institute, Coordinator for the National Cancer
Institute’s Smoking, Tobacco and Cancer Program, Bethesda, Maryland
Sir Richard Doll, Emeritus Professor of Medicine, University of Oxford,
Acting Director, Imperial Cancer Research Fund, Cancer Epidemiology and
Clinical Trials Unit, Oxford, England
J. David Erickson, D.D.S., Ph.D., Chief, Birth Defects and Genetic
Diseases Branch, Division of Birth Defects and Developmental Disabilities,
Center for Environmental Health and Injury Control, Centers for Disease
Control, Atlanta, Georgia
Michael P. Eriksen, Sc.D., Director, Behavioral Research Program,
Department of Cancer Prevention and Control, University of Texas M.D.
Anderson Cancer Center, Houston. Texas
Virginia L. Ernster, Ph.D., Professor of Epidemiology, Department of
Epidemiology and International Health, School of Medicine, University of
California, San Francisco, California
Roberta G. Ferrence, Ph.D., Prevention Studies Department, Addiction
Research Foundation, Toronto, Ontario, Canada
Jonathan E. Fielding, M.D., M.P.H., Professor of Public Health and
Pediatrics, University of California at Los Angeles, Los Angeles,
California, Vice President and Health Director, Johnson and Johnson Health
Management, Inc., Santa Monica, California
John R. Finnegan, Jr., Ph.D., Assistant Professor, School of Public
Health, University of Minnesota, Minneapolis, Minnesota
Martin Fishbein, Ph.D., Professor of Psychology and Research Professor,
Institute of Communications Research, University of Illinois,
Champaign-Urbana, Illinois
Brian R. Flay, D.Phil., Associate Professor and Director, Prevention
Research Center, School of Public Health, University of Illinois at Chicago,
Chicago, Illinois
William H. Foege, M.D., M.P.H., Executive Director, The Carter Center,
Emory University, Atlanta, Georgia
Peter L. Frommer, M.D., Deputy Director, National Heart, Lung, and Blood
Institute, National Institutes of Health, Bethesda, Maryland
Lawrence Garfinkel, M.A., Vice President for Epidemiology and Statistics,
Director, Cancer Prevention, American Cancer Society, New York, New York
Donald W. Garner, J.D., Professor of Law, Southern Illinois University
School of Law, Carbondale, Illinois
Russell E. Glasgow, Ph.D., Research Scientist, Oregon Research Institute,
Eugene, Oregon
Thomas J. Glynn, Ph.D., Program Director for Smoking Research, Smoking,
Tobacco, and Cancer Program, National Cancer Institute, Bethesda, Maryland
Frederick K. Goodwin, M.D., Administrator, Alcohol, Drug Abuse, and
Mental Health Administration, Rockville, Maryland
Nancy P. Gordon, Sc.D., Behavioral Scientist, Division of Research,
Northern California Kaiser Permanente Medical Care Program
Leonard Green, Ph.D., Professor of Psychology, Department of Psychology,
Washington University, St. Louis, Missouri
Ellen R. Gritz, Ph.D., Director, Division of Cancer Control, Jonsson
Comprehensive Cancer Center, University of California, Los Angeles, Los
Angeles, California
Neil E. Grunberg, Ph.D., Associate Professor, Department of Medical
Psychology, Uniformed Services University of the Health Sciences, Bethesda,
Maryland
Dudley H. Hafner, Executive Vice President, American Heart Association,
Dallas, Texas
James A. Harrell, M.A., Acting Director, Office of Disease Prevention and
Health Promotion, Office of the Assistant Secretary for Health, Washington,
D.C.
