Liz Szabo

USA TODAY

A new report from the surgeon general finds that smoking causes even more physical and financial damage than previously estimated, killing 480,000 Americans a year from diseases that include diabetes, colorectal cancer and liver cancer.

The report, released today, represents the first time the surgeon general has concluded that smoking is "causally linked" to these diseases. The report finds that smoking causes rheumatoid arthritis, erectile dysfunction and macular degeneration, a major cause of age-related blindness. Smoking causes inflammation, impairs immune function and increases the risk of death from tuberculosis, an infectious disease. Smoking also harms pregnant women and their fetuses by causing birth defects called cleft lips and palates and by causing ectopic pregnancy, which occurs when a fertilized egg implants in the fallopian tubes instead of the uterus.

The new report — issued 50 years after the first surgeon general report on smoking — finds that exposure to secondhand smoke, previously linked to cancer and heart attacks, also causes strokes.

"Amazingly, smoking is even worse than we knew," says Thomas Frieden, director of the Centers for Disease Control and Prevention. "Even after 50 years, we're still finding new ways that smoking maims and kills people."

In spite of 31 previous surgeon general reports on smoking, "the battle is not over," says acting Surgeon General Boris Lushniak. "The problem isn't solved. We still have 18% of our adult population smoking. And 5.6 million kids who are alive today will die early unless we take immediate action."

If it undertakes aggressive measures — such as educational campaigns, tax increases and bans on smoking in public places — Lushniak says the USA has the potential to "create a tobacco-free generation."

The report raises the annual death toll from smoking by about 37,000 additional lives lost, noting that tobacco has killed 20 million Americans since 1964, when the first surgeon general report on smoking was released. The higher death tolls reflect new science about how tobacco harms the body, the report says.

Nearly 2.5 million of those premature deaths were in non-smokers exposed to secondhand smoke. An additional 100,000 were babies who died of sudden infant death syndrome (SIDS) or complications from prematurity, low birth weight or other conditions caused by parental smoking.

Edward McCabe, the March of Dimes' chief medical officer, says he hopes the report will give women even more motivation to quit smoking before becoming pregnant. Nearly 21% of women of childbearing age smoke, although many quit at least temporarily after learning they're pregnant.

The American Diabetes Association has long advised diabetics to avoid tobacco smoke, says Robert Ratner, the group's chief scientific and medical officer. Smoking impairs how the body responds to insulin, he says.

Ratner says the science on smoking and diabetes is not clear-cut. Though population-based studies show smokers have an increased risk of diabetes, Ratner says, "I am unaware of any data which directly links smoking to causing diabetes."

Smoking exacts a huge financial toll, as well, costing the country nearly $286 billion a year in direct medical costs of smokers and those exposed to secondhand smoke, as well as in lost productivity due to premature deaths, the new surgeon general report says.

The report notes that the country has made major progress in combating tobacco since the 1964 report. Adult smoking rates have fallen by more than half since then to about 18%. In 2011, for the first time, a Gallup poll found that a majority of Americans supported a ban on smoking in all public places.

David Sutton, a spokesman for Altria, the parent company of tobacco giant Philip Morris USA, says he doesn't contest the scientific evidence that cigarettes cause cancer and other diseases.

"As we've said for some time, there is no safe cigarette," Sutton says. Philip Morris supports strong FDA regulation of tobacco, as well as tobacco-free products, such as electronic cigarettes. "FDA regulation has the potential to reduce the harm caused by smoking."

A spokesman for R.J. Reynolds Tobacco, a leading cigarette maker, declined to comment.

The American Lung Association and other health groups say the USA should aim to reduce adult smoking rates to less than 10% within the next 10 years.

The lung association outlined several steps to achieve this goal:

•The White House should release long-awaited rules regulating all tobacco products, including e-cigarettes and cigars. The group called on the White House to ensure all smokers have access to approved smoking-cessation medications and counseling.

•Congress should increase federal tobacco taxes and close loopholes, so all tobacco products are taxed equally.

•The Food and Drug Administration should remove menthol-flavored cigarettes from the market as a way to reduce the number of new smokers.

•States should fully fund anti-smoking efforts. States receive about $80 per person a year from the Master Settlement Agreement of 1998, between tobacco companies and state attorneys general, Frieden says. Although the CDC recommends that states spend at least $12 per person annually on tobacco control, states spend an average of $1.50. In comparison, Frieden says, the tobacco industry spends an average of $28 per person each year to promote its products.