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Science in the News

Systematic Review Shows Cigar and Cigarette Smoking Share Similar Health Risks

May 09, 2014

In a recent systematic review,1 researchers from the FDA Center for Tobacco Products found that current cigar smoking—with no previous history of cigarette or pipe smoking--was associated with higher risk of developing oral cancer, coronary heart disease, cancer of the esophagus, larynx, lung and pancreas, and increased risk of death from all causes.  The study, available online from the journal BMC Public Health, was featured in news articles from CNBC and other organizations.

Using data from 22 epidemiologic studies, the authors evaluated the association between current, exclusive cigar smoking and all-cause and cause-specific mortality, focusing specifically on mortality and disease risks in primary cigar smokers (those without any prior history of cigarette or pipe smoking).  Data on health risks for secondary cigar smokers (those with a previous history of cigarette or pipe smoking) were presented separately because former cigarette smokers are more likely to inhale when smoking. Accordingly, secondary cigar smokers are considered to have a different profile of disease risks due to their higher level of inhalation and exposure to cigar smoke.

Among the primary conclusions of the systematic review:

  • Primary cigar smokers are at higher risk of developing numerous types of cancer (oral, esophageal, laryngeal, lung, and pancreatic) and aortic aneurysm (an abnormal, balloon