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Surgeon General report identifies more health hazards from smoking
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Diabetes, colorectal and liver cancer, rheumatoid arthritis, erectile dysfunction, age-related macular degeneration and other conditions have now been added to the list of diseases caused by cigarette smoking or exposure to secondhand smoke, according to a new report issued by the Surgeon General of the United States.
The Health Consequences of Smoking – 50 Years of Progress: A Report of the Surgeon General, comes 50 years after the Surgeon General issued the first report on the health consequences of smoking, which concluded that smoking was a cause of lung cancer.
Major conclusions
The new report, issued by acting Surgeon General Boris D. Lushniak, MD, MPH, outlines updated findings on disease risks from smoking, and estimates that 5.6 million Americans currently aged younger than 18 years will die prematurely from smoking-related causes if current smoking trends are not curbed. The report also concluded that cigarette smoking increases the risk for all-cause mortality in men and women, and that the relative risk for death from cigarette smoking has increased in the past 50 years.
“Smoking remains the leading preventable cause of premature disease and death in the United States,” Lushniak wrote in a preface to the report. “The science contained in this and prior Surgeon General’s reports provide all the information we need to save future generations from the burden of premature disease caused by tobacco use. However, evidence-based interventions that encourage quitting and prevent youth smoking continue to be underutilized.”
CV findings
Evidence is now sufficient to conclude that the increase in risk for any kind of stroke from exposure to secondhand smoke is approximately 25% (HR=1.25; 95% CI, 1.12-1.38), according to the report.
CVD, not lung cancer, has been implicated as the largest smoking-attributable cause of death in the United States, and claims more lives of smokers aged 35 years and older annually than lung cancer. Moreover, exposure to secondhand smoke causes more deaths from CVD than from lung cancer.
There is also evidence suggesting that smoke-free laws and policies covering workplaces, restaurants and bars are associated with a reduction in coronary events (RR=0.85; 95% CI, 0.82-0.88), but the effect is not observed in people aged 65 years and older (RR=0.98; 95% CI, 0.953-1.008). Implementation of smoke-free laws or policies has also been associated with reductions in cerebrovascular events, angina and out-of-hospital sudden cardiac death.
“One statistic stands out for our organization ─ about 7.8 million of the 20 million [Americans who died smoking-related premature deaths over the last 50 years] tragically died from cardiovascular and metabolic diseases,” Nancy Brown, CEO of the American Heart Association, said in a press release. “Two and half million of those who died were nonsmokers exposed to secondhand smoke. Ongoing exposure, according to the report, can increase your risk of stroke by 20 to 30 percent. But smoke-free policies can result in a reduction of coronary events in people younger than 65. More importantly, smokers who quit by age 40 can virtually eliminate their risk of heart disease. Even if you give up smoking later in life, you can still dramatically reduce your risk. This new information gives a welcome boost to the American Heart Association’s efforts to pass smoke-free laws in all 50 states and increase resources to help people quit smoking.”
Diabetes findings
The report concluded that cigarette smoking is a cause of diabetes, and that the risk for developing diabetes is 30% to 40% higher for current smokers than for nonsmokers (RR=1.37; 95% CI, 1.31-1.44).
Research has also revealed a dose-response relationship: The risk for developing diabetes rises with an increase in the number of cigarettes smoked. Light smokers, defined in most studies as those who smoke fewer than 20 cigarettes per day, have a higher risk for developing diabetes compared with nonsmokers (RR=1.25; 95% CI, 1.14-1.37), but the effect is greater among heavy smokers compared with nonsmokers (RR=1.54; 95% CI, 1.4-1.68).
Cancer findings
A number of meta-analyses have demonstrated that smoking confers an increased risk for liver cancer. According to the report, in one meta-analysis, current smoking carried an elevated risk for hepatocellular carcinoma in cohort studies (RR=1.7; 95% CI, 1.5-1.9) and case-control studies (RR=1.6; 95% CI, 1.2-2.1), while in another meta-analysis the association was stronger in cohort studies than in case-control studies.
The report also details sufficient evidence to conclude that there is a causal relationship between smoking and colorectal adenomatous polyps and colorectal cancer.
Current smokers have a higher risk for adenomas compared with never-smokers (RR=2.14; 95% CI, 1.86-2.46), and the association was also strong among former smokers (RR=1.47; 95% CI, 1.29-1.67). A number of meta-analyses concluded that current and/or former smoking raises the risk for colorectal cancer and related mortality, although the effect size in such analyses varied.
