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1989 Surgeon General Report: Reducing the Health Consequences of Smoking


Introduction


Letter to the Speaker of the House

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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Letter to the President

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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Forward

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:

  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.

     

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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Preface

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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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 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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Table of Contents

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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