1. What are the health effects associated with cigar smoking?

From the available scientific evidence, it is now clear that cigar smoking causes a variety of cancers including cancers of the oral cavity (lip, tongue, mouth, throat), esophagus, larynx, and lung. Furthermore, there is evidence which strongly suggests that cigar smoking is associated with cancer of the pancreas. Many of these cancers are associated with extremely low cure rates. For example, approximately 11 percent to 14 percent of patients with lung and esophageal cancers survive five years after diagnosis and only about 4 percent of pancreatic patients survive five years.

Daily cigar smoking, particular among those who inhale, also causes an increased risk for coronary heart disease and chronic obstructive pulmonary (lung) disease.

2. What are the health risks associated with moderate cigar use?

Smoking only one to two cigars per day has significant health risks. For example, smoking one to two cigars per day doubles the risk for oral cancers and esophageal cancer compared to someone who has never smoked. And someone smoking at the same moderate level (one to two cigars daily) increases the risk of cancer of the larynx by more than six times that of a nonsmoker.

Like cigarette smoking, the risks from cigar smoking increase with the number of cigars smoked per day. Smoking three to four cigars per day increases the risk of oral cancers to 8.5 times greater than the risk of a nonsmoker, and smoking more than five cigars daily raises the oral cancer risk to 16 times the level for nonsmokers.

3. What is the effect of inhalation on disease risk?

One of the major differences between cigar and cigarette smoking is the degree of inhalation. Almost all cigarette smokers report inhaling while the majority of cigar smokers do not.

In spite of these differences, cigar smokers and cigarette smokers have similar levels of risk for oral, throat, and esophageal cancers. For example, the risk of oral cancers among daily cigar smokers (smoking one or more cigars per day) who do not inhale is seven times greater than for nonsmokers; larynx cancer risk is more than 10 times greater than that of nonsmokers. Even the risk of lung cancer among non-inhalers who are daily cigar smokers is double the risk of nonsmokers.

However, the degree of inhalation of cigars does have a strong effect on disease risk. Compared to nonsmokers, cigar smokers who reported inhaling deeply had 27 times the risk of oral cancer, 15 times the risk for esophageal cancer, and 53 times the risk of cancer of the larynx.

Cigar smokers have increased risks for lung and laryngeal cancers as well as heart and lung disease, compared to nonsmokers. But the risks for these diseases are lower for cigar smokers compared to cigarette smokers. Reduced inhalation probably plays a strong role in lowering these risks. However, with regular use and inhalation, the heart and lung disease risks of cigar smoking may approach those of cigarette smoking. In fact, the lung cancer risk from inhaling moderately when smoking five cigars per day is comparable to that from smoking one pack a day of cigarettes.

Inhalation also plays a role with cigar smokers who have a history of cigarette smoking. This group of smokers is more likely to inhale cigar smoke. For these smokers, the disease risks are uniformly higher than among cigar smokers who have never smoked cigarettes.

4. Why are the health risks associated with cigar smoking different from those associated with smoking cigarettes?

Health risks associated with both cigars and cigarettes are strongly linked to the degree of smoke exposure. Since smoke from cigars and cigarettes are composed of many of the same toxic and carcinogenic compounds, the differences in health risks appear to be related to differences in daily use and level of inhalation.

Most cigarette smokers smoke every day and inhale. In contrast, as many as three-quarters of cigar smokers smoke only occasionally, and some may smoke only a few cigars per year. The majority of cigar smokers do not inhale.

All smokers, whether or not they inhale, directly expose the lips, mouth, throat, larynx and tongue to smoke. In addition, smoke constituents in the saliva are swallowed into the esophagus. This exposure probably accounts for the fact that oral and esophageal cancer risks are similar in both cigar smokers and cigarette smokers.

For non-inhalers, the larynx, which lies between the oral cavity and lung, receives less exposure than the mouth and oral cavity. Thus, cancer of the larynx occurs at lower rates in cigar smokers than cigarette smokers.

However, for smokers who inhale, the lung is much more heavily exposed and many more smoke constituents are absorbed into the blood compared to non-inhalers. Therefore, cigarette smokers experience higher rates of coronary heart disease, chronic obstructive lung disease and lung cancer than cigar smokers.

