In summary, the majority of studies so far reported indicate
that cigarette smokers run a higher risk of developing postopera-
tive pulmonary complications than do nonsmokers, corroborating
a long-held clinical impression. The risk of developing such com-
plications appears to increase with increasing dosage of cigarette
smoke.

SUNNARY AND CONCLUSIONS

1. Cigarette smoking is the most important cause of chronic ob-
structive bronchopulmonary disease in the United States. Ciga-
rette smoking increases the risk of dying from pulmonary emphy-
sema and chronic bronchitis. Cigarette smokers show an increased
prevalence of respiratory symptoms, including cough, sputum pro-
duction, and breathlessness, when compared with nonsmokers.
Ventilatory function is decreased in smokers when compared with
nonsmokers.

2. Cigarette smoking does not appear to be related to death from
bronchial asthma although it may increase the frequency and se-
verity of asthmatic attacks in patients already suffering from this
disease.

2. The risk of developing or dying from COPD among pipe and/
or cigar smokers is probably higher than that among nonsmokers
while clearly less than that among cigarette smokers.
4. Ex-cigarette smokers have lower death rates from COPD
than do continuing smokers. The cessation of cigarette smoking
is associated with improvement in ventilatory function and with
a decrease in pulmonary symptom prevalence.
5. Young, relatively asymptomatic, cigarette smokers show
measurably altered ventilatory function when compared with non-
smokers of the same age.

6. For the bulk of the population of the United States, the im-
portance of cigarette smoking as a cause of COPD is much greater
than that of atmospheric pollution or occupational exposure. HOW-
ever, exposure to excessive atmospheric pollution or dusty occupa-
tional materials, and cigarette smoking may act jointly to produce
greater COPD morbidity and mortality.

`7. The results of experiments in both animals and humans have
demonstrated that the inhalation of cigarette smoke is associated
with acute and chronic changes in ventilator-y function and pul-
monary histology. Cigarette smoking has been shown to alter the
mechanism of pulmonary clearance and adversely affect ciliary
function.

8. Pathological studies have shown that cigarette smokers who
die of diseases other than COPD have histologic changes charac-


teristic of COPD in the bronchial tree and pulmonary parenchyma
more frequently than do nonsmokers.
9. Respiratory infections are more prevalent and severe among
cigarette smokers, particularly heavy smokers,  than among
nonsmokers.

10. Cigarette smokers appear to develop postoperative pulmo-
nary complications more frequently than nonsmokers.

CHRONIC OBSTRUCTIVE BRONCHOPULXONARY

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217


RRONCHOPTJLMONARY

APPENDIX TABLES

219


TABLE AZ.-,Smoliing and c/Lronic obslrrrctiua pttlwonar~ discase su'ttptonls'-percolt prevalence
     (Numbcn in garcnthcwe rcprcscnt tolnl number of individusl in yatiiculnr smoking group)
               Shl = Smokera.      NS = Nanamokcra.     EX ; Ex-amokere.

Author,
  ycllr,
countl-Y,  Nutt$rO;nd                                  Drcnlhl~~snns
                       Cowh        Sputum production      or dyspnea       Chest illncssses        Other         Commenle
rcfcrcnce     DoPUhtiOn                                                                           ____
Short     2,031 male and     NS I... 1.6 (496)                              NS ,, .ID.O                 C.hril illnrssra

Oswnld    3,602 male nnd                                                            Chronic Bronchilir   Chronic
and      2.2*12 femnle                                                                 nfh        br<lncllltlJ
Mcdvei,    clerical                                                              NS , ., 16.8  (470   J~fi$,rLl IlY
1956.     workers (k-65                                                    sm ., ..16.4 (1.940)    halrilul\l
England   YCRt3 of age.                                                                FClTdCl       cuuuh nnd
(178).                                                                      NS  ,.,.,. 12.1 (610)   Rpill"",
                                                                     sm .,,... la.8 (618)   ,>rducLllln.

PhilliDe    1.274 mnle       NS `2.0  (461)
et al.,     fnctor~ workcn   sm . ..Gl.O  (823)
1966.     wiLhout overt
U.S.A.    pulmonary
(185).    dircnsc or
        hcnrt failure.

   Higgins    301 male nnd                    Ccmoh and spufum                               Chronic Bronchilia
    1957,     280 ffmnle                         hfolcs           Malea          `41&l            Malts
    Enslnnd   i-oral dwellers                  NS . ,,  7.1   (28)   NS..........7.1 NS . . . ..I... a.6 NS I,,.... 3.6
   (II?).    26-74 yeDrS of                  SM . ,. ,. 63.9  (222)   531 ..I. . . . ...19.8  Shl . . . . . . . . . 17.1  Sbf  , ., I.. 9.9
            we.                            FtWU21.24         Ft??7l~fGJ         FO7I&#           FL-?Mlt-,
                                   NS ., ,, 4.6 (176)   NS .,I. . . . ...21.6  NS . 9.7  NS . ,, . ., 3.4
                                     sm ,... 17.2   (93)   sm . , . 9.1  Shf .a . . ..16.1  Shl . . . . 8.6
k
r


T,\nr.~ A2.-Smokhg and chronic obstructive pulmonary, disease sl/jliptotlis +m+xnt pcvalence (coral.)
       (Numbers in pnrcnthcvrs rcyrescnt tatnl number of individunl~ in vnrticular smoking nroUV)
                 Sbl = Smokers.      NS = Nunsmokers.      EX = Ex.amokrra.

and      92 frmnlcs
Cochran.   randomly chosen
1958.      (members of an
England   agricullurel
(114).     commur*itu.)

