Warning: Surgeon General Finds that Cigarette Smoking Is Even More Dangerous to Your Health

Posted on by John Howard, MD, David Weissman, MD, Casey Chosewood, MD

hand holding cigaretteIn 1964, the United States was a place where over 50% of adult males smoked tobacco. Smoking was accepted in any indoor environment, on airplanes, and in elevators. Even Saturday morning cartoon shows had cigarette sponsors. But, on January 11, 1964, Surgeon General Luther Terry released the first Surgeon General’s Report called Smoking and Health and concluded that smoking caused cancer.

Over the next 45 years, 28 additional reports on tobacco smoking followed from various Surgeons General. On December 9, 2010, the current U.S. Surgeon General, Dr. Regina Benjamin, issued the 30th Surgeon General’s Report on the dangers of smoking tobacco. The 30th Report is entitled How Tobacco Smoke Causes Disease: The Biology and Behavioral Basis for Smoking-Attributable Disease.

[Read more on tobacco smoke in the workplace]

It’s fair to ask “why issue another report?” Despite 29 previous reports, tobacco use remains the leading cause of preventable death in the United States, and is responsible for 443,000 deaths each year. Thirty percent of all cancer deaths are due to tobacco. Each day 1,200 lives of current and former smokers are lost prematurely due to tobacco-related diseases. As HHS Secretary Kathleen Sebelius noted, “Every day, almost 4,000 youth try a cigarette for the first time and 1,000 youth become regular, daily smokers.”

The new Report is a weighty one. Spanning over 700 pages, it presents a detailed, scientific look at the toxicology and biology behind nicotine addiction and tobacco smoking, including carcinogenic effects and the adverse effects on cardiopulmonary and reproductive health. Many additional scientific and other international publications for the general public and healthcare providers are available at http://www.smokefree.gov and http://www.ahrq.gov/path/tobacco.htm

Brief Summary of Findings from the 2010 Surgeon General’s Report

  1. There is no safe level of exposure to tobacco smoke. The evidence on the mechanisms by which smoking causes disease indicates that there is no risk-free level of exposure to tobacco smoke.
  2. Damage from tobacco smoke is immediate. Evidence in the new Report indicates that the risk does not increase in a linear fashion with increasing exposure, and even low levels of exposure to tobacco—such as a few cigarettes a day, occasional smoking, or exposure to secondhand tobacco smoke—are sufficient to substantially increase the risk of adverse cardiac events.
  3. Smoking longer means more damage. Through multiple defined mechanisms, the risk and severity of many adverse health outcomes caused by smoking are directly related to the duration and level of exposure to tobacco smoke.
  4. Cigarettes are designed for addiction. Sustained use and long-term exposures to tobacco smoke are due to the powerfully addicting effects of tobacco products, which are mediated by diverse actions of nicotine and perhaps other compounds, at multiple types of nicotine receptors in the brain.
  5. Even low levels of exposure, including exposure to secondhand tobacco smoke, are dangerous. In 2006, the Surgeon General reported that the scientific evidence was sufficient to conclude that there is no risk-free level of exposure to secondhand smoke. The 2010 Report provides a more detailed review of the mechanisms that validate that conclusion. Low levels of exposure, including exposures to secondhand smoke, lead to a rapid and sharp increase in endothelial dysfunction and inflammation, which are implicated in acute cardiovascular events and thrombosis.
  6. There is no safe cigarette. There is insufficient evidence that product modification strategies—including new cigarette products—to lower emissions of specific toxicants in tobacco smoke reduce the risk for major adverse health outcomes.

HHS Comprehensive Strategy to End the Tobacco Epidemic

In November of 2010, the U.S. Department of Health and Human Services announced a new comprehensive control strategy for tobacco smoking reduction.
See http://www.hhs.gov/ash/initiatives/tobacco/tobaccostrategicplan2010.pdf

A major impetus for the new HHS tobacco control strategy is that the proportion of tobacco smokers in the U.S. has remained stuck at the 20% level since 2003. For seven years, there has been no progress in reducing tobacco smoking in the U.S. And, even though 25 states have enacted comprehensive tobacco smoking control laws, 25 states have none. Among the states with the highest 2009 smoking prevalence were Kentucky (25.6 percent), West Virginia (25.6 %) and Oklahoma (25.5 %). Prevalence was lowest in Utah (9.8 %) California (12.9 %), and Washington State (14.9 %).
See http://www.cdc.gov/media/pressrel/2010/r101104.html

California was the first state to enact tobacco control laws in 1994 and California has seen a four-fold faster reduction in lung cancer incidence than states without smoking bans. The new goal for Health People 2020 will be to reduce tobacco smoking prevalence from 20% to 12%.