Jeffrey E. Harris, M.D., Ph.D., Visiting Associate Professor, Department
of Biostatistics, Harvard School of Public Health, Boston, Massachusetts;
Clinical Associate, Medical Services, Massachusetts General Hospital,
Boston, Massachusetts; Associate Professor of Economics, Massachusetts
Institute of Technology, Cambridge, Massachusetts
Jack E. Henningfield, Ph.D., Chief, Biology of Dependence and Abuse
Potential Assessment Laboratory, Addiction Research Center, National
Institute on Drug Abuse, Baltimore, Maryland
Carol J. Hogue, Ph.D., Director, Division of Reproductive Health, Center
for Chronic Disease Prevention and Health Promotion, Centers for Disease
Control, Atlanta, Georgia
Elvin Hilyer, Associate Director for Policy Coordination, Centers for
Disease Control, Atlanta, Georgia
Richard Jessor, Ph.D., Professor of Psychology, Director of the Institute
of Behavioral Science, University of Colorado at Boulder, Boulder, Colorado
Lloyd D. Johnston, Ph.D., Program Director, Institute for Social
Research, University of Michigan, Ann Arbor, Michigan
John T. Kalberer, Jr., Ph.D., Deputy Director, Division of Disease
Prevention, Office of Disease Prevention, Office of the Director, National
Institutes of Health, Bethesda, Maryland
Martha F. Katz, M.P.A., Director, Office of Program Planning and
Evaluation, Centers
for Disease Control, Atlanta, Georgia
John H. Kelso, Acting Administrator, Health Resources and Services
Administration,
Rockville, Maryland
Larry Kessler, Sc.D., Surveillance and Operations Research Branch,
National Cancer
Institute, Bethesda, Maryland
A. Joan Klebba, M.A., Statistician, Division of Vital Statistics,
National Center for
Health Statistics, Centers for Disease Control, Hyattsville, Maryland
Lloyd J. Kolbe, Ph.D., Acting Director, Division of Adolescent and School
Health, Center
for Chronic Disease Prevention and Health Promotion, Centers for Disease
Control,
Atlanta, Georgia
Jeffrey P. Koplan, M.D., M.P.H., Director, Center for Chronic Disease
Prevention and
Health Promotion, Centers for Disease Control, Atlanta, Georgia
Lynn T. Kozlowski, Ph.D., Head, Behavioral Research on Tobacco Use,
Addiction Research
Foundation, Toronto, Ontario, Canada
Marshall W. Kreuter, Ph.D., Director, Division of Chronic Disease Control
and Community
Intervention, Center for Chronic Disease Prevention and Health Promotion,
Centers for Disease Control, Atlanta, Georgia
Harry A. Lando, Ph.D., Associate Professor, Division of Epidemiology,
School of
Public Health, University of Minnesota, Minneapolis, Minnesota
Charles A. LeMaistre, M.D., President, University of Texas M.D. Anderson
Cancer
Center, Houston, Texas
Claude Lenfant, M.D., Director, National Heart, Lung, and Blood
Institute, National
Institutes of Health, Bethesda, Maryland
Eugene M. Lewit, Ph.D., Associate Professor, Departments of Medicine and
Preventive
Medicine and Community Health, Office of Primary Health Care Education,
UMDNJ-New Jersey Medical School, Newark, New Jersey
Bryan R. Luce, M.B.A., Ph.D., Battelle Human Affairs Research Center,
Washington, D.C.
Dolores M. Malvitz, Dr.P.H., Dental Disease Prevention Activity, Center
for Prevention Services, Centers for Disease Control, Atlanta, Georgia
Alfred C. Marcus, Ph.D., Associate Director, Division of Cancer Control,
Jonsson Comprehensive
Cancer Center, University of California at Los Angeles, Los Angeles,
California
James S. Marks, M.D., M.P.H., Deputy Director for Public Health Practice,
Center for
Chronic Disease Prevention and Health Promotion, Centers for Disease
Control, Atlanta,
Georgia
James O. Mason, M.D., Dr.P.H., Director, Centers for Disease Control,
Atlanta, Georgia
Robin J. Mermelstein, Ph.D., Assistant Professor, Prevention Research
Center, School
of Public Health, University of Illinois at Chicago, Chicago, Illinois
Dannie C. Middleton, M.D., Medical Officer, Document Development Branch,
Division of Standards Development and Technology Transfer, National
Institute for
Occupational Safety and Health, Centers for Disease Control, Atlanta,
Georgia
Gregory J. Morosco, Ph.D., M.P.H., Coordinator, National Heart, Lung, and
Blood
Institute’s Smoking Education Program, National Institutes of Health,
Bethesda,
Maryland
Joseph P. Mulholland, Ph.D., Bureau of Economics, Federal Trade
Commission,
Washington, D.C.
