M9-Preface

Smoking and Tobacco Control Monograph No. 9

Preface

The recent increase in cigar consumption began in 1993 and was dismissed

by many in public health as a passing fad that would quickly dissipate. Recently

released data from the U.S. Department of Agriculture (USDA) suggests that the

upward trend in cigar use might not be as temporary as some had predicted. The

USDA now projects a total of slightly more than 5 billion cigars were consumed

last year (1997) in the United States. Sales of large cigars, which comprise about

two-thirds of the total U.S. cigar market, increased 18 percent between 1996 and

1997. Consumption of premium cigars (mostly imported and hand-made)

increased even more, an astounding 90 percent last year and an estimated 250

percent since 1993. In contrast, during this same time period, cigarette

consumption declined 2 percent.

This dramatic change in tobacco use raises a number of public health

questions: Who is using cigars? What are the health risks? Are premium cigars

less hazardous than regular cigars? What are the risks if you don't inhale the

smoke? What are the health implications of being around a cigar smoker?

In order to address these questions, the National Cancer Institute (NCI)

undertook a complete review of what is known about cigar smoking and is

making this information available to the American public. This monograph,

number 9 in a series initiated by NCI in 1991, is the work of over 50 scientists

both within and outside the Federal Government. Thirty experts participated in

the multi-stage peer review process (see acknowledgments). The conclusions

presented in the monograph represent the best scientific judgment, not only of

the NCI, but also of the larger scientific community.

There is sufficient evidence to conclude that a causal relationship exists

between regular cigar use and cancers of the lung, larynx, oral cavity, and

esophagus. Heavy cigar smoking, particularly for those who inhale, causes an

increased risk of coronary heart disease and chronic obstructive pulmonary

disease. There is also suggestive evidence for a relationship between cigar

smoking and cancer of the pancreas, but the evidence is insufficient at this time

to draw a causal inference. The data in this monograph strengthen and extend

the conclusions on disease risks contained in several reports of the Surgeon

General on smoking and health.

After a careful assessment of the available scientific evidence, the following

overall conclusions are warranted:

Cigar smoking can cause oral, esophageal, laryngeal, and lung

cancers. Regular cigar smokers who inhale, particularly those who

smoke several cigars per day, have an increased risk of coronary

heart disease and chronic obstructive pulmonary disease.

Preface

Regular cigar smokers have risks of oral and esophageal cancers

similar to those of cigarette smokers, but they have lower risks of

lung and laryngeal cancer, coronary heart disease, and chronic

obstructive pulmonary disease.

Cigar use in the U.S. has increased dramatically since 1993. Adult

prevalence of cigar use in California has increased predominantly

among occasional cigar smokers. A substantial number of adult

former and never smokers of cigarettes are currently smoking cigars.

In contrast to cigarettes, much of the increased use of cigars by

adults appears to be occurring among those with higher incomes

and greater educational attainment.

Adolescent cigar use is occurring at a substantial level and is

currently higher than that recorded for young adults prior to 1993.

Currently, cigar use among adolescent males exceeds the use of

smokeless tobacco in several states. This use of cigars is occurring

among both males and females.

Some in the cigar trade have made the claim that cigar smokers experience

little or no increased disease risk. This claim is not supported by the available

scientific evidence and misleads cigar smokers to believe that cigar smoke is less

harmful than cigarette smoke. We believe an accurate statement is that the

risks of tobacco smoke exposure are similar for all sources of tobacco

smoke, and the magnitude of the risks experienced by cigar smokers

is proportionate to the nature and intensity of their exposure.

Differences in the intensity of tobacco smoke exposure between cigarette and

cigar smokers result from differences in the inhalation of the smoke and

differences in the proportion of smokers who smoke every day. While almost all

cigarette smokers inhale, the majority of cigar smokers do not. This may be due

to differences in the pH of the smoke produced by these two products. Cigar

smoke contains a substantial fraction of its nicotine as free nicotine, which can

be readily absorbed across the oral mucosa. In contrast, cigarette smoke is more

acidic, and the protonated form of nicotine it contains is much less readily

absorbed by the oral mucosa. As a result, cigarette smokers must inhale to get

their desired quantity of nicotine, whereas cigar smokers can ingest sufficient

quantities of nicotine without inhaling. This reduction in inhalation is one of

the reasons for the difference in disease risks between cigarette and cigar smokers.

However, even those who do not inhale have disease risks higher than those

who have never smoked any tobacco product. As this monograph clearly

demonstrates, regular cigar smokers who have never smoked cigarettes, even

those who do not inhale, experience significantly elevated risks for cancers of the

larynx, oral cavity (including pharynx), and esophagus.

For the California survey, current prevalence among adults was defined as a positive response to:

1) Have you ever smoked cigars? and 2) Do you now smoke cigars every day or some days?

iii

Smoking and Tobacco Control Monograph No. 9

Another reason for a difference in risk between cigarette and cigar smokers is

a difference in the frequency with which the two products are used. Most

cigarette smokers smoke every day. In contrast, as many as three-quarters of

cigar smokers smoke only occasionally, and some may only smoke a few cigars

per year. This difference in frequency of exposure translates into lower disease

risks.

We do not know the risk of addiction posed by cigar smoking. But the

difference in smoking patterns suggests a potential difference in addictive

properties between cigarettes and cigars.

Of special concern are the risks for those individuals who are mixed smokers

(current smokers of both cigars and cigarettes), or who switch to smoking cigars

from smoking cigarettes. A sizable fraction of today's cigar smokers are current or

past cigarette smokers. These individuals are much more likely to continue to

inhale when they switch to smoking cigars, and may therefore remain at much

higher risk for all the major smoking related diseases than are cigar smokers who

have never smoked cigarettes.

To those individuals who may be thinking about smoking cigars, our advice

is — don't. Cigars are not safe alternatives to cigarettes and may be addictive.

To those cigarette smokers who are thinking of switching to cigars, don’t be

misled. Unless you substantially reduce your exposure to smoke, your risks will

remain unchanged.

To those currently smoking cigars, quitting is the only way to eliminate the

documented harm that can result from cigar smoking.

Once regular tobacco use is established, no matter whether it’s cigarettes,

cigars, or smokeless tobacco, quitting may become extremely difficult.

To all smokers and nonsmokers, tobacco smoke contains over 4,000

compounds, including dozens of carcinogens. Because of their greater mass,

cigars generate much higher levels of many of these indoor pollutants than do

cigarettes. Smoke from a single cigar burned in a home can require 5 hours to

dissipate, thereby exposing other household members to a sizable involuntary

health risk.

A special concern generated by the data in this monograph is the rate of cigar

use among adolescents. Prior to the current upswing in cigar use, most cigar

smokers were middle aged or older men, and they began smoking cigars as adults.

In contrast, several studies now report cigar smoking prevalence rates among

adolescent males that are more than double the rates of smokeless tobacco use.

In a 1996 survey of Massachusetts school students in grades 6 through 12,

prevalence of current cigar use among males ranged from 3.2 percent in 6th

graders to 30 percent in high school. Adolescent girls also report surprisingly

Preface

high rates of cigar use, with 6-7 percent of girls in high school reporting they

smoked cigars in the past 30 days. Similar findings are reported in other studies.

This high rate of cigar use among adolescents raises significant public health

questions and has serious implications for public health programming. Will

these high rates of cigar use continue as these youth move into adulthood? Will

nicotine addiction develop in these adolescent users and thereby influence their

inhalation and consumption patterns? Will cigar smoking transition large

numbers of youth into regular cigarette use later in life? If regular cigar use

develops, will quitting prove as difficult for cigars as it is for cigarettes?

It is premature to label cigar use as the next tobacco epidemic in the making;

but we would be wise to remember that a similar problem of smokeless tobacco

use confronted us in the late 1970's, and it was a number of years before the

public health community became concerned. Now, 20 years later, consumption

of smokeless tobacco, especially moist snuff, has reached record levels — 60

million pounds last year, and shows no sign of waning. The vast majority of all

snuff users are younger-age adults and adolescents, a pattern not dissimilar to the

current pattern of cigar use.

This monograph provides us with a snapshot of a rapidly changing pattern of

behavior with important potential public health consequences. I commend the

authors for providing the nation with clear and invaluable information about

this disturbing change in tobacco use.

Richard D. Klausner, M.D.

Director

National Cancer Institute

Smoking and Tobacco Control Monograph No. 9

Acknowledgments

Cigars: Health Effects and Trends was developed under the editorial direction of

Donald R. Shopland, Coordinator, Smoking and Tobacco Control Program

(STCP), National Cancer Institute, Bethesda, Maryland.

The Senior Scientific Editor for this monograph was David M. Burns, M.D.,

Professor of Medicine, School of Medicine, University of California San Diego, San

Diego, California. The Consulting Scientific Editors were Dietrich Hoffmann,

Ph.D., Associate Director, American Health Foundation, Valhalla, New York and

K. Michael Cummings, Ph.D., M.P.H., Senior Research Scientist, Roswell Park

Cancer Institute, Buffalo, New York. The Managing Editor for this monograph was

Richard H. Amacher, Project Director, KBM Group Inc., Silver Spring, Maryland.

The editors and STCP staff members gratefully acknowledge the

many researchers and authors who made this monograph possible.

Attributions for each chapter are as follows:

Chapter 1. Cigar Smoking: Overview David M. Burns, M.D.

and Current State of the Professor of Medicine

Science School of Medicine

University of California San Diego

San Diego, CA

Chapter 2. Trends in Cigar Karen K. Gerlach, Ph.D., M.P.H.

Consumption and Epidemiologist

Smoking Prevalence Office on Smoking and Health

Centers for Disease Control and Prevention

Atlanta, GA

K. Michael Cummings, Ph.D., M.P.H.

Senior Research Scientist

Department of Cancer Control and

Epidemiology

Roswell Park Cancer Institute

Buffalo, NY

Andrew Hyland, M.A.

Data Analyst

Department of Cancer Control and

Epidemiology

Roswell Park Cancer Institute

Buffalo, NY

Elizabeth A. Gilpin, M.S.

Senior Statistician

Cancer Prevention and Control

University of California San Diego

La Jolla, CA

Acknowledgments

Michael D. Johnson, Ph.D.

Chief

Data Analysis and Evaluation Unit

California Department of Health Services

Tobacco Control Section

Sacramento, CA

John P. Pierce, Ph.D.

Professor and Associate Director

Cancer Prevention and Control

Sam M. Walton Professor for Cancer

Research

University of California San Diego

La Jolla, CA

Chapter 3. Chemistry and Toxicology Dietrich Hoffmann, Ph.D.

Associate Director

American Health Foundation

Valhalla, NY

Ilse Hoffmann, B.S.

Research Coordinator

American Health Foundation

Valhalla, NY

Chapter 4. Disease Consequences of Thomas G. Shanks, M.P.H., M.S.

Cigar Smoking Principal Statistician

University of California San Diego

San Diego, CA

David M. Burns, M.D.

Professor of Medicine

School of Medicine

University of California San Diego

San Diego, CA

Chapter 5. Indoor Air Pollution James L. Repace, M.S.

from Cigar Smoke Repace Associates

Bowie, MD

U.S. EPA Office of Radiation and

Indoor Air (Retired)

Wayne R. Ott, Ph.D.

Visiting Scholar

Department of Statistics

Consulting Professor

Department of Civil and Environmental

Engineering

Stanford University

Stanford, CA

Neil Klepeis, M.S.

School of Public Health

Environmental Health Sciences

University of California, Berkeley

Berkeley, CA

vii

Smoking and Tobacco Control Monograph No. 9

Chapter 6. Pharmacology and Reginald V. Fant, Ph.D.

Abuse Potential Pinney Associates, Inc.

of Cigars Bethesda, MD

Jack E. Henningfield, Ph.D.

Vice President

Research and Health Policy

Pinney Associates, Inc.

Bethesda, MD

Associate Professor

Department of Psychiatry and Behavioral

Sciences

Johns Hopkins University

School of Medicine

Baltimore, MD

Chapter 7. Marketing and John Slade, M.D.

Promotion of Cigars Professor of Clinical Medicine

University of Medicine and Dentistry of

New Jersey

Robert Wood Johnson Medical School

Saint Peter’s Medical Center

New Brunswick, NJ

Chapter 8. Policies Regulating Cigars Gregory N. Connolly, D.M.D., M.P.H.

Director of the Massachusetts Tobacco

Control Program

Massachusetts Department of Public Health

Boston, MA

We gratefully acknowledge the following distinguished scientists, researchers, and

others, both in and outside Government, who contributed critical reviews or assisted in

other ways:

Anthony Alberg, Ph.D., M.P.H.

Assistant Scientist

Johns Hopkins University

Baltimore, MD

Dileep G. Bal, M.D.

Chief

Cancer Control Branch

California Department of Health Services

Sacramento, CA

Steve Bayard, Ph.D.

Director

Office of Risk Assessment

Health Standards Program

OSHA, Department of Labor

Washington, DC

Neal L. Benowitz, M.D.

Professor of Medicine

Chief

Division of Clinical Pharmacology

and Experimental Therapeutics

University of California San Francisco

San Francisco, CA

Lois Biener, Ph.D.

Senior Research Fellow

Center for Survey Research

University of Massachusetts Boston

Boston, MA

Michele Bloch, M.D., Ph.D.

Chair

Tobacco Control and Prevention

Subcommittee

American Medical Women’s Association

Alexandria, VA

Acknowledgments

viii

Tom Capehart, M.S.

Agricultural Economist

Economic Research Service

United States Department of Agriculture

Washington, DC

Sir Richard Doll, F.R.S., F.R.C.P.

Emeritus Professor of Medicine

Radeliffe Infirmary

University of Oxford

Oxford

United Kingdom

Michael Eriksen, Sc.D.

Director

Office on Smoking and Health

National Center for Chronic Disease

Prevention and Health Promotion

Centers for Disease Control

and Prevention

Atlanta, GA

Lawrence Garfinkel, M.A.

Consultant

American Cancer Society

New York, NY

Ellen Gritz, Ph.D.

Professor and Chair of the Department of

Behavioral Science

University of Texas

MD Anderson Cancer Center

Houston, TX

S. Katharine Hammond, Ph.D., CIH

Associate Professor of Environmental

Health Sciences

School of Public Health

University of California

Berkeley, CA

Thomas P. Houston, M.D.

Director

Department of Preventative

Medicine and Environmental Health

American Medical Association

Chicago, IL

John Hughes, M.D.

Professor

Department of Psychiatry

Ira Allen School

University of Vermont

Burlington, VT

Murray J. Kaiserman, Ph.D.

Acting Director

Office of Tobacco Control

Health Protection Branch

Ottawa, Ontario

CANADA

C. Everett Koop, M.D.

Bethesda, MD

U. S. Surgeon General (1981-1989)

Claude Lenfant, M.D.

Director

National Heart, Lung, and Blood Institute

National Institutes of Health

Bethesda, MD

Alan I. Leshner, Ph.D.

Director

National Institute on Drug Abuse

National Institutes of Health

Rockville, MD

John L. Pauly, Ph.D.

Cancer Research Scientist V

Department of Molecular Immunology

Roswell Park Cancer Institute

Buffalo, New York

John Pinney, B.A.

President

Pinney Associates, Inc.

Bethesda, MD

Richard W. Pollay, Ph.D., M.B.A.

Professor of Marketing

Faculty of Commerce

University of British Columbia

Vancouver, British Columbia

CANADA

Bill Rickert, Ph.D.

President

Labstat Incorporated

Kitchener, Ontario

Associate Professor

Department of Statistics

University of Waterloo

Waterloo, Ontario

CANADA

Nancy A. Rigotti, M.D.

Director

Tobacco Research and Treatment Center

General Internal Medicine Unit

Massachusetts General Hospital

Boston, MA

Smoking and Tobacco Control Monograph No. 9

Jeffrey Wasserman, Ph.D.

Consultant

The RAND Corporation

Santa Monica, CA

Judith Wilkenfeld, J.D.

Special Advisor to the Commissioner

Food and Drug Administration

Rockville, MD

Ernst L. Wynder, M.D.

President

American Health Foundation

New York, NY

Mitchell R. Zeller, J.D.

Associate Commissioner

Food and Drug Administration

Rockville, MD

Finally, the editors and STCP staff members would also like to acknowledge the

contributions of the following individuals who provided technical and editorial assistance

in the preparation of this monograph. We would particularly like to acknowledge the staff

of Business Images, Vienna, Virginia, especially Allen Côté, Marleen Flegel, and Ken Snow

for their invaluable assistance during the final production phase of the monograph.

KBM Group, Inc., Silver Spring, MD

Shelia Russell McCullers, M.S., Information Coordinator/Assistant Managing Editor

Thomas H. Gough, B.A., Technical Editor

Barbara A. Hatfield, A.A.,Copy Editor/Research Assistant

Keith W. Stanger, A.A., Graphics Designer

Heidi Volf, B.A., Copy Editor/Research Assistant

Carleen H. Wallington, M.S., Copy Editor/Research Assistant

Tobacco Control Policies Project, University of California San Diego,

San Diego, CA

Christy M. Anderson, B.S., Statistician

Maureen Arnn, B.S., Project Assistant

Robert W. Davingnon, M.S., Production Editor

Victoria L. Dirac, B.A., Project Assistant

Kathryn B. Gower, B.A., Statistical Assistant

Jacqueline M. Major, M.S., Statistician

Jonathan M. Samet, M.D., M.S.

Professor and Chairman

Department of Epidemiology

School of Hygiene and Public Health

Johns Hopkins University

Baltimore, MD

Jesse L. Steinfeld, M.D.

San Diego, CA

U. S. Surgeon General (1969-1973)

Michael J. Thun, M.D.

Vice President

Epidemiology and Surveillance Research

American Cancer Society

Atlanta, GA

Kenneth E. Warner, Ph.D.

Richard D. Remington Collegiate

Professor of Public Health

Department of Health Management

and Policy

School of Public Health

The University of Michigan

Ann Arbor, MI

Acknowledgments

Melissa L. Sage, B.A., Project Assistant

Jerry W. Vaughn, B.S., Programmer/Analyst

Kristina M. Webb, Project Assistant

HOW THIS MONOGRAPH This volume is the ninth in the series of Smoking and Tobacco

WAS PREPARED Control monographs published by the National Cancer

Institute (NCI) since their inception in 1991. One of the major reasons for

establishing the monograph series was to provide a mechanism for the rapid,

systematic, and timely dissemination of information important to the research

and public health communities about emerging issues in smoking and tobacco

use control. While the focus of the monographs has primarily centered on topics

related to public health interventions, this volume is somewhat of a departure in

that it is the first comprehensive examination of what we know about current

trends in cigar use and resultant health implications.

CIGARS: Health Effects and Trends, is being published, in part, because of the

growing and sustained interest in cigars as reflected by the countless inquiries

received over the past two years about the topic by NCI’s Office of Cancer

Communications.

Prior to 1994, smoking of cigars had declined by 60 percent in the United

States, a downward trend which started in the mid-1960’s. Surveys conducted

from the mid-1950’s through the early 1990’s confirmed that cigar smoking was

declining. The public health community assumed, incorrectly it now appears,

that cigar smoking would continue to decline in popularity and did not warrant

further investigation. But starting in the early 1990’s, the downward trend in

cigar use began to reverse; and between 1993 and 1997, cigar consumption

increased almost 50 percent with consumption of large, premium cigars increas-

ing nearly 250 percent.

Public interest, spurred by new magazines devoted entirely to cigars and cigar

smoking, and the social environment that cigar smoking purportedly involves,

was enough to rapidly increase the consumption of cigars. Unfortunately, the

public has been led to believe that cigar smoking is far less of a threat to an

individual’s health than cigarette smoking simply because it is a cigar. The

present monograph is an attempt to dispel this misconception and put the risks

of cigar smoking into their proper context.

The Smoking Tobacco and Control Program (STCP) staff continually

monitors the consumption of all forms of tobacco products, and consequently,

the recent interest and increased consumption of cigars was considered important

enough to the nation’s health to prepare a health oriented publication regarding

cigar smoking.

Once the decision was made by the STCP Coordinator to look into the matter

of cigar smoking, a broad outline was developed showing the major chapters or

topics to be covered in the monograph. A three-person scientific editorial team

was established, consisting of the Senior Scientific Editor, David M. Burns,

Professor of Medicine, University of California San Diego, California, and two

Smoking and Tobacco Control Monograph No. 9

Consulting Scientific Editors, Dietrich Hoffmann, Associate Director, American

Health Foundation, Valhalla, New York, and K. Michael Cummings, Senior

Research Scientist, Roswell Park Cancer Institute, Buffalo, New York. After a more

detailed outline was developed, potential authors were identified and contacted to

determine their willingness to write individual chapters or sections of the

monograph.

A one-day meeting was convened in the Washington, D.C. area in February

1997 involving the entire monograph team. Each lead author presented an

overview of his/her assignment, including how they proposed approaching their

particular chapter, potential sources to be used, the need for primary or secondary

data analysis, and gaps or overlaps in coverage. Discussions and recommendations

followed each presentation.

PEER REVIEW Preliminary draft chapters were delivered to the NCI approximately

4 months following the initial meeting in Washington. The senior scientific

editor, in consultation with the other science editors, reviewed all chapter drafts

for scientific and technical content and advised authors if revisions were needed.

All chapter drafts were distributed to two or more outside experts knowledgeable in

the subject area of the chapter. All review comments received were considered and

a new iteration of the monograph was generated. The revised version of the entire

monograph was sent to a select list of 12 senior level reviewers as well as to a

number of Public Health Service agency heads, for review and comments. All

comments received from this review cycle were also integrated and a third version

of the volume was generated. A total of 30 outside experts participated in the peer

review.

CIGARS: Health Effects and Trends was the work of dozens of individuals, and is

organized into 8 chapters:

Chapter 1: Cigar smoking: Overview and current state of the science.

Chapter 2: Trends in cigar consumption and smoking prevalence.

Chapter 3: Chemistry and toxicology.

Chapter 4: Disease consequences of cigar smoking.

Chapter 5: Indoor air pollution from cigar smoke.

Chapter 6: Pharmacology and abuse potential of cigars.

Chapter 7: Marketing and promotion of cigars.

Chapter 8: Policies regulating cigars.

xiii

Smoking and Tobacco Control Monograph No. 9

Contents

Preface ...............................................................................................i

Acknowledgments ......................................................................................... v

Chapter 1. Cigar Smoking: Overview......................................... 1

and Current State of the Science

Trends in Consumption .............................................................. 1

Disease Risks ........................................................................... 3

Inhalation ................................................................................ 4

Nicotine Addiction .................................................................. 11

Adult Use .............................................................................. 11

Adolescent Use ...................................................................... 13

Marketing .............................................................................. 14

Environmental Tobacco Smoke ................................................ 17

Regulation and Taxation .......................................................... 18

Overall Conclusions ................................................................ 19

References ............................................................................. 19

Chapter 2. Trends in Cigar Consumption ................................ 21

and Smoking Prevalence

Introduction ........................................................................... 21

Discussion ............................................................................. 48

Monitoring Recommendations .................................................. 51

Conclusions ........................................................................... 52

References ............................................................................. 53

Chapter 3. Chemistry and Toxicology ...................................... 55

Historical Notes ...................................................................... 55

The Cigar .............................................................................. 55

Chemistry of Cigar Tobacco ..................................................... 59

Chemistry and Analysis of Mainstream Cigar Smoke .................. 64

Sidestream Smoke and Environmental Tobacco Smoke ............... 76

Acknowledgments

xiv

Chapter 3. Chemistry and Toxicology (Continued)

Toxicity and Carcinogenicity of Cigar Smoke ............................. 83

Biomarkers for the Uptake of Tobacco Smoke ............................ 93

Summary and Research Needs .................................................. 95

Conclusions ........................................................................... 97

References ............................................................................. 97

Chapter 4. Disease Consequences of Cigar Smoking ............. 105

Definition of Terms............................................................... 105

The CPS-I Study ................................................................... 106

All Cause Mortality............................................................... 110

Cause Specific Mortality........................................................ 113

Lung Cancer ........................................................................ 114

Oral Cancers ........................................................................ 120

Cancer of the Larynx ............................................................. 127

Cancer of the Esophagus ........................................................ 130

Bladder and Urinary System Cancers....................................... 130

Pancreatic Cancer ................................................................. 137

Coronary Heart Disease ......................................................... 140

Chronic Obstructive Pulmonary Disease (COPD) ...................... 145

Cerebro-Vascular Disease ...................................................... 149

Aortic Aneurysm .................................................................. 151

Conclusions ......................................................................... 155

References ........................................................................... 155

Appendix: Methods Used in Analyzing CPS-I Data ................... 159

Chapter 5. Indoor Air Pollution From Cigar Smoke ............. 161

Introduction ......................................................................... 161

Mathematical Models for Cigar ETS Concentrations ................. 161

Cigar Emissions: Machine Smoking ........................................ 162

Cigar Emissions: Human Smoking .......................................... 164

Measurements at Cigar Smoking Socials .................................. 170

Discussion ........................................................................... 175

Conclusions ......................................................................... 177

References ........................................................................... 178

Table of Contents

Smoking and Tobacco Control Monograph No. 9

Chapter 6. Pharmacology and ................................................. 181

Abuse Potential of Cigars

Introduction ......................................................................... 181

Early Observations of Addictive Effects .................................. 181

Nicotine Dosing Capability of Cigars ...................................... 182

Inhalation of Cigar Smoke ..................................................... 183

Rate of Nicotine Absorption ................................................... 185

Nicotine Dependence ............................................................ 187

Factors Influencing Nicotine Dependence ................................ 189

Conclusions ......................................................................... 191

References ........................................................................... 192

Chapter 7. Marketing and Promotion of Cigars.................... 195

Introduction ......................................................................... 195

Sales Patterns ....................................................................... 195

Advertising .......................................................................... 198

Promotion ............................................................................ 203

Availability .......................................................................... 215

Discussion ........................................................................... 215

Conclusions ......................................................................... 217

References ........................................................................... 217

Chapter 8. Policies Regulating Cigars .................................... 221

Regulation of Cigar Products .................................................. 221

Health Warnings ................................................................... 223

Disclosure of Cigar or Smoke Product Constituents ................... 223

Advertising Restrictions ........................................................ 224

Regulation of Cigar Smoking in Public Places .......................... 225

Litigation ............................................................................. 225

Restrictions on Youth Access to Cigars .................................... 226

Taxation .............................................................................. 226

Conclusions ......................................................................... 232

References ........................................................................... 232

Smoking and Tobacco Control Monograph No. 9

Cigar Smoking: Overview and

Current State of the Science

David M. Burns

Cigars were one form of Native American tobacco use observed by

Columbus and early European settlers. A long, thick bundle of twisted

tobacco leaves wrapped in a dried palm or maize leaf was used by Native

Americans as a primitive cigar. Smoking of cigars is recorded on artifacts of

the Mayas of the Yucatan region of Mexico, and the Mayan verb “sikar,”

meaning to smoke, became the Spanish noun “cigarro.”

Among early English colonists of the 1600’s, tobacco was used

predominantly in the form of smokeless tobacco or smoked in pipes,

although tobacco was also smoked as cigars at this time. Records dating

from the late 1700’s suggest that most cigars were imported from the West

Indies and Cuba during the Colonial period.

The first U.S. cigar factory was established in Connecticut in 1810. Cigar

manufacturing spread to other parts of the U.S. as cigar use slowly gained in

popularity. Through the 1880’s and early 1900’s, cigars remained a popular

form of tobacco use, with most cigars made of locally grown tobacco and

marketed locally. By 1900, tobacco used in the form of cigars accounted for

2.0 of the 7.5 pounds of tobacco consumed per adult in the U.S., second only

to chewing tobacco’s 3.5 pounds per adult (USDA 1997, Burns et al 1997).

However, the amount of tobacco consumed as cigars declined as the

popularity of cigarettes increased around the time of World War I.

Tobacco used to manufacture cigars is different from that used in

cigarettes and other tobacco products. Tobacco contained in cigar filler,

binder and wrappers is predominantly air-cured tobacco in contrast to the

flue-cured tobacco common in cigarettes. Cigar tobacco is then aged and

subjected to a multi-step fermentation process that can last several months,

and this process is largely responsible for the flavor and aroma characteristic

of cigars. Small cigars on the U.S. market have straight bodies and weigh

between 1.3 and 2.5 grams each. Large cigars vary markedly in size and

shape, with the most common dimensions being 110-150 mm long and up to

17 mm in diameter, and they contain between 5 and 17 grams of tobacco

(Chapter 3). By contrast, the most popular brands of cigarettes are 85 mm

long and contain less than one gram of tobacco.

TRENDS IN Since 1993, cigar sales in the U.S. have increased by almost 50%,

CONSUMPTION with the largest increase occurring in sales of large cigars (USDA,

1997). Figure 1 presents U.S. cigar consumption from 1880 through 1997

and shows that cigar consumption declined following the introduction and

marketing of modern blended cigarettes in 1913, and this decline was

accelerated by the Great Depression beginning in 1929. Cigar consumption

remained below that found at the turn of the century until 1964 when it

increased dramatically, possibly as a response to the publication of the first

Surgeon General’s report with its warning about the disease risks of smoking

cigarettes.

Chapter 1

Figure 1

Total U.S. cigar consumption 1880-1997 and significant events in the use of cigars

1875

U.S. Cigar Consumption (Billions)

1895

1915

1935

Year

1955

1975

1995

Modern blended

cigarettes introduced

First Surgeon General’s Report

Advertising of little

cigars begins on TV

Great

Depression

Cigar Aficionado begins publishing

Ban on TV Advertising

of little cigars

Smoking and Tobacco Control Monograph No. 9

A loop-hole in the 1969 law banning advertising of cigarettes on

television and radio allowed the introduction and television advertising

of small cigars, which look and smoke much like cigarettes. Small cigar

consumption increased rapidly until these ads were also banned from

television and radio in 1973, and cigar consumption then began a steady

decline lasting almost 20 years. Marketing approaches to cigar sales linking

cigar smoking to wealth and success as portrayed in magazines such as Cigar

Aficionado, and utilizing events such as cigar nights at popular restaurants,

gained widespread prominence beginning in 1992. Sales of cigars, particularly

large cigars, have increased substantially since that time. Accompanying this

marketing has been the suggestion that cigars, particularly premium cigars,

have minimal if any disease risk associated with their use as long as they are

used in “moderation” (Shanken, 1997).

The recent change in tobacco use raises a number of important public

health questions. What are the disease consequences of cigar smoking? What

is the risk of addiction to nicotine from this form of tobacco use? Are the

marketing practices that underlie this change in cigar consumption resulting

in adolescent use of cigars? What are the risks of environmental tobacco

smoke exposure from cigar smoking?

DISEASE RISKS The smoke from both cigars and cigarettes is formed largely from the

incomplete combustion of tobacco, and therefore it comes as no surprise

that cigar smoke is composed of the same toxic and carcinogenic constituents

found in cigarette smoke (Chapter 3). Cigars have more tobacco per unit;

and correspondingly, take longer to smoke and generate more smoke per unit.

Additionally, the lower porosity of cigar wrappers results in more of carbon

monoxide per gram of tobacco burned; and the higher nitrate content of cigar

tobacco results in higher concentrations of nitrogen oxides, carcinogenic

N-nitrosamines and ammonia. When bioassayed in animals, the tar of cigar

smoke is more carcinogenic than cigarette smoke tar (Davies and Day, 1969).

There is little evidence from what is known about the tobacco content and

manufacture of premium cigars to suggest that they are less hazardous than

other cigars. Clearly, cigar smoke is as, or more, toxic and carcinogenic than

cigarette smoke; and differences in disease risks produced by using cigarettes

and cigars relate more to differences in patterns of use, and differences in

inhalation, deposition and retention of cigarette and cigar smoke than to

the differences in smoke composition.

The similarities of cigar and cigarette smoke suggest that similar patterns

of diseases should occur among individuals with similar intensities and

durations of smoke exposure. When cigar smokers who have never used

other tobacco products are compared to individuals who have never used

any tobacco product, a clear pattern of excess disease emerges that can be

related to the frequency of cigar use and the pattern of inhalation (Chapter 4).

Demonstration of a close association between the intensity of cigar smoke

exposure and rates of excess disease provide compelling evidence for

a causal association between cigar smoking and disease occurrence. Most

of the cancers caused by cigarette smoking occur at increased rates among

Chapter 1

regular cigar smokers. Cigar smokers who inhale deeply, particularly those

who smoke several cigars per day, have higher rates of coronary heart disease

and chronic obstructive pulmonary disease (COPD).

Figure 2 presents mortality ratios (ratio of the death rate in smokers

compared to never smokers) among male cigar and cigarette smokers for some

of the diseases associated with cigarette smoking. The ratios presented are for

smokers of all numbers of cigarettes or cigars combined. The mortality data

were derived from the American Cancer Society Cancer Prevention Study I

(CPS-I) a twelve year follow-up of over 1 million men and women (Garfinkel,

1985). These data were provided by the American Cancer Society and define

relative risks for those who have smoked exclusively cigars and those who have

smoked exclusively cigarettes, with each group of smokers being compared to

those who have never smoked any tobacco product. All of these mortality

ratios, except those for COPD, are statistically significantly increased among

cigar smokers (Chapter 4). The figure demonstrates that tobacco smoke

generated by cigars can lead to many of the same diseases produced by tobacco

smoke from cigarettes.

However, the pattern of excess disease risk among cigar smokers is not

identical to that observed in cigarette smokers. Mortality ratios among

cigarette smokers are much higher than those among cigar smokers for

coronary heart disease, COPD and lung cancer. In contrast, mortality ratios

for oral and esophageal cancer are similar among cigarette and cigar smokers.

The mortality ratio for laryngeal cancer is intermediate between these two

patterns. Table 1 presents mortality ratios, and their 95 percent confidence

intervals, for the major causes of excess mortality among cigar smokers. The

risk ratios are presented by number of cigars smoked per day and depth of

inhalation to demonstrate the dose-response relationships evident for cigar

smoking and these diseases; and similar data are presented for cigarette

smokers to allow comparison of the magnitude of the effects.

INHALATION An explanation for the difference in mortality pattern between cigarette

smokers and cigar smokers lies in differences in the depth and likelihood of

inhalation of tobacco smoke between these two groups of smokers. Most

cigarette smokers report inhaling the smoke into their lungs, while over three-

quarters of the males in CPS-I who have only smoked cigars report that they

never inhale (Chapter 4). This difference in inhalation is likely due to the

more acidic pH of cigarette smoke. The smoke of most cigars has an alkaline

pH; and as a result, nicotine contained in the smoke can be readily absorbed

across the oral mucosa without inhalation into the lung (Chapter 3). The

more acidic pH of cigarette smoke produces a protonated form of nicotine

which is much less readily absorbed by the oral mucosa, and the larger

absorptive surface of the lung is required for the smoker to receive his or her

desired dose of nicotine. As a result, cigarette smokers must inhale to ingest

substantial quantities of nicotine, the active agent in smoke, whereas cigar

smokers can ingest substantial quantities of nicotine without inhaling.

Inhalation substantially increases the exposure of lung tissue to tobacco smoke

and increases absorption of many smoke constituents, most notably carbon

monoxide (Turner et al., 1977; Wald et al., 1981).

Smoking and Tobacco Control Monograph No. 9

Figure 2

Mortality ratios for tobacco induced diseases among male cigar and cigarette smokers in

comparison with never smokers

Coronary

Heart

Disease

COPD Lung

Cancer

Laryngeal

Cancer

Oral

Cancer

Esophageal

Cancer

Mortality Ratio

Cigarette Smokers

Data from the 12 year follow-up of CPS I

Primary Cigar Smokers

The oral mucosa is exposed to similar amounts of smoke by those who

do and those who do not inhale deeper into the respiratory tract. In contrast,

the lung is much more heavily exposed in those who inhale; and absorption

of many smoke constituents into the blood is greater among those who

inhale. This difference in exposure to smoke by different tissues is the most

likely explanation for the differences in mortality pattern among cigar and

cigarette smokers. Cigar smokers who do not inhale receive a high smoke

exposure to the mouth and tongue, and smoke constituents in their saliva

are swallowed down their esophagus, producing the observed increased

risks of oral and esophageal cancers. The lung and systemic organs such

as the heart receive much less exposure to smoke constituents in those cigar

Chapter 1

Table 1

Mortality ratios, and 95% confidence intervals, for select causes of death in male cigar only vs cigarette only smokers by amount

smoked daily and depth of inhalation Cancer Prevention Study I, 12 year follow-up

Amount Smoked Daily

Cigars per Day Cigarettes per Day

Cause of death Nonsmoker 1-2 cigars 3-4 cigars 5+ cigars <1 pack 1 pack >1 pack

All causes of death 1.0 1.02 1.08 1.17 1.46 1.69 1.88

(.97-1.07) (1.02-1.15) (1.10-1.24) (1.43-1.49) (1.66-1.71) (1.85-1.91)

Cancer of buccal cavity 1.0 2.12 8.51 15.94 5.93 6.85 12.04

& pharynx combined* (0.43-6.18) (3.66-16.77) (8.71-26.75) (4.28-8.02) (5.37-8.62) (9.81-14.63)

Cancer of esophagus 1.0 2.28 3.93 5.19 2.41 4.3 5.6

(0.74-5.33) (1.43-8.55) (2.23-10.22) (1.61-3.46) (3.32-5.48) (4.35-7.10)

Cancer of larynx 1.0 6.46 — 26.03 8.7 25.69 23.59

(0.72-23.27) (8.39-60.74) (4.75-14.59) (18.66-34.48) (17.33-31.37)

Cancer of lung 1.0 0.99 2.36 3.40 6.75 12.86 20.23

(0.54-1.66) (1.49-3.54) (2.34-4.77) (6.18-7.37) (12.14-13.60) (19.20-21.30)

Cancer of pancreas 1.0 1.18 1.51 2.21 1.69 2.17 2.41

(0.69-1.89) (0.86-2.45) (1.40-3.32) (1.41-2.00) (1.89-2.47) (2.08-2.77)

COPD 1.0 1.39 1.78 1.03 8.86 12.51 15.04

(0.74-2.38) (0.89-3.18) (0.37-2.23) (7.96-9.84) (11.48-13.60) (13.73-16.45)

Coronary heart disease 1.0 0.98 1.06 1.14 1.4 1.58 1.65

(0.91-1.07) (0.96-1.16) (1.03-1.24) (1.36-1.45) (1.54-1.62) (1.60-1.69)

Smoking and Tobacco Control Monograph No. 9

Table 1

(continued)

Self-Reported Depth of Inhalation

Cigars Cigarettes

Cause of death Nonsmoker None Slight Moderate to Deep None, Slight Moderate Deep

All causes of death 1.0 1.04 1.19 1.6 1.54 1.65 1.9

(1.00-1.08) (1.09-1.30) (1.38-1.84) (1.50-1.57) (1.63-1.67) (1.86-1.94)

Cancer of buccal cavity 1.0 6.98 7.83 27.88 6.26 8.43 12.48

& pharynx combined* (4.13-11.03) (1.57-22.88) (5.60-81.46) (4.47-8.53) (7.00-10.06) (9.61-15.94)

Cancer of esophagus 1.0 3.4 1.9 14.84 2.94 4.06 4.95

(1.90-5.61) (0.02-10.58) (2.98-43.37) (1.97-4.23) (3.30-4.94) (3.55-6.72)

Cancer of larynx 1.0 10.6 — 53.26 22.19 13.49 27.54

(3.87-23.07) (0.70-296.32) (14.74-32.07) (10.01-17.78) (18.44-39.56)

Cancer of lung 1.0 1.97 1.89 4.93 9.33 13.13 17.11

(1.48-2.57) (0.81-3.72) (1.80-10.72) (8.61-10.10) (12.53-13.75) (16.00-18.28)

Cancer of pancreas 1.0 1.55 2.16 2.26 1.99 2.01 2.38

(1.12-2.07) (0.99-4.10) (0.45-6.60) (1.66-2.36) (1.79-2.25) (1.98-2.83)

COPD 1.0 1.09 2.05 4.52 8.8 12.28 16.07

(0.66-1.70) (0.66-4.77) (0.91-13.22) (7.85-9.85) (11.42-13.18) (14.49-17.78)

Coronary heart disease 1.0 1.01 1.23 1.37 1.45 1.52 1.71

(0.96-1.07) (1.07-1.41) (1.07-1.75) (1.41-1.50) (1.49-1.55) (1.66-1.76)

*excludes salivary gland

Chapter 1

smokers who do not inhale; and correspondingly, non-inhaling cigar

smokers have lower rates of coronary heart disease, COPD and lung cancer

than inhaling cigar smokers or cigarette smokers. The larynx, which

connects the lung and oral cavity, has a pattern of disease intermediate

between that of the lung and the mouth.

The importance of dose and inhalation for lung cancer risk among cigar

smokers are presented in Figure 3 where modeled lung cancer risk data from

CPS-I for cigar smokers of different numbers of cigars per day and different

patterns of inhalation are compared to the risks for a one pack per day

cigarette smoker (Chapter 4). When cigar smokers don’t inhale or smoke

few cigars per day, the risks are only slightly above those of never smokers.

Risks of lung cancer increase with increasing inhalation and with increasing

number of cigars smoked per day, but the effect of inhalation is more

powerful than that for number of cigars per day. When 5 or more cigars

are smoked per day and there is moderate inhalation, the lung cancer risks

of cigar smoking approximate those of a one pack per day cigarette smoker.

As the tobacco smoke exposure of the lung in cigar smokers increases to

approximate the frequency of smoking and depth of inhalation found in

cigarette smokers, the difference in lung cancer risks produced by these

two behaviors disappears.

The claim has been made that cigar smokers who smoke few cigars or

do not inhale have no increased risk of disease (Shanken, 1997). A more

accurate statement would be that the risks experienced by cigar smokers

are proportionate to their exposure to tobacco smoke.

Among regular cigar smokers who had never smoked cigarettes in the

CPS-I study and who did not inhale, statistically significant increased risks

for cancers of the lung, oral cavity, larynx, pancreas and esophagus are

observed (Chapter 4). Risks for coronary heart disease are significantly

elevated only for smokers of 3 or more cigars per day or those who inhale.

Relative risks for COPD increase with increasing inhalation, but the risks

do not reach statistical significance for the CPS-I data. It should also be

noted that increased risks of lung cancer and heart disease have been

reported for nonsmokers at levels of tobacco smoke that occur with

environmental tobacco smoke exposure (EPA, 1992; Cal EPA, 1997).

Risks among occasional cigar smokers are difficult to measure because

of the wide variability in frequency of smoking among occasional cigar

smokers and the marked variation in the amounts of tobacco contained

in different cigars. However, it is reasonable to assume that the risks for

occasional cigar smokers lie somewhere between those for individuals whose

only exposure to tobacco smoke is environmental tobacco smoke and those

of regular cigar smokers. As occasional cigar smokers smoke more frequently

or inhale more deeply, their exposure to tobacco smoke increases, and with

that increased exposure comes a proportionate increase in disease risks.

Smoking and Tobacco Control Monograph No. 9

Figure 3

Lung cancer death rates for cigar smokers with different patterns of inhalation and number of cigars per day compared with one

pack per day cigarette smokers

200

400

600

800

1,000

Lung Cancer Death Rate per 100,000

PYO

1,200

20 cigarettes/day, initiation at age 18

Age

5+ cigars/day, moderate inhalation

3-4 cigars/day, moderate inhalation

5+ cigars/day, no inhalation

never smoker

Chapter 1

The relationship of cigar smoking and alcohol consumption, particularly

for oral cancers, has not been evaluated; but the established interaction

between cigarette smoking and alcohol consumption for oral cancers and

the frequent association of cigar smoking with alcohol consumption raise

the question of an increased risk from the combination of these two

behaviors.

Cigarette Smokers As described earlier, a number of cigarette smokers may have

Who Switch to switched to cigars in response to health warnings following

Cigars release of the first Surgeon General’s Report in the belief that

smoking cigars resulted in a lower disease risk (Chapter 2). Data from the

CPS-I study demonstrate the limitations of this approach to risk reduction.

Cigar smokers who have previously been cigarette smokers report higher

rates of inhalation of tobacco smoke than do cigar smokers who have never

smoked cigarettes (Chapter 4). These former cigarette smokers also have

higher rates of most smoking induced diseases in CPS-I than do cigar smokers

who have never smoked cigarettes, and their rates remain above those for

smokers who stop using all tobacco products (Higgins et al., 1988). It is not

possible to define the independent contributions of their past cigarette

smoking and current cigar smoking behaviors with regard to these disease

risks, but it is clear that the risks remain above those for cigar smokers who

have never smoked cigarettes. Existing data suggest that any reductions in

disease risks that accompany switching from smoking cigarettes to smoking

cigars are conditional on a reduction in exposure to tobacco smoke with

the change in tobacco product smoked. Individuals who have previously

smoked cigarettes are more likely to inhale cigar smoke when they switch to

smoking cigars, and this increased inhalation may reduce or eliminate any

risk reduction with the change from cigarettes to cigars, particularly if cigars

are smoked daily or as a means of satisfying an addiction to nicotine.

Risks Among Almost all of the disease risk data for cigar smoking are based on

Women observations among males, but it is reasonable to assume that risks

among females would also be proportionate to the intensity and duration

of their exposure. In several European countries where women have smoked

cigars for many years, it appears that the risks for smoking related diseases

are similar for male and female cigar smokers. The lower prevalence and

frequency of use among females in the U.S. would be expected to translate

into lower rates of chronic disease due to cigar smoking in the female

population, particularly given the long duration of use required to produce

these diseases. However, cigarette smoking among women has been shown to

increase the fetal and maternal complications of pregnancy (USDHHS, 1990),

and these complications result from smoking during the comparatively short

duration of the pregnancy. Data on the risks of cigar smoking during

pregnancy are not sufficient to define the risks, but there is no reason to

expect that cigar smoke would be any less toxic for the mother or fetus.

Regular cigar smoking, particularly with inhalation, should be presumed to

have risks similar to that of cigarette smoking for the pregnant smoker.

Smoking and Tobacco Control Monograph No. 9

NICOTINE Cigars can deliver nicotine to the smoker in concentrations comparable

ADDICTION to those delivered by cigarettes and smokeless tobacco (Chapter 6).

However, the alkaline pH of cigar smoke, and the tendency of cigar smokers

not to inhale, result in the nicotine being absorbed predominantly across the

oral mucosa rather than in the lung. This route of absorption leads to a slower

rise and lower peak of the arterial levels of nicotine delivered to the brain

compared to the absorption that occurs across the alveolar-capillary surface of

the lung in most cigarette smokers. The rapidity of absorption and rate of rise

in arterial nicotine levels may be important determinants of the potential for

nicotine ingestion to lead to addiction (Jasinski et al., 1984). However, nicotine

absorbed across the oral mucosa is capable of forming a powerful addiction

as demonstrated by the large number of individuals addicted to smokeless

tobacco (USDHHS 1988); and cigar smoke can be inhaled into the lung where

it would be absorbed as readily as cigarette smoke

ADULT USE The pattern of use of cigars also sheds some light on the addictive nature

of cigar smoking in comparison with other forms of tobacco use, at least for

adults. The fraction of adult cigar smokers who smoke cigars every day is

much smaller than the fraction of cigarette or smokeless tobacco users who

use every day (Chapter 2). This suggests that cigar smoking among adults,

while probably able to cause addiction to nicotine, is less likely to do so than

cigarette smoking or smokeless tobacco use. Data from California, which

show that the recent change in cigar use among adults is largely an increase

in occasional use, also suggests that the addictive potential of cigars is lower

than that for cigarettes (Gerlach et al., 1998).

Whatever reassurance is provided by the largely occasional use of cigars

among adults must be tempered by spread of this behavior among groups

who have traditionally had low rates of cigarette use. The prevalence of

current cigar and cigarette smoking by income level for adult males in

California is presented in Figure 4, and it is apparent that the recent increase

in cigar smoking is largely among the affluent in contrast to the marked

decline in cigarette smoking that occurs with increasing income (Chapter 2).

A similar picture is evident with educational attainment, with the highest rates

of cigar use and lowest rates of cigarette use occurring among those with the

highest educational attainment. Increasing numbers of women, who

historically have had very low rates of cigar use, are also currently smoking

cigars.

The spread of cigar smoking into groups with low rates of cigarette use

is accompanied by a dramatic increase in cigar use among never smokers.

Among adult California males in 1996, forty percent of current cigar smokers

have smoked less than 100 cigarettes in their entire life which is the definition

typically used to define a never smoker.

Increasing cigar use among upper income and educational level adults

raises concern that the success in reducing smoking among these groups may

be at risk of reversal. This may be particularly true if the use of cigars by these

groups enhances the norms created by cigar marketers that portray cigar use as

a socially acceptable, sophisticated and relatively safe behavior. Anecdotal

Chapter 1

Figure 4

Prevalence of current cigarette and cigar smoking among California males of different

incomes, 1996

<=10,000

10,001-

20,000

20,001-

30,000

30,001-

50,000

Income

50,001-

75,000

75,000+

Percent

Cigars

Cigarettes

observation suggests that cigars are currently smoked in situations where

cigarette smokers are reluctant to light up, a marked reversal of the norm

banning cigar smoking even in environments where cigarette smoking was

allowed.

Use of cigars by adults who have never used cigarettes, or by former

cigarette smokers, raises a concern that use of cigars and the nicotine

ingestion that accompanies cigar smoking may lead to cigar smokers

initiating or relapsing to cigarette smoking. The fraction of tobacco used as

cigarettes expanded rapidly in the early years of this century at the expense

of pipes, cigars and smokeless tobacco, in part because cigarettes were a

convenient method of getting a rapid intense dose of nicotine in a short

interval of time (Burns et al., 1997). The potential for current cigar smokers

to begin seeking the psychoactive effects of nicotine on a more regular basis

through the more convenient form of a cigarette is a real risk based on our

Smoking and Tobacco Control Monograph No. 9

historical experience with these two tobacco products. Concern about relapse

to cigarette smoking by former cigarette smokers who start smoking cigars is

heightened by the observation in California adults that among those who

were former cigarette smokers one year ago, cigar smokers are twice as likely

to have relapsed to smoking cigarettes as former cigarette smokers who do not

use cigars (Chapter 2). This observation does not separate the likelihood that

cigar smoking leads to relapse of cigarette smoking from the possibility that

relapsing cigarette smokers take up smoking cigars as well, but it raises

a concern that cigar use may place former cigarette smokers at risk of relapse.

Of equal concern is the observation that the fraction of male adult

never smokers who began smoking cigarettes in the last two years is over

two times higher among current cigar smokers than among those who don’t

smoke cigars (Chapter 2). Again, it is impossible to separate the likelihood of

cigar smoking leading to initiation of cigarette smoking from the possibility

that those who initiate cigarette smoking are also likely to smoke cigars; but

the commonality in both of these behaviors is nicotine ingestion, and it

would not be surprising if use of cigars predisposed an individual to the use of

cigarettes.

ADOLESCENT Data on cigar use among adolescents is also alarming (Chapter 2).

USE Few data on past adolescent cigar use are available, largely because

it was a behavior felt to be uncommon enough not to be worthy of

examination until recently. However, several recent surveys of adolescents

show a substantial fraction of both male and female adolescents who report

both ever and current use of cigars (CDC, 1997a; Chapter 2). Male cigar

smoking prevalence still exceeds that for females among adolescents, but the

gender difference is less than for adults. Table 2 presents the prevalence of

cigar use among adolescents in Massachusetts by educational grade level,

and it is clear that there is a substantial level of cigar use, even prior to high

school.

Addiction to nicotine is a process that occurs almost exclusively during

adolescence and young adulthood (USDHHS, 1994). The age of initiation of

cigar smoking, prior to the recent increase in cigar use, was much older than

that for cigarette smoking (Chapter 2); and this difference in age of initiation

may be partially responsible for the lower addictive potential of cigars, as

manifest by the high rate of occasional, as compared to daily, cigar smoking

among adults. Now that initiation of cigar smoking is common among

adolescents, whatever resistance to addiction is offered by an older age of

initiation would be expected to disappear. The reassurance provided by the

low rate of daily cigar smoking among adults may be illusionary now that

initiation of cigar smoking is extending into those age groups where

development of addiction to nicotine is common. Several generations of

adolescents have become addicted to tobacco products that allow nicotine

to be absorbed through the lung (cigarettes) and to tobacco products that

allow nicotine to be absorbed through the oral mucosa (smokeless tobacco).

Cigars can deliver nicotine through both of these routes, and large numbers

of adolescents are currently being exposed to nicotine through use of cigars.

It is premature to conclude that current generations of adolescents who are

Chapter 1

Table 2

Prevalence of cigar use in the last year, and all forms of tobacco use in the last 30 days by

school grade, Massachusetts, 1996

Grade

6 7 8 9 10 11 12

Past Year Use 5.0 8.3 20.3 20.6 29.6 31.8 31.3

of Cigars (4.2-5.8) (6.6-10.0) (17.7-22.9) (18.1-23.1) (26.9-32.3) (28.7-34.8) (28.2-34.4)

Past 30-Day Use 2.0 4.4 10.9 10.4 16.0 18.4 13.4

of Cigars (1.1-2.9) (1.3-7.5) (8.9-12.9) (8.5-12.3) (13.8-18.2) (15.9-20.9) (11.0-15.8)

Males

Cigarettes 10.7 13.7 24.6 27.2 32.2 35.5 45.1

(8.0-13.4) (10.7-16.7) (20.8-28.4) (23.2-31.2) (28.3-36.1) (31.0-40.0) (40.3-49.9)

Smokeless 2.6 2.5 5.7 4.4 10.9 14.3 13.6

(1.2-4.0) (1.2-3.8) (3.7-7.7) (2.5-6.3) (8.3-13.5) (11.0-17.6) (10.3-16.9)

Cigars 3.2 4.3 13.0 14.9 24.9 30.3 23.7

(1.6-4.8) (2.6-6.0) (10.0-16.0) (11.7-18.1) (21.3-28.5) (25.9-34.7) (19.6-27.8)

Females

Cigarettes 5.7 19.0 27.5 33.0 35.3 42.0 36.6

(3.7-7.7) (15.5-22.5) (23.3-31.7) (29.1-36.9) (31.1-39.5) (37.6-46.4) (32.2-41.0)

Smokeless 0.1 0.2 0.8 1.3 1.2 0.5 0.6

(-0.8-1.0) -0.2-0.6) (0.0-1.6) (0.4-2.2) (0.2-2.2) (-0.1-1.1) (-0.1-1.3)

Cigars 0.8 4.6 8.4 6.6 6.1 7.7 4.1

(-1.5-3.1) (2.7-6.5) (5.8-11.0) (4.5-8.7) (4.0-8.2) (5.3-10.1) (2.3-5.9)

ingesting nicotine from cigars will not become addicted simply because older

generations of cigar smokers, who began smoking as adults, were less likely to

become addicted.

Current cigarette smoking prevalence rates among adults have remained

relatively unchanged over the last few years (CDC, 1997b), ending four

decades of decline in prevalence; and the prevalence of cigarette smoking

among adolescents has increased recently (CDC, 1996). The contribution

of increasing cigar use among both adults and adolescents to these trends

remains unexplored, but the temporal association of these two phenomena

suggests that it should be a high priority for future investigation.

MARKETING Recent marketing efforts have promoted cigars as symbols of a luxuriant

and successful lifestyle. Endorsements by celebrities including athletes,

elaborate cigar smoking events and the resurgence of cigar smoking in movies

have all contributed to the increased visibility of cigar smoking in society

and probably have lowered barriers to cigar use in public. Publication of cigar

lifestyle magazines such as “Cigar Aficionado”, which began in 1992, antedate

Smoking and Tobacco Control Monograph No. 9

the increase in cigar consumption which began in 1993. Linkage of cigar

smoking to an opulent and powerful lifestyle, and the featuring of highly

visible women smoking cigars, is a core element of cigar promotion; and

it has been successful in increasing cigar consumption among men and

initiating cigar smoking as a behavior among women (Chapter 7).

Evaluation of the effects of cigar promotional efforts on adolescent cigar

smoking is only just beginning due to the recent nature of this phenomenon,

but cigars are not the first tobacco product to be heavily promoted in ways

likely to influence adolescent use. Celebrity endorsements by popular

heroes, including athletes, were a prominent part of the mass marketing

of cigarettes during the first half of this century (Kluger, 1996).

By the late 1940’s and early 1950’s, print and television advertising

commonly featured athletes and movie stars describing the pleasures of

smoking individual brands of cigarettes (Figure 5). The individuals portrayed

here are only a tiny fraction of those who endorsed cigarette smoking. In

response to the concern about the disease consequences of smoking, the

tobacco industry adopted a voluntary code of advertising during the mid

1960’s that prohibited the use of endorsements by athletes and other

celebrities perceived to appeal to youth (USDHHS, 1994). Denied celebrity

Figure 5

Popular sport figures in tobacco advertisements circa 1940’s-1960’s

Chapter 1

endorsement in their advertising, the cigarette companies developed lifestyle

and image related advertising, most notably the Marlboro cowboy and

“Smooth Joe Camel” ads that have allowed these two brands to capture the

majority of adolescent smokers (CDC, 1994). Virginia Slims advertisements

linked cigarette smoking to independence and power as well as to thinness.

Cigarette promotion through events like the Cool Jazz Festival and Formula

One auto racing linked cigarettes to a glamorous and exciting lifestyle, while

sponsorship of cultural events linked cigarettes to sophistication and

provided borrowed credibility. One outcome of these marketing approaches

is that the overwhelming majority of cigarette smokers begin smoking, and

become addicted, during adolescence (USDHHS, 1994).

Intensive marketing of smokeless tobacco began in the 1970’s and

was followed by a dramatic rise in use of these products (USDHHS, 1993).

Smokeless tobacco products were marketed then, as cigars are being marketed

now, despite strong scientific evidence that they cause disease. The

difference in risk between the enormous risks of cigarette smoking and the

more moderate risks of smokeless tobacco and

cigar use is touted to reassure the users that the

products “used in moderation” have little risk. At

the same time, advertising in the print media and

on television (where cigarette advertising was

banned) featured endorsements by celebrities and

athletes, and smokeless tobacco promoted lifestyle

and image related events that linked smokeless

tobacco use with rodeo and auto racing. Once

again, adolescent males responded to these

promotional approaches; and it was

only after a generation of young males became

addicted to smokeless tobacco that endorsement

by athletes was discontinued because of its appeal

to youth. Again, the advertisement for smokeless

tobacco portrayed here (Figure 6) represents only

a few of the athletes that promoted smokeless tobacco use.

