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Introduction
Many people view cigar smoking as more sophisticated and less dangerous
than cigarette smoking. Yet a single large cigar
can contain as much tobacco as an entire pack of cigarettes. The
secondhand smoke it gives off and that others breathe in can fill a
room for hours.
The purpose of this document is to describe what cigars are, the recent
trends in their use, and the possible health effects they may have on
the
people who smoke them and those around them.
How Are Cigars Different From
Cigarettes?
A cigar is defined, for tax purposes, as "any roll of tobacco
wrapped in leaf tobacco or in any substance containing tobacco," while
a cigarette is "any roll of tobacco wrapped in paper or any substance
not containing tobacco." Unlike most manufactured cigarettes, cigars do
not usually include a filter.
Most cigars are made up of a single type of air-cured or
dried
tobacco. Cigar tobacco leaves are first aged for about a year and then
fermented in a multi-step process that can take from 3 to 5 months.
Fermentation causes chemical and bacterial reactions that change the
tobacco and give cigars a different taste and smell from cigarettes.
Cigars come in different sizes, some as small as a cigarette
(called a cigarillo), others much larger. Large cigars typically
contain between 5 and 17 grams of tobacco. There are about 29 grams in
an ounce, so a very large cigar can contain more than half an ounce of
tobacco. This is as much tobacco as a whole pack of cigarettes. Large
cigars can take between 1 to 2 hours to smoke.
Who Smokes Cigars?
Cigar smoking continues to be a popular trend in the United States
where a "cigar culture" is supported by cigar magazines, shops, and
bars or clubs. Many cigar smokers consider themselves to be
connoisseurs, similar to wine experts. Cigars are viewed as a
sophisticated, affordable luxury that represents success, and cigar
smokers are portrayed to have a high degree of taste and refinement.
This image is fueled in part by the efforts of the tobacco industry to
glamorize cigars and the willingness of movie stars and athletes to be
paid and photographed smoking cigars. Teenagers and young adults may be
particularly vulnerable because of the mistaken idea that cigars are a
safe alternative to cigarettes.
According to the US Department of Agriculture (USDA), cigar use has
increased since the early 1990s. Most of this increase was between 1993
and 1999, when the use of both large cigars and cigarillos (little
cigars) climbed an estimated 70%. An estimated 5.3 billion cigars were
consumed in the United States in 2006 -- a 9% increase from the
previous year. The production of little cigars went from 1.5 billion in
1997 to about 5.1 billion in 2006. These "cigars" are often sold in
packs of 20, just like cigarettes. Some companies add strawberry,
chocolate, and other sweet flavors, which appeal to younger smokers.
Because of the lower taxes, they are less expensive than cigarettes.
This also makes it easier for younger smokers.
Sales of premium cigars, most of which are hand-made and
imported, have increased over much of the last decade. The sharp rise
in the popularity of gourmet coffee and microbrewery beers is thought
to go along with the large increase in cigar smoking, particularly
among young and middle-aged white men (ages 18 to 44) with higher than
average incomes and education.
Cigar smoking occurs mainly among males between the ages of 35
and 64 who have higher educational backgrounds and incomes, but recent
studies suggest new trends. Most new cigar users today are teenagers
and young adult males (ages 18 to 24) who smoke occasionally (less than
daily). In 2006, about 12% of Americans aged 18 to 25 had smoked a
cigar within the last month, compared to the average of 6% from all
ages.
The general rise in cigar smoking in recent years has not been
limited to the adult population, however. According to surveys from the
Centers for Disease Control and Prevention (CDC), the level of cigar
use among adolescents and teenagers in recent years has been higher
than that of spit (oral tobacco) tobacco use. As of 2006, about 4% of
teens aged 12 to 17 had smoked a cigar in the past month.
Are Cigars Addictive?
