Cigarettes: What the Warning Label Doesn't Tell You

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The First Comprehensive Guide to the Health Consequences of Smoking

Editor-in-Chief: Kathleen Meister, M.A.Editors: Gilbert L. Ross, M.D. Karen L. Schneider Elizabeth M. Whelan, Sc.D., M.P.H.Afterword by George D. Lundberg, M.D.- - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - -First Edition: New York, American Council on Science and Health, 1996
Second Printing: New York, Prometious Book, 1997
Second Edition: New York, American Council on Science and Health, 2003

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Cigarette Smoking: A Public Health Disaster

Kathleen Meister, M.A.

It is rare if not impossible to find examples in history that match tobacco's programmed trail of death and destruction. I use the word programmed carefully. A cigarette is the only consumer product which when used as directed kills its consumer.

Dr. Gro Harlem Brundtland1Director-General, World Health Organization (1998-2003)

Starting in 1966, cigarette packages sold in the U.S. were required to carry the following statement on their labels:

Caution: Cigarette Smoking May Be Hazardous to Your Health

This has to rank as one of the most profound understatements in human history.

The later versions of the label which used slightly stronger language and gave a bit more detail were not much better.

Cigarette smoking is not merely "hazardous to your health." It is an utter health disaster of a magnitude that could never be summarized in a little warning box on a product label.

On a global basis:

  • The use of tobacco, primarily in the form of cigarettes, kills four million people a year 11,000 a day.1 The death toll is expected to increase to more than eight million a year by 20202 because smoking rates in developing countries are increasing.
  • Based on current trends, it is estimated that more than 500 million people living today will die as a result of smoking.3
  • By 2020, it is predicted that tobacco use will cause over 12 percent of deaths globally.3

In the United States:

  • Smoking is the leading cause of preventable death, accounting for about 440,000 deaths per year4 roughly one in every five deaths.5
  • Each year smoking steals more than five million years from the potential lifespans of those who have died.4
  • If current trends continue, more than six million American children living today will die prematurely because of a decision that they will make, most likely during adolescence the decision to smoke cigarettes, which often leads to addiction.6

To put these statistics into perspective, it may be helpful to consider the impact of smoking in comparison to that of six other major causes of death in the United States: alcohol abuse, drug abuse, AIDS, motor vehicle crashes, homicide, and suicide. All six of these causes combined account for only half as many deaths each year as smoking does.7

Although national polls indicate that nearly 90 percent of Americans "know" that smoking is hazardous, most know it only in a superficial sense. They would find it difficult to compare the magnitude of this hazard with that of the many other hazards described on the warning labels of consumer products.

Consider, for example, the labels on packages of charcoal that warn that burning charcoal in a closed environment can result in the release of carbon monoxide. The warning is longer and more detailed than any of the four rotating warnings currently required on cigarette packages. It even includes drawings of three settings (a home, a tent, and a vehicle) in which charcoal grills should never be used.8,9 Consumers who read both the cigarette labels and the charcoal label might reasonably conclude that charcoal is at least as important a hazard as cigarettes. But in reality, carbon monoxide poisoning due to the indoor burning of charcoal accounts for about 20 deaths in the U.S. each year. That's less than one ten-thousandth of the number of deaths due to cigarette smoking.

The charcoal label and the cigarette label also fail to make a crucial distinction between the two products. Charcoal is safe when used correctly. Cigarettes are deadly when used as intended.

To give consumers a true idea of the hazards they face when smoking cigarettes, it would be necessary to have a warning label the size of a book specifically, the book you're now reading. In the pages of this book, the American Council on Science and Health (ACSH) will give you detailed information on the health impact of smoking, with each chapter addressing the effects viewed by a different medical specialty field. As you read this book, you will learn that cigarette smoking has adverse effects on virtually every part of the body and that it increases the risk of a wide variety of health problems.

You probably already know that if you smoke, you are increasing your risk of developing lung cancer. But you may not have known that you are also increasing your risk of conditions as diverse as pneumonia (Chapter 1), osteoporosis (Chapter 8), multiple sclerosis (Chapter 12), hearing loss (Chapter 14), macular degeneration (the leading cause of blindness in the elderly) (Chapter 15), and diabetes (Chapter 17). If you are a man, you are also increasing your risk of cancer of the penis (Chapter 2) and impotence, or erectile dysfunction (Chapter 11). If you are a woman, you are increasing your risks of cervical cancer (Chapter 2), infertility (Chapter 10), miscarriage (Chapter 10), and multiple complications of pregnancy (Chapter 10).