Hillary Mutt, M.P.H., Research Associate, Department of Health Services
Management
and Policy, School of Public Health, University of Michigan, Ann Arbor,
Michigan
Herbert W. Nickens, M.D., M.A., Director, Office of Minority Health,
Public Health
Service, Washington, D.C.
Richard W. Niemeier, Ph.D., Acting Director, Division of Standards
Development and
Technology Transfer, National Institute for Occupational Safety and
Health, Centers
for Disease Control, Atlanta, Georgia
Stuart L. Nightingale, M.D., Associate Commissioner for Health Affairs,
Food and
Drug Administration, Rockville, Maryland
Ira S. Ockene, M.D., Professor of Medicine; Director, Preventive
Cardiology, Division
of Cardiovascular Medicine, University of Massachusetts Medical School,
Worcester,
Massachusetts
Horace G. Ogden, Consultant, Gaithersburg, Maryland
Patrick M. O’Malley, Ph.D., Associate Research Scientist, Institute for
Social Research,
University of Michigan, Ann Arbor, Michigan
Mario A. Orlandi, Ph.D., M.P.H., Chief, Division of Health Promotion
Research,
American Health Foundation, New York, New York
Carole Tracy Orleans, Ph.D., Senior Investigator, Behavioral Medicine and
Director of
Smoking Cessation Services, Fox Chase Cancer Center, Philadelphia,
Pennsylvania
Gerry Oster, Ph.D., Vice President, Policy Analysis, Inc., Brookline,
Massachusetts
Clifford H. Patrick, Ph.D., Senior Public Health Advisor, Office of
Minority Health,
Washington, D.C.
Cheryl L. Perry, Ph.D., Associate Professor, Division of Epidemiology,
School of
Public Health, University of Minnesota, Minneapolis, Minnesota
Michael Pertschuck, J.D., Co-director, Advocacy Institute, Washington,
D.C.
Edward L. Petsonk, M.D., Senior Medical Officer, Clinical Investigations
Branch,Division of Respiratory Disease Studies, National Institute for
Occupational Safety and Health, Centers for Disease Control, Atlanta, Georgia
John P. Pierce, M.Sc., Ph.D., Chief, Epidemiology Branch, Office on
Smoking and Health, Center for Chronic Disease Prevention and Health Promotion,
Centers for Disease Control, Rockville, Maryland
John M. Pinney, Executive Director, Institute for the Study of Smoking
Behavior and Policy, John F. Kennedy School of Government, Harvard University,
Cambridge, Massachusetts
Edward T. Popper, M.B.A., D.B.A., Associate Professor of Marketing,
Bryant College, Smithfield, Rhode Island
William F. Raub, M.D., Deputy Director, National Institutes of Health,
Bethesda, Maryland
Dorothy P. Rice, B.A., Sc.D.(Hon.), Professor in Residence, Department of
Social and Behavioral Sciences, School of Nursing, University of California, San
Francisco, San Francisco, California
Lynn Gloeckler Ries, M.S., Division of Cancer Prevention and Control,
Surveillance and Operations Research Branch, National Cancer Institute, Bethesda,
Maryland
Ruth Roemer, J.D., Adjunct Professor of Health Law, School of Public
Health, University of California at Los Angeles, Los Angeles, California; Past President,
American Public Health Association
Kenneth J. Rothman, Dr.P.H., Professor of Family and Community Health,
University of Massachusetts Medical School, Worcester, Massachusetts
Jonathan M. Samet, M.D., Professor of Medicine, Department of Medicine;
Chief, Pulmonary Division, University of New Mexico, Albuquerque, New Mexico
Thomas C. Schelling, Ph.D., Lucius N. Littauer Professor of Political
Economy, Director,Institute for the Study of Smoking Behavior and Policy, John F. Kennedy
School of Government, Harvard University, Cambridge, Massachusetts
Marvin A. Schneiderman, Ph.D., National Academy of Sciences, National
Research Council, Board on Environmental Studies and Toxicology, Washington, D.C.