Even though people smoke cigars for different reasons, the
fact is, like cigarettes, cigars can become addictive. Nicotine is the
substance in tobacco that causes addiction. Most cigars have as much
nicotine as several cigarettes. One cigarette delivers about 1 to 2
milligrams of nicotine, while many popular brands of cigars contain
between 100 and 200 milligrams, or as even many as 444 milligrams of
nicotine.
If cigar smokers inhale, nicotine is absorbed as rapidly as it
is with cigarettes. For those who do not inhale, the nicotine is
absorbed more slowly through the lining of the mouth. The smoke of
cigars dissolves more easily in saliva than cigarette smoke. This means
cigar smokers can get the desired dose of nicotine without inhaling the
smoke into the lungs. People who use oral or spit tobacco products
absorb nicotine the same way. Nicotine in any form is highly addictive.
Do Cigars Cause Cancer?
Cigar smoking increases your risk of death from many cancers,
including:
- lung
- oral cavity (lip, tongue, mouth, throat)
- esophagus (the tube connecting the mouth to the stomach)
- larynx (voice box)
Studies have shown that male cigar smokers are 4 to 10 times more
likely to die from oral and laryngeal cancers than non-smokers. In
addition, when saliva containing cigar smoke chemicals is swallowed,
the esophagus is exposed to carcinogens (cancer-causing agents). The
death rate from esophageal cancer is many times higher in male cigar
smokers than in males who have never smoked. For those who inhale,
cigar smoking appears to be linked to death from cancer of the pancreas
and bladder, too.
How you smoke and how much you smoke are both important. Cigar
smokers may spend up to an hour smoking a single large cigar that can
contain as much tobacco as a pack of cigarettes. Smoking more cigars
each day or inhaling cigar smoke leads to more exposure and higher
risks. Studies have shown your risk of death is higher if you smoke 3
or more cigars than if you smoke 2 or fewer cigars a day. The health
risks linked to occasional cigar smoking (less than daily) are not
known.
Does Inhaling Affect the Risk
of Cancer?
While almost all cigarette smokers inhale, most cigar smokers
do not. This may be because cigar smoke is generally more irritating to
the eyes, nose, throat, and breathing passages. A new trend among cigar
companies is to change the fermenting process of their products to make
them easier to inhale. This same curing and fermenting process further
enhances the flavor but also increases the levels of harmful
ingredients.
For those who do not inhale, tobacco smoke does not reach the
lungs in the same amounts as it does in cigarette smokers. As a result,
the risk of death from lung cancer is not as high as it is for
cigarette smokers. Still, it is many times higher than the risk for
non-smokers.
Cigar smokers who have smoked cigarettes are more likely to
inhale. According to a recent American Cancer Society study, those who
inhale have an increased risk of death from lung cancer -- 11 times
greater than that of non-smokers.
The study also found that for those cigar smokers who inhale,
the risks are increased for other types of cancer. Compared to
non-smokers, cigar smokers who inhale deeply:
- are 6 times more likely to die from oral cancer
- are 39 times more likely to die from cancer of the
larynx
- face more than twice the risk of death from pancreatic
cancer
- face more than 3 times the risk of death from bladder
cancer
Do Cigars Cause Other Health Problems?
Cigarette smoking is known to increase the risk of lung
diseases such as emphysema and chronic bronchitis. Cigarette smokers
have twice the risk of dying of heart attacks as do non-smokers. And
smoking is a major risk factor for peripheral vascular disease, a
narrowing of the blood vessels that move blood through the arms and
legs.
While the link is not quite as strong as with cigarette
smoking, cigar smoking (especially for people who inhale) increases the
risk of heart disease and lung diseases, such as emphysema and chronic
bronchitis.
At this time there are no studies that clearly show a link
between cigar smoking and either peripheral vascular disease or stroke.
However, a recent study found cigar smoking, as well as cigarette
smoking, is linked to a man's inability to achieve erection (a
condition known as erectile dysfunction, or ED).