You may have realized that smoking could land you in a cardiologist's office, but you may not have realized that it could also prompt visits to a dermatologist (Chapter 5) for the treatment of psoriasis, to an ophthalmologist (Chapter 15) for the treatment of cataracts, to a dentist (Chapter 16) for the treatment of periodontal disease, or to a gastroenterologist (Chapter 18) for the treatment of ulcers. All of these diseases are promoted by smoking. Your smoking might also land your child in a pediatrician's office. As you will learn in Chapter 9, exposure to parental smoking increases a child's risk of some of the most common and troublesome health problems of childhood, including colds, bronchitis, ear infections, and asthma. It also increases an infant's risk of dying of sudden infant death syndrome.

Smoking is able to cause such widespread health damage because it affects the whole body not just the organs of the respiratory tract that are directly exposed to cigarette smoke. Within seconds after cigarette smoke is inhaled, some 4,000 toxic byproducts are absorbed into the bloodstream and transported to every cell in the body. Nicotine and other tobacco smoke components can be measured in such seemingly remote tissues and fluids as seminal fluid, cervical secretions, the eyes, and the hair. Smoking doesn't just affect the lungs; it affects everything. But warning labels that mention only a few diseases don't give smokers this message.

Another important message that cigarette warning labels don't give you is that many of the adverse health effects of cigarette smoking are irreversible that is, they do not disappear completely after smoking cessation. Although it is true, as one of the rotating warning labels indicates, that quitting smoking reduces health risks, many of those risks are only partially reversible. Ex-smokers continue to face increased risks of many smoking-related diseases and health problems, including lung cancer,10-12 bladder cancer,13 chronic obstructive lung disease,14,15 osteoporosis,16,17 macular degeneration,18,19 cataracts,20 and musculoskeletal pain.21 Only for heart disease and stroke is there good evidence that the risks ever return to those of a lifelong nonsmoker and even that takes from five to 15 years after smoking cessation.15,22-25

It has been estimated that between 10 and 37 percent of ex-smokers will die of smoking-related causes.26 Although this is certainly better than the situation among people who continue to smoke (approximately half of whom will die of a smoking-related disease), it is a clear indicator that some of the harm caused by smoking cannot be undone.

In addition, for many people, smoking itself is irreversible. Even with multiple attempts and the help of modern smoking cessation therapies, many smokers never succeed in quitting smoking permanently. The addictive power of nicotine (a topic discussed in detail in Chapter 13) is so strong that millions of people continue to smoke (despite multiple attempts to quit) even though they know that cigarettes may kill them.

Young people who assume that all of the health hazards of cigarettes will disappear in a puff of smoke when they quit are wrong dead wrong. And those who think that smoking for only a few years or smoking only a relatively small number of cigarettes per day is harmless are also wrong. Smoking for as short a time as five years can cause damage some of it permanent to the lungs, heart, eyes, throat, urinary tract, digestive organs, bones, joints, and skin.27And research has shown that even smoking "occasionally" (less-than-daily), smoking of only 3 to 5 grams of tobacco daily (approximately 4 to 7 cigarettes), or smoking "without inhaling" can increase rates of heart disease and overall mortality.28,29

Actually, the idea that smoking just a little can be harmful to health should not come as a surprise. The amount of tobacco smoke exposure that results from smoking in small amounts is similar to the amount that results from frequent exposure to tobacco smoke in the environment. It is well documented that exposure to environmental tobacco smoke irritates the eyes, nose, and respiratory tract; increases the risk of respiratory ailments; exacerbates existing respiratory diseases, such as emphysema and asthma; and if exposure is extensive is a risk factor (though a weak one) for heart disease and lung cancer.30

In terms of health effects, cigarette smoking is quite different from the drinking of alcoholic beverages.31 It is possible indeed, it is common for people to drink alcoholic beverages safely, and there is substantial scientific evidence showing that the consumption of moderate amounts of alcohol has net health benefits for some people. In contrast, there is no such thing as a potentially beneficial "moderate" level of smoking. While it is true that smoking may actually protect against a few diseases (most notably Parkinson's disease [see Chapter 12] and ulcerative colitis [see Chapter 18]), probably as a result of pharmacological actions of nicotine, these potential benefits are more than offset by the extensive harm caused by smoking's other effects in the body.