David Schottenfeld, M.D., M.Sc., John G. Searle Professor and Chairman,
Department of Epidemiology, School of Public Health, Professor of Internal Medicine,
School of Medicine, University of Michigan, Ann Arbor, Michigan
Lowell E. Sever, Ph.D., Assistant Director for Science, Division of Birth
Defects and Developmental Disabilities, Center for Environmental Health and Injury
Control,Centers for Disease Control, Atlanta, Georgia
Saul Shiffman, Ph.D., Associate Professor, Department of Psychology;
Director, Psychology Clinic, University of Pittsburgh, Pittsburgh, Pennsylvania
Donald R. Shopland, Public Health Advisor, Smoking, Tobacco, and Cancer
Program, Office of the Director, Division of Cancer Prevention and Control,
National Cancer Institute, Bethesda, Maryland
John Slade, M.D., Department of Medicine, University of Medicine and
Dentistry of
New Jersey, New Brunswick, New Jersey
Jesse L. Steinfeld, M.D., former Surgeon General, Public Health Service,
San Diego, California
Steven D. Stellman, Ph.D., Assistant Commissioner for Biostatistics and
Epidemiologic Research, New York City Department of Health, New York, New York
Michael A. Stoto, Ph.D., Senior Staff Officer, Institute of Medicine,
National Academy
of Sciences, Washington, D.C.
James A. Swomley, Managing Director, American Lung Association, New York,
New
York
Owen T. Thomberry, Ph.D., Director, Division of Health Interview
Statistics, National
Center for Health Statistics, Centers for Disease Control, Hyattsville,
Maryland
William M. Tipping, Executive Vice President and Chief Executive Officer,
American
Cancer Society, Atlanta, Georgia
Dennis D. Tolsma, M.P.H., Assistant Director for Public Health Practice,
Centers for
Disease Control, Atlanta, Georgia
Frederick L. Trowbridge, M.D., Director, Division of Nutrition, Center
for Chronic
Disease Prevention and Health Promotion, Centers for Disease Control,
Atlanta,
Georgia
Diana Chapman Walsh, Ph.D., University Professor, Professor of Public
Health and
Associate Director of the Health Policy Institute, Boston University,
Boston, Massachusetts
Judith P. Wilkenfeld, J.D., Program Advisor, Cigarette Advertising and
Testing,
Federal Trade Commission, Washington, D.C.
Ronald W. Wilson, M.A., Director, Division of Epidemiology and Health
Promotion,
National Center for Health Statistics, Centers for Disease Control,
Hyattsville,
Maryland
Deborah M. Winn, Ph.D., Deputy Director, Division of Health Interview
Statistics, National
Center for Health Statistics, Hyattsville, Maryland
Ernst L. Wynder, M.D., President, American Health Foundation, New York,
New York
James B. Wyngaarden, M.D., Director, National Institutes of Health,
Bethesda, Maryland
The editors also acknowledge the contributions of the following staff
members and others who assisted in the preparation of this Report.
Margaret Anglin, Secretary, Office on Smoking and Health, Rockville,
Maryland
Charles Appiah, Project Clerk, The Circle, Inc., McLean, Virginia
John Artis, Courier, The Circle, Inc., McLean, Virginia
John L. Bagrosky, Associate Director for Program Operations, Office on
Smoking and Health, Rockville, Maryland
Sonia Balakirsky, Secretary, Office on Smoking and Health, Rockville,
Maryland
Carol A. Bean, Ph.D., Project Director, The Circle, Inc., McLean,
Virginia
Marissa Bernstein, Editorial Assistant, The Circle, Inc., McLean,
Virginia
Doreen M. Bonnett, Senior Editor, The Circle, Inc., McLean, Virginia
Catherine E. Burckhardt, Editorial Assistant, Office on Smoking and
Health, Rockville, Maryland
Gayle A. Christman, Administrative Assistant, The Circle, Inc., McLean,
Virginia
Carol K. Cummings, Secretary, Office on Smoking and Health, Rockville,
Maryland
Karen M. Deasy, Assistant to the Director for Special Projects, Office on
Smoking and Health, Rockville, Maryland
Joanna Ebling, Word Processing Specialist, The Circle, Inc., McLean,
Virginia
David Fry, Editor, The Circle, Inc., McLean, Virginia
Lynn Funkhauser, Word Processing Specialist, The Circle, Inc., McLean,
Virginia
Amy Garson, Student Intern, Office on Smoking and Health, Rockville,
Maryland
Gary A. Giovino, Ph.D., Epidemiologist, Office on Smoking and Health,
Rockville, Maryland
Ametta G. Glover, Secretary, Office on Smoking and Health, Rockville,
