Surgeon General’s Report
6 Executive Summary
for the brain, has lasting adverse consequences for brain
development. Nicotine exposure during pregnancy also
contributes to adverse reproductive outcomes, such as
preterm birth and stillbirth.
Cancer: Lung cancer, the first of many deadly dis-
eases to be identified in a Surgeon General’s report as
being caused by smoking (Chapter 6), is now the nation’s
most common cancer killer among men and women. Two
studies carried out by the American Cancer Society have
been key sources of information on the risks of lung can-
cer in smokers. These two studies each followed more
than 1 million U.S. men and women, starting in 1959
for the first study and then again in 1982 for the second.
Results from these studies have now been compared with
data combined from several large populations followed
from 2000–2010 (Thun et al. 1997a,b, 2013). Although
the risk of lung cancer for never smokers in all three stud-
ies stayed about the same, the risk to smokers increased
steadily. Among women, risk of lung cancer went up dra-
matically. In the 1959 study, women smokers were 2.7
times more likely than women never smokers to develop
lung cancer; by 2000–2010 that additional risk for women
smokers had jumped nearly tenfold, to 25.7. For men who
smoked, the risk more than doubled, from 12.2 to 25.0
between the first and last studies. These relative risks
increased over the same period as the prevalence of smok-
ing and the average number of cigarettes consumed per
smoker decreased. Although the incidence of squamous
cell carcinoma of the lung—the type of lung cancer most
often diagnosed among smokers at the start of the lung
cancer epidemic—declined as smoking rates dropped, the
incidence of adenocarcinoma of the lung increased dra-
tion and design of the cigarette itself may have had some
impact on the relative risk of lung cancer, as well as on the
shift in the types of lung cancer occurring in the contem-
porary cohorts of smokers (Thun et al. 2013).
This latest Surgeon General’s report also evaluated
the evidence on other cancers, and concluded that smok-
ing is a cause of liver cancer and of colorectal cancer, the
fourth most diagnosed cancer in the United States and
the cancer responsible for the second largest number of
cancer deaths annually (Chapter 6). The report found that
the evidence is suggestive but insufficient to conclude
that smoking and exposure to secondhand smoke cause
breast cancer, and that smoking is not a cause for pros-
tate cancer. The report also found that smoking increases
the risk of dying from cancer and other diseases in cancer
patients and survivors, including breast and prostate can-
cer patients.
Respiratory diseases: In the 1964 Surgeon Gen-
eral’s report, smoking was found to be a cause of “chronic
bronchitis,” a term used then for the disease now gener-
ally referred to as chronic obstructive pulmonary disease
(COPD) (Fletcher et al. 1959). Because smoke is inhaled
into the lung and its components are deposited and
absorbed in the lungs, it has long been linked to adverse
effects on the respiratory system, causing malignant and
nonmalignant diseases, exacerbating chronic lung dis-
eases, and increasing the risk for respiratory infections.
The scientific literature showing associations with mul-
tiple diseases of the respiratory tract is extensive as is the
evidence supporting the biologic plausibility of smoking as
a cause of these associations (Chapter 7). This report has
reviewed the updated evidence on COPD. Mortality from
COPD continues to rise, and smoking remains responsi-
ble for the vast majority of cases (Chapter 7). As for lung
cancer, comparison of the findings of the two American
Cancer Society studies with the more recent studies span-
ning 2000–2010 showed rising risks for COPD, particu-
larly in women. Recent studies show that the relative risk
for COPD in women has risen greatly, reaching 22.4 com-
pared to never smokers, and similar to the risk in men
(Thun et al. 2013).
For asthma, another obstructive lung disease, the
evidence was found to be sufficient to infer that smoking
worsens asthma in adults who smoke (Chapter 7). The ben-
efits of implementing smokefree policies have been shown
for workers with asthma (Eisner et al. 1998; Menzies et al.
2006; Ayres et al. 2009; Wilson et al. 2012). Evidence con-
sidered in this report points to a reduction in admissions
for respiratory diseases following the implementation of a
smokefree policy (Tan and Glantz 2012). Tuberculosis was
once a leading cause of death in the United States. Now
far less frequent in the United States, it remains promi-
nent worldwide. Evidence reported over the last decade is
sufficient to lead to a conclusion that smoking increases
the risk for tuberculosis and for dying from tuberculosis
(Chapter 7).
Cardiovascular diseases: Although lung cancer
is often assumed to be the largest smoking-attributable
cause of death in the United States, cardiovascular disease
actually claims more lives of smokers 35 years of age and
older every year compared with lung cancer (Chapter 8).
Exposure to secondhand smoke causes significantly more
deaths due to cardiovascular disease than due to lung
cancer, and this new report finds that exposure to second-
hand smoke is also a cause of stroke. Exposure to second-
hand smoke increases the risk for stroke by an estimated
20–30%. Even so, the evidence is clear that reductions in
smoking and exposure to secondhand smoke have con-
diseases since the late 1960s. Smokefree laws and policies
have been proven to reduce the incidence of heart attacks