Cigar smoking is currently a popular trend in the United States, especially among young men and women. It is fueled in part by the efforts of the tobacco industry to glamorize cigars and the willingness of movie stars and athletes to be photographed smoking cigars.

Contents: History Ingredients and Tobacco Levels Cigars and Cancer Secondhand Smoke Addiction Weak Regulations

Especially for women, the industry seems to have tapped into an impulse among some to be slightly outrageous, to do something a little over the line, to be freed from old restrictions and stereotypes.

Teenagers and young adults may be particularly vulnerable because of the mistaken idea that cigars are a safe alternative to cigarettes. In reality, cigars greatly increase the risk of lung and oral cancers; and they deliver a large, addictive dose of nicotine.

The consumption of large cigars and cigarellos has been increasing since 1993. An estimated 3.8 billion large cigars and cigarillos were expected to be consumed in 2001. Small-cigar production increased from 1.5 billion pounds in 1997 to an estimated 2.4 billion pounds in 2001. Sales of premium cigars, most of which are hand-made and imported, have increased an estimated 150% since 1973.

The sharp rise in the popularity of in gourmet coffee and microbrewery beers has led to a large increase in cigar smoking particularly among young and middle-aged white men (ages 18 to 44) with higher than average incomes and education.

The rise in cigar smoking is not limited to the adult population. Surveys show that the current level of cigar use among adolescents and teenagers is higher than that of smokeless tobacco use.

• About 7% of middle school students (grades 6-8) had smoked cigars on at least one of the past 30 days. Nationwide, 15% of U.S. high school students (grades 9 to 12) have smoked cigars, cigarillos, or little cigars on at least one of the past 30 days.
• Male students (22%)were more likely than female students (9%) to smoke cigars currently.

Among US college students, a recent Harvard study found that 23% had smoked cigars at some point in their lives and about 16% of men and 4% of women were cigar smokers at the time of the survey.

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."

Most cigars are made up of a single air-cured or dried burley tobacco. Cigar tobacco leaves are first aged for about a year and then fermented in a multi-step process that can take from three to five 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, others much larger. Large cigars typically contain between 5 and 17 grams of tobacco. It is not unusual for some premium brands to have as much tobacco in one cigar as in a whole pack of cigarettes. Large cigars can take between one and two hours to smoke.

Do Cigars Cause Cancer?

Cigar smoking increases the risk of death from several cancers, including cancer of the lung, oral cavity (lip, tongue, mouth, throat), esophagus (the tube connecting the mouth to the stomach), and larynx (voice box). Smoking more cigars each day or inhaling cigar smoke leads to more exposure and higher risks. For those who inhale, cigar smoking appears to be linked to cancer of the pancreas and bladder as well.

Most large scale studies have looked at the number of deaths from cancer in cigar smokers, not the number of cancer cases. While this might lead to an underestimation of the number of cancer cases caused by cigar smoking, the figures are still alarming.

• If you smoke cigars, your risk of death from larngeal, oral,or esophageal cancers is 4 to 10 times the risk compared to non-smokers.
• Studies have shown your risk of death is even higher if you smoke 3 or more cigars a day. However, your risk of death from these types of cancer is lower if you smoke 2 or fewer cigars a day.

The health risk associated with occasional cigar smoking (less than daily) is 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. For those who do not inhale, tobacco smoke does not reach the lungs in the same quantity as it does in cigarette smokers. Therefore, the risk of death from lung cancer is not as high as it is for cigarette smokers, but is still three times higher than the risk for nonsmokers. Cigar smokers with a history of cigarette smoking, however, are more likely to inhale. Those who inhale have an increased risk of death from lung cancer eleven times greater than that of nonsmokers.

The risks for those who inhale are also increased in other types of cancer. Compared to nonsmokers, cigar smokers who inhale deeply are six times more likely to die from oral cancer, twice as likely to die from esophageal cancer, and 39 times more likely to die from cancer of the larynx. They also face more than twice the risk of death from pancreatic cancer and more than three times the risk of death from bladder cancer compared to nonsmokers.

Do Cigars Cause other Health Problems?

Cigarette smoking is known to increase the risk of respiratory 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 carry blood to the leg and arm muscles.

While the association is not as strong as with cigarette smoking, cigar smoking (especially for people who inhale) appears to increase the risk of heart and respiratory diseases. At this time there are no studies that conclusively 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 erectile dysfunction in men (the inability to achieve erection).

What about Secondhand Cigar Smoke?

Because cigars have 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 poisons (toxins) and cancer-causing agents (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-minobiphenyl)
• 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 to 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.