The American Council on Science and Health has prepared this book to inform smokers and those who may be thinking about trying cigarettes about the health risks that they face. The book is also intended as a primer to inform participants in the public policy debate about cigarettes. Public health professionals, health care providers, and antismoking activists will find the book to be a unique reference source regarding the hazards of cigarette smoking.

In view of the grave importance of the subject matter in this book, ACSH wants to present readers with a report of the highest caliber. To that end, each chapter of this book has been carefully researched by ACSH and then reviewed by an expert in the corresponding field of medicine. For this revised edition, each chapter has been updated to reflect the latest scientific findings and then reviewed again to ensure that it is accurate and current. ACSH is grateful for the assistance of the experts who reviewed the first and second editions of this book; without their help, this book could not exist.

The commercial manufactured cigarette made its appearance as a consumer product in the early years of the twentieth century. By the end of the century, it had killed more than 100 million people.32 It is the hope of the authors of this book that if people learn the full truth about the magnitude and extent of the risks of cigarette smoking, the history of cigarettes in the twenty-first century will have a happier ending.


1 World Health Organization, Tobacco Free Initiative Web site,

2 World Health Organization, Tobacco Free Initiative Web site,

3 The Cancer Council (Australia), Global Smoking Statistics,

4 Centers for Disease Control and Prevention. Annual smoking-attributable mortality, years of potential life lost, and economic costs United States, 1995-1999. JAMA 2002;287:2355-2356.

5 Centers for Disease Control and Prevention. Cigarette smoking-related mortality (fact sheet), July 2001, available online at

6 Centers for Disease Control and Prevention. Overview (of Tobacco Information and Prevention Source statistics), November 2002, available online at

7 Centers for Disease Control and Prevention. Comparative causes of annual deaths in the United States, November 2000, available online at

8 Consumer Product Safety Commission. CPSC votes to revise the carbon monoxide warning label on charcoal packaging, press release #96-106, issued April 18, 1996.

9 Consumer Product Safety Commission. CPSC warns never use charcoal grills indoors, press release #99-051, issued January 15, 1999.

10 Samet JM. The health benefits of smoking cessation. Medical Clinics of North America 1992;76:399-414.

11 Halpern MT, Gillespie BW, Warner KE. Patterns of absolute risk of lung cancer mortality in former smokers. Journal of the National Cancer Institute 1993;85:457-464.

12 Wakai K, Seki N, Tamakoshi A, Kondo T, Nishino Y, Ito Y, Suzuki K, Ozasa K, Watanabe Y, Ohno Y. Decrease in risk of lung cancer death in males after smoking cessation by age at quitting: findings from the JACC study. Japanese Journal of Cancer Research 2001;92:821-828.

13 Hartge P, Silverman D, Hoover R, Schairer C, Altman R, Austin D, Cantor K, Child M, Key C, Marrett LD, et al. Changing cigarette habits and bladder cancer risk: a case-control study. Journal of the National Cancer Institute 1987;78:1119-1125.

14 He Y, Taihing L, Shi Q, Huang J, Zhang F, Wan Z, Li L. A prospective study on smoking, quitting, and mortality in a cohort of elderly in Xi'an, China. Zhonghua Liu Xing Bing Xue Za Zhi 2002;23:186-189.

15 U.S. Department of Health and Human Services. Health Benefits of Smoking Cessation. A Report of the US Surgeon General. Rockville, MD: National Institute on Drug Abuse, 1990.

16 Ward KD, Klesges RC. A meta-analysis of the effects of cigarette smoking on bone mineral density. Calcified Tissue International 2001;68:259-270.

17 Law MR, Hackshaw AK. A meta-analysis of smoking, bone mineral density, and risk of hip fracture: recognition of a major effect. British Medical Journal 1997;315:841-846.

