So far it was not known whether it carried an increased risk of cardiovascular disease, but a recent study has provided evidence to that effect.

Over 17,500 men aged 30 to 85 were enrolled in the Kaiser Permanente Medical Care Program between 1964 and 1973. They had never smoked cigarettes, and were not currently pipe smokers. Their health was carefully followed from 1971 through 1996, using hospitalization discharge records and local tumor registries.

There were over 1,500 cigar smokers at entry - about 9% of the total - and their subsequent health records were compared with those of the 91% non-smokers. The analyses took into account the health information collected at enrollment, medical history, alcohol consumption, and any exposure to occupational hazards such as solvents, pesticides, asbestos and silica.

The cigar smokers were slightly older, more obese, had higher blood pressure, higher cholesterol levels and were more likely to have diabetes, than non-cigar smokers; also, they consumed more alcohol than non-smokers. Most of them smoked less than 5 cigars a day.

After adjusting for age, it was found that cigar smokers were 1.27 times more likely to develop coronary heart disease, and 1.45 times more likely to develop COPD, than non-smokers. There was no evidence that cigar smokers were more likely to have a stroke or disease of the leg arteries than non-smokers.

Cigar smokers had about twice the risk of cancer of the throat, larynx, esophagus and lung as non-smokers. The risks were greater among those who smoked 5 or more cigars daily, compared with those who smoked fewer than 5. Alcohol consumption seemed to increase the risk for these cancers (except cancer of the lung) still further. Cigar smoking was not associated with an increased risk of cancer of the pancreas, kidney, bladder, colon or rectum.

Obviously, these findings must be compared with those for cigarette smoking. Various studies have shown that cigarette smoking by men causes a 1.5 to 3 times likelihood of coronary heart disease, 9 to 25 times the risk of COPD, 8 to 24 times the risk for lung cancer and 4 to 12 times the risk for mouth/throat cancer. However, as about half the cigar smokers in the Kaiser Permanente study said that they quit smoking within the first 8 years after enrollment, the actual effects of cigar smoking may have been underestimated. Cigar smoke is not usually deeply inhaled, which may explain the lowered risks of COPD and lung cancer among cigar smokers, compared with cigarette smokers.

The resurgence of cigar smoking in the United States in recent years is worrying, in view of the findings of this, and other, studies. Older persons, even if non-smokers themselves, can play an effective role by advising their children (and grandchildren) about the risks of all forms of tobacco.

Cigars and Your Health

Debora J. Orrick, M.A., LCDC, CTAC-ACP
drkoop.com

The old lie that smoking is cool is rearing its ugly head again. While going to swank cigar bars becomes a part of the night life across the country, a message is being sent that cigar smoking is trendy, sophisticated and safe. Many cigar smokers erroneously believe that cigars are not as hazardous to their health as cigarettes because they are smoked differently. The fashion of smoking cigars has been fueled by the promotion of cigar smoking by all types of celebrities and public figures, such as President Clinton, Luciano Pavarotti, Wayne Gretzky, Sylvester Stallone and Salma Hyak. Cigars have reached such high popularity that cigar stores, salons and bars are opening all over the United States; there is even a cigar magazine for the connoisseur, whose cover has been graced by super models, super stars and super powers.

Unfortunately, most new cigar smokers are poorly informed about the major health risks associated with daily cigar smoking; and new smokers in general greatly underestimate the potential health effects of smoking and often regret their naivete after they have become dependent to the drug and the habit. Seventy percent of regular smokers wish they could stop and wish that they had never started in the first place.

Cigar smoking has increased dramatically in the United States in the 1990s, especially among women and teen-agers. Between 1993 and 1997, cigar sales jumped 50 percent. Current usage levels are the highest in 20 years. Since 1993, cigar and cigarillo use has increased by 45 percent, and the use of premium cigars (which can cost more than $10 each) has increased a dramatic 250 percent. By 1997, more than 10 million Americans smoked cigars; that is three million more than in 1994, which represents an incredible increase in just three years! The greatest increase in cigar use has been with young and middle-aged Caucasian adults with higher-than-average incomes and education. Adult men are eight times more likely than women to use cigars. More teen-agers use cigars than smokeless tobacco. One out of every four teen-agers reports having smoked a cigar at least once, and as many as 30 percent of teens report having smoked a cigar in the last month.

Research shows that three-quarters of cigar smokers smoke occasionally and that 76 percent of them smoke fewer than five cigars a day. Occasional cigar smoking (once or twice a month) is considered to be of minimal health risk unless you have special or hereditary factors that would place you at higher risk for tobacco-related illnesses or tobacco addiction. If you have parents or grandparents who are or were addicted to tobacco, if you grew up in a home with one or more chronic smokers and high levels of second-hand smoke, or if there have been unusually high levels or many types of cancers in your family (particularly in your parents and grandparents), you may be at a higher risk.