Taking Care of Yourself
If you have ever used cigars, now or in the past, tell your
health care provider so he or she can be sure that you have the
preventive health care you need. It is well known that cigar use puts
you at risk for certain health-related illnesses. This means part of
your health care should focus on related screening and preventive
measures to help you stay as healthy as possible. For example, you will
want to be certain that you regularly check the inside of your mouth
for any changes and see your doctor or dentist if you have any changes
or problems. The American Cancer Society recommends that periodic
check-ups should include oral cavity (mouth) exams. By doing this cigar
users may be able to find oral changes and leukoplakia (white patches
on the mouth membranes) early. This may help prevent oral cancer.
You should also be aware of any of the following:
- any change in a cough (for example, you cough up more mucus
than usual)
- a new cough
- coughing up blood
- hoarseness
- difficulty breathing
- wheezing
- headaches
- chest pain
- loss of appetite
- weight loss
- general fatigue (tiredness)
- repeated respiratory infections
Any of these could be signs of lung cancer or a number of
other lung conditions and should be reported to your doctor. While
these can be signs of a problem, many lung cancers do not cause any
noticeable symptoms until they are advanced and have spread to other
parts of the body.
If you have any health concerns that may be related to your
cigar use, please see your health care provider as quickly as possible.
Taking care of yourself and getting treatment for small problems will
give you the best chance for successful treatment. The best way,
though, to take care of yourself and decrease your risk for
life-threatening lung problems is to quit using any form of tobacco.
What About Secondhand Cigar
Smoke?
Because cigars contain more tobacco than cigarettes, and because they
often burn for much longer, they give off greater amounts of secondhand
smoke, also known as environmental tobacco smoke (ETS) or passive
smoke. Secondhand smoke includes both the smoke from the end of the
cigar and the smoke exhaled by the smoker.
In general, secondhand smoke from cigars contains many of the
same toxins (poisons) and carcinogens as cigarette smoke but in higher
concentrations. Some of the toxins or irritants in cigar smoke include:
- carbon monoxide
- nicotine
- hydrogen cyanide
- ammonia
- volatile aldehydes
Carcinogens in cigar smoke include the following:
- benzene
- aromatic amines (especially carcinogens such as
2-naphthylamine and 4-aminobiphenyl)
- vinyl chloride
- ethylene oxide
- arsenic
- chromium
- cadmium
- nitrosamines
- polynuclear aromatic hydrocarbons
There are some differences between cigar and cigarette smoke,
though. These differences are due to the long aging and fermentation
process used for cigar tobacco and the fact that the cigar wrapper is
not as porous as cigarette paper.
Cigar tobacco has a high concentration of nitrogen compounds
(nitrates and nitrites). During fermentation and smoking, these
compounds give off several tobacco-specific nitrosamines (TSNAs), some
of the most potent human carcinogens known. Also, because the cigar
wrapper is less porous than cigarette paper, the tobacco doesn't burn
as completely. The result is a higher concentration of nitrogen oxides,
ammonia, carbon monoxide, and tar -- all very harmful substances.
In a recent study, researchers found that the concentrations
of carbon monoxide at 2 cigar social events in San Francisco were
higher than the levels found on a busy California freeway. Had these
indoor exposures lasted 8 hours, they would have exceeded the National
Ambient Air Quality Standards for outdoor air established by the
Environmental Protection Agency. While the health effects on
non-smokers at cigar social events have not been studied, there is
clearly an increased risk of lung cancer from long-term exposure to
secondhand smoke.
Are There Laws Regulating
Cigars?
Cigars have fewer federal regulations than cigarettes and oral
tobacco products. Until recently, health warnings required on other
tobacco products were not found on cigars. However, warnings of proven
health risks much like those required for cigarettes have been added to
cigar packaging and advertisements. This is a result of a legal
settlement in June of 2000 between the Federal Trade Commission and the
7 largest US cigar companies (representing 95% of the US market). The
labels carry 1 of the following 5 surgeon general warnings, on a
rotating basis:
- Cigar smoking can cause cancers of the mouth and throat,
even if you do not inhale.
- Cigar smoking can cause lung cancer and heart disease.
