impaired exercise capacity because of angina pectoris, intermittent claudication, or COPD (US Surgeon General, 2004).

Smoking also interacts with other cardiac risk factors to increase the risk of cardiovascular disease. It increases heart rate, transiently increases blood pressure, and increases the complications of hypertension, including coronary heart disease and chronic renal disease. It also produces insulin resistance and increases the risk of non-insulin-dependent diabetes, which is another risk factor for coronary heart disease and chronic renal disease. Smoking is associated with an atherogenic lipid profile (higher low-density lipoprotein and lower high-density lipoprotein concentrations with more oxidized low-density lipoprotein), which aggravates the adverse effects of genetic factors, diet, or diabetes on blood lipids. Women who use oral contraceptives and smoke have a substantially increased risk of myocardial infarction and stroke, particularly if they are over 35 years old (US Surgeon General, 2004).

After acute myocardial infarction, the risk of recurrent myocardial infarction or death is much higher in current smokers than in former smokers. Smoking increases morbidity and mortality in patients with heart failure. Smoking cessation reduces mortality at least as much as does taking medications for heart failure (US Surgeon General, 2004).

Chronic Lung Disease

More than 80% of cases of COPD in the United States are attributed to smoking. Smoking also increases the risk of respiratory infection, including pneumonia, and results in greater disability from viral respiratory tract infection. Pulmonary disease caused by smoking includes the overlapping syndromes of chronic bronchitis, emphysema, and airway obstruction (US Surgeon General, 2004). Smoking also causes premature onset of decline in lung function and accelerates the age-related decline. Sustained smoking abstinence results in a return of the rate of lung-function decline to that of a never smoker (US Surgeon General, 2004).

Smoking may contribute to the development of asthma, but this potential link is confounded by the increased rate of pulmonary infections in smokers. Among asthmatics, current smokers experience more severe asthma, that is, more frequent symptoms and attacks. Exposure to secondhand smoke has been associated with increased risk of asthma in nonsmoking adults.

Smoking is associated with other pulmonary disorders, including respiratory bronchiolitis and desquamative interstitial pneumonia (Craig et al., 2004), interstitial lung disease (US Surgeon General, 2004),



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