The Family Smoking Prevention and Tobacco Control Act (FSPTCA) gives the U.S. Food and Drug Administration (FDA) explicit regulatory authority over tobacco products. FDA now has the authority to require companies to reveal all of the ingredients in tobacco products—including the amount of nicotine—and to prohibit the sale of tobacco products labeled as “light,” “mild,” or “low.”

In November, FDA announced a proposed rule titled Required Warnings for Cigarette Packages and Advertisements. The proposed rule would require nine new larger and more noticeable textual warning statements, and color graphic images depicting the negative health consequences of smoking to appear on cigarette packages and in cigarette advertisements. The public has an opportunity to comment on 36 proposed images through January 9, 2011. By June 22, 2011, FDA will select the final nine graphic and textual warning statements after a comprehensive review of the relevant scientific literature, the public comments, and results from an 18,000 person study. Implementation of the final rule on September 22, 2012 will ultimately prohibit companies from manufacturing cigarettes without new graphic health warnings on their packages for sale or distribution in the United States. In addition, manufacturers, importers, distributors and retailers will no longer be allowed to advertise cigarettes without the new graphic health warnings in the United States. By October 22, 2012, manufacturers can no longer distribute cigarettes for sale in the United States that do not display the new graphic health warnings.

HHS’ new comprehensive tobacco control strategy also includes the following elements:

  • The Affordable Care Act gives Americans in private and public health plans access to recommended preventive care, like tobacco use cessation, at no additional cost.
  • The American Recovery and Reinvestment Act (ARRA) invested $225 million to support local, state, and national efforts to promote comprehensive tobacco control and expand tobacco quitlines like 1.800.QUIT.NOW
  • The Children’s Health Insurance Program Reauthorization Act (CHIPRA) raised the federal cigarette tax by 62 cents per pack. Raising the price of tobacco products is a proven way to reduce tobacco use, especially among price-sensitive populations such as youth.

Tobacco and Occupation

Tobacco smoking remains common in many occupational groups, with prevalence often exceeding 30%. Smoking is an especially important risk for blue-collar workers who are also exposed to occupational carcinogens. For example, risks from tobacco smoking and asbestos exposure are multiplicative. Integrating health protection programs for workers with health promotion or wellness programs that can provide modern smoking cessation services is a critical need. NIOSH believes that integrating protection and promotion best supports the goal of total worker health. Tobacco-free workplaces, on-site tobacco cessation services, and comprehensive, employer-sponsored healthcare benefits that provide multiple quit attempts, have all been shown to increase tobacco treatment success.

Even non-smoking workers are at risk from tobacco smoke. Secondhand exposures are an important problem for workers in environments such as gaming, food service, and other occupations where they are often around smokers. Even though they do not smoke themselves, these workers may have measurable levels of chemical contaminants from cigarette smoke in their blood or urine. As the Surgeon General’s Report points out, even intermittent exposure to secondhand smoke can be harmful. For example, workplace exposure to tobacco significantly increases the risk for adult-onset asthma. Because secondhand smoke is an avoidable risk to all who are exposed, the U.S. Department of Health and Human Services has set a Healthy People 2020 goal that 100% of workplaces should be covered by indoor worksite policies that prohibit smoking.

Dr. Howard is the director of the National Institute for Occupational Safety and Health.

Dr. Weissman is the director of NIOSH’s Division of Respiratory Disease Studies.

Dr. Chosewood is the director of NIOSH’s Total Worker Health Program (WorkLife).


Posted on by John Howard, MD, David Weissman, MD, Casey Chosewood, MDTags

34 comments on “Warning: Surgeon General Finds that Cigarette Smoking Is Even More Dangerous to Your Health”

Comments listed below are posted by individuals not associated with CDC, unless otherwise stated. These comments do not represent the official views of CDC, and CDC does not guarantee that any information posted by individuals on this site is correct, and disclaims any liability for any loss or damage resulting from reliance on any such information. Read more about our comment policy ».

    My dad is dying of emfizema, hes only in his late fifties. The problem is that people know they are dying or going to die from it but they are STILL willing to do it for the pay off. The real fight is to get kids to not try it at all, and secondly to promote self esteem and the knowledge that they wont be alive to play with their grandchildren in those that still make this poor choice.