- Tobacco use increases the risk of infertility, stillbirth,
and low birth weight.
- Cigars are not a safe alternative to cigarettes.
- Tobacco smoke increases the risk of lung cancer and heart
disease, even in nonsmokers.
Today cigars are exempt from federal tobacco regulations that
restrict youth access and limit advertising. However, all 50 states and
the District of Columbia have laws that either clearly address youth
access to cigars or limit youth access to all tobacco products.
Since the mid-1960s the Federal Trade Commission has overseen
a testing program to report the amount of tar, nicotine, and carbon
monoxide for most brands of cigarettes. Cigars, however, are not
included, and makers of cigars do not have to report such levels to any
federal agency.
Cigarettes and oral tobacco products cannot be advertised on
television, radio, or any other form of electronic communication
regulated by the Federal Communications Commission. At this point, this
ban does not include cigars.
Cigars are easy to get, especially for youth. A study done
many years ago at the University of California found more than 140
Internet sites marketing cigars, with almost one third having potential
youth appeal. Only about one quarter of these sites prohibited sales to
minors. On about one third of the sites, cigars could be purchased with
money orders, cashier's checks, or cash-on-delivery (COD) -- options
that make it hard to verify the age of the buyer.
Federal tax rates for cigars are going up, but they are still
much lower than the federal tax on cigarettes. Small cigars have a
federal tax rate of 4 cents per pack of 20. Large cigars have a federal
tax of 5 cents maximum per cigar. Taxes on cigars are also collected by
many (but not all) states at varying rates. This is good for the
tobacco companies. They can sell packs of 20 "small cigars" at a final
cost that is usually much less than that of cigarettes.
Conclusion
Tobacco in any form is a deadly product. Ongoing research is
giving us more and more evidence that cigar smoking can cause a number
of serious health problems. The rising rates of cigar smoking,
especially among young people, indicate the need for public awareness
and a wide-ranging national policy to deal with this growing public
health problem.
Additional Resources
More Information From Your
American Cancer Society
The following information may
also be helpful to you. These materials may be ordered from our
toll-free number, 1-800-ACS-2345 (1-800-227-2345).
Guide
to Quitting Smoking (also available in Spanish)
Helping a Smoker Quit:
Do's and Don'ts
Questions
About Smoking, Tobacco, and Health (also available
in Spanish)
Quitting
Smoking -- Help for Cravings and Tough Situations (also
available in Spanish)
National Organizations and Web
Sites
In addition to the American Cancer Society, other sources of
patient information and support include:
American Heart Association
Telephone: 1-800-AHA-USA-1 (1-800-242-8721)
Internet Address: www.amhrt.org
American Stroke Association
Telephone: 1-888-4-STROKE (1-888-478-7653)
Internet Address: www.strokeassocation.org
American Lung Association
Telephone: 1-800-586-4872 (connects to local office)
1-800-548-8252 (connects to National Call Center)
Internet Address: www.lungusa.org
Centers for Disease Control and Prevention
Office on Smoking and Health
Telephone: 1-800-232-4636
Internet Address: www.cdc.gov/tobacco/how2quit.htm
National Cancer Institute
Telephone: 1-800-4-CANCER (1-800-422-6237)
1-877-448-7848 (smoking
cessation help)
Internet Address: www.cancer.gov
Nicotine Anonymous
Telephone: 1-877-TRY-NICA (1-877-879-6422) for pre-recorded information
1-415-750-0328 (for local contact numbers or to leave a voicemail
message)
Internet Address: www.nicotine-anonymous.org
Smokefree.gov
(Online materials, including info on state telephone-based programs)
Telephone: 1-800-QUITNOW (1-800-784-8669)
Internet Address: www.smokefree.gov
*Inclusion on this list does not imply endorsement
by the American Cancer Society.
Please call 1-800-ACS-2345 any time, any day you have
questions or need help. The American Cancer Society has information,
resources, and support available on any cancer-related topic.
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