Having twice demonstrated that image related advertising

and celebrity endorsement could create a new market for little

used tobacco products, it should not be surprising that those

involved in the cigar trade would utilize the same approaches.

The use of celebrities like Demi Moore and Arnold

Schwarzenegger (Figure 7) to endorse cigar smoking along

with the images of Michael Jordan and Madonna smoking

cigars are an important part of creating a lifestyle image for

cigar use (Chapter 7). Athletes are also once again endorsing

cigar use including such prominent super stars as Wayne

Gretzky (Figure 8). Having demonstrated the success of this

approach in influencing adolescent tobacco use twice in this

century, we should not be surprised by the current high rates

of cigar use among adolescent males and females.

Figure 7

Figure 6

Smoking and Tobacco Control Monograph No. 9

The use of endorsements to allay health fears associated

with cigar smoking is also as old as the Camel Campaign that

touted “More doctors smoke Camels”. The eerie similarity of

two quotes sixty years apart in time make the point that the

message of reassurance is the same, it is only the product that is

different.

“For a good sense of deep-down contentment – just give

me Camels. After a good man-sized meal, that little phrase

‘Camels set you right’ covers the way I feel. Camels set me

right whether I’m eating, working – or just enjoying life. All

the years I’ve been playing, I’ve been careful about my physical

condition. Smoke? I smoke and enjoy it. My cigarette is a

Camel.”

Baseball Legend Lou Gehrig, The Saturday Evening Post of April 24, 1937

“The enjoyment of a cigar after a hard week gives me a feeling

of well-being and relaxation that a Valium could not match.

While there may be a more ideal form of stress reduction, I haven’t

yet discovered anything else as effective and easy”

Ear Nose and Throat Surgeon M. Hal Pearlman, M.D., Cigar Aficionado,

Spring 1993

Marketing a product is intended to increase the use of the

product, and it is probably naïve to assume that cigar manufacturers

would not adopt marketing approaches proven to increase the use

of other tobacco products, absent a regulatory prohibition. The

“intent” of the marketers may be to reach adults, but it is hard to

ignore the fact that twice before in this century this same “intent”

to reach adults has grabbed children.

ENVIRONMENTAL One highly visible approach to cigar marketing has been the

TOBACCO SMOKE cigar smoking event. These events commonly include meals

and entertainment, and are marketed as a means of experiencing fine cigars

(Chapter 7). Individuals attending these events may smoke cigars only at the

event and may smoke only a few cigars per year. However, employees who

work these events, and who are exposed to the environmental tobacco smoke

generated at them, may have much more frequent exposure. These events,

and the re-emergence of cigar smoking in public areas frequented by

nonsmokers, raise the question of the contribution of cigar smoking to

environmental tobacco smoke (ETS) exposure.

Comparison of the contribution of cigarettes and cigars to ETS requires

consideration of three issues: Differences in the composition of cigarette and

cigar smoke, differences in the emission rates per minute between cigarettes

and cigars, and differences in the mass of tobacco burned (and corresponding

duration of smoking) between cigars and cigarettes. Tobacco smoke produced

by cigars contains most of the same toxic and carcinogenic constituents found

in cigarette smoke (Chapter 3). There is marked variation in the relative

Figure 8

Chapter 1

concentrations of these constituents present in cigar smoke across different

types and sizes of cigars. In general however, large cigars produce more

carbon monoxide, as well as higher amounts of nitrogen oxides and

carcinogenic N-nitrosamines, per gram of tobacco burned, and the free

ammonia in tobacco smoke is higher due to the more alkaline pH of the

smoke (Chapter 3). It is likely this difference in free ammonia that results

in the more pungent smell of cigar smoke.

Cigars generate slightly lower amounts of respirable suspended

particulates (RSP) per minute compared to cigarettes (Chapter 5), but

somewhat higher amounts of carbon monoxide (CO). The major difference

between cigarettes and cigars is the amount of tobacco contained in each

product. Cigarettes generally contain less than one gram of tobacco and are

smoked for about 7-8 minutes, with a substantial interval between cigarettes.

Large cigars commonly contain 5-17 grams of tobacco, and are smoked over

intervals as long as 60-90 minutes. Thus cigars, while generating similar

amounts of ETS per minute compared to cigarettes, continue generating

smoke for a much longer period of time; and therefore, the total amount of

ETS generated by a single large cigar is much greater than that by a single

cigarette.

Continued generation of ETS by cigar smoking may be of particular

importance at cigar smoking events where most of the attendees smoke

cigars. It is likely that the number of individuals generating ETS at any point

in time would be higher at these events because of the longer time required

to finish a cigar. The shorter time required to finish a cigarette, and the

interval between cigarettes, would result in fewer individuals smoking at any

point in time.

Concern about increased generation of smoke at cigar events is born out

by measurements of smoke constituents at these events. Levels of CO in the

air at these events are similar to those on a crowded California freeway

(Repace et al., 1998). These data confirm the belief that cigars can contribute

substantial amounts of tobacco smoke to the indoor environment; and,

when large numbers of cigar smokers congregate together in a cigar smoking

event, the amount of ETS produced is sufficient to be a health concern for

those regularly required to work in those environments (Chapter 5).

REGULATION Cigars are treated separately from cigarettes and smokeless tobacco

AND TAXATION for purposes of taxation and often for purposes of regulation.

Traditionally they have been taxed at lower rates, and are not covered by

the currently proposed FDA regulations for tobacco (Chapter 8). In contrast,

cigar smoking was eliminated in airplanes and other locations well ahead

of the time that cigarette smoking was eliminated. More recently, a number

of States have increased the taxes on cigars; but the norms against cigar

smoking in public locations seem to be changing in favor of allowing cigar

smoking in more areas, including areas where cigarette smoking is not

considered acceptable.

Smoking and Tobacco Control Monograph No. 9

OVERALL CONCLUSIONS

1. Cigar smoking can cause oral, esophageal, laryngeal and lung cancers.

Regular cigar smokers who inhale, particularly those who smoke several

cigars per day, have an increased risk of coronary heart disease and

chronic obstructive pulmonary disease.

2. Regular cigar smokers have risks of oral and esophageal cancers similar to

those of cigarette smokers, but they have lower risks of lung and laryngeal

cancer, coronary heart disease and chronic obstructive pulmonary

disease.

3. Cigar use in the U.S. has increased dramatically since 1993. Adult

prevalence of cigar use in California has increased predominantly among

occasional cigar smokers. A substantial number of former and never

smokers of cigarettes are currently smoking cigars. In contrast to

cigarettes, much of the increased use of cigars appears to be occurring

among those with higher incomes and greater educational attainment.

4. Adolescent cigar use is occurring at a substantial level and is currently

higher that that recorded for young adults prior to 1993. Currently, cigar

use among adolescent males exceeds the use of smokeless tobacco in

several states. This use is occurring among both males and females.

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Trends in Cigar Consumption and Smoking Prevalence

Trends in Cigar Consumption

and Smoking Prevalence

Karen K. Gerlach, K. Michael Cummings, Andrew Hyland, Elizabeth A. Gilpin,

Michael D. Johnson, and John P. Pierce

INTRODUCTION The use of cigars appears to be on the increase in the United States

based on reports in the popular press and the emergence of cigar bars and cigar

events (Chapter 7). This chapter examines trends in cigar smoking prevalence

and patterns of cigar use. Data on cigar sales are examined to assess overall

trends in cigar use, while national and regional survey data on self-reported cigar

use are used to evaluate changing patterns of cigar use among different age,

gender, and racial groups.

Trends in Cigar Figure 1 depicts tobacco consumption in the United States by major

Production, Sales, product category for the period 1880 through 1997 (Milmore and

and Consumption Conover, 1956; U.S. Department of Agriculture, 1996, 1997). These

data are expressed in pounds of tobacco consumed per adult rather than in

individual units such as cigars or cigarettes, so that direct comparisons between

product categories can be made. Cigars accounted for a larger percentage of

overall tobacco consumption in the early decades of the twentieth century than

they do currently. By the mid-1920’s, cigar consumption began to decline as

cigarettes became the predominant form of tobacco consumed. Cigar

consumption increased slightly in the early 1950’s and again in the mid-1960’s,

possibly as a result of male cigarette smokers switching to cigars in response to

publicity about the health dangers of cigarettes.

From 1964 until 1993, cigar consumption declined by 66 percent in the

United States (U.S. Department of Agriculture, December 1996), however

between 1993 and 1997, overall cigar consumption increased nearly 50 percent.

The recent upturn in cigar smoking since 1993 is due mainly to an increase in the

sale of large cigars, which increased by 68 percent from 1993 to 1997 (Table 1).

Despite the recent growth in cigar sales, cigars still constitute only a small

fraction of the tobacco market in comparison with other tobacco products.

Figure 2 summarizes consumption data for United States of large cigars and

cigarillos and small cigars between 1950 and 1997 (U.S. Department of

Agriculture, September 1997). Before 1971, small cigars made up only a tiny

fraction of cigar sales. However, the sale of small cigars increased by 254 percent

between 1971 and 1972 (U.S. Department of Agriculture, December 1996) in

conjunction with an increase in television advertising. The increased television

advertising resulted from a loophole in the federal law (The Public Health

Chapter 2

Figure 1

Per-capita consumption of different forms of tobacco in the US 1880-1997

Trends in Cigar Consumption and Smoking Prevalence

Figure 2

U.S. estimated consumption of cigars 1950 to 1997

Chapter 2

Cigarette Smoking Act of 1969) that prohibited cigarette advertising on radio and

television, but which did not prohibit the advertising of cigars (U.S. Department

of Health and Human Services, 1989). Television advertising by manufacturers of

small cigars increased dramatically in 1972 and 1973 filling the void left by

cigarette advertisers, and sales of small cigars soared. In September 1973, Congress

passed a law banning the broadcast advertising of small cigars (The Little Cigar

Act - PL93-109) (U.S. Department of Health and Human Services, 1989); and the

consumption of small cigars dropped steadily until the early 1990’s when it

rebounded slightly.

As seen in Figure 2, the consumption of large cigars and cigarillos enjoyed a

resurgence in 1964, possibly due to cigarette smokers switching from cigarettes to

cigars following the first report to the U.S. Surgeon General on smoking and

health (U.S. Public Health Service, 1964). After 1965, consumption of large cigars

and cigarillos steadily declined until 1992. Since 1993, consumption of cigars of

all types (i.e., small, large, and large premium cigars) has increased (Maxwell,

1997); but by far the largest percentage increase has been in the consumption of

premium cigars. Between 1993 and 1996, sales of premium cigars increased by

nearly 154 percent.

Recent Trends in The recent upward trend in cigar sales in the United States may

Self-reported Use signal an increase in the prevalence of cigar smoking, an increase

in the number of cigars smoked among current users, or some combination. This

chapter examines national and regional survey data on self-reported cigar use in

an attempt to evaluate trends in the patterns of cigar use among different age,

gender, and racial groups.

Table 1.

Cigar consumption in the United States, 1993-1997

Cigar type millions of cigars millions of cigars % change

consumed consumed (1993-1997)

(1993) (1997)

large 2,138 3,589 67.9

small 1,280 1,447 13.0

total 3,418 5,036 47.3

Source: U.S. Department of Agriculture

Tobacco Situation and Outlook Report,

December 1997, TSB-240.

Data Sources The principal sources of nationally representative survey data to estimate

trends in cigar use by adults are the 1970, 1987, 1991, and 1992 National Health

Interview Surveys (NHIS), the 1986 Adult Use of Tobacco Survey (AUTS), and the

1992/93 and 1995/96 Current Population Surveys (Table 2a). Additionally, some

non-national surveys have included questions that can be used to estimate recent

trends in cigar smoking prevalence among adults. These surveys include the

Trends in Cigar Consumption and Smoking Prevalence

Table 2a

Data sources for adult cigar smoking prevalence

Chapter 2

Table 2a (

Continued

)

Data sources for adult cigar smoking prevalence

Trends in Cigar Consumption and Smoking Prevalence

1990 and 1996 California Adult Tobacco Use survey, and the cross-sectional and

cohort surveys conducted in 22 North American communities in 1989 and 1993

as part of the National Cancer Institute’s Community Intervention Trial for

Smoking Cessation (COMMIT) project (U.S. Public Health Service, 1995; Hyland

et.al, 1997) (Table 2a). Surveys that examine cigar smoking among adolescents

are included in Table 2b. It is important to note that differences in survey

methodology and the measures used to define cigar use make it difficult to

reliably compare trends in cigar use behavior between surveys. For example,

some surveys have restricted their definition of current cigar use to individuals

who report having smoked at least 50 cigars in their lifetime. Other surveys have

asked about “regular” use of cigars without defining the frequency of cigar

smoking. Few surveys have questioned cigar smokers about the quantity and

type of cigars typically consumed.

Prevalence of Ever Smoking Prevalence of ever smoking cigars was assessed by each of

Cigars Among Adults the national adult surveys (Table 3). Cigar smoking is

predominantly a male behavior. The overall male ever cigar smoking prevalence

declined slightly from 1986 to 1991, and then increased slightly in 1992. This

change in prevalence may also have occurred among females, but the prevalence

among females is so low that it is difficult to define a change with confidence.

Table 2a (

Continued

)

Data sources for adult cigar smoking prevalence

Chapter 2

Table 2b

Data sources for adolescent cigar smoking prevalence

The prevalence estimates from the Current Population Surveys are

significantly lower than those from the other national surveys, and this may be

due to differences in wording of the questions on cigar smoking in these surveys.

Respondents to the Current Population Survey were asked whether they had

“ever regularly used” cigars, but respondents in the Adult Use of Tobacco Survey

(AUTS) and in the NHIS were asked whether they had “ever smoked” cigars. Use

of the words “regular use” on the Current Population Survey may have implied a

more frequent use of cigars, and, therefore, those respondents who had smoked

cigars infrequently may have been less likely to respond affirmatively to this

question.

Trends in Cigar Consumption and Smoking Prevalence

Table 3

Cigar ever smoking prevalence from national surveys

1986 AUTS 1987 NHIS 1991 NHIS 1992 NHIS 1992-93 CPS 1995-96 CPS

Total Male 43.0±1.5 38.0±1.0 35.5±1.0 40.2±1.8 7.9±0.2 7.3±0.2

Age

18–24 31.5±4.2 24.7±2.0 22.3±2.3 29.5±4.8 2.3±0.3 3.0±0.3

25–34 37.9±3.2 30.0±1.5 25.8±1.5 34.4±3.2 3.3±0.3 3.4±0.3

35–44 46.3±3.3 39.4±2.0 36.5±1.8 39.1±3.3 6.5±0.4 5.4±0.3

45–64 11.3±0.4 9.7±0.4

45-54 52.8±4.1 44.5±2.3 45.3±2.3 45.8±4.2

55–64 50.5±4.1 48.3±2.4 45.7±2.4 49.6±4.7

65+ 49.8±4.3 49.5±2.0 44.4±2.1 48.4±4.1 17.0±0.7 15.2±0.07

Hispanic Origin*

Hispanic 34.7±6.5 22.5±2.6 21.3±3.0 25.5±4.7 3.5±0.4 3.0±0.4

Non-Hispanic White 43.6±1.6 39.2±1.1 36.8±1.0 41.5±1.8 9.0±0.2 8.4±0.2

Race

White 45.3±1.6 39.9±2.4 37.5±1.1 42.2±1.9

Black 29.7±5.1 26.6±3.3 25.2±2.5 32.0±4.7 5.6±0.5 4.8±0.5

Asian or PI 21.4±9.3 15.5±3.7 17.0±4.7 15.2±6.5 2.4±0.6 1.9±0.5

Other** 40.5±12.0 41.4±7.2 25.4±6.2 32.4±12.8 7.8±2.2 8.8±2.3

Educational Level

<12 44.6±3.5 42.5±2.1 37.6±2.1 38.9±3.4 9.6±0.5 7.9±0.5

12 43.7±2.6 37.9±1.4 35.4±1.5 41.1±2.9 7.8±0.3 7.3±0.3

13–15 41.3±3.1 35.4±1.8 33.7±2.2 41.6±3.3 7.2±0.4 7.0±0.4

16+ 41.6±3.1 36.2±1.7 35.3±1.7 38.6±3.2 7.7±0.4 7.1±0.4

1986 AUTS 1987 NHIS 1991 NHIS 1992 NHIS 1992-93 CPS 1995-96 CPS

Total Female 3.5±0.6 3.8±0.3 3.1±0.2 3.7±0.5 0.29±0.04 0.28±0.04

Age

18–24 2.2±1.3 4.5±0.9 2.7±0.7 5.0±1.7 0.16±0.07 0.16±0.08

25–34 4.2±1.2 4.7±0.6 3.0±0.6 4.7±1.2 0.23±0.07 0.26±0.08

35–44 5.1±1.4 4.2±0.6 4.3±0.6 3.2±0.9 0.36±0.09 0.35±0.09

45–64 0.42±0.09 0.35±0.08

45–54 4.4±1.7 4.3±0.9 3.5±0.6 4.1±1.5

55–64 2.9±1.4 3.0±0.6 3.3±0.7 3.2±1.3

65+ 2.0±1.1 1.7±0.4 1.6±0.5 2.2±0.9 0.21±0.07 0.21±0.07

Hispanic Origin*

Hispanic 6.6±3.6 2.7±0.9 1.7±0.6 2.9±1.3 0.23±0.11 0.18±0.10

Non-Hispanic White 3.3±0.6 3.9±0.3 3.2±0.3 3.8±0.5 0.32±0.04 0.30±0.04

Race

White 3.7±0.6 3.9±0.4 3.3±0.3 4.1±3.5

Black 1.9±1.3 2.9±0.6 1.6±0.4 1.8±0.9 0.23±0.09 0.21±0.09

Asian or PI 7.2±7.3 2.0±1.8 1.6±1.4 1.1±1.6 0.05±0.09 0.19±0.16

Other** 6.5±6.3 5.5±4.3 7.3±5.8 7.1±6.2 0.78±0.67 1.40±0.85

Educational Level

<12 3.4±1.3 3.6±0.5 2.7±0.5 3.2±1.0 0.38±0.10 0.32±0.09

12 3.3±0.9 3.6±0.4 3.1±0.4 3.2±0.8 0.25±0.05 0.24±0.05

13–15 3.9±1.1 4.7±0.6 3.2±0.5 4.7±1.4 0.30±0.07 0.28±0.07

16+ 3.9±1.4 3.6±0.6 3.3±0.6 4.3±1.0 0.31±0.09 0.32±0.08

*The White and Black categories in NHIS included those of Hispanic origin whereas in the CPS, all Hispanics are included in the Hispanic

category.

**The 1995/96 CPS category “Other” contains only American Indians. All other respondents were assigned to existing categories.

Chapter 2

The prevalence of cigar smoking by age and gender shows that, in surveys

conducted between 1986-1992, older males were more likely than younger males

to have ever smoked cigars. Ever cigar smoking did not vary by age among

females. The prevalence of ever smoking was lower in every age group in the

Current Population Surveys, but the pattern of ever cigar smoking by age group

among males in the Current Population Surveys was similar to that seen with the

other national surveys. Older males showed a significant decline in ever smoking

prevalence between 1992/93 and 1995/96 in the Current Population Surveys.

However, this decline was not evident among younger males, and there was a

small but statistically significant increase among males 18-24 years of age.

Non-Hispanic males were more likely than Hispanic males to have ever

smoked cigars. This pattern was seen on all national surveys. There were no

differences between Hispanic and non-Hispanic females. White males were more

likely than black males to report ever having smoked cigars. Rates for white and

black males decreased slightly from 1986 to 1991, but then rose again in 1992.

White females were somewhat more likely than black females to have ever

smoked cigars, but the rates for females did not vary by race from 1986 to 1992.

In 1987, males with fewer than 12 years of education were more likely than

males with greater than 12 years of education to report ever smoking cigars. This

difference by education is the opposite of that seen in more recent surveys.

There were no differences in ever cigar smoking rates by education among

women.

Data for the state of California can also be used to compare cigar smoking in

1990 with that in 1996. Table 4 presents the ever cigar smoking prevalence for

the State of California in 1990 and 1996 and shows an overall decline in ever

smoking prevalence among males, with no change among females. The

prevalence of ever smoking among males in California increased substantially

with age in the 1990 survey; but, between 1990 and 1996, the prevalence of ever

smoking declined among older age groups and increased in the 18-24 year old

group, resulting in a flattening in the gradient of ever smoking with age. Ever

smoking prevalence among women showed little change with age in 1990; but in

1996, there was a decline in ever smoking prevalence among older age groups

and an increase in the 18-24 year old group sufficient to produce an inverse

gradient with age.

Prevalence of Current Figure 3 shows changes in the percentage of adult current

Cigar Smoking cigar users among males and females in the United States between

1970 and 1992 using data collected from the NHIS. These data reveal that cigar

use has always been predominantly a male behavior. Between 1970 and 1992,

the prevalence of cigar use among adult males declined by 80 percent. The

decline in cigar use by males was evident in all age and racial groups (data not

shown). The highest prevalence of cigar use was among males between the ages

of 35 and 64 years. Male and female prevalence of current cigar smoking among

adults nationally also declined between 1986-1992 for all races (Table 5). Except

for 1987, there were no significant differences among the races in current cigar

smoking prevalence. By 1992, cigar use was a behavior rarely seen among

Trends in Cigar Consumption and Smoking Prevalence

Table 4

Current and ever cigar smoking prevalence among California adults, 1990 and 1996

Chapter 2

Figure 3

Percentage of adults (18+ years of age) who currently use cigars* by sex,

National Health Interview Surveys, 1970, 1987, 1991, and 1992

females of any age or among men under the age of 25 years.Data from the 1992/

93 and 1995/96 Current Population Surveys confirm the overall low prevalence

of cigar use among both men and women. In 1992/93, only 1.7 percent of males

and 0.5 percent of females reported current regular use of cigars. However, the

reported regular use of cigars increased slightly among males (i.e., to 2 percent)

and females (i.e., to 0.6 percent) in 1995/96 suggesting a reversal in the 2-decade

long decline in cigar use among adults in the United States.

Data from the longitudinal tracking survey of adults conducted between

1989 and 1993 in 22 North American communities as part of the NCI’s COMMIT

project also point to an increase in cigar use (Hyland et.al, in press). The 1989

and 1993 surveys asked whether the respondent regularly smoked cigars or

cigarillos (regular was defined as 3-4 times/week). Averaged across the 22

communities, the prevalence rate of regular cigar use increased 133 percent from

0.9 percent in 1989 to 2.1 percent in 1993. The reported increase in regular cigar

use was observed in all 22 communities and seen in every gender, age, race,

income, and smoking status category. The 1993 data show that both regular and

occasional cigar use were more frequently reported by younger respondents and

current cigarette smokers. The higher prevalence of cigar use among younger

adults represents a dramatic change from earlier surveys of cigar users.

* Current use identified those persons who had smoked 50+ cigars in their lifetime who currently smoke cigars

Trends in Cigar Consumption and Smoking Prevalence

Table 5

Cigar current smoking prevalence from national surveys

*The White and Black categories in NHIS included those of Hispanic origin whereas in the CPS, all Hispanics are included in the Hispanic

category.

**The 1995/96 CPS category “Other” contains only American Indians. All other respondents were assigned to existing categories.

Chapter 2

The 1990 and 1996 California Adult Tobacco Use Surveys are perhaps the

best source of data available to estimate recent trends in cigar use behavior.

California adults were asked about their current cigar smoking habits in 1990 and

1996. Over this 6-year interval, cigar smoking increased among both males and

females (Table 4). The rates of cigar smoking increased among males of each

race, but the increase was greatest among white and black males. Current cigar

smoking prevalence remained unchanged among males with less than a high

school education. In contrast, males with higher educational attainment and

income, and younger males, had increases in cigar smoking prevalence. Figure 4

compares current cigar smoking prevalence in 1990 and 1996 for different age

groups of males and clearly demonstrates that the increase in current cigar

smoking prevalence is predominantly occurring among younger age males (18-

44). A similar shift in cigar smoking prevalence is also occurring among young

women, but the prevalence of current cigar smoking remains low among women.

The increase in current cigar smoking prevalence with increasing educational

attainment and income (Table 4) is in marked contrast to the pattern observed

among cigarette smokers. Prevalence of cigarette smoking decreases with

increasing educational attainment and income. Figure 5 contrasts the 1996 data

for current cigarette and cigar smoking among California males by education and

Figure 6 provides the same contrast for income level. Clearly the influence of

these socioeconomic factors on these two tobacco-use behaviors is quite different.

Recent changes in use of cigars may be confined to current cigarette smokers,

or it may also be occurring among those who are not current cigarette smokers.

Table 6 presents data from the 1990 and 1996 California tobacco use surveys that

classify cigar and cigarette smoking by whether only one tobacco product is

currently being used or whether both products are currently being used. In 1996,

60 percent of males who reported currently smoking cigars did not smoke

cigarettes at the time of the survey, and 40 percent had never smoked more than

100 cigarettes in their lifetime (the definition of a never smoker). There was an

increase in male current cigar smoking prevalence between 1990 and 1996 for

current and former cigarette smokers, as well as for never smokers, but the

proportionate increase (278 percent) is greatest among never smokers. The

increase in cigar only use between 1990 and 1996 is also greater for those groups

with higher educational attainment and income.

Prevalence of Former There is little information available on the frequency with which

Cigar Smoking cigar smokers quit smoking cigars. Data from the 1991 NHIS

show that, among those males who had smoked 50 or more lifetime cigars, a

larger percentage of older males were former cigar smokers as compared to

younger males (Table 7). Former cigarette smokers were also more likely than

current or never cigarette smokers to be a former cigar smoker.

The California survey has data on the frequency with which people who

reported ever using cigars responded “not at all” when asked whether they

smoked some days, every day, or not at all. This group can be considered former

cigar smokers and can be further divided by whether the respondent reported

Trends in Cigar Consumption and Smoking Prevalence

14.0

12.0

10.0

8.0

6.0

4.0

2.0

0.0

18-24

25-44 45-64

65+

Age Group

Percent

1990

1996

30.0

25.0

20.0

15.0

10.0

5.0

0.0

<12

12 13-15

16+

Level of Education

Percent

Cigarettes

Cigars

Figure 4

Prevalence of current cigar smoking among California males of different ages, 1990 and 1996

Figure 5

Prevalence of current cigarette and cigar smoking among California males of different levels of

education, 1996

Chapter 2

Figure 6

Prevalence of current cigarette and cigar smoking among California males of different incomes, 1996

30.0

25.0

20.0

15.0

10.0

5.0

0.0

<-10,000 10,000-

20,000

20,001-

30,000

30,001-

50,000

50,001-

75,000

75,000+

Income

Percent

Cigarettes

Cigars

Trends in Cigar Consumption and Smoking Prevalence

Table 6

Prevalence of cigar use in California, alone and in combination with cigarette use,

1990 and 1996

Chapter 2

Table 7

Current occasional, current daily and former cigar smoking rates, 1991 NHIS

smoking at least 50 lifetime cigars (Table 8). Among male Californians in 1996,

35.2 percent had ever smoked cigars, 8.8 percent currently smoked cigars and

26.4 percent were former cigar smokers. The prevalence of former cigar smoking

increases with increasing age and level of education. The majority of former

cigar smokers, using this definition of former smoker, had smoked fewer than 50

cigars in their lifetime.

Current daily cigar smoker = smoked

≥

50 cigars in life-time and smoking cigars daily at time of

interview.

Current occasional = smoked

≥

50 cigars in life-time but was not smoking cigars every day at

time of interview.

Former cigar smoker = smoked

≥

50 cigars in life-time but was not smoking at time of interview.

Never smoked regularly = never smoked

≥

50 cigars in life-time.

Trends in Cigar Consumption and Smoking Prevalence

Table 8

Detailed cigar smoking status among California adults, 1996

Chapter 2

Table 9

Frequency of cigar smoking among current cigar smokers, 1986 AUTS

Smoking Patterns— In 1986, more than half the current cigar smokers smoked less than

Frequency once per week, while 28.7 percent smoked at least once per day

(Table 9). The younger the smoker, the less likely he was to report smoking cigars

daily. Among those who reported that they currently smoke cigars, former and

never cigarette smokers were more likely than current cigarette smokers to smoke

cigars on a daily basis. The predominance of occasional use among cigar smokers

is not a recent phenomenon. Only one quarter of current cigar smokers reported

smoking daily in 1955 (Chaenszel, Shimkin and Miller, 1956).

In the 1991 NHIS, those respondents who had smoked 50 or more lifetime

cigars were asked whether they currently smoked cigars “some days,” “everyday,”

or “not at all.” Less than one percent of males were current daily cigar smokers;

females were even less likely than males to be smoking cigars daily (Table 7).

Black males were somewhat more likely than white males to be daily cigar

smokers. Males between the ages of 45-64 were more likely than younger males

to be smoking cigars daily. Some day smoking also varied with age, with males

aged 35-64 having the highest rates of some day cigar smoking.

Data from California (Table 10) show that between 1990 and 1996 there was

little change in male prevalence of daily cigar smoking, and the increase in cigar

Trends in Cigar Consumption and Smoking Prevalence

Table 10

Current cigar smoking prevalence among adult male Californians who have and have not smoked 50 or more cigars in their

lifetime, 1990 and 1996

Chapter 2

smoking prevalence was confined largely to the occasional cigar smoking group

(those who reported smoking cigars some days). The largest increase was in those

some day cigar smokers who had not yet smoked 50 cigars in their lifetime, and

the biggest increase among those who had not smoked 50 cigars in their lifetime

was in the youngest age group. These California data suggest that there has been

a dramatic increase in occasional cigar use recently, and that much of the change

that has occurred would have been missed if the evaluation were confined only

to those who had smoked more than 50 cigars in their lifetime.

Smoking Patterns— Among those cigar smokers who reported that they had smoked

Quantity cigars regularly in 1987, 56.4 percent (95 percent CI, 54.3-58.6

percent) reported smoking 1-2 cigars per day; 26.4 percent (95 percent CI, 24.5-

28.3 percent) reported smoking between 3 and 5 cigars per day, and 12.7 percent

(95 percent CI, 11.3-14.0 percent) reported smoking 6 or more cigars per day.

Unfortunately, most recent surveys have not collected information on quantity

of cigars smoked making it impossible to assess trends on this important

exposure variable.

Age of Initiation Among the national surveys, only the 1987 NHIS asked adults

of Cigar Smoking about the age at which they first smoked cigars, and this question

was only asked of those who had smoked more than 50 cigars in their lifetime.

The age of initiation of cigar smoking was older than that for cigarette smoking.

Among cigarette smokers, 60.2 percent had begun smoking regularly prior to age

18, whereas only 24.6 percent of those who had smoked more than 50 cigars in

their lifetime had started prior to age 18 (Table 11). Recent data on adolescent

use suggests that the age of initiation of cigar use currently may be much

younger than in the past.

Adolescent During 1996, four surveys asked teenagers about their cigar smoking.

Cigar Smoking Some surveys defined current smoking as having smoked cigars in the

past 30 days; other surveys used a measure of use in the past year.

A national survey conducted by the Robert Wood Johnson Foundation

(RWJF) found that 26.7 percent (95 percent CI, 25.0-28.4 percent) of 14-19 year

olds had smoked at least one cigar in the past year (Centers for Disease Control

and Prevention (CDC), 1997). Male adolescents (37 percent) were more than

twice as likely as female adolescents (16 percent) to have smoked a cigar in the

last year (Table 12). Those who smoked cigarettes or used smokeless tobacco in

the previous month were more likely to have smoked cigars than those who had

not used other tobacco products. There was a remarkably small difference in

cigar smoking by age, with 14-16-year-old adolescents reporting smoking at a

24.4 percent rate as compared to 27.5 percent of 19-year-old teens.

The adolescent respondents were asked how many cigars they had smoked in

the previous year. Nearly 3.0 percent had smoked more than 50 cigars in the

previous year. Cigarette smokers and smokeless tobacco users were more likely

than nonusers to have smoked 50 or more cigars in the previous year. The

percentage of these teenagers who had consumed 50 or more cigars in one year

was larger than the percentages of young adults who had smoked 50 or more

cigars in their lifetime measured by the earlier NHIS (Figure 7).

Trends in Cigar Consumption and Smoking Prevalence

Table 11

Age of initiation of cigarette and cigar smoking for white and black males, 1987 NHIS

Table 12

Cigar use in the past year among adolescents, 1996 RWJF National Survey

Chapter 2

Figure 7

Lifetime use of cigars by grade and gender

7 8 9 10 11 12

Percent

Females

Males

Total

Grade

Massachusetts Department of Public Health Survey, 1996

Trends in Cigar Consumption and Smoking Prevalence

The Massachusetts Department of Public Health assessed cigar use in grades 6

through 12 (CDC, 1997). The prevalence of ever having smoked a cigar increased

with increasing grade and leveled off at over 40 percent for students in grades 10

through 12 (Figure 7, Table 13). Males in all grades were more likely than

females to have ever smoked a cigar. Lifetime use of cigars by race (Figure 8) in

Massachusetts showed that whites were more likely than other racial groups to

have ever smoked a cigar.

The Massachusetts youth were also asked about past year and past month use

of cigars. Past year use of cigars increased with increasing grade, with the largest

increase between grades 7 and 8 (Table 13). The past year use for students in

grades 9-12 (comparable in age to the students from the RWJF survey) showed

that 28.1 percent had smoked a cigar in the past year, which was similar to the

RWJF estimate of 26.7 percent. Past 30 day cigar use was highest in grade 11 for

both male and female adolescents (Table 13). Cigar use was significantly higher

Table 13

Prevalence of cigar use in the last year, and all forms of tobacco use in the last 30 days, by

school grade, Massachusetts, 1996

Chapter 2

than smokeless tobacco use for males in grades 8 through 12 and for females in

grades 7 through 12. White students had the highest rate of past 30 day use,

followed by blacks and Hispanics (Figure 9).

California also surveyed adolescents to estimate their rates of cigar smoking

(Table 14). Males were more likely than females to have ever smoked a cigar.

Older students were more likely than younger students to have ever smoked a

cigar. White students were somewhat more likely than students of other races to

have ever smoked a cigar. The California Tobacco Survey also asked youths

between the ages of 12 and 17 about past 30-day cigar smoking. Males were

more likely than females to be currently smoking cigars. The rates of current

cigar smoking increased with age, and were somewhat higher among white and

Hispanic adolescents.

Rates for ever smoking cigars and past 30-day cigar smoking were lower

among the California teens than among the students in Massachusetts. This may

be due to the different methodologies used in these surveys. The Massachusetts

survey was anonymously conducted in schools; the California survey was a

household survey conducted via the telephone. School based surveys of teens

produce higher prevalence estimates for cigarette smoking than telephone

surveys in the home (U.S. Department of Health and Human Services, 1994). It is

possible that this is also true for cigar smoking behavior.

Figure 8

Ever cigar smoking by race among teenagers

White

Percent

Black Hispanic Asian Native

American

All Races

Massachusetts — 1996

Trends in Cigar Consumption and Smoking Prevalence

White

Percent

Black Hispanic

Race

Asian Native

American

Massachusetts, 1996

Figure 9

Past month use of cigars among teenagers by race

Table 14

Ever cigar smoking and current smoking in the last 30 days among California teenagers, 1996

Chapter 2

Another school based teen survey was conducted in 1996 among ninth grade

students in two New York counties (CDC, 1997). The median age of these

students was 14. Males were more likely than females to have smoked a cigar in

the previous 30 days (Table 15). As was seen on the RWJF national survey,

cigarette smokers and smokeless tobacco users were substantially more likely

than those who had not used other tobacco products to report having smoked a

cigar in the previous month. As was seen in Massachusetts, smokeless tobacco

use was lower than cigar use among these students (CDC, 1997).

DISCUSSION Data from the U.S. Department of Agriculture clearly demonstrate an

increase in the number of cigars consumed per year since 1993. State and

national surveys of smoking behavior suggest that competing trends in cigar

usage are occurring. Among older males, cigar usage continues to decline.

However, among young and middle-aged males, occasional use of cigars appears

to be increasing dramatically. Adolescents of both genders are also using cigars,

and some surveys show that their rates of use meet or exceed those of adults prior

to 1993.

The only national adult data on cigar smoking collected after 1992 is from

the Current Population Surveys, and these surveys show a low prevalence of cigar

smoking and very little change between 1992-3 and 1995-6. Part of the

explanation for the apparent difference between the consumption trends and the

prevalence trends may lie in the wording of the questions used in the Current

Population Surveys. The questions on this survey asked whether cigars were

currently, or had ever been, “regularly used.” This is in contrast to the NHIS

Table 15

Prevalence of adolescent cigar smoking in the past 30 days by various characteristics,

New York, 1996

Gender

Cigarette Smoking Status

Smokeless Tobacco Use Status

Trends in Cigar Consumption and Smoking Prevalence

which asked whether the respondent had ever smoked cigars or currently smoked

cigars. The difference in questions probably leads to a different subset of cigar

smokers who answer positively. Occasional cigar smokers and those who have

smoked fewer than 50 cigars in their lifetime may be more likely to answer no to

the Current Population Survey “use regularly” question, but respond yes to the

NHIS “smoke” question. Support for this explanation of the differences between

survey results is provided by survey data from California, where the prevalence of

male daily cigar smoking did not change between 1990 and 1996, and where

much of the change in cigar use was among those who have not yet smoked 50

cigars in their lifetime.

Changes in prevalence of occasional smoking in California between 1990 and

1996 are larger among well-educated and upper-income males and females. This

pattern is markedly different from that seen with cigarette smoking. Cigar

smoking increased among never smokers as well as among former cigarette

smokers. Initiation of tobacco use with cigars after becoming an adult is markedly

different from the predominantly adolescent initiation seen with cigarette

smoking.

Among California males who were never cigarette smokers 2 years prior to the

1996 survey, by 1996 4.16 percent (+/- 2.08 percent) of those who smoked cigars

were currently smoking cigarettes (new initiation) in contrast to 1.70 percent (+/-

0.45 percent) of those who did not smoke cigars. It is impossible to separate the

likelihood of cigar smoking leading to initiation of cigarette smoking from the

possibility that those who initiated cigarette smoking were also likely to smoke

cigars; but the commonality in both of these behaviors is nicotine ingestion, and it

would not be surprising if use of cigars predisposed an individual to the use of

cigarettes. It remains to be seen whether those who have never used tobacco

products prior to using cigars as adults will be able to remain occasional tobacco

users or will shift either to regular cigar use or begin smoking cigarettes.

Another concern is former cigarette smokers who are currently smoking cigars

occasionally. This group presumably includes a substantial number of individuals

who were nicotine-addicted while they were smoking cigarettes, and who may be

at increased risk of re-initiating their nicotine addiction due to their exposure to

the nicotine in cigars. Among California males who were former cigarette smokers

1 year ago, cigar smokers reported a current cigarette smoking (relapse) rate of

16.35 percent (+/- 6.50 percent) in contrast to the 7.06 percent (+/- 1.83 percent)

rate of current cigarette smoking among those who did not smoke cigars. This

observation does not separate the likelihood that cigar smoking leads to relapse of

cigarette smoking from the possibility that relapsing cigarette smokers take up

smoking cigars as well, but it raises a concern that cigar use may place former

cigarette smokers at increased risk of relapse.

Non daily smoking is also the predominant mode of cigar use among

adolescents, but this pattern of use is of much greater concern for this group

because the use of cigarettes and smokeless tobacco, two powerfully addictive

forms of tobacco, are also largely used occasionally during adolescence (U.S.

Department of Health and Human Services, 1994). Data from California

(Table␣ 16) show that a small number of male adolescents may have smoked cigars

Chapter 2

Table 16

Use of cigars by adolescents in California, 1996

Trends in Cigar Consumption and Smoking Prevalence

on 10 or more of the last 30 days. This frequency of use suggests that cigar

smoking among adolescent males is more than simple one-time experimentation.

The major concern is that this frequent use of a product that can provide

nicotine in substantial doses (Henningfield et. al, 1996) will lead to addiction

among those adolescents currently using cigars with some regularity (Chapter 6).

A second concern is the use of cigars by adolescents who have never used

other tobacco products. Table 17 shows an increased prevalence of cigar use

among male adolescents who use cigarettes or smokeless tobacco, a finding

present in most other recent surveys of adolescent use (CDC, 1997). Only 0.4

percent of those who have never used either cigarettes or smokeless tobacco are

currently smoking cigars, and only 3.6 percent have ever smoked cigars.

MONITORING If the emerging public health problem of cigar smoking is to be

RECOMMENDATIONS tracked successfully, tools for monitoring it must be designed to

measure the variable of interest in the most efficient manner possible. Questions

on cigar use should be included in surveys designed to measure tobacco use, and

the questions about cigar use should be standardized so that there is uniformity

of data collection. This will require researchers in the field of tobacco control to

establish standard definitions similar to those developed for cigarette smoking

(CDC, 1994).

It is recommended that (1) no threshold level of cigar smoking be required

before a respondent is asked about current cigar smoking status; (2) duration of

cigar smoking be asked of all respondents who ever smoked cigars whether or not

they are current cigar smokers; (3) age of initiation be asked of all respondents

who have ever smoked a cigar; and (4) some measure of frequency and type of

cigar smoked and of the quantity of cigars smoked be asked of all who have ever

smoked cigars.

Table 17

Prevalence of cigar smoking among adolescent males in California by the status of their use of

other tobacco products

Chapter 2

CONCLUSIONS

1. U.S. consumption of cigars has increased dramatically since 1993, reversing a

decline in cigar consumption that had persisted for most of this century.

2. In 1996, large inexpensive cigars (<$1 retail) and cigarillos accounted for the

greatest share of cigar sales (60.3 percent) followed by small cigars (33.2

percent), and large premium cigars (6.5 percent). In recent years, cigar sales

have increased in all three categories, but the fastest growing segment of the

cigar market has been the premium cigar category where sales have increased

by 154 percent since 1993.

3. Limited national data and data from California suggest that the prevalence of

cigar use among adults has increased since 1993. Much of that increase in

California has been in occasional cigar smoking. There has been little change

in the prevalence of daily cigar use among California adults between 1990

and 1996.

4. Among California adults in 1996, the prevalence of occasional cigar smoking

increased with level of education and income, a pattern opposite that seen

with cigarette smoking. This increase in prevalence with increasing level of

education and income is not seen for daily cigar smoking.

5. Males are more likely to smoke cigars than females.

6. The prevalence of current cigar smoking among adults has increased between

1990 and 1996 for both current and former cigarette smokers in California,

but the largest proportionate increase was among those who report never

having smoked cigarettes. This suggests that many adults who have never

smoked cigarettes are initiating tobacco use with cigars at ages when, prior to

1993, there had been little new initiation of tobacco use.

7. Multiple state and national surveys demonstrate a substantial rate of cigar

smoking, both use in the last 30 days and ever use, among adolescents of

both genders.

Trends in Cigar Consumption and Smoking Prevalence

Blackard, C.Z. Booming: In anti-tobacco America,

cigars’ sales growth is staggering. Tobacco Reporter

(May): 64, 1996.

Centers for Disease Control and Prevention. Cigarette

smoking among adults—United States, 1992, and

changes in the definition of current cigarette

smoking. MMWR. Morbidity and Mortality Weekly

Report 43: 342-346, 1994.

Centers for Disease Control and Prevention. Cigar

smoking among teenagers—United States,

Massachusetts and New York, 1996. MMWR.

Morbidity and Mortality Weekly Report 46: 433-440,

1997.

Giovino, G.A., Schooley, M.W., Zhu, B., Chrismon,

J.H., Tomar, S.L., Peddicord, J.P., Merritt, R.K.,

Husten, C.G., Eriksen, M.P. Surveillance for

selected tobacco-use behaviors—United States,

1900-1994. MMWR. Morbidity and Mortality Weekly

Report 43: 26, 1994.

Haenzel, W., Shimkin, M.B., Miller, H.P. Tobacco

Smoking Patterns in the United States. Public Health

Monograph No. 45, 1956.

Henningfield, J.E., Hariharan, X., Kozlowski, L.T.

Nicotine content and health risks of cigars. Journal

of the American Medical Association 276: 1857-1858,

1996.

Hyland, A., Cummings, K.M., Shopland, D.R., Lynn,

W.R. Prevalence of cigar use in 1989 and 1993 in

22 North American communities. Accepted for

Publication, American Journal of Public Health,

1998.

Maxwell, J.C., Jr. The Maxwell Consumer Report: The

Cigar Industry in 1996. Richmond, VA: Wheat

First Butcher Singer, March 21, 1997.

Milmore, B.K., Conover, A.G. Tobacco Consumption in

the United States, 1880-1955. In: Tobacco Smoking

Patterns in the United States. W. Haenszel, M.B.

Shimkin, H.P. Miller (Editors). Public Health

Monograph No. 45, pp. 107-111, 1956.

U.S. Code of Federal Regulations. Title 26 [Internal

Revenue Service] Part 270: Manufacture of cigars

and cigarettes. (As adopted at 26 F.R. 8173,

effective October 1, 1961). B (270) 3-B (270) 5,

October 31, 1970.

U.S. Department of Agriculture. Tobacco Situation and Outlook

Report. TBS-237. Washington, DC: U.S. Department of

Agriculture, Commodity Economics Division, Economic

Research Service, 1996.

U.S. Department of Agriculture. Tobacco Situation and

Outlook Report. TBS-239. Washington, DC: U.S.

Department of Agriculture, Commodity Economics

Division, Economic Research Service, 1997.

U.S. Department of Health, Education, and Welfare. The

Health Consequences of Smoking. DHEW Publication No.

73-8704. Rockville, MD: U.S. Department of Health,

Education and Welfare, Public Health Service, p. 175,

1973.

U.S. Department of Health and Human Services. Reducing the

Health Consequences of Smoking: 25 years of Progress: A

Report of the Surgeon General. DHHS Publication No.

(CDC) 89-8411. Atlanta, GA: U.S. 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,

p. 511, 1989.

U.S. Department of Health and Human Services. Preventing

Tobacco Use Among Young People: A Report of the Surgeon

General. Atlanta, GA: U.S. Department of Health and

Human Services, Public Health Service, Centers for

Disease Control and Prevention, National Center for

Chronic Disease Prevention and Health Promotion,

Office on Smoking and Health, pp. 107-114, 1994.

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Advisory Committee to the Surgeon General of the Public

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US Department of Health Education and Welfare,

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REFERENCES

Smoking and Tobacco Control Monograph No. 9

Chemistry and Toxicology

Dietrich Hoffmann and Ilse Hoffmann

HISTORICAL Early information on the smoking of cigars originates from artifacts of

NOTES the Mayas of the Yucatan region of Mexico. Smoking of tobacco was

part of the religious rituals and political gatherings of the natives of the

Yucatan peninsula as shown in the artwork on a pottery vessel from the 10th

century (Figure 1) where a Maya smokes a string-tied cigar (Kingsborough,

1825). Five hundred years later, in 1492, when Christopher Columbus

landed in America, he was presented with dried leaves of tobacco by

the House of Arawaks. Columbus and his crew were thus the first Europeans

who became acquainted with tobacco smoking. Early in the 16th century,

Cortez confirmed that tobacco smoking was practiced by the Aztecs in

Mexico. In addition, tobacco was grown in Cuba, Haiti, several of the West

Indian Islands, and on the East coast of North America from Florida to

Virginia (Tso, 1990).

The Mayan verb sikar, meaning to “smoke,” became the Spanish noun

cigarro. The form of cigar Columbus had first encountered was a long, thick

bundle of twisted tobacco leaves wrapped in dried leaves of palm or maize.

In 1541, the Cuban cigar appeared in Spain. The first person known to have

grown tobacco in Europe was Jean Nicot, the French ambassador to Portugal.

He introduced tobacco and tobacco smoke at the royal court of Paris, where

Catherine de Medici and her son, King Charles IX, used it to treat migraine

headaches (Jeffers and Gordon, 1996). In 1570, the botanist Jean Liebault

was the first to grow tobacco in France; he gave the plant the scientific name

Herba Nicotiana, in honor of Jean Nicot. However, the name tobacco, which

is derived from the American Indians’ word tobacco, remained in common

use.

In 1828, the chemists, Posselt and Reimann of the University of

Heidelberg, isolated nicotine as the major pharmacoactive ingredient in

tobacco. In 1895, Pinner established the chemical structure of nicotine as

that of 3-(1-methyl-2-pyrrolidinyl)pyridine.

THE CIGAR There are many types of cigars on the market. The U.S. Department of

the Treasury (1996) defines a cigar as “any roll of tobacco wrapped in leaf

Types and tobacco or in any substance containing tobacco,” while a cigarette is

Definitions defined as “any roll of tobacco wrapped in paper or in any substance

not containing tobacco.” In North America, and in many parts of Europe,

there are at least four types of cigars, namely, little cigars, small cigars (also

called cigarillos), regular cigars, and premium cigars (Figure 2). For taxation

purposes, the U.S. Department of the Treasury (1996) differentiates only

between small cigars, weighing not more than three pounds per thousand

(≤ 1.36 g/cigar), and large cigars, weighing more than three pounds per

thousand.

Chapter 3

Figure 1

A man smoking a Maya’s string-tied cigar depiected on a pottery vessel,

dated 10th century or earlier, found in Mexico.

Courtesy of the General Research Division, The New York Public Library, Astor, Lenox,

and Tilden Foundaitons.

In general, little cigars contain air-cured and fermented tobaccos. They are

wrapped either in reconstituted tobacco or in cigarette paper that contains

tobacco and/or tobacco extract. Some little cigars marketed in the U.S. have

cellulose acetate filter tips and are shaped like cigarettes (length 70 - 100

mm, weight 0.9 - 1.3 g each; Hoffmann and Wynder, 1972).

The small cigars on the U.S. market have straight bodies, weigh between

1.3 and 2.5 g each, are 70 - 120 mm long, and are open on both ends. To

some extent they are comparable to the stumpen, a form of cigar primarily

smoked in Switzerland and some parts of Germany. In the Far East, small

cigars, called cheroots, are made from heavy-bodied burley-type tobacco.

The Indian cheroots are produced from light, air-cured tobacco (Voges,

1984). In Denmark and some other parts of Scandinavia, similar types of

cigars are also called cheroots but like the small U.S. cigars, they are more

akin to the Swiss stumpen.

Regular cigars appear on the market in various sizes and shapes. In the

U.S., their dimensions are generally 110 - 150 mm in length, up to 17 mm in

diameter, and they weigh between 5 and 17 g. Regular cigars are rolled to a

tip, on at least one end. Some of them carry a ‘banderole,’ or decorative foil

or paper strip, to indicate the brand’s name (Wynder and Hoffmann, 1967;

Brunnemann and Hoffmann, 1974a; Schmeltz et al., 1976a and 1976b;

Voges, 1984). Many of the regular cigars on the U.S. market are machine-

made; others are hand-rolled.

Smoking and Tobacco Control Monograph No. 9

Figure 2

Types of cigars on the U.S. Market in 1996: (1) bidi (imported from India), (2)

little cigar with filter tip, (3) small cigar with plastic mouth piece, (4) regular cigar,

(5) and (6) premium cigar.

In recent years the popularity of premium cigars has increased in the

United States. With diameters ranging from 12 to 23 mm and lengths

between 12.7 and 21.4 cm, these cigars carry bands with an imprint of their

brand name and/or manufacturer’s name or logo. They are imported in large

numbers from the Dominican Republic, Honduras, Mexico, Jamaica, and

other countries (O’Hara, 1996). In 1996, the two most popular types of

premium cigars on the U.S. market were the “Coronas” and the “Lonsdales.”

The recorded 96 brands of Coronas were between 12.7 and 15.2 cm (5 - 6

inches) long and ranged in price between $1.10 and $8.60 apiece. The 111

recorded brands of Lonsdales were between 15.2 and 17.8 cm (6 - 7 inches)

long and sold for $1.50 to $11.00 per cigar (Cigar Aficionado, 1996).

Cigar Tobacco Tobacco belongs to the Solanaceae family. Primarily two species,

Nicotiana tabacum and Nicotiana rustica, are used for the manufacture of

chewing tobacco, oral and nasal snuff, cigarettes, cigars, and pipe tobacco.

Chapter 3

Most of the tobacco products manufactured in North America, Western

Europe, and Africa are made of N. tabacum. N. rustica is predominately used

in South America, Russia, the former republics of the U.S.S.R., and Poland;

and, to some extent, also in India and Turkey. Within the N. tabacum

species, four types are commonly used: bright (Virginia), burley (Kentucky),

Maryland, and Turkish (oriental) tobaccos. Bright tobaccos are flue-cured by

drying with artificial heat; burley and Maryland tobaccos are air-cured; and

Turkish tobaccos are sun-cured.

Cigars consist of a filler (the inner part of the cigar), a binder, and a

wrapper. The filler, binder, and wrapper of small cigars, regular cigars, and

premium cigars are all made with air-cured and fermented tobaccos (Cornell

et al., 1979). Since the mid-fifties, the binders and/or wrappers of many of

the regular brands (but not of premium brands) are made from reconstituted

cigar tobacco (Moshy, 1967). In general, about 85 percent of the weight of a

cigar is contributed by the filler, 10 percent by the binder, and 5 percent by

the wrapper (Frankenburg and Gottscho, 1952).

The air-curing process of burley and Maryland tobaccos is characterized

by slow, gradual drying of the leaf. Usually, the whole tobacco plant is cut

off at ground level and hung in sheds or barns. However, in the case of

tobaccos used for many regular cigars and premium cigars, the leaves are

primed and hung individually on strings in sheds or barns for air-curing.

It is important to ensure ample air flow through the barns during this

process. Sometimes it is necessary to raise the temperature in the barns using

charcoal fires, thereby creating a relative humidity of 65 - 75 percent. During

air-curing, tobacco leaves normally reach the yellow stage 10 - 12 days after

harvesting, and the brown stage after another 6 or 7 days. To complete the

air-curing process requires 30 - 40 days. During this time, 80 - 85 percent of

the water content of the leaves is lost. The total nitrogen content is reduced

by about 30 percent and the protein-nitrogen content by about 50 percent;

however, the percentage of nitrate nitrogen doubles, and the nicotine

content remains practically unchanged. Following air-curing, the leaves are

aged for up to two years, or even longer. During this time, the nicotine

content is reduced by 30 - 50 percent, whereas protein, ammonia, and nitrate

nitrogen contents generally remain unchanged (Wolf, 1967).

To become cigar tobacco, the leaves need to be fermented. After about 1

year of storage and aging, the leaves are placed in special rooms for

fermentation at about 45°C and a relative humidity of 60 percent. After 3 - 5

weeks, the leaves are removed from the rooms, repacked, and returned. The

repacking process is repeated several times to induce “sweating.” The baled

leaves are occasionally slightly moistened. The temperature in the center of

the bales may reach up to 58°C. During the fermentation, chemical and

bacterial reactions lead to the formation of carbon dioxide, ammonia, water,

and various volatile compounds. Carbohydrates in the leaves are reduced by

50 - 70 percent, organic acids by up to 30 percent, and a major portion of the

polyphenols is degraded. The degradation of polyphenols during curing

causes the browning of the leaves; whereas during fermentation, their

Smoking and Tobacco Control Monograph No. 9

degradation ensures the oxygenation of several leaf components. The pH of

the fermented tobacco is slightly alkaline (Wolf, 1967; Wiernik et al., 1995).

During curing and fermentation of air-cured tobacco, nitrate is partially

reduced to nitrite, primarily by microbal action. This contributes to the

N-nitrosation of nicotine, converting it into the highly carcinogenic,

tobacco-specific N-nitrosamines (TSNA), N

’

-nitrosonornicotine (NNN), and

4-(methylnitrosamino)-1-(3-pyridyl)-1-butanone (NNK) (Burton et al., 1992;

Hoffmann et al., 1994; Wiernik et al., 1995).

Manufacture Cigars consist of filler, binder, and wrapper; all of which are air-cured

of Cigars and fermented. In recent decades, some brands of regular cigars

(though not premium cigars) have used reconstituted cigar tobacco as binder,

wrapper, or both (Moshy, 1967; Halter and Ito, 1980). Cigars are either hand-

rolled (Jeffers and Gordon, 1996) or machine-made (Van der Boor, 1996).

The flavor and aroma of cigars and their smoke are, in large measure, the

results of precisely controlled fermentation of the tobacco. Most little cigars

are machine-made, much like cigarettes, except that fermented cigar tobacco,

not blends of cured tobaccos are used (20, 30, or 50 cuts per inch); the little

cigars have wrappers which contain tobacco.

CHEMISTRY OF Processed tobacco contains at least 3,050 different compounds.

CIGAR TOBACCO Table 1 lists the major groups of compounds that have been

identified in tobacco (Roberts, 1988). Most of these are already present in the

green tobacco leaf, others are formed during curing, aging, and fermentation.

Although only a portion of the 3,050 compounds has been identified

specifically in cigar tobacco, one may assume that the full spectrum of

compounds is present in cigar tobacco, albeit in many cases, at different

levels of concentration than are present in cigarette tobaccos. Exceptions to

the qualitatively comparable constituents of cigar and cigarette tobaccos are

agents such as pesticides, that are applied to tobacco during cultivation of the

plant, and agents that are added during the processing of the tobaccos.

In the case of the insect control agents, the last reports on organic

chlorinated hydrocarbons were published in the 1960s. DDT concentration

was significantly higher in cigar tobacco (10.0 - 53.0 µg/g) than in cigarette

tobacco (2.0 - 6.0 µg/g), whereas DDD and endrin concentrations in cigar

tobaccos (10 - 15 µg/g and 0.0 - 0.5 ppm) and cigarette tobaccos (12 - 23 µg/g

and < 0.5 - 2 ppm) were comparable (Lawson et al., 1964). However, in the

seventies, chlorinated pesticides were banned for use on tobacco; thus, their

concentrations in U.S. tobacco declined by > 98 percent by 1994 (Djordjevic

et al., 1995b). An overview of the pesticides currently applied to U.S. tobacco

plants and a discussion of their residues on tobacco was presented by Sheets

(1991).