Edwards   1,131 male out-
et al..     ImticntY on
1959.     lists of
Ennlnod   lmlcral prnc-
(74).     titionera >60
        YCPci of DBF.

Cammrnta

Couoh and sputum    NS .,... . . . . ...33.3 NS I..,. 0.0           hlalca
NS     (6)  S!d . . . . . . . . . ...29.3 SH 16.0     NS . . . . . . . 0.0
Sbf ., ..24.0  (151     FtWIalW        Femdcs      SM  . . . 6.7
NS ., ,, 3.1   (G4)  NS . . . . . ...46.3 NS . 10.9          FCrntllC#
Shl .I ,I 3.0  (20)  SH ..,.., .20.0 Shf ..I 10.0     NS  . ,,,, .` 0.0
                                        S.M  ,,....I 6.0

                                          Chronic bronchilir
                                        NS  .,, ,, 1C.6   (151)
                                        Cigarette8 29.1   (778)
                                        l-9 . ...23.4  (236)
                                        lo-19 . ...31.2  (361)
                                       >20  . . . . . 33.7 (176)
                                       Pipe  . . . 18.6  (340)

-

Flick     222 mnle        NS . . . . . . . 10.0  (61) NS ..,,,.... 26.0  (49)               NS . . 30.0 (47)
and      pntitnts not     sm ,. ,. ..66.0 (167) Sbl ,, ..66.0 (1.66)               SM . . . 60.0(138)
Pnton,    auffvrina from
1359.     avert rnnlio-
U.S.A.    D\lllilOnF.~y
(86).     dincnac. ZO..OO
        r*rnofopc.

Hiuuina    716 maln In                    Couoh and c~ulutn                               Chronic bronchitis
et al.,     VR?/OUI                      SM ,. ., ., ,. 7.1  (86)  NS . ,. . . . . .a.., 0.4 NS s I. . . 7.1     SM  , ,,.., 14.3
106D.     OCCUD~UO~~                   NS ,. ., ,. 36.0  (1176)  SM ,, ,, ,, ,. ,, .24.9 SM .a .a 20.2     NS . . . . . . 3.b
England   26-64 yc(~rc,
(IIS).    of age.


--

Liebnchuetr,l47 male        NS ,. ,, ,. 0.0  (621

   lC59,     soldiers       Shi ,. ., ,. 13.0  (83)
   Elsland   20-30 years
    tl.76).    of ogc.
  - --
  Ashford    4.014 male
   Et al.,                                                                  Rcnpiraloru ayrn~,lomr Rwpirntov
           coal workers.                                                          NS . . . . . . 103  (677)   symplumn-
   lQC\.                                                                     EX  . ,. ,. 19.6
   ,England                                                                           (123)   "bronchitis
                                                                           and/or
    (11).                                                                 Cignrcttes 21 1 (1,604)
                                                                           Pipe only 36.1  (202)   uthmn". Nu
                                                                           Cizarcttn           duua 1.<,1>,-
3                                                                           and DIDC 37.1   (90)   tionslaip
                                                                           AIlShI 21.7 (3,210   f"Ul-ld.


t4             TAllI E A2.- .Ytt~okin~~ 117rtf chrouic obstricclilrc prtlt~lcr?rcrrl~ tliucccw .ul/~Jr/J~o~~lY'--
td                                         ],c:rcclll /murlfcm: (CWll.)

IP               (N\,,,,~,Q~ ,n ,,nrcnthws rrprcucnt t,,tuI n,,n\l~cr of l,~dlvldunl~ in ~nrtlcufnr amokinv k!:ro'JD)
                                 SM z= Slnok~rr.      NS ~1 Nunanwkvra.      1,:~ := Ex.smokurs.