5. What are the hazards for nonsmokers exposed to cigar smoke?

Because cigars contain a greater mass of tobacco than cigarettes, they generate greater amounts of environmental tobacco smoke (ETS — also known as secondhand or passive smoke). ETS includes the smoke released from the smoldering cigar plus the exhaled smoke. In general, however, the ETS from cigars and cigarettes contains many of the same toxins and irritants (including carbon monoxide, nicotine, hydrogen cyanide, ammonia, volatile aldehydes) and human carcinogens (including benzene, aromatic amines, including the bladder carcinogens 2-naphthylamine and 4-aminobiphenyl, vinyl chloride, ethylene oxide, arsenic, chromium, cadmium, nitrosamines, and polynuclear aromatic hydrocarbons).

There are, however, some differences between cigar and cigarette smoke due primarily to the long aging and fermentation process for cigar tobaccos and lack of porosity of the cigar wrapper compared to cigarettes. Cigar tobaccos contain high concentrations of nitrogen compounds (nitrates and nitrites) which during fermentation and smoking give rise to increased levels of several tobacco-specific nitrosamines — some of the most potent human carcinogens known. In addition, the nonporous cigar wrapper makes combustion of cigar tobacco even more incomplete than cigarette tobacco. As a result, compared to cigarette smoke, the concentrations of nitrogen oxides, ammonia, carbon monoxide, and tar are higher in cigar smoke.

In addition, the larger size of most cigars (more tobacco) and longer smoking time, produces higher exposures of nonsmokers to many toxic compounds, including carbon monoxide, respirable suspended particulates, and polynuclear aromatic hydrocarbons than a cigarette. It has been estimated that compared to a cigarette, a large cigar emits up to 20 times more ammonia, five to 10 times more cadmium (a carcinogenic metal) and methylethylnitroasimine (a volatile nitrosamine), and up to 80 to 90 times as much of the highly carcinogenic tobacco-specific nitrosamines.

6. Are cigars addictive?

Nicotine is the agent in tobacco and tobacco smoke capable of producing addiction or nicotine dependence. Most cigars contain nicotine in quantities equivalent to several cigarettes and can deliver nicotine in concentrations comparable to those delivered by cigarettes and smokeless tobacco.

When cigar smokers inhale, nicotine is absorbed rapidly as it is with cigarette smoke inhalation. For those who do not actively inhale, nicotine is absorbed predominantly through the lining of the mouth which leads to a slower rise and lower peak of nicotine in the blood compared to cigarette smokers who absorb nicotine primarily through the lungs. However, both inhaled and noninhaled nicotine can be highly addictive. For example, the large number of people addicted to smokeless tobacco demonstrates that nicotine absorbed through the lining of the mouth is capable of forming a powerful addiction.

Studies documenting the frequency or intensity of nicotine dependence and withdrawal symptoms from cigar smoking have not been conducted. However, the pattern of cigar smoking in the population — infrequent use, low number of cigars smoked per day, and lower rates of inhalation compared to cigarette smokers — suggests that cigar smokers are less likely to be dependent on nicotine than cigarette smokers. Specifically, the fraction of adult cigar smokers who smoke daily appears to be smaller than the fraction of everyday cigarette or spit tobacco users. Also, recent data show that increase cigar use among adults is largely an increase in occasional smoking, suggesting that the risk of addiction is lower for cigars than for cigarettes. (See question 10).

7. What are the current patterns of cigar use in this country?

Since 1993, cigar use in the U.S. has increased nearly 50 percent. Small cigar consumption has increased modestly since 1993, about 13 percent, whereas consumption of large cigars has increased nearly 70 percent during this time period. Sales of premium cigars, most of which are hand-made and imported from the Dominican Republic, Honduras, Jamaica and other countries, has increased even more — an estimated 250 percent. These trends are in sharp contrast to cigarettes where consumption has declined by 2 percent since 1993.

8. Are the current trends in cigar smoking different than in past decades?

Yes. The increased cigar use since 1993 marks the reversal of a sustained decline in cigar smoking over the past several decades. Until 1993, consumption of large cigars had declined each year since 1965. Total cigar consumption (large and small cigars) declined by about 66 percent from 1973 until 1993.