In general, flavor additives are not applied to cigar tobacco which is quite

different from the treatment of tobacco formulated for cigarettes, especially

in the case of filter cigarettes designed to yield low nicotine emission (Doull

et al., 1994; Hoffmann and Hoffmann, 1997). It is also different from pipe

tobacco formulation (LaVoie et al., 1985) and possibly from the formulation

of tobacco for small cigars. Furthermore, it is unlikely that plasticizers are

Chapter 3

Table 1

Compounds identified in tobacco and smoke

No. in No. in No. in

Functional Groups Tobacco Smoke Tobacco and Smoke

Caboxylic Acids 450 69 140

Amino Acids 95 18 16

Lactones 129 135 39

Esters 529 456 314

Amines & Imines 205 227 32

Anhydrides 10 10 4

Aldehydes 111 106 48

Carbohydrates 138 30 12

Nitriles 4 101 4

Ketones 348 461 122

Alcohols 334 157 69

Phenols 58 188 40

Amines 65 150 37

Sulfur Compounds 3 37 2

N-Heterocycles:

Pyridines 63 324 46

Pyrroles & Indoles 9 88 3

Pyrazines 21 55 18

Non-aromatics 13 43 7

Polycyclic Aromatics 1 36 0

Others 4 50 2

Ethers 53 88 15

Hydrocarbons:

Saturated Aliphatics 58 113 44

Unsaturated Aliphatics 338 178 10

Monocyclic Aliphatics 33 138 25

Polycyclic Aliphatics 55 317 35

Miscellaneous 112 110 19

Inorganics & Metals 105 111 69

Source: D.L. Roberts, 1988

used for manufacturing small, regular and premium cigars which do not

contain reconstituted tobacco, whereas plasticizers (e.g., glyceryl triacetate,

triethylene glycol diacetate) are applied to filter tips in the production of little

cigars. When reconstituted tobacco is chosen as a binder and/or wrapper for

regular cigars, such cigars will contain plasticizers and other tobacco

treatment products in addition to humectants, adhesives, and/or inorganic

additives (Moshy, 1967).

Distinct quantitative differences between cigar and cigarette tobaccos

are primarily related to the long aging and fermentation process of cigar

tobacco. Table 2 shows some of the distinct differences for a select number

of compounds as they occur in cigar tobacco and in the four major types

of cigarette tobaccos. Cigar tobacco contains only traces of polyphenols

Smoking and Tobacco Control Monograph No. 9

Table 2

Comparison of some selected components in the tobacco of cigars and of four cigarette

Tobacco Types (% of dry weight of tobacco)

Type of Tobacco

Component Cigar Burley Maryland Bright Oriental

Nitrate 1.4 - 2.1 1.4 - 1.7 0.9 < 0.15 < 0.1

pH 6.9 - 7.8 5.2 - 7.5 5.3 - 7.0 4.4 - 5.7 4.9 - 5.3

Reducing Sugars 0.9 - 2.7 1.5 - 3.0 1.2 7.0 - 25.0 5.5

Total Polyphenols < 0.1 2.0 1.6 5.1 4.5

Nicotine 0.6 - 1.7 2.0 - 2.9 1.1 - 1.4 1.2 - 1.9 1.1

Paraffins 0.3 - 0.32 0.34 - 0.39 0.34 - 0.41 0.24 - 0.28 0.37

Neophytadiene 0.4 - 0.8 0.4 0.40 0.3 0.2

Phytosterols 0.14 - 0.16 0.3 - 0.39 0.38 0.3 - 0.45 0.26

Citric Acid 5.5 - 6.0 8.22 2.98 0.78 1.03

Oxalic Acid 3.3 - 3.6 3.04 2.79 0.81 3.16

Maleic Acid 1.5 - 1.8 6.75 2.43 2.83 3.87

References: Wolf, 1967; Hoffmann and Wynder, 1972; Schmeltz et al., 1976a and 1976b; Tso, 1990.

(< 0.1 percent; Table 2) compared to cigarette tobaccos (1.6 - 5.1 percent).

The nitrate content of cigar tobacco is relatively high (1.4 - 2.1 percent

versus. < 0.1 - 1.7 percent in U.S. cigarette tobacco blends) and the amounts

of phytosterols are lower in cigar tobacco (0.14 - 0.16 percent versus. 0.26 -

0.45 percent). In respect to the nitrate content,

the pH of a suspension of tobacco in water, and the percentage of reducing

sugars, cigar tobacco is comparable to the two types of air-cured cigarette

tobaccos, namely, burley and Maryland (Wolf, 1967; Hoffmann and Wynder,

1972; Tso, 1990; Schmeltz et al., 1976a and 1976b).

During the processing of tobacco, especially during air-curing and

aging, nitrate is partially reduced to nitrite (Burton et al., 1992; Hoffmann

et al., 1994; Wiernik et al., 1995). Nitrite is a strong N-nitrosating agent of

secondary and tertiary amines. Consequently, during these stages of tobacco

processing, N-nitrosamines are formed (Hoffmann et al., 1994). In tobacco,

we distinguish between volatile nitrosamines (VA), nonvolatile nitrosamines

(NVA), nitrosamino acids (NA), and tobacco-specific N-nitrosamines

(TSNA). The latter group is of significance for several reasons. TSNA are

formed by N-nitrosation of nicotine and of the minor Nicotiana alkaloids,

nornicotine, anatabine, and anabasine (Figure 3). Among the seven TSNA, 4-

(methylnitrosamino)-1-(3-pyridyl)-1-butanone (NNK), N

’

-nitrosonornicotine

(NNN), and 4-(methylnitrosamino)-1-(3-pyridyl)-1-butanol (NNAL) are

strong carcinogens in mice, rats, hamsters, and mink. N

’

-Nitrosoanabasine

(NAB) is weakly carcinogenic, while N

’

-nitrosoanatabine (NAT),

4-(methylnitrosamino)-4-(3-pyridyl)-1-butanol (iso-NNAL), and

4-(methylnitrosamino)-4-(3-pyridyl)butyric acid (iso-NNAC) are inactive

in carcinogenesis assays (Hoffmann et al., 1994). Furthermore, in the

Chapter 3

Figure 3

Formation of tobacco-specific N-nitrosamines. Iso-NNAC, 4-(methylnitrosamino)-4-(3-pyridyl)-

butyric acid; NNA, 4-(methylnitrosamino)-4-(3-pyridyl) butyric aldehyde; NNK, 4-

(methylnitrosamino)-1-(3-pyridyl)-1-butanone; NNN, N’-nitrosonornicotine; NAT, N’-

nitrosoamatabine; NAB, N’-nitrosoanabasine; iso-NNAL, 4-(methylnitrosamino)-4-(3-pyridyl)-

1-butanol; NNA, 4-(methylnitrosamino)-4-(3-pyridyl)-1-(3-pyridyl)-1-(3-pyridyl)-1-butanol

Nornicotine

Demethylation

Nicotine

Enzymatic

Oxidation

NNN

NNK

Reduction

Nitrosation

Anabasine

NAT

Anatabine

NAB

NNAL

NNA

CHO

Iso-NNAL

Iso-NNAC

COOH

Cotinine Acid

COOH

Source: Hoffmann et al., 1994.

smoke of a nonfilter cigarette, about 45 percent of NNN originates by transfer

from the tobacco, whereas the remainder is pyrosynthesized during smoking

(Hoffmann et al., 1977). Between 23 percent and 35 percent of the NNK in

smoke originates from the tobacco by transfer (Adams et al., 1983). NNN in

cigar tobacco is present at levels of 3.0 - 10.7 µg/g, in the tobacco of little cigars

at 11.1 - 13.0 µg/g, in tobacco of nonfilter cigarettes at 1.5 - 2.2 µg/g, and in

tobacco of filter cigarettes at 5.0 - 6.6 µg/g. NNK levels in the four tobacco

types are 1.2 - 1.3 µg/g, 3.5 - 4.5 µg/g, 0.5 - 0.8 µg/g, and 0.4 - 1.0 µg/g,

respectively (Brunnemann et al., 1983). During fermentation of cigar tobacco,

a small portion of nicotine is converted into 2,3-dihydronicotine, which easily

forms 4-methylamino-1-(3-pyridyl)-1-butanone (Frankenburg et al., 1958).

The latter, a secondary amine, is rapidly N-nitrosated to NNK. This compound

and the higher nitrate levels in cigars may explain why more NNK is formed in

little and regular cigars than during the processing of cigarette tobacco.

Table 3 presents data obtained in a comparative study of the

concentrations of nicotine, nitrate, volatile nitrosamines (VNA), nonvolatile

nitrosamines (NVNA), and TSNA in cigar and cigarette tobacco (Brunnemann

et al., 1983). All seven of the VNA identified are carcinogenic in mice, rats,

and/or hamsters. The nonvolatile nitrosoproline is neither carcinogenic in rats

nor in hamsters, while N-nitrosodiethanolamine (NDELA) does cause cancer in

Smoking and Tobacco Control Monograph No. 9

Table 3

Nicotine nitrate and N-nitrosamines in the tobacco of U.S. cigars little cigars, and nonfilter

and filter cigarettes (ng/g)

Little Nonfilter Filter

Compound Cigars Cigars Cigarettes Cigarettes

Nicotine, % 1.10 1.66 - 1.72 1.81 - 2.05 1.45 - 2.04

Nitrate, % 1.98 0.74 - 0.89 0.7 - 1.08 0.81 - 1.23

Volatile Nitrosamines

Nitrosodimethylamine n.dt. 43 250 - 280 n. dt. - 6.7

Nitrosodiethylamine 3.2 11 n. dt. - 47 n. dt. - 2.0

Nitrosodi-n-propylamine 11.8 nd n. dt. n. dt. - 2.3

Nitrosodi-n-butylamine 0.9 nd n. dt. - 65 n. dt.

Nitrosopiperidine 22 nd 5.5 - 13.3 n. dt. - 7.0

Nitrosopyrrolidine 20 19 n. dt. - 4.9 n. dt. - 9.9

Nitrosomorpholine 44 nd 3.7 - 4.1 n. dt. - 10.0

Non-Volatile Nitrosamines

Nitrosodiethanolamine 108 420 115 194

Nitrosoproline 1130 nd 880 - 1200 1450 - 2300

Tobacco-Specific Nitrosamines

-Nitrosonornicotine 2940 4500 1830 - 1960 1940 - 3200

Total TSNA 4780 9300 3610 - 4090 3730 - 8900

Abbreviations: nd, not determined; n. dt., not detected.

Source: Brunnemann and Hoffmann, 1981; Brunnemann et al., 1983.

mice, rats, and hamsters. The concentrations of the VNA and TSNA are

somewhat higher in cigar tobaccos than in cigarette tobaccos. Since the

nitrate content of the tobaccos of the little cigars tested was not exceptionally

high (0.74 - 0.89 percent), other factors must be correlated with these high

NDELA and TSNA values.

As already mentioned, tobacco also contains nitrosamino acids. The

noncarcinogenic N-nitrosoproline and N-nitrosopipecolic acid belong to this

group. In addition, cigarette tobaccos were found to contain the carcinogenic

N-nitrososarcosine, 3-(methylnitrosamino)propionic acid, and 4-(methylni-

trosamino)butyric acid (Djordjevic et al., 1989). Cigar tobacco has not yet

been analyzed for these nitrosamino acids.

Cigar tobaccos, like other types of processed tobaccos, contain at least

28 metals and more than ten metalloids (Wynder and Hoffmann, 1967;

Iskander et al., 1986). Their concentrations range from 5,300 to 97,000 µg

calcium/g tobacco to trace amounts, as in the case of mercury (0.05 µg/g

tobacco) (Wynder and Hoffmann, 1967; Andren and Harriss, 1971). Most

of the metals and metalloids are essential elements for the tobacco plant.

Others, such as lead, arsenic, and mercury, are trace contaminants. Small

Chapter 3

portions, at most a few percent of the metals and metalloids, transfer from

the tobacco into the smoke. Among those that transfer into the smoke and

are thus inhaled, the International Agency for Research on Cancer (1987)

considers arsenic, beryllium, chromium, nickel, and cadmium as human

carcinogens (IARC, 1993a, 1993b).

Like all types of tobacco, cigar tobacco contains, or may contain,

radioactive elements such as radium-226 and polonium-210 at

concentrations ranging from 0.1 - 0.47 and 0.18 - 0.46 pCi/g cigar tobacco

respectively) (Tso et al., 1966a). Phosphate fertilizers are the major source

of these radioelements (Tso et al., 1966b); minor contributions come from

airborne particles carrying lead-210 and polonium-210. These particles are

trapped by the trichomes on the undersides of the tobacco leaves (Martell,

1974). A minor amount of polonium-210 transfers into the mainstream

smoke and is thus inhaled by the smokers. The U.S. National Council on

Radiation Protection and Measurement (1987) ascribes about 1 percent of the

risk for lung cancer after 50 years of cigarette smoking to the role of

polonium-210 inhaled as a tobacco smoke constituent.

CHEMISTRY AND It is one of the objectives of tobacco-related research to design

ANALYSIS OF smoking devices that can simulate human smoking patterns

MAINSTREAM under reproducible conditions. Smoking instruments that are

CIGAR SMOKE widely accepted today are piston-type machines which generate

puff profiles that simulate the puff profiles of smokers (Wynder

Smoking Conditions and Hoffmann, 1967). For the smoking of cigarettes by

machines, the U.S. Federal Trade Commission (FTC) (Pillsbury et al., 1969)

adopted and modified a method that was initially devised by Bradford et al.

in 1936. This method employs, as standard smoking conditions, one puff per

minute, of two-seconds duration with a volume of 35 ml; the butt length is

23 mm for nonfilter cigarettes and filter length plus overwrap, plus 3 mm,

for filter cigarettes (Table 4). The U.K., Germany, and the Cooperative Center

for Scientific Research Relative to Tobacco (Centre De Cooperation Pour Les

Recherches Scientifiques Relatives Au Tabac, CORESTA) in Paris, France,

developed similar standard smoking parameters (Brunnemann et al., 1976a).

The FTC smoking schedule has also been employed for the determination of

“tar,” nicotine, carbon monoxide, and other smoke constituents in the

mainstream smoke of little cigars (Hoffmann and Wynder, 1972; Schmeltz et

al., 1976a).

In the course of smoke-uptake analyses, it soon became clear that the

employed machine-smoking conditions do not simulate the smoking habits

of consumers of filter cigarettes; most certainly they are not even close

to the average smoking parameters observed for smokers of filter cigarettes

delivering low levels ≤( 1.2 mg/cigarette, according to the FTC method) of

nicotine (Russell, 1980a; Herning et al., 1981; Fagerström, 1982; Haley et al.,

1985). With a recently developed “tobacco smoke inhalation testing

system,” it has been shown that smokers of cigarettes with low nicotine

yields ≤( 1.2 mg/cigarette according to FTC method) titrate nicotine uptake

by taking, on average, 12 ± 2.7 puffs per cigarette (FTC 10) with average puff

The scientific definition of "tar" is the total particulate matter collected by a Cambridge filter after subtacting

moisture and nicotine. (SG Report 1972, Chapter 9)

Smoking and Tobacco Control Monograph No. 9

Table 4

Standard conditions for machine smoking of cigars, cigarettes, and pipe

Parameters Cigars (CORESTA)

Cigarettes (FTC)

1,4

Pipes (CORESTA)

Weight 2.5 - 8.0 g 0.9 - 1.1 g 1.2 g (filling)

Puff:

Frequency 1/40 seconds 1/60 seconds 1/20 seconds

Duration (sec.) 1.5 2 2

Volume (ml) 40 35 50

Butt length (mm) 33 23 nonfilter 1.0 g burned

Pillsbury et al., 1969;

International Committee for Cigar Smoking, 1974;

Miller, 1963;

Little cigars are smoked as

cigarettes.

volumes of 52 ± 5.7 ml (FTC 35 ml), puff durations of 1.7 ± 0.24 seconds (FTC

2.0 seconds), every 28.5 ± 10.3 seconds (FTC 58 seconds). When operated

with the same parameters that were determined for individual smokers, a

smoking machine produced smoke yields per cigarette of 28 - 40 mg “tar”

(FTC 11 - 14 mg) and 2.1 - 2.5 mg nicotine (FTC 0.9 - 1.0 mg). Smoke

emissions of the carcinogenic BaP were 23.2 - 25.5 ng (FTC 11.9 - 21.9 ng)

and those of NNK were 30.1 - 33.9 ng (FTC 14.4 - 14.9 ng) per cigarette

(Djordjevic et al., 1995a).

Today, more than 97 percent of all cigarettes in the U.S. have filter tips

(Creek et al., 1994) and about 75 percent of these give FTC-measured nicotine

yields of ≤ 1.2 mg/cigarette. The FTC data for “tar,” nicotine, and carbon

monoxide are, therefore, of limited usefulness and can, at most, compare

relative smoke yields of commercial cigarettes generated under the FTC

standardized smoking conditions.

Rickert et al. (1985) examined the delivery of “tar,” nicotine and CO per

liter of smoke for different tobacco products. They found that the mean

yields per liter of smoke were highest for small cigars followed by hand-rolled

and manufactured cigarettes and were lowest for large cigars. Total delivery

was greatest for large cigars because of their larger amount of tobacco.

So far, only a study by Miller (1963) has been concerned with a

standardized method for pipe smoking. The pipe is filled with 1.2 g tobacco

and is smoked by taking five puffs per minute, of two-seconds duration and a

50-ml volume per puff. Miller also determined nicotine in the tobacco and

the smoke yields of the tobaccos from a filter cigarette (1.58 percent nicotine)

and two pipe tobaccos (1.52 percent and 1.30 percent nicotine), all smoked in

a pipe bowl. Then, smoking 1.0 g of the tobacco from a filter cigarette under

the pipe smoking conditions, he found 59.5 mg “tar,” 7.15 mg nicotine, and

1.36 vol. % CO, whereas the pipe tobaccos gave 53.3 and 56.4 mg “tar”, 5.18

and 6.12 mg nicotine, and 1.04 and 1.10 vol% CO. When the filter cigarette

tobacco was smoked in a cigarette with such standard cigarette-smoking

conditions, the yields for the 1 g of tobacco smoked were: 24.1 mg “tar,”

Mainstream smoke (MS) is the smoke a smoker draws into his mouth from the butt end or mouth piece of a

cigar, cigarette, or pipe. Sidestream smoke (SS) is the smoke emitted form the burning cone of a cigar or

cigarette, or pipe during the interval between puffs. (SG Report 1979 Chapter 14)

Chapter 3

1.63 mg nicotine, and 4.89 vol% CO. Clearly, pipe smoking produces

much higher yields of “tar” and nicotine per gram of tobacco than cigarette

smoking.

It has been reported that with increasing number of puffs per given cigar,

and also with increasing puff volume per given unit of time (puff velocity),

the amount of tobacco burned rises linearly (Rice and Scherbak, 1976).

CORESTA developed a standard smoking method for cigars with the following

parameters: one puff of 20 ml volume is taken during 1.5 seconds every

40 seconds. The cigars are smoked to a butt length of 33 mm. In 1974, the

International Committee for Cigar Smoke Study of CORESTA chose these

smoking parameters as an average of the observations made on cigar smokers

in France, Germany, the U.S., and the U.K. The smoke yields for cigars

reported in the literature since 1974 are based on the CORESTA method

(Table 4). However, for smoke analyses of little cigars, the cigarette-smoking

parameters of the FTC are applied. To date, the testing of the actual smoking

parameters of cigar smokers by a computer-assisted instrument has not

been reported. Table 4a presents the dimensions and yield characteristics

of cigarettes, little cigars, large cigars, and premium cigars smoked under

these standardized machine smoking conditions.

Physicochemical Tobacco smoking, like the burning of all organic matter, is a

Nature of Cigar process of incomplete combustion governed by several in air factors

Smoke relating to the combustibility of certain leaf components (such

as laminae, ribs, and stems), insufficient supply of oxygen, and the existence

of a temperature gradient in the burning cone.

At least three types of reactions occur simultaneously during smoking:

pyrolysis, pyrosynthesis, and distillation. The process of tobacco burning leads

to thermal degradation, in which organic matter is broken down into smaller

molecules (pyrolysis). The newly formed fragments, or radicals, are often

unstable and may recombine with identical and/or other radicals to form

components that were not originally present in tobacco. This process is called

pyrosynthesis. Distillation of certain compounds from the tobacco into the

smoke is the third process occurring during smoking. Compounds such as

nicotine and some low-molecular-weight terpenes participate in this third

process. They decompose only partially (Osdene, 1976). Some of the metals

transfer into the smoke stream while entrained in microfragments of ash

(Wynder and Hoffmann, 1967). It has been suggested that the presence of

high-molecular-weight pigments and other high-molecular-weight components

in tobacco smoke is due to the sharp thermal gradient behind the burning cone

which leads to cellular rupture, thereby expelling these compounds into the

smoke stream where they form the nuclei of the smoke particles (Stedman et

al., 1966).

The smoke from a burning tobacco product is divided into the mainstream

smoke and the sidestream smoke. The heat produced during the burning of

one gram of tobacco is estimated to be 4.5 - 5.0 kcal. The temperature in the

burning cone of a cigar reaches 930°C, in that of a cigarette up to 910°C; it

Smoking and Tobacco Control Monograph No. 9

Table 4a

Smoke yields of leading U.S. cigarettes

without and with filter tips, little cigars with

filter tips, cigars

, and premium cigars

1997

Pall Mall Marlboro Swisher King Macanudo

Parameters Non-filter Filter Sweets Edward Premium

Cigarettes Cigarettes Little Cigars Cigars Cigars

Length (mm) 85 85 100 138 176

Weight (g) 1.1 1.0 1.24 8.06 8.01

Puff (No) 11 10 18.5 89.7 119.4

Total Smoke (L) 0.385 0.35 0.4 1.8 2.4

“Tar” (mg) 26 16 24 37 44

CO (mg) 18 14 38 96 97

Nicotine (mg) 1.7 1.1 3.8 9.8 13.3

BaP (ng) 20 16 26.2 96.0 97.4

NNN (ng) 280 200 595 1225 1225

NNK (ng) 160 130 310 1200 1145

The cigarettes were smoked under FTC conditions: 1 puff/min, 35 ml, 2-second puff duration

butt length NF, 23 mm; F., 29 mm. (FTC) Pillsbury et al., 1969

Little cigars, cigars; and premium cigars were smoked under the conditions of the International Committee for Cigar Smoke

Study (ICCSS): 1 puff/40 seconds, 20 ml, 1.5-second puff duration, butt length 33 mm. Values are averages of 3 runs.

(ICCSS) International Committee for Cigar Smoke Study, 1974.

Abbreviations: BaP, Benzo (

) pyrene; NNN, N

-nitrosonornicotine; NNK, 4-(methylnitrosamino)

-1-(3-pyridyl)-1-butanone.

Source: Unpublished data Hoffmann, D. American Health Foundation

decreases to 820°C between puffs (Figure 4) (Touey and Mumpower, 1957a;

1957b). Taking four puffs per minute with volumes of 10, 15, or 20 ml, Adams

(1968) reported that peak temperatures of 1,117°C and 1,290°C occur during

smoking of small cigars and 1,139°C and 1,160°C have been measured for

large cigars. Using cigar tobacco in a cigarette, peak temperatures of 944°C

and 970°C were recorded (Table 5).

The temperature of the mainstream smoke emitting from the mouthpiece

with early puffs from cigars and cigarettes lies only a few degrees above room

temperature (25° - 30°C). The temperature of subsequent puffs rises gradually

above 50°C and can even reach 75°C with the last puff of a cigar that is

smoked down to 10 mm (Borowski and Seehofer, 1962).

In general, the pH of the whole smoke of cigars increases from the early

puffs when it is ~ 6.5, to ~ 8.0 for the last (35th) puff. The pH of the puffs

of small cigars increases from 6.5 to 7.4 (14th puff), that of little cigars from

pH 6.5 to 7.5 (9th puff), and that of cigarettes decreases from pH 6.0 to

5.7 (11th puff) (Table 5). This phenomenon is of major significance, since

above pH 6.0 the smoke contains unprotonated (free) nicotine. Thus, the

last puff of a cigar with a pH of 8.0 contains about 50 percent unprotonated

Chapter 3

Figure 4

Temperature profiles in the burning cones of cigarettes and cigars

200

400

600

800

1,000

Temp., °C.

123456

Recorder Chart Travel, In.

Cigarettes

Cigars

Chart speed 1 in./min..

91011

Source: Touey and Mumpower, 1951a.

Smoking and Tobacco Control Monograph No. 9

Table 5

Comparison of some physicochemical parameters of the mainstream smoke

of cigars and cigarettes

Parameters Cigars Little Cigars Cigarettes

3rd Puff 6.5 6.5 6.0

Last Puff 8.0 7.4 5.7

Temperature

During puffing, range, °C 1139˚ - 1160˚ n. a. 944 - 970

Between puffs, °C 820 n. a. 800

Reducing Activity

(units of DCIP)

Particulate Phase 45.0 n. a. 108.3

Gas Phase 10.1 n. a. 4.9

n. a., not available.

Brunnemann and Hoffmann, 1974a;

Adams, 1968;

Bilimoria and Nisbet, 1972.

nicotine in the vapor phase; that of a small cigar, at pH 7.4, about 30 percent

unprotonated nicotine; and the last puff of a little cigar, at pH 7.5, has

about 32 percent unprotonated nicotine. On the other hand, the smoke of

the U.S. blended cigarette does not contain unprotonated nicotine when

tested under current FTC smoking conditions (Figures 5 and 6) (Brunnemann

and Hoffmann, 1974a). Unprotonated nicotine is present in the vapor phase

of the inhaled smoke; protonated nicotine resides in the particulate phase.

Unprotonated nicotine is absorbed through the mucous membrane of the

oral cavity and delivers a dose of the pharmacoactive agent, that “satisfies”

the primary cigar smoker without his inhaling the smoke (Armitage and

Turner, 1970).

The smoke of fresh (unaged) mainstream smoke of a U.S. blended,

nonfilter cigarette contains about 5 × 10

spherical droplets with a particle-

size distribution of 0.1 - 1.0 micron (maximum around 0.2 micron) (Keith

and Derrick, 1961). Slightly less than half of the particles are neutral,

whereas most of the particles carry only one electrical charge and these are

evenly divided between those with negative and those with positive charges

(Norman and Keith, 1975). There is a lack of published data on particle

concentration and particle size distribution in cigar smoke and also on the

electrical charges of cigar smoke particles.

All tobacco smoke products exhibit significant reducing activity.

Studies using the reduction of 2,4-dichloroindophenol as a marker of the

reducing potential of tobacco smoke have shown that cigarette smoke has

a significantly higher reducing potential than cigar or pipe smoke. In

cigarette smoke, about 96 percent of the reducing activity of the total smoke

Chapter 3

100

% of protonated and unprotonated nicotine species

123456

78910

11 12

Source: Brunnemann and Hoffmann, 1974.

Figure 5

Degree of protonation of nicotine in relation to pH.

Smoking and Tobacco Control Monograph No. 9

5.5

6.0

6.5

7.0

7.5

8.0

8.5

345678

Puffs

9101112

13 14

20 25

30 35 40

(1) little cigar I

(2) little cigar II

(3) cigar

(4) Kentucky reference cigarette

(5) blended filter-tipped cigarette (85 mm)

(6) blended cigarette without filter (85 mm)

Source: Brunnemann and Hoffmann, 1974a and 1974b.

Figure 6

pH of total mainstream smoke of various tobacco-products

Chapter 3

resides in the particulate phase, while in cigar smoke, 82 percent is found in

the particulate phase (Table 5) (Bilimoria and Nisbet, 1972).

Chemical Tobacco smoke contains more than 4,000 individual components;

Composition about 500 of these occur in the gas phase. The major gas-phase

of Cigar Smoke constituents in cigar smoke are 51.8 - 54.6 volume% nitrogen

(for cigarettes, 55 - 72 vol%), 4.1 - 4.2 vol% oxygen (9.2 - 14.3

Gas Phase* vol%), 15.5 - 16.7 vol% carbon dioxide (6.9 - 13.4 vol%), and

9.7 - 12.7 vol% carbon monoxide (1.9 - 6.3 vol%) (Boyd et al., 1972). These

comparisons strongly indicate that the combustion during puff drawing from

cigars is even less complete (oxygen 4.1 - 4.2 vol%; CO, 1.9 - 6.3 vol%) than

that during cigarette smoking. A primary reason for the low concentration of

and the high concentration of CO in cigar smoke is the lack of porosity

of the cigar binder and wrapper compared to that of cigarette paper. The

porosity of cigarette paper accelerates the delivery of oxygen into the tobacco

column and the diffusion of certain gaseous components (e.g., CO, CO

, NO)

through the paper into the environment.

Table 6 presents select volatile components in the smoke of cigars, little

cigars, and cigarettes. Remarkably, the concentrations of nitrogen oxides

(NO

) and ammonia are significantly higher in cigar smoke than in cigarette

smoke. Formation of nitrogen oxides and ammonia is primarily linked to

the nitrate content of the cigar tobacco, the incomplete combustion, and

the lack of porosity of cigar binders and wrappers. The amounts of ammonia

reported in the smoke of cigars and cigarettes may not only originate from

the ammonia produced in the reducing atmosphere of the burning cone but

can also, to a minor extent, come from amides which partially decompose in

the sulfuric acid that is used for trapping the ammonia from the smoke

(Brunnemann and Hoffmann, 1975). In the smoke of cigars, up to 0.8

percent is present as free ammonia at pH levels between 6.8 and 7.2; whereas

cigarette smoke contains only up to 0.01 percent of free ammonia at a pH

between 5.3 and 5.6 (Figure 7) (Sloan and Morie, 1976). The higher

quantities of free ammonia contribute to the pungency of cigar smoke.

Cigar smoke also contains a large number of volatile amines (Pailer et al.,

1969). However, there is a lack of quantitative data. The levels of volatile

N-nitrosamines are also higher in cigar smoke than in cigarette smoke,

again primarily because of the higher nitrate content of the cigar tobacco

compared to that of cigarette tobacco. Furthermore, cigar smoke contains

a large spectrum of volatile agents, such as volatile olefins, dienes (1,3-

butadiene, isoprene, etc.), volatile nitriles, and halogenated hydrocarbons.

* The classification of the tobacco smoke aerosol into gas phase and particulate phase is based on

the separation of the smoke that occurs when it is drawn through a Cambridge glass fiber filter

CM-113. Fifty percent of the components are from the gas phase and pass through the filter.

That portion of the smoke which is trapped on the filter consists of particulate phase

components. These are arbitrary definitions, they do not fully reflect the conditions prevailing

in undiluted, unaged smoke; however, they serve as guidelines.

Smoking and Tobacco Control Monograph No. 9

Table 6

Components in mainstream smoke of cigars and cigarettes: gas phase

(values are given for 1.0 g tobacco smoked)

Non-filter Little Filter

Component Cigars Cigarettes Cigars Cigarettes Ref.

Carbon monoxide, mg 39.1 - 64.5 16.3 22.5 - 44.9 19.1 1-3

Carbon dioxide, mg 121 - 144 61.9 47.9 - 97.9 67.8 1-3

Nitrogen oxides (NO

), µg 159, 300 160 45, 150 90 - 145 1

Ammonia, µg 30.5 95.3 200, 322 98 4

Hydrogen cyanide, µg 1,035 595 510, 780 448 2

Vinyl chloride, ng n.a. 17.3, 23.5 19.7, 37.4 7.7 - 19.3 5

Isoprene, ng 2,750 - 3,950 420, 460 210 , 510 132 - 990 1.6

Benzene, µg 92 - 246 45, 60 n.a. 8.4 - 97 1,6-8

Toluene, µg n.a. 56, 73 n.a. 7.5 - 112 1,7

Pyridine, µg 49 - 153 40.5 61.3 27.6, 37.0 9

2-Picoline, µg 7.9 - 44.6 15.4 17.0 14.8, 15.6 9

3-+4-Picoline, µg 17.9 - 100 36.1 32.9 12.6, 20.2 9

3-Vinylpyridine, µg 7.0 - 42.5 29.1 21.2 102, 192 9

Acetaldehyde, µg 1,020 960 850, 1,390 94.6 2

Acrolein, µg 57 130 55, 60 87.6 2

N-Nitrosodimethylamine, ng n.a. 16.3 - 96.1 555 7.4 10

N-Nitrosopyrrolidine, µg n.a. 13.8 - 50.7 24.5 6.6 10

n.a., data not available.

References: (1) Wynder and Hoffmann, 1967; (2) Hoffmann et al

, 1973; (3) Brunnemann and Hoffmann,

1974b; (4) Brunnemann and Hoffmann, 1975; (5) Hoffmann et al

, 1976; (6) Brunnemann et al

, 1990; (7)

Osman and Barson, 1964; (8) Appel et al

, 1990; (9) Brunnemann et al

, 1978; (10) Brunnemann et al

, 1977b.

However, the available literature offers few quantitative data for cigar smoke,

except for a report on the presence of vinyl chloride (Hoffmann et al., 1976).

Particulate Phase The particulate phase of tobacco smoke contains at least 3,500

individual components (Roberts, 1988). Most of our knowledge about the

physicochemical nature and composition of tobacco smoke derives from

studies on cigarette smoke.

Only limited research has been done on the chemical composition of

cigar smoke. One would expect cigar smoke chemistry to be qualitatively

similar to that of cigarette smoke, except for differences caused by the use

of additives, by the pH effects, and by the lower concentrations of oxygen

available to support combustion. Cigar smoke may contain components

that derive from additives incorporated into reconstituted tobacco sheets,

and these may be different from additives used in reconstituted tobacco

formulations for cigarettes (Moshy, 1967; Halter and Ito, 1980). The tobacco

of low-yielding cigarettes is often treated with flavor additives (Doull et al.,

1994). Such flavor additives are generally not used for cigars except for some

little cigars with filter tips.

Chapter 3

Figure 7

Fraction of free ammonia and methylamine vs. pH.

0.2

0.4

0.6

0.8

1.0

Fraction of Each Species

6 87 910111213

Source: Sloan and Morie, 1976.

Quantitative similarities are seen when one compares the smoke yields of

cigars and cigarettes per gram tobacco smoked (Table 7). This is the case for

the smoke yields of volatile phenols and polynuclear aromatic hydrocarbons

(PAH), compounds primarily pyrosynthesized during smoking. However,

“tar” yields per gram of cigar tobacco burned are somewhat higher because

the nonporous cigar binder and wrapper make the combustion less complete

than that of cigarette tobacco combustion of which is facilitated by highly

porous cigarette paper (Rickert et al., 1985). Also, cigars have larger diameters

than cigarettes which further hinders more complete combustion. The

nicotine yields in the mainstream smoke of cigars are also generally higher

than in the mainstream smoke of cigarettes because the latter contain a

tobacco blend, while most cigars are made solely from burley tobacco that

delivers a weakly alkaline smoke with a high proportion of unprotonated

nicotine.

The significantly lower yields of long-chain paraffin hydrocarbons in

cigar smoke compared to cigarette smoke can, in part, be explained by the

loss of such hydrocarbons during fermentation of the cigar tobacco (Wolf,

1967). The low yields of the long-chain hydrocarbons in cigar smoke are

likely also attributable to the very intense “cracking” of these compounds

during smoking. The high yield of N-nitrosodiethanolamine seen in the

smoke of little cigars was probably related to the treatment of the tobacco

of these little cigars with the sucker growth inhibitor MH-30, maleic hydrazide

Smoking and Tobacco Control Monograph No. 9

Table 7

Components in the mainstream smoke of cigars and cigarettes: particulate phase

(values are given for /g tobacco smoked)

Non-filter Little Cigars Filter

Smoke Component Cigars Cigarettes with Filter Cigarettes Ref.

“Tar” (FTC), mg 38.0 - 40.6 16.0 - 36.1 17.4 - 31.8 8.0 - 20.3 1,2,3

Nicotine, mg 2.9 - 3.1 1.7 - 2.65 0.6 - 1.8 0.6 - 1.4 1,2,3

Tridecane, µg 1.2 14.3 4,5

Pentadecane, µg 0.8 14.3 4,5

Eicosane, µg 0.8 27.4 4,5

Docosane, µg 0.6 26.2 4,5

Cholesterol, µg 27.5 49.0

Camposterol, µg 53.4 57.4

Stigmasterol, µg 97.5 152

β-Sitosterol, µg 74.1 82.5

Phenol, µg 24 - 107 96 - 117 37.0 19.0 - 33.2 2,7

-Cresol, µg 19 - 21 22 - 26 4.3 4.2 - 6.8 2,7

- and

-Cresol, µg 19 - 62 50 - 58 18.0 17 - 23.3 2,7

Catechol, µg 318 129 - 169 178 8

Formic acid, µg 109 - 121 400 9

Acetic acid, µg 286 - 320 900 9

Quinoline, µg 2.0 - 4.1 1.67 0.66 0.62 10

Naphthalene, ng 3,900 - 5,000 1,780 11

1-Methylnaphthalene, ng 1,390 - 1,760 1,110 11

2-Methylnaphthalene, ng 1,720 - 2,130 1,470 11

Acenaphthene, ng 16 50 12,13

Anthracene, ng 119 109 12,13

Pyrene, ng 176 125 12

Fluoranthene, ng 201 125 12

Benz(

)anthracene, ng 39 -92.5 92 44.3 40.6 12

Benzo(

)pyrene, ng 30 - 51 47 - 58.8 25.7 26.2 12

N-Nitrosodiethanolamine, ng 5.7 4.6 700 38 13

-Nitrosonornicotine, ng 820 300 7,100 390 14

NNK, ng 4.90 140 5,400 190 14

-Nitrosoamabasine 4.90 410 2,200 460 14

Copper, ng 40 - 160 < 10 - 100 15

Lead, ng 160 - 280 100 - 510 15

Cadmium, ng 2.0 - 38 16 - 82 15

Zinc, ng 360 - 2,500 120 - 920 15

Nickel, ng 2,500 - 7,000 300 - 600 16,17

Small cigar without filter.

-Nitrosoanatabine contains 10 - 15% N

-nitrosoanabasine.

References: (1) Hoffmann et al., 1963; (2) Wynder and Hoffmann, 1967; (3) Hoffmann and Wynder, 1972; (4) Spears et al.,

1963; (5) Osman et al., 1965; (6) Schmeltz et al., 1975a; (7) Osman et al., 1963; (8) Brunnemann et al., 1976;

(9) Schmeltz and Schlotzhauer, 1961; (10) Dong et al., 1978; (11) Schmeltz et al., 1976a; (12) Campbell and

Lindsey, 1957; (13) Brunnemann and Hoffmann, 1981; (14) Hoffmann et al., 1979a; (15) Franzke et al., 1977;

(16) Sunderman and Sunderman, 1961; (17) Stahly and Lard, 1977.

Chapter 3

diethanolamine. Since 1980-1981, due to an official ban, the use of MH-30

on tobacco has been greatly reduced (Brunnemann and Hoffmann., 1991a).

As to be expected, the smoke of cigars contains significantly higher

amounts of the carcinogenic, tobacco-specific N-nitrosamines (TSNA) than

cigarette smoke (Table 7). A major reason for the elevated levels of TSNA in

cigar smoke is the relatively high concentration of nitrate in cigar tobacco.

During curing and fermentation, nitrate is partially reduced to nitrite, an

important precursor for the N-nitrosation of amines, including alkaloids

like nicotine; nitrate constitutes up to 2.0 percent of the cigar tobacco (Table

3). The nitrosamines formed from nicotine are NNK and NNN (Figure 3).

The latter is also formed in high yields from nornicotine (Hoffmann et al.,

1994). In laboratory animals, NNK and NNN are metabolically activated

by α-hydroxylation which results in the formation of unstable α-hydroxy

nitrosamines. These decompose to yield alkylating agents that react with

the nuclear DNA in vitro and also in vivo (Hecht and Hoffmann, 1989; Hecht,

1996). Lesions formed by this reaction give rise to tumors in the target

organs. NNN elicits carcinoma of the esophagus in rats. In explants of

human esophageal tissue, NNN is also (-hydroxylated, although to varying

extents. The degree of α-hydroxylation of NNN varies between individuals

and is likely related to phenotypic differences (Castonguay et al., 1983). In

this regard, it is of interest to recall that the risk for cancer of the esophagus

among cigar smokers is comparable to that of cigarette smokers (Kahn, 1966;

Schottenfeld, 1984; U.S. Department of Health and Human Services, 1989)

(Chapter 4).

Like most plants, tobacco contains a number of metal ions; a small

percentage of these transfers into the mainstream smoke of tobacco products.

The reported transfer rates into cigar smoke were for lead 2.0 - 6.6 percent

(cigarette smoke 3.4 - 19.7 percent), for zinc 1.0 - 8.5 percent (cigarette smoke

0.6 - 4.6 percent), for cadmium 0.3 - 2.3 percent (cigarette smoke 1.1 - 7.3

percent), and for copper 0.1 - 0.8 percent (cigarette smoke 0.3 - 1.1 percent)

(Franzke et al., 1977). The high transfer rate of nickel into tobacco smoke ((

20 percent) has been explained by the formation of the volatile nickel

carbonyl (bp 43°C) (Sunderman and Sunderman, 1961; Stahly and Lard,

1977). Cigar tobacco was reported to contain between 1.1 and 4.9 (g nickel

per gram tobacco. In inhalation studies, nickel carbonyl (Ni[CO]

) induced a

few pulmonary tumors in rats; upon intravenous injection of this compound,

19 out of 20 rats developed lung tumors (International Agency for Research

on Cancer, 1990).

SIDESTREAM Environmental tobacco smoke (ETS) is the term used to describe

SMOKE AND indoor air pollutants derived from burning tobacco products.

ENVIRONMENTAL The major contributor to ETS is the sidestream smoke (SS) that

TOBACCO SMOKE originates between puffs from smoldering cigars, cigarettes,

or pipes. Lesser contributions to ETS come from the smoke

Sources of emitted at the butt end of a burning cigar or cigarette and/or

Environmental from the mouthpiece of a pipe stem, and also from gases diffusing

Tobacco Smoke through cigarette paper. Exhaled smoke also contributes to ETS.

Smoking and Tobacco Control Monograph No. 9

It has been known for a long time that the alkaline cigar SS is irritating

to eyes, ears, and throats of people, especially in enclosed environments with

limited ventilation, such as offices and other workplaces and conveyances.

The ph levels of cigar Tobacco and of its smoke are slightly alkaline

(Wolf, 1967; Brunnemann and Hoffmann, 1974a). This contributes to the

unpleasant odor of cigar butts, which contain partially unprotonated, readily

volatilizing ammonia, pyridine, methyl- and ethylpyridines, 3-vinylpyridine,

2,4-, 2,6-, and 3,s-dimethylpyridines as well as allylalcohol, ethylmercaptan,

volatile phenols, aliphatic nitriles, and benzonitrile (Peck et al., 1969; Adler

et al., 1971).

The Physicochemical SS is primarily formed in the burning cones and hot zones

Nature of Sidestream of cigars, cigarettes, and pipes between the drawing of puffs.

Smoke The smoldering tobacco releases more of many compounds

into the SS than into mainstream smoke (MS).

This applies especially to those agents that are preferably formed in

reducing atmospheres, namely ammonia, aliphatic and aromatic amines, and

volatile N-nitrosamines (Table 8). When SS is generated, several compounds

result from the degradation of tobacco constituents of low volatility. These

include benzene, toluene, 3-vinylpyridine (from the Nicotiana alkaloids), and

polynuclear aromatic hydrocarbons (PAH). Smoke components that are

formed by oxidation, such as catechol and hydroquinone, are released into

SS in significantly lower amounts than into MS (Schmeltz et al., 1975a,b;

Schmeltz et al., 1979; Klus, 1990; Guerin et al., 1992).

Because of the release of relatively large quantities of ammonia, the pH

of the SS of cigarettes is neutral (MS slightly acidic) and that of cigars is

alkaline (Figure 8; see Figure 6 to compare with the pH of MS). Therefore,

the SS of both cigarettes and cigars contains a greater proportion of

unprotonated nicotine and ammonia than the MS (Figures 5 and 7;

Brunnemann and Hoffmann, 1974a; Morie, 1972).

Few physicochemical parameters of cigar SS are available in the accessible

literature (Table 9). It is likely that they are generally similar to those of

cigarette SS. Under standardized machine-smoking conditions (FTC method)

(Pillsbury et al., 1969), the generation of MS from cigarettes requires, on

average, 10 puffs of 35 ml each and a total of 20 seconds, while the

formation of SS occurs over 550 seconds. During these periods, 347 mg

tobacco are burned to generate MS and 411 mg tobacco are burned to

produce SS. In the MS of a nonfilter cigarette one finds 10.5 × 10

particles;

in the SS, 35 × 10

particles (Scassellati-Sforzolini and Savino, 1968); the

particle sizes range from 0.1 to 1.0 µm in MS and from 0.01 to 0.8 µm in SS,

with means of 0.4 µm and 0.32 µm, respectively (Carter and Hasegawa, 1975;

Hiller et al., 1982). Ingebrethsen and Sears (1985) reported that particle size

declines in line with the degree of dilution of SS by air. Diluting SS from

226 µg/m

to 26 µg/m

and down to 1.4 µg/m

reduces the median diameter

from 0.210 to 0.196 and to 0.185 µm, while the percentage of particles with

diameters <0.10 µm increases from about 39 to 54, and to 73 percent of the

Chapter 3

Constituent Amount in MS Range in SS/MS

Catechol 100-360 µg 0.6-0.9

Hydroquinone 110-300 µg 0.7-0.9

Aniline 360 ng 30

2-Toluidine 160 ng 19

2-Naphthylamine 1.7 ng 30

4-Aminobiphenyl 4.6 ng 31

Benz[

]anthracene 20-70 ng 2-4

Benzo[

]pyrene 20-40 ng 2.5-3.5

Cholesterol 22 µg 0.9

γ-Butyrolactone 10-22 µg 3.6-5.0

Quinoline 0.5-2 µg 8-11

Harman 1.7-3.1µg 0.7-1.7

N’

-Nitrosonornicotine 200-3,000 ng 0.5-3

NNK 100-1,000 ng 1-4

-Nitrosodiethanolamine 20-70 ng 1.2

(continues)

Table 8

Distribution of select constituents in fresh, undiluted mainstream smoke and diluted sidestream

smoke from nonfilter cigarettes

Constituent Amount in MS Range in SS/MS

Vapor phase

Carbon monoxide 10-23 mg 2.5-4.7

Carbon dioxide 20-40 mg 8-11

Carbonyl sulfide 18-42 µg 0.03-0.13

Benzene 12-48 µg 5-10

Toluene 100-200 µg 5.6-8.3

Formaldehyde 70-100 µg 0.1-≅50

Acrolein 60-100 µg 8-15

Acetone 100-250 µg 2-5

Pyridine 16-40 µg 6.5-20

3-Methylpyridine 12-36 µg 3-13

3-Vinylpyridine 11-30 µg 20-40

Hydrogen cyanide 400-500 µg 0.1-0.25

Hydrazine 32 ng 3

Ammonia 50-130 µg 40-170

Methylamine 11.5-28.7 µg 4.2-6.4

Dimethylamine 7.8-10 µg 3.7-5.1

Nitrogen oxides 100-600 µg 4-10

-Nitrosodimethylamine 10-40 ng 20-100

-Nitrosodiethylamine ND-25 ng <40

-Nitrosopyrrolidine 6-30 ng 6-30

Formic acid 210-490 µg 1.4-1.6

Acetic acid 330-810 µg 1.9-3.6

Methyl chloride 150-600 µg 1.7-3.3

Particulate phase

Particulate matter 15-40 mg 1.3-1.9

Nicotine 1-2.5 mg 2.6-3.3

Anatabine 2-20 µg <0.1-0.5

Phenol 60-140 µg 1.6-3.0

Smoking and Tobacco Control Monograph No. 9

Table 8

(continued)

Cadmium 100 ng 7.2

Nickel 20-80 ng 13-30

Zinc 60 ng 6.7

Polonium-210 0.04-0.1 pCi 1.0-4.0

Benzoic acid 14-28 µg 0.67-0.95

Lactic acid 63-174 µg 0.5-0.7

Glycolic acid 37-126 µg 0.6-0.95

Succinic acid 110-140 µg 0.43-0.62

National Research Council, 1986.

total ETS particles. In respect to particle sizes in the MS and SS of cigars, it is

likely that similar parameters prevail; however, precise data are currently

not available.

Environmental The tobacco smoke released into the environment from a burning

Tobacco Smoke cigarette, cigar, or pipe, and the exhaled smoke (that portion not

retained by the smoker) is usually diluted by air several hundred-fold and

often a thousand-fold before the ETS-polluted aerosol is inhaled

(International Agency for Research on Cancer, 1986; U.S. Department of

Health and Human Services, 1986; National Research Council, 1986; Guerin

et al., 1992). However, to date only one model study with cigar smoke as a

source for ETS has been reported (Nelson et al., 1997). It involved the

concurrent smoking of three cigars of one brand by three men over a 10-

minute period in a 45 m

chamber. The environmental conditions were

static, i.e., there was neither air supply nor recirculation of the air in the

chamber. Table 10 compares ETS data from this model study with the data

from a model study with six cigarette smokers located for 10 minutes in the

same chamber under identical (static) chamber conditions (Nelson et al.,

1996 and 1997). Clearly, the smoking of three cigars by three smokers

during 10 minutes polluted the air significantly more with CO (16.9 to 25.3

ppm), nitrogen oxides (412 to 520 ppb), nicotine (168 to 450 µg/m

), and

respirable suspended particulate matter (RSP; 1,520 to 5,770 µg/m

) than the

smoking by six cigarette smokers which generated 0.629 to 0.782 ppm CO,

226 to 461 ppb nitrogen oxides, 49 to 61 µg/m

nicotine, and 1,170 to 1,960

µg/m

RSP (Table 10). The greater degree of ETS pollution generated by the

three cigar smokers can be explained, at least in part, by the fact that these

cigar smokers burned cumulatively between 21.4 g and 33.9 g of tobacco

while the six cigarette smokers burned only between 3.77 g and 4.69 g

tobacco during the same time. This model study documents clearly what has

been assumed, namely that cigar smokers pollute enclosed environments to a

significantly higher degree than cigarette smokers. Studies of the levels of

CO produced under actual cigar smoking conditions are described in

Chapter 5 (Repace et al., 1998).

ETS differs from freshly generated mainstream smoke in a number of

ways. The conditions under which MS is formed are very different from

Chapter 3

6.5

7.0

7.5

9.0

8.5

8.0

1 32 45678

Puffs

910111213 14

those prevailing during SS formation, and the latter is the main contributor

to ETS. The pH of SS is different from that in the MS of cigars and cigarettes

(Figures 6 and 8), reflecting the presence of free ammonia and creating major

differences in the degree of unprotonated nicotine (Figures 5 and 7). In

addition, with the higher degree of air dilution of SS, more nicotine

evaporates from the particulate phase into the vapor phase. Eudy et al. (1986)

reported that 90 - 95 percent of the nicotine is present in the vapor phase of

(1) little cigar I

(2) little cigar II

(3) French (black tobacco) cigarette

(4) Kentucky reference cigarette

(5) blank (air)

Source: Brunnemann and Hoffmann, 1974a and 1974b.

Figure 8

pH of total sidestream smoke of various tobacco-products

Smoking and Tobacco Control Monograph No. 9

Table 9

Some selected compounds in the sidestream smoke of cigars, little cigars, nonfilter cigarettes

and filter cigarettes (values are given for 1 g tobacco burned)

Nonfilter Little Cigar Filter

Compound Cigars Cigarette with Filter Tips Cigarette Ref.

Ammonia, mg 7.18 (44) 9.34 (47) 7.14 (13) 1

6.11 (64) 12.9 (40)

Hydrogen cyanide, µg 134 (0.85) 114 (0.17) 167 (0.37) 2

141 (0.30)

Pyridine, µg 665 - 800 (5013) 420 (10) 3

2-Picoline, µg 170 - 255 (6-20) 160 (10) 3

3- and 4-Picoline, µg 600 - 930 (–51) 380 (13) 3

3-Vinylpyridine, µg 595 - 900 (14-80) 800 (28) 3

NDMA, ng 473 (6.4) 930 (50) 2,280 (412) 950 (129) 4,5

NEMA, ng 15 (1.4) 74 (30) 97 (15) 129 (95) 4,5

NDEA, µg 72.6 (35.3) 29 (26) 56 (89) 4,5

NPYR, µg 128 (10.5) 410 (27.3) 922 (32) 758 (89) 4,5

Cholesterol, µg 23.6 (0.9) 9.5 (0.6)

Campesterol, µg 32.5 (0.) 12.5 (0.8)

Stigmasterol, µg 67.0 (0.7) 11.8 (0.8)

β-Sitosterol, µg 35.0 (0.5) 9.8 (0.8)

NNN, µg 4.27 (5.2) 2.13 (7.1) 1.14 (0.16) 0.19 (0.48) 7

NNK, µg 4.03 (8.3) 0.63 (3.7) 1.05 (0.15) 0.24 (1.3) 7

NAB, µg 0.34 (0.82) 0.71 (0.34) 0.19 (0.41) 7

Numbers in parentheses SS/MS.

Little cigar without filter.

References: (1) Brunnemann and Hoffmann, 1974; (2) Brunnemann et al., 1977a; (3) Brunnemann et al., 1978;

(4) Brunnemann et al., 1977b; (5) Brunnemann and Hoffmann, 1991; (6) Schmeltz et al., 1975a and

1975b; (7) Hoffmann et al., 1979.

ETS. The particle mass median diameter in ETS is significantly smaller than

the particle diameter of inhaled MS (Carter and Hasegawa, 1975;

Ingebrethsen and Sears, 1985). Furthermore, even compounds with

relatively high molecular weight, such as the paraffin hydrocarbons C

, have been found to be present in the vapor phase of ETS to a

significant degree (Ramsey et al., 1990).

Exhaled smoke may also contribute more to the particulate than to the

vapor phase of ETS (Baker and Procter, 1990).

The time elapsing between generating and inhaling mainstream smoke is

only fractions of seconds or, at most, seconds; thus, chemical reactions

between constituents of freshly generated MS are limited compared to

reactions during the aging of ETS, which may go on for periods up to a few

hours and may be influenced by various atmospheric conditions. Certain

ETS constituents may react with other materials in an enclosed environment,

or components may be absorbed by textiles or by the surfaces of furniture.

Chapter 3

Table 10

Contribution of cigar and cigarette smoke to environmental tobacco smoke model

studies in a 45 m

room operated in the static mode

Cigars

Cigarettes

ETS - component C F D B E A FF FFLT ULT 100

Tobacco burned, g 7.11 7.33 10.5 7.77 10.3 6.53 0.7 0.661 0.629 0.782

CO, ppm 20.0 16.8 22.8 18.3 24.7 25.3 6.3 6.0 6.4 7.7

, ppb 572 412 445 526 472 520 234 226 242 261

3-Ethenylpyridine, µg/m

114 125 136 149 128 185 25 27 34 27

Nicotine, µg/m

168 202 283 290 169 450 51 61 49 56

RSP, µg/m

1810 1520 2920 2280 1280 5770 1440 1330 1170 1960

Solanesol, µg/m

43 26 16 74 21 102 45 44 35 53

No air supply, no air recirculation.

Three cigar smokers smoked the same cigar brands concurrently for 10 minutes.

Six cigarette smokers smoked the same cigarette brands concurrently.

Abbreviations: ETS, environmental tobacco smoke; Nox, nitrogen oxide plus nitrogen dioxide; RST, respirable suspended particulate matter; FF, full flavor cigarette;

FFLT, full flavor-low “tar”; ULT, ultra low “tar” cigarette; 100, full flavor-low “tar” 100 mm cigarette.

References: Nelson et al., 1997; Nelson et al., 1996.

Smoking and Tobacco Control Monograph No. 9

This is the case with nicotine. The ratio between smoke components in ETS

thus undergoes changes over time.

Tables 11 and 12 list some data for specific constituents of the vapor

phase and of the particulate phase of ETS. These tables present only a

fraction of the data that are known about ETS composition. (More detailed

information is in the following sources: U.S. Department of Health and

Human Services, 1986; National Research Council, 1986; Guerin et al., 1992.)

The tables do indicate some elevation in the concentration of toxic agents

in enclosed environments polluted with ETS compared to outdoor air.

Moreover, there are concerns about an apparent ongoing TSNA formation

during aging of ETS, yet there are no data in the literature to verify this

phenomenon.

Tables 11 and 12 also list trace amounts of those agents in ETS that

IARC (1987) regards as either “carcinogenic to humans,” or as “probably or

possibly carcinogenic to humans.” These include the human carcinogens

benzene and the aromatic amines 2-naphthylamine and 4-aminobiphenyl, as

well as the animal carcinogens 1,3-butadiene, isoprene, acrylonitrile,

formaldehyde, acetaldehyde, volatile N-nitrosamines, tobacco-specific

N-nitrosamines, and various polynuclear aromatic hydrocarbons.

TOXICITY AND As stated earlier, tobacco smoke contains at least 4,000

CARCINOGENICITY compounds (Roberts, 1988). At first glance, it appears to

OF CIGAR SMOKE be an insurmountable task to identify all of the individual

chemicals and groups of chemicals that are involved in the toxicity or

carcinogenicity of the smoke of cigars, cigarettes, or pipes. However,

intensive research in the tobacco sciences and advances in our

understanding of toxicology and carcinogenesis during the past five decades

have enabled scientists to define which agents, or groups of agents, are major

contributors to the biologic activities of tobacco smoke (U.S. Department of

Health and Human Services, 1989; Hoffmann et al., 1997).

Toxicity Tables 6 and 7 list several smoke constituents that contribute to the

overall toxicity and carcinogenicity of cigar smoke. Carbon monoxide and

nicotine are major contributors to the acute toxicity of cigar smoke. Among

agents which also add to the acute toxicity of cigar smoke are nitrogen

oxides, hydrogen cyanide, ammonia, and volatile aldehydes.

Human hemoglobin has 210 times greater affinity for carbon monoxide

than for oxygen. Inhaling tobacco smoke with up to 6 volume percent of CO

diminishes the oxygen carrying capacity of the blood. Carboxyhemoglobin

(COHb) concentration in the blood of nonsmokers amounts to about 0.5

percent, whereas in smokers it may reach 8 - 9 percent. The relationship

between smoking and CO intoxication has received little attention. In 1969,

Hamill and O’Neill reported two cases of CO intoxication of cigar smokers.