In a recent study, researchers found that the concentrations of carbon monoxide at two cigar social events in San Francisco were higher than the levels found on a busy California freeway. Had these indoor exposures lasted eight 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 nonsmokers 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 Cigars Addictive?

Nicotine is the substance in tobacco that causes addiction. Most cigars have as much nicotine as several cigarettes. When cigar smokers inhale, nicotine is absorbed as rapidly as it is with cigarettes. For those who do not inhale, it is absorbed, more slowly through the lining of the mouth. People who use smokeless tobacco absorb nicotine the same way. Both inhaled and non-inhaled nicotine are highly addictive.

Are there Federal Laws Regulating Cigars?

Cigars have fewer federal regulations than do cigarettes and smokeless tobacco. In 1996, the Food and Drug Administration (FDA) started regulating cigarettes and smokeless tobacco products as drugs. Cigars, however, were not included.

Until recently, health warnings required on other tobacco products were absent on cigars. However, the legal settlement in June of 2000 between the Federal Trade Commission and the seven largest US cigar companies (representing 95% of the US market) called for health warnings on cigar packages. The labels will carry warnings of the risk of cancers of the lung, mouth and throat, and other known dangers linked to smoking such as heart disease; infertility, stillbirth, and low birth weight of children of smokers; and the risks of lung cancer and heart disease for nonsmokers who breathe the smoke.

Cigars have been exempt from federal tobacco regulations that restrict youth access and limit advertising. 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.

A study conducted at the University of California found more than 140 internet sites marketing cigars on the internet, 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 age identification of the buyer difficult.

Finally, federal tax rates for cigars are increasing, but are much lower than the federal tax on cigarettes. Small cigars have a federal tax rate of $0.04 per pack of 20. Large cigars have a federal tax of $0.05 maximum per cigar.

There is a mounting body of evidence indicating that cigar smoking can lead to a number of serious health problems. The alarming increase in the rates of cigar smoking, especially among young people, shows how urgently the country needs stronger cigar regulations and a comprehensive national policy to deal with this growing health public health dilemma.

References

American Cancer Society. Cancer Facts and Figures 2003. Atlanta, GA.

Centers for Disease Control and Prevention (CDC). Youth Tobacco Surveillace--United States, 1998-1999. MMMWR 2000; 49 (SS10): 1-93.

Federal Tax and Fee Rate Chart for Tobacco Products. Available at compnet.state.md.us/attd/ttinfo/fedttratechart.asp. 2002 Comptroller of Maryland.

Federal Trade Commission (FTC). FTC Announces Settlements Requiring Disclosure of Cigar Health Risks. 2000. Available at ftc.gov/opa/2000/06/cigars.htm

Feldman H, Johannes C, Derby C, Kleinman K, Mohr B, Araujo A, et al. Erectile dysfunction and coronary risk factors: prospective results from the Massachusetts male aging study. Prev Med 2000; 30(4):328-338.

Ibarren C, Tekawa I, Sidney S, Friedman G. Effect of cigar smoking on the risk of cardiovascular disease, chronic obstructive pulmonary disease, and cancer in men. N Eng J Med 1999; 340(23):1773-1780.

Malone R, Bero L. Cigars, youth, and the internet link. Am J Pub Health 2000; 90(5):790-792. National Cancer Institute (NCI). Cigars: Health Effects and Trends. Monograph #9. 1998. Available at rex.nci.nih.gov/NCI_MONOGRAPHS/MONO9.HTM.

National Cancer Institute (NCI). Questions and Answers About Cigar Smoking and Cancer. 2000. Available at cis.nci.nih.gov/fact/3_65.htm

Rigotti N, Lee J, Wechsler H. US college students' use of tobacco products: results of a national survey. JAMA 2000; 284(6):699-705.

Shapiro J, Jacobs E, Thun M. Cigar smoking and the risk of death from tobacco-related cancers. J Nat Cancer Inst 2000; 92(4):333-337.

Shopland DR. US Cigar Consumption, 1950-1996. JNCI. 89 (14): 999.

US Department of Health and Human Services. Reducing the Health Consequences of Smoking: 25 Years of Progress. A Report of the Surgeon General. US Department of Health and Human Services, Public Health Service Centers for Disease Control, Center for Chronic Disease Prevention and Health Promotion, Office on Smoking and Health. DHHS Publication No. (CDC) 89-8411, 1989.

US Department of Health and Human Services. The Health Consequences of Smoking: Nicotine Addiction: A Report of the Surgeon General, US DHHS, PHS, CDC. Office on Smoking and Health. DHHS Publ# (CDC) 88-8406, 1988.

Revised: 11/01/02