Maryland
Victoria M. Grier, Conference Coordinator, The Circle, Inc., McLean,
Virginia
Andree C. Harris, Program Analyst, Center for Chronic Disease Prevention
and Health Promotion, Centers for Disease Control, Atlanta, Georgia
Evridiki Hatziandreu, M.D., Dr.P.H., Epidemic Intelligence Service
Officer, Office on Smoking and Health, Rockville, Maryland
Patricia E. Healy, Technical Information Specialist, Office on Smoking
and Health, Rockville, Maryland
Timothy K. Hensley, Technical Publications Writer, Office on Smoking and
Health, Rockville, Maryland
Robert S. Hutchings, Associate Director for Information and Program
Development, Office on Smoking and Health, Rockville, Maryland
Karen Jacob, Senior Editor, The Circle, Inc., McLean, Virginia
Beth Jacobsen, Student Intern, Office on Smoking and Health, Rockville,
Maryland
Sheila M. Jones, Word Processing Specialist, The Circle, Inc., McLean,
Virginia
Kathleen M. Keever, Secretary, Department of Public Health Policy and
Administration, School of Public Health, University of Michigan, Ann Arbor, Michigan
Rick Keir, Senior Editor, The Circle, Inc., McLean, Virginia
Jennifer L. Kirscht, M.P.H., Statistics Consultant, Department of Public
Health Policy and Administration, School of Public Health, University of Michigan, Ann
Arbor, Michigan
Laura Y. Martin, Program Analyst, Office of Program Planning and
Evaluation, Centers for Disease Control, Atlanta, Georgia
Daniel F. McLaughlin, Editor, The Circle, Inc., McLean, Virginia
Sherry L. Mills, M.D., M.P.H., Epidemic Intelligence Service Officer,
Office on Smoking and Health, Rockville, Maryland
Nancy A. Miltenberger, M.A., Senior Editor, The Circle, Inc., McLean,
Virginia
Elizabeth Mugge, Special Assistant, Office of the Deputy Director,
Division of Cancer Prevention and Control, National Cancer Institute, Bethesda, Maryland
Millie R. Naquin, M.ED., Research Assistant, Office on Smoking and
Health, Rockville, Maryland
Regina Nwankwo, Editor, The Circle, Inc., McLean, Virginia
Ruth C. Palmer, Secretary, Office on Smoking and Health, Rockville,
Maryland
Lida Peterson, Computer Systems Manager, The Circle, Inc., McLean,
Virginia
Renate Phillips, Desktop Publishing/Graphic Artist, The Circle, Inc.,
McLean, Virginia
Margaret E. Pickerel, Public Information and Publications Specialist,
Office on Smoking and Health, Rockville, Maryland
Rose Mary Romano, Chief, Public Information Branch, Office on Smoking and
Health; Rockville, Maryland
Tamara Shipp, Publications Assistant, The Circle, Inc., McLean, Virginia
Edwin Silverberg, Supervisor, Statistical Information Service, American
Cancer Society
Linda R. Spiegelman, Administrative Officer, Office on Smoking and
Health, Rockville, Maryland
Traion Stallings, Word Processing Specialist, The Circle, Inc., McLean,
Virginia
Daniel R., Tisch, Senior Project Manager, The Circle, Inc., McLean,
Virginia
Pamela Wilson, Editor, The Circle, Inc., McLean, Virginia
Louise G. Wiseman, Technical Information Specialist, Office on Smoking
and Health, Rockville, Maryland
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Top
Foreword...................................................i
Preface....................................................iii
Acknowledgments....................................ix
1. Historical Perspective, Overview, and
Conclusions...............................................1
2. Advances in Knowledge of the Health Consequences of
Smoking.........................33
3. Changes in Smoking-Attributable
Mortality...............................................117
4. Trends in Public Beliefs, Attitudes, and Opinions About
Smoking......................................171
5. Changes in Smoking Behavior and Knowledge About
Determinants...............................259
6. Smoking Prevention, Cessation, and Advocacy
Activities...............................................379
7. Smoking Control Policies..................465
8. Changes in the Smoking-and-Health Environment: Behavioral and
Health Consequences.............................645
Glossary ................................................685
Index .....................................................689
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