      Author,
       YPUi-.     NumLcrnnd                                 Urcnthlc~sncas
      country.      type uf        Cough        Sputum prduction     01 dyapnea      Chest illnesses        Other         Comment.9
     rrfcrrncc    nnpulntion
    -______- --
    Dnwcr.    06 malt nnd      NS . . . . . . . . 4.1  (49)   NS .,. . . ...20.4                  NS . . . .31.7                    Cheat lllnws-
     1861.     11 lcmulc      Shl .#. .27.0  (76)   Shl  . . . . . ...34.2                  Sht ,,.,.I 88.2                     clllY!t COllll
     U S.A.    bnuk om~~loycoa l'lvc, clunr 1.   (19)   l'inc. clgor lG.4                 I'il~c.cluar                       duringcach
     01).     40.10ycnrs                                                     63.0                     01 Ilint z
             of I,YV.                                                                           Wlr~tPIR.
              -
    Flrtchvr nnd 3G3 mnlc I.w~don                                                                           --
                       NS . ,  8 ,   (80) NS  ..,..,.a., 8.7    NS . . . . . . . . .  .I   NS . . .a. 4.S
     Tlukcr,    trQnalwrt     t-14 g./dny 16.6 (1GC)   I-14 a./dny ..ZI.U    1..14 n./dny *. 8.2   1-14 n./doy
     lOGI,     Cm[ll"Yl'L*     >lS . . . ...27.0 (110)   >lG  . . . . . . . ..aO.D    >lG . . ...*.. 8.0         8.2
     Ynulnnd   40 GoYchrI                                         >lS . ...10.7
      185).     01 DPB.

    Read     170 malcand           M&a
      and      132 Iernnlc     NS ..,..s.. 4.4
      SCIIJY.     indlvldunla     SM . . . . . ...23.1
      1961.     lntervicwed     EX . . . . . ...21.2
      Auatdlr   inanoub           FHlt.llC~
      (191).    Datient       NS , 4.9
             clinic (not     SM . . . . . ...18.6
             all paticntsl,

     BIlebum   1.461rnale      NS . . . . ...10.2  (263)   NS..........ll.O NS.......... 9.8
      et al..     llaht        SM . . . . . . ..23.3(1.108)   SM ., . . . . ...30.4    SM . . . . . . . ...14.6
      IDVZ.     Industry      <I wck.           <I wck-
      U.S.A.                                           <1 rx~ck-year .lO.O
             cmvloym in     YCar . . . ..ll.O  (267)
      (PO.                                year . . . ...12.0     I- u . . . . . ...12.0
             C~lifomla.     l- 9 . . . ..I?.0 (2Ed)    l- 9 . . . . . . ..u.o    lb-10 . . . . . . ..ll.O
                      10-19 . . ...26.0 (aos)   lib-19 . . . . . ...32.0    20-29 . . . . ...18.0
                        20.29  . . ...21.0 (236)   20-2'3 . . . . . . . . 34.0    30-39 . . . . . ...21.0
                        30-31  . . ...28.0 (144)   30-39 . . . . . ...40.0    40-49 . . . . . ...13.0
                        ra-49  . . . ..ae.o  (12)   40-49 . . . . . . . . 37.0    m-59 * ,. .* . . .9&O
                        60-69  . . ...84.0  (28)   So-60 . . . . . ...46.0    >60  .,. . . ,, .29.0
                        PO  . . . ..GO.O  (24)   X0  *..II... 62.0


?`,\uLE AZ.-Slnoking and chronic obstwclil~e pulmomr~ discasc' .S~III~~O~II.S `-.-pcrcoil prcunleuce (co?it.)
       (Numbers In ~nrentbrsw re~resrnt tutnl number ol individunls in ~nrticular smoking aroun)
                 SM = Smokcra.     NS = Nonsrnoken.     EX = Ex-smokers.

Author,
  YCPT,     Number snd                                  nrenthlcssnns
countrY,      type of         Cough        Sputum Drduction     or dyspnea      Chest illness-        Other        Commcnte
refrrencc   population
           -
Boucot    6,137 mslcs      NS . . 13.0  (806)
et Ill.. 1862.  cnroliina      SM .31,6(6.331)
U.S.A.    in pulmonary
(36).     neoplasm project.

Ftrria    90 male and                                                            Chraic Nonrpccific
CL &I,.     71 female                                                            Reepiralory Dbcosc
llC2.     Rnx mill-                                                                 n1a1ca   Frtlld<I
U.S.A.    workers.                                                             NS  ..lG,O(?O) lO.O(GO)
(Rf).                                                                      ES  , 12.6(16)
                                                                         I-20 .27.3(X22) , ,
                                                                    >20 .63.1(32) GO.0 (4)

   Fenis    642 male and                                                             Chronic Irorkchilir   hgc-,prcifir
    and      6?5 frmnle                                                                 ?lrnlCI        r*tm.
    AlldCrWn.  wnidcnts of                                                           NS  . . . . . . 13.8  (126)
    1962.     New Iinmpshire                                                        EX . ,, ,, ..lI.O   (77)
    U S.A.    town chosen                                                          Cianrcttcs 40.3  (340)
    IElI.     by randurn                                                            l-10 . ...218
           rumpling of                                                           11-20 . .34.2
           CC"S"S.                                                              21-30 . 4?.3
                                                                           31-40 G1.1
                                                                           >:I  ., .SG.3
                                                                           F'cnlol~,
                                                                           NS . 0.4  (97Lo
                                                                           El . 10.8   (37)
                                                                           Cignrcttn 19.8  (208)
                                                                           I-10 .13.1
                                                                           II-20 ..I. 22.2
                                                                           21-30
                                                                           31-40 .27.3
F=:                                                                           >41  .`
u                                                                           --