Both were secondary cigar smokers, practicing inhalation of the smoke just as

they did with cigarettes. One smoked 40 - 50 cigars, the other up to 15 cigars

per day. Both had CO intoxication with polycythemia and decreased arterial

oxygen saturation. Their COHb concentrations were 13 - 15 percent and 12 -

13 percent, respectively. In primary cigar smokers, COHb amounts to about

Chapter 3

Table 11

Concentrations of ETS-compounds in indoor air - vapor phase*

Concentration

Compound Mean Range Reference

Carbon Monoxide, ppm

25 offices 2.8 Szadkowski et al., 1976

Nonsmoking offices 2.6 Szadkowski et al., 1976

Office: 72m

-40 cigs/day < 2.5 - 4.6 Harke, 1974

Office: 78m

-70 cigs/day < 2.5 - 9.0 Harke, 1974

Offices - 66, urban area 2.3 ± 2.0 0.1 - 10.5 Guerin et al., 1992

Offices - 57, control-outdoor 2.5 ± 2.3 NR - 10.4 Guerin et al., 1992

Working areas - 221 situations 2.2 0.0 - 31.9

controls - 450 situations 2.1 0.0 - 21.9 Guerin et al., 1992

Restaurants, 49 3.4 ± 1.2 2.0 - 7.9 Guerin et al., 1992

13 controls 3.0 ± 0.6 2.0 - 4.1 Guerin et al., 1992

Restaurants, 99 4.2 ± 2.7 1.5 - 42.3 Guerin et al., 1992

99 outdoor controls 2.5 ± 2.1 0.3 - 13.7 Guerin et al., 1992

Nitrogen Oxides, ppb

10 Office Buildings, NO

24 ± 7 11 - 32 Guerin et al., 1992

outdoor controls, NO

27 ± 11 Guerin et al., 1992

5 Office Buildings, NO

16 ± 5 7 - 20 Guerin et al., 1992

outdoor controls 14 ± 6 Guerin et al., 1992

44 workrooms

, 227 determ., NO 82 Weber and Fischer, 1986

44 workrooms

, 227 determ., NO

64 Weber and Fischer, 1986

44 workrooms

, 102 determ., NO 66 Weber and Fischer, 1986

44 workrooms

, 102 determ., NO

49 Weber and Fischer, 1986

Aliphatic Hydrocarbons µg/m

Ethane 56 - 100 Löfroth et al., 1989

outdoor air, control 8 - 9

Propane 30 - 70 Löfroth et al., 1989

outdoor air, control 6 - 7

1,3-Butadiene

11 - 19 Löfroth et al., 1989

outdoor air, control < 1 - 1

(Bar at 3 different days) 3.5 27 - 4.5 Brunnemann et al., 1990

Isoprene

, 6 taverns 85 - 150 Löfroth et al., 1989

outdoor air, control < 1 - 1

4 restaurants 42.6 16.6 - 90 Higgins et al., 1991

1 bar, 3 samplings 97 60 - 106 Brunnemann et al., 1990

Aromatic Hydrocarbons, µg/m

Benzene

, 6 coffee houses 100 50 - 150 Badré et al., 1978

3 train spaces 68 20 - 100 Badré et al., 1978

cars, ventilation 30 20 - 40 Badré et al., 1978

cars, no ventilation 150 Badré et al., 1978

trains Löfroth et al., 1989

outdoor air, control 6 -

bar, 3 samplings 31 31 - 36 Brunnemann et al., 1990

Smoking and Tobacco Control Monograph No. 9

Table 11

(continued)

Concentration

Compound Mean Range Reference

Toluene, coffee house 448 40 - 1,040 Badré et al., 1978

4 train compartments 1128 180 - 1,870 Badré et al., 1978

car, ventilation 500 Badré et al., 1978

car, no ventilation 30 50 - 70 Badré et al., 1978

bar, 3 days 55 41 - 80 Brunnemann et al., 1990

Formaldehyde

, (tavern) µg/m

89 - 109 Löfroth et al., 1989

Acetaldehyde

(tavern) µg/m

183 - 204 Löfroth et al., 1989

coffees 460 170 - 630 Badré et al, 1978

trains 546 65 - 1,040 Badré et al, 1978

automobile - ventilation 370 260 - 480 Badré et al, 1978

automobile - no ventilation 1080 Badré et al, 1978

Acetonitrile bowling alley, µg/m

75.9 Higgins et al., 1991

residence, smoke 17.3 Higgins et al., 1991

residence, no smoke 3.4 Higgins et al., 1991

4 restaurants 17.5 2.4 - 48.9 Higgins et al., 1991

Acrylonitrile

bowling alley, µg/m

1.8 Higgins et al., 1991

residence, smoker 0.8 Higgins et al., 1991

residence, nonsmoker 0.6 Higgins et al., 1991

4 restaurants 0.6 0.1 - 1.9 Higgins et al., 1991

Pyridine bowling alley, µg/m

38 Higgins et al., 1991

residence, smoker 6.5 Higgins et al., 1991

residence, nonsmoker 0.6 Higgins et al., 1991

4 restaurants 5.0 0.8 - 15.7 Higgins et al., 1991

3-Vinylpyridine bowling alley, µg/m

3.6 Higgins et al., 1991

residence, smoker 6.4

residence, nonsmoker 3.2 ND

4 restaurants 3.2 0.2 - 6.4

415 nonsmokers, smoker’s home Jenkins et al., 1996

16 h breathing some samples 14.0 Jenkins et al., 1996

520 nonsmokers, workplace

8 h breathing some samples 5.52

Volatile N-Nitrosamines µg/m

-Nitrosodimethylamine

train, beverage car 0.11 - 0.13 Brunnemann and

Hoffmann, 1978

bar 0.24 Brunnemann and

Hoffmann, 1978

discotheque 0.09 Brunnemann and

Hoffmann, 1978

The concentrations of individual components in ETS reported before 1985-1988 are, in general, significantly higher

than those reported today. This is a consequence of measures to limit indoor smoking or to ban smoking entirely,

as in the case of US airlines.

a,b,c

These compounds are all carcinogenic to animals. According to the International Agency for Research

on Cancer (1987), compounds are:

carcinogenic to humans;

probably carcinogenic to humans; and

possibly carcinogenic to humans.

Chapter 3

Table 12

Concentrations of ETS-compounds in indoor air - particulate phase*

Concentration

Compound Mean Range Reference

Nicotine**, µg/m

(residences, 47 houses) 2.2 0.1 - 9.4 Lederer & Hammond, 1991

(residences, 3 houses) 11.1 7.6 - 14.6 Muramatsu et al

, 1984

(offices, 44) 1.1 0.0 - 16.0 Weber & Fischer, 1986

(offices, 10) 2.3 0.3 - 6.7 Thompson et al

, 1989

(restaurants, 6 coffees) 25 - 52 Badré et al

, 1978

(restaurants, 5 coffees) 14.8 7.1 - 27.8 Muramatsu et al., 1984

(cafeterias, 3) 26.4 11.6 - 42.2 Muramatsu et al., 1984

2.3 - 4.4 Thompson et al

, 1989

(bars, 2) 8.4 4.7 - 13.0 Kirk et al

, 1968

(bars, 5) 7.4 2.0 - 13.1 Miesner et al

, 1989

(pubs, 3) 31 Muramatsu et al

, 1987

Automobile (natural ventilation) 65 Badre et al

, 1978

(ventilation) 1,010 Badre et al

, 1978

Trains (8) 16.4 8.6 - 26.1 Muramatsu et al

, 1984

Airplanes, (48 smoking seats) Oldaker & Conrad, 1987

(20 nonsmoking seats) 5.5 ≤0.08 - 40.2 Oldaker & Conrad, 1987

Aromatic Amines, µg/m

2-Naphthylamine

(offices) 0.27 - 0.34

4-Aminobiphenyl

0.1

Carcinogenic PAH, µg/m

Benzo(

)fluoranthene

(rooms) 0.132 - 0.578 Gundel et al

, 1990

(outdoor air) 0.007 - 0.098 Gundel et al

, 1990

Benzo(

)pyrene

(common smoking conditions) 0.2 - 10 Guerin et al

, 1988

(heavy smoking conditions) 10 - 20 Guerin et al

, 1988

Benzo(

)pyrene (room air) 3.25 Adlkofer et al

, 1989

Tobacco-Specific

-Nitrosamines, µg/m

-Nitrosonornicotine

(3 bars) 11.8 4.3 - 22.8 Brunnemann et al

, 1992

(2 restaurants) nd. - 1.8 Brunnemann et al

, 1992

(2 train comparts.) n.d. Brunnemann et al

, 1992

(smoker’s home) n.d. Brunnemann et al

, 1992

4-(Methylnitrosamino)-1-(3-pyridyl)-1-butanone

(3 bars) 14.9 9.6 - 23.8 Brunnemann et al

, 1992

(2 restaurants) 1.4, 3.3 Brunnemann et al

, 1992

(2 train comparts.) 4.9 - 5.2 Brunnemann et al

, 1992

(smoker’s home) 1.9 Brunnemann et al

, 1992

*See footnote of Table 9.

**Although in ETS, generally, 90-95% of the nicotine is in the vapor phase for didactic reasons, nicotine in ETS is listed

under “Particulate Phase”.

n = not detected.

a,b,c

The compounds are all carcinogenic to animals. According to the International Agency for Research on Cancer (1987),

compounds are:

carcinogenic to humans;

probably carcinogenic to humans; and

possibly carcinogenic to humans.

Smoking and Tobacco Control Monograph No. 9

2 percent; in secondary cigar smokers, the values are usually higher, up to 11

percent (Castleden and Cole, 1973).

Ciliatoxic Development of squamous epithelium metaplasia is likely to be

Agents accentuated by the presence of ciliatoxic compounds that cause mucus

stagnation. This knowledge motivated several investigators to identify the

ciliatoxic agents in tobacco smoke in in vitro and in vivo assays (Kensler and

Battista, 1963; Wynder et al., 1963; Bernfeld et al., 1964; Dalhamn and

Rylander, 1966). Battista (1976) tabulated the existing knowledge about

the chemical nature of ciliatoxic agents in tobacco smoke (Table 13).

Although the concentrations of ciliatoxic agents per volume of cigar smoke

are somewhat higher than those in cigarette smoke, the lungs of primary

cigar smokers will only be exposed to a fraction of these toxic agents because

these smokers tend to inhale far less of the smoke than cigarette smokers do.

However, secondary cigar smokers who are inhaling this smoke into their

lungs will have significant exposure to ciliatoxins.

Genotoxicity During the past two decades, in vitro and in vivo short-term assays have

been employed to establish the genotoxicity of xenobiotic agents in order

to gain an indication of their carcinogenic potential. Genotoxic agents have

the ability to form DNA adducts and DNA-oxidation products in cellular

nuclei, or otherwise change the configuration of DNA. So far, only one

short-term test for the genotoxicity of cigar “tar” has been reported. Sato et

al. (1977) tested five cigar “tars” for their mutagenic activities on the

Salmonella typhimurium tester strains TA98 and TA100 and compared these

activities with those of eight cigarette “tars.” The genotoxic agents in these

“tars” were metabolically activated with an S9 liver fraction of untreated rats.

The number of revertants induced by 1 mg of cigar “tar” in TA100 was 922 ±

63; those in TA98 were 2,320 ± 305. One mg of cigarette “tar” caused, on

average 735 ± 101 revertants in TA 100 and 1,460 ± 317 revertants in TA98.

The mutagenicity of cigar “tars” was significantly higher (in TA100, p = 0.01;

in TA98, p = 0.004) when compared to cigarette “tars.”

Carcinogenicity The first report on the carcinogenicity of the “tar” from cigars was

and Carcinogenic conducted with denicotinized “tar” by Croninger et al., 1958

Agents (Table 14). Subsequently, three additional bioassays with cigar

“tar” were reported in the literature (Table 14). Several of these studies,

especially the study by Davies and Day (1969) reported a significantly higher

tumorigenic activity with cigar “tar” in mouse skin than with cigarette “tar,”

as reflected in the induction of both papilloma and carcinoma in the skin.

This result was expected since cigar “tar” contains higher concentrations of

carcinogenic PAH.

Table 15 lists those agents in cigarette and cigar smoke that, according

to the International Agency for Research on Cancer (1987, 1990, 1991,

1993a, 1993b, 1994, 1996), are animal carcinogens; ten of these are also

carcinogenic in humans. Because data for cigar smoke are lacking, the yields

of carcinogens in the smoke of cigarettes made exclusively from bright and

blended tobacco are compared with those in the smoke of cigarettes made

exclusively from burley tobacco (Table 16). Because cigars are primarily

Chapter 3

Table 13

Vapor phase constituents with high ciliatoxic potency -

in vitro

Amount in Smoke (µg/puff)

Compound Potency Typical (Range)

Hydrogen Cyanide +++ 38 (16-63)

Formaldehyde +++ 5 (2.5-11)

Acrolein +++ 10 (5.6-10.4)

Sulfur Dioxide +++ <1

Crotonaldehyde ++ 1.6

2,3-Butanedione ++ 12

Ammonia ++ 1

Nitrogen Dioxide ++ <10

Methacrolein + 1

Vinyl Acetate + 0.5

Nitric Oxide + 60 (12-75)

(8 puffs)

Score (µg/puff)

+++ High = ≤50

++ Moderate = 50-100

+ Low = 100-500

Vapor phase constituents with low ciliatoxic potency - in vitro

Aliphatic Hydorcarbons Ethers

Cyclopentane Furan

Cyclopentene 2-Methylfuran

Cis

-1,3-Pentadiene 2,5-Dimethylfuran

Trans

-1,3-Pentadiene

2-Methyl-1,3-Butadiene

Esters

Limonene Methyl Formate

Methyl Acetate

Aromatic Hydrocarbons

Ethyl Acetate

Benzene

Toluene

Nitriles

Acetonitrile

Aldehydes

Propionitrile

Acetaldehyde Acrylonitrile

Propionaldehyde Isobutyronitrile

Butyraldehyde Methacrylonitrile

Valeraldehyde

Isovaleraldehyde

Sulfur Compounds

Pivaldehyde Hydrogen Sulfide

2-Methylvaleraldehyde

Other Nitrogenous Compounds

Nitrous Oxide

Ketones

Acetone Miscellaneous

2-Butanone Carbon Dioxide

2-Pentanone Carbon Monoxide

3-Pentanone Phenol Vapor

+≥ 500 µg/puff needed to achieve activity comparable to cigarette smoke. None of the above are present in cigarette smoke

at levels ≥ 20 % of the amount needed for biological activity.

Source: Battista, 1976

Smoking and Tobacco Control Monograph No. 9

Table 14

Comparison of the induction of papilloma and carcinoma in the skin of mice with “tars” from cigars and cigarettes

“Tar”

dose per Applications Cigar “Tar” “Tar” from Control Cigarettes

Mouse % “Tar” application, each # % % # % %

Strain Sex Suspension mg week mice papilloma cancer mice papilloma cancer Reference

Swiss F 33 25 3 100 33 18 Croninger et al

, 1958

CAF

F 33 25 3 100 50 10 Croninger et al

, 1958

Swiss F 50 - NF 40 3 100 65* 41 100 47 37 Croninger et al

, 1958

Swiss M,F 50 3 42 40 40 24 Kensler, 1962

Swiss M,F 50 3 42 40 34 34 Kensler, 1962

CAF

M 50 21 3 87 27.5 15 86 27 15 Homburger et al

, 1963

CAF

F 50 21 3 82 37.5* 19 96 15 23 Homburger et al

, 1963

ICI - Albino F 25 75 2 144 44.4** 27.1** 144 27.8 13.2 Davies & Day, 1969

ICI - Albino F 12.5 37.5 2 144 20.8* 11.1** 144 7.6 0.7 Davies & Day, 1969

ICI - Albino F 6.25 18.7 2 144 6.3 2.1 Davies & Day, 1969

Abbreviations: NF, nicotine free “tar.”

Cigar “tar” induces significantly more papilloma or carcinoma than the cigarette control “tar.”

*p ≤ 0.05; ** p ≤0.01.

Chapter 3

Table 15

Carcinogens in tobacco and tobacco smoke

IARC evaluation

evidence of

carcinogenicity

Compound In processed In mainstream In In humans

tobacco

smoke

laboratory

(per gram) (per cigarette) animals

PAHs

Benz(a)anthracene 20-70 ng Sufficient

Benzo(b)fluoranthene 4-22 ng Sufficient

Benzo(j)fluoranthene 6-21 ng Sufficient

Benzo(k)fluoranthene 6-12 ng Sufficient

Benzo(a)pyrene 0.1-90 ng 20-40 ng Sufficient Probable

Dibenz(a,h)anthracene 4 ng Sufficient

Dibenzo(a,I)pyrene 1.7-3.2 ng Sufficient

Dibenzo(a,l)pyrene present Sufficient

Indeno(1,2,3-cd)pyrene 4-20 ng Sufficient

5-Methylchrysene 0.6 ng Sufficient

Aza-arenes

Quinoline 1-2 µg Sufficient

Dibenz(a,h)acridine 0.1 ng Sufficient

Dibenz(a,j)acridine 3-10 ng Sufficient

7-H-Dibenzo(c,g)-carbazole 0.7 ng Sufficient

N-Nitrosamines

N-Nitrosodimethylamine ND-215 ng 0.1-180 ng Sufficient

N-Nitrosoethylmethylamine 3-13 ng Sufficient

N-Nitrosodiethylamine ND-2.8 ng Sufficient

N-Nitrosopyrrolidine 5-50 ng 3-60 ng Sufficient

N-Nitrosodiethanolamine 50-3000 ng ND-68 ng Sufficient

N-Nitrososarcosine 20-120 ng Sufficient

N-Nitrosonornicotine 0.3-89 µg 0.12-3.7 µg Sufficient

4-(Methylnitrosamino)-3- 0.2-7 µg 0.08-0.77 µg Sufficient

(pyridyl)-1-butanone

N’-Nitrosoanabasine 0.01-1.9 µg 0.14-4.6 µg Limited

N-Nitrosomorpholine ND-690 ng Sufficient

Aromatic amines

2-Toluidine 30-200 ng Sufficient Inadequate

2-Napththylamine 1-22 ng Sufficient Sufficient

4-Aminobiphenyl 2-5 ng Sufficient Sufficient

N-Heterocyclic amines

AaC 25-260 ng Sufficient

MeAaC 2-37 ng Sufficient

IQ 0.26 ng Sufficient Probable

Trp-P-1 0.29-0.48 ng Sufficient

Trp-P-2 0.82-1.1 ng Sufficient

Glu-P-1 0.37-0.89 ng Sufficient

Glu-P-2 0.25-0.88 ng Sufficient

PhlP 11-23 ng Sufficient Possible

Aldehydes

Smoking and Tobacco Control Monograph No. 9

Table 15

(continued)

IARC evaluation

evidence of

carcinogenicity

Compound In processed In mainstream In In humans

tobacco

smoke

laboratory

(per gram) (per cigarette) animals

Formaldehyde 1.64-7.4 µg 70-100 µg

Sufficient Limited

Acetaldehyde 1.4-7.4 µg 18-1400 µg

Sufficient Inadequate

Miscellaneous organic compounds

1,3-Butadiene 20-75 µg Sufficient Probable

Isoprene 450-1000 µg Sufficient Possible

Benzene 12-70 µg Sufficient Sufficient

Styrene 10 µg Limited Possible

Vinyl chloride 1-16 µg Sufficient Sufficient

DDT

20-13,400 ng 800-1200 ng Sufficient Possible

DDE

7-960 ng 200-370 ng Sufficient

Acrylonitrile 3.2-15 µg Sufficient Limited

Acrylamide Present Sufficient Probable

1,1-Dimethylhydrazine 60-147 µg Sufficient

2-Nitropropane 0.73-1.21 µg Sufficient

Nitrobenzene 25.3 ng Sufficient Possible

Ethyl carbamate 310-375 ng 20-38 ng Sufficient

Ethylene oxide 7 µg Sufficient Sufficient

Di(2-ethylhexyl)phthalate Present 20 µg Sufficient

Furan 18-30 µg Sufficient Inadequate

Benzo(b)furan Present Sufficient Inadequate

Inorganic compounds

Hydrazine 14-51 ng 24-43 ng Sufficient Inadequate

Arsenic 500-900 ng 40-120 ng Inadequate Sufficient

Beryllium 15-75 mg 0.5 mg Sufficient Sufficient

Cobalt 90-1,400 mg 0.13-0.2 mg Sufficient Inadequate

Nickel 2000-6000 ng 0-600 ng Sufficient Limited

Chromium 1000-2000 ng 4-70 ng Sufficient Sufficient

Cadmium 1300-1600 ng 41-62 ng Sufficient Sufficient

Lead 8-10 µg 35-85 ng Sufficient Inadequate

Polonium-210 0.2-1.2 pCi 0.03-1.0 pCi Sufficient Sufficient

No designation indicates that IARC has not evaluated the compound.

ND, not detected.

PAH, polynuclear aromatic hydrocarbons: AaC, 2-amino-9H-pyrido[2,3-b]indole; MeAaC, 2-amino-3-methyl-9H-pyrido[2,3-

b]indole; IQ, 2-amino-3-methylimidazo[4,5-b]quinoline; Trp-P-1, 3-amino-1,4-dimethyl-5H-pyrido[4,3-b]indole; Trp-2, 3-

amino-1-methyl-5H-pyrido[4,3-b]indole; Glu-P-1, 2-amino-6-methyl[1,2-a:3’,2”-d]imidazole; Glu-P-2, 2-aminodipyrido[1,2-

a:3’,2’-d]imidazole; PhlP, 2-amino-1-methyl-6-phenylimidazo[4,5-b]pyridine.

The 4

report of the Independent Scientific Committee on Smoking and Health (1988) published values for the 14 leading

British cigarettes in 1986 (51.4% of the market) of 20-1050 µg/cigarette (mean 910 µg) for acetaldehyde.

During the last decade, DDT and DDE levels have been drastically reduced in U.S. cigarette tobacco ((60 ng and (13 ng).

Source: Hoffmann and Hoffmann, 1997

Chapter 3

Table 16

Known carcinogens (ng/cigarette) in the smoke of bright or blond and burley and black tobacco

Carcinogens Bright or blended tobacco Burley or black tobacco

I. Volatile nitrosamines

NDMA NF 6.8-13.8 29

F 1.8-5.7 4.3

NEMA NF (0.1-1.8 2.7

F 0.4-1.0 0.5

NPYR NF 11.0-30.3 25

F 3.1-8.7 10.5

NDMA NF 9.4-48.4 38.8-76.4

NEMA NF (0.1-7.1 2.1-6.3

NPYR NF 6.9-41.2 22.7-36.1

II. NDELA NF (Exp. Cigarettes) 30-51 290

III. TSNA

NNN NF (Exp. Cigarettes) 620 3700

NNK NF (Exp. Cigarettes) 420 320

NAT

NF (Exp. Cigarettes) 410 4600

NNN NF 85-255 512-625

NNK NF 70-156 108-432

NAT

NF 81-225 266-353

NNN NF 29 203

NNK NF 40-136

NAT

NF 45 108

NNN NF 79-885 550-800

NNK NF 62-185 84-470

NAT

NF 75-380 225-520

NNN F 213 117-389

NNK F 32 13-55

NAT

F 92 74-196

IV. Aromatic amines

2-Toluidine NF 32.2 162

F 41.0 66.8

2-Naphthylamine NF 1.0 1.7

F 2.1 1.8

4-Aminobiphenyl NF 2.4 4.6

F 0.3-0.2 23

V. 2-Nitropropane NF 220-1190 1430-2180

Smoking and Tobacco Control Monograph No. 9

Table 16

(continued)

Carcinogens Bright or blended tobacco Burley or black tobacco

VI. PAH

BaA NF (Exp. Cigarettes) 21.0-25.9 10.7-16.7

BaP NF (Exp. Cigarettes) 38-53 24

NF (Exp. Cigarettes) 7.5-9.6 25

NF (Exp. Cigarettes) 35.4 19.7

VII. Volatile Aldehydes

Formaldehyde NF (Exp. Cigarettes) 26,800-36,300 16,100-25,100

Acetaldehyde NF (Exp. Cigarettes) 797,000-906,000 726,000-966,000

IX. Benzene 27,000 12,000

X. Quinoline F 620 1200

Note.

Abbreviations: NDMA, nitrosodimethylamine; NEMA, nitrosoethylamine; NPYR, nitrosopyrrolidine; NDELA,

nitrosodiethanolamine; TSNA, tobacco-specific

-nitrosamines; NNN,

N’

-nitrosonornicotine; NNK, 4-

(methylnitrosamino)-1-(3-pyridyl)-1-butanone; NAT,

N’

-nitrosoanatabine; BaA, benz[a]anthracene; BaP,

benzo[a]pyrene; NF, nonfilter; F, filter. The pH of the smoke of blond type cigarettes varies between 6.15 (1

puff) and

5.7 (last puff); the pH of the French black cigarette with filter tip measures from 6.8 to 7.4 and without filter tip from 6.6

to 6.95 cm. With pH above 6, the toxicity of the smoke increases.

Black cigarettes = French type black cigarettes made exclusively from Burley tobacco; Blond cigarettes = Virginia type

cigarettes and U.S. Blended cigarettes.

NAT contains some N’-nitrosoanabasine (NAB).

Hoffmann and Hoffmann, 1997

made with burley tobacco, this table also indicates those carcinogens that

would be expected to be more prevalent in cigar smoke than in cigarette

smoke (Hoffmann and Hoffmann, 1997).

BIOMARKERS FOR Estimates of the smoker’s exposure to toxic and carcinogenic

THE UPTAKE OF smoke constituents are based on the measurements of certain

TOBACCO SMOKE biomarkers. In general, these are determined in saliva, blood,

urine, and/or exhaled air.

Upon inhaling alkaline cigar smoke, nicotine is absobed

Nicotine through the mucous membranes in the

oral cavity as well as across the alveolar surface of the lung. The nicotine

concentration in the blood of a cigar smoker rises gradually (Russell et al.,

1980). In blood with a pH of 7.4, about 31 percent of the nicotine is present

in unprotonated form. Nicotine transfers from the bloodstream across cell

membranes, including those of the central nervous system. In the case

of those secondary cigar smokers and of cigarette smokers who inhale

tobacco smoke, the aerosol reaches the small airways and alveoli of the

lung from which nicotine is quickly absorbed. Within minutes, the blood

concentration of nicotine rises to a maximum (U.S. Department of Health

Chapter 3

and Human Services, 1988). Using nicotine-

C and measuring the

radioisotope in exhaled air, Armitage et al., (1975) found that cigarette

smokers absorb 82 - 92 percent of the inhaled nicotine; those who do not

inhale the smoke absorbed about 29 percent of inhaled nicotine.

After smoking one piece of the respective product, the nicotine level in

the plasma of cigarette smokers rose from 25 to between 35 and 40 ng/ml;

that of secondary cigar smokers rose from 12.8 to 45.6 ng; and that of

primary cigar smokers changed from 3.4 to 5.2 ng/ml as average

measurements in five smokers per group (Turner et al., 1977). These data

show clearly that the primary cigar smokers takes up far less nicotine because

he does not inhale the smoke deep into the lungs as in the case with cigarette

smokers and secondary cigar smokers.

Carbon Monoxide The determination of carboxyhemoglobin (COHb) is regarded as

the most reliable assay for the uptake of carbon monoxide by smokers. In

nonsmokers who have no significant exposure to CO in their occupational

or home environment, the COHb level is below 1.7 percent; even levels as

low as 0.2 percent COHb have been reported in nonsmokers. Turner et al.

(1977) reported the mean concentration of COHb in 1,933 cigarette smokers

to be 4.78 percent, with 94.7 percent of the measurements indicating COHb

to be ( 1.7 percent. The mean COHb concentration for 39 primary cigar

smokers was 1.36 percent and none showed COHb levels above 1.7 percent.

One hundred and fifty-four secondary cigar smokers had a mean COHb

concentration of 6.8 percent; 97.4 percent of these had concentrations above

1.7 percent. These data were confirmed by several additional reports, all of

which clearly show that the primary cigar smoker tends to inhale not at all or

only very shallowly, while the secondary cigar smoker inhales the smoke at

least as deeply as the cigarette smoker does.

The determination of CO in exhaled breath is not as reproducible as the

COHb determination that measures uptake of CO. However, the method can

be readily executed in an office or at any site by just asking the subject to

exhale into a CO meter. Ockene et al. (1987) conducted a large-scale study

and measured 1.8 - 2.1 CO in the exhaled breath of primary cigar smokers

and 3.3 - 11.0 in the breath of secondary cigar smokers. Similar findings

were reported by others (Cowie et al., 1973; Goldman, 1976, Wald et al.,

1981).

Hydrogen Cyanide The smoke of 1 g tobacco from a cigar contains 1,000 µg of

hydrogen cyanide (HCN), and that from a little cigar contains up to 780 µg.

The smoke of 1 g cigarette tobacco contains up to 600 µg of HCN (Table 6).

The release of HCN into the sidestream smoke per gram of tobacco burned in

a little cigar amounts to 114 µg and that in cigarettes reaches 134 - 167 µg

(Table 9). Although HCN is liberated from certain food items (cyanogens;

e.g. cabbage, broccoli, conifers, vegetables, and certain nuts), the quantities

produced in this manner are significantly lower than the amounts of HCN

inhaled as a tobacco smoke constituent (Galanti, 1997). Therefore, they

usually do not interfere with the assay of thiocyanate, the most important

metabolite of HCN, in physiological fluids of smokers. Thiocyanate

Smoking and Tobacco Control Monograph No. 9

concentration is determined by a colorimetric method in an autoanalyzer

(Butts et al., 1974). In one study, the mean concentration of thiocyanate in

the saliva of 30 nonsmokers on a cyanogen-containing diet was 101 ± 51 µg/

ml; in 15 nonsmokers on a diet free of cyanogens, thiocyanate levels were 92

± 90µg/ml, and in the saliva of 20 smokers it was 413 ± 172 µg/ml (p < 0.01

vs. both nonsmokers’ groups) (Galanti, 1977).

Pechacek et al. (1985) reported serum thiocyanate levels in never

smokers at 2.52 ± 1.60 µg/ml, in primary cigar and pipe smokers at 4.22 ±

2.56 µg/ml, in secondary cigar and pipe smokers at 5.63 ± 3.55 µg/ml, and

in cigarette smokers at 8.34 ± 3.03 µg/ml.

Benzene Benzene, a leukomogenic agent, is a ubiquitous contaminant of the

respiratory environment. The American Conference of Governmental

Industrial Hygienists has set the upper permissible limit of a time-weighted

concentration of benzene for an 8-hour work day and a 40-hour work week

(TWA) at 10 ppm (32 µg/L) (American Conference of Governmental

Industrial Hygienists, 1996). Benzene in the smoke of 1 g tobacco burned

as a cigar, amounts to between 90 and 250 µg per gram tobacco (est. 80-

200 µg/L); from 1 g tobacco smoked as a cigarette, one obtains between

8 and 60 µg benzene (est. 25-180 µg/L).

Polynuclear Tobacco smoke contains at least ten carcinogenic PAH (Hoffmann

Aromatic and Hoffmann, 1997). Benzo(a)pyrene (BaP) concentration in

Hydrocarbons environmental samples and food items serves as a surrogate measure

(PAH) of PAH-related carcinogenic potential. Per gram tobacco BaP yields

in the mainstream smoke (MS) of cigars range from 30 to 51 ng; in MS of

little cigars, 26 ng; and in MS of a cigarette without a filter tip, 26 - 59 ng

(Table 7). Up to 90 percent of the PAH in cigarette smoke is retained upon

inhalation in the respiratory tract of a long-term smoker; however, only a

small percentage of the PAH is absorbed from food as found in the digestive

tract (Bresnick et al., 1983; Grimmer, 1983; Rahman et al., 1986).

Carcinogenic PAH are primarily contact carcinogens. They are

metabolically activated by P450 isozymes to their ultimate carcinogenic

forms, the dihydrodihydroxy epoxides (Dipple et al., 1984). They form

intracellular adducts with macromolecules, including DNA (Dipple et al.,

1984). The prevailing DNA adduct formed through BaP metabolism is

(+)trans-anti-7,8-dihydro-9-hydroxy-10-N

-guanosine (Geacintov et al.,

1997).

Among biomakers of uptake and metabolic activation of smoke

constituents in cigarette smokers, hemoglobin adducts of 4-aminobiphenyl,

BaP, and other PAH have been measured, and urinary metabolites and/or

detoxification products of NNK and/or benzene have been quantified. As an

indicator of endogenous N-nitrosation, leading to N-nitrosamine formation,

N-nitrosoproline has been determined in the urine of cigarette smokers.

Similar biomarker studies for cigar smokers are lacking.

Chapter 3

SUMMARY AND Today, several types of cigars are marketed in the United States:

RESEARCH NEEDS little cigars, (each weighing less than 1.36 g), regular cigars, small

cigars, cigarillos, and premium cigars.

Primary cigar smokers tend not to inhale the cigar smoke, whereas

primary cigarette smokers do tend to inhale the cigarette smoke. The

principal reason for this difference is the pH of cigar smoke which is initially

6.2 for early puffs and rises to 8.0 for later puffs. At alkaline pH conditions,

part of the nicotine is present in unprotonated form in the vapor phase.

Unprotonated, volatile nicotine is absorbed through the mucous membrane

of the oral cavity and is quickly transported via the bloodstream to the

various sites, including the central nervous system, where it exerts the

pharmacological effects that seem to “satisfy” the smoker. The elevated pH

of the smoke of cigars is caused by the relatively high nitrate content of the

air-cured and fermented cigar tobacco (1.4 - 2.1 percent) compared to the

nitrate content of the U.S. blended cigarette tobacco (0.5 - 1.7 percent).

In the burning cigar, part of the nitrate is reduced to ammonia and

part of it yields NO

. Nitrogen dioxide in the smoke contributes to the

N-nitrosation of secondary and tertiary amines. The most abundant amines

in tobacco smoke, nicotine and the minor Nicotiana alkaloids, are thereby

nitrosated and become TSNA. Some TSNA are formed by pyrosynthesis and

some TSNA transfer from the tobacco into the smoke. TSNA are present in

significantly higher amounts in cigar smoke than in cigarette smoke.

Tobacco smoke contains more than 4,000 individual compounds with

about 500 of these in the gas phase. One gram of tobacco burned in a cigar

delivers between 39 and 65 mg carbon monoxide and 160 - 300 µg nitrogen

oxides compared to maxima of 19 mg carbon monoxide and up to 160 µg of

nitrogen oxides for the same amount of tobacco burned in a cigarette. These

high concentrations of CO and NO

in cigar smoke are due to the very low

porosity of the cigar binder and wrapper which contrasts with the high

porosity of cigarette paper.

Many toxic agents and 62 known carcinogens have been identified

among the 4000 compounds in cigarette smoke. Fewer of these have been

identified in cigar smoke. However, it is highly likely that most of the toxic

and carcinogenic constituents found in cigarette smoke are also present

in cigar smoke, albeit at different concentrations. Disregarding studies on

the effects of additives to cigar tobacco, there is only a limited need to

specifically identify toxic and carcinogenic compounds in cigar smoke.

There exists a need to investigate two particular areas with regard to

health effects of cigar smoking. One is the study of the smoking patterns

of primary and secondary cigar smokers and of the uptake of toxic and

carcinogenic smoke constituents by both types of cigar smokers, as well as

the study of metabolism of critical constituents by the cigar smoker. It is

especially important to verify the possibility of endogenous formation of

carcinogenic N-nitrosamines in cigar smokers. Except for a few isolated

investigations on nicotine uptake by cigar smokers, these aspects remain

unexplored.

Smoking and Tobacco Control Monograph No. 9

The second area of needed investigation relates to the reduction of toxic

and carcinogenic agents in cigar smoke, including nicotine. Can the porosity

of the cigar wrapper be changed? Is it possible, by addressing this aspect and

others, to reduce the high yields of carbon monoxide and “tar” in cigar

smoke? Are there ways to reduce the high nitrate content of cigar tobacco?

In view of the increasing consumption of cigars in the United States, our

knowledge regarding the uptake and metabolic fate of the toxic and

carcinogenic agents in cigar smoke, and means for their reduction in

the smoke should be intensified. Such efforts need to parallel public health

measures toward informing the consumers about the ill effects of cigar

smoke on human health.

CONCLUSIONS

1. Cigar smoke contains the same toxic and carcinogenic compounds

identified in cigarette smoke.

2. When examined in animal studies, cigar smoke tar appears to be at least

as carcinogenic as cigarette smoke tar.

3. The differences in risk between cigarette smoking and cigar smoking

appear to be related to the differences in patterns of use of those two

tobacco products, principally non-daily use and less inhalation among

cigar smokers, rather than a difference in the composition of the smoke.

4. The amount of nicotine available as free, unprotonated nicotine is

generally higher in cigars than in cigarettes due to the higher pH of cigar

smoke. This free nicotine is readily absorbed across the oral mucosa, and

may explain why cigar smokers are less likely to inhale than cigarette

smokers.

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Disease Consequences of Cigar Smoking

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the Smoking and Health (DHHS 1973; DHHS 1979). Studies published during

the last two decades are emphasized, and original analyses of the cigar

smoking data subset from the CPS-I study are presented. The tables

summarizing research on specific diseases include studies discussed in the

previous publications. However, only the studies published since 1976 will

be reviewed in this chapter.

Cigar smoking has largely been a male behavior in the US, and so most

studies have exclusively utilized male populations. These data should be

applied with caution to the increasing numbers of women who are smoking

cigars.

Many epidemiological studies combine cigar and pipe smokers together,

or combine primary cigar smokers [those without prior history of cigarette

smoking] with secondary cigar smokers [those with varying histories of

prior cigarette or pipe smoking] and mixed smokers [those who currently

smoke cigars and cigarettes or pipes]. These combinations are often made

necessary by the small number of cigar smokers present in these studies, but

they make the resulting rate comparisons problematic in describing the effect

of cigar use. Further, many of the cigar studies have been done in European

countries, which have different traditions of cigar smoking, including different

tobaccos, differing sizes of cigars, and different levels of inhalation.

DEFINITION The definition of a cigar is given in another section of this monograph

OF TERMS (Chapter 3). For this chapter the term means any of the products

which are purchased as cigars. Cheroots, which are classed with cigars in

some studies, are small cigars, made of heavy-bodied tobaccos. For a more

complete discussion of tobacco products, plant varieties and manufacture,

see the IARC Monograph “Tobacco Smoking” (IARC, 1986; Chapter 3).

A primary cigar smoker is a smoker who smokes only cigars and

who has never smoked cigarettes or a pipe; these subjects give us the purest

estimation of the effect of cigar smoking. A secondary cigar smoker

currently smokes only cigars, but previously smoked cigarettes and/or a pipe,

either in combination with cigars or exclusively. Because of earlier use of

other tobaccos, the health effects of cigar smoking derived from secondary

cigar smokers may be affected by the earlier pattern of smoking.

The level of exposure to cigar smoke is usually measured in cigars per

day, which is an imprecise measure because of the varying sizes of cigars.

Some studies use a measure of grams smoked per day, weighting varying sizes

of cigars differently. Others attempt to quantify lifetime cigar consumption,

Chapter 4

106

using years of cigar smoking or equivalent pack-years of cigarettes, or some

other cumulative measure. Level of exposure is also referred to as intensity

of smoking and dose. The comparison of cigarette and cigar exposures is

further complicated by the older age of initiation of cigar smoking in

comparison to cigarette smoking (Chapter 2) and the profound effect

of duration of exposure on disease risk.

Inhalation becomes a critical issue with cigar smoking, since degree

of inhalation varies widely among cigar smokers. Many studies provide a

self-reported measure of inhalation, such as: none, slightly, moderately,

deeply. Such measures are shown to have a degree of validity by the, positive

association with rates of some diseases, such as lung cancer. Further studies

by Herling and Kozlowski (1988) and Wald and Watt (1997) have shown that

self-reported inhalation predicts expired-air carbon monoxide and

carboxyhaemoglobin levels, which argues for the validity of self-reported

inhalation measures.

The expression log(x) means the natural log of x. Absolute rates are given

in numbers of cases or deaths per 100,000 person-years. The abbreviation OR

stands for odds ratio; RR, for risk ratio. Confidence intervals are given for the

95 percent range for the given statistic. When not otherwise indicated, the

rates given are for mortality due to disease in the specified classification.

THE CPS-I STUDY The Cancer Prevention Study I of the American Cancer Society,

conducted between 1959 and 1972, was one of the largest prospective cohort

studies ever undertaken, following more than one million individuals for

twelve years (Garfinkel, 1985). Many results from the CPS-I study have been

previously published, but for cigar-related mortality rates, only summary

rates from the first four years of the follow-up period have been published

(Hammond, 1966). The ACS has made this data set available for a more

detailed analysis. Because of the size of the data set, the detail of smoking

behavior information gathered, and the relatively large number of cigar

smokers among the subjects, this study provides an opportunity to consider

the relationship of number of cigars per day and inhalation to mortality rates

from many diseases. Data from CPS-I was used because of the larger number

of cigar smokers in the study in comparison with the CPS-II.

The data gathered on each subject in the CPS-I study includes a smoking

history, with age of initiation to cigarette smoking, number of cigarettes/

cigars/pipes smoked per day, and level of inhalation, though no information

was gathered about age of initiation of smoking cigars or pipes. Since US

mortality rates for blacks are different from those for whites and because

blacks are under-represented in the CPS-I study, the analyses of CPS-I data

which follow are restricted to white subjects. Further, there are few female

cigar smokers in the data set, so the analyses are restricted to white males.

The number of subjects in various smoking behavior groups in the CPS-I

data set are given in Table 1.

In presenting results from the CPS-I data set, tables are constructed

for Mortality Rate Ratios (MRR) for various diseases in order to provide

107

Smoking and Tobacco Control Monograph No. 9

Table 1

Number of subjects in smoking groups in CPS-I Study, white male subjects

Smoking Group N

Neversmokers 92,307

Current Primary Cigar Smokers 15,191

Current Primary Pipe Smokers 9,623

Current Cigarette Only Smoker 174,997

Current Cigar, Pipe & Cigarette Smokers 3,471

Current Mixed Cigar & Pipe Smokers 6,767

Current Mixed Cigar & Cigarette Smokers 10,294

Current Mixed Pipe & Cigarette Smokers 11,470

Current Secondary Cigar Smokers 7,404

Current Secondary Pipe Smokers 7,033

Former Primary Cigar Smokers 5,446

Former Primary Pipe Smokers 3,549

Former Cigarette Only Smokers 42,225

Former Mixed Cigar & Cigarette 4,649

Former Mixed Pipe & Cigarette 10,724

Former Mixed Cigar & Pipe 3,952

Former Cigar, Pipe & Cigarette Smokers 6,921

Total White Male Subjects 442,455

comparisons between smoking groups. All MRR’s compare a smoking group

to the neversmoker group and are age-standardized to the neversmoker

age distribution from the study. See the appendix on methods for details.

All rates given are rates of mortality, as specified by the primary cause of

death from the death certificate.

In the tables presenting CPS-I rate ratios, primary and secondary cigar

smokers are divided into levels of 1-2, 3-4, and 5 or more cigars per day.

Smokers of both cigars and cigarettes have tobacco exposure information

available for cigarettes only. Levels of inhalation for all smokers are

subjectively reported by the subjects, using the following scale: none, slightly,

moderately, deeply. The distribution of these responses for primary and

secondary cigar smokers and cigarette only smokers is given in Figure 1 and

reveals that cigarette smokers are much more likely to report deep inhalation

than primary cigar smokers, with secondary cigar smokers having an

intermediate pattern. These inhalation patterns show that primary and

secondary cigar smoker rates, when not stratified by levels of inhalation, are

dominated by individuals who inhale slightly or not at all; whereas,

unstratified cigarette-only smoker rates are dominated by those who inhale

moderately or deeply. Degree of inhalation is a continuum, with the

subjective evaluation providing only an approximate measure.

Chapter 4

108

Figure 1

Levels of inhalation from CPS-1 study

90%

80%

70%

60%

50%

40%

30%

20%

10%

Percent reporting

Primary Cigar Cigarette OnlySecondary Cigar

78.4%

14.1%

4.0%

0.5%

58.0%

23.8%

13.0%

2.2%

5.9%

13.1%

55.4%

24.8%

Level of Inhalation:

none

slightly

moderately

deeply

109

Smoking and Tobacco Control Monograph No. 9

Table 2

All cause mortality and cigar smoking: mortality ratios by type of smoking (males only, except as noted)

Rate Ratio (RR)

Never- Mixed, Cigar

Prospective Studies Sample Size* Smoker Cigar & Cigarette Cigarette

Hammond & Horn (1958) 187,783 1.0 1.22 1.36 1.68

Doll & Peto (1976) 41,000 1.0 1.09** 1.20 1.64

Best (1966) 78,000 1.0 1.06 1.22 1.54

Kahn (1966) 293,000 1.0 1.10 1.51 1.84

Hammond (1966) 440,559 1.0 1.25 1.57 1.86

Carstensen (1987) 25,129/1,256/131 1.0 1.39 (1.16-1.65) 1.45 (1.36-1.54)

Sandler (1989) 46,926/1,671/504 1.0 1.20** (1.07-1.35) 1.41 (1.29-1.55)

Lange (1992) male 6,511/808/326 1.0 1.6 (1.3-2.0) 1.9 (1.6-2.4) plain

1.8 (1.4-2.3) filter

Lange (1992) female 7,703/770/185 1.0 1.8 (1.4-2.2) 2.4 (2.0-2.9) plain

1.7 (1.4-2.1) filter

Ben-Shlomo (1994) secondary 19,018/658/132 1.0 1.20 (1.01-1.43) 2.00 (1.92-2.07)

Wald & Watt (1997) primary 21,520/1,309/113 1.0 1.23**(0.99-1.75) 2.26 (1.97-2.58)

Wald & Watt (1997) secondary 21,520/522/69 1.33**(1.03-1.73)

CPS-I primary 442,455/15,072/3,754 1.0 1.08 (1.05-1.12) 1.47 (1.41-1.53) 1.66 (1.64-1.68)

CPS-I secondary 442,455/7,349/1,462 1.12 (1.06-1.18)

* for prospective studies reviewed, the number of cigar smokers and number of deaths in this group are also given.

**cigar and pipe combined

Chapter 4

110

ALL CAUSE There is a consistent pattern of elevated overall mortality for all groups

MORTALITY of smokers, and a dose-response effect for increasing exposure to tobacco

smoke is present in the CPS-I data. The exposure is variously measured as

cigars/cigarettes/pipes per day, grams of tobacco per day, lifetime dose in

pack-years, duration of smoking, etc. and can be further modified by

describing the level of inhalation of smoke.

In a Swedish prospective mortality study which followed 25,129 men

from 1963 through 1979 (Carstensen, 1987), the All-Cause Mortality RR for

cigar-only smokers is 1.39 (1.16-1.65) compared to neversmokers, based on

131 deaths during the follow-up period. The corresponding RR for cigarette-

only smokers is 1.45 (1.36-1.54). The cigar only group is based on smoking

behavior at the time of the initial survey, and thus is a combination of

primary and secondary cigar smokers. The authors note that no information

is available on inhalation patterns of Swedish cigar smokers. Rates are

standardized by age and residence.

In a 12-year follow-up study of 46,926 individuals of both sexes in

Washington County, Maryland (Sandler, 1989) from 1963-1975, for pipe/

cigar smokers a RR of All Cause Mortality of 1.83 (1.13-2.96) was calculated

for men under 50 years of age and 1.13 (1.00-1.28) for men over 50 years of

age, providing an overall rate of 1.20 (1.07-1.35). These rates were adjusted for

age, housing quality, schooling, and marital status. Smoking categories were

based on usage at the time of the 1963 interview and do not reflect prior

history or changes during the follow-up.

Lange et al. (1992) report on the Copenhagen City Heart Study, a Danish

prospective population-based study of 6,511 men and 7,703 women, followed

from 1976 through 1989, which included 1,578 smokers of cheroots/cigars

of both sexes. The questionnaire included an inhalation question (yes/no).

Smoking groups are based on behavior at enrollment and do not distinguish

based on previous smoking. Thus cigar/cheroot includes both primary and

secondary cigar/cheroot smokers. This study found a RR of total mortality

for cigar/cheroot smokers of 1.8 (1.4-2.2) in women and 1.6 (1.3-2.0) in men,

age-adjusted and compared to neversmokers of the same sex. These rates are

somewhat lower than those found for smokers of unfiltered cigarettes, which

were 2.4 (2.0-2.9) for women and 1.9 (1.6-2.4) for men. Mortality rates for

cigar/cheroot smokers with self-reported inhalation were compared with

cigarette smokers who reported inhaling. For those cigar/cheroot smokers

with inhalation, the ratio of total mortality for women was 1.6 (1.2-2.2)

compared to female smokers of cigarettes who inhaled; and 1.0 (0.8-1.2) for

male cigar/cheroot smokers with inhalation compared to male smokers of

cigarettes with inhalation. For cigar/cheroot smokers who do not inhale,

the ratios as compared to inhaling cigarette smokers were 0.6 (0.5-0.8) for

women and 0.7 (0.6-0.8) for men, both significantly lower.

Ben-Shlomo et al. (1994) present smoking results from the Whitehall

prospective cohort study of 19,018 men from the British Civil Service

aged 40-69, with 18 years of follow-up beginning in 1967. Too few primary

cigar smokers (n=105) were available for reliable results. Secondary cigar

111

Smoking and Tobacco Control Monograph No. 9

smokers (n=658) produced a significantly elevated age-adjusted RR for all-

cause mortality of 1.20 (1.01-1.43) when compared to neversmokers, while

current cigarette smokers (n=7,921) had a RR of 2.00 (1.92-2.07). The authors

note that the RR for secondary cigar smokers is similar to that for former

cigarette smokers who had a RR of 1.15 (1.08-1.23). Smoking categories are

based on questions at the beginning of the study, with no reclassification

during the 18 years of follow-up.

Wald and Watt (1997) compare primary cigar and pipe smokers and

secondary cigar and pipe smokers who switched from cigarettes at least

20 years previously to neversmokers, former smokers, and cigarette smokers,

using data from a prospective study of 21,520 professional men in London

aged 35-64 years, recruited in 1975-82 and followed to October 1993.

Compared to neversmokers, primary pipe/cigar smokers have an age-adjusted

RR of mortality of 1.23 (0.99-1.75) and secondary pipe/cigar smokers who

switched from cigarettes at least 20 years previously have a RR of 1.33 (1.03-

1.73), while cigarette smokers have a RR of 2.26 (1.97-2.58). The study

includes self-reported inhalation level and carboxyhaemoglobin saturation at

initial exam. Comparison of these measures confirm the validity of self-

reported inhalation measures; both demonstrate the relatively higher levels of

inhalation of secondary cigar and pipe smokers compared to primary (never-

cigarette) cigar and pipe smokers. Carboxyhaemoglobin saturation was found

to be related to the risk of the three smoking related diseases investigated

[coronary heart disease, lung cancer, and COPD] across all smoking categories,

and in their analysis explained all of the variance related to smoking. A lower

level of mean total tobacco consumption of 8.1 g/day is noted for both

primary and secondary pipe and cigar smokers compared to 20.0 g/day for

cigarette smokers. Group classification is based on data from the initial

examination and does not reflect any changes in smoking behavior during

the average 14.3 years of follow-up.

The All Cause Mortality ratios for the CPS-I data are given in Tables 3 and

4, by numbers of cigars/cigarettes per day and level of inhalation. Generally

rates are significantly elevated as compared to neversmokers. Only the lowest

level of smoking (1-2 cigars per day) fails to show significance in the risk for

combined ages for primary and secondary cigar smokers. In every case

MRR's are particularly elevated for smokers less than 65 years of age.

There are positive gradients with numbers of cigars per day and with levels

of inhalation. Rates for moderate and deep inhalers of cigars reach levels

similar to cigarette smokers.

In order to assess the relative contributions of age, cigars per day, and

inhalation level to the rates of all-cause mortality, the primary cigar smoker

data was tabulated into cells by the factors of 5-year chronological age,

number of cigars per day (1-2, 3-4, 5+), and level of inhalation (0,1,2,3,

as coded for none, slightly, moderately, deeply). For each cell the absolute

rate of mortality was calculated. These data were subjected to a step-wise

multivariate Poisson regression with each factor and its log square and square

root transforms included as factors. The strongest factors in this procedure

are shown in Table 5. The purpose was to test the significance of each factor

Chapter 4

112

Table 3

Rate ratio of all-cause mortality by level of cigar/cigarettes per day

Age (years)

Daily Use 35-49 50-64 65-79 80+ Combined (95% CI) Deaths*

PRIMARY CIGAR 3,698/19667

1-2 0.72 1.10 1.02 0.97 1.02 (0.97, 1.07)

3-4 1.98 1.18 1.10 0.95 1.08 (1.02, 1.15)

5 + 1.64 1.38 1.17 0.98 1.17 (1.10, 1.24)

Combined 1.32 1.21 1.09 0.97 1.08 (1.05, 1.12)

SECONDARY CIGAR 1,452/19667

1-2 0.94 1.08 1.05 0.93 1.02 (0.93, 1.12)

3-4 1.37 1.57 1.26 0.74 1.17 (1.07, 1.28)

5 + 1.66 1.66 1.16 0.86 1.18 (1.08, 1.29)

Combined 1.29 1.43 1.15 0.84 1.12 (1.06, 1.18)

CIGAR & CIGARETTE 2,225/19667

1-19 1.65 1.68 1.29 1.06 1.31 (1.23, 1.39)

20 2.73 2.09 1.55 1.49 1.66 (1.55, 1.78)

21 + 2.73 2.15 1.99 1.11 1.78 (1.61, 1.97)

Combined 2.30 1.91 1.44 1.15 1.47 (1.41, 1.53)

CIGARETTE ONLY 38,220/19667

1-19 1.92 1.73 1.50 1.16 1.46 (1.43, 1.49)

20 2.45 2.15 1.70 1.29 1.69 (1.66, 1.71)

21 + 2.81 2.48 1.95 1.26 1.88 (1.85, 1.91)

Combined 2.49 2.17 1.68 1.21 1.66 (1.64, 1.68)

Based on data from CPS-I Study. Age-standardized rate ratio for smoking group compared to neversmokers.

* Number of deaths in subject group/neversmoker group.

as explanatory terms for the trend in the data, not to propose a model of

biological action. More information about the procedure followed is given

in the appendix.

Age is the strongest factor, reflecting the positive association of

advancing age with mortality. For the inhalation factor, the square and

square root transformation were assessed, in addition to the coded variable.

The square of depth of inhalation is the most significant of these inhalation

transforms, and is the most strongly significant factor in predicting the rate

of mortality. The square of inhalation was a better fit than inhalation,

emphasizing the effect of inhalation in increasing mortality rates. The

number of cigars per day also is a significant factor, though the strength

of the association is less than for age or inhalation.

Summary Risk ratios of All Cause Mortality for cigar smokers are higher than rates

for neversmokers, though generally lower than rates observed for cigarette

smokers. Cigar smokers who inhale exhibit all cause mortality rates that are

higher than the rates for cigar smokers who do not inhale, and the risk ratios

for inhaling cigar smoke approach the rates for cigarette smokers. The risk

ratios increase with increasing number of cigars smoked per day and

increasing depth of inhalation.

113

Smoking and Tobacco Control Monograph No. 9

Table 4

Rate ratio of all cause mortality by level of inhalation

Age (years)

Level of Inhalation 35-49 50-64 65-79 80+ Combined (95% CI) Deaths*

PRIMARY CIGAR 3,580/19667

None 1.13 1.16 1.05 0.94 1.04 (1.00, 1.08)

Slight 1.80 1.30 1.19 1.08 1.19 (1.09, 1.30)

Moderate-deep 1.02 1.87 1.72 1.22 1.60 (1.38, 1.84)

Combined 1.27 1.22 1.08 0.96 1.08 (1.04, 1.11)

SECONDARY CIGAR 1,400/19667

None 1.45 1.11 1.13 0.81 1.04 (0.97, 1.11)

Slight 1.01 1.57 1.18 0.83 1.16 (1.04, 1.29)

Moderate-deep 1.30 2.18 1.30 0.77 1.33 (1.16, 1.51)

Combined 1.32 1.40 1.16 0.81 1.11 (1.05, 1.17)

CIGAR & CIGARETTE 2,344/19667

None, slight 1.98 1.64 1.31 1.07 1.32 (1.24, 1.40)

Moderate 2.49 1.99 1.58 1.36 1.61 (1.51, 1.73)

Deep 2.68 2.41 1.92 1.24 1.84 (1.66, 2.03)

Combined 2.34 1.90 1.45 1.14 1.46 (1.41, 1.52)

CIGARETTE ONLY 39,825/19667

None, slight 2.04 1.97 1.57 1.14 1.54 (1.50, 1.57)

Moderate 2.45 2.14 1.68 1.22 1.65 (1.63, 1.67)

Deep 2.75 2.42 1.92 1.44 1.90 (1.86, 1.94)

Combined 2.49 2.18 1.68 1.20 1.66 (1.64, 1.68)

Based on data from CPS-I Study. Age-standardized rate ratio for smoking group compared to neversmokers.

* Number of deaths in subject group/neversmoker group.

Table 5

Results of step-wise poisson regression of absolute all-cause mortality rates

Variable Coeffecient SE F-test Probability

(Constant) 1.2211 0.00165

Age (years) 0.09559 0.0000217 1557.2 <10

-10

***

Inhalation

(0-3) 0.09887 0.000100 64.5 <10

-10

***

Cigars per day 0.02689 0.0000942 5.4 0.02*

***p<0.0001; **p<0.01; *p<0.05

CAUSE SPECIFIC The determination that cigar smoking can cause a specific disease

MORTALITY is based on a review of all the available information and draws

heavily on the similarities between the composition of cigar and cigarette

smoke described in Chapter 3. Data on cigarette smoking and disease risks

are much more extensive, and it is probably reasonable to assume that most

of the diseases caused by the inhalation of tobacco smoke from cigarettes

can be caused by the inhalation of tobacco smoke from cigars. However,

this chapter examines the data for a number of causes of death and reaches

Chapter 4

114

conclusions about the evidence on cigar smoking and disease based on a

number of criteria, including: the replication of a result in more than one

study, the presence of a dose response relationship with number of cigars

smoked per day and depth of inhalation, the demonstration of independent

effects of inhalation and number of cigars per day in a regression modeling

of the CPS-I data, and the presence of a relationship in larger and better

controlled studies.