    In addition to the excellent content of this blog, CDC issued a much less technical 16 page digest called “…what it means to you.” In this document aimed squarely at the public at large there is a vignette on heart attacks (p9), it states: “A public smoking ban drastically cutheart attacks. Pueblo, Colorado banned smoking in workplaces and all public areas in July 2003. The number of people hospitalized for heart attacks dropped 41 percent in 3 years.” Jan 2002-June 2003 257/10e5; July 2003-Dec 2004 187/10e5; Jan 2005-June 2006 152/10e5.

    The key really is education at an early age. When I was in Canada last year all the cigarette packages had disturbing images of what would eventually happen to your organs and other consequences when you smoke. I doubt we could implement something similar with the tobacco lobbies here, but it would really help users (especially the young ones) not to start smoking.

    I forgot to read the other blog posts, I just wanted to add in response to Ainsley’s comment that while I generally don’t agree that the government should directly tell people what to do with their own bodies like a smoking ban, however in this case it proves that it is effective. I know that correlation doesn’t equal causation, but the numbers that Ainsley posts are just staggering. 41% in only 3 years, I really have to double check that one to see if it’s correct. If it is, then all states should implement a similar policy.

    It is almost impossible to quit smoking when all the people around you are doing so. It makes you become the minority in the group. This is what happens in the factory where most workers are heavy smokers.

    Would imposing a higher tax on cigarette do good? I’d say I am all for it since I am a non-smoker, but that would be a totally biased suggestion. However if the health hazard of smoking cigarette would pose a far greater threat to smokers and non-smoker alike then it I believe it is high time to resort to this measure to curb the threat.

    Increased cigarette taxes have been reported to decrease smoking rates (see references below). NIOSH is strongly committed to smoke-free work places and to promoting healthy lifestyles among those who work. An important part of a healthy lifestyle is abstinence from use of tobacco products. NIOSH is in favor of examining all possible approaches to achieving that goal.

    1. http://ajph.aphapublications.org/cgi/content/abstract/82/1/94 The effect of state cigarette tax increases on cigarette sales, 1955 to 1988
    2. http://www.medicalnewstoday.com/articles/137936.php Medical News Today
    3. http://www.who.int/tobacco/statistics/tobacco_atlas/en/ WHO: The Tobacco Atlas
    4. http://www.tobaccofreekids.org/research/factsheets/pdf/0146.pdf

    I think it would be great if more facts about addiction and the pyschological aspects of smoking were focused on. We all know the health risks of smoking already, and finding out they are even worse isn’t likely to do much. It is great for keeping kids off cigarettes in the first place though.

    Interesting read.

    I think people should just switch to electronic cigarettes, according to studies it’s a lot safer than regular cigarettes. I’m not saying it’s not harmful but i think it is less chemicals than the regular cig. And the vapor is a lot better for our environment.

    Thank you for your comments. Many may not be familiar with e-cigarettes (a type of electronic nicotine delivery system). E-cigarettes are an emerging alternative to traditional forms of tobacco use that were first introduced into the U.S.A. in 2007. They generally have a cartridge containing a liquid consisting of varying amounts of nicotine, propylene glycol, glycerine, and flavorings. Inhalation draws the fluid to a heating element, creating a vapor that subsequently condenses into a smoke-like fume. Passive exposure to e-cigarette emissions can deliver nicotine to bystanders, causing increases in their serum cotinine levels (Flouris 2013). Nicotine has the potential to cause adverse reactions, particularly in those with underlying cardiovascular problems (Sobieraj 2013). Because e-cigarettes are relatively new products, not enough time has gone by to fully understand the potential chronic effects of smoking them or being passively exposed to their emissions (Drummond 2014). The British Medical Association has taken the position that use of e-cigarettes should be prohibited in workplaces and public places. Many States and Localities in the U.S.A. have passed regulations that include e-cigarettes in bans on smoking in public places. In fact, just yesterday (3/4/2014) Los Angeles, CA joined a growing number of cities banning the use of e-cigarettes in parks, restaurants and most workplaces.

    Drummond MB, Upson D. Electronic cigarettes. Potential harms and benefits. Ann Am Thorac Soc. 2014 Feb;11(2):236-42

    Flouris AD, Chorti MS, Poulianiti KP, Jamurtas AZ, Kostikas K, Tzatzarakis MN, Wallace Hayes A, Tsatsakis AM, Koutedakis Y. Acute impact of active and passive electronic cigarette smoking on serum cotinine and lung function. Inhal Toxicol. 2013 Feb;25(2):91-101.