While overall smoking rates have declined, the risk for developing adenocarcinoma of the lung has increased since the 1960s because of changes in the design and composition of cigarettes, according to the report.
There is a lack of sufficient evidence to establish a causal relationship between smoking and prostate cancer or breast cancer, but evidence exists suggesting that smokers are more likely to die of prostate cancer than nonsmokers, and that active smoking and exposure to secondhand smoke increase risk for breast cancer, the report states.
In addition, patients with cancer who smoke have worse outcomes than cancer patients who do not smoke, researchers found.
Rheumatoid arthritis findings
There is enough evidence to conclude that smoking causes rheumatoid arthritis, according to the report. In one meta-analysis, compared with never smokers, there was an elevated risk for rheumatoid arthritis among ever-smokers (RR=1.4; 95% CI, 1.25-1.58), current smokers (RR=1.35; 95% CI, 1.17-1.55) and past smokers (RR=1.25; 95% CI, 1.1-1.4).
In addition, researchers have found that cigarette smoking may reduce the effectiveness of tumor necrosis factor-alpha inhibitors.
Respiratory findings
Smoking is the dominant cause of chronic obstructive pulmonary disease, including all elements of the COPD phenotype such as emphysema and damage to the airways of the lung, the report states.
The Surgeon General cited enough evidence to infer a causal relationship between smoking and increased risk for tuberculosis, as well as recurrent tuberculosis and mortality from tuberculosis, according to the report. However, existing evidence is not sufficiently clear to establish a relationship between secondhand smoke and tuberculosis.
Available evidence suggests, but does not conclude, that there is a causal relationship between cigarette smoking and the incidence and exacerbation of asthma in children, adolescents and adults.
Ophthalmologic findings
Current evidence is sufficient to infer a causal relationship between cigarette smoking and neovascular and atrophic forms of age-related macular degeneration. A number of studies have demonstrated strong links between the two, according to the report.
In addition, four published studies have found that smoking exacerbates a genetic factor that increases risk for age-related macular degeneration, the report states. Researchers have also found a suggestion that smoking cessation reduces the risk for advanced age-related macular degeneration.
Other findings
According to additional information in the report:
- Maternal smoking in early pregnancy causes orofacial clefts.
- Maternal active smoking causes ectopic pregnancy.
- Smoking can cause erectile dysfunction.
- Components of cigarette smoke impact components of the immune system.
- Altered immune systems compromised by cigarette smoking are associated with increased risk for pulmonary infections.
Future efforts
“Over the last 50 years, tobacco control efforts have saved 8 million lives, but the job is far from over,” Howard K. Koh, MD, MPH, HHS assistant secretary for health, stated in a press release. “This report provides the impetus to accelerate public health and clinical strategies to drop overall smoking rates to less than 10% in the next decade.”
For more information:
Lushniak BD. The Health Consequences of Smoking — 50 Years of Progress: A Report of the Surgeon General.Perspective
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Michael B. Steinberg, MD, MPH, FACP
The release of the 2014 Surgeon General’s Report reinforces and adds to the overwhelming evidence for the devastating effects of tobacco use on our society. From an oncological standpoint, adding to the existing data that tobacco use results in one-third of all cancer deaths and is the single largest risk factor for cancer, the Surgeon General provides evidence linking tobacco use to new cancer outcomes, such as liver and colon cancers. Mounting evidence also exists that patients with cancer have poorer outcomes if they continue to use tobacco.
Besides the importance of new data regarding tobacco-caused disease, another critical message from the Surgeon General to health care providers is the understanding that “evidence-based interventions that encourage quitting continue to be underutilized.” We have arrived at a place in our society where we know tobacco kills and we have treatments that work, but we have failed to pay for and utilize these treatments in the same way we do for other chronic conditions, such as diabetes and hypertension. How can we justify continuing to not reimburse providers for delivering evidence-based tobacco treatment in the same way we pay for diabetes care? How can we justify allowing insurance companies to set limits as to how long someone can use tobacco cessation medications or in what combinations? We would not stand for such regulations dictating how we can prescribe hypertensive medications (eg, “Your plan only pays for 3 months of blood pressure medications” or “Your plan only covers you to make one quit attempt per year.”).
Finally, how can we in good conscience justify not funding effective tobacco control programs? To my dismay, my own state of New Jersey ranks last in the nation in tobacco control funding — of the nearly $1 billion New Jersey collects on tobacco products each year, the state does not even spend $1 to help its citizens battle this deadly condition. This is appalling. The time has come to stop looking for more tobacco-caused disease, and start implementing and paying for what works — effective tobacco treatment.
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