LUNG CANCER The causal link between cigarette smoking and lung cancer has led to

a number of studies examining a similar link between cigar and pipe smoking

and lung cancer. These studies have demonstrated an elevated risk for lung

cancer among cigar smokers, but the magnitude of the risk is lower than that

for cigarette smokers. The 1979 review article provides references to studies

up to that time (DHHS, 1979). Table 6 summarizes the case-control and

prospective studies of lung cancer and cigar smoking.

Joly, Lubin, and Caraballoso (1983) conducted a case-control study of

male and female lung cancer cases in Cuba, in part focused on differentiating

level of risk between dark Cuban and lighter Virginia tobaccos. Analyses

are provided for male cigar only and mixed cigar and cigarette smokers. No

separation is made between primary and secondary cigar smokers. Controls

are a mixed group of hospital non-tobacco-related cases and neighborhood

matches. For cigar-only smokers an OR of 4.4 (2.3-8.2) is reported overall; for

mixed smokers a OR of 15.0 (9.0-24.9) is reported, comparing to the OR of

14.1 (8.8-22.6) for male cigarette smokers. There was a significant increase

in lung cancer risk with increasing duration of smoking for both groups

of cigar smokers, but the level of daily consumption was not significantly

related to risk. Depth of inhalation for cigar-only smokers is reported, noting

a significant positive trend in OR with increasing depth and frequency of

inhalation. There was a significant trend for mixed smokers of cigars and

cigarettes to inhale more frequently and more deeply than cigar-only smokers.

Lubin, Richter, and Blot (1984) present the cigar and pipe subset of a

larger case-control study of western European male lung cancer cases, with

6,920 cases and 13,460 controls. Controls matched hospital patients whose

admission was not for a tobacco-related illness. There were 37 cases with cigar-

only smoking with an estimated RR of 2.90 (2.1-4.0) and 180 mixed cigarette

and cigar cases with a RR of 6.87 (5.5-8.5). Tables in the paper present the

trend with years of cigar smoking (not significant) and number of cigars per

day (significant), which increases to a RR of 8.93 (6.8-11.1) for smokers of

7 or more cigars per day. A table presents significant increasing risk with both

frequency and depth of inhalation for cigar only smokers, though the same

table for mixed cigar and cigarette smokers is not significant. When smoking

cigars, mixed cigar/cigarette smokers were more likely to inhale than cigar -

only smokers; and when smoking cigarettes, less likely to inhale than cigarette-

only smokers.

Benhamou, Benhamou, and Flamant (1986) present analysis of the

cigar smoking subset of 1,529 French lung cancer cases: 9 are exclusive cigar

smokers and 68 are mixed cigar and cigarette smokers, compared to exposure

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Smoking and Tobacco Control Monograph No. 9

Table 6

Lung cancer and cigar smoking: mortality ratios by type of smoking (males only except as noted)

Odds Ratio (OR)

Never- Mixed, Cigar

Prospective Studies Sample Size* Smoker Cigar & Cigarette Cigarette

Levin (1950) 236/481 0.7 2.1

Schrek (1950) 82/522 0.6 1.7

Wynder & Graham (1950) 605/780 5.1 15.7

Sadowsky (1953) 477/615 2.4 5.6 3.7

Wynder & Cornfield (1953) 63/133 2.5 8.5

Randig (1954) 415/381 5.3 5.0

Mills & Porter (1950) 444/430 6.0** 5.4

Mills & Porter (1957) 484/1588 2.8** 4.5

Lombard & Snegireff (1959) 500/1839 1.7** 8.1

Wicken (1966) 803/803 2.2** 4.2 4.3

Abelin & Gsell (1967) 118/524 3.4 5.7

Wynder (1970) 210/420 2.0** 12.4

Joly (1983) 607/1,108 4.4 (2.3-8.2) 15.0 (9.0-24.9) 14.1 (8.8-22.6)

Lubin (1984) 6,920/13,460/37 2.90 (2.1-4.0) 6.87 (5.5-8.5) 9.03 (7.9-10.3)

Benhamou (1986) 1,529/2,899 5.6 (2.3-13.5) 8.5 (5.4-13.6) 13.3 (9.3-19.1)

Higgins (1988) 2,085/3,948 3.1 (1.8-5.6) 10.5 (7.8-14.4) 16.0 (12.2-20.9)

10+ cigars/day 25.1 (7.2-87.4)

Chapter 4

116

Table 6 (continued)

Rate Ratio (RR)

Never- Mixed, Cigar

Prospective Studies Sample Size* Smoker Cigar & Cigarette Cigarette

Hammond & Horn (1958) 187,783 1.0 1.02 7.63 10.73

Doll & Peto (1976) 41,000 1.0 5.80** 8.20 14.00

Best (1966) 78,000 1.0 2.94 14.91

Kahn (1966) 293,000 1.0 1.59 12.14

Carstensen (1987) 25,129/1,256/11 1.0 7.6 (3.7-13.6) 7.4 (5.8-9.3)

Lange (1992) male 6,511/808/47 1.0 6.0 (2.2-17) 7.3 (2.6-20) plain

6.0 (2.2-19) filter

Lange (1992) female 7,703/770/14 1.0 4.9 (3.0-12) 7.9 (2.9-21) plain

4.8 (1.7-13) filter

Ben-Shlomo (1994) secondary 19,018/658/20 1.0 7.64 (4.6-11.8) 11.92 (10.7-13.2)

Wald & Watt (1997) primary 21,520/1,309/6 1.0 3.19** (1.07-9.50) 16.4 (7.55-44.2)

Wald & Watt (1997) secondary 21,520/522/9 8.64** (3.19-23.3)

CPS-I primary 442,455/15,072/73 1.0 2.10 (1.63-2.65) 11.31 (9.72-13.07) 12.39 (11.97-12.83)

CPS-I secondary 442,455/7,349/86 6.29 (5.01-7.79)

*For prospective studies reviewed, the number of cigar smokers and number of deaths in this group are also given.

**Cigar and pipe combined.

117

Smoking and Tobacco Control Monograph No. 9

data from 2,899 matched hospital controls. In comparison to non-smokers,

this study yields an OR of 5.6 (2.3-13.5) for the cigar only smokers and

8.5 (5.4-13.6) for the mixed cigar and cigarette smokers, as compared to

an OR of 13.3 (9.3-19.1) for the cigarette only smokers. A test of secondary-

cigar smokers yielded lower risk (RR=0.40, p<.01) compared to cigarette only

smokers after adjustment for combined duration of smoking. The authors

explain this lower risk as an effect of reduction in inhalation reported when

changing from cigarettes to cigars, cigar-only smokers reporting lower rates

of inhalation than mixed cigar and cigarette smokers, and cigarette-only

smokers reporting highest levels of inhalation.

Higgins, Mahan, and Wynder (1988) present the cigar and pipe subset of a

lung cancer case-control study involving 24 hospitals in 6 cities of the United

States, including 2,085 cases and 3,948 matched hospital controls. Cigar-only

smokers have a lung cancer OR of 3.1 (1.8-5.6), based on 18 cases. Former

cigar only smokers have an OR of 2.5 (1.3-4.8), based on 12 cases quit for at

least one year. Mixed smokers, comprised of cigarette and cigar, cigarette

and pipe, or smokers of all three products, have an OR of 10.5 (7.8-14.4).

The authors also examine the change in lung cancer risks among cigarette

smokers who switch to cigars, as compared to those who quit smoking all

tobacco products. A table, partially reproduced in Figure 2, shows the

continuing risk for secondary cigar and/or pipe smokers broken into decades

of years since switching from cigarettes to cigar/pipe smoking. Figure 2 shows

uniformly higher risks for secondary cigar/pipe smokers than for former

cigarette smokers who have stopped all smoking, suggesting that the benefits

of cessation or cigarette smoking are diminished in the presence of continued

cigar use. Analyses of dosage, duration of smoking and inhalation were

performed combining primary cigar and pipe smokers (never smoked

cigarettes), by weighting each cigar or pipeful as one unit. This comparison

showed smokers of fewer than 5 cigars/pipefuls per day as not different from

neversmokers with an OR of 0.8 (0.3-2.1), but smokers of 5-9 cigars/pipefuls

per day have an OR of 3.2 (1.6-6.3) and smokers of 10 or more cigars/pipefuls

per day an OR of 6.7 (3.4-13.3). The group smoking ten or more cigars per day

excluding pipe smokers, has an OR of 25.1 (7.2-87.4). The risk with duration

of smoking is significant after 30 years of smoking. Rates are significantly

elevated for cigar/pipe smokers who inhale, with OR of 12.3 (4.0-37.7)

compared to an OR of 2.3 (1.4-3.8) for those who do not inhale.

In a large prospective study of 25,129 Swedish men from 1963 through

1979, as reported by Carstensen, Pershagen, and Eklund (1987), approximately

5 percent of the study population were cigar smokers. For lung cancer, an age-

adjusted RR of 7.6 (3.7-13.6) is reported for cigar only smokers, which is

similar to the overall risk of 7.4 (5.8-9.3) for cigarette smokers. The test for

trend by grams/day of any tobacco is highly significant. There is a similar

linear trend in RR for lung cancer by grams/day of tobacco smoked for

cigarette, pipe and cigar comsumption, with the RR for cigars slightly lower.

Tobacco use habits were only recorded at the beginning of the study and do

not account for changes in smoking pattern during the 17 years of the study.

Chapter 4

118

Figure2

Decreasing odds ratio for lung cancer by years of cessation of cigarette smoking,

by quitting or switching to cigars/pipe (Higgins, 1988).

In the Danish prospective study previously discussed (Lange, 1992),

overall mortality from lung cancer for male smokers of cheroots/cigars was

reported at an age-adjusted RR of 6.0 (2.2-17) versus neversmokers, compared

to the RR of 7.3 (2.6-20) for smokers of non-filter cigarettes and

6.0 (2.2-19) for smokers of filter cigarettes. For females, the corresponding

RRs are 4.9 (3.0-12) for cheroot/cigar-only smokers, 7.9 (2.9-21) for plain

cigarettes, and 4.8 (1.7-13) for filter cigarettes. In comparing mortality rates

by inhalation level, the inhaling cigarette smoker is used as the comparison

group. The RR for inhaling cigar/pipe smokers is 1.1 (0.7-1.6); for non-

inhaling cigar/pipe smokers, 0.4 (0.3-0.6). Cigarette smokers who do not

inhale are reported at 0.2 (0.1-0.8), also significantly lower than inhaling

cigarette smokers. For females, the Risk Ratio of inhaling cigar/cheroot

smokers compared to inhaling cigarette smokers is 1.5 (0.5-3.7); the

comparison of non-inhaling cigar/cheroot smokers to inhaling cigarette

smokers, 0.4 (0.2-0.9); and non-inhaling cigarette smokers to inhaling

cigarette smokers, 0.3 (0.1-0.8). The categories of tobacco use are a snapshot

of the habits at enrollment in the study and do not reflect prior useage

or changes during the period of follow-up. Consequently, primary and

secondary cigar smokers are pooled, and reported rates may be higher

than would be found for primary cigar/cheroot smokers. Conversely,

any cessation or reduction in smoking during the period of the study

would not be reflected in these statistics.

<10 yrs

Odds Ratio for lung cancer mortality

10-19 yrs 20-29 yrs 30+ yrs

Years of cigarette smoking cessation

11.9

9.9

6.1

5.3

3.7

4.8

1.9

secondary

cigar / pipe

former

smoker

119

Smoking and Tobacco Control Monograph No. 9

Wald and Watt (1997) report an age-adjusted RR of lung cancer of

3.19 (1.07-9.50) for primary cigar/pipe smokers and 8.64 (3.19-23.3) for

secondary cigar/pipe smokers who switched from cigarettes at least 20 years

before the beginning of the study, compared to a RR of 16.4 (7.55-44.2) for

current cigarette smokers. These rate differences are consistent with the

pattern of total tobacco consumption and levels of inhalation noted earlier.

Tables 7 and 8 present age-standardized lung cancer mortality ratios from

the CPS-I study by level of cigars/cigarettes per day and by level of inhalation.

Generally these tables show a positive gradient with quantity smoked. The

gradient in Table 8 for levels of inhalation is strongly positive, with highest

rates for the deepest inhalation level.

To assess the strength of association of the factors of numbers of cigars

per day and level of inhalation to rates of lung cancer deaths, the absolute

rates of lung cancer for primary cigar smokers were subjected to a step-wise

Poisson analysis of variance. For details, see the appendix. The results are

summarized in Table 9.

Depth of inhalation shows the strongest association with rates of

lung cancer deaths. The values for inhalation are an arbitrary scale for the

responses: ‘none’, ‘slight’, ‘moderate’, and ‘deeply’. The square and square

root transform of the values were also tested in the regression, with the

square transformation testing as the strongest factor. The chronological age

variable is also highly significant, but in contrast to the analysis of all cause

mortality, age is a less powerful predictor of lung cancer risk than inhalation.

The number of cigars per day is also significant in predicting rates, with a

positive slope.

Age specific lung cancer death rates from CPS-I for cigar smokers of

various numbers of cigars smoked per day and different inhalation patterns

can be modeled to compare the effects of number of cigars smoked per day

and inhalation on lung cancer death rates. Figure 3 is a graph of the modeled

rates of lung cancer deaths for several cigar smoking groups, in comparison to

smokers of 20 cigarette per day rates and neversmokers. All rate curves are

based on Poisson regression of observed absolute rates. The rates for cigar

smokers vary depending on the parameters of smoking behavior. Cigar

smokers smoking five or more cigars per day with moderate inhalation

approach the rates of smokers of 20 cigarette per day; cigar smokers smoking

one or two cigars per day with no inhalation are near rates for neversmokers.

The modeled rates in Figure 3 present a pattern of disease risk for cigar smokers

that increases with increasing exposure of the lung to cigar smoke. As the

number of cigars smoked per day increases and more importantly, as the depth

of inhalation increases, the risk of developing lung cancer increases from those

of someone who has never smoked to those of someone who has smoked 20

cigarettes per day.

Summary Studies of lung cancer mortality among cigar smokers provide a convincing

pattern of elevated lung cancer risks for cigar smokers. Lung cancer mortality

ratios increase with increasing number of cigars smoked per day and with

Chapter 4

120

Table 7

Rate ratio of cancer of the lung and bronchus by level of cigar/cigarettes per day

Age (years)

Daily Use 35-49 50-64 65-79 80+ Combined (95% CI) Deaths*

PRIMARY CIGAR 73/191

1-2 0.83 1.27 0.66 0.9 (0.54,1.66)

3-4 2.35 3.02 1.02 2.36 (1.49,3.54)

5 + 13.71 3.86 3.19 2.10 3.40 (2.34,4.77)

Combined 4.04 2.24 2.34 1.09 2.10 (1.63,2.65)

SECONDARY CIGAR 83/191

1-2 7.86 2.18 3.20 4.16 3.18 (1.78,5.24)

3-4 6.78 10.84 6.54 8.52 (5.87,11.97)

5 + 11.92 5.97 7.21 (5.02,10.03)

Combined 2.93 6.98 6.54 4.98 6.29 (5.01,7.79)

CIGAR & CIGARETTE 182/191

1-19 5.35 6.92 8.22 7.57 7.64 (5.87,9.77)

20 12.03 14.31 17.24 19.69 16.73 (13.24,20.85)

21 + 8.56 19.18 15.46 13.37 (9.55,18.21)

Combined 8.51 11.81 11.78 9.69 11.31 (9.72,13.07)

CIGARETTE ONLY 3,166/191

1-19 5.17 7.17 8.38 2.39 6.75 (6.18,7.37)

20 12.51 13.03 14.72 8.15 12.86 (12.14,13.60)

21 + 13.09 19.48 23.36 14.62 20.23 (19.20,21.30)

Combined 11.18 13.97 14.28 5.61 12.39 (11.97,12.83)

Based on data from CPS-I Study. Age-standardized rate ratio for smoking group compared to neversmokers.

* Number of deaths in subject group/neversmokers group.

increasing depth of inhalation. When depth of inhalation and number of

cigars per day are examined together, depth of inhalation is more powerful in

predicting lung cancer risk than number of cigars smoked per day. Limited

data exist on risks for those who switch from smoking cigarettes to smoking

only cigars, but the data that do exist suggest that lung cancer risks of

switching to cigars is substantially above that for cigarette smokers who stop

smoking all tobacco products.

Overall, lung cancer risks for cigar smokers may be similar to those seen in

cigarette smokers once they are adjusted for differences in level of inhalation

and quantity of tobacco smoked per day. The data clearly establish cigar

smoking as a cause of lung cancer.

ORAL CANCERS Both primary and secondary cigar smokers are less likely to inhale

deeply than are cigarette smokers (Figure 1), and this difference in inhalation

patterns is a major determinant of the differences in lung cancer risks that

occur due to smoking cigars and cigarettes. However, the mouth and oral

cavity are exposed to the carcinogens in smoke whether the smoke is inhaled

or not.

121

Smoking and Tobacco Control Monograph No. 9

Table 9

Results of step-wise poisson regression of absolute rates of lung cancer deaths

Variable Coeffecient SE F-test Probability

(Constant) –2.4107 0.0119

Inhalation

(0-3) 0.3557 0.000523 37.2 <10-

***

Age (years) 0.07514 0.000159 27.7 <10

-5

***

Cigars per Day 0.2324 0.000727 11.7 0.001**

***p<0.0001; **p<0.01; *p<0.05

Table 8

Rate ratio of cancer of the lung and bronchus by level of inhalation

Age (years)

Level of Inhalation 35-49 50-64 65-79 80+ Combined (95% CI) Deaths*

PRIMARY CIGAR 69/191

None 1.94 2.30 1.16 1.97 (1.48,2.57)

Slight 2.90 1.02 1.89 (0.81,3.72)

Moderate-deep 6.96 5.90 4.93 (1.80,10.72)

Combined 4.09 2.36 2.27 1.15 2.11 (1.64,2.67)

SECONDARY CIGAR 83/191

None 5.30 5.99 4.78 5.41 (3.93,7.27)

Slight 11.25 7.00 6.78 10.22 7.63 (4.66,11.78)

Moderate-deep 12.79 12.35 9.77 (5.88,15.25)

Combined 2.99 6.93 6.87 5.15 6.47 (5.15,8.01)

CIGAR & CIGARETTE 183/191

None, slight 10.29 11.65 4.86 9.64 (7.75,11.85)

Moderate 10.48 10.04 8.50 28.16 12.92 (9.81,16.70)

Deep 18.80 17.90 23.12 16.84 (12.08,22.85)

Combined 8.22 11.50 11.84 9.53 11.20 (9.66,12.92)

CIGARETTE ONLY 3,162/191

None, slight 7.68 11.76 10.72 2.47 9.33 (8.61,10.10)

Moderate 9.95 14.01 15.07 7.46 13.13 (12.53,13.75)

Deep 15.14 16.26 19.22 13.58 17.11 (16.00,18.28)

Combined 11.27 14.18 14.24 5.62 12.44 (12.02,12.88)

Based on data from CPS-I Study. Age-standardized rate ratio for smoking group compared to neversmokers.

* Number of deaths in subject group/neversmokers group.

Spitz (1988) presented a case-control study of 185 squamous cell carcinoma

of the upper aerodigestive tract, including larynx, tongue, orohypopharynx,

floor of mouth, and other cancers of the oral cavity, demonstrating an OR of

2.8 (1.5-5.5) for cigar use for all oral cancer sites combined. The cigar category

appears to include both primary and secondary cigar smokers, and non-

smokers may include ex-smokers.

Blot et al. (1988) report a case-control study of 1,114 oral and pharyngeal

cancer cases, excluding salivary and nasopharyngeal carcinoma, with 1,268

Chapter 4

122

Figure 3

Lung cancer death rates for cigar smokers with different patterns of inhalation and number of

cigars per day compared with one pack per day cigarette smokers

population-based controls. Pooling primary cigar and/or pipe smokers they

report an OR of 1.9 (1.1-3.4) adjusted for age and alcohol consumption,

which rises to 16.7 (3.7-76.7) for men smoking 40 or more cigars per week,

but this ratio is based on only 14 cases and 1 control. A positive gradient in

risk is also shown with increasing consumption of alcohol. An OR of 1.9 for

cancer of the tongue and 1.6 for cancer of the pharynx among pipe/cigar

smokers as compared to neversmokers is reported, but neither confidence

intervals nor the data to calculate them are provided.

Merletti et al. (1989) report a case-control study of cancer of the oral

cavity-oropharynx in Torino, Italy, with 122 cases of both sexes and 606

population-based controls. Male cigar smokers, with or without the

combination of other tobacco products, have a higher risk than cigarette-only

smokers based on 11 cases, with OR = 14.6 (4.7-45.6), compared to an OR of

3.9 (1.6-9.4) for cigarette smokers. OR's are age-adjusted and based on male

neversmokers rates.

123

Smoking and Tobacco Control Monograph No. 9

Table 10

Oral cancer and cigar smoking: rate ratios by type of smoking (males only)

Odds Ratio (OR)

Never- Mixed, Cigar

Case-Control Studies Sample Size* Smoker Cigar & Cigarette Cigarette

Lip

Broders (1920) 537/500 0.8 0.0

Ebenius (1943) 439/300 0.7

Levin (1950) 143/554 1.9 1.4

Sadowsky (1953) 571/615 1.1 0.4 1.4

Wynder (1957) 14/115 0.8 2.2 1.0

Staszewski (1960) 394/912 2.1** 2.4

Keller (1970) 301/265 1.4 2.6

Oral

Spitz (1988) incl larynx 185/185 2.8 (1.5-5.5) 4.5 (2.4-8.5)

Blot (1988) 1,114/1,268 1.9** (1.1-3.4) 1.9 (1.3-2.9)

40+ cigars/week 12/7 16.7 (3.7-76.7)

Merletti (1989) 86/385 14.6 (4.7-45.6) 3.9 (1.6-9.4)

Franceschi (1990) 157/1,272 20.7** (5.6-76.3) 11.1 (3.4-34.8)

Franceschi (1992) mouth 104/726 21.9** (3.8-125.6) 11.8 (3.6-38.4)

Tongue

Franceschi (1992) 102/726 3.4** (0.3-39.1) 10.5 (3.2-34.1)

Rate Ratio (RR)

Mixed, Cigar

Prospective Studies Cigar & Cigarette Cigarette

Hammond & Horn (1958) 187,783 1.0 5.00 5.06

Doll & Hill (1976) 41,000 1.0 9.00** 10.00 14.00

Hammond (1966) 440,559 1.0 4.94** 9.90

Kahn (1966) oral 293,000 1.0 4.11 4.09

Kahn (1966) pharyngeal 1.0 3.06** 12.54

Chow (1993) nasopharyngeal 248,046/2 1.0 1.0** (0.2-5.2) 3.9 (1.5-10.3)

CPS-I combined oral 442,455/15,072/26 1.0 7.92 (5.12-11.69) 10.72 (6.24-17.17) 8.23 (7.17-9.40)

*For prospective studies reviewed, the number of cigar smokers and number of deaths in this group are also given.

**Cigar and pipe combined.

Chapter 4

124

Franceschi et al. (1990) present the results of a case-control study in

northern Italy of 157 male oral cavity cancers, 134 pharyngeal cancers,

and 162 laryngeal cancers, with 1,272 male controls composed of matched

hospital inpatients with conditions unrelated to tobacco and alcohol. For

smokers of cigars or pipes only, they found an age-adjusted OR of 20.7 (5.6-

76.3) for oral cavity cancer based on 6 cases and an OR of 2.8 (0.3-26.1) for

laryngeal cancer based on 1 case, in comparison to neversmokers. Franceschi

et al. (1992) also reported a case-control study of 102 men with cancer of the

tongue and 104 patients with cancer of the mouth, compared to 726 hospital

controls. For cigar or pipe only smokers an OR of 3.4 (0.3-39.1) is calculated

for tongue cancer based on 1 case, and an OR of 21.9 (3.8-125.6) for cancer of

the mouth based on 5 cases, both compared to neversmokers.

Chow et al. (1993) report the 26-year follow-up of 250,000 US veterans.

They do not find any increased risk of nasopharyngeal cancer among cigar

and pipe-only smokers with an age-adjusted RR of 1.0 (0.2-5.2), but they do

report a RR of 3.9 (1.5-10.3) for all current cigarette smokers taken together,

compared to neversmokers.

Analyses from the CPS-I study for combined buccal and pharyngeal

cancers are presented in Tables 11 and 12. These tables include deaths

coded for lip, tongue, floor of mouth, mouth unspecified and mouth other,

oral mesopharynx, nasopharynx, hypopharynx and pharynx unspecified.

Cancer of the salivary glands is not included in this grouping because separate

analyses show that these cancers do not appear to be related to tobacco

consumption. Table 16 is included to demonstrate this lack of relationship

between cigarette smoking and cancer of the salivary glands. There are

insufficient data to provide a similar table for cigar smokers and cancer of the

salivary glands, but the lack of deaths in the cigar smoking group provides

evidence of the lack of relationship between this cancer and cigar exposure.

Rates for combined oral/pharyngeal cancers for primary and secondary cigar

smokers are approximately equal to rates for cigarette smokers (Table 11).

A positive gradient is seen with number of cigars/cigarettes per day. Rates for

smokers of 5+ cigars per day are higher than rates for smokers of 21+ cigarettes

per day. Table 12 shows a positive gradient for inhalation among cigar-only

and cigarette-only groups, with very high rates for moderate-deep inhalation

of cigars. The cigar and cigarette group does not show this effect, but the data

on inhalation here is complicated, involving two tobacco products, and the

coding for this study does not allow separate indication of inhalation for

cigars and cigarettes.

Tables 13 and 14 provide a more focused look at the pharyngeal cancers,

combining codings for oral mesopharynx, nasopharynx, hypopharynx and

pharynx unspecified. Elevated rates are observed for these cancers among

all smokers, with a strong positive gradient for numbers of cigars/cigarettes

per day and level of inhalation. Rates for cigar and cigarette smokers are

approximately equivalent, with highest rates for smokers of both cigars and

cigarettes. There is not enough data on secondary cigar smokers to generate

a table. A step-wise Poisson regression analysis confirmed a significant

125

Smoking and Tobacco Control Monograph No. 9

Table 11

Rate ratio of buccal and pharyngeal cancer combined by level of cigars/cigarettes per day*

Age (years)

Daily Use 35-49 50-64 65-79 80+ Combined (95% CI) Deaths**

PRIMARY CIGAR 25/18

1-2 2.33 2.12 (0.43,6.18)

3-4 7.06 6.56 8.51 (3.66,16.77)

5 + 10.54 15.50 15.94 (8.71,26.75)

Combined 5.33 7.37 7.92 (5.12,11.69)

SECONDARY CIGAR 8/18

1-2 4.39 (0.06,24.45)

3-4

5 + 5.23 19.62 13.73 (5.50,28.30)

Combined 1.85 6.89 6.58 (2.83,12.97)

CIGAR & CIGARETTE 17/18

1-19 9.16 6.93 7.29 (2.66,15.86)

20 12.00 15.41 13.42 (5.78,26.44)

21 + 39.04 23.86 (4.80,69.71)

Combined 8.32 13.01 10.72 (6.24,17.17)

CIGARETTE ONLY 216/18

1-19 5.98 4.99 5.93 (4.28, 8.02)

20 10.74 4.34 6.85 (5.37, 8.62)

21 + 13.41 12.21 12.04 (9.81,14.63)

Combined 10.52 6.49 8.23 (7.17, 9.40)

Based on data from CPS-I study. Age-standardized rate ratio for smoking group compared to neversmokers.

* Includes: lip, tongue, floor of mouth, other parts of mouth, mouth unspecified, oral mesopharynx, nasopharynx,

hypopharynx, pharynx unspecified, not including salivary glands.

** Number of deaths in subject group/neversmoker group.

association of absolute rates of pharyngeal cancers for primary cigar smokers

with age (F=20.5, p<.0001), inhalation (F=7.7, p<.01), and a marginally

significant association with cigars per day (F=3.6, p=.07).

The data on cancer of the tongue is summarized in Table 15, providing

comparisons based on numbers of cigars/cigarettes and depth of inhalation.

Primary and secondary cigar smokers are pooled to provide enough data.

These tables show highly elevated rates of tongue cancer for all smokers, with

a strong positive gradient by numbers of cigars/cigarettes per day and depth

of inhalation. These rates must be considered as approximate, since they are

based on only two deaths among the neversmoker comparison group, and

nine deaths among the cigar smokers.

Summary The risk of oral and pharyngeal cancers are similar for cigar smokers

and cigarette smokers, with an overall risk seven to ten times higher than for

neversmokers. Positive gradients are observed when rates are stratified by

numbers of cigars per day, demonstrating a dose-response relationship

between cigar smoke exposure and risk of these cancers. Further, the level

of inhalation affects the rates of these cancers, with highest rates for cigar

smokers who inhale moderately or deeply. No relationship between smoking

Chapter 4

126

Table 12

Rate ratio of combined buccal and pharyngeal cancer by level of inhalation*

Age (years)

Level of Inhalation 35-49 50-64 65-79 80+ Combined (95% CI) Deaths**

PRIMARY CIGAR 25/18

None 4.12 5.85 6.98 (4.13,11.03)

Slight 6.92 9.04 7.83 (1.57,22.88)

Moderate-deep 22.36 33.43 27.88 (5.60,81.46)

Combined 5.40 7.07 7.85 (5.03,11.68)

SECONDARY CIGAR 8/18

None 3.08 3.67 3.27 (0.66, 9.56)

Slight 14.32 8.75 (1.76,25.58)

Moderate-deep 13.24 24.19 (2.72,87.32)

Combined 1.89 7.08 6.77 (2.92,13.34)

CIGAR & CIGARETTE 17/18

None, slight 8.90 12.27 10.47 (4.78,19.87)

Moderate 3.42 9.62 7.02 (1.89,17.97)

Deep 15.15 14.08 13.65 (3.67,34.95)

Combined 8.01 12.31 10.20 (5.94,16.33)

CIGARETTE ONLY 227/18

None, slight 8.81 5.44 6.26 (4.47, 8.53)

Moderate 11.09 5.68 8.43 (7.00,10.06)

Deep 12.33 8.66 12.48 (9.61,15.94)

Combined 10.91 6.23 8.32 (7.27, 9.48)

Table 13

Rate Ratio of pharyngeal cancer by level of cigars/cigarettes per day*

Age (years)

Daily Use 35-49 50-64 65-79 80+ Combined (95% CI) Deaths**

PRIMARY CIGAR 12/10

1-2 6.40 3.81 (0.77,11.13)

3-4 4.23 13.51 7.52 (2.02,19.26)

5 + 4.22 19.54 9.92 (3.20,23.16)

Combined 2.52 12.19 6.73 (3.47,11.75)

CIGAR & CIGARETTE 10/10

1-19 13.40 5.36 (0.60,19.35)

20 9.60 35.02 18.81 (6.87,40.93)

21 + 79.42 31.77(3.57,114.69)

Combined 3.30 26.94 12.43 (5.95,22.86)

CIGARETTE ONLY 101/10

1-19 3.16 5.65 4.91 (2.95, 7.67)

20 5.77 7.38 6.04 (4.27, 8.29)

21 + 6.72 15.88 9.91 (7.20,13.31)

Combined 5.46 8.53 6.90 (5.62, 8.39)

* Includes: oral mesopharynx, nasopharynx, hypopharynx, and pharynx unspecified. Based on data from CPS-I study.

Age-standardized rate ratio for smoking group compared to neversmokers.

** Number of deaths in subject group/neversmoker group.

*Based on data from CPS-I Study. Age-standardized rate ratio for smoking group compared to neversmokers.

**Number of deaths in subject group/neversmokers group.

127

Smoking and Tobacco Control Monograph No. 9

Table 14

Rate ratio of pharyngeal cancer by level of inhalation*

Age (years)

Level of Inhalation 35-49 50-64 65-79 80+ Combined (95% CI) Deaths**

PRIMARY CIGAR 12/10

None 3.20 11.31 6.86 (3.28,12.61)

Slight 12.43 4.97 (0.06,27.66)

Moderate-deep 38.67 15.47 (0.20,86.07)

Combined 2.55 12.52 6.91 (3.56,12.07)

CIGAR & CIGARETTE 10/10

None, slight 28.61 11.44 (3.69,26.70)

Moderate 4.11 9.83 5.99 (0.67,21.62)

Deep 9.09 38.71 20.03 (4.03,58.52)

Combined 3.18 25.45 11.77 (5.64,21.65)

CIGARETTE ONLY 111/10

None, slight 5.92 7.06 5.79 (3.58, 8.84)

Moderate 6.04 8.98 8.16 (6.24,10.49)

Deep 6.53 8.40 9.59 (6.42,13.78)

Combined 6.04 8.24 7.34 (6.04, 8.84)

*Based on data from CPS-I study. Age-standardized rate ratio for smoking group compared to neversmokers.

**Number of deaths in subject group/neversmoker group.

and salivary gland cancer was observed. The data clearly establish cigar

smoking as a cause of oral cancer.

CANCER OF Burch et al. (1981) report a case-control study of 204 laryngeal cancer

THE LARYNX cases between 1977 and 1979 in southern Ontario compared to

matched neighborhood controls. The summary RR for cigar smokers,

estimated by logistic regression, is reported as 2.9, compared to 6.1 (3.0-12.5)

for cigarette smokers. But the criterion for the cigar category (primary,

secondary, or ever-cigar) is not stated, and the confidence interval for cigar

smokers is not reported and cannot be estimated since the numbers of cases

are not given.

Freudenheim et al. (1992) conducted a case-control study of 250 cases of

laryngeal cancer and matched neighborhood controls in western New York.

No significant trend related to cigar use is shown. Cigar use is reported in

cigar-years, without distinguishing between heavy use for a shorter period

and light use over many years. The categories of tobacco use (ever-cigarette/

ever-cigar/ever-pipe) appear to overlap, not distinguishing between mixed

cigarette and cigar smokers, secondary cigar smokers, etc; the overlapping

categories prevent clear conclusions with respect to cigar use.

Muscat and Wynder (1992) report a case-control study of laryngeal

cancer with 194 subjects and 184 age-matched hospital controls between

1985 and 1990, a subset of a larger study. Compared to neversmokers, an OR

of 4.3 (1.7-16.4), adjusted for age and alcohol use, is reported for combined

pipe and cigar smokers, apparently primary and secondary cigar/pipe smokers

combined.

Chapter 4

128

Table 15

Rate ratio of cancer of the tongue*

Age (years)

35-49 50-64 65-79 80+ Combined (95% CI) Deaths**

By Level of Cigars/Cigarettes per Day

PRIMARY & SECONDARY CIGAR 9/2

1-2

3-4 13.67 22.51 (4.52,65.76)

5 + 23.96 45.91 34.94 (12.76,76.05)

Combined 11.91 14.83 18.14 (8.37,34.82)

CIGARETTE ONLY 61/2

1-19 14.16 6.85 10.51 (5.03,19.32)

20 14.07 7.89 15.54 (8.69,25.63)

21 + 33.67 41.38 37.53 (26.28,51.96)

Combined 21.24 14.97 19.61 (15.00,25.19)

By Level of Inhalation

PRIMARY & SECONDARY CIGAR 9/2

None 5.23 9.61 13.72 (4.42,32.02)

Slight 21.92 23.80 22.86 (2.57,82.53)

Moderate-deep 45.03 22.51 (0.29,125.26)

Combined 12.09 11.40 16.98 (7.31,33.45)

CIGARETTE ONLY 61/2

None, slight 12.83 9.29 11.06 (4.76,21.79)

Moderate 22.26 13.61 17.93 (12.56,24.83)

Deep 24.57 23.06 36.72 (21.75,58.03)

Combined 21.12 14.32 19.11 (14.65,24.50)

Table 16

Rate ratio of cancer of the salivary glands*

Age (years)

35-49 50-64 65-79 80+ Combined (95% CI) Deaths**

By Level of Cigars/Cigarettes per Day

CIGARETTE ONLY 14/11

1-19 3.90 1.36 1.33 (0.43, 3.11)

20 1.03 1.38 2.64 1.18 (0.43, 2.57)

21 + 3.92 0.36 (0.07, 1.04)

Combined 0.40 2.86 1.55 1.13 (0.62, 1.90)

By Level of Inhalation

CIGARETTE ONLY 15/11

None, slight 2.54 2.42 1.61 (0.52, 3.76)

Moderate 0.67 3.93 0.82 0.72 (0.31, 1.41)

Deep 1.71 0.88 0.47 (0.05, 1.71)

Combined 0.39 3.22 1.47 1.12 (0.62, 1.84)

*Based on data from CPS-I study. Age-standardized rate ratio fro smoking group compared to neversmokers.

**Number of deaths in subjet group.neversmoker group.

*Based on data from CPS-I study. Age-standardized rate ratio fro smoking group compared to neversmokers.

**Number of deaths in subjet group.neversmoker group.

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Smoking and Tobacco Control Monograph No. 9

Table 17

Cancer of the larynx and cigar smoking : mortality ratios by type of smoking (males only)

Never- Mixed, Cigar

Studies Sample Size* Smoker Cigar & Cigarette Cigarette

Case-Control Odds Ratio (OR)

Burch (1981) 204/204 ever 2.9 6.1 (3.0-12.5)

Freudenheim (1992) 250/250 NS

Muscat (1992) 194/184 4.3* (1.7-16.4) 13.8 (2.3-27.1)

Prospective Rate Ratio (RR)

Kahn 293,000 1.0 10.33 9.95

CPS-I 442,455/15,072/7 1.0 10.02 (4.0-20.6) 19.09 (7.7-39.3) 19.68 (16.1-23.8)

* For prospective studies reviewed, the number of cigar smokers and number of deaths in this group are also given.

** Cigar and pipe combined

Chapter 4

130

The CPS-I results for laryngeal cancer are given in Tables 18 and 19. The

RRs for combined levels of cigars per day and combined levels of inhalation

are lower than for cigarette smokers, but the RRs for smokers of five or more

cigars per day, and the RRs for those cigar smokers reporting deep inhalation,

are markedly elevated. However, these rates are determined by small

numbers of cases in both the cigar smokers and neversmokers, and therefore

the confidence intervals on these rates are wide, though generally strongly

significant.

Summary The risk of laryngeal cancer is significantly elevated among cigar smokers,

approaching the RR for cigarette smokers for smokers of five or more cigars

per day or cigar smokers who inhale moderately or deeply. The data, while

limited by the number of deaths from laryngeal cancer, support a positive

relationship between number of cigars smoked per day and laryngeal cancer

risk. The data taken as a whole support cigar smoking as a cause of laryngeal

cancer.

CANCER OF The esophagus is exposed to the carcinogens from tobacco smoke

THE ESOPHAGUS which collect on the surface of the mouth and are swollowed

with saliva. It is also exposed to smoke which is deposited in the mucus

cleared from the lung and swallowed, as well as to systemically absorbed

carcinogens.

The Franceschi et al. study (1990), noted above, includes a case-control

comparison of 288 esophageal cancer cases. The 7 cigar and pipe smoker

cases produce an OR of 6.7 (2.3-19.8) compared to neversmokers; cigarette

smokers have an OR of 3.8 (2.2-6.6) in this study.

Tables 21 and 22 provide the rates of esophageal cancer for the cigar

smoking categories and cigarette-only smokers from the CPS-I data. The

rates are comparable across cigars and cigarettes, with a positive gradient for

numbers of cigars/cigarettes smoked each day. A step-wise Poisson regression

analysis confirmed a significant association of absolute rates of pharyngeal

cancers for primary cigar smokers with age (F=19.3, p<.0001), inhalation

(F=12.1, p=.001), and cigars per day (F=7.3, p=.01).

Summary The risk of esophageal cancer is several times higher among cigar smokers

than among neversmokers, with RR of occurrence similar to that for cigarette

smokers. A dose-response effect is confirmed with higher rates for cigar

smokers with higher numbers of cigars per day or with deeper inhalation.

The data establish cigar smoking as a cause of esophageal cancer.

BLADDER AND In a case-control study of 75 bladder cancer cases of both sexes

URINARY SYSTEM in northern New Jersey primarily focused on industrial chemical

CANCERS exposure, Najem et al. (1982) found a significant risk of bladder

cancer for individuals with a history of cigarette smoking with an OR of 2.0

(1.1-3.7) compared to neversmokers. They found no relationship between

cigar smoking and risk for bladder cancer.

In a Danish case-control study of bladder cancer cases of both sexes,

165 male and 47 female, matched to 165 male and 94 female randomly-

131

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Table 18

Rate ratio of cancer of the larynx by level of cigar/cigarettes per day*

Age (years)

Daily Use 35-49 50-64 65-79 80+ Combined (95% CI) Deaths**

PRIMARY CIGAR 7/4

1-2 6.64 6.45 (0.72,23.27)

3-4

5 + 21.08 28.22 26.03 (8.39,60.74)

Combined 6.76 10.75 10.02 (4.01,20.64)

CIGAR & CIGARETTE 7/4

1-19 19.89 15.48 12.71 (1.43,45.90)

20 24.00 20.28 16.14 (1.81,58.26)

21 + 94.58 32.53 39.91 (8.02,116.61)

Combined 33.72 21.31 19.09 (7.65,39.33)

CIGARETTE ONLY 105/4

1-19 12.24 7.66 8.70 (4.75,14.59)

20 29.36 27.58 25.69 (18.66,34.48)

21 + 43.58 25.38 23.59 (17.33,31.37)

Combined 30.65 19.34 19.68 (16.10,23.83)

Table 19

Rate ratio of cancer of the larynx by level of inhalation*

Age (years)

Level of Inhalation 35-49 50-64 65-79 80+ Combined (95% CI) Deaths**

PRIMARY CIGAR 7/4

None 8.70 9.53 10.60 (3.87,23.07)

Slight

Moderate-deep 106.52 53.26 (0.70,296.32)

Combined 6.84 10.99 10.32 (4.13,21.26)

CIGAR & CIGARETTE 7/4

None, slight 54.83 10.30 18.86 (5.07,48.28)

Moderate 22.38 5.59 (0.07,31.13)

Deep 161.85 80.93 (9.09,292.18)

combined 32.44 20.08 18.15 (7.27,37.40)

CICARETTE ONLY 107/4

None, slight 28.19 18.94 22.19 (14.74,32.07)

Moderate 27.88 13.03 13.49 (10.01,17.78)

Deep 30.59 39.79 27.54 (18.44,39.56)

Combined 29.21 19.57 19.36 (15.87,23.39)

*Based on data from CPS-I Study. Age-standardized rate ratio for smoking group compared to neversmokers.

**Number of deaths in subject group/neversmoker group.

*Based on data from CPS-I study. Age-standardized rate ratio fro smoking group compared to neversmokers.

**Number of deaths in subjet group.neversmoker group.

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132

Table 20

Esophageal cancer and cigar smoking: rate ratios by type of smoking (males only)

Rate Ratio

Never- Mixed, Cigar

Studies Sample Size* Smoker Cigar & Cigarette Cigarette

Case-Control

Sadowsky (1953) 104/615 4.8 3.3 3.8

Wynder (1957) 39/115 3.1 0.4 2.6

Pernu (1960) 202/713 5.9 2.7

Schwartz (1961) 249/249 8.6 11.7

Wynder & Bross (1961) 150/150 3.6 3.7 2.8

Martinez (1969) 120/360 2.0 2.2 1.5

Martinez (1970) 346/346 2.0 2.5 1.7

Franceschi (1990) 288/1,272 6.7** (2.3-19.8) 3.8 (2.2-6.6)

Prospective Rate Ratio (RR)

Hammond & Horn (1958) 187,783 1.0 5.00 5.06

Doll & Peto (1976) 41,000 1.0 3.70** 9.0 4.70

Hammond (1966) 440,559 1.0 3.97** 4.17

Kahn (1966) 293,000 1.0 5.33 6.17

CPS-I 442,455/15,072/20 1.0 3.60 (2.2-5.6) 3.57 (2.3-5.2) 3.966 (3.4-4.6)

* For prospective studies reviewed, the number of cigar smokers and number of deaths in this group are also given.

** Cigar and pipe combined.

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Table 21

Rate ratio of cancer of the esophagus by level of cigar/cigarettes per day*

Age (years)

Daily Use 35-49 50-64 65-79 80+ Combined (95% CI) Deaths**

PRIMARY CIGAR 19/30

1-2 1.86 2.62 2.28 (0.74, 5.33)

3-4 4.71 2.46 7.73 3.93 (1.43, 8.55)

5 + 2.34 7.19 5.19 (2.23,10.22)

Combined 2.80 3.94 4.72 3.60 (2.17, 5.62)

SECONDARY CIGAR 7/30

1-2 2.64 (0.03,14.67)

3-4 3.12 1.56 (0.02, 8.68)

5 + 10.44 4.99 5.63 (1.81,13.14)

Combined 3.73 2.70 3.52 (1.41, 7.25)

CIGARETTE ONLY 162/30

1-19 1.83 2.69 2.73 2.41 (1.61, 3.46)

20 1.03 4.47 5.24 4.30 (3.32, 5.48)

21 + 0.98 6.23 5.55 5.60 (4.35, 7.10)

Combined 1.18 4.67 4.44 1.80 3.96 (3.37, 4.62)

Table 22

Rate ratio of cancer of the esophagus by level of inhalation*

Age (years)

Level of Inhalation 35-49 50-64 65-79 80+ Combined (95% CI) Deaths*

PRIMARY CIGAR 19/30

None 2.59 4.27 2.93 3.40 (1.90, 5.61)

Slight 1.90 (0.02,10.58)

Moderate, deep 14.91 10.31 14.84 (2.98,43.37)

Combined 2.84 4.01 4.98 3.69 (2.22, 5.76)

SECONDARY CIGAR 7/30

None 4.29 2.69 4.15 (1.34, 9.68)

Slight 4.45 2.22 (0.03,12.37)

Moderate, deep 8.95 2.69 (0.04,14.94)

Combined 3.81 2.78 3.62 (1.45, 7.46)

CIGARETTE ONLY 170/30

None, slight 3.21 3.22 2.21 2.94 (1.97, 4.23)

Moderate 1.36 5.18 4.92 4.06 (3.30, 4.94)

Deep 1.30 4.86 5.18 4.95 (3.55, 6.72)

Combined 1.15 4.75 4.46 1.66 3.97 (3.39, 4.61)

*Based on data from CPS-I Study. Age-standardized rate ratio for smoking group compared to neversmokers.

**Number of deaths in subject group/neversmoker group.

*Based on data from CPS-I study. Age-standardized rate ratio fro smoking group compared to neversmokers.

**Number of deaths in subjet group.neversmoker group.

Chapter 4

134

Table 23

Bladder and urinary system cancer: mortality rate ratio by type of smoking (males only, except as noted)

Odds Ratio (OR)

Never- Mixed, Cigar

Sample Size* Smoker Cigar & Cigarettes Cigarette

Najem (1982) 75/142 ns 2.0 (1.1-3.7)

Mommsen (1983) male 165/165 2.3 (0.7-7.4) 3.5 (1.5-7.9)

Mommsen (1983) female 3.2 (1.3-7.7)

Morrison (1984) male 1435/1852 ns 1.9 (1.2-2.7)

Morrison (1984) female 2.4 (1.6-3.2)

Hartge (1985) 2982/5782 1.33 (.92-1.94) 3.36 (2.8-4.0)

Jensen (1987) 388/787 2.5 (0.2-28.4) 3.6 (2.2-5.8) 2.9 (1.8-4.8)

Slattery (1988 332/686 2.46 (1.01-5.95) 3.69 (2.58-5.26)

Burch (1989) 826/792 0.97 (.69-1.36) ever 2.65 (1.82-3.86)

Kunze (1992) 531/531 1.4 (0.9-2.4) 3.6 (2.4-5.4)

highest consumption category

Prospective Studies Rate Ratio (RR)

Kahn (1966) 293,000 1.0 0.94 2.15

CPS-I primary 442,455/15,072/26 1.0 1.38 (0.89-2.04) 2.48 (1.42-4.03) 3.17 (2.83-3.54)

CPS-I secondary 442,455/7,349/9 1.0 1.23 (0.56-2.33)

*For prospective studies reviewed, the number of cigar smokers and number of deaths in this group are also given.

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selected matched contols, Mommsen and Aagaard (1983) found significant

risk associated with current cigarette smoking, with OR's: male, 3.5 (1.5-7.9);

female, 3.2 (1.3-7.7). The reference group is not indicated, and may be

neversmokers or not-current-smokers of cigarettes. For cigars or cigarillos

only, an OR of 2.3 (0.7-7.4) is indicated for men, with insufficient data for

women. If previous and current smoking habits are both included, the OR

associated with cigar/cigarillo smoking becomes 1.4 (0.9-2.2) for men and

3.3 (1.3-8.5) for women; combining men and women results in a OR of

1.9 (1.3-2.8). The OR for women and combined sexes are significant,

but the OR for men is not significant.

Morrison et al. (1984) reported a large international case-control study

of 1,435 bladder cancer cases in Boston, Manchester UK, and Nagoya Japan,

with controls matched by sex and age in electoral registers. They found

significant risk associated with ever cigarette smoking across the three sites

with an OR approximately twice that for neversmokers, an OR of 1.9 (1.2-2.7)

for men and 2.4 (1.6-3.2) for women. There was a marked trend with number

of cigarettes per day. This study found no relationship between cigar

smoking and bladder cancer. Data for numbers of cigar smoking cases and

controls is not provided.

Hartge, Hoover and Kantor (1985) report on a large case-control study

of bladder cancer, with 2,972 patients and 5,782 controls, cases from

10 geographic areas of the US and controls randomly selected from the

general population weighted to age, sex, and geographic distribution of

cases. The focus of this study was risk related to pipes, cigars, and smokeless

tobacco. For primary cigar smokers (never smoked cigarettes) an OR of

1.33 (0.92-1.94) was calculated in comparison to neversmokers, adjusted for

race, age, and residence; for primary pipe smokers, an OR of 1.23 (0.75-2.00);

for smokers of pipes and cigars but no cigarettes, an OR of 1.40 (1.01-1.93).

In comparison, an OR of 3.36 (2.8-4.0) was observed for current cigarette

smokers. Further explorations among the primary cigar smokers regarding

level of inhalation, duration of cigar smoking, weekly consumption, and

lifetime dose are inconclusive, without trend and not significant.

Similarly, Jensen et al. (1987), reporting on a case-control study of

388 bladder cancer cases of both sexes in Copenhagen, Denmark, found no

significant relationship between cigar/cigarillo smoking and bladder cancer,

for ever cigar/cigarillo smokers, cigar/cigarillo only smokers, or by amount

of cigars/cigarillos smoked per day. An overall OR of 2.9 (1.8-4.8) was found

for cigarette-only smokers of both sexes combined.

Slattery et al. (1988) conducted a population based case-control study

of 332 white men compared to 686 controls selected by random digit dialing

and matched by age and sex; all were residents of Utah. This study focused

on the effect of cigarette smoking on the risk of bladder cancer associated

with coffee, tea, alcohol and other forms of tobacco. Strong associations

were found for cigarette smoking and bladder cancer, including positive

trends with duration of smoking, cigarettes per day, lifetime packs, and

inhalation, with an OR of about 4.0 for heavy users. These values were

Chapter 4

136

similar for both current and ex-smokers of cigarettes. For primary cigar

smokers who had never smoked cigarettes, an OR of 2.46 (1.01-5.95) was

calculated; whereas, for those cigar smokers who had ever smoked cigarettes,

an OR of 0.99 (0.61-1.60) was determined.

Burch et al. (1989) report a case-control study in Alberta and Ontario,

Canada between 1979 and 1982, comparing 826 cases and 792 neighborhood

controls matched for age and sex. They found significant associations for

cigarette smoking with an OR of 2.65 (1.82-3.86) for current cigarette smokers.

Gradients are reported with age first smoked, duration, cigarettes per day and

total pack years. The only cigar comparison reported is ever/never smoked

cigars, without stratifying by cigarette history; this comparison provides an

OR of 0.97 (0.69-1.36), with no trend indicated.

In a case-control study of 531 male and 144 female matched pairs in

Germany, Kunze et al. (1992) found smoking of cigars did not alter the risk

of bladder cancer. Controlling for cigarette smoking, the rates by lifetime

consumption of cigars shows positive trend, but the OR's are not significant.

The results of the tabulations for bladder cancer in the CPS-I data are

given in Tables 24 and 25, with tables by level of consumption and level of

Table 24

Rate ratio of cancer of the urinary bladder and urinary system, by level of

cigar/cigarettes per day*

Age (years)

Daily Use 35-49 50-64 65-79 80+ Combined (95% CI) Deaths**

PRIMARY CIGAR 25/102

1-2 1.29 0.79 0.78 (0.29, 1.71)

3-4 1.63 1.44 2.42 1.68 (0.77, 3.18)

5 + 2.75 1.42 3.32 2.03 (0.97, 3.73)

Combined 1.87 1.18 1.72 1.38 (0.89, 2.04)

SECONDARY CIGAR 9/102

1-2 4.79 0.65 1.02 (0.20, 2.97)

3-4 9.02 0.63 2.36 (0.76, 5.50)

5 + 0.52 0.32 (0.00, 1.80)

Combined 4.30 0.59 1.23 (0.56, 2.33)

CIGAR & CIGARETTE 16/102

1-19 0.77 4.00 1.42 (0.38, 3.65)

20 6.00 3.57 4.84 (2.41, 8.66)

21 + 1.75 1.10 (0.01, 6.10)

Combined 1.99 1.82 4.60 2.48 (1.42, 4.03)

CIGARETTE ONLY 318/102

1-19 2.98 1.97 3.11 2.35 (1.85, 2.94)

20 1.03 4.94 2.95 3.80 3.39 (2.82, 4.03)

21 + 3.94 5.46 3.72 4.63 4.16 (3.43, 4.99)

Combined 1.99 4.67 2.76 3.50 3.17 (2.83, 3.54)

*Based on data from CPS-I study. Age-standardized rate ratio for smoking group compared to neversmokers.

**Number of deaths in subject group/neversmoker group.

137

Smoking and Tobacco Control Monograph No. 9

Table 25

Rate ratio of cancer of the urinary bladder and urinary system, by level of inhalation*

Age (years)

Level of Inhalation 35-49 50-64 65-79 80+ Combined (95% CI) Deaths*

PRIMARY CIGAR 24/102

None 3.02 1.20 1.83 1.57 (1.00, 2.36)

Slight

Moderate-deep 2.42 1.52 (0.02, 8.44)

Combined 2.42 1.12 1.56 1.38 (0.88, 2.05)

SECONDARY CIGAR 9/102

None 2.97 0.63 0.77 (0.21, 1.98)

Slight 3.57 0.82 2.87 (0.58, 8.40)

Moderate-deep 11.41 1.45 (0.16, 5.25)

Combined 4.40 0.61 1.26 (0.58, 2.40)

CIGAR & CIGARETTE 17/102

None, slight 1.31 2.68 2.30 (1.15, 4.12)

Moderate 3.44 0.61 12.74 3.82 (1.23, 8.92)

Deep 4.58 (0.06,25.46)

Combined 1.91 1.73 5.49 2.62 (1.53, 4.20)

CIGARETTE ONLY 331/102

None, slight 6.08 3.17 2.14 3.00 2.51 (1.98, 3.15)

Moderate 1.35 4.49 2.73 5.02 3.48 (2.98, 4.03)

Deep 1.30 6.46 3.71 2.15 3.67 (2.92, 4.55)

Combined 1.93 4.74 2.68 3.70 3.17 (2.84, 3.53)

*Based on data from CPS-I study. Age-standardized rate ratio for smoking group compared to neversmokers.

**Number of deaths in subject group/neversmoker group.

inhalation respectively. Generally the age-adjusted rates calculated for cigars

are not significant. There is a positive trend with numbers of cigars for

primary cigar smokers, but no trend is seen with increasing depth of

inhalation. On the other hand, we do see significant rates and significant

trends for cigarette-only smokers, both cigarettes per day and inhalation

presenting a convincing pattern of increasing risk with increasing exposure.

Summary Although a few studies have indicated a significant relationship between

cigar smoking and bladder cancer, several other studies have not found

convincing evidence that smoking cigars increases the risk of bladder cancer.

PANCREATIC Farrow and Davis (1990) conducted a case-control study of 148 married

CANCER male pancreatic cancer cases from three counties in Washington state,

compared to 188 controls also married men, matched by age and selected

by a random digit dialing procedure. For current cigarette smokers, an OR

of 3.2 (1.8-5.7) was found, compared to neversmokers. Ever use of cigars

produced an OR of 0.7 with confidence interval that included 1.0. No data

are shown for primary cigar-only smokers.

Bueno de Mesquita et al. (1991) carried out a population-based case-

control study of 176 pancreatic cancer cases of both sexes matched to 487

controls from the Netherlands. For combined categories of cigarette smokers,

Chapter 4

138

Table 26

Pancreatic cancer and cigar smoking: rate ratios by type of smoking (males only, except as noted)

Odds Ratio (OR)

Never- Mixed, Cigar

Sample Size* Smoker Cigar & Cigarettes Cigarette

Case-Control Studies

Farrow (1990) 148/188 NS 3.2 (1.8-5.7)

Bueno de Mesquita (1991)

ever cigar 176/487 0.8 (0.5-1.3) 2.0 (1.2-3.1)

Muscat (1997) male 484/954 3.1 (1.4-6.9) 1.6 (1.1-2.4)

Muscat (1997) female 2.3 (1.4-3.5)

Prospective Studies Rate Ratio (RR)

Kahn (1966) 293,000 1.0 1.52 1.84

CPS-I primary 442,455/15,072/57 1.0 1.62 (1.22-2.11) 2.43 (1.72-3.34) 2.07(1.90-2.25)

CPS-I secondary 442,455/7,349/20 1.0 1.80 (1.10-2.78)

*For prospective studies reviewed, the number of cigar smokers and number of deaths in this group are also given.