Peak cigar sales in this country occurred in the decade following the publication in 1964 of the first Surgeon General's report warning about the health risks of smoking cigarettes. A loop-hole in the l969 law banning advertising of cigarettes on television and radio allowed the advertising of small cigars. (Small cigars are the size of cigarettes and the most popular brands contain filters and look like cigarettes.) Small cigar consumption increased rapidly in the early 1970s until television and radio ads for these products were banned by Congress in l973. After that, total cigar consumption began a steady decline which lasted 20 years.

Cigar use began to increase in the early 1990s coinciding with an increase in promotional activities for cigars. Some of these activities include the publication of Cigar Aficionado magazine beginning in 1992, the use of cigars by celebrities, and media coverage of highly publicized social events such as cigar banquets and cigar parties that featured expensive imported premium cigars.

9. Who are the new cigar users?

The current evidence strongly suggests that most new cigar users are teenagers and young adult males who smoke occasionally (less than daily).

Teenage boys are twice as likely to smoke cigars as teenage girls while adults males are about eight times more likely to smoke cigars, compared to adult females.

However, among older males (65 and older), cigar use has continued to declined since 1992.

10. How much has adult use increased?

Two large state-wide studies conducted among California adults in 1990 and 1996 report that cigar use has nearly doubled among males (from 4.8 percent to 8.8 percent) and increased nearly five times among women (from 0.2 percent to 1.1 percent). The greatest rate of increase was seen among younger males age 18 to 24 (from 4.2 percent to 12.4 percent — a nearly 200 percent increase).

Cigar use also appears to be increasing among higher socioeconomic status individuals, a group that had, in recent decades, chosen not to use tobacco (either by quitting or not beginning). In the California study, cigar use among males increased with increasing level of both education and income. Among California males with college or graduate degrees, for example, cigar use increased from 4.6 percent in 1990 to 11.4 percent in 1996 — an increase of approximately 150 percent. A similar pattern was observed by level of income where the highest rates of current use were seen among males with incomes greater than $50,000 a year.

This picture is opposite to what is observed among cigarette smokers, where the proportion of smokers declines with increasing income and education.

11. Are teens now using cigars?

Yes. A number of new studies (1996) are reporting high rates of use among not only teens but pre-teens. Furthermore, usage appears to be increasing among adolescent females as well as males.

One nationally representative study conducted in 1996 by the Robert Wood Johnson Foundation found that 26.7 percent of teenagers between the ages of 14 and 19 reported smoking one or more cigars in the past year. Nearly 3 percent of the sample reported smoking 50 or more cigars in the past 12 months.

Some school-based studies report that among adolescent boys the current level of cigar smoking exceeds their use of smokeless tobacco. For example, among nearly 7,000 Massachusetts school children, current cigar smoking (smoked cigars in the past 30 days) among males in the ninth through 12th grade was 14.9, 24.9, 30.3 and 23.7 percent, respectively. These rates are double their reported use of smokeless tobacco. Smokeless tobacco use is virtually non-existent among adolescent girls (usually less than 1 percent), but in the Massachusetts survey 6 percent or more of ninth, 10th and 11th grade girls reported they used cigars in the past month.

12. Is teenage cigar use likely to lead to nicotine addiction?

Even though there has been relatively little published research on nicotine dependence in cigar smokers, several observations are notable. Addiction studies with cigarettes and spit tobacco show clearly that addiction to nicotine occurs almost exclusively during adolescence and young adulthood when young people begin using these tobacco products. Some researchers are concerned that the current high rate of adolescent cigar use may result in a higher probability for nicotine dependence in this younger age group.

Two additional observations raise the concern that use of cigars may predispose individuals to the use of cigarettes. Data from the California survey showed that the relapse rate of former cigarette smokers who smoked cigars was twice as great as the relapse rate of former cigarette smokers who did not smoke cigars. The second is the observation that cigar smokers were more than twice as likely to take up cigarette smoking for the first time than people who never smoked cigars.

13. What is a cigar? How is it different from a cigarette?

For tax purposes, the Department of Treasury defines cigars as "any roll of tobacco wrapped in leaf tobacco or in any substance containing tobacco" while a cigarette is defined as "any roll of tobacco wrapped in paper or in any substance not containing tobacco."

Cigarettes are relatively uniform in size and appearance and contain less than one gram of tobacco each. Cigars, on the other hand, vary considerably in size, from the size of a cigarette to more than 7 inches long. Large cigars typically contain between 5 and 17 grams of tobacco.

