Surgeon General's Report Links More Diseases to Smoking

Miriam E. Tucker

January 17, 2014

On the fiftieth anniversary of the first Surgeon General's report on smoking, researchers continue to link the practice to new diseases, and public health officials urge even more forceful efforts to bring America to the smoking "end game."

"Today marks a new era in the fight against tobacco-related death and disease.... Enough is enough," said acting Surgeon General Boris Lushniak, MD, MPH, in announcing a new report, The Health Consequences of Smoking—50 Years of Progress, at a White House briefing.

US Department of Health and Human Services Secretary Kathleen Sebelius said, "We've made a lot of progress since the first Surgeon General's report, but we're still a country addicted to tobacco."

The 980-page report is divided into 3 sections, starting with a historical perspective with overview and conclusions, followed by a compilation of available public and privately funded research about the health consequences of active and passive smoking and a section entitled "Tracking and Ending the Epidemic," which provides data about smoking, along with recommendations for bringing the smoking "epidemic" to an end.

The research section is the largest, reflecting a huge accumulation of knowledge since the first Surgeon General's report linking smoking with lung cancer. "Amazingly, 50 years in, we're still finding out new ways that tobacco maims and kills people," noted Thomas R. Frieden, MD, head of the Centers for Disease Control and Prevention (CDC), also speaking at the briefing.

Indeed, diabetes, rheumatoid arthritis, immune dysfunction, tuberculosis, colorectal cancer, liver cancer, age-related macular degeneration, and erectile dysfunction are among the diseases that can now be added to the ever-growing list for which evidence strongly supports a causal association with smoking.

Also new on the list are orofacial clefts in the infants of women who smoke during pregnancy, as well as stroke resulting from secondhand smoke.

"Physicians may find surprising that we continue to causally link additional diseases to smoking. The list just keeps getting longer," the report's editor, Jonathan M. Samet, MD, told Medscape Medical News.

Continuing to conduct such research is worthwhile, even though everyone knows smoking is unhealthful, said Dr. Samet, director of the University of Southern California Institute for Global Health and professor and Flora L. Thornton Chair, Department of Preventive Medicine, Keck School of Medicine, University of Southern California, Los Angeles.

"The story isn't complete for some things. It has turned out to be a valuable and informative body of research for learning how disease is caused. A lot of the mechanistic work has generality. Understanding how smoking causes cancer spills over into other carcinogens.... There is generality in what we find."

Good and Bad News

On the up side, the prevalence of current ciga¬rette smoking among US adults has dropped considerably since 1964, going from 42% then to just 18% in 2012, and encouragingly, more than half of all people who ever smoked are now former smokers. Yet nearly 42 million adults and 3.5 million middle and high school students in the United States continue to smoke.

Annual costs attributable to smoking during 2009-2012 were estimated at $289 to $332 billion, including $132.5 to $175.9 billion for direct medical care for adults, according to the report.

Since 1964, 20 million people have died prematurely from cigarette smoking or secondhand smoke. Nearly half a million people die from smoking annually, and another 16 million people live with smoking-related illnesses.

Smoking among women has increased during the last 50 years to the point where rates of some of the illnesses, including lung cancer and chronic obstructive pulmonary disease, are equivalent to or greater than those rates among men.

What is more, smokers today are more likely to die of lung cancer caused by smoking, because the chemicals in cigarettes have changed over the years, Dr. Lushniak pointed out.

The report unequivocally blames the tobacco industry for advertising and promotional activities aimed at children. "The tobacco epidemic was initiated and has been sustained by the aggressive strategies of the tobacco industry, which deliberately misled the public on the risks of smoking cigarettes," Dr. Lushniak said.

"In the US alone, tobacco companies spend a million dollars an hour 24/7 to market their deadly and addictive products.... Enough is enough," he repeated.

Public Health Efforts

Secretary Sebelius outlined the Obama administration's antismoking efforts, including the 2009 legislation that gave the US Food and Drug Administration regulatory authority over tobacco products and the expansion of coverage for tobacco cessation mandated in the 2010 Affordable Care Act (ACA).

A new increase in the federal excise tax will raise the cost of a pack of cigarettes by $0.94, and the CDC's new tobacco prevention campaign, called "Tips from Former Smokers," is also part of the federal "end-game strategy" efforts, Sebelius said. However, she noted, "The federal government can't do this alone. We need an all-hands-on-deck approach."

Clinicians Called to Action

Among the report's recommendations for "accelerating the national movement to reduce tobacco use" are calls for taking advantage of the ACA's antismoking provisions to provide access to treatments such as counseling and medication for all smokers, and particularly those with significant mental and physical comorbidities.

The report also calls for "expanding smoking cessation for all smokers in primary and specialty care settings by having health care providers and systems examine how they can establish a strong standard of care for these effective treatments."

Dr. Samet told Medscape Medical News, "We still need physicians to be involved, to do what they should be doing with their patients who smoke. More and more they are, but we can still do better."

The Health Consequences of Smoking—50 Years of Progress: A Report of the Surgeon General, 2014. US Department of Health & Human Services. Full text

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