    Sobieraj DM, White WB, Baker WL. Cardiovascular effects of pharmacologic therapies for smoking cessation. J Am Soc Hypertens. 2013 Jan-Feb;7(1):61-7.

    I think it might be incredible if more realities about enslavement and the pyschological parts of smoking were centered around. We all know the wellbeing dangers of smoking as of recently, and figuring out they are far more detestable isn’t prone to do much. It is extraordinary for keeping children off smoke in any case however.

    Before posting this comment I want to make the disclosure that I sell [e-cigarette company name removed], so that there is no doubt about where I am coming from when responding to the authors’ subsequent posting about e-cigarettes.

    As the articles cited by the authors’ indicate, the jury is still out about the individual benefits of using e-cigarettes as an alternative, less dangerous type of smoking method. Vapeman, who raised this issue, was of the opinion that e-cigarette vapor is a lot better for the environment than second hand smoke. In response to this the authors provided a citation to (Flouris 2013) to indicate that even passive exposure to e-cigarette vapor can increase a bystander’s nicotine levels.

    I do not believe that this article presents a pertinent response to Vapeman’s assertion that e-cigarette vapor is better for the environment. Common sense would tell us that the composition of the aerosol emitted by an e-cigarette is different from the aerosol composition encountered by a bystander experiences contact with traditional secondhand smoke.

    If we are dealing with two different gasses, and taking the anecdotal evidence that e-cig vapor does not linger in the local environment the way that second-hand smoke does as true, I think Vapeman’s assertion raises a question about the whether a bystander’s likelihood of general exposure to nicotine in the environment is legitimately lessened because e-liquid vapor diffuses itself more quickly than tobacco smoke, whereas the article cited compares each aerosol’s effect upon the body.

    Electronic cigarettes: Are they safer than tobacco? Or are they a high-tech way to hook a new generation on a bad nicotine habit? Nobody knows yet. Research into the effects of e-cigarettes lags behind their popularity. But ready or not, the era of e-cigarettes is here. It’s a booming, billion-dollar industry – on track to outsell tobacco products within a decade.

    With the rates of young users on the rise, it is obvious that there needs to be a change in strategy. Simply increasing prices will not stop new adopters but proper education can. Teaching the youth about the dangers of “tobacco products” should be the first line of defense.

    Electronic cigarettes: Are they safer than tobacco? Or are they a high-tech way to hook a new generation on a bad nicotine habit? Nobody knows yet. Research into the effects of e-cigarettes lags behind their popularity. But ready or not, the era of e-cigarettes is here. It’s a booming, billion-dollar industry – on track to outsell tobacco products within a decade.

    I am no scientist but it doesn’t take one to recognize that 4 chemicals are way better in the long run compared to 4000! E-cigs are a great way to help kick the habit – period.

    It’s this that gives united states the backdrop on talks about whether the Food And Drug Administration ought to be regulating e-cigarettes.

    I’m trying to find any information on e-cigarettes as a safe or unsafe alternative to cigarettes. While nicotine can be reduced, are there other chemicals in e-cigarettes that are harmful?

    People start smoking for fun and they never know when they become addictive to it.
    Casino hotels or resorts are good example of this. even people who don’t smoke like casino dealers are effecting from this.

    Don’t look for that to change anytime soon.

    Because many gamblers smoke, the gaming industry says smoking is good for Nevada’s economy. It must be ban soon everywhere.

    Smoking is dangerous. We all know that. Now we need to help them quit and deal qith nicotine addiction.
    Most smokers are trying to quit cold turkey. But they do not prepare for that do not read about nicotine and withdrawal. That is why when they quit they stert feel worse and decide to return to smoking. It is better to read guide about quitting cold turkey.
    To quit successfully people should be prepared.

    I suggest that the CDC do the following things. First, find Yul Brynner’s statement he made in the 1980s telling people who are smoking tobacco to quit and for those who have not started smoking tobacco to not start. Second, encourage all television channels and especially those who have been asked to run a public service announcement every so often to run that public service announcement by Yul Brynner on either 11 July or on 10 October at their own choice. There should be no penalties if they don’t do it or if the channel provides a similar message. Yul’s statement is already on YouTube and probably also is on the other social websites.

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