It is not unusual for some premium cigars to contain the tobacco equivalent of an entire pack of cigarettes. Large cigars can take between one and two hours to smoke, whereas most cigarettes on the U.S. market take less than 10 minutes to smoke.

U.S. cigarettes are made from different blends of tobaccos. Most cigars are composed primarily of a single tobacco (air-cured or dried burley tobacco). Cigar tobacco leaves are aged for about a year and then subjected to a multi-step fermentation process which can last three to five months. The chemical and bacterial reactions during fermentation change the composition of the tobacco and produce the unique flavor and aroma of cigars.

14. What are the federal laws regulating cigars?

Cigars are subject to many fewer federal regulations that cigarettes and smokeless tobacco products.

In 1996, the Food and Drug Administration (FDA) assumed jurisdiction over cigarettes and smokeless tobacco products as drugs, but not over cigars. One result is that cigars have been excluded from regulations that would restrict youth access and limit advertising. For example, the regulation adopted in 1996 by the FDA to prohibit the sale of cigarettes and smokeless tobacco products to persons under age 18, as well as to restrict advertising directed toward youth, does not include cigars. (However, all 50 states and the District of Columbia have laws which either specifically address youth access to cigars or limit youth access to all tobacco products.)

Health warnings are required on cigarettes and smokeless tobacco labels, but no federal laws require health warnings on cigars. (None of the contents of tobacco products are required to be listed on the label.)

Since the mid-1960s, the Federal Trade Commission has overseen a testing program to report yields of tar, nicotine and carbon monoxide for most brands of cigarettes. No such federal testing is done to monitor levels of these smoke constituents for cigars nor are cigar manufacturers required to report such levels to any federal agency.

Federal laws prohibit the advertising of cigarettes and smokeless tobacco products on electronic media, including television, radio and any other form of electronic communication regulated by the FCC. However, the ban does not include large cigars and cigarillos.

Finally, federal tax rates are structured so that the maximum tax on a cigar is 3 cents per cigar, irrespective of the price of the cigar.

15. What are issues that need further research?

• Health effects associated with occasional cigar smoking (less than daily use).
• Nicotine dependence for cigar users, including withdrawal symptoms for both regular and occasional cigar users.
• Smoking patterns of primary and secondary cigar smokers (primary smokers have had no prior smoking history, unlike secondary smokers who have smoked other tobacco products.)
• Biological uptake of toxic and carcinogenic smoke constituents by primary and secondary cigar smokers along with the metabolism of critical constituents of cigar smoke.
• Surveillance mechanisms that tract the trends in the prevalence of cigar smoking among teenagers and adults.
• Measurement of environmental tobacco smoke (ETS, also know as secondhand smoke) exposures from cigars and their health effects on high-risk populations, particularly nonsmoking employees in bars and restaurants, at catered cigar events, and in casinos where cigar smoking is encouraged. Exposure levels of ETS and their health effects should also be studied in the children and spouses of cigar smokers.
• Chemical studies to better understand the toxicity and carcinogenicity of cigars and cigar smoke. The individual constitutents found in different types of cigars should be measured and compared to other tobacco products, such as cigarettes and smokeless tobacco.

16. How was the monograph put together?

Cigars: Health Effects and Trends was developed under the editorial supervision of Donald R. Shopland, coordinator of the Smoking and Tobacco Control Program at the National Cancer Institute (NCI) in Bethesda, Md. The NCI supports more than $80 million in smoking-related research annually, and since 1991, the Institute has published an on-going monograph series on smoking and tobacco-use control. The current report on cigars is the ninth monograph in the series.

More than 50 scientists and other experts were involved in the compilation of the monograph, including 30 who participated as peer reviewers. Topics covered include trends in cigar use, the health consequences of smoking cigars, indoor air pollution resulting from cigar smoke, the toxic and carcinogenic compounds found in cigar smoke, the addictive potential of cigars, marketing and promotion of cigars, and policies regulating taxation, labeling and sale of cigars.

David M. Burns, M.D., professor of Medicine at the University of California in San Diego, Calif., was the senior scientific editor for the monograph. Consulting scientific editors were Dietrich Hoffmann, Ph.D., associate director, American Health Foundation, Valhalla, N.Y., and K. Michael Cummings, Ph.D., M.P.H., senior research scientist, Roswell Park Cancer Institute, Buffalo, N.Y.