Cigar vs. Cigarette Use
One of the main thrusts behind cigars' popularity is the belief that they are a safe alternative to cigarettes because the smoke is not inhaled, and because cigars are commonly used only occasionally and not daily. Traditionally, cigar smokers hold the smoke in their mouth and throat, allowing nicotine and other chemical compounds to be absorbed through the mucous lining of the mouth and throat, rather than inhaling the smoke into their lungs.

A smoker can spend more than an hour puffing on a cigar, which has the equivalent risk of oral cancers as smoking a pack of cigarettes a day. Daily cigarette smokers and daily cigar smokers have similar levels of risk for oral cancers. Smokers who smoke more than five cigars per day have lung cancer risks comparable to smoking a pack of cigarettes a day.

The real difference between cigar and cigarette smoking is the type of cancers that cigar smokers develop, which is usually a head or neck cancer instead of the lung cancer so common among cigarette smokers. Unfortunately, people who switch from using cigarettes to cigars tend to smoke cigars the way they smoked cigarettes: by inhaling deeply and smoking often. Inhalation seems to raise the health risks of cigars so that the smoker will face the same health risks as with cigarette smoking.

Unlike cigarettes, cigars do not have filters to reduce their tar and nicotine content. Cigar packages do not carry the Surgeon General's health warnings that are required on other tobacco products. Like cigarettes, the additives in cigars are not regulated by any consumer or governmental agency and do not have to be reported or put on the label.

Cigar Smoke and Nicotine Content
Researchers currently believe that as few as five milligrams of nicotine a day is enough to cause addiction to the drug. The average cigarette has around one milligram of nicotine in it, and cigars have much higher levels of nicotine -- up to 400 milligrams in large, long cigars. This means that one cigar a day may be enough to cause addictive changes in your brain cells. Tobacco smoke contains more than 4,000 chemical compounds, including the following substances, which are also contained in household products with warning labels telling you to avoid inhaling them:

• formaldehyde
• ammonia
• urethane
• naphthalene

Other cigar smoke contents include the following substances:

• carbon monoxide
• hydrogen cyanide
• arsenic
• nicotine
• benzene
• vinyl chloride
• ethylene oxide
• other volatile aldehydes
• cadmium
• radioactive polonium 210

Because of the long aging and fermentation process for cigar leaves, because of the larger size of cigars and because of the toxic way it burns due to cigars' nonporous wrappers, cigar smoke has 20 times more ammonia than cigarettes and 80 to 90 times the number of highly carcinogenic, tobacco-specific nitrosamines. Cigar smoke also contains 30 times more carbon monoxide than cigarette smoke.

Cigars and Your Health
The National Cancer Institute of the National Institute of Health has determined that cigars are not safe alternatives to cigarettes and may cause addiction to nicotine. Regular cigar smoking increases risks for heart disease, lung disease and cancers of the mouth, throat and lung. Daily cigar smokers who do not inhale have a 27 percent higher risk of heart disease than nonsmokers, and a 45 percent higher risk of chronic obstructive pulmonary disease (COPD), a blanket term for emphysema and chronic bronchitis. Cigar smokers who inhale have a 53 times greater risk of larynx cancer, 27 times greater risk of oral cancer and 23 percent greater risk of heart disease. Drinking three or more alcoholic beverages a day with your cigar increases your average risk of mouth and throat cancers, because alcohol is extremely effective in dissolving the carcinogens from the smoke into the bloodstream.

Overall, cancer death rates of cigar smokers are 34 percent higher than those of nonsmokers, and cigar smokers are three to five times more likely to die of lung cancer than are nonsmokers. One study found that 90 percent of cigar smokers have precancerous changes in the cells of their voice box. There are also strong links between cigar smoking and cancer of the pancreas and the very rare male breast cancer.

Second-Hand Cigar Smoke
The second-hand smoke from a single cigar burned in a home can take five hours to dissipate. Secondhand cigar smoke contains the same 4,000 chemical compounds found in other tobacco products. Many of these compounds occur in much higher quantities in cigars than in cigarettes. These include unusually high amounts of ammonia, carbon monoxide, nitrosamines and easily inhaled particles -- all potent carcinogens!

No studies have been conducted to determine the health effects of nonsmokers who frequent cigar social events and clubs, but a significant body of evidence clearly demonstrates an increased risk of lung cancer, asthma and other lung diseases from secondhand cigarette smoke. Research conducted at two cigar events in San Francisco found carbon monoxide levels were higher than the levels found on a busy California freeway. Had these exposures lasted more than eight hours, they would have exceeded the National Ambient Air Quality Standards for outdoor air, which were established by the Environmental Protection Agency.

Recommendations About Cigars
Because the health risks are so high, U.S. Surgeon General David Satcher and the American Cancer Society have made the following recommendations regarding cigars:

• Adopt measures identical to those employed in the fight against cigarette smoking.
• Raise taxes on all tobacco products.
• Require health warning labels.
• Increase public education programs about the risks of cigar smoking, especially for children and teen-agers.
• Adopt laws limiting access to all tobacco products by children and teens.