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an OR of 1.96 (1.23-3.12) was found, compared to neversmokers. Ever use of

cigars by 36 subjects produced an OR of 0.8 (0.5-1.3), not providing any

evidence of increased risk.

Muscat et al. (1997) gathered case-control data on 484 male and female

pancreatic cancer cases and 954 non-tobacco related matched hospital

controls at several hospitals. Their results include for current male cigarette

smokers an OR of 1.6 (1.1-2.4) and current female cigarette smokers

2.3 (1.4-3.5), compared to same-sex neversmokers. Trend with increasing

consumption is shown, particularly for women. For male pipe/cigar smokers

an overall OR of 2.1 (1.2-3.8) was determined. For male cigar only smokers a

OR of 3.1 (1.4-6.9) was determined, compared to never and former cigarette

smokers combined. These cigar only smokers may include former cigarette

smokers, as well as lifetime cigar only smokers.

Tables 27 and 28 present the results of tabulation of pancreatic cancer

cases in the CPS-I data. Overall significance is shown for cigar-only and

secondary cigar smokers, as well as for cigarette smokers. For all groups,

positive trend is shown with numbers of cigars per day and levels of

inhalation. The levels of cigars/cigarettes per day in Table 27 and levels

of inhalation in Table 28 show values for cigar smokers similar to those

for cigarette smokers. A step-wise Poisson regression analysis confirmed

Table 27

Rate ratio of pancreatic cancer, by level of cigar/cigarettes per day*

Age (years)

Daily Use 35-49 50-64 65-79 80+ Combined (95% CI) Deaths**

PRIMARY CIGAR 56/198

1-2 1.52 0.78 1.79 1.18 (0.69, 1.89)

3-4 2.03 2.76 1.51 (0.86, 2.45)

5 + 2.71 2.72 2.21 (1.40, 3.32)

Combined 1.48 1.72 1.69 1.62 (1.22, 2.11)

SECONDARY CIGAR 20/198

1-2 0.51 0.56 (0.06, 2.01)

3-4 0.64 3.36 1.90 (0.82, 3.74)

5 + 1.56 2.12 12.23 3.71 (1.78, 6.83)

Combined 0.92 1.74 3.60 1.80 (1.10, 2.78)

CIGAR & CIGARETTE 38/198

1-19 10.71 1.79 3.02 2.74 2.67 (1.67, 4.04)

20 1.66 2.44 1.74 (0.83, 3.20)

21 + 2.13 3.35 2.35 (0.86, 5.12)

Combined 4.26 1.81 2.89 2.10 2.43 (1.72, 3.34)

CIGARETTE ONLY 549/198

1-19 3.75 1.85 1.77 1.07 1.69 (1.41, 2.00)

20 3.58 2.34 2.34 1.30 2.17 (1.89, 2.47)

21 + 3.95 2.39 2.67 1.59 2.41 (2.08, 2.77)

Combined 3.76 2.24 2.24 1.20 2.07 (1.90,2.25)

*Based on data from CPS-I study. Age-standardized rate ratio for smoking group compared to neversmokers.

**Number of deaths in subject group/neversmoker group.

Chapter 4

140

Table 28

Rate ratio of pancreatic cancer by level of inhalation*

Age (years)

Level of Inhalation 35-49 50-64 65-79 80+ Combined (95% CI) Deaths**

PRIMARY CIGAR 56/198

None 1.43 1.60 1.67 1.55 (1.12, 2.07)

Slight 2.05 2.45 2.16 (0.99, 4.10)

Moderate-deep 2.26 3.09 2.26 (0.45, 6.60)

Combined 1.59 1.76 1.60 1.66 (1.25, 2.16)

SECONDARY CIGAR 19/198

None 1.24 1.41 2.59 1.55 (0.80, 2.72)

Slight 1.86 1.92 (0.52, 4.92)

Moderate-deep 1.04 4.37 2.53 (0.51, 7.39)

Combined 0.94 1.79 2.80 1.69 (1.02, 2.64)

CIGAR & CIGARETTE 40/198

None, slight 10.55 1.73 3.14 2.64 2.69 (1.72, 4.00)

Moderate 1.80 1.72 1.42 (0.68, 2.62)

Deep 1.60 5.80 3.42 (1.25, 7.45)

Combined 4.11 1.74 2.95 1.88 2.40 (1.71, 3.27)

CIGARETTE ONLY 569/198

None, slight 2.41 2.14 0.95 1.99 (1.66, 2.36)

Moderate 3.71 2.16 2.24 1.01 2.01 (1.79, 2.25)

Deep 5.05 2.19 2.24 2.95 2.38 (1.98, 2.83)

Combined 3.66 2.22 2.25 1.19 2.06 (1.90, 2.24)

*Based on data from CPS-I study. Age-standardized rate ratio for smoking group compared to neversmokers.

**Number of deaths in subject group/neversmoker group.

a significant association of absolute rates of pancreatic cancers for primary

cigar smokers with age (F=32.1, p<10

-6

), inhalation (F=17.5, p<.0001), and

cigars per day (F=5.0, p=.03).

Summary Cigar smokers have higher rates of pancreatic cancer than nonsmokers,

particularly those who smoke higher number of cigars per day. Regression

analysis confirms significant relationships with the factors of age, inhalation,

and cigars per day for primary cigar smokers. These data suggest that cigar

smoking is a cause of pancreatic cancer.

CORONARY Matroos, Magnus and Strackee (1979) report a case-control study

HEART DISEASE conducted in the Netherlands comparing 397 cases of acute

myocardial infarction and 102 cases of fatal coronary attack, which taken

together are referred to as acute coronary events, to 891 neighborhood

controls matched by sex and age. Compared to noncurrent smokers

(neversmokers plus former smokers), cigar smokers as a group had an OR of

3.1 (2.0-5.1); the OR for cigarette smokers of 1 pack/day was 2.1 (1.5-2.8) and

for 2 packs/day was 2.0 (1.0-3.8), both lower than cigar smokers. The OR

of coronary events for cigar inhalers compared to non-current smokers was

3.4 (1.8-7.1); the OR for non-inhaling cigar smokers was 2.9 (1.8-5.2). For

cigar smokers, OR's for coronary events were not significantly different when

141

Smoking and Tobacco Control Monograph No. 9

Table 29

Coronary heart disease and cigar smoking: rate ratios by type of smoking (males only)

Odds Ratio (OR)

Never- Mixed, Cigar

Sample Size* Smoker Cigar & Cigarettes Cigarette

Case-Control Studies

Matroos (1979) coronary events 499/891 3.1 (2.0-5.1) 2.1 (1.5-2.8)

Kaufman (1987) MI, age 40-54 572/934

Primary cigar 1-4 cigars/day 0.9 (0.3-2.7)

Primary cigar 5+ cigars/day 1.7 (0.6-4.8)

Secondary cigar 1-4 cigars/day 1.5 (0.6-3.6)

Secondary cigar 5+ cigars/day 4.5 (2.2-9.2)

Prospective Rate Ratio (RR)

Hammond & Horn (1958) 187,783 1.0 1.28 1.70

Doll & Peto (1976) 41,000 1.0 1.03** 1.28 1.62

Best (1966) 78,000 1.0 0.99 1.60

Hammond (1966) age 45-54 440,559 1.0 1.15 2.81

Hammond (1966) age 55-64 1.35 1.84

Hammond (1966) age 65-74 0.93 1.45

Hammond (1966) age 75-84 1.10 1.24

Kahn (1966) 293,000 1.0 1.04 1.74

Gyntelberg (1981) first MI 5,212

Cigar Smokers 427 1.0 2.4 (1.4-3.8) 2.1 (1.7-2.7)

Cheroot 1,208 1.0 2.8 (2.1-3.6)

>6 Cheroots/day 315 1.0 4.2 (2.6-6.3)

Jajich (1984) elderly 2,674/265/32 1.0 1.67 (1.13-2.36) 1.94 (1.59-2.34)

Carstensen (1987) 25,129/1,256/42 1.0 1.16 (0.83-1.57) 1.48 (1.33-1.64)

Nyboe (1991) first MI 12,196 (see Table 30)

Ben-Shlomo (1994) secondary 19,018/658/42 1.0 0.91 (0.65-1.23) 1.74 (1.63-1.86)

Wald & Watt (1997) primary 21,520/1,309/33 1.0 0.98** (0.67-1.44) 2.27 (1.81-2.84)

Wald & Watt (1997) secondary 21,520/522/25 1.29** (0.88-1.99)

CPS-I primary 442,455/15,072/1527 1.0 1.05 (1.00-1.11) 1.29 (1.21-1.38) 1.54 (1.52-1.57)

CPS-I secondary 442,455/7,349/612 1.0 1.09 (1.01-1.18)

* For prospective studies reviewed, the number of cigar smokers and number of deaths in this group are also given.

** Cigar and pipe combined.

Chapter 4

142

hypertension was present or absent. An association between angina and

coronary events was not demonstrated for cigar smokers.

Kaufman et al. (1987) analyzed interview data in a case-control study of

572 men with non-fatal first myocardial infarction compared to 934 hospital

controls with non-tobacco related hospital admissions. Subjects and controls

were restricted to ages 40-54; both subjects and controls had to be either

never-cigarette smokers or to have stopped smoking cigarettes for at least

2 years. Thus a comparison was afforded between primary and secondary

pipe and cigars smokers. The estimated RR's of MI for subjects who had never

smoked cigarettes were elevated but not significant for smokers of 5 or more

cigars per day, pipe only, or cigars and pipe. For former cigarette smokers,

those who had smoked 5 or more cigars per day showed an elevated RR of

4.5 (2.2-9.2); the RR for those who had smoked fewer than 5 cigars or pipes

were slightly elevated but not significant.

In a prospective study of 5,249 Danish men followed for 7 years,

Gyntelberg et al. (1981) found the highest rates of myocardial infarction for

smokers of 6 or more cheroots/day (315 subjects), with a RR of 4.2 (2.6-6.3),

compared to neversmokers. Overall, cheroot smokers (1,208 subjects) had

a RR of 2.8 (2.1-3.6), all cigarette smokers (2,125 subjects) 2.1 (1.7-2.7), and

smokers of more than 10 cigarettes/day (875 subjects) 2.5 (1.2-5.2). A

multiple logistic regression analysis showed that cheroot smoking was a

significant factor for risk of MI. No information on previous smoking habits

was obtained, and smoking categories were allowed to overlap, so the cheroot

smokers would include both former and present cigarette and pipe smokers.

The authors also note that 75 percent of cheroot smokers indicate inhalation,

comparable to the rate of inhalation among cigarette smokers (74 percent).

The RR's presented do not appear to be age adjusted.

Jajich, Ostfeld and Freeman (1984) report on a prospective mortality

study of coronary heart disease in 2674 Chicago residents, aged 65 through

74, balanced for sex and black/white races drawn from a probability sample of

persons receiving old age assistance, followed for 4.5 years during 1965-1970.

Crude mortality ratios show a significant RR of 1.67 (1.13-2.36) for cigar/pipe

smokers in comparison to neversmokers, while current cigarette smokers had

a significant RR of 1.94 (1.59-2.34). However, when the analysis was adjusted

for other factors, cigar/pipe smoking was not significant, though current

cigarette smoking was significant.

In the Swedish prospective study (Carstensen 1987, see lung cancer) an

age-adjusted RR of 1.16 (0.83-1.57) for ischaemic heart disease is calculated

for cigar-only smokers compared to 1.48 (1.33-1.64) for cigarette smokers.

There is no trend for increased risk with increasing consumption of cigars,

given in grams/day. Though inhalation data was recorded, no analysis is

presented for cigar smokers. Categorization as cigar only smokers is made

by present behavior at the time of the initial survey questionaire, and may

include former cigarette and pipe smokers.

143

Smoking and Tobacco Control Monograph No. 9

Nyboe et al. (1991) studied the risk of first acute myocardial infarction

in a population-based prospective study of 12,196 Danish subjects of both

sexes, aged 30 or more. Their analysis finds highly significant effects related

to amount of tobacco per day and inhalation of smoke. There was no

statistically significant difference related to type of tobacco, whether plain

or filtered cigarettes, cigars/cheroots or pipes. They found no relationship

to duration of smoking in the past. Rates for former smokers were the same

as for neversmokers, and did not decrease with length of time since cessation

of smoking. The overall rates by grams/day (all tobacco) and inhalation are

reproduced in Table 30. The conversion rates used were 1 cigarette = 1 gm,

1 cheroot = 3 gm, 1 cigar = 5 gm, and pipe tobacco by weight. The RR's in

Table 30 are not stated to be age adjusted; the RR's for women are higher not

because absolute rates are higher, but because the rate for the comparison

neversmoker group is lower.

In the British prospective study discussed above (Ben-Shlomo et al., 1994,

see all-cause mortality) the secondary cigar smoker group (n=658) produced

an age-adusted RR for death from coronary heart disease of 0.91 (0.65-1.23)

when compared to neversmokers, while current cigarette smokers (n=7,921)

had a RR of 1.74 (1.63-1.86). Smoking categories are based on questions at

the beginning of the study, with no reclassification during the 18-years of

follow-up.

Wald and Watt (1997), in the follow-up study of 21,520 men discussed

previously, report a RR of ischaemic heart disease of 0.98 (0.67-1.44) for

primary cigar/pipe smokers and 1.29 (0.88-1.99) for secondary cigar/pipe

smokers who switched from cigarettes at least 20 years before the beginning

of the study, compared to a RR of 2.27 (1.81-2.84) for current cigarette

smokers. These rates are consistent with total tobacco consumption, levels

of inhalation, and carboxyhaemoglobin levels reported.

The tables for Coronary Heart Disease from the CPS-I data (Tables 31 and

32) show rate ratios compared to neversmokers by numbers of cigars/

Table 30

Estimated effect of tobacco smoking (all forms) on risk of acute myocardial

infarction among females and males*

RR of First Acute MI

Smoking group Females Males

Nonsmokers 1.0 1.0

Noninhalers 1.5 1.2

Inhalers

1-14 gm/day 3.6 1.6

15-29 gm/day 4.6 2.1

>30 gm/day 9.4 2.9

*Nyboe, 1991, p.444.

Chapter 4

144

Table 31

Rate ratio of coronary heart disease by level of cigar/cigarettes per day*

Age (years)

Daily Use 35-49 50-64 65-79 80+ Combined (95% CI) Deaths**

PRIMARY CIGAR 1,505/8,202

1-2 0.72 0.97 0.99 0.99 0.98 (0.91, 1.07)

3-4 2.08 1.09 1.05 1.02 1.06 (0.96, 1.16)

5 + 3.07 1.33 1.11 0.94 1.14 (1.03, 1.24)

Combined 1.77 1.12 1.04 0.99 1.05 (1.00, 1.11)

SECONDARY CIGAR 609/8,202

1-2 0.44 1.11 1.19 0.76 1.06 (0.92, 1.21)

3-4 1.67 1.22 1.24 0.68 1.10 (0.95, 1.27)

5 + 2.43 1.60 1.07 0.69 1.10 (0.96, 1.26)

Combined 1.46 1.32 1.17 0.72 1.09 (1.01, 1.18)

CIGAR & CIGARETTE 862/8,202

1-19 0.90 1.63 1.06 0.93 1.15 (1.04, 1.27)

20 4.02 2.15 1.31 1.08 1.47 (1.31, 1.64)

21 + 2.29 1.82 1.55 1.51 1.61 (1.36, 1.89)

Combined 2.34 1.84 1.19 0.98 1.29 (1.21, 1.38)

CIGARETTE ONLY 1,5659/8,202

1-19 3.10 1.80 1.36 1.08 1.40 (1.36, 1.45)

20 3.92 2.15 1.48 1.21 1.58 (1.54, 1.62)

21 + 4.58 2.28 1.53 1.22 1.65 (1.60, 1.69)

Combined 4.01 2.11 1.45 1.14 1.54 (1.52, 1.57)

*Based on data from CPS-I Study. Age-standardized rate ratio for smoking group compared to neversmokers.

**Number of deaths in subject group/neversmoker group.

cigarettes per day and by level of inhalation. The lowest levels of each table

for cigar smokers are not significantly different from neversmokers; however,

the rates for higher levels of cigars per day and moderate and deep inhalation

are significantly elevated.

The coronary heart disease data for primary cigar smokers from the CPS-I

study was subjected to a Poisson step-wise regression analysis in order to test

the association of the factors of chronological age, reported inhalation level,

and number of cigars per day. The independent variable tested was the

absolute rates of coronary heart disease mortality. The analysis produced the

following significant factors (Table 33): The level of inhalation is significant

in determining the rate of coronary disease. The square and square root

transformations of this arbitrary scale for inhalation were also tried, but in

this case the flat scale (0,1,2,3) fit best. The number of cigars per day was

also marginally significant, in this case the log transformation of the data fit

better than the flat scale of number of cigars.

Summary The studies of cigar smoking and coronary events present a pattern of

slightly elevated rates among cigar smokers who smoke heavily or inhale

deeply. The Danish study (Nyboe, 1991) and the CPS-I data provide evidence

of increasing rates with increasing numbers of cigars smoked each day; these

145

Smoking and Tobacco Control Monograph No. 9

Table 32

Rate ratio of coronary heart disease by level of inhalation*

Age (years)

Level of Inhalation 35-49 50-64 65-79 80+ Combined (95% CI) Deaths*

PRIMARY CIGAR 1461/8202

None 1.65 1.13 1.01 0.90 1.01 (0.96, 1.07)

Slight 2.79 1.10 1.13 1.51 1.23 (1.07, 1.41)

Moderate-deep 0.82 1.61 1.44 1.37 (1.07, 1.75)

Combined 1.79 1.11 1.04 0.99 1.05 (1.00, 1.11)

SECONDARY CIGAR 586/8,202

None 1.54 1.06 1.11 0.79 1.02 (0.92, 1.13)

Slight 0.69 1.55 1.23 0.47 1.10 (0.93, 1.30)

Moderate-deep 2.44 1.91 1.30 0.42 1.23 (0.99, 1.51)

Combined 1.49 1.31 1.15 0.69 1.08 (0.99, 1.17)

CIGAR & CIGARETTE 910/8,202

None, slight 1.42 1.42 1.03 1.05 1.12 (1.02, 1.24)

Moderate 3.57 2.12 1.43 0.74 1.43 (1.28, 1.58)

Deep 1.99 2.33 1.66 0.90 1.62 (1.37, 1.90)

Combined 2.37 1.83 1.20 0.97 1.29 (1.21, 1.38)

CIGARETTE ONLY 16,241/8,202

None, slight 3.46 1.94 1.40 1.06 1.45 (1.41, 1.50)

Moderate 3.88 2.03 1.43 1.17 1.52 (1.49, 1.55)

Deep 4.46 2.43 1.56 1.27 1.71 (1.66, 1.76)

Combined 4.00 2.11 1.44 1.13 1.53 (1.51, 1.56)

*Based on data from CPS-I Study. Age-standardized rate ratio for smoking group compared to neversmokers.

**Number of deaths in subject group/neversmoker group.

studies, plus those by Wald and Watt (1997) and Gyntelberg (1981), present

evidence for elevated rates for those inhaling cigar smoke. These data

establish that cigar smokers who smoke several cigars per day or who inhale

are at increased risk for coronary heart disease.

CHRONIC OBSTRUCTIVE Data from the prospective Cophenhagen City Heart Study

PULMONARY DISEASE (Lange 1992, see all-cause mortality) provides Chronic

(COPD) Obstructive Pulmonary Disease (COPD) rates for male and

female smokers of cigars and cheroots, with neversmokers as the comparison

group. Cheroots are commonly smoked by women as well as men in Denmark.

Table 33

Results of step-wise poisson regression of absolute rates of coronary heart disease deaths

Variable Coeffecient SE F-test Probability

(Constant) –0.05063 0.00269

Age (years) 0.09950 0.0000345 651.6 <10

–10

***

Inhalation (0-3) 0.2258 0.000397 20.8 0.00002***

Cigars per day 0.1443 0.000589 3.9 0.05*

***p<0.0001; **p<0.01; *p<.005.

Chapter 4

146

Table 34

COPD and cigar smoking: rate ratios by type of smoking (males only except as noted)

Never- Primary Mixed, cigar

Prospective Studies Sample size* Smoker Cigar & cigarette Cigarette

Hammond & Horn (1958) 187,783 1.0 1.29 2.85

Doll & Peto (1976) 41,000 1.0 9.33** 11.33 24.67

Best (1966) emphysema 78,000 1.0 3.33 5.85

bronchitis 78,000 1.0 3.57 11.42

Hammond (1966) emphysema 440,559 1.0 1.37** 6.55

Kahn (1966) 293,000 1.0 0.79 10.08

Lange (1992) male 6,511/808/4 1.0 3.7 (1.1-12) 6.4 (2.0-20) plain

Lange (1992) male 7.9 (2-3-27) filter

Lange (1992) female 7703/770/4 1.0 10 (2.3-48) 15 (3.1-65) plain

Lange (1992) female 16 (3.6-70) filter

Ben-Shlomo (1994) secondary 19,018/658/10 1.0 1.43 (0.68-2.63) 3.24 (2.86-3.65)

CPS-I primary 442,455/15,072/30 1.0 1.42 (1.0-2.0) 7.95 (6.1-10.2) 11.70 (11.1-12.3)

CPS-I secondary 442,455/7,349/33 1.0 4.39 (3.0-6.2)

*For prospective studies reviewed, the number of cigar smokers and number of deaths in this group are also given.

** cigar and pipe combined

147

Smoking and Tobacco Control Monograph No. 9

The overall RR for women cigar and cheroot smokers for mortality due to

COPD is 10 (2.3-48) and for men 3.7 (1.1-12). These rates are calculated to be

0.7 and 0.5 of the rate for cigarette smokers, both significantly lower.

However, when considering only those subjects reporting inhalation of

cigars/cheroots, the rate compared to smokers of cigarettes with inhalation is

2.1 times greater for women (0.8-5.3) and 0.9 (0.5-1.6) for men.

In the Whitehall prospective study (Ben-Shlomo, 1994), the secondary

cigar smoker group (n=658) produced an age-adusted RR for death from

COPD of 1.43 (0.68-2.63) when compared to neversmokers, while current

cigarette smokers (n=7,921) had a RR of 3.24 (2.86-3.65). Smoking categories

are based on questions at the beginning of the study, with no reclassification

during the 18 years of follow-up.

Tables 35 and 36 show the rate ratio for COPD for the various smoking

groups by numbers of cigars/cigarettes per day and by inhalation in the CPS-I

data. There is a positive gradient of rates with levels of inhalation across all

groups. The trend of increasing rates with increasing numbers of cigars/

cigarettes is less convincing, except for cigarettes where inhalation is usual.

The confidence intervals for rates of COPD for all primary cigar combinations

Table 35

Rate ratio of COPD by level of cigars/cigarettes per day*

Age (years)

Daily Use 35-49 50-64 65-79 80+ Combined (95% CI) Deaths**

PRIMARY CIGAR 30/119

1-2 1.61 1.84 1.39 (0.74, 2.38)

3-4 2.02 1.44 2.27 1.78 (0.89, 3.18)

5 + 1.00 1.16 1.03 (0.37, 2.23)

Combined 0.88 1.43 1.74 1.42 (0.96, 2.03)

SECONDARY CIGAR 33/119

1-2 1.48 3.19 2.64 (1.06, 5.44)

3-4 1.84 6.16 4.33 (2.07, 7.97)

5 + 8.96 5.03 8.39 6.68 (3.82,10.85)

Combined 4.25 4.79 3.71 4.39 (3.02, 6.16)

CIGAR & CIGARETTE 63/119

1-19 7.04 3.27 9.87 5.82 (3.77, 8.60)

20 12.12 10.39 16.50 12.44 (8.26,17.98)

21 + 9.01 9.76 6.84 (3.27,12.58)

Combined 8.92 6.09 10.83 7.95 (6.11,10.17)

CIGARETTE ONLY 1,376/119

1-19 6.89 9.71 8.32 8.86 (7.96, 9.84)

20 12.06 13.57 10.72 12.51 (11.48,13.60)

21 + 13.92 18.61 8.99 15.04 (13.73,16.45)

Combined 11.45 13.09 9.18 11.70 (11.09,12.34)

*Based on data fromCPS-I study. Age-standardized rate ratio for smoking group compared to neversmokers.

**Number of deaths in subject group/neversmoker group.

Chapter 4

148

Table 36

Rate ratio of COPD by level of inhalation.*

Age (years)

Level of Inhalation 35-49 50-64 65-79 80+ Combined (95% CI) Deaths**

PRIMARY CIGAR 27/119

None 1.00 1.94 1.09 (0.66, 1.70)

Slight 1.98 3.15 2.05 (0.66, 4.77)

Moderate-deep 6.39 6.31 4.52 (0.91,13.22)

Combined 0.61 1.38 1.65 1.32 (0.87, 1.92)

SECONDARY CIGAR 32/119

None 2.72 4.65 3.36 (1.96, 5.39)

Slight 2.21 4.46 17.14 7.68 (3.31,15.14)

Moderate-deep 11.51 7.07 5.84 (2.34,12.02)

Combined 3.79 4.93 3.84 4.42 (3.02, 6.24)

CIGAR & CIGARETTE 65/119

None, slight 4.05 4.22 6.78 4.92 (3.08, 7.45)

Moderate 13.34 7.89 8.99 9.17 (6.09,13.25)

Deep 12.77 9.26 41.19 19.00 (10.63,31.34)

Combined 8.96 6.06 9.69 7.61 (5.87, 9.70)

CIGARETTE ONLY 1,445/119

None, slight 8.17 9.10 8.46 8.80 (7.85, 9.85)

Moderate 11.52 13.69 10.00 12.28 (11.42,13.18)

Deep 14.41 19.51 10.62 16.07 (14.49,17.78)

Combined 11.56 13.06 9.29 11.74 (11.14,12.36)

*Based on data from CPS-I Study. Age-standardized rate ratio for smoking group compared to neversmokers.

**Number of deaths in subject group/neversmoker group.

include 1.0, so none of these rates are significantly different from the rate for

neversmokers, though the trend with inhalation is marked.

The CPS-I data was subjected to a step-wise Poisson analysis of variance

for each combination of factors in order to assess the association of the

various factors to the absolute rates of mortality caused by COPD. This

analysis yielded the following significant factors (Table 37): There is a

strongly significant effect related to age. The square of inhalation was a

stronger factor than inhalation or square root of inhalation, showing a

highly significant relationship to the rates of mortality. The analysis does

not show an effect related to numbers of cigars per day.

Summary The Lange study (1992) and the regression analysis of the CPS-I data

support the hypothesis that rates of COPD for cigar smokers who inhale are

significantly elevated. From the CPS-I analysis, the number of cigars smoked

daily is less significant in determining risk of COPD than the degree of

inhalation. The data taken as a whole support the conclusion that cigar

smoking can cause COPD in smokers who inhale deeply.

149

Smoking and Tobacco Control Monograph No. 9

Table 37

Results of step-wise poisson regression of absolute rates of COPD

Variable Coeffecient SE F-test Probability

(Constant) –9.6843 0.0226

Age (years) 0.1763 0.000291 46.5 <10

–8

***

Inhalation

(0-3) 0.7509 0.00117 39.4 <10

–7

***

Cigars per day — 0.2 0.89 NS

***p<0.0001; **p<0.01; *p<0.05.

CEREBRO-VASCULAR The Whitehall prospective study (Ben-Shlomo, 1994),

DISEASE (CVD) produced a RR of CVD of 1.00 (0.77-1.28) for the secondary

cigar smoker group, compared to neversmokers, while current cigarette

smokers had a RR of 1.74 (1.64-1.83).

In a prospective study of 7,735 British men followed for 12.75 years,

Wannamethee et al. (1995) found elevated rates of major stroke events (fatal

and non-fatal) in both primary pipe or cigar smokers and secondary smokers.

The age-adjusted RR for primary pipe or cigar smokers was 2.4 (0.8-7.6). For

secondary pipe or cigar smokers the RR was 3.2 (1.5-6.8). Both are similar to

the rates for light cigarette smokers 3.6 (1.8-6.9) (1-19 cigarettes per day). For

comparison, the cigarette-only smokers show a RR of stroke of 4.1 (2.2-7.4).

When the secondary pipe or cigar smokers are stratified into normotensive

and hypertensive groups, the RR for the normotensive group is 7.8 (2.1-30.0)

and for the hypertensive group 1.9 (0.7-5.2), compared to neversmokers in

the same normotensive/hypertensive group.

Haheim et al. (1996) report on risk of fatal stroke in the Oslo study,

analyzing data on 16,173 men followed for 18 years, beginning in 1972. In

their analysis, all smoking groups have significantly increased risk of stroke.

The RRs adjusted for age, diastolic blood pressure and blood glucose level

were 3.6 (1.05-12.3) for cigar/pipe only smokers; 6.7 (2.4-18.5) for cigarette-

only smokers; 9.8 (3.3-29.6) for smokers of cigarettes and pipe/cigar.

Smoking groups were divided according to smoking habits at the beginning

of the study, so the cigar/pipe group includes some proportion of secondary

smokers who formerly smoked cigarettes. No information is presented on

inhalation habits.

The results of the tabulations of CPS-I data for cigar smokers are given

in Tables 39 and 40. None of the cigar tables are convincing—neither the

RR's for primary cigar smokers by level of cigars per day nor the RR's by depth

of inhalation for primary cigar smokers are significant or show any trend,

though the results for cigarette-only smokers are significantly elevated.

Summary It is difficult to reconcile the results from the European studies and the

CPS-I results. The analyses for the Wannamethee (1995) and Haheim (1996)

studies present strong evidence that there is increasing stroke frequency

related to smoking cigars and pipes. These RRs are adjusted for age as well

Chapter 4

150

Table 38

Cerebrovascular disease and cigar smoking: rate ratios by type of smoking (males only)

Rate Ratio (RR)

Never- Mixed, Cigar

Prospective Studies Sample Size* Smoker Cigar & Cigarette Cigarette

Hammond & Horn (1958) 187783 1.0 1.31 1.30

Doll & Peto (1976) 41000 1.0 1.15* 1.21 1.34

Best (1966) 78000 1.0 1.28 0.88

Hammond (1966) 440559 1.0 1.09* 1.40 1.41

Kahn (1966) 293000 1.0 1.08 1.52

Ben-Shlomo (1994) secondary 19018/658/64 1.0 1.00 (0.77-1.28) 1.74 (1.64-1.83)

Wannamethee (1995) primary 7735/187/4 1.0 2.4*† (0.8-7.6) 4.1 (2.2-7.4)

Wannamethee (1995) secondary 7735/561/16 1.0 3.2*† (1.5-6.8)

Haheim (1996) 16173/1623/7 1.0 3.6* (1.05-12.3) 9.8* (3.3-29.6) 6.7 (2.4-18.5)

CPS-I, primary 442455/15072/435 1.0 0.96 (0.87-1.06) 1.12 (0.97-1.29) 1.24 (1.20-1.29)

CPS-I, secondary 442455/7349/134 1.0 0.92 (0.77-1.09)

* For prospective studies reviewed, the number of cigar smokers and number of deaths in this group are also given.

** Cigar and pipe combined

† Major stroke event—fatal or non-fatal

151

Smoking and Tobacco Control Monograph No. 9

Table 39

Rate ratio of cerebrovascular disease, by level of cigar/cigarettes per day*

Age (years)

Daily Use 35-49 50-64 65-79 80+ Combined (95% CI) Deaths**

PRIMARY CIGAR 431/2,556

1-2 1.87 1.24 1.02 0.95 1.01 (0.88, 1.17)

3-4 3.30 1.35 1.10 0.89 1.05 (0.88, 1.23)

5 + 0.74 0.81 0.79 0.79 (0.64, 0.97)

Combined 1.64 1.11 0.98 0.90 0.96 (0.87, 1.06)

SECONDARY CIGAR 133/2,556

1-2 1.46 0.93 0.88 0.95 (0.71, 1.26)

3-4 1.95 0.94 0.69 0.92 (0.67, 1.24)

5 + 3.42 1.06 0.93 0.79 0.89 (0.64, 1.22)

Combined 1.17 1.45 0.93 0.79 0.92 (0.77, 1.09)

CIGAR & CIGARETTE 190/2,556

1-19 2.14 1.76 1.15 0.62 0.99 (0.80, 1.20)

20 2.41 2.49 1.19 1.39 1.40 (1.08,1.79)

21 + 10.16 2.72 1.26 1.94 1.71 (1.16, 2.45)

Combined 4.32 2.19 1.15 0.82 1.12 (0.97, 1.29)

CIGARETTE ONLY 2,932/2,556

1-19 2.99 1.67 1.30 0.96 1.19 (1.12, 1.27)

20 3.16 2.03 1.26 0.97 1.22 (1.15, 1.29)

21 + 3.66 2.47 1.38 0.87 1.27 (1.19, 1.36)

Combined 3.32 2.11 1.31 0.95 1.24 (1.20, 1.29)

*Based on data from CPS-I study. Age-standardized rate ratio for smoking group compared to neversmokers.

**Number od deaths in subject group/neversmoker group.

as other factors such as diastolic blood pressure and body mass, whereas

the CPS-I results presented are only age-adjusted. The Haheim cigar data

is probably mixed primary and secondary cigar/pipe smokers. The CPS-I

primary cigar data are primarily individuals who report that they do not

inhale (78 percent), while inhalation information is not provided by the

other studies. If inhalation rates are much higher in the European studies,

this could explain some of the differences found in the RR of stroke between

the two groups of studies.

AORTIC Risk ratios of aortic aneurysm are shown to be elevated for both cigarette-

ANEURYSM only and cigar-only smokers by two prospective studies. The results for

the CPS-I data are given in Tables 42 and 43, by level of cigars/cigarettes per

day and by level of inhalation. Though the trend with increasing level for

cigar smokers is not clear, the overall result is highly significant: 1.76 (1.29-

2.35) for primary cigar smokers, 2.82 (1.91-4.00) for secondary cigar smokers,

3.32 (2.34-4.58) for cigar and cigarette smokers, and 4.96 (4.62-5.31) for

cigarette only smokers. The cigarette-only smokers do show a strong positive

trend both with increasing consumption of cigarettes per day and with

increasing levels of inhalation.

Chapter 4

152

Table 40

Rate ratio of cerebrovascular disease by level of inhalation

Age (years)

Level of Inhalation 35-49 50-64 65-79 80+ Combined (95% CI) Deaths*

PRIMARY CIGAR 410/2,556

None 1.13 0.86 0.95 0.88 0.91 (0.82, 1.02)

Slight 2.11 1.00 0.90 1.06 (0.79, 1.39)

Moderate-deep 13.98 1.69 1.08 1.16 1.22 (0.74, 1.91)

Combined 1.65 1.10 0.96 0.89 0.95 (0.86, 1.04)

SECONDARY CIGAR 132/2,556

None 0.81 1.09 0.84 0.95 (0.76, 1.18)

Slight 4.50 2.31 0.60 0.72 0.83 (0.55, 1.20)

Moderate-deep 2.86 0.80 0.54 0.88 (0.52, 1.38)

Combined 1.20 1.49 0.95 0.79 0.93 (0.78, 1.11)

CIGAR & CIGARETTE 202/2,556

None, slight 4.22 2.00 1.17 0.64 1.03 (0.85, 1.25)

Moderate 4.19 1.88 1.08 1.42 1.31 (1.01, 1.67)

Deep 3.54 3.58 1.22 0.86 1.30 (0.88, 1.86)

Combined 4.18 2.21 1.15 0.82 1.12 (0.97, 1.29)

CIGARETTE ONLY 3,083/2,556

None, slight 2.81 2.12 1.34 1.04 1.29 (1.21, 1.38)

Moderate 3.25 2.07 1.26 0.83 1.16 (1.10, 1.22)

Deep 3.66 2.25 1.35 1.08 1.33 (1.22, 1.43)

Combined 3.31 2.12 1.31 0.96 1.25 (1.20, 1.29)

Baed on data from CPS-I study. Age-standardized rate ratio for smoking group compared to neversmokers.

*Number od deaths in subject group/neversmoker group.

The step-wise Poisson analysis of absolute rates of mortality due to aortic

aneurysm of primary cigar smokers in the CPS-I study shows a significant

effect for the factors of age (F=66.1, p<10

-10

) and the square of inhalation

(F=45.3, p<10

-8

), but no significant effect for number of cigars per day (F=2.1,

p=.15). The moderate-deep inhalers for primary cigar do show an elevated

effect of RR=4.94 (1.59-11.52) in Table 43, a rate similar to the level for

cigarette-only smokers.

Summary The CPS-I study provides evidence that the risks of aortic aneurysm are

elevated for smokers, both for cigar smokers and cigarette smokers. Among

cigar smokers, the RR's for inhalers approach the risks observed for cigarette

smokers. The data from CPS-I support cigar smoking as a cause of aortic

aneurysm.

153

Smoking and Tobacco Control Monograph No. 9

Table 41

Aortic aneurysm and cigar smoking: rate ratios by type of smoking (males only)

Rate Ratio (RR)

Never- Mixed, Cigar

Prospective Stufies Sample Size* Smoker Cigar & Cigarette Cigarette

Kahn (1966) 293,000 1.0 2.06 5.24

CPS-I primary 442,455/15,072/46 1.0 1.76 (1.29-2.35) 3.32 (2.34-4.58) 4.96 (4.62-5.31)

CPS-I secondary 442,455/7,349/31 1.0 2.82 (1.91-4.00)

*For prospective studies reviewed, the number of cigar smokers and number of deaths in this group are also given.

Chapter 4

154

Table 42

Rate ratio of aortic aneurysm by level of cigar/cigarettes per day*

Age (years)

Daily Use 35-49 50-64 65-79 80+ Combined (95% CI) Deaths**

PRIMARY CIGAR 46/149

1-2 2.67 1.69 1.35 1.82 (1.11, 2.81)

3-4 0.96 1.57 0.88 (0.35, 1.82)

5 + 3.44 2.17 2.87 2.62 (1.58, 4.09)

Combined 2.17 1.61 1.76 1.76 (1.29, 2.35)

SECONDARY CIGAR 31/149

1-2 2.78 3.62 3.03 (1.51, 5.43)

3-4 4.60 3.39 2.80 (1.34, 5.16)

5 + 5.59 2.64 2.64 (1.26, 4.85)

Combined 4.31 3.14 2.82 (1.91, 4.00)

CIGAR & CIGARETTE 37/149

1-19 3.23 4.07 2.59 3.48 (2.13, 5.38)

20 2.24 3.49 2.32 (1.15, 4.14)

21 + 3.68 5.58 3.72 (1.36, 8.10)

Combined 2.97 4.17 1.99 3.32 (2.34, 4.58)

CIGARETTE ONLY 805/149

1-19 3.78 3.11 4.38 3.03 3.75 (3.25, 4.31)

20 7.11 4.23 6.15 3.94 5.17 (4.62, 5.77)

21 + 4.93 5.33 8.28 4.50 6.65 (5.90, 7.46)

Combined 5.54 4.36 5.92 3.49 4.96 (4.62, 5.31)

Table 43

Rate ratio of aortic aneurysm by level of inhalation

Age (years)

Level of Inhalation 35-49 50-64 65-79 80+ Combined (95% CI) Deaths*

PRIMARY CIGAR 45/149

None 2.06 1.59 1.78 1.73 (1.22, 2.39)

Slight 1.23 1.39 1.00 (0.20, 2.92)

Moderate-deep 7.93 4.02 4.94 (1.59,11.52)

Combined 2.20 1.65 1.68 1.77 (1.29, 2.37)

SECONDARY CIGAR 30/149

None 2.82 2.97 2.18 (1.22, 3.59)

Slight 8.00 3.28 3.52 (1.69, 6.47)

Moderate-deep 3.87 3.99 2.94 (0.95, 6.87)

Combined 4.41 3.23 2.67 (1.80, 3.82)

CIGAR & CIGARETTE 37/149

None, slight 2.57 2.15 2.49 2.32 (1.30, 3.82)

Moderate 3.08 6.71 4.17 (2.38, 6.77)

Deep 3.01 8.20 4.92 (1.80,10.72)

Combined 2.85 3.93 1.78 3.12 (2.20, 4.31)

CIGARETTE ONLY 827/149

None, slight 2.84 3.73 3.59 3.46 (2.94, 4.06)

Moderate 6.76 4.50 6.55 2.87 5.17 (4.71, 5.65)

Deep 5.19 4.83 8.17 4.88 6.57 (5.68, 7.55)

Combined 5.39 4.26 5.85 3.45 4.89 (4.56, 5.23)

Based on data from CPS-I study. Age-standardized rate raio for smoking group compared to neversmokers.

*Number of deaths in subject group/neversmoker group.

*Based on data from CPS-I study. Age-standardized rate raio for smoking group compared to neversmokers.

**Number of deaths in subject group/neversmoker group.

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Smoking and Tobacco Control Monograph No. 9

CONCLUSIONS

1. Regular cigar smoking causes cancer of the lung, oral cavity, larynx,

esophagus, and probably cancer of the pancreas.

2. Heavy cigar smokers, and those who inhale deeply, are at increased risk

for coronary heart disease and can develop chronic obstructive

pulmonary disease (COPD). Data from CPS-I suggest that cigar smokers

have an increased risk for aortic aneurysm.

3. On average, cigar smokers are less likely to inhale cigar smoke than are

cigarette smokers to inhale cigarette smoke, and this reduced inhalation

of tobacco smoke probably explains the lower risks of coronary heart

disease, COPD, and lung cancer seen among cigar smokers compared to

cigarette smokers.

4. The risks of cancers of the oral cavity and esophagus are similar among

cigarette and cigar smokers, probably due to the similar doses of tobacco

smoke delivered to these areas by smoking cigars and cigarettes.

5. Former cigarette smokers who currently smoke cigars are more likely to

inhale deeply than cigar smokers who have never smoked cigarettes, and

their risks are intermediate between cigarette smokers and cigar smokers

who have never smoked cigarettes.

6. Cigarette smokers who switch to smoking only cigars have lung cancer

risks that are lower than continuing cigarette smokers, but these risks

appear to be substantially greater than those for individuals who have

quit smoking all tobbaco products.

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Chapter 4

158

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159

Smoking and Tobacco Control Monograph No. 9

Appendix: Methods Used

In Analyzing CPS-I data.

AGE Many tables are presented which provide mortality risk

STANDARDIZATION ratios (RR) comparing observed rates for a particular disease

for a smoking group to rates for neversmokers. In all these tables, age

standardization has been carried out (Rothman, 1986). The differences in the

age composition of different subject groups would affect these comparisons

if no standardization were applied. For example, in the CPS-I data the age

distribution of primary cigar smokers is somewhat older than that of

cigarette-only current smokers, because of changing patterns in uptake over

time, and perhaps because of effects of differential mortality (NCI, 1997). In

order to make the groups comparable, all CPS-I rates and ratios for combined

age groups have been standardized to the age profile of the neversmoker

group, because the neversmokers are used as the reference comparison group

in determining the risk ratio for the various smoking groups. The

neversmoker subject group was selected as the reference group in preference

to a USA Population standard because the population standard is skewed to

younger age groups, where smoker mortality is lower and data from this

study are sparse. Thus, using a USA population standard would make rates of

disease for smokers appear to be lower and increase variability. In each case

rates are calculated for 5-year age groups (... 55.0-59.99, 60.0-64.99, ...) and

are standardized by weighting the contribution of the 5-year aged group

according to the proportion of the neversmoker population in that age

group. All rates given are rates of primary cause of mortality, as specified

by the primary cause of death from the death certificate. Confidence

intervals are calculated using the methods described in Breslow and Day

(1980, p. 131; 1987, p. 69).

STEP-WISE To test for a significant association of the factors of numbers of cigars

POISSON per day, level of inhalation, and chronological age to rates of mortality

REGRESSION for a specific disease, the absolute rates for each combination of factors

were subjected to a step-wise regression analysis using Poisson regression

(Breslow and Day, 1987). The objective of the regression analyses was not to

propose a biological model or predict rates of mortality, but to assess the

relative significance of factors and combinations of factors.

The factors were grouped as follows:

cigars per day value used in analysis

1-2 cpd 2

3-4 cpd 4

5+ cpd 7

depth of inhalation value used in analysis

none 0

slightly 1

moderately 2

deeply 3

Chapter 4

160

chronological age value used in analysis

40-44.99 42.5

45-49.99 47.5

50-54.99 52.5

55-59.99 57.5

Age was advanced during the 12 years of follow-up, with the data

tabulated into cells of current combinations of values. If smoking behavior

changed at the time of follow-up interviews, subjects were reclassified or

deleted from subject groups appropriately. All cells with at least 20 person-

years-of-observation (PYO) were retained for the analyses. For the primary

cigar subjects, there were typically 60-70 cells of combinations of factors

which met the minimum criteria for inclusion. Some portion of these cells

had at least one death, and hence a positive rate estimate for the disease.

When no death had occured for a combination of factors, no rate estimate

was possible, but these cells were also included with a 0.0 rate used. All cells,

including those with no deaths, were included in the regression in order not

to overestimate rates.

Several transformations of each variable were included, in order to test

the significance of possible variations. For the variable age, both the flat

values and log(age) were tested. For cigars per day, both the flat values and

log(cpd) were tested. For depth of inhalation, the flat values, as well as the

square and square root transformations, were tested. All regressions were

weighted to the square root of the observed PYO for the cell, thereby

weighting each cell in proportion to the confidence attached to the estimate

provided by that cell.

Data preparation was done in SAS; tabulation into cells of factors,

calculation of rates and standardization was done in Pascal; statistical

analysis of data was done in S-Plus.

161

Smoking and Tobacco Control Monograph No. 9

Indoor Air Pollution From Cigar Smoke

James L. Repace, Wayne R. Ott, and Neil E. Klepeis

INTRODUCTION

Smoking in enclosed spaces exposes occupants to indoor air pollution

from the by-products of tobacco combustion in confined spaces where airborne

contaminant removal is slow and uneven. This chapter investigates the factors

determining the indoor environmental tobacco smoke exposure from cigar

smoking. Mathematical models allow the prediction of the levels of indoor

pollutants, such as environmental tobacco smoke (ETS).

The physical design of the cigar, leaf type and composition, and wrapper

type may all affect the cigar emissions (Schmeltz et al., 1976) (Chapter 3). For a

given composition, the mass of a cigar consumed during smoking is the primary

determinant of the quantity of its emissions. The greater mass of tobacco in

cigars relative to cigarettes leads to a prolonged smoking time and greater total

emissions when a single cigar is smoked compared to a single cigarette. An

alternate means of comparing emissions from cigars with those of cigarettes is to

compare the emission per minute or per gram of tobacco burned. Both the

emission rates and the number of minutes a tobacco product is smoked need to

be considered when comparing the contribution of cigars and cigarettes to ETS.

The emissions of cigars differ from those of cigarettes due to differences in

construction and engineering and differences in tobacco leaf (Chapter 3). The

number of puffs taken to smoke a large cigar is dependent on the size of the cigar

and may be as high as 100, whereas for a cigarette, it is approximately 10 (Rickert

et al., 1985).

MATHEMATICAL ETS concentrations of indoors can be predicted with reasonable

MODELS FOR CIGAR accuracy by application of a mass balance model (Leaderer, 1990).

ETS CONCENTRATIONS This model shows that the average concentration, Z

ave

, of ETS

pollutants in indoor air is directly proportional to the pollutant mass emission

rate and inversely proportional to the rate at which a unit volume of indoor air is

cleared of ETS (Ott et al., 1992; Leaderer, 1990; Repace, 1987a,b).

Ott et al.(1992) have shown that the time-averaged ETS concentration Z

ave

(in units of µg/m

), is given by:

ave

= g

ave

/φν (1)

where g

is the cigar emission rate in units of µg/min, n

ave

is the average number

of cigars being smoked during the averaging time ∆T, where the generation

rate need not be uniform, i.e., the number of cigars being smoked at any instant

may vary. We define n

ave

= t

/∆T where t

is the total duration of smoking (Repace

et al., 1996). The quantity φ = qφ

is the effective air exchange rate in units of hr

-1

is the air exchange rate due to ventilation alone, and v is the space volume in

units of m

. The term q is an empirically-derived factor (q > 1) expressing the

Chapter 5

162

increase in removal over ventilation alone due to such processes as surface

sorption of particulate matter (Repace, 1987). The estimation accuracy of this

equation improves as the correction term ∆Z/φ∆T becomes small compared to

ave

, where ∆Z is the difference between the initial and final observed concentra-

tions (Ott et al., 1996).

For each individual cigar (Repace, 1987), the change over time of the ETS

pollutant concentration during smoking, assuming a uniform generation rate,

is given by Z(t), the concentration at time t where e is the base of natural

logarithms:

Z(t) = Z

(1 - e

φt

) (2)

After a long time period, the pollutant concentration approaches an equilibrium

value Z

, but most cigars typically are extinguished before reaching their

equilibrium value. The equilibrium value is a function of the emissions space

volume and ventilation rate and is defined by the equation.

= g

/φν (3)

Once smoking has ended, at a time t

, the concentration will decay as:

Z(t) = Z(t

) e

(t - t

)

(4)

where Z(t

) is given by Equation 2 with t = t

. Equations 2 through 4 are

illustrated in Figure 1.

Equations 1 through 4 allow the results from field surveys and chamber

experiments to be generalized, estimating concentrations for pollutants from ETS

in a variety of indoor settings. These predictions require determination of the

values of n

ave

, g

, ν, and φ. It is possible to determine φ by experiment and to

measure or estimate ν, and to determine φ

from either measurement or estima-

tion from tables of ventilation rates (Repace, 1987). The emission factor, g

, must

be measured for the ETS constituent of interest.

CIGAR EMISSIONS: The chemical composition of cigar smoke is described elsewhere

MACHINE SMOKING in this monograph (Chapter 3).

Sidestream smoke is the major contributor to ETS for cigarettes (Adams et al.,

1987; Surgeon General (SG), 1986); there is little available data on the relative

amounts of sidestream and exhaled mainstream smoke for cigars. On a per-cigar

basis, large cigars deliver substantially higher amounts of carbon monoxide (CO)

and other sidestream gas-phase constituents than little cigars or cigarettes, and

substantially higher amounts of sidestream ammonia (Schmeltz, et al., 1976).

Armitage et al. (1978) collected the exhaled mainstream and sidestream smoke of

seven male habitual smokers of both little cigars and cigarettes and reported

that the sidestream nicotine emissions averaged 30.9 percent + 5.4 percent of

total cigar nicotine, while exhaled mainstream smoke averaged 12.7 percent + 9.0

percent. The cigar butt retained 20.1 percent + 8.8 percent, while the smoker

retained the remainder, in an amount similar to cigarette smoking.

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Smoking and Tobacco Control Monograph No. 9

Figure 1.

Growth and decay of the concentration (in normalized units) of an ETS pollutant as a function of

time (in hours) as predicted by the mass balance model (solid line), respectively given by Equations 2

and 4 in the text. In this example, the air exchange rateφ = 0.84 hour

-1

, is equivalent to the ASHRAE

Standard for an office, and is slightly higher than the average closed window air exchange rate for a

home. Smoking begins at time

= 0, and ends at time

= 3 hours. The figure represents the concen-

tration from three cigars of 1 hour duration each smoked over a 3-hour period; the average number

of cigars smoked during the 3-hour period, is thus 1, from Equation 1. The concentration at the end

of the three hour smoking period is calculated by Equation 2 as

(3) = 0.93

. The dashed curve

shows the concentration which would occur if smoking continued; after a long time, the equilibrium

concentration

, described by Equation 3 in the text, is approached. The actual decay of concen-

tration after smoking ceases is given by Equation 4.

Chapter 5

164

CIGAR EMISSIONS: Machine smoking in chambers under standard conditions can

HUMAN SMOKING provide a comparison of the relative emissions of various tobacco

products. However, in order to understand how differences among tobacco

products affect ETS concentrations, we must also measure emissions and

concentrations when cigars are smoked by human smokers who, unlike

machines, smoke idiosyncratically.

Emissions of RSP, CO, Repace and Lowrey (1982) measured Respirable Suspended

and Nicotine from Cigars Particles RSP (particles less than 3.5 microns in aerodynamic

diameter) and CO emissions of a popular-priced, mass-market cigar (Marsh-

Wheeling Stogie, length ≈5-1/2”, ring size ≈38, mass ≈7 g) smoked in a well-

mixed volume ν = 51 m

in a mechanically ventilated office building. The

logarithms of the RSP and CO concentrations plotted versus time show a straight-

line decay pattern from which the air exchange rate can be calculated (Figure 2).

The cigar was smoked by a regular cigar smoker for 20 minutes, yielding a

predicted equilibrium of Z

= 830 µg/m

for RSP and 13.4 ppm (15,340 µg/m

)

for CO, calculated using Equation 3. The total calculated RSP emissions were

RSP

= 51m

x 830 µg/m

x 20 min / 16 min = 52.9 mg, and the RSP emission rate

was g

RSP

= G

RSP

= 52.9 mg/20 min = 2.65 mg/min. For CO, the total emissions

were G

= (51 m

x 15,340 µg/m

x 20 min) / 13.7 min = 1142 mg, using τ =1/φ

= 13.7 min (φ = 4.38 hr

-1

) yielding a CO emission rate of g

= G

= 57.12 mg/

min. Neither the fraction of the cigar smoked nor the after-smoking weight was

recorded.

In 1978, by comparison, a single king-sized Marlboro was smoked by a

smoker for t

= 5.33 mins in a ν = 29 m

unventilated but well-mixed bedroom

with the windows and door closed (Repace and Lowrey, 1980). The value of Z

1773 µg/m

for ETS-RSP was calculated using Equations 2 and 4, and the mean

residence time for the RSP was τ = 16.39 mins (R

= 0.80). Using Equation 3 (with

φ =1/τ ), the total RSP emissions were calculated to be G

RSP

= 29 m

x 1773 µg/m

5.33 min / 16.39 min = 16.72 mg per cigarette, and the RSP emission rate was g

RSP

= G

RSP

= 3.14 mg/min. The cigarette RSP emission rate is actually higher than

the cigar, although the total RSP emissions of the cigar are much greater due to

the four-fold greater smoking duration and larger mass of tobacco in the cigar.

Leaderer and Hammond (1991) measured the emissions of 10 U.S. brands of

cigarettes and 1 cigar (a cigarillo -- B. Leaderer, personal communication, 1997)

as smoked by human smokers. From data presented in the paper, an estimated

total of 440 U.S. cigarettes and 40 cigars were smoked in this study. The average

smoking duration for the cigarettes was 7.5 mins; the average duration for the

cigars was not specified, but appears to be the same as for the cigarettes. The RSP

emissions of the 10 brands of cigarettes representing 48 percent of the sales-

weighted U.S. market in 1987, averaged G

RSP

cig

= 27 + 3.4 mg/g, where an

average of M

cig

= 0.63 + 0.023 g of tobacco was smoked per cigarette. This results

in an emission rate of 2.27 mg of RSP per minute. The total average cigar emis-

sions were G

cigar

= 48 + 9.1 mg/g. The physical characteristics of the cigar were not

specified; however, a cigarillo typically contains less than 1.3 g of tobacco. The

165

Smoking and Tobacco Control Monograph No. 9

Figure 2.

Growth and decay of RSP and CO from a cigar smoked by a smoker in a mechanically ventilated 51

office at the U.S. Naval Research Laboratory’s main computer building in Washington D.C. in

1978. The effective air exchange rates of RSP and CO are similar (about 4 ach) due to the effect of

three mixing fans. By contrast, when the ventilation and mixing fans were not used, the effective air

exchange rate for RSP was 1 ach, and for CO, 0.43 ach (Repace and Lowrey, 1982).

Chapter 5

166

steady-state chamber nicotine concentration for the cigars was essentially the same

as for the cigarettes, whereas the RSP emissions were 28 percent higher for the

cigar.

Klepeis et al. (in press) report cigar smoking in two locations: a residence and

an office. These experiments consisted of the smoking of a cigar by a person in

both locations, and by a smoking machine in the latter. The effects on real-time

pollutant concentrations of various cigar durations, smoking styles, and ventilation

rates were measured.

In some of the experiments, two-minute average RSP concentrations were

measured with a TSI Model 8510 piezobalance. For one experiment, particle-bound

polycyclic aromatic hydrocarbon (PAH) concentrations were measured with an

EcoChem PAS 1002i Realtime PAH monitor (West Hills, CA).

The ventilatory air exchange rate was determined using Equation 4 by

observing the exponential decay of CO concentration after smoking had

stopped, thus including only the removal from air flow in and out of the room. In

contrast, the effective air exchange rate for RSP or PAH, which includes

mechanisms of RSP or PAH removal such as deposition and ventilation, was

measured by observing the exponential decay of RSP and PAH concentrations.

Together with the room volume and the observed pollutant time series, these decay

rates provided a means to calculate CO and RSP emission factors for each cigar.

In the residence, Klepeis et al. (in press) report results for a single cigar smoked

by a human smoker on two separate days in a 97 m

parlor. Measurements of the

particle size distribution showed that the bulk of the cigar aerosol mass was in the

particle-size range 0.1 to 2.5 µm. A regular cigar smoker smoked the cigar for 1 to 2

hours. Once the levels had declined to near background, a different smoker

smoked a cigarette for 9 minutes providing a comparison of the cigar and cigarette

emissions under the similar conditions (Figure 3).

The upper curves of Figure 3 show the real-time PAH concentrations of the

cigar and cigarette and the lower curves show the real-time RSP concentrations.

The mass balance model predicts the pollutant concentration time series with

reasonable accuracy (Figure 3, bottom) (Klepeis, et al., in press).

The ratio of CO to RSP concentrations is 1 ppm of CO per 165 µg/m

of RSP

for a Santona cigar smoked on day 1 (Table 1). The ratio of particulate PAH to RSP

concentrations is 1 µg/m

of particulate PAH per 238 µg/m

of RSP for a Paul

Garmirian cigar smoked on day 2. By contrast, for a Marlboro cigarette, the ratio is

1 µg/m

of particulate PAH per 137 µg/m

of RSP. However, the total PAH

emissions for the cigar are twice that of the cigarette due to the much longer

smoking duration and mass of the cigar.