18 Seddon JM, Willett WC, Speizer FE, Hankinson SE. A prospective study of cigarette smoking and age-related macular degeneration in women. JAMA 1996;276:1141-1146.

19 Christen WG, Glynn RJ, Manson JE, Ajani UA, Buring JE. A prospective study of cigarette smoking and risk of age-related macular degeneration in men. JAMA 1996;276:1147-1151.

20 Christen WG, Glynn RJ, Ajani UA, Schaumberg DA, Buring JE, Hennekens CH, Manson JE. Smoking cessation and risk of age-related cataract in men. JAMA 2000;284:713-716.

21 Palmer KT, Syddall H, Cooper C, Coggon D. Smoking and musculoskeletal disorders: findings from a British national survey. Annals of Rheumatic Diseases 2003;62:33-36.

22 American Lung Association. "What are the benefits of quitting smoking?" Available at Accessed January 30, 2003.

23 Tverdal A, Thelle D, Stensvold I, Leren P, Bjartveit K. Mortality in relation to smoking history: 13 years' follow-up of 68,000 Norwegian men and women 35-49 years. Journal of Clinical Epidemiology 1993;46:475-487.

24 Jorenby DE. Smoking cessation strategies for the 21st century. Circulation 2001;104:e51.

25 Kawachi I, Colditz GA, Stampfer MJ, Willett WC, Manson JE, Rosner B, Hunter DJ, Hennekens CH, Speizer FE. Smoking cessation in relation to total mortality rates in women. A prospective cohort study. Annals of Internal Medicine 1993;119:992-1000.

26 Centers for Disease Control and Prevention. Projected smoking-related deaths among youth United States. Morbidity and Mortality Weekly Report 1996;45:971-974.

27 American Council on Science and Health. The Irreversible Health Effects of Cigarette Smoking, New York, ACSH, 1998.

28 Luoto R, Uutela A, Puska P. Occasional smoking increases total and cardiovascular mortality among men. Nicotine and Tobacco Research 2000;2:133-139.

29 Prescott E, Scharling H, Oster M, Schnohr P. Importance of light smoking and inhalation habits on risk of myocardial infarction and all cause mortality. A 22-year follow up of 12,149 men and women in the Copenhagen city heart study. Journal of Epidemiology and Community Health 2002;56:702-706.

30 American Council on Science and Health. Environmental Tobacco Smoke: Health Risk or Health Hype? New York, ACSH, 1999.

31 American Council on Science and Health. A Comparison of the Health Effects of Alcohol Consumption and Tobacco Use in America, New York: ACSH, 2000.

32 Ravenholt RT. Tobacco's global death march. Population and Development Review 1990;16:213-239.

Table of Contents
Cigarettes: The Undisclosed Medical Risks
Dr. Elizabeth M. WhelanPreface
Dr. Gilbert L. RossIntroduction
Cigarette Smoking: A Public Health Disaster

Kathleen Meister, M.A.Chapter 1
Smoking and Lung DiseaseChapter 2
Oncology: Smoking and Cancer Risk

Chapter 3
Smoking and Heart Disease

Chapter 4
Smoking and Peripheral Vascular Disease

Chapter 5
Smoking and the Skin

Chapter 6
Surgical Risk and Smoking

Chapter 7
Smoking and Orthopedic Problems

Chapter 8
Smoking and Rheumatologic Conditions

Chapter 9
Environmental Tobacco Smoke and Pediatric Illnesses

Chapter 10
Smoking and Complications in Obstetrics and Gynecology

Chapter 11
Urology: Effects of Smoking on the Kidneys, Excretory System, and Male Sexual and Reproductive Function

Chapter 12
Smoking and Neurological Disorders and Stroke

Chapter 13
Psychiatry: Smoking, the Brain, Behavior, and Addiction

Chapter 14
Otolaryngology: Problems of the Ears, Nose, and Throat Associated with Smoking

Chapter 15
Smoking and the Eyes

Chapter 16
Smoking and Oral Health

Chapter 17
The Endocrine System, Metabolism, and Smoking

Chapter 18
Gastrointestinal Diseases and Smoking

Chapter 19
Smoking and the Immune System

Chapter 20
Smoking and Emergency Medicine

George D. Lundberg, M.D.


Also see our site for teens detailing the specific health effects of smoking: