Cigars -- still tobacco, still dangerous to your health

Many people view cigar smoking as more sophisticated and less dangerous than cigarette smoking. Yet one large cigar can contain as much tobacco as an entire pack of cigarettes. And the secondhand smoke it gives off, which others breathe in, can fill a room for hours.

It is important to know 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 cigarettes, cigars do not usually have 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. This is what gives cigars a different taste and smell from cigarettes.

Cigars come in many sizes. The smallest, known as little or small cigars, are about the size of a cigarette. Other than the fact that they are brown, they even look like cigarettes. Many have filters.

Slightly larger cigars are called cigarillos. Although they contain more tobacco, studies suggest that some people use them more like cigarettes -- smoking every day and often inhaling -- than cigars.

Large cigars may contain more than a half an ounce of tobacco. This is as much tobacco as a whole pack of cigarettes. It can take from 1 to 2 hours to smoke a large cigar.

Who smokes cigars?

Cigar smoking is still popular in the United States where a "cigar culture" is supported by cigar magazines, shops, and bars or clubs. Many cigar smokers think of themselves as connoisseurs, much like wine experts. They may view cigars as a sophisticated, affordable luxury that represents status and success. Some see cigar smoking as a sign 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 open to this kind of cigar marketing. But the proposed link between cigars and success isn't grounded in reality. In fact, cigar use is higher in unemployed adults than in people who work full or part time. And college graduates are slightly less likely to smoke cigars than adults with lower education levels.

According to the U.S. Department of Agriculture (USDA), the use of large cigars and cigarillos increased by an estimated 124% between 1993 and 2007. An estimated 4.8 billion large cigars and cigarillos were consumed in the United States in 2007.

The increase in smoking little or small cigars has been even more dramatic. Production went from 1.5 billion in 1997 to about 5.9 billion in 2007. These "cigars" are often sold in packs of 20, just like cigarettes. Their size, shape, filters, and packaging make them look like cigarettes, except for their color. Some companies add strawberry, chocolate, and other sweet flavors, which appeal to younger smokers. As of October 2009, such flavors can no longer be added to cigarettes, but as of now there no such restrictions on little cigars. This may lead to an even greater increase in small cigar smoking as tobacco companies take advantage of the lack of regulation of these products.

In recent years, because of lower taxes, little cigars cost much less than cigarettes in most states. This made them easier for younger smokers to afford. As of April 2009, the federal tax rate on little cigars is the same as that for cigarettes ($1.01 per pack of 20). Whether this will affect the sales of little cigars remains to be seen.

Sales of large cigars increased through much of the 1990s but appear to have leveled off over the last decade.

Cigar smokers in the past were mainly middle-aged and older men with higher education and income, but many new cigar users today are teenagers and young adult males who smoke once in a while (less than daily). According to the Substance Abuse and Mental Health Service Administration's 2008 survey, about 11% of Americans aged 18 to 25 had smoked a cigar within the last month, compared to the average of 5% from all ages.

The level of cigar use among teens (aged 12 to 17) in 2008 was about 4%, which is higher than the level of spit (oral or smokeless) tobacco use. In some states, more high school boys smoke cigars than cigarettes. Much of this is because of little cigars, which are often a cheaper alternative to cigarettes.

Are cigars addictive?

Cigars do contain nicotine, the substance in tobacco that addicts people. If cigar smokers inhale, nicotine is absorbed through the lungs as quickly as it is with cigarettes. For those who do not inhale, the nicotine is absorbed more slowly through the lining of the mouth. Cigar smoke dissolves more easily in saliva than cigarette smoke. This means cigar smokers can get the desired dose of nicotine without inhaling the smoke into their lungs. People who use oral or spit tobacco products absorb nicotine the same way. Nicotine in any form is highly addictive.

Even though people smoke cigars for different reasons, the fact is, like cigarettes, cigars deliver nicotine. Most cigars have as much nicotine as several cigarettes. Cigarettes contain an average of about 8 milligrams (mg) of nicotine, but only deliver about 1 to 2 mg of nicotine to the smoker. Many popular brands of cigars contain between 100 and 200 mg, or even as many as 444 mg of nicotine. The amount of nicotine a cigar delivers to a smoker can vary a great deal even among people smoking the same type of cigar. How much nicotine is taken in depends on a number of things like:

• how long the person smokes the cigar
• how many puffs are taken
• whether or not the smoker inhales

Given these factors and the large range of cigar sizes, it is almost impossible to make good estimates of the amounts of nicotine cigars deliver. That said, Health Canada estimates that the filtered little cigars that are the size and shape of cigarettes contain about the same amount of nicotine as a cigarette. If these are smoked like cigarettes (inhaled), they would probably deliver a similar amount of nicotine, but this has not been fully tested.

Does smoking cigars raise your risk of cancer and death?

Regular cigar smoking increases your risk for many cancers, including:

• lung
• lip, tongue, mouth, throat (oral cavity)
• esophagus (the tube connecting the mouth to the stomach)
• voice box (larynx)

Studies have shown that regular cigar smokers are 4 to 10 times more likely to die from cancers of the mouth, larynx, and esophagus than non-smokers. 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 an hour smoking one 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. The health risks linked to occasional cigar smoking (less than daily) are not known.

Does inhaling affect the risk of cancer?

Although almost all cigarette smokers inhale, in the past most cigar smokers have not. This may be because cigar smoke tends to irritate the eyes, nose, throat, and breathing passages. A new trend among cigar companies is to change the fermenting process to make cigar smoke 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 for cigar smokers who don't inhale 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 an 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 cigar smokers who inhale, the risks are increased for other types of cancer. Compared to non-smokers, cigar smokers who inhale deeply:

• are 7 times more likely to die from oral cancer
• are 39 times more likely to die from cancer of the voice box (larynx)
• face about 3 times the risk of death from cancer of the pancreas
• face about 4 times the risk of death from bladder cancer

Do cigars cause other health problems?

Heart and lung disease

Cigarette smoking is known to increase the risk of lung diseases like emphysema and chronic bronchitis. Cigarette smokers also have twice the risk of dying of heart attacks as do non-smokers. While the link is not quite as strong as with cigarette smoking, cigar smoking (especially for people who inhale) also increases the risk of heart disease and lung diseases, such as emphysema and chronic bronchitis.

Heart and lung diseases can steal away a person's enjoyment of life long before they cause death. These problems may start when smokers are in their 40s, and tend to worsen with age. Smoking-related illness can make it harder for a person to breathe, get around, work, or play.

Other effects on the body

Cigar smoking, like cigarette smoking, is linked to gum disease, where the gums shrink away from the teeth. It also raises the risk that your teeth will fall out.

At least one study has linked cigar smoking to sexual impotence in men (an inability to get an erection, also known as erectile dysfunction).

Taking care of yourself

If you have ever smoked 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. Cigar use puts you at risk for certain health problems. 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, your doctor might recommend that you regularly check the inside of your mouth for any changes, such as red or white patches or sores. See a doctor or dentist right away if you have any changes or notice problems. The American Cancer Society recommends that medical check-ups should include oral cavity (mouth) exams. By doing this, cigar users may be able to find out about changes such as leukoplakia (white patches in the mouth) early. This may help prevent oral cancer.

You should also tell a doctor about any of the following:

• any change in a cough (for example, you cough up more phlegm or mucus than usual)
• a new cough
• coughing up blood
• hoarseness
• trouble breathing
• wheezing
• chest pain
• loss of appetite
• weight loss
• feeling tired all the time (fatigue)
• frequent lung or respiratory infections (like pneumonia or bronchitis)

Any of these could be signs of problems with the lungs or other parts of the respiratory system and should be reported to a doctor.

People who are regular cigar smokers are at higher risk for lung cancer. Unfortunately, in many cases lung cancer doesn't cause symptoms until it is advanced, and at this time there are no widely recommended screening tests for this cancer. The American Cancer Society recommends that people who are at increased risk for lung cancer, such as smokers, former smokers, or people who have been exposed to secondhand smoke, be aware of their lung cancer risk. If you are in this group, talk with your doctor about your likelihood of developing lung cancer and about the potential benefits and risks of lung cancer screening. After discussing what is and is not known about the value of early lung cancer detection, if you and your doctor decide in favor of testing, then be sure to have it done at a center that has experience in all aspects of testing people at high risk.

If you have any health concerns that you think may be caused by your cigar use, please see a health care provider right away. Taking care of yourself and getting treatment for problems before they get worse will improve your odds 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. This is also known as environmental tobacco smoke (ETS) or passive smoke. Secondhand smoke includes both the smoke from the end of the burning cigar and the smoke exhaled by the smoker.

In general, secondhand smoke from cigars contains many of the same toxins (poisons) and carcinogens (cancer causing agents) as cigarette smoke. Some of the toxins or irritants in cigar smoke include:

• carbon monoxide
• nicotine
• hydrogen cyanide
• ammonia
• volatile aldehydes

Cigar smoke includes the following agents that cause cancer (carcinogens):

• 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 aging and fermenting of 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). When the fermented cigar tobacco is smoked, these compounds give off several tobacco-specific nitrosamines (TSNAs), some of the most potent substances known to cause cancer in humans. 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.

Are there laws regulating cigars?

Cigars have fewer federal regulations than cigarettes and oral tobacco products.

Warnings of proven health risks, much like those required for cigarettes, were added to most cigar ads and packages as a result of a legal settlement in June 2000 between the Federal Trade Commission and the 7 largest U.S. cigar companies (representing 95% of the U.S. market). The labels on cigars made by these 7 companies 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 non-smokers.

In 2009, a new federal law gave the Food and Drug Administration (FDA) broad powers to regulate tobacco products (cigarettes and oral tobacco products), including marketing, promotion, labeling, and many other aspects of their sale to the public. Cigars are considered tobacco products under the new law, but the law does not automatically apply to cigars. The FDA must first issue a regulation deeming cigars to be subject to the law, which it has not yet done.

At this time, cigars are exempt from federal tobacco regulations that limit advertising and restrict underage children from buying cigars. But all 50 states and the District of Columbia have laws that either clearly address children and teens' access to cigars or forbid underage children from buying any tobacco products.

Cigarettes, little cigars, 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 regular cigars.

Despite the laws that forbid underage children from buying them, cigars are easy to get. A study done in the year 2000, found more than 140 Internet sites that sold cigars, with almost 1 in 3 having potential youth appeal. Only about 1 out of 4 of these sites clearly banned sales to minors. On about 1 out of 3 of the sites, cigars could be bought with money orders, cashier's checks, or cash-on-delivery (COD) -- options that make it hard to check the age of the buyer.

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. But cigars are not required to go through these tests, and makers of cigars do not have to report such levels to any federal agency.

As of April 2009, federal tax rates for cigars have gone up. Little cigars are now taxed at a rate of $1.01 per pack of 20, the same rate as for a pack of cigarettes. The federal tax on cigarillos and large cigars depends on the price of the cigar, but can be up to a maximum of 40 cents per cigar. Taxes on cigars are also collected by many (but not all) states at varying rates. Whether the recent tax increases affect cigar use, especially among teens, remains to be seen.

Research and reduction in smoking is still needed

Tobacco in any form is a deadly product. Research continues to show that cigar smoking can cause a number of serious health problems. The rising rates of cigar smoking, especially among young people, point out 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, 1-800-227-2345.

• 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)

• Child and Teen Tobacco Use (also available in Spanish)

• Tobacco-Related Cancers Fact Sheet

National organizations and Web sites*

Along with the American Cancer Society, other sources of information and support include:

American Heart Association & American Stroke Association
Heart Association
Toll-free number: 1-800-AHA-USA-1 (1-800-242-8721)
Web site: www.americanheart.org
Stroke Association
Toll-free number: 1-888-4-STROKE (1-888-478-7653)
Web site: www.strokeassociation.org
Quitting tips and advice can be found at everydaychoices.org or by calling 1-866-399-6789

American Lung Association
Toll-free number: 1-800-548-8252
Web site: www.lungusa.org
Printed quit materials are available, some in Spanish. Also offers the tobacco cessation program "Freedom from Smoking Online" at www.ffsonline.org

Centers for Disease Control and Prevention
Office on Smoking and Health
Toll-free number: 1-800-232-4636
Free quit support line: 1-800-784-8669 (1-800-QUIT-NOW)
TTY: 1-800-332-8615
Web site: www.cdc.gov/tobacco

National Cancer Institute
Toll-free number: 1-800-4-CANCER (1-800-422-6237) for cancer information
Toll-free tobacco quit line: 1-877-448-7848 (1-800-QUITNOW)
Web site: www.cancer.gov
Direct tobacco Web site: www.smokefree.gov
Quitting information, cessation guide, and counseling is offered, as well as information on state telephone-based quit programs

Nicotine Anonymous
Toll-free number: 1-877-TRY-NICA (1-877-879-6422)
Web site: www.nicotine-anonymous.org
For free information, meeting schedules, printed materials, or information on how to start a group in your area

QuitNet
Web site: www.quitnet.com
Offers free, cutting edge, effective tobacco cessation services to people worldwide

*Inclusion on this list does not imply endorsement by the American Cancer Society.

No matter who you are, we can help. Contact us anytime, day or night, for information and support. Call us at 1-800-227-2345 or visit www.cancer.org.

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Last Medical Review: 10/01/2009
Last Revised: 10/01/2009