In a field study of a 521 m

sports tavern, investigators machine-smoked four

Dutch Masters Corona Deluxe cigars in 11 minutes, two at a time. Figure 7 shows

the results for CO (Mage and Ott 1996, Ott et al. 1996). This experiment used the

decay of cigar CO to determine the ventilatory air exchange rate of the tavern,

= 7.5 ach. Similarly, the decay rate of RSP (less background) yielded the effective

air exchange rate for cigar RSP, φ = 7.63 ach. They used three CO monitors and two

167

Smoking and Tobacco Control Monograph No. 9

Figure 3.

The time series, i.e., growth and decay of PAH and RSP concentration with time, measured in a

naturally ventilated San Francisco residence while a Paul Garmarian cigar and a Marlboro cigarette

were smoked sequentially by two different persons on March 9, 1997. The upper plot shows the

source activity pattern (rectangles) and the PAH data, while the bottom plot shows the simulta-

neously measured RSP data and the RSP time series predicted by the mass balance model (Klepeis et

al., in press).

Chapter 5

168

Figure 4.

Relative Emissions, Cigars versus Cigarettes: For each of the measured compounds, large cigars

produce greater total emissions than cigarettes. For CO, RSP, PAH, and Cadmium, the emissions

ratios are for ETS. For all others except benzene, they are for sidestream smoke. For benzene, they

are for mainstream smoke. (Brunnemann et al. 1977; Appel et al. 1990; Brunnemann, Stahnke, and

Hoffmann 1978; Brunnemann, Yu, and Hoffmann 1979; Brunnemann Adams and Hoffmann 1979;

Brunnemann and Hoffmann 1978; Klepeis et al. in press; Brunnemann and Hoffmann, 1975.)

169

Smoking and Tobacco Control Monograph No. 9

Table 1

CO, RSP, and Nicotine Emission Factors

Measured in Various Cigar and Cigarette Studies

Source

Ave Source

Total ETS

Mass ETS emissions

Experiment Description Duration Emission Rate Source Emissions Smoked per Mass Smoked

Klepeis et al. (in press)

1 Sante Fe Fairmont cigar 7.8 min 140 mg CO/min 1.1 g CO 6 g 190 mg CO/g

smoked by a machine in

49.6 m

office (4/6/96); 4.5 ach

1 Sante Fe Fairmont cigar 24 min 50 mg CO/min 1.2 g CO 6.1 g 200 mg CO/g

smoked by a machine in a

49.6 m

office (4/7/96); 0.12 ach

1 AyC Grenadiers cigar 10 min 87 mg CO/min 890 mg CO 4.9 g 180 mg CO/g

smoked by a machine in a

49.6 m

office (4/27/96); 0.12 ach

1 AyC Grenadiers cigar 11.5 min 67 mg CO/min 780 mg CO 4.9 g 160 mg CO/g

smoked by a machine in a

49.6 m

office (4/29/96); 4.5 ach

1 Santona cigar smoked by a person in 76 min 14 mg CO/min 1.1 g CO 8.8 g 130 mg CO/g

a 97 m

parlor of a (1.3 hrs) residence

(3/1/97); 2.0 ach; 2.5 eff ach for RSP

1.0 mg 78 mg RSP 8.9 mg RSP/g

RSP/min

1 Paul Garmirian cigar 90 min 0.95 mg RSP/min 86 mg RSP 10.8 g 8.0 mg RSP/g

smoked by a person in a (1.5 hrs)

97 m

parlor of a residence

(3/9/97); 0.9 ach; 1.2 eff ach 0.0042 mg 0.38 mg PAH 0.035 mg PAH/g

for RSP and 1.5 for PAH PAH/min

1 Marlboro cigarette smoked 7 min 1.9 mg RSP/min 16 mg RSP 0.4 g 40 mg RSP/g

by a person in a 97 m

parlor

of a residence (3/9/97); 1.3

eff ach for RSP and 2.0 for PAH

0.022 mg 0.18 mg PAH 0.45 mg PAH/g

PAH/min

Repace and Lowrey (1982) 20 min 57 mg CO/min 1.14g CO not

1 Marsh Wheeling Stogie

smoked by a person in a 51 recorded

office; 3.8 ach for RSP;

4.4 ach for CO (mechanical

ventilation). 2.7 mg RSP/min 53 mg RSP

Nelson (1994) 13.8 + 3.1 mg ETS

50 top brands of cigarettes RSP per cigarette

smoked by a person in an

unventilated room (analyzed by

Repace et al., in press) 1.8 + 0.28 mg

ETS nicotine per cigarette

Klepeis et al. (1996) 11.9 mg CO/min

Cigarette smoking in two

airport lounges 1.43 mg RSP/min

CPRT (1990) 10.3

+ 2.4 mg RSP/g

13 brands of cigars sold not not not not

in Canada

reported reported reported reported 0.13

+ 0.08 mg

nicotine/g

Mage and Ott (1996) 11 min SW, 240 mg SW, 1.2 g CO not

4 cigars smoked two at a time (all sources) CO/min per cigar recorded

by separate machines in a 521 m

tavern (8/24/94); 7.2 ach; results

are from two monitors, one in SW NW, 250 mg NW, 1.3 g CO

booth and one in NW booth CO/min per cigar

Notes:

Calculations of emission factors are based on a single-compartment mass balance model, which assumes uniform mixing.

Experi-

ment descriptions include the type of cigar or cigarette source, the location where smoking took place, the room volume, and the air exchange

rate and/or effective air exchange rate, which includes all removal mechanisms (both are in units of air changes per hour).

Ave Source

Emission Rate is the average emission rate over the time the source(s) was(were) on and over all the individual sources that were ever active.

Total Source Emissions is the total mass emitted over all sources.

Mass Smoked is the measured difference between the mass of the

unsmoked cigar(s) or cigarette(s) source and the mass after smoking.

Emissions per Mass Smoked is Total Source Emissions divided by

Mass Smoked. 1 ppm = 1.145 mg/m

at 25

C and 1 ATM.

Source: Because of the exceptional and multi-source nature of this composite table, the general reference for the “Experiment

description” column is: Klepeis et al. (in press). Specific references for horizontal data fields are noted in bold in the table.

Chapter 5

170

RSP monitors, in three locations: a central table, a Southwest corner booth and a

Northwest corner booth. The 30 minute average RSP concentration for the two

monitors was 194 µg/m

. The 30 minute average CO concentration for the three

locations was 1.7 ppm (Mage and Ott, 1996).

Emissions of particulate phase Available evidence suggests that cigar smoke contains

Polycyclic Aromatic Hydro- many of the same carcinogenic PAH’s that are found

carbons (PAH’s) from Cigars in cigarette smoke (SG,1979; IARC, 1986).

Real-time measurements of particle-bound PAH’s (4 or more ringed

compounds) are possible using a newly-developed photo-ionization monitor

(EcoChem, West Hills, CA). Investigators have applied this new monitor to make

real-time measurements of PAH aerosols from tobacco smoking and other sources

in homes, automobiles, and outdoor ambient conditions (Buckley and Ott, 1996;

Wilson et al., 1993; 1994; Ott et al., 1994).

Klepeis et al. (in press) used the EcoChem 1002i monitor in a 97 m

San

Francisco parlor with a human smoking a Paul Garmirian cigar. The cigar caused

the particle-bound PAH level to increase by as much as 2500 ng/m

above a near-

zero background concentration, while a Marlboro cigarette increased the levels by

1700 ng/m

above background. Using a calibration factor of 1000 ng/m

per pA,

they report that the total PAH emission for the cigar was 380 µg, while the

cigarette emitted 180 µg. The emission rate and the total emissions per gram (22

µg/min, and 450 µg/g respectively) were higher for the cigarette than for the

cigar (4.2 µg/min, and 35 µg/g respectively), but the cigar emitted twice as much

total PAH as the cigarette because of its longer smoking time. The PAH concen-

trations of both the cigar and the cigarette shown in the upper part of Figure 3

generally track the RSP emissions shown in the lower part of the figure.

Figure 4 presents the total emission of various smoke constituents for cigars

contrasted with that from cigarettes. For CO, RSP, PAH, and Cd, the emissions

ratios are for ETS. For all others except benzene, they are for sidestream smoke.

MEASUREMENTS AT Klepeis et al. (in press) report results from two field experiments in

CIGAR SMOKING which an investigator wearing a concealed CO personal monitor

SOCIALS attended public social events that featured cigar smoking. The

hidden miniaturized monitoring instrument was a Langan L15 Personal Exposure

Measurer™ equipped with a battery-powered data logger (Langan, 1992). The

monitor was carried in the inside pocket of a jacket. Measurements were logged

every minute in the first field study, and every 15 seconds in the second study.

The first cigar smoking social event, a “Cigar Smoker,” was held in a

private club in suburban San Francisco. Four different types of cigars were

available at the entrance. The private club was a large house with two adjoining

rooms (a large reception hall with a mezzanine and a food preparation area)

measuring 1560 ft

(155 m

) in total area, with a volume of 570 m

. The event’s

sponsors opened all doors and windows to allow maximum flow of outdoor air.

The investigator wearing the monitor smoked the first cigar only partially

and then mingled with the other guests. Because the monitor was carried for

several hours while traveling to and from the party, it is possible to compare the

171

Smoking and Tobacco Control Monograph No. 9

in-vehicle and outdoor CO concentrations with those measured during the cigar

smoker (Figure 5). As many as 89 persons were present (when 50 persons were

present, there were 12 women and 38 men). Indoor CO concentrations during

the smoker ranged between 5 and 11 ppm, yielding an indoor average of about 6

ppm. The highest CO concentrations occurred on the upstairs mezzanine of the

main hall. If we adjust the observed CO concentrations by subtracting the

ambient CO levels of 1.5 ppm measured outside the building on the sidewalks,

the cigar smokers contributed about 4.5 ppm. The CO levels were similar to

those measured during the rush-hour freeway drive to the event on Route 280,

which is a major arterial roadway between San Francisco and San Jose, California.

The high air exchange rate caused by the wide-open doors and windows prob-

ably reduced the interior CO concentrations considerably.

The second concealed monitoring field study (Klepeis et al., in press) took

place at a cigar banquet held in a downtown San Francisco restaurant. This cigar

banquet featured three premium cigars per person: [a Hoyo De Monterrey

Epicure #2, (5”, ring gauge 50) (Curtis, 1995) a Romeo Y Julieta Gold Label

Churchill (7”, ring gauge 47) (Curtis, 1995) and a Partagas Series “D” #4,

(Robusto, 4-7/8”, ring gauge 50) (Curtis, 1995, Resnick, 1996). Figure 6 shows the

CO concentration time series from the point when the investigator departs from

home in Redwood City, driving North on California Highway 101 to San Fran-

cisco. The CO averages about 4 ppm on this leg of the trip.

The CO concentration spikes to about 18 ppm in the confines of the parking

garage, whereas it is only 1 ppm on the street. The guests received the first cigar

when they entered the door, which was kept open during the entire social, and

they gathered around the bar to socialize for about an hour prior to being seated

for dinner. The indoor levels in the restaurant-bar during the first hour, due to

about 24 smokers at the bar (including the investigator) were 13 to 17 ppm

(Figure 6). At 7:45 PM the patrons were all seated for dinner at individual tables

of 4 to 6 persons. After everyone was seated, waiters distributed the second

imported cigar to all and began serving the three-course dinner. The investigator

was seated with five other persons; all six smoked cigars during dinner; the

investigator’s cigar was only partially smoked. The third cigar was distributed

just before dessert; the investigator did not smoke his. Overall, more than 100

cigars were smoked during this banquet; “laser lighters” rather than matches

were used to ignite the cigars.

The indoor CO concentration averaged over the 3-hour-and-20-minute

event was 10 ppm, and about 75 percent of the 40 persons present were smoking

cigars at any instant of time. Based on measurements outdoors on downtown

sidewalks before and after the event, ambient CO concentrations were found to

be about 1 ppm, so the indoor CO concentration caused by cigar smoking was

about 9 ppm. If the cigar dinner had lasted more than 8 hours, then indoor CO

concentrations would have violated the National Ambient Air Quality Standard

(NAAQS) adopted by the Environmental Protection Agency (EPA) to protect

public health (9 ppm CO for 8 hours).

Chapter 5

172

Figure 5.

The carbon monoxide (CO) personal concentration time series measured before, during and after attendance at a “cigar party” in the San

Francisco Bay Area on January 1, 1997. The total volume of the establishment was about 570 m . At one point in the evening 89 persons

were present of whom about two thirds were estimated to be smoking cigars. Notice that the background CO levels outdoors are be-

tween 1 and 2 ppm, and that the average CO concentration while driving from San Jose to the party (5.5 ppm; 5:00 PM - 6:20 PM) is

similar to the average concentration while present at the party (5.8 ppm; 6:26 PM - 8:09 PM) (Klepeis et al. In press).

173

Smoking and Tobacco Control Monograph No. 9

Figure 6.

CO concentrations measured using a concealed personal exposure monitor at a cigar dinner party in downtown San Francisco. The

investigator carried the Langan L15 CO Personal Exposure Measurer concealed beneath his dinner jacket. Concentrations were logged

every 15 seconds, and the background value (concentration that would occur in the absence of indoor sources) was estimated as 1 ppm

(Klepeis et al. In press).

Chapter 5

174

Figure 7(b).

RSP concentration time series measured in a 548 m3 tavern at three locations after investigators

machine-smoked four cigars in the central area (Ott, Switzer, and Robinson, 1996). The RSP

concentration (PM

3.5

) was measured with two piezobalances in the middle of the room and at the

southwest corner booth. Figures 7 (a) and 7(b) suggest that when averaged over a length of time

long compared to the source duration, it doesn’t matter where you are in the tavern, illustrating both

the validity of the well-mixed assumption for the mass-balance model and the futility of spatial

separation of smokers and nonsmokers as a putative public health measure.

Figure 7(a).

CO concentration time series measured in a 548 m3 tavern at three locations after investigators

machine-smoked four cigars in the central area. The air exchange rate was 7.5 air changes per hour.

Despite the wide separation of the three monitors (approx. 6 - 7 m) the simultaneous CO exposures

at all three locations are nearly within + 10 percent of the overall average concentration (1.84 ppm),

which is used by ASTM (ASTM E 741) as a criterion for uniformity of mixing (Mage and Ott, 1996).

175

Smoking and Tobacco Control Monograph No. 9

CO concentrations recorded on the freeway while driving to and from this

cigar banquet averaged 4.5 ppm, similar to values observed on the freeway while

driving to the earlier cigar smoker social. This observation is the same as the

average in-traffic CO concentration measured on 96 trips on a year-long study of

an urban arterial highway in the San Francisco Bay Area (Ott et al., 1996). After

leaving the restaurant, the investigator walked to a San Francisco bar where

several cigarettes were being smoked but no cigars; indoor CO levels were about

4.5 ppm, much lower than at the cigar dinner.

These studies show that cigar smoking can considerably elevate indoor CO

concentrations in a restaurant, even when the doors are wide open, and the

ventilation system is operating.

DISCUSSION Klepeis et al. (in press) report that the average emission rate and total

emissions per source are not good emission factors for use in comparisons

between different cigars and/or other tobacco sources, because they depend on

smoking style, smoking duration, or the mass of the cigar smoked. Emission per

mass smoked is a better basis for use in comparisons of cigar potencies, since it

provides a normalized measure of the ability of a tobacco source to produce ETS-

pollutant concentrations. Klepeis et al. (in press) report that CO emissions per

mass smoked (Table 1) ranged from 130 mg CO/g to 200 mg CO/g for three

different brands of cigars and two different smoking styles (i.e., by a machine and

by a person) in five settings. Two different Santa Fe Fairmont cigars smoked by a

machine gave CO emissions per mass smoked that were very similar (190 and

200 mg/g). The AyC Grenadiers cigars emitted CO in amounts of 160 and 180

mg/g when smoked by a machine. A Santona cigar smoked in a residential parlor

generated CO mass emissions that were somewhat smaller (130 mg/g), which

might be due to either the different smoking style or the different cigar brand

(Table 1).

RSP emissions per mass smoked for two cigar experiments in a residential

parlor were 8.0 and 8.9 mg RSP/g (Klepeis et al., in press). These RSP emission

factors are comparable to the results found for the 13 brands of medium and

large cigars smoked in a Canadian Report (CPRT, 1990) described above, which

averaged 10.3 + 2.39 mg RSP/g. By contrast, the RSP emissions per mass smoked

for a cigarette in the same residence was 40 mg/g, which is five times larger than

the emissions per mass smoked for the cigar.

Emissions of PAH per mass smoked were calculated for both the cigar and the

cigarette in the second residential experiment of Klepeis et al.(in press) from

Figure 3. Although the errors in estimation of the PAH background levels intro-

duce additional uncertainty (about 20 to 30 percent error), cigarettes appear to

generate more PAH than cigars (PAH emissions of 0.45 versus 0.035 mg/g).

Cigars appear to emit less RSP and PAH per mass burned than cigarettes, but

cigars contain more tobacco than cigarettes and also tend to be smoked for much

longer time periods (10 minutes or less for a cigarette versus an hour or more for

cigars).

Chapter 5

176

The Effects of Cigar Using the mathematical models presented earlier, the concentration

Smoking On Indoor of ETS in an enclosed space will be directly proportional to the

Air Pollution smoker density (g

ave

/ν) and inversely proportional to the effective

air exchange rate φ. The effective air exchange rate for nonreactive gases is the

same as the air exchange rate due to building ventilation plus infiltration, and for

particles may be somewhat higher due to surface sorption or air cleaning (Repace,

1987).

Ventilation rates for mechanically ventilated buildings are recommended by

the American Society of Heating, Refrigerating and Air Conditioning Engineers

(ASHRAE, 1990) and are typically incorporated into local building codes. In

buildings without ventilation systems, closed-window air exchange rates are

determined by the tightness of the building structure, and open-window

ventilation rates may be comparable to or higher than in mechanically ventilated

buildings. Typical closed-window residential air exchange rates are of the order

of 0.75 ach. Typical mechanical air exchange rates designed for commercial

buildings are a function of the density of human occupancy, and range from 0.84

air changes per hour (ach) for office buildings to 7 ach for restaurants.

If the ventilation rate φ

is determined by the building structure and

condition and the building volume is fixed, the concentration of ETS in a

building will be determined by the number of smokers, their smoking rate, and

the emission rate of the tobacco product.

The concentrations of certain ETS constituents can be compared to the National

Ambient Air Quality Standards (NAAQS) for regulated outdoor air pollutants. The

NAAQS for particulate matter <10 µm (PM

) is 50 µg/m

on an annual basis, and on

a 24-hour basis, 150 µg/m

, with one exceedance allowed per year. Recently the U.S.

EPA adopted a new fine particle standard. This proposed EPA NAAQS for PM

2.5

(particle size < 2.5 µm) is 15 µg/m

averaged on an annual basis, or 65 µg/m

on a

24-hr average basis with one allowed violation (i.e., no more than one day at each

monitor in a location may exceed the specified daily standard concentration).

The RSP level from a single Paul Garmirian cigar smoked in a San Francisco

residence (Klepeis et al., in press) averaged 160 µg/m

over a 4.7- hour period (Table

1), or 31 µg/m

averaged over a 24-hour period. By comparison, the Marlboro

cigarette smoked in the same San Francisco residence averaged 65 µg/m

over a

period of 2.75 hours, or 7 µg/m

averaged over 24- hour period.

The current NAAQS for carbon monoxide is 9 ppm, an 8 hour time-weighted

average (TWA)(USEPA, 1996). The average CO concentration measured during

the cigar party (5.8 ppm) (Figure 3) is slightly greater than encountered on a

California freeway (5.5 ppm), despite the fact that all the doors and windows

were open.

On a per-cigarette basis, Ott et al. 1992, Rosanno and Owens 1969, and

Rickert et al. 1984 report total CO emissions ranging from 40 to 70 mg per

cigarette for sidestream smoke. On a rate basis, Ott et al. (1992) report an average

CO emission rate of 9.4 mg CO/min for cigarettes, which is much lower than the

14 to 140 mg /min emission rates that Klepeis et al. (in press) found for cigars.

177

Smoking and Tobacco Control Monograph No. 9

On a mass basis, Klepeis et al. (in press) report that CO emissions for cigars are

between 100 and 200 mg/g (Table 1). If the mass of a cigarette smoked is about

0.4 g, as it was for one of the experiments of Klepeis et al. (in press), then the

cigarette CO emissions per mass smoked would also be in the range of 100 to 175

mg /g. However, the larger total mass of a cigar results in the total CO emissions

of cigars studied by Repace and Lowrey (1982) and Klepeis et al. (in press) (Table

1) averaging more than 1000 mg/cigar, placing the total cigar CO emissions

about 1000/50 = 20 times that of a cigarette.

The cigar RSP emissions reported by Klepeis et al. (in press) and Repace and

Lowrey (1982) for 3 cigars averaged about 77 mg per cigar. By contrast, (Table 1)

data from Nelson (1994) as analyzed by Repace et al. (in press) show ETS-RSP

emissions of about 14 + 3 mg/cig for the top 50 brands of cigarettes; an RSP

datum, 16 mg/cig reported by Klepeis et al.(in press) for a single Marlboro is

consistent with these results. This suggests that total RSP emissions of large

cigars are 5 to 6 times greater than cigarettes.

From the limited data available (Table 1) it appears that the total PAH

emissions of a large Paul Garmirian cigar (380 µg) is only twice that of a Marlboro

cigarette (180 µg) because the PAH emission rate for the Marlboro was 5 times as

large as for the cigar. The total PAH emissions for the cigar, however, were twice

as great as the cigarette because of the more than ten-fold larger smoking time for

the cigar. (Table 1 and Figure 2).

Cigar size and the extended smoking time compensate for the cigar’s lower

emission rate for RSP and PAH and enhance the delivery of CO to the indoor

environment. Smoking a single cigar can result in a much higher exposure of

nonsmokers to CO, RSP, and PAH than smoking a single cigarette.

CONCLUSIONS

1. ETS from cigar smoke is a major and increasing source of exposure to indoor

air pollution.

2. When smoked in confined indoor spaces at typical smoking and ventilation

rates, cigars may produce concentrations of certain regulated ambient air

pollutants, including CO and RSP, which can violate federal air quality

standards and add to the level of these compounds already in the ambient air

from other combustion sources.

3. Measurements of the CO concentrations at a cigar party in a hall and at a

cigar banquet in a restaurant showed carbon monoxide levels comparable to

those observed on a crowded California freeway.

4. The smoking of one cigar generates more Respirable Suspended Particles

(RSP) and Polycyclic Aromatic Hydrocarbons (PAH) than the smoking of one

cigarette due to the larger mass of tobacco contained in a cigar, but the

amount of PAH and RSP generated per gram of tobacco burned appears to be

somewhat lower for cigars compared to cigarettes.

Chapter 5

178

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from small cigars. Clinical Pharmacol Ther 23:

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L., and Lyle R.E., eds. Lyon, France: IARC

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Brunnemann, K.D., and Hoffmann, D. Chemical

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and cigar smoke. J Chromatogr Sci 13: 159-163,

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Brunnemann, K.D., Stahnke, G., Hoffmann, D.

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181

Smoking and Tobacco Control Monograph No. 9

Pharmacology and Abuse Potential of Cigars

Reginald V. Fant and Jack E. Henningfield

INTRODUCTION Cigar tobacco contains the highly addictive drug nicotine in

concentrations similar to those observed in cigarettes; however, since most

cigars contain more tobacco, they also contain more nicotine than cigarettes.

Most cigar smokers do not inhale cigar smoke, and those who do inhale far

less than typical cigarette smokers (Chapter 4). The pH of the smoke from

most cigars is sufficiently alkaline to enable efficient absorption of nicotine

through the oral and nasal mucosa. These basic observations, along with the

behavioral observation that some cigar smokers report symptoms of

dependence and withdrawal similar to those of cigarette smokers, have led

the American Psychiatric Association to include cigars along with cigarettes in

their manual listing drug dependence and other disease states (American

Psychiatric Association, 1987). This chapter will review the scientific

evidence supporting the categorization of cigars as dependence-producing

nicotine delivery devices.

EARLY OBSERVATIONS The history of tobacco use includes accounts of cigar

OF ADDICTIVE EFFECTS smoking by native Americans dating back more than

1000 years. In fact, when the term addiction was applied to describe the

enslavement of some people to their tobacco in the late 1700’s, the main

forms of tobacco smoking were cigar and pipe smoking (Murray et al., 1991).

The cigarette, which is now the most commonly used nicotine delivery

device, did not make its appearance in common use until the 1840’s (McKim,

1986).

It has long been recognized that cigars contain and deliver psychoactive

doses of nicotine. The concept that tobacco strain, growing conditions, and

manipulation of the pH of nicotine preparations could greatly affect the

amount of nicotine available from cigars was reported by Graham and

Carr in 1924. In 1925, Mendenhall noted that the experiments in which a

pipe or cigar was smoked were more likely to have subjects report feelings

of being dizzy or sick than experiments in which subjects smoked cigarettes,

presumably because the cigars and pipes delivered more nicotine than

cigarettes. In 1931, Lewin reported on the psychoactive effects of cigars,

noting the ceremonial use of cigars to produce a strong psychosis during

which a young man can “see spirits which prophesy his future and endow

him with strength, knowledge and happiness” (from Phantastica: Narcotic

and Stimulating Drugs, Their Use and Abuse reprinted in English by E. P.

Dutton and Company, 1964). Lewin concluded that the pharmacological

effects of tobacco, smoked or unsmoked, were primarily due to the nicotine

released from the tobacco and absorbed by the person. Other pharmacologic

effects of cigar smoking, including tolerance, pleasure, and tranquilization

were described by Gies et al. in 1921, who concluded that these effects

contributed to the habitual use of cigars. Interestingly, Gies and colleagues

(1921) listed cigars before cigarettes in the order of greatest to least degree of

psychoactive and toxic potency.

Chapter 6

182

Other psychological and physiological effects of cigar smoking have

also been referenced in classic early psychopharmacology research. Bates

reported on the cardiovascular (Bates, 1922a), as well as the cognitive and

psychomotor (Bates, 1922b) effects of cigar smoking. Bates showed that

smoking increased systolic and diastolic blood pressure, as well as heart rate.

Mixed results of cigar smoking and cigar smoke deprivation were seen on

psychomotor and cognitive performance tasks which included arithmetic

and dart throwing. Dixon (1928) also reported on the cardiovascular effects

of cigar smoking as well as the on the cognitive-enhancing effects of cigar

smoking and the lowered cognitive performance produced by deprivation

from cigars. In 1927, Dixon reported on the psychoactive and performance

effects of cigar smoking and stated that “acquired tolerance to nicotine is

probably the same as that of morphine” (p. 20). Thus the concept that many

of the effects of cigar smoking are due to nicotine has been understood for

well over 70 years.

NICOTINE DOSING Cigars contain and deliver a wide range of biologically-active

CAPABILITY OF chemicals, several of these such as nicotine, acetaldehyde, and

CIGARS carbon monoxide can serve to modify behavior. However, of all

the chemicals known to be common across most cigar brands, nicotine is the

only known dependence-producing drug present in substantial quantities.

This section examines the nicotine dosing capabilities of cigars in greater

detail to determine how cigars compare to products known to readily cause

nicotine addiction, namely cigarettes and smokeless tobacco.

The nicotine delivery of cigars is a complex issue due to the variability

in size, nicotine content, and pH of various cigar brands. Henningfield et al.

(1996) examined characteristics of ten cigar brands selected from a cigar

retailer in Baltimore. Table 1 summarizes the results of this study. The

weight of the cigars examined ranged from 0.77 to 22 g, and the nicotine

content of these products ranged from 10 to 444 mg. The pH of the tobacco

in solution also varied greatly, with values ranging from 6.2 to 8.2. By

contrast, cigarettes typically weigh less than 1 g and contain an average of

8.4 mg nicotine (Benowitz et al., 1983), and cigarette tobacco is generally

mildly acidic with pH values ranging from 5.5 to 6 (Brunneman and

Hoffmann, 1974). Additionally, in 1996, 98.2 percent of cigarettes produced

in the United States had filters which prevent the direct contact of the

cigarette tobacco with the lips and the buccal mucosa (United States

Department of Agriculture, 1997).

The data in Table 1 indicate that cigars contain amounts of nicotine

ranging (on the low end) from that equivalent to a single cigarette to (on

the high end) that equivalent to an entire pack of cigarettes. With the

exception of cigars that are similar in size to cigarettes, most cigars contain

nicotine in quantities equivalent to several cigarettes. In addition, the higher

pH of cigar tobacco and cigar smoke may result in a higher proportion of the

nicotine contained in a cigar being in free unprotonated form and more

available for absorption via the mouth, nose, and throat than is the case with

cigarettes.

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Smoking and Tobacco Control Monograph No. 9

Table 1

Physical characteristics of ten cigars selected at random from a cigar retailer in Baltimore, MD,

November 1995* (Reprinted from Henningfield et al., 1996)

Total

Nicotine Nicotine

Length Diameter Weight Concentration Content Tobacco

Code (mm) (mm) (g) (mg/g) (mg) pH

A 68 8 0.77 14.95 16.59 6.2

B 79 8 1.12 9.00 10.08 6.6

C 124 17 9.56 17.40 166.30 6.8

D 125 12 4.20 4.70 19.74 7.6

E 138 17 12.60 8.43 106.22 7.3

F 148 12 5.78 10.74 62.07 7.2

G 149 16 10.06 7.75 77.79 8.0

H 170 17 15.37 16.35 251.30 6.7

I 198 21 22.00 22.00 444.00 7.1

J 214 20 21.29 8.90 189.50 8.2

* Nicotine content was determined by the HPLC method. Smoke pH was not assessed; however, the pH of the tobacco

was determined by suspending 2 g of tobacco in 10 ml of water, mixing, then testing at fixed intervals up to 60 min.

INHALATION OF The manner in which a person smokes a cigar also affects nicotine

CIGAR SMOKE delivery. Some cigar smokers regularly inhale smoke, whereas

others inhale very little (Turner et al., 1977). The pKa of nicotine is 8.02,

which means that 50 percent of nicotine is in an unionized state, and this free

unprotonated nicotine is present in the vapor phase of cigar smoke which

contributes to the nicotine's rapid absorption through the oral mucosa (Lide,

1991). Therefore, nicotine from cigars which generate smoke with a high pH

could readily be absorbed across the buccal mucosa, and smokers would not

need to inhale the smoke deeply into the lung to absorb substantial amounts

of nicotine. Absorption of nicotine through the buccal mucosa is highly pH

dependent; absorption in the lung is less influenced by pH due to the much

larger absorptive surface area of the lung. The smoke from cigarettes and

those cigars which produce low–pH smoke must therefore be inhaled in order

to absorb substantial amounts of nicotine. In contrast, cigar smokers with a

high–pH smoke can absorb nicotine by holding the smoke in their mouth,

or they can increase their absorption by inhaling. These differences in the

absorption of nicotine from cigar and cigarette smoke are likely to contribute

to the lower rates of inhalation among cigar smokers.

A cigar can also function much like a smokeless tobacco product such

as chewing tobacco or oral snuff (i.e., “spit tobacco”) and permit extraction

of nicotine from the unburned tobacco so that it can be absorbed directly

through the buccal mucosa and lips. This is possible for two reasons which

Chapter 6

184

distinguish most cigars from most cigarettes: (1) most cigars have neither

filters nor tips and are designed and used in a manner such that tobacco

leaf material is in direct contact with the lips and to a lesser extent, with the

tongue and gums; this contact serves to moisten the leaf and enable extraction

of its nicotine; (2) most cigars are manufactured with tobacco leaf material

which has been cured and/or buffered so as to produce a mildly alkaline

tobacco which facilitates nicotine transfer.

Several studies have examined the absorption of nicotine from cigar

smoke in human cigar smokers as well as in animals exposed to cigar smoke.

Armitage and Turner (1970) examined delivery of nicotine by cigars and

cigarettes through the oral mucosa in cats. The authors found that

pharmacologic responses to the smoke were greater following cigar smoke

exposer than following cigarette smoke exposer despite the fact that more

nicotine was present in the cigarette smoke (4.4 mg versus 4.0 mg after 30

puffs of cigarette and cigar smoke, respectively). The authors interpreted these

results to mean that more nicotine was absorbed from the cigar smoke due to

the higher pH values in the cigar smoke (pH = 5.4 for cigarette and 8.5 for cigar

smoke). Armitage and Turner (1970) also describe a separate experiment in

which carotid blood levels of nicotine were measured after placing solutions of

nicotine with pH values of 6, 7, and 8 in the mouths of cats. The authors

found that absorption of nicotine in the first 2.5 min was 8 times higher

following the pH 8 solution compared to the pH 6 solution.

Pechacek et al. (1985) examined serum thiocyanate levels, a chemical

marker for inhaled tobacco smoke, in cigarette smokers, ex-cigarette-smoking

cigar and pipe smokers, and never-cigarette-smoking cigar and pipe smokers.

The authors found that cigarette smokers inhaled the greatest amount of

tobacco smoke, followed by ex-cigarette smokers, then never-cigarette-smoking

smokers of cigars and pipes. The authors suggest that most cigarette smokers

inhale, whereas only some cigar smokers inhale, and that inhalation among

cigar smokers is influenced by former cigarette smoking status. Serum

thiocyanate levels were also related to the number of cigars smoked per day;

subjects who smoked four or more cigars per day had serum thiocyanate levels

comparable to cigarette smokers who smoked ten cigarettes per day. However,

most of these heavy (> 4 per day) cigar smokers also tended to be ex-cigarette-

smokers.

Similar results were found in a study by Turner et al. (1986) in

which carboxyhemoglobin was used as the biological marker of inhaled

tobacco smoke. Turner et al. found that the mean concentration of

carboxyhemoglobin was 4.8 percent of the total hemoglobin among cigarette

smokers, compared to 0.9 percent among never-cigarette- smoking cigar

smokers and 6.8 percent former-cigarette smoking cigar smokers.

Combined data from more than 8,000 tobacco smokers, of whom more

than 1,000 smoked cigars or pipes, from the Multiple Risk Factor Intervention

Trial (MRFIT) confirmed significant levels of tobacco exposure (based on serum

thiocyanate) and smoke inhalation (based on expired air carbon monoxide)

among cigar smokers as compared to non tobacco users (Ruth and Neaton,

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Smoking and Tobacco Control Monograph No. 9

1991). Not surprisingly, overall levels of nicotine and smoke exposure were

lower and more variable among cigar smokers than among cigarette smokers.

Another analysis of data from MRFIT indicated that switching from cigarette

smoking to cigar or pipe smoking resulted in decreased smoke exposure, but

that levels remained significantly higher than those observed during tobacco

abstinence (Ockene et al., 1987). The former cigarette smokers were also

more likely to report inhaling cigar or pipe smoke into the lung than were

cigar smokers who had never smoked cigarettes. The MRFIT data on cigar

smoke inhalation patterns by former cigarette smokers are consistent with

those reported in Chapter 2 and show that less than 15 percent of cigar

smokers who never smoked cigarettes reported inhaling smoke into the lung,

more than 20 percent of former cigarette smokers and approximately

two-thirds of concurrent cigar and cigarette smokers reported inhaling.

These data confirm that some cigar smokers who formerly or currently

smoke cigarettes are likely to obtain regular doses of nicotine by inhalation

of smoke directly into the lung.

RATE OF NICOTINE Armitage et al. (1978) examined the absorption of nicotine from

ABSORPTION small cigars labeled with 14C-nicotine. The authors found that

the amount of nicotine delivered to the smoker’s mouth during cigar

smoking was greater that that during cigarette smoking, but the proportion

retained by the subject was similar for cigars and cigarettes. Arterial nicotine

concentrations were comparable for the two products, but the rise in arterial

plasma nicotine levels was faster for cigarettes than for the small cigars. This

difference in rates of delivery is probably due to the route of absorption since

cigarette smoke is delivered largely through the lung, whereas cigar smoke is

delivered through both the oral and lung routes, mostly buccal in subjects

where there is little inhalation. Nicotine delivery to the brain is slower when

nicotine is absorbed across the oral mucosa compared to absorption across

the alveolar surfaces of the lung (Benowitz et al., 1988). In addition,

absorption through the pulmonary route is more complete than through

the oral route, which accounts for the fact that, whereas more nicotine was

actually delivered to the mouth by the small cigars than by the cigarettes,

similar amounts were actually retained.

Inhalation parameters have a dramatic affect on nicotine delivery. A

study which examined the absorption of nicotine from non-inhaled cigar

smoke found nicotine delivery to be slower than that observed following

cigarette smoke inhalation (Russell et al., 1980). The authors studied the

nicotine absorption from a single small cigar (6.2 g) and found an increase

in plasma nicotine of 16.5 ng/ml after 1 hour of smoking the single cigar

(Medallion Petit Corona).

Despite the acidic pH of cigarette smoke, inhalation into the lung can

produce arterial nicotine concentrations as much as ten times greater than

those concurrently observed in venous blood. Arterial levels achieving

values of nearly 100 ng/ml have been reported with smokers smoking a

single cigarette (Henningfield et al., 1993).

Chapter 6

186

In summary, cigars have the capability to provide high levels of nicotine

exposure, whether or not their smoke is inhaled. Furthermore, measures

of physiologic response (e.g., Gies, 1921; Bates, 1922a, 1922b), as well as the

toxicological consequences of cigar smoking (Chapter 3 and 4), demonstrate

that humans can be exposed to high levels of nicotine through their

consumption of cigars. On the other hand, the extraordinary variability

in cigar nicotine content, the pH of tobacco and tobacco smoke , and

inhalation patterns of cigar smokers imply that a wide range of levels of

absorption, and potentially of dependence, would be expected to occur.

Drug Addiction: “Drug addiction” is the common term for the various medical

Basic Concepts and social disorders related to the compulsive ingestion of

and Definitions psychoactive chemicals. The term “drug addiction” is often used

interchangeably with the term “drug dependence” even though the term

“drug dependence” is the preferred technical term in the scientific and

medical literature. In this report, the terms “addiction” and “dependence”

will be used interchangeably to refer to the syndrome of drug seeking

behavior that meets criteria described in Table 2.

The occurrence of an abstinence-induced withdrawal syndrome may

also play a role in the development of drug dependence. A drug withdrawal

syndrome reflects an adaptation of behavioral and physiologic processes such

that physiologic, cognitive and behavioral functioning are impaired when

the drug is no longer present. This effect of drug exposure can complicate the

process of achieving and maintaining drug abstinence, and the symptoms

Table 2

1988 Surgeon General’s report criteria for drug dependence (US DHHS, 1988)

Primary Criteria:

Highly controlled or compulsive use

Psychoactive effects

Drug-reinforced behavior

Additional Criteria:

Addictive behavior often involves:

stereotypic patterns of use

use despite harmful effects

relapse following abstinence

recurrent drug cravings

Dependence-producing drugs often produce:

tolerance

physical dependence

pleasant (euphoriant) effects

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Smoking and Tobacco Control Monograph No. 9

can be so unpleasant as to precipitate relapse in those who do achieve

abstinence (Jaffe, 1985; US DHHS, 1988). Drug addiction can be powerful

even in the absence of a withdrawal syndrome, however. In fact, the

majority of people monitored in surveys by the National Institute on Drug

Abuse who regularly use addictive drugs (including cocaine and marijuana)

report that they have not experienced withdrawal, even though many of

these people feel dependent and have been unable to maintain abstinence

(US DHHS, 1988).

NICOTINE Tolerance to the effects of nicotine is demonstrated by the fact that

DEPENDENCE most cigarette smokers increase their consumption of cigarettes over

time. Daily use increases over several years and then stabilizes. Only 10 to

15 percent of cigarette smokers smoke fewer than five cigarettes per day

(Shiffman, 1989; Giovino, 1991). Between 1/3 and 1/2 of people that try

even one cigarette develop an escalating pattern of use. This rate is much

higher than that seen with other addictive drugs (US DHHS, 1994). Current

epidemiological data suggest that the majority of adult cigar smokers

maintain patterns of intermittent use and smoke fewer cigars per day than is

seen in cigarette smokers (Chapter 2).

The extensive studies of time course and symptomology of withdrawal

symptoms that have been conducted in cigarette smokers have not been

duplicated in cigar smokers; however, several lines of evidence suggest

that it may be possible for cigar smokers to develop a similar syndrome

of withdrawal. Withdrawal symptoms from cigarettes, which primarily

involve lung-delivered nicotine, are generally similar in nature, but higher

in magnitude when compared to withdrawal symptoms associated with

smokeless tobacco use, which primarily involve bucally-absorbed nicotine

(Figure 1) (Centers for Disease Control and Prevention, 1994). A pattern of

increasing severity of symptom development with increasing frequency of

use is present for use of both cigarettes and smokeless tobacco. Other

research on withdrawal from cigars and smokeless tobacco confirms the

similarities in withdrawal symptoms across nicotine delivery formulations.

However, it appears that formulations which deliver nicotine very slowly

(e.g., nicotine patch and smokeless tobacco), or in generally low daily

doses (e.g., nicotine gum as typically used), result in weaker syndromes

of abstinence-associated withdrawal. Discontinuation of smokeless

tobacco results in less reliable and/or weaker syndromes of withdrawal

than discontinuation of cigarette smoking (e.g., Hatsukami et al., 1987;

Henningfield, et al., 1997). These observations raise the possibility that

withdrawal syndromes may be associated with regular heavy cigar smoking

(which typically involves less lung exposure to nicotine than cigarette

smoking). However, comparisons are complicated by the extraordinarily

wide variation in nicotine delivery characteristics across cigars and smoke

inhalation patterns of cigar smokers along with the absence of specific data

for cigar smokers.

Chapter 6

188

Percent Ratings of “Yes”

“Find it hard to concentrate”

0 1-14 15-29 30

10.0

20.0

30.0

40.0

50.0

Cigarette Smokers

SLT Users

60.0

70.0

80.0

90.0

Percent Ratings of “Yes”

0 1-14 15-29 30

0.0

10.0

20.0

30.0

40.0

50.0

Cigarette Smokers

SLT Users

60.0

70.0

80.0

90.0

Percent Ratings of “Yes”

0 1-14 15-29 30

0.0

10.0

20.0

30.0

40.0

50.0

Cigarette Smokers

SLT Users

60.0

70.0

80.0

90.0

“Feel more irritable”

“Strong need/urge to smoke/chew”

Days Used in Past 30 Days

Figure 1

Symptoms of nicotine withdrawal among adolescents and young adults by the number of days

of reported use of cigarettes or smokeless tobacco within the past month. Reported withdrawal

symptoms significantly increased as a function of days used (Centers for Disease Control and

Prevention, 1994).

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Smoking and Tobacco Control Monograph No. 9

FACTORS INFLUENCING The level of dependence of nicotine in adults has been

NICOTINE DEPENDENCE found to be inversely related to the age of initiation of

smoking when measured by diagnostic criteria of the American Psychiatric

Association (Breslau et al., 1992) or by Fagerstrom Tolerance Questionnaire

Score (Henningfield, 1987). Because cigars vary so widely in their nicotine

dosing characteristics, it is possible for an individual to obtain as much

nicotine from one or two cigars with substantial nicotine dosing capacity

as from a much larger number of smaller cigars or cigarettes. Because

nicotine may be extracted directly from lip contact with the cigar tip itself,

the common practice of keeping an unlit cigar in the mouth may also

contribute to the total daily nicotine intake of some cigar smokers.

For many people, the process of graduation from first use to addiction

is not immediate and can take months or even years (US DHHS, 1988).

Initial experiences with tobacco, as with other addictive substances, are often

negative, requiring social pressures and other factors to maintain exposure

until the addiction develops (Haertzen et al., 1983). Over the course of many

months, tolerance develops such that dysphoric subjective effects become

minimal and much higher doses are needed to obtain the desired euphoric

effects. At that point, mood, behavior, physiologic function, and cognition

require the continued presence of nicotine to enable the person to feel

normal — the person has become dependent.

With respect to cigarette smoking, 80 to 90 percent of all current

cigarette smokers smoke more than five cigarettes and the vast majority of

these individuals display symptoms of nicotine dependence. Some

individuals who smoke fewer than six cigarettes per day appear able to smoke

with a much greater degree of volition and display few symptoms of nicotine

withdrawal upon cessation (Shiffman, 1989; US DHHS, 1988).

The proportion of cigar smokers showing clear signs of dependence

remains unknown. Lower rates of inhalation in cigar smokers and slower

absorption of nicotine through the buccal mucosa suggest that cigar smoking

may have a lower potential to induce addiction to nicotine than cigarette

smoking . In addition, it is plausible that persons who never had been

nicotine dependent and who began smoking cigars in adulthood would be

at a lower risk for developing dependence than children and adolescents

who take up tobacco use. It does appear that a much higher proportion of

adult cigar users compared to adult cigarette smokers are non daily users

(Chapter 2).

It has long been observed that drug use that is restricted to occurring

only in conjunction with social rituals may be less likely to escalate to

patterns of abuse and severe dependence (e.g., Falk, 1983). These

observations suggest that cigar smokers who do not begin smoking until

adulthood, and who were not formerly nicotine-dependent, and who smoke

only in certain settings (e.g., New Year’s Eve) might be less likely to escalate

their use and become dependent than someone who began smoking at a

younger age.

Chapter 6

190

Nicotine polacrilex gum and transdermal patch systems have low abuse

liability, in part because rapid absorption is not possible from either nicotine

delivery system. (Henningfield and Keenan, 1993; Henningfield and Stitzer,

1991; US DHHS, 1988). Cigar smoke may be inhaled, producing the same

virtually instantaneous effects of nicotine delivery produced by cigarette

smoking, or cigar smoke may be held in the nose and mouth providing a

somewhat slower rate of nicotine absorption as occurs with smokeless tobacco

products. Both routes of nicotine delivery are well-documented to lead to

dependence and withdrawal with other forms of tobacco use (cigarettes and

smokeless tobacco (US DHHS, 1986, 1988).

Henningfield and Keenan (1993) examined the pharmacokinetics of

nicotine delivered by different routes of administration as well as the changes

in subjective “liking” for the drugs. They found that nicotine delivered

intravenously and through cigarette smoke was very rapidly absorbed and

produced high scores on a question of subjective “liking” which may be

indicative of the abuse liability of the drug (Jasinski et al., 1984). Nicotine

delivered transdermally, however, was absorbed slowly and produced very

low scores of drug liking, despite the achievement of comparable venous

plasma levels. Because nicotine delivery through cigar smoke is primarily

through the oral mucosa with delivery through the pulmonary route as well

for those who inhale the smoke, it is likely that the delivery kinetics of

nicotine may be more comparable to smokeless tobacco which had scores

of subjective liking falling somewhere between those of transdermal and

cigarette delivery. These observations suggest that the risk of becoming

nicotine dependent might be somewhat lower in the cigar smokers as

opposed to cigarette smokers.

It is likely that nicotine tolerance and physical dependence to cigars may

develop among heavy regular users. However, there would be little basis to

expect that substantial levels of physical dependence would be observed in

people who rarely smoked on two or more consecutive days. Nicotine has

a half-life of approximately 2.5 hours and therefore, smoking a single cigar

or smoking with a non-daily frequency would not create a chronic exposure

to nicotine. Exposure of at least a few weeks is felt to be necessary to create

the degree of physical dependence that would enable substantial withdrawal

symptoms to develop upon cessation of use (American Psychiatric

Association, 1994). Table 3 gives DSM-IV criteria for nicotine withdrawal.

The novice cigar smoker would certainly feel a number of adverse effects

during smoking the first cigar, much as a first-time cigarette smoker would.

These effects would include the nausea and lightheadedness associated with

nicotine administration. After several cigars, however, these effects should

dissipate, allowing the cigar smoker to use more of the product.

191

Smoking and Tobacco Control Monograph No. 9

Table 3

DSM-IV criteria for nicotine withdrawal (American Psychiatric Association, 1994)

A. Daily use of nicotine for at least several weeks.

B. Abrupt cessation of nicotine use, or reduction in the amount of nicotine used, followed within 24 hours by

four (or more) of the following signs:

(1) dysphoric or depressed mood

(2) insomnia

(3) irritability, frustration, or anger

(4) anxiety

(5) difficulty concentrating

(6) restlessness

(7) decreased heart rate

(8) increased appetite or weight gain

C. The symptoms in Criterion B cause significant distress or impairment in social, occupational, or other

important areas of functioning.

D. The symptoms are not due to a general medical condition and are not better accounted for by another

mental disorder.

CONCLUSIONS

1. Cigars contain amounts of nicotine that vary from the amounts

contained in a single cigarette to the amount contained in a pack or

more of cigarettes. The amount of nicotine is usually proportional

to the amount of tobacco contained in the cigar.

2. There is substantial variability in the pH of the tobacco smoke produced

by cigars, but most cigars produce smoke that is more alkaline than

cigarette smoke. This alkaline pH facilitates nicotine absorption across

the oral mucosa and may explain why cigar smokers are less likely to

inhale than cigarette smokers.

3. There is sufficient nicotine absorption among regular heavy cigar

smokers to expect that nicotine dependence might develop, but studies

to document the frequency or intensity of nicotine dependence have not

been published.

4. The pattern of cigar use in the population (infrequent use, low number

of cigars smoked per day, and lower rates of inhalation compared to

cigarette smokers) suggest that cigar use which begins in adulthood may

be less likely to produce dependence than cigarette smoking. However,

most of the cigar smokers studied began smoking cigars as adults. The

current trend of adolescent cigar use generates a concern that prior low

adult rates of developing dependence may not apply to cigar use begun

during adolescence.

Chapter 6

192

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Office Publication No. S/N 017-001-00491-0).

Atlanta, GA: U.S. Government Printing Office,

1994.

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Smoking and Tobacco Control Monograph No. 9

Marketing and Promotion of Cigars

John Slade

INTRODUCTION This chapter examines the recent commercial history of cigars in

the United States. Sales patterns, advertising, and apparent promotional

activities are explored. Most of the discussion of marketing activities is

descriptive, since few quantitative data are available. There is almost no

publicly available information on how the increased visibility that cigars

have achieved since about 1992 has been financed. Accordingly, what are

described in this chapter as promotional activities are not necessarily the

result of activities by commercial interests. They are, though, activities

that have probably contributed to the promotion of cigar consumption.

SALES PATTERNS Figure 1 charts the mean retail price of cigars from 1976 through

1996, adjusted for inflation. The inflation adjusted price of small cigars fell

steadily over the period, losing 52 percent of their initial average price by

1996. Inflation adjusted prices for cigarillos ended the period about where

they had begun despite a prolonged dip during the 1980’s. Large cigars

showed generally steady overall prices with some year to year fluctuations in

the 70’s and 80’s, but 1994 and 1995 were two consecutive years of

substantial increases in mean price, probably reflecting the relative growth of

the premium segment.

In a prospectus for the initial public offering of 5.4 million shares of

company stock, Consolidated Cigar Holdings Inc. pointed to several factors

which it believes have contributed to the increase in cigar sales in recent

years.

The Company believes that the growing cigar market and

increased demand for cigars continue to offer the Company

substantial growth opportunities. Recently, cigar smoking has

gained popularity in the United States, resulting in a significant

increase in consumption and retail sales of cigars, particularly for

premium cigars. Management believes that this increase in cigar

consumption and retail sales is the result of a number of factors,

including: (i) the increase in the number of adults over the age

of 50 (a demographic group believed to smoke more cigars than

any other demographic segment) and (ii) the emergence of an

expanding base of younger affluent adults who have recently

started smoking cigars and who tend to smoke premium cigars.

The Company believes the increase in cigar smoking is in large part

attributable to a positive and improving image of cigar smoking

resulting from increased publicity, including the success of Cigar

Aficionado magazine, the increased visibility of use by celebrities

and the proliferation of “Cigar Smokers” dinners and other special

events for cigar smokers. (Consolidated Cigar Holdings Inc., 1996,

p. 3)

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196

Figure 1

Mean retail price of various size cigars, U.S. 1976-1996, corrected for CPI (1982-1984 = 100)

Source: Maxwell, 1997

350

300

Dollars per Thousand

250

200

150

100

‘76

‘80 ‘85 ‘90 ‘95

Little

Cigarillo

Large

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Similarly, the CEO and the President of Culbro have stated,

The emergence and rise in popularity of cigar dinners, cigar

clubs, cigar bars and successful magazines such as Cigar Aficionado

lend additional credence to the link that now exists between

premium cigars and affluent consumers. (Culbro Corporation,

1996, p. 2)

The marketing of cigars has emphasized premium cigars; however,

when market shares of different brands are examined, inexpensive brands

of machine-made cigars actually dominate the cigar market (Table 1). The

leading brand is a machine-made variety of little cigars, Swisher Sweets,

which had a 19 percent market share in 1996. In contrast, the heavily

advertised premium brand Macanudo has only a 0.8 percent share. (General

Cigar is building Macanudo into a major name brand with a coordinated

campaign of advertising, sportswear, and ventures such as Club Macanudo

(Smoke Signals, 1997; Culbro Corporation, 1996).) Table 2 lists premium

brands of the largest U.S. cigar companies.

While there is a plethora of brands, styles, and sizes of cigars, only a

few companies sell most of them (Table 3). Just five companies, Swisher

International, Havatampa, Consolidated Cigar, Middleton, and Culbro

(General Cigar), control 95 percent of the market in the United States. Except

for Havatampa, which only sells machine-made cigars, each of the major

companies sells both premium and non-premium brands. In addition to the

major companies, a welter of small companies manufacture and import

premium cigars.

The market for little cigars is even more concentrated, with just three

companies, Swisher International, Consolidated Cigar, and Tobacco Exporters

International, controlling 86 percent of the market (Table 4). Swisher alone,

with its Swisher Sweets little cigars, has a 42 percent share. Table 4 also lists

the major brands of little cigar now on the market.

Many companies which manufacture or import cigars are involved in

other aspects of the tobacco business. Table 5 lists cigar companies which

also sell other tobacco products.

The recent rise in cigar sales has led to increased value of cigar companies

as investments. Several have made public share offerings and both popular

and trade magazines have offered information about these potential

investments (Wall Street Report, 1997; Luz, 1997; Finora, 1997).

There has been a marked increase in the number of smoke shops since

1992 (Flying High, 1997). The number of retail specialty tobacco outlets has

increased from 2,358 in 1992 to 4,948 in 1996. A sign that this increase has

drawn in many small businessmen who have not previously been involved

in the trade is the publication of an extensive article in a trade magazine

about the function of sales representatives (Scott, 1997).

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198

Table 1

Market share large cigars and cigarillos, United States, 1996, millions and percent

Brand Company Units Percent

Swisher Sweets Swisher Int’l 601 19.4

Phillies Havatampa Inc 462 15.0

Havatampa Havatampa Inc 258 8.3

White Owl General Cigar 184 6.0

Dutch Masters Consolidated 138 4.5

Garcia y Vega General Cigar 138 4.5

Antonio y Cleopatra Consolidated 124 4.0

King Edward Swisher Int’l 105 3.4

Muriel Consolidated 100 3.2

Backwoods Consolidated 98 3.2

Robert Burns General Cigar 87 2.8

El Producto Consolidated 53 1.7

William Penn General Cigar 44 1.4

Tijuana Smalls General Cigar 34 1.1

Macanudo General Cigar 26 0.8

Universal Swisher Int’l 24 0.8

La Corona Consolidated 13 0.4

Bering Swisher Int’l 10 0.3

Partagas General Cigar 9 0.3

Roi-Tan Consolidated 7 0.2

Canaria d’Oro General Cigar 2 0.1

Other, non-premium 340 11.0

Other, premium 233 7.5

Total 3,090 99.9

Premium brands in bold face.

Note: A premium cigar is hand-made, is comprised entirely of natural, long filler tobacco, and has a

retail price of more than $1.00.

Sources: Data on premium cigars and market share, Maxwell, 1997. Data on total U.S. consumption,

USDA, 1997.

ADVERTISING Only a small amount of conventional advertising appears for cigars.

Measured media spending increased from $1.1 million in 1994 to $4.0 million

in the first nine months of 1996 (Table 6). Most advertising for cigars appears

in magazines; 39 magazines carried cigar advertising in this 3-year period. As

of December 1996, the price for a one time insertion of a full-page, four-color

advertisement in Cigar Aficionado was $18,360 while a similar ad in Smoke cost

$7,950.

Cigar advertising employs a variety of themes. Cigars are presented as

lavish, even outrageous, yet affordable luxuries and indulgences. Other ads

depict a rich history and tradition of cigar making or appeal to nostalgia in

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Table 2

Premium brands of the major cigar companies

Company Premium brands

Consolidated Cigar H. Upmann

Montecristo

Don Diego

Te-Amo

Santa Damiana

Royal Jamacia

Primo Del Rey

Montecruz

General Cigar Macanudo

Partagas

Punch

Hoyo de Monterrey

Cohiba

Excalibur

Ramon Allones

Temple Hall

El Rey Del Mundo

Canaria D’Oro

Cifuentes

Bolivar

Belinda

Bances

Swisher Int’l Bering

Pléiades

Table 3

Large cigars and cigarillos, United States, 1996. Market share, company by

company, millions and percent

Company Units Percent

Swisher Int’l, Inc. 758 24.5

Havatampa 720 23.3

Consolidated Cigar 634 20.5

Culbro (General Cigar) 527 17.1

Middleton 310 10.0

M & N Standard Cigar 47 1.5

House of Windsor 30 1.0

Others 64 2.1

Total 3,090 100.0

Sources: Data on market share, Maxwell, 1997. Data on total U.S. consumption, USDA, 1997.

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200

Table 4

Little cigars, United States, 1996. Market share and leading brands, company by

company, millions and percent

Company Units Percent

Swisher Int’l Inc. 632 42.4

Swisher Sweets Little

Consolidated 340 22.8

Dutch Treats

Tobacco Exporters Int’l 316 21.2

Winchester

Havatampa, Inc. 139 9.3

Omega

Between the Acts

Madison

Hav-a-tampa

Lane Limited 76 5.1

Captain Black

House of Windsor 1 0.1

Little Nippers

Change in Inventory (14) (0.9)

Total 1,490 100.0

Source: Maxwell, 1997.

Table 5

Cigar companies that also manufacture tobacco products that are regulated by the

Food and Drug Administration

Company Regulated Products

Commonwealth Brands Cigarettes

Cigarette tobacco

Consolidated Cigar Cigarette tobacco

Finck Cigar Smokeless tobacco

Lane Limited Cigarette tobacco

Red Lion International Cigarette tobacco

Smokeless tobacco

Nat Sherman Cigarettes

Pinkerton Group Smokeless tobacco

Swisher International, Inc. Smokeless tobacco

UST Smokeless tobacco

Sources: Smoke 2(1):40-41, Winter 96/97; Tobacco Reporter, 1996; UST Annual Report.

Smokeless tobacco includes oral snuff.

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Table 6

Measured media spending for cigars, United States 1994, 1995, 1996

(first 9 months for ’96), $000’s

Company 1994 1995 1996

(9 months)

CULBRO CORP. (General Cigar)

General Cigar 60 42 n/a

Garcia Y Vega n/a n/a 24

Macanudo 234 1,503 1,597

Partagas 375 689 134

DAVIDOFF OF GENEVA, INC.

Davidoff Cigars 128 249 230

MACANDREWS & FORBES HOLDINGS (Consolidated Cigar)

Don Diego n/s 83 406

H Upmann 96 187 366

Te-Amo 193 104 303

RICHEMONT AG

Dunhill n/a 30 173

Winchester Little Cigars 107 54 150

SWISHER INTERNATIONAL INC.

Swisher Sweets Little Cigars n/a 121 296

THOMPSON CIGAR CO.

Thompson Cigars n/a 277 n/a

TRIPLE C ACQUISITION CORP.

Consolidated Cigars n/a 111 287

Total 1,193 3,450 3,966

Source: Leading National Brands, 1997.

other ways; for instance, by evoking a romantic vision of pre-revolutionary

Cuba. Many ads create a personal link with the company owners, founders,

or the artisans and the farmers who create the product and its raw material.

Some advertising seeks to expand the market for cigars by legitimizing

new users and new settings for use. The former is illustrated by the ads

which invite women to smoke cigars. An example of the latter is an ad

for a brand sold by U.S. Tobacco International, Don Tomás (U.S. Tobacco

International, 1997). The ad shows a man dressed in a terry cloth robe,

holding a coffee cup, smoking a cigar. The ad copy reads,

What time of day should you light up a cigar? We know

people who wouldn’t think of having their first cup of caffe latte

without firing up a good cigar. Then there are the traditionalists

who wait until the after dinner single malt is served to light up

their handmade Don Tomás Presidentes. When you really get

down to it, as long as the label says Don Tomás you’re in for

a treat, day or night.(p.253)

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202

Just by asking the question, U.S. Tobacco International legitimizes an

expansion of when cigars are smoked, especially by people who think of

themselves as not being bound by tradition. Smoking cigars with morning

coffee is not in exchange for consumption later in the day. Like promoting

soft drinks as a breakfast beverage, it is a marketing tactic which is aimed at

expanding the market.

Sexuality permeates many of the ads (Figure 2), and it can be especially

blatant in ads from some of the smaller companies. An ad for a 3.5 inch-long

cigarillo shows an attractive couple having a good time, each holding the

product. The copy reads, “For the women who say size doesn’t matter,

and the men who actually believe them” (Caribbean Cigar, 1997, p. 33).

Some ads work at a more sophisticated level. An ad for Macanudo,

which is part of a “campaign aimed at younger adult smokers” (Culbro

Corporation, 1996, p. 5), shows an attractive woman and a handsome older

man, both holding cigars and looking directly at the camera. The headline

reads, “And they thought you’d have nothing in common.” The copy creates

suggestions of professional tension and competition between the two, but

their cigars create an affirming bond that is “to be shared like wit. To be

savored like wisdom” (Cigar Aficionado, May/June 1997a, p. 9).

Figure 2

Sexuality in cigar advertisements

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Smoking and Tobacco Control Monograph No. 9

PROMOTION By far the most important ways cigars have been presented to the

public have been through various promotional activities.

Lifestyle The resurgence of cigar use in the United States has been closely

magazines associated with the glossy lifestyle magazine, Cigar Aficionado, published

by Marvin R. Shanken. Launched in the Fall of 1992, the magazine was

targeted for what Shanken asserted was an increasing number of men who

enjoy smoking expensive cigars (Shriver, 1992). The publication has grown

from 130 pages per issue to more than 400 and has increased its publication

frequency from four to six times annually. Its circulation has grown from

40,000 (Conrad, 1996) to 400,119 (New York Times, 1997. Each issue

promotes cigar use as part of successful, indulgent living through interviews

with celebrities, sports stars, and others. Reviews of expensive cigars are

offered as well as lavish descriptions of cigar accessories such as lighters and

humidors. The editorial context is how to live life to the fullest in a style

reminiscent of Esquire, GQ or Playboy. While advertising for cigars and their

perquisites are prominent, sellers of upscale clothing, luxury cars, expensive

watches, jewelry, premium liquor, casinos, other resorts, and perfume also

feature their goods and services in this publication. Each issue has an article

about gambling.

Cigar Aficionado has launched a line of clothing and accessories named for

the magazine. A Cigar Aficionado branded fragrance for men was promoted in

time for holiday shopping (Washington Post

Magazine, 1998) (Figure 3)

Most cover stories feature profiles of

prominent people whose cigar use is illustrated on

the cover and described in the accompanying

article (Table 7) (Figure 4).

Articles romanticize Actor James Woods (Figure 5) told

cigar smoking his interviewer, “When you smoke

a cigar, time stops. And you can sort out your

thoughts. Contemplate. You can just kind of

hold it and puff it and just drift down the stream

of your thoughts for an hour or so. Thank God

for cigars. At least there is one place where I can

be quiet for a moment and actually be alone with

my thoughts” (Cigar Aficionado, 1997b, p.147,

149). There are also frequent defiant comments

about cigars in reaction to what are depicted as

puritanical or radical emblems in the culture.

Woods remarked, “Cigar smoking is the kind of

thing a feminist would whine about. . . .And

that’s a good thing” (Cigar Aficionado, 1997, p.144).

A feature story on Claudia Schiffer (Figure 6) opens with an indignant

blast at dissipation and drug use in the modeling profession:

Source: Washington Post

Magazine, 1998

Figure 3

Cigar Aficionado

fine

fragrance

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204

Table 7

Persons featured on covers of

Cigar Aficionado

and

Smoke

, 1993 - Winter 1998

Year Persons

Cigar Aficionado

1993 Groucho Marx

Winston Churchill

1994 Rush Limbaugh

Fidel Castro

Bill Cosby

George Burns

1995 Ron Perelman

Jack Nicholson

Linda Evangelista

Tom Selleck

1996 Matt Dillon

Arnold Schwartzenegger

Demi Moore

Danny Devito

1997 Wayne Gretzky

Janet Jones

James Woods

Claudia Schiffer

Michael Richards

1998 Denzel Washington

Smoke

1996 Pierce Brosnan

Tom Arnold

Red Hot Chili Peppers

Mel Gibson

1997 Elle Macpherson

Jeff Goldblum

Carmen Electra

Claudia Schiffer is talking tough. There’s a problem in the

world of fashion these days, she says — the fact that too often

models have to look like junkies just to be cool. “I think fashion

should be promoting beauty and health,” she says. “That doesn’t

happen if the model looks anorexic, unhealthy, tired, if the

photography makes her look as if she’s on drugs or been out

partying all night. That kind of thing can end up hurting young

women or girls who feel they have to imitate the models they see

in the magazines. That’s not what fashion is about. For me,

fashion is about beauty.” (Rothstein, 1997, p. 170)

The article and magazine cover include seven large photos of the

supermodel cum cigar in alluring poses (Rothstein, 1997). The contrast being

drawn between drug use and dissipation on the one hand and cigar use on the

other could not be more clear.

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Figure 4

Jack Nicholson, Matt Dillon, and Bill Cosby

The magazine has created a following. Readers send in

photographs of themselves and their cigar-related activities.

Several pages have been devoted to photos of readers showing

off cigar-related vanity license plates (Photo Gallery, 1997a;

Photo Gallery, 1997b).

From time to time, the

publisher takes on criticisms of

cigar use in the editorial he writes

for each issue, taking the

Environmental Protection Agency

(EPA) report on environmental

tobacco smoke and the proposed

Occupational Safety and Health

Administration (OSHA) rule on

tobacco smoke in the work place to

task (Shanken, 1993; Shanken,

1997c), issuing a call to action

against the “new Prohibition” in another

(Shanken, 1994), and expressing sharp

disagreement with critics of cigar use as indulging

in “scare tactics” in another (Shanken, 1997a).

Within days of the announcement from the

Centers for Disease Control that surveys show that

kids now frequently use cigars (Kaufman et al.,

Figure 5

James Woods

Source: Cigar Aficionado,

May/June 1997

Figure 6

Claudia Schiffer

Source: Cigar Aficionado,

August 1997

Source: Cigar Aficionado, Summer 1995, Spring 1996, and Autumn 1994.

Chapter 7

206

Source: Cigar Aficionado,

Spring 1993

Figure 7

Ear, nose, and throat

surgeon

1997), posted a column on the magazine’s web page proclaiming that cigars

are for adults only and not for teenagers (Shanken, 1997b). He has blasted

the American Cancer Society for publishing

public service ads about cigars and Brooks

Brothers for stopping the use of cigars as props for

models in its advertising (Shanken, 1997d).

The posture taken is that the occasional, non-

inhaled, moderate use of cigars is OK even though

potentially serious problems can sometimes arise

when cigar use is outside of these parameters.

The studied reassurance the magazine offers has

been reinforced by a column written by a cigar-

loving Ear, Nose, and Throat (ENT) surgeon, who

was photographed in surgical scrubs holding a

cigar (Pearlman, 1993) (Figure 7). A similar image

was evoked in a photograph which illustrated an

article on cosmetics and cosmetic

surgery for men. A plastic surgeon

posed in a white lab coat, holding

a cigar (Wolfson, 1997) (Figure 8).

The periodical has not only

been sanctioned by physicians, it

has been blessed by a person of the

cloth. In its second issue, the magazine published a letter from

an anonymous member of the clergy, who praised the new

publication and reflected on the importance of a cigar in

composing sermons. “In moderation, ten a week or so, cigar

smoking, I declare, is not a sin. Gentlemen, you have my

blessings. Those who do like the art and transcendental

experience of smoking a fine cigar need not worry of divine

retribution. I think God understands” (An inspired preacher,

1992).

By 1996, the success of Cigar Aficionado spawned imitation

from a tobacco trade publisher, Lockwood, in the form of

Smoke, whose subtitle is “Cigars, pipes and life’s other burning

desires.” It, too, has seen an increase in pages, from 182 in the premier issue

to 464 in the Summer 1997 issue. Smoke, which seems targeted at a

somewhat younger, more hip audience, has a similar mix of cigar features

and general lifestyle articles. Its covers also feature celebrities smoking cigars

(Table 7) (Figure 9). Another similar magzine, Cigar Monthly, has featured

various cover stories (Figure 10).

These three publications have been imitated in France (French Toast,

1996). In keeping with the style of its American cousins, the cover of the

March 1997 issue of L’Amateur de Cigare features General Charles de Gaulle

with a cigar.

Figure 8

Cosmetic surgeon

Source: Cigar Aficionado,

March/April 1997

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Smoking and Tobacco Control Monograph No. 9

Figure 9

Mel Gibson, Carmen Electra, Jeff Goldblum, and Elle Macpherson

Source: Smoke, Anniversary Issue Winter 1996-1997, 2nd Anniversary Issue Winter 1997,

Summer 1997, and Spring 1997

Figure 10

Cigar Monthly

cover stories

Source: Cigar Monthly, April 1995,

November 1995, March

1996, July 1996, 1997

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208

The hedonistic themes these magazines explore are captured in the

concluding exchange from an interview published in Smoke with actress Kim

Cattrall (Cattrall, 1996).

Q. What do you think all the buzz is about cigars?

A. It’s a very large phallic symbol that men like to play with — and women

like to watch them. I understand the attraction. Just holding one, there’s

sort of a power related there.

Cigar-centered The current era of fancy cigar dinners and other entertainments

Dining and focused on cigars seems to have begun around 1988 (Luz, 1997).

Entertainment

From its own beginnings four years later, Cigar Aficionado

sponsored gala affairs and dinner parties at expensive restaurants featuring

cigars, wines, and celebrity guests. Similar events, which build word of mouth

advertising, have become widespread, and the magazine publicizes restaurants

that offer “smoker nights.” In a 1992 issue, there was a list of 32 domestic

and 4 foreign restaurants and cigar clubs that offered such events (Smoker

Nights, 1992); by Spring 1997, the number of listings had grown to 591

entries in the United States and 70 listings from outside the country (Smoker

Nights, 1997). Magazine subscribers receive formal invitations to events

sponsored by the magazine, and the magazine regularly features photographs

from these events in its pages. The popularity and acceptability of these

events is illustrated by the fact that a restaurant at Walt Disney World has

hosted cigar dinners (Scott, 1996a).

Sometimes, these events are linked to charitable causes. In New Jersey,

cigar nights have provided fund-raising settings for the Women’s Center of

Monmouth County, the Make-A-Wish Foundation of New Jersey, the Easter

Seal Society of New Jersey, and the Cerebral Palsy Association of Middlesex

County (Henderson, 1996; Henderson, 1997a; Henderson, 1997b; Robert

Kucharski, personal communication, June 5, 1997). An event called

“Celebrity Smoke ’97,” sponsored by Smoke, was produced by Celebrity

Fund-raisers, Inc. and benefitted a charity called The Miami Project (Celebrity

Smoke ’97, 1997). A $1,000-per-ticket cigar dinner and viewing of the film

“Napoleon” (accompanied by a 65 piece orchestra) is to benefit the Culinary

Institute of America at Greystone and the North Beach Homeless Project of

San Francisco (Coppola and Shanken, 1997).

In October 1994, Cigar Aficionado sponsored a dinner in Paris called the

“Dinner of the Century” (Nights to Remember, 1994). Formal invitations for

the event indicated that a portion of the ticket price would be donated to the

United Nations Children’s Fund (UNICEF). When the director of UNICEF was

informed of this unsolicited and unwanted association, an attorney for

UNICEF put the organizers on notice that they were to stop using the name of

the children’s fund in association with the dinner. Instead, a donation was

made to CaP Cure, a charity for prostate cancer research (Ron Davis, personal

communication, October 1994).

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Smoking and Tobacco Control Monograph No. 9

Adding a charitable dimension to these events may add a sense of

mainstream mission, purpose, and respectability to what may simultaneously

be regarded as daring, flaunting of convention, and even somewhat

underground. Not only is a cigar dinner fun for itself and more so for

being a bit of a slap at puritanical attitudes, it can also be for a good cause.

Scott, writing in a trade magazine for retail tobacco shops, has described

how to organize a cigar dinner.

Cigar dinners, if planned and executed well, are an excellent

way to build your business. They work best as a promotional tool,

just like advertising. The nice thing about them, as a business

builder, is they can be operated at a break-even level. What other

advertising medium do you use that costs you nothing? The dealer

who thinks he can make a profit on cigar dinners, however, will

probably find his dinners, non-competitively priced, won’t yield

the results he wants. (Scott, 1996a, p.44)

Ed Kotoch, owner of the Tobacco Road stores in Las Vegas, says,

“Instead, think of a cigar event as a way to get to know your

customers better, especially the ones who just breeze in and out of

your store; or to meet your customers’ cigar-smoking friends whom

they bring to the dinner; or to say ‘thank you’ to a few selected and

valued customers.” (Scott, 1996a, p. 44)

The article offers detailed advice on planning, organizing, and conducting

these events. A balanced blend of entertainment, food, wine and cigars is to

be sought. Cautioning against seeking venues in restaurants owned by non-

smokers, Scott advises making sure that ventilation is adequate and even

providing additional air filters because, he notes, “cigars put out a lot of

smoke” (Scott, 1996a, p. 46). In selecting cigars for the evening, he suggests

a mix of full-bodied and mild cigars. He especially suggests

providing a selection of smaller, mild cigars for women so that

they can more easily participate in the revelry. For a ticket

price of $75-$90, Scott suggests a budget of $20-$25 for food,

$5 for tips, $15 for cigars, $10 for a gift, $15-$20 for drinks,

$5 for invitations, and complimentary tickets for the dinner

speaker and the people who represent the cigar and beverage

distributors.

Entertainments such as these serve to further embed cigar

use in the culture, socialize people to the use of cigars, and

teach novices how to use them. The luxurious settings foster

the high-class image with which the cigar industry seeks to

associate itself. In Augusta, Georgia, Mike Smith, proprietor

of Cigar Affairs, hosts cigar dinners, such as the Spring Big

Smoke (Barshafsky, 1997) (Figure 11).

Sanctioned social clubs organized around cigars have

appeared on a number of major college campuses (Barry,

1997).

Figure 11

Augusta

Source: Augusta,

September 1997

Chapter 7

210

Smoking clubs appeared in many communities in the mid-1990s.

Among the most elaborate are cigar bars identified with Macanudo brand

cigars, the Club Macanudo in Chicago and in New York (Club Macanudo,

1997). At the New York club, which offers patrons a cigar school for initiates,

a large painting of the bar hangs in the dining room. The painting features

Culbro executives Edgar M. Cullman, Sr. and his son, Edgar M. Cullman, Jr.,

as well as Marvin Shanken surrounded by famous people who smoked cigars.

Winston Churchill and John F. Kennedy are joined by Madonna, Whoopi

Goldberg, Michael Jordan, Julie Andrews, Linda Evangelista, Richard Pryor,

Jack Nicholson, Robert deNiro, Orson Wells, and Bruce Willis. Patrons are

offered menus for both food and cigars. Culbro products are featured in great

variety with prices ranging up to $40, but there are also a few offerings of

lesser quality from other major purveyors. Among the holders of humidors

at the Club are a number of New York-based magazines, including Esquire,

Vanity Fair, Business Week, Sports Illustrated, U.S. News and World Report, and

Golf Digest.

Retail establishments devoted to smoking seem in part a reaction to the

elimination of smoking from more and more indoor spaces. The fashion

brings to mind the early history of smoking in 17th century England where

customers would leave their pipes at the local tobacco shop. They would

come to the shop not just to purchase tobacco but to smoke as well.

Newspaper The resurgence in popularity of cigars has been covered, and in part

stories about fueled by, articles in newspapers. Among the twenty daily newspapers

cigars indexed by the Dialog data base, there were 325 articles over the seven-

year period 1990 - 1996 that dealt with news about cigars or feature stories

about their increasing popularity in the culture. Coverage of cigars was fairly

constant for the first 5 years of the period, and then showed an abrupt

upswing (Table 8). Uncritical stories describing this as a social or as a fashion

phenomenon have been common in newspapers as well as on television

magazine shows. Much of this coverage was stimulated by a public-relations

effort by cigar manufactures intended to promote positive stories in the news

media linking cigar use to luxury and power (Klein, 1998).

A highly successful race horse named Cigar (Figure 12) appeared on the

sports pages beginning in May 1995 with a victory at Pimlico. The horse

was featured in 103 stories in these same twenty newspapers in 1995 and

in 212 stories the following year.

Women and Cigar smoking by women has been one of the sub-themes of cigar

cigars publicity. Celebrity women and their cigars have frequently been

featured in the cigar magazines (Figure 13). Madonna smoked a cigar on

the David Letterman show in 1994 (Conrad, 1996). Feature stories in

newspapers, popular news magazines, and on television have highlighted

this as a new trend (Figure 14). A recent book describes and explains cigar

smoking for women (Edmark, 1995), and a retail trade magazine has

published an article on how to “capitalize on the marketing differences

the gender gap provides” (Ashley, 1997b, p. 162). These phenomena increase

the visibility not only of women smoking cigars, but of cigar use itself.

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Smoking and Tobacco Control Monograph No. 9

Table 8

News and features about cigars. Twenty daily newspapers Indexed by Dialog

1990-1996

Year Number of articles

1990 23

1991 19

1992 20

1993 36

1994 24

1995 81

1996 122

Total 325

Source: Dialog

Internet Cigars are featured on the

advertising world wide web at many

and promotion sites (Mason, 1996).

There are online catalogs for

ordering as well as links that

provide background information

and ratings. Both cigar lifestyle

magazines maintain elaborate sites.

One site sponsored “Operation

Cigar Lift” for U.S. troops stationed

in Bosnia in 1996 (Smoke Signals,

1996).

Ashley has

described the ins and outs of

setting up and running a web site

for people in the retail cigar

business (Ashley, 1997a). He

describes how selling on the

Internet has transformed the way

a number of retailers operate, with

some now providing frequent

updates of their inventories online.

Websites for cigars may receive

tens of thousands of visits

monthly. The sites operated by

manufacturers not only provide

information and images about

specific brands but also link

customers with retailers who carry

the products. There are discussion

groups and news groups as well on

Figure 13

Demi Moore

Source: Cigar Aficionado,

Autumn 1996

Figure 12

The race horse, Cigar

Source: Cigar Aficionado, Winter 1996/1997

Figure 14

Jenny McCarthy

Source: Newsweek, July 21,

1997

Chapter 7

212

these sites. Sites also can offer search capabilities to people looking for

particular products or product characteristics.

Catalogs and Cigars have long been available by mail order, but the resurgence

cigar-related in popularity of expensive cigars has prompted the introduction of

items new specialty catalogs for cigar users such as one called The Cigar

Enthusiast. Accessories for cigars have begun appearing in more established

upscale catalogs such as those from Herrington, Frontgate, Huntington

Clothiers, and Hammacher Schlemmer.

The cigar craze has nourished the cottage industry that produces cigar

accessories such as lighters, cutters, ashtrays, and humidors. Oddities such

as devices which provide a place to put a lit cigar on a golf

course while the user takes a shot have appeared on the

market. A “breath cleanser” for cigar smokers is being sold

(Cigar Clear, 1996). New cigar-themed clothing companies,

selling silk screened whimsy or classical cigar art (based on

cigar box paintings and cigar bands) have appeared: The Five

Cent Cigar Co., Smoke Rings, and The Original Cigar Clothing

Company. The Nat Sherman Catalog (Figure 15) offers a

variety of cigar accessories (Figure 16)

Books (Hacker, 1996; Shanken,

1996), videos (Dees, 1996),

lithographs (Mazur, 1996), and

even compact discs related to cigars

(Schmorr, 1996) have appeared on

the market. One of these books

includes a curiously lighthearted

chapter on health effects (titled

“But will they stunt your growth?”)

which emphasizes the supposed

advantage of cigar tobacco having

fewer additives and the fact that

inhalation is optional with cigars

(because nicotine absorption from

cigar smoke, unlike that from

cigarette smoke, does not depend

on inhalation) (Scott, 1996b).

Dunhill has long offered high-end men’s

clothing and accessories in association with its

core tobacco products business.

Virtually alone among the major cigar

companies, General Cigar has borrowed other

marketing techniques prominent in the cigarette

industry for some of its mass-market cigars as well

(Coeytaux, Altman and Slade, 1995; Altman,

Levine, Coeytaux, Slade and Jaffe, 1996). General

Cigar has run a series of promotions for its White

Figure 15

The Nat Sherman Catalog

Source: Nat Sherman Catalog,

1998

Figure 16

Cigar accessories –

The Nat Sherman Catalog

Source: Nat Sherman Catalog,

1998

213

Smoking and Tobacco Control Monograph No. 9

Owl and Garcia y Vega brands which involve returning proofs of purchase for

branded t-shirts and other premiums. It has even developed a small catalog

for the Garcia y Vega brand. Moreover, General Cigar has launched a line of

expensive sportswear geared to its premium brands (Culbro Corporation,

1996). It also plans a branded line of cigar smoking accessories (Smoke

Signals, 1997). The president of the parent company, Edgar M. Cullman, Jr., is

quoted in the annual report as saying, “General Cigar’s brand extensions in

new classic sportswear set the stage for our lifestyle-driven company of

tomorrow” (Culbro Corporation, 1996, p. 8).

There have been other sporadic, small efforts at promoting mass-market

cigars, but generally, the makers of these products have not devoted large

amounts of money to their promotion in recent years. Swisher International

briefly supported a NASCAR race team for Swisher Sweets, and the makers of

the little cigar Winchester published booklets of football and baseball statistics

and schedules in 1995 that were distributed through some retail outlets.

Sportswear for Macanudo does not imitate the understated elegance of

Dunhill. Instead, Culbro features the Macanudo name prominently on each

article of clothing, so the caps, sports shirts, jackets, and sweatshirts are

themselves advertisements for the brand in much the same manner that

cigarette companies promote their brands through promotional items.

Among the ways General Cigar seeks to promote Macanudo is through

furniture. The William Allen Company of High Point, North Carolina offers

two stuffed armchairs retailing for about $2,500 each which feature the

Macanudo crest design on the upholstery. A leather chair has the crest on a

kidney pillow and the seat deck, while a mohair chair has it on the seat

cushion (William Allen, 1997). On introducing these products to a furniture

store, the Allen salesman passes out cigars and offers a $700 Macanudo

smoking jacket for sale as well.

Borrowed glory Cigars have become a common prop, on magazine covers (Mott,

1992) (Figure 17), in fashion photography, for men’s accessories such as ties,

and among popular musicians, movie stars and other

celebrities. A popular history recounts many of the famous

names, past and present, associated with cigars (Conrad, 1996).

The cigar may be intended to be provocative or to project

“power, authority and self-confidence” (Mott, 1992, p. 46).

When the Chicago Bulls won the NBA championship in 1996,

Michael Jordan and Dennis Rodman celebrated with cigars, and

their smoking was widely seen on television. George Dessart of

the American Cancer Society criticized these sports stars,

saying, “By displaying these cigars at the moment they were the

most visible athletes in the world, Michael Jordan and the

Chicago Bulls served as the worst type of role model for

millions of children worldwide. After all, if Michael Jordan and

the Chicago Bulls smoke, it must be cool and it can’t be that

bad for you” (Campaign for Tobacco-Free Kids, 1996).

Source: The New Yorker,

September 23, 1996

Figure 17

The New Yorker

Chapter 7

214

At least some of the gratuitous public cigar display so evident in recent

years may be because of commercial sponsorship. In the 50’s and 60’s,

celebrities such as Ernie Kovacs, Danny Thomas, and Sid Caesar did

commercials for Dutch Masters,

and Edie Adams cooed “Pick me up and

smoke me sometime” for Muriel (Kiersh, 1997, p. 105). George Burns smoked

another machine-made brand from Consolidated Cigar, El Producto Queens,

exclusively for many years. Each month, he

received 300 of the stogies from the manufacturer

for free. While it is not known if he also received

an honorarium or a sponsorship fee in addition to

the free cigars, he repeatedly refused to even try

any other brand (Kiersh, 1997). Consolidated

Cigar is trying to capitalize on this long-standing

association by creating a special series of El

Producto cigars it is calling the “George Burns

Collection” (Kiersh, 1997). It is not known if this

venture involves the payment of a licensing fee to

the Burns estate, but such considerations are

common for other products.

Cigars and Cigars have become a common prop in movies

the Movies (Independence Day, 1996; Batman and Robin,

1997). In at least one case, though, the cigars

featured in advertising were not apparent in the

movie itself. Ads for the 1996 movie The First

Wives Club (Paramount) showed Goldie Hawn,

Diane Keaton and Bette Midler

with stogies (Figure 18) while in

both the movie itself and the book

on which the movie was based,

these characters never used cigars

(Thomas, 1996). When the HBO

movie Weapons of Mass Distraction

was advertised in Cigar Aficionado,

the characters held cigars (Cigar

Aficionado, 1997c) (Figure 19).

When the same movie was

advertised in The New Yorker, the

characters’ hands were empty

(New Yorker, May 19, 1997)

(Figure 20). Cigar manufactures

paid Hollywood brokers to feature

their products in movies including

Independence Day (Klein, 1998).

Source: Cigar Aficionado, May/

June 1997

Figure 19

Weapons of Mass

Distraction–with cigars

Source: The New Yorker,

May 1997

Figure 20

Weapons of Mass

Distraction–without cigars

Source: Fairfax County TV

Guide

Figure 18

First Wife’s Club

This brand evokes memories of Rembrandt’s contemporaries even though tobacco was mainly

consumed in pipes throughout the low countries at that time.

215

Smoking and Tobacco Control Monograph No. 9

AVAILABILITY Inexpensive cigars are mostly sold as self-service items in grocery

stores, convenience stores and pharmacies. The growth of the premium cigar

trade has been accompanied by an increase in outlets for expensive cigars

beyond tobacconists and other specialized retailers. Major manufacturers

are seeking to expand traditional outlets for premium cigars to include

hotel shops, wine shops, restaurants, and upscale specialty and department

stores (Smoke Signals, 1997). Vending machines for premium cigars are

commercially available and have begun to appear in some locations

(Trendwatch, 1997).

DISCUSSION Cigar use began to increase after promotional activities for cigars

stepped up beginning in 1992. The cigar market was stagnant (Chapter 2)

before Cigar Aficionado was launched, even though Marvin Shanken has

said he launched the magazine in response to an increase in use of premium

cigars. In a prospectus, Consolidated Cigar Holdings attributes the increase

in cigar consumption largely to the magazine, to the use of cigars by

celebrities (Figure 21), and to the proliferation of social events that feature

cigars (Consolidated Cigar Holdings, 1996). These efforts have increased

the visibility of cigar consumption, have normalized cigar use, and have

Source: Cigar Aficionado, Spring 1993, February 1998, October 1997, Winter 1994

Figure 21

Groucho Marx, Denzel Washington, Michael Richards, and George Burns

Chapter 7

216

broken down barriers for cigars. Among the barriers that seem to have been

broken has been use by kids (Kaufman et al., 1997). These efforts have a

familiar ring. Public relations techniques to normalize and popularize

cigarette use in general and among women in particular were used by

cigarette makers earlier in the century (Kluger, 1996).

While nearly all promotional energy for cigars has been focused on

premium versions, fully 83 percent of the unit growth in the consumption of

large cigars and cigarillos has been for inexpensive, non-premium, machine-

made brands. Advertising for specific premium brands, which is directed at

expanding the market serves the dual role of promoting both cigars and a

particular brand (Montego y Cia. 1997; U.S. Tobacco International, 1997).

Moreover, despite disclaimers to the contrary (Shanken, 1997b), an inevitable

effect of fostering a somewhat outrageous fashion among adults is that its

appeal to kids will grow.

Measured marketing expenditures for cigars was only $4 million for the

first 9 months of 1996, yet the industry had more than $1.2 billion in sales.

To the extent that they exist at all, the unmeasured marketing

expenditures may be devoted to activities such as planting feature stories

about cigars in newspapers and television, securing celebrity endorsements

of cigar smoking, promoting cigar dinners, financing the expansion of retail

tobacco shops, and of restaurants, clubs and bars that encourage cigar

smoking, achieving placements in popular entertainment and in fashion

magazines, and facilitating the development of communications channels,

such as magazines, books and web sites.

It may be that individual cigar companies are working by themselves

or in concert to facilitate at least some of these public relations activities,

because the bulk of the industry is concentrated in only a few companies

(Table 3). Efforts to boost cigar use in general will mainly benefit those

companies that are already well positioned.

The more sophisticated companies, especially Culbro (General Cigar) and

Consolidated Cigar, seem to be taking integrated marketing approaches to

building franchises for their major brands. Although the use of sex and

celebrity to sell cigarettes has been forbidden by the cigarette industry’s

voluntary code since 1965, these appeals are regular features of cigar

marketing.

Additional information is needed to better characterize marketing efforts

for cigars. Specifically, there should be:

• Continued efforts to describe advertising and promotional efforts for

cigars as well as to understand the dynamics of the market and the

companies involved in it,

• Compilation of marketing expenditures for cigars as the Federal Trade

Commission already does for cigarettes and smokeless tobacco products,

217

Smoking and Tobacco Control Monograph No. 9

• A survey of prominent people who have been publicly associated with

cigar use to learn about the extent to which they have received

sponsorship fees or any other consideration from commercial cigar

interests,

• Research to learn how different segments of the public understand cigars,

especially in relationship to cigarettes. One possibility is that since cigars

are often experienced as being more acutely noxious than cigarettes, the

increased acceptability of their use may undermine public perceptions of

the harmfulness of cigarettes. The public may also have misconceptions

about the role of nicotine in cigar use. In other words, apart from the

direct toxicity of cigars, does the cigar craze undermine public health

efforts to control the cigarette epidemic?

• Research to learn which brands of cigar are popular with the young and

how marketing, price, and availability affect brand choice for this group,

and

• Research to learn the extent to which advertising and promotion for

cigars, including things as commonplace as cigar bands, reaches and

affects kids.

CONCLUSIONS

1. Cigar use began to increase in the United States after promotional

activities for cigars increased beginning in 1992.

2. Promotional activities for cigars have increased the visibility of cigar

consumption, normalized cigar use, and broken down barriers to cigar

use.

3. Although the use of sex and celebrity to sell cigarettes has been forbidden

by the cigarette industry’s voluntary code since 1965, these appeals are a

regular feature of cigar marketing.

The preparation of this chapter has been supported in part by grants

from the Robert Wood Johnson Foundation.

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Smoking and Tobacco Control Monograph No. 9

Policies Regulating Cigars

Gregory N. Connolly

A number of Federal and State policies cover tobacco products. Table 1 presents

the Federal policy approach to the different forms of tobacco use. Table 2 pre-

sents the policy approaches of the State level. In general, Cigars are exempted

from many of the regulations that apply to other tobacco products, particularly

at the Federal level.

REGULATION OF In 1906, Congress passed the first Federal Food and Drug Law. The

CIGAR PRODUCTS Act defined medicines and preparations recognized in the United

States Pharmacopoeia (USP) or the National Formulary. Tobacco was listed in

the 1890’s edition but purportedly was deleted in the 1905 edition in exchange

for support from tobacco-state congressmen for passage of the law (Neuberger,

1963). The 1906 act was superseded by the Federal Food, Drug and Cosmetic Act

(FFDCA) passed in 1938 (Neuberger, 1963). The Act revised the definition of

drug to also include “articles intended for use in the diagnosis, care, mitigation,

treatment or prevention of disease in man or animal” and “articles (other than

food) intended to affect the structure or any function of the body of man or

other animals.”

In 1960, the Food and Drug Administration (FDA) received new authority to

regulate consumer products with passage of the Federal Hazardous Substances Act

(FHSA). Tobacco products were not specifically excluded, but FDA did not assert

jurisdiction over tobacco products at that time. In 1972, authority for FHSA was

transferred to the newly created Consumer Products Safety Commission (CPSC).

The agency was sued in 1974 for failure to consider a petition to set upper limits

on tar in cigarettes. Federal court subsequently ruled the CPSC must consider the

petition. Within 6 weeks of this decision, Congress amended the FHSA specifi-

cally excluding tobacco products, including cigars.

In 1970, Congress passed the Controlled Substances Act to prevent the abuse

of drugs, narcotics and other addictive substances. The law specifically excluded

tobacco and tobacco products from the definition of a “controlled substance” in

21 U.S.C. 802 (Cigar Association of America, 1986) thus excluding cigars. In

1976, Congress enacted the Toxic Substances Control Act and it also excluded

tobacco and tobacco products from the definition (15 USC 802C6). A summary

of Federal regulatory policies for tobacco products is included in Table 1. A

summary of state policies is included in Table 2.

In 1996, the FDA declared that nicotine in cigarettes and smokeless tobacco

was a drug and asserted jurisdiction over these products as devices for delivery of

Chapter 8

222

Table 1

Federal policies on tobacco products

Cigarettes Smokeless Tobacco Cigars

1. Labeling Requirements Package and Print Ads Package and Print Ads None

Four Rotational Three Rotational

Health Warnings Health Warnings

2. Advertising Restrictions Prohibits Advertising Prohibits Advertising Prohibits Little Cigar

on TV and Radio on TV and Radio Advertising on TV and

Radio

3. Report to Congress Biennial Biennial None

4. Nicotine/Toxic

Constituent Disclosure Nicotine, Tar, CO Nicotine None

5. Additive Reporting Confidential List Confidential List None

to DHHS to DHHS

6. Regulation as a

Drug Delivery Device FDA FDA None

7. Youth Access Synar Amendment Synar Amendment Synar Amendment

FDA 21CFR801 FDA 21CFR801

8. Taxation $0.24 Per Pack of 20 $0.027 per

container

0.00125 small cigar

(1.2 oz

) 12.75% of wholesale

price of large cigar but

not more than $0.03 a

cigar

Note: Department of Health and Human Services (DHHS)

Food and Drug Administration

Table 2

State and local policies on tobacco products

Cigarettes Smokeless Tobacco Cigars

1. Labeling Requirements Preempted Preempted California

2. Advertising Restriction Preempted Preempted None

3. Nicotine Disclosure MA, TX MA, TX TX

4. Nicotine/Toxic

Constituent Reporting MA, TX, MN MA, TX, MN TX, MN

5. Youth Access

6. Taxation 50 States 42 States 41 States

(average #0.317 per (40 state average of (36 state tax average

pack or 37.8% or 25.3% of wholesale 21.7% of wholesale

wholesale price) price) price)

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Smoking and Tobacco Control Monograph No. 9

the drug nicotine; however, the agency did not assert jurisdiction over cigars. In

the proposed rule, little cigars were included, but deleted in the final rule that

cited insufficient evidence of use by children and insufficient evidence that cigars

were drug delivery devices under the act, as well as differences in definition of

little cigars and cigarettes for tax purposes.

HEALTH WARNINGS There is no Federal law requiring health warnings on cigars. At the

State level, California adopted in 1986 the Safe Drinking Water and Toxic

Substances Enforcement Act that required warnings on products that contain

chemicals that cause cancer or reproductive risks. In response to the threat of

litigation, cigar manufacturers and retailers agreed to place the following warning

label on cigars sold in the state: “Warning: This product contains/produces

chemicals known to the state of California to cause cancer and birth defects or

other reproductive harm.” Manufacturers of cigars also print the California

warnings on the packages of manufactured cigars sold nationally. Cigars sold

singly generally do not bear the California warning outside of the state.

DISCLOSURE OF CIGAR Following passage of the Federal Cigarette Labeling and

OR SMOKE PRODUCT Advertising Act in 1965, the Federal Trade Commission (FTC)

CONSTITUENTS developed a machine system for measuring tar and nicotine

yield of cigarettes and provided, in an annual report to

Tar, Nicotine, and CO Congress, the yields of tar and nicotine as the most popular

brands (Pillsbury et al., 1969). The system was not designed to predict actual tar

and nicotine intake among humans, only to provide a relative measure between

brands. The system was modified in 1981 to include carbon monoxide (CO).

Cigarette manufacturers disclose tar and nicotine yield of their brands in adver-

tisements under a 1971 consent agreement with the FTC. Cigarette manufactur-

ers generally list tar and nicotine levels on packages of low-yield cigarettes, but

not on packages containing cigarettes with greater than 8 milligrams of tar.

Cigar manufacturers are not required to report tar, nicotine, and CO content

of their products to the Federal Government. Texas and Minnesota require

nicotine reporting of cigars. The International Committee for Cigar Smoking

Studies, which represents cigar manufacturers, concluded that it is technically

possible to smoke cigars by machine (International Committee, 1974). However,

the committee notes that, given the range in cigar size and variability of the

products, it is very difficult to produce valid tar deliveries, and that ranking cigars

by tar content is virtually meaningless and of minimal value to the consumer.

Texas requires cigar manufacturers to disclose nicotine yield of its products

to the Department of Health based on standards to be adopted by the Depart-

ment (Vernon’s Texas Codes Annotated, 1998). Minnesota requires cigar manu-

facturers to disclose “hazardous substances contained in the burned or unburned

state, which may include certain components of tar and carbon monoxide”

(Minnesota Secretary of State Office, 1997). Massachusetts also requires compa-

nies to report nicotine yield of cigarettes and smokeless tobacco products to

consumers based on what the user is expected to take within the body.

44424-federal regulation vol. 61 no. 168 8/28/80.

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224

Small cigars and packaged cigars bear the following statement on the

package in response: “These cigars are predominantly a natural tobacco with

non-tobacco ingredients added.” This has been done in response to California

law (Wilson, 1988). Cigar manufacturers are not required by Federal law to

disclose added constituents or nicotine and tar contents. The manufacturers have

neither voluntarily developed a protocol nor voluntarily disclosed their addi-

tives.

Added Ingredients Cigarette manufacturers are required to report ingredients added to

tobacco to the Secretary of the Department of Health and Human Services

(DHHS). The list does not provide the level of the additive or the brand that it is

placed in, and is kept confidential by DHHS. DHHS is authorized to report to

Congress on its research on additives and health risks, but has yet to do so since

it received the authority in 1984. DHHS has no authority to regulate or remove

harmful additives.

When the FDA asserted jurisdiction over cigarettes and smokeless tobacco as

drug delivery devices, it considered requiring disclosure of ingredients added to

these products, but decided not to do so. The comprehensive Smokeless Tobacco

Health Education Act of 1986 requires similar ingredient reporting to DHHS for

smokeless tobacco products and requires manufacturers to report nicotine yield,

but does not require nicotine content to be listed on advertisements or packages.

Cigarette and smokeless tobacco manufacturers voluntarily released their list of

additives in 1994 in response to public concerns. Cigar manufacturers have not

done so.

Massachusetts requires cigarette and smokeless tobacco manufacturers to file

an annual report with the Department of Public Health that lists added ingredi-

ents by brand in descending order by weight or other measure (Phillips, 1997).

Cigars are not included.

Texas requires reporting of ingredients added to cigars and Minnesota

requires reporting of constituents in the cigar or cigar smoke that are on the

state’s “hazardous substances” list.

ADVERTISING Federal advertising restrictions on cigarettes and smokeless tobacco

RESTRICTIONS products include the prohibition of electronic advertising, including

television, radio, and any other form of electronic communication regulated by

the Federal Communications Commission (FCC). Cigarettes and smokeless

tobacco are not directly advertised by large manufacturers on the Internet,

however, there are over 150 cigar websites on the Internet, many of which sell or

advertise cigars (Cigar Association of America, 1986).

In 1973, the Little Cigar Act (PL93-109) banned broadcast advertising of

“Little Cigars” defined as “any roll of tobacco wrapped in leaf tobacco or any

substance containing tobacco as to which one thousand units weigh not more

than 3 pounds.” The ban did not extend to large cigars and cigarillos which can

still be advertised on electronic medium today.

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Smoking and Tobacco Control Monograph No. 9

The advertising and promotion of cigarette and smokeless tobacco products

have also been restricted through voluntary measures, adopted by their respective

trade associations, the Tobacco Institute and the Smokeless Tobacco Council,

ostensibly to protect children from being encouraged to smoke or use smokeless

tobacco. The codes have a number of similar provisions, such as prohibiting

models in ads who appear to be under the age of 25, not to associate smoking

with glamour, physical fitness, or wealth, and not to place brand-name tobacco

products in movies. As described in Chapter 7, cigar manufacturers’ advertising

and promotion of cigars have not adhered to those voluntary codes (Falit, 1997).

If the codes were strictly applied to cigar advertising, current cigar advertising

and promotion would be severely restricted. Famous actors and athletes, includ-

ing Demi Moore, Arnold Schwartzenegger, and Wayne Gretsky promote cigar use

(Chapter 7). Major themes presented in cigar advertisements include wealth,

athletic fitness, and sexual attractiveness. The tobacco industry stopped market-

ing of cigarettes on college campuses in the 1960’s. A recent story in Smoke

magazine describes emerging cigar social clubs on college campuses (Barry, 1997).

REGULATION OF An earlier chapter of this monograph reports on cigar smoking and

CIGAR SMOKING environmental tobacco smoke (ETS) generated by cigar use (Chapter 5).

IN PUBLIC PLACES

Early restrictions on cigarette smoking included bans on cigars and pipes. In

1971, the Civil Aeronautics Board (CAB) restricted cigarette smoking on airlines

to a limited number of seats, and at the same time banned cigar and pipe smok-

ing entirely.

States and local jurisdiction have extensively regulated cigar smoking as part

of ordinances that have restricted cigarette smoking. More completed reviews of

state and local ordinances are available in an earlier monograph in this series

(Monograph 3) and from the Centers for Disease Control and Prevention (State

Tobacco Highlights, 1996). In general, cigars are more strictly regulated than

cigarettes by these ordinances, probably because of the greater irritation and

annoyance produced by cigar smoke.

LITIGATION Cigarette and smokeless tobacco manufacturers have been sued by ,

individuals classes of persons, and the majority of states for the alleged harm

their products have caused to consumers and for the related health costs of

treating tobacco related diseases.

The Culbro Corporation, a major cigar manufacturer, has been named in

seven suits in Florida since 1995, although it was served in only four cases. In

each case, Culbro was voluntarily dismissed as a defendant. One of the suits in

which the company was named but not served as a defendant was a class action

suit claiming that the plaintiffs were addicted and harmed by cigar smoking.

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226

A principal defense made by tobacco manufacturers in the litigation is that

consumers have been adequately warned of the harm that cigarettes can cause

through health warning labels and are knowledgeable about the risks associated

with cigarette smoking. Cigarette manufacturers argue that consumers voluntar-

ily assume the risks and therefore they should not be held accountable. Cigarette

manufacturers have acknowledged that smoking is a risk factor for certain

diseases although they argue the association is not causal. Cigar manufacturers,

on the other hand, are not required to place health warnings on their products,

except in California. The failure of cigar manufacturers to place warnings on all

of their products, coupled with the marketing of their products, may place them

at risk of liability in the future.

RESTRICTIONS ON At the Federal level, the FDA adopted a regulation on August 23, 1996,

YOUTH ACCESS TO to prohibit the sale of cigarettes and smokeless tobacco products to

CIGARS persons under 18, as well as to restrict advertisements and

promotions directed toward youth. The FDA rule does not include cigars. The

Federal Alcohol, Drug Abuse and Mental Health Act was amended in 1992 to

include a requirement for states to establish 18 years of age as the minimum age

for the purchase of tobacco products. If a state did not establish such a require-

ment, the state would not receive full funding for Federal substance abuse block

grants. Cigars are included in this Act.

TAXATION In 1864, Congress passed a law placing an excise tax on tobacco

Federal Tax of Cigars products, and in the following year collected 11.4 million dollars in

revenue, with only .1 percent coming from cigarette taxation. By 1920, cigarettes

accounted for almost half of the 58 million dollars collected at the Federal level,

and in 1996, cigarettes represented 98 percent.

The current Federal tax on cigars (Table 3) is broken into two categories.

Small cigars are taxed at $1.125 per thousand or approximately one tenth of a

cent per small cigar. The small cigar is defined as having a weight no more than

3 pounds per 1,000 units, and resembling cigarettes in size and weight. The

Federal tax on a package of 20 cigarettes is 24 cents while the tax on 20 small

cigars is about one tenth that or 2.25 cents for 20 small cigars.

The tax on large cigars (cigars weighing more than 3 pounds per thousand) is

12.75 percent of the wholesale price, but not more than $30.00 per thousand. At

this rate, there is a maximum tax of 3 cents per cigar. Based on this weight

classification, cigarillos, manufactured, and premium cigars, would all be classi-

fied as large cigars.

The estimated average manufacturers price for a package of five cigarillos is

$0.60 per package or $120.00 per thousand. Based on that amount, the tax at

12.75 percent for 1,000 would be $16.20 or $1.62 per cigarillo. The estimated

wholesale price of the manufactured cigar is 36 cents per cigar, or $360.00 per

thousand. If the thousand were taxed at 12.75 percent, the resulting tax would

be $51.00 per thousand above the maximum taxable level of $30.00 per thou-

sand.

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Smoking and Tobacco Control Monograph No. 9

The Federal tax on a typical manufactured or premium cigar would therefore

be limited to 3 cents per cigar. This tax scheme is particularly favorable to

manufacturers of premium cigars whose very costly cigars can only be taxed at a

maximum of 3 cents per unit. Thus as price increases due to inflation or de-

mand, Federal tax diminishes as a percent of price. Table 3 summarizes the

Federal taxes on different types of cigars and Table 4 compares the tax rate for

cigarettes and various types of cigars as a percent of the wholesale price.

Table 4

Wholesale price and federal tax per pound of various tobacco products

Wholesale Price per Federal Tax per Tax as a %

Products Pound of Tobacco Pound of Tobacco of Wholesale Price

Cigarettes $19.05 $3.432 28.6%

Small Cigar $15.87 $0.51 3.2%

Tiparillo $19.66 $1.95 12.75%

Manufactured Cigar $19.21 $1.59 8.3%

Premium Cigar $34.09 $0.68 2%

Table 3

Estimated weight, price, and federal tax per 1,000 pounds of tobacco products

Tobacco Product

(weight Est. Weight/Thousand Price/Thousand Fed Tax/Thousand %Tax

Wholesale Price) Units Units Units of Price

Small Cigars

(1 gram @$0.035 each) 2.205 lbs. $35.00 $1.125 3.2%

Tiparillos

(3 grams @$0.12 each) 6.614 lbs. $120.00 $15.30 12.57%

Manufactured Cigars

(8.5 grams @$0.36 each) 18.74 lbs. $360.00 $30.00 8.3%

Premium

(20 grams @$1.50 each) 44.100 lbs. $150.00 $30.00 2%

Cigarettes

(1 gram @$0.042 each) 2.205 LBS. $42.00 $12.00 28.6%

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228

State Taxation of Cigars As of January 1, 1996, the number of states taxing cigars was

41, with 36 placing a single average tax of 21. 7 percent on the manufacturers’ or

wholesalers’ price (Table 5). Five states have a tax system similar to that of the

Federal Government that have multiple rates according to the weight or price of

the cigar. Of the 36 states with the single rate, Washington has the highest tax of

74.9 percent of the wholesale price, and North Carolina the lowest, 2 percent.

Ten states had rates higher than 25 percent, and 26 lower. By comparison, 50

states tax cigarettes at an average tax of 31.7 cents per pack or 37 percent of the

wholesale price of $84.00 per thousand. Forty states tax smokeless tobacco at an

average rate of 25.3 percent of the wholesale price. According to the Tobacco

Institute, 337.2 million dollars in gross tax revenue was generated from state

taxation of tobacco products other than cigarettes in 1996. This represents 4.8

percent of the total tax revenue from all tobacco products.

In recent years, there has been an increasing trend at the state level to

impose taxes on tobacco products other than cigarettes. In 1970, 21 states taxed

cigars and the number remained virtually constant up until 1995 (22 states).

However, by 1990, the number of states rose to 33 and by 1996 was 41 states.

Not only did the number of states taxing cigars increase, but also the rate in-

creased by almost 30 percent from 1983 to 1996. In 1983, 14 states levied a flat

rate on the wholesale price of cigars of 21.3 percent. By 1996, the same states

increased the average rate 28.2 percent. Total state tax revenue for tobacco

products other than cigarettes increased from $32.6 million in 1975 to $62.3

million in 1985, and today is $337.2 million. In 1975, other tobacco products

made up 3.4 percent of all tobacco tax revenue at the state level, and by 1996

rose to 4.8 percent. Table 5 summarizes the taxation of cigars by individual

states.

All 50 states and the District of Columbia have enacted some form of legisla-

tion with respect to the sale of cigars to minors. According to NCI’s State Cancer

Legislative Database, through November 1997, 29 states and DC explicitly

prohibit the sale of cigars to minors. The remaining states prohibit the sale of

tobacco products to minors, implicitly covering cigars (Table 6).

In conclusion, the number of states taxing cigars has increased sharply over

the last 10 years, and the vast majority tax cigars as a percent of wholesale price.

Such a tax structure will result in an increase in revenue as cigar prices go up.

This is the opposite of the Federal system which sets a maximum rate of 3 cents

per large cigar. Thus as the price of large cigars increase, the proportion of tax on

the price decreases.

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Smoking and Tobacco Control Monograph No. 9

Table 5

State tax rates on cigars

State Tax rates States with no tax rates

on cigars

Alabama Cigars, retailing for: District of Columbia

(a) 3 1/2 cents each or less, $1.50 per thousand; Florida

(b) More than 3 1/2 and not more than 5 cents each, $3.00 per thousand; Kentucky

(d) More than 8 and not more than 10 cents each, $7.50 per thousand; Pennsylvania

(e) More than 10 and not more than 20 cents each, $15 per thousand; Virginia

(f) More than 20 cents each, $20.25 per thousand. West Virginia

Little Cigars: 2 cents for each 10 or fraction thereof. Wyoming

Alaska 75% of wholesale price.

Arizona Cigars retailing for:

(a) 5 cents each or less, 6.4 cents for each 3 cigars;

(b) More than 5 cents, 6.4 cents each

Little cigars: 12.9 cents for each 20 or fraction thereof.

Arkansas 23% of manufacturers' invoice price.

California 29.37% of wholesale price effective 7/1/97-6/30/98.*

Colorado 20% of manufacturers' price.

Connecticut 20% of wholesale price – all OTP.

Delaware 15% of wholesale price.

Georgia Little cigars: weighing not more than 3 pounds per 1,000: 2 mills each.

All other cigars: 13% wholesale price.

Hawaii 40% of wholesale price.

Idaho 40% of wholesale sales price.

Illinois 18% of wholesale price.

Indiana 15% of wholesale price.

Iowa 22% effective 6/1/91 of wholesale sales price.

Kansas 15% of original invoice price from the manufacturer to the wholesaler.

Louisiana Cigars with a list price of $120 per thousand or less, tax is 8% of net invoice price;

Cigars with a list price of over $120 per thousand, tax is 20% of net invoice price.

Maine 16% of wholesale sales price.

Massachusetts 15% of wholesale price.

Michigan 16% of wholesale price.

Minnesota 35% of wholesale price.

Mississippi 15% of manufacturers' list price.

*CA reset at the beginning of each fiscal year.

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230

Table 5 (

Continued

)

State tax rates on cigars

State Tax rates States with no tax rates

on cigars

Missouri 10% of manufacturers' price.

Montana 12.5% of wholesale price.

Nebraska 15% of wholesale price.

Nevada 30% of wholesale price.

New Jersey 48% of wholesale price.

New Mexico 25% of product value.

New York 20% of wholesale price – all OTP.

North Carolina 2% of wholesale price.

North Dakota 28% of wholesale price.

Ohio 17% of wholesale price.

Oklahoma Cigars, cheroots, stogies, etc., weighing more than 3 pounds

per thousand, retailing for:

(a) 4 cents each or less, $10 per thousand;

(b) More than 4 cents each, $30 per thousand;

Little cigars: 2 cents for each 8 or fraction thereof.

South Dakota 10% of wholesale price.

Tennessee 6% of wholesale price.

Texas Tax on cigars is based on weight per 1,000 and retail selling price.

(a) Cigars weighing not more than 3 pounds per 1,000, 1 cent for each 10 cigars;

(b) Cigars weighing more than 3 pounds per 1,000 and retailing for not more

than 3.3 cents each, $7.50 per 1,000;

retailing for over 3.3 cents each, containing no substantial amount of

nontobacco ingredients, $11.00 per $1,000;

(d) Cigars of all description weighing more than 3 pounds per 1,000 and

retailing for over 3.3 cents each, containing a substantial amount of

nontobacco ingredients, $15.00 per $1,000.

Utah 35% of manufacturers' selling price exclusive of any trade discount,

special discount, or deal.

Vermont 41% of distributors' price.

Washington 74.9% of wholesale price.

Wisconsin 20% of wholesale price.

Source: Tobacco Institute, Washington, D.C.

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Smoking and Tobacco Control Monograph No. 9

Table 6

States with laws prohibiting the sale of cigars to minors

(Through November 30, 1997)

State Type of Prohibition State Type of Prohibition

Alabama

* Montana *

Alaska * Nebraska x

Arizona * Nevada x

Arkansas x New Hampshire *

California x New Jersey x

Colorado * New Mexico x

Connecticut x New York *

Delaware * North Carolina x

District of Columbia * North Dakota *

Florida x Ohio x

Georgia x Oklahoma *

Hawaii x Oregon x

Idaho * Pennsylvania x

Illinois * Rhode Island *

Indiana * South Carolina x

Iowa x South Dakota *

Kansas * Tennessee x

Kentucky x Texas *

Louisiana * Utah *

Maine x Vermont *

Maryland * Virginia *

Massachusetts x Washington x

Michigan * West Virginia *

Minnesota * Wisconsin *

Mississippi * Wyoming *

Missouri *

Source: National Cancer Institute, State Cancer Legislative Database, Bethesda, MD: SCLD

Legend: * Denotes states that have enacted laws explicitly prohibiting the sale of cigars to minors

x Denotes states that have enacted laws prohibiting the sale of tobacco/tobacco products to minors

Alabama does not prohibit the sale of cigars or tobacco products to minors; instead the purchase of cigars by minors

is prohibited.

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232

CONCLUSIONS

1. There is less Federal and State regulation of cigars when compared to

cigarettes and smokeless tobacco. The Synar Amendment is the only Federal

statute, outside of the tax codes, that specifically includes cigars.

2. The voluntary codes restricting marketing practices established by the

tobacco trade associations are regularly violated by cigar advertising and

promotional activities.

3. Federal tax rates selectively favor premium cigars over other cigars and

tobacco products, by capping the tax rate at 3 cents per cigar.

4. With the exception of warnings mandated by California’s Proposition 65,

cigars do not carry warning labels.

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Barry, S.T. Collegiate smokes. Smoke 2(2): 138-150,

1997.

Cigar Association of America, Inc. Cigar Advertising

Standards. Washington, DC: Cigar Association of

America, Inc., 1986.

Falit, J.L. Cigar advertising targeting “baby-boomers”

and other adults. Tobacco Control, 6:240-242, 1997.

Federal Register, Vol. 61 No.168, 8/28/80, p. 44424.

International Committee, p. 4, 1974.

Minnesota Secretary of State Office. Minnesota General

Laws Chapter 227 H.F. No. 117. Minneapolis:

Minnesota Secretary of State Office, 1997.

Neuberger, M.D. Smoke Screen: Tobacco and the Public

Welfare. Englewood Cliffs, New Jersey: Prentice-Hall,

1963.

Phillips, F. Cigarette statute is upheld. Boston Globe,

February 8, 1997.

Pillsbury et al. Cigar Smoking Studies, p. 3, 1969.

Centers for Disease Control and Prevention. State Tobacco

Highlights. Washington, DC: Centers for Disease

Control and Prevention, 1996.

Vernon’s Texas Codes Annotated. Disclosure of Ingredients

in Cigarettes and Tobacco Products. Vol.1: Health and

Safety. St. Paul: West Group, pp.192-194, 1998.

Wilson, D.S. Cigars and pipe tobacco to get warning

labels. New York Times, October 19, 1988.