Perspectives in Disease Prevention and Health Promotion Smoking and Cardiovascular Disease

The U.S. Department of Health and Human Services' (DHHS) 1983 report on the health consequences of smoking reviews the evidence associating smoking with coronary heart disease (CHD) and other forms of cardiovascular disease (CVD). It concludes that cigarette smoking is a major cause of CHD for both men and women and should be considered the most important of the known modifiable risk factors for CHD (1).

The report estimates that up to 30% of deaths from CHD can be attributed to cigarette smoking; approximately the same percentage of cancer deaths have been attributed to smoking. However, because there are more CHD deaths in the United States than cancer deaths (565,000, compared with 416,000 in 1980), estimates of cigarette smoking-related CHD deaths (170,000) are higher than estimates of cigarette smoking-related cancer deaths (125,000).

Atherosclerosis, the main underlying process of CVD, is characterized by the accumulation of lipid in the intima of large elastic arteries (aorta) and medium-sized muscular arteries (coronary, femoral, carotid, and others). Autopsy studies have demonstrated a significant positive relationship between smoking and atherosclerosis. The evidence is most striking for atherosclerosis of the aorta, but a significant positive relationship exists with lesions of the coronary arteries. Coronary Heart Disease

Prospective mortality studies involving over 20 million person years of observation reveal that smokers have a 70% greater CHD death rate than nonsmokers. Heavy smokers (those who smoke two or more packs per day) have an almost 200% greater CHD mortality rate than nonsmokers.

Cigarette smoking increases the risk of developing CHD, and this effect is independent of the other major risk factors for CHD. However, smoking interacts with the other major risk factors (elevated serum cholesterol and hypertension) to substantially increase the CHD risk beyond the sum of the independent components (Figure 1). Each factor contributes about the same order of magnitude of risk for CHD. When one factor is present, the risk approximately doubles; with two factors, the risk is fourfold greater; and when all three are present, the CHD risk is eightfold greater than when none of the three factors are present.

Cigarette smokers experience a twofold to fourfold greater risk for sudden cardiac death than do nonsmokers. This risk is dose-related when measured by the number of cigarettes smoked per day.

A synergistic relationship between oral contraceptive use and cigarette smoking exists for myocardial infarction. Women who use both have a 10-times higher risk than women who use neither.

A substantial benefit of smoking cessation in reducing the risk of CHD can be detected within a few years of cessation. Ten years after cessation, the CHD risk of an ex-smoker approaches that of a person who has never smoked. Cerebrovascular Disease

An association between smoking and cerebrovascular disease has been found in numerous prospective mortality studies. This relationship is stronger in younger age groups. The increased risk of cerebrovascular disease from smoking appears to decrease rapidly after cessation.

The combination of smoking and oral contraceptives is associated with marked increase of risk in women for one particular type of cerebrovascular disease--subarachnoid hemorrhage. Other Forms of Vascular Disease

Smoking is the major modifiable risk factor for atherosclerotic peripheral vascular disease. Smoking cessation is important in the clinical management of patients with peripheral vascular disease, as it is with other forms of CVD. Mortality due to rupture of abdominal aortic aneurysms is more common among smokers than among nonsmokers. Intervention Studies

The 1983 DHHS report notes that one of the elements supporting the judgment of causality in the smoking-CHD relationship is the effect of smoking cessation: smokers reduce their excess risks when they stop smoking. The report describes numerous intervention programs and trials in this country and abroad, concluding that the effectiveness of the interventions increases when multiple methods such as individual counseling, group sessions, and media campaigns are appropriately combined with proper reinforcement and follow-up. Reported by the Office on Smoking and Health, Public Health Svc; Behavioral Epidemiology and Evaluation Br, Div of Health Education, Center for Health Promotion and Education, CDC.

Editorial Note

Editorial Note: The DHHS report on smoking and cardiovascular disease (1) summarizes evidence on the association of smoking and several forms of CVD, especially the well-established relationship between smoking and CHD. The report adds additional support to the statement in the 1979 Surgeon General's Report on Health Promotion and Disease Prevention that "Cigarette smoking is clearly the largest single preventable cause of illness and premature death in the United States" (2).

Progress has been made in reducing the proportion of adults who regularly smoke in the United States from 43% in 1966 to 33% in 1980. Risk-factor prevalence surveys in 1982 indicate a range of 23%-37% among participating states (3-5).

It has been estimated that, from 1964 to 1978, more than 200,000 premature, smoking-related deaths were avoided because persons had either not started smoking or had given up smoking cigarettes (6). Nevertheless, with over 300,000 premature, smoking-related deaths every year, additional efforts to prevent cigarette smoking and to promote smoking cessation are essential.

References

1. Office on Smoking and Health. The health consequences of smoking: cardiovascular disease. A report of the surgeon general. Rockville, Maryland: Public Health Service, U.S. Department of Health and Human Services, 1983.

2. Office of the Assistant Secretary for Health. Healthy people, the surgeon general's report on health promotion and disease prevention. Public Health Service, U.S. Department of Health, Education, and Welfare, 1979;121.

3. CDC. Behavioral risk factor prevalence surveys--United States, first quarter 1982. MMWR 1983;32:141-3.

4. CDC. Behavioral risk factor prevalence surveys--United States, second quarter 1982. MMWR 1983;32:370-2.

5. CDC. Behavioral risk-factor prevalence surveys--United States, third quarter 1982. MMWR 1983;32:603-4, 609-10.

6. Warner KE, Murt HA. Premature deaths avoided by the antismoking campaign. Am J Public Health 1983;73:672-7.

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