17. Who are the authors of the monograph?

Trends in Cigar Consumption:
Karen K. Gerlach, Ph.D., M.P.H, Centers for Disease Control and Prevention,
Atlanta, Ga. (now with Robert Wood Johnson Foundation, Princeton, N.J.)
K. Michael Cummings, Ph.D., M.P.H., Roswell Park Memorial Institute, Buffalo, N.Y.
Andrew Hyland, M.S., Roswell Park Memorial Institute, Buffalo, N.Y.
Elizabeth A. Gilpin, M.S., University of California, San Diego, Calif.
Michael D. Johnson, Ph.D., California Department of Health Services, Sacramento, Calif.
John Pierce, Ph.D., University of California, San Diego, Calif.

Chemistry and Toxicology of Cigars:
Dietrich Hoffmann, Ph.D., American Health Foundation, Valhalla, N.Y.
Ilse Hoffmann, B.S., American Health Foundation, Valhalla, N.Y.

Disease Consequences of Cigar Smoking:
Thomas G. Shanks, M.P.H., M.S., University of California, San Diego, Calif.
David M. Burns, M.D., University of California School of Medicine, San Diego, Calif.

Indoor Air Pollution from Cigar Smoke:
James L. Repace, M.S., U.S. Environmental Protection Agency, Washington, D.C.
Wayne Ott, Ph.D., Stanford University, Stanford, Calif.
Neil Klepeis, M.S., Lockheed Martin Environmental, Las Vegas, Nev.

Pharmacology of Abuse Potential of Cigars:
Reginald V. Fant, Ph.D., Pinney Associates, Bethesda, Md.
Jack E. Henningfield, Ph.D., The Johns Hopkins University School of Medicine and Pinney Associates, Bethesda, Md.

Marketing and Promotion of Cigars:
John Slade, M.D., Robert Wood Johnson Medical School, New Brunswick, N.J.

Policies Regulating Cigars:
Gregory N. Connolly, D.M.D., M.P.H., Massachusetts Department of Public Health, Boston, Mass.

18. What are the sources of the data for the report?

The report contains new data in nearly every chapter. In some instances, new studies were commissioned, while in others new, more detailed data analyses of previous studies were conducted.

For example, in Chapter 2, which reviews trends in cigar smoking, two new data sets which examine cigar smoking behavior among both adults and children were made available to the NCI by the California State Department of Health. New analyses were conducted on data from national surveys (National Health Interview Surveys and the Current Population Surveys).

For Chapter 3, the NCI provided a small amount of funding to the American Health Foundation to analyze the chemical composition of leading brands of small (cigarette- sized) cigars, machine-made mass-produced cigars, and hand-rolled premium cigars and to compare them to the best selling brands of filter and non-filter cigarettes.

In the chapter on disease consequences, Chapter 4, new analyses of the data from the Cancer Prevention Study (CPS-I) were undertaken to distinguish the health risks of cigar-only smokers from the health risks of cigarette-only smokers (450,000 white males in total). (CPS-I, conducted between 1959 and 1972 by the American Cancer Society, followed more than one million people for 12 years.) Risk information on male cigar smokers is presented for each major disease in this chapter.

For Chapter 5, the authors performed three separate experiments to assess the contribution of cigar smoke to indoor air pollution. One study, using a stationary monitor, measured environmental tobacco smoke (ETS) in the home comparing one Marlboro cigarette with one, large premium cigar (Paul Garmirian Churchill). In two other experiments, using a personal monitor, one of the authors measured ambient carbon monoxide levels at two separate cigar events, a cigar party and a cigar dinner both held in the San Francisco Bay Area.

Chapters 6, 7, and 8 each contain considerable quantities of new information. For example, in Chapter 7, information is presented on market share of various brands of cigars as well as market share by company. Data are also presented showing the feature stories or news coverage of cigars in 20 daily newspapers from 1990 through 1996. Chapter 8 contains information on state tax rates for cigars as well as which states have laws that specifically address youth access to cigars.

19. Are copies of the monograph currently available?

Copies of the monograph are available by calling 1-800-4-CANCER (1-800-422-6237). By May 1, the text will be available on NCI's website: http://rex.nci.nih.gov; click on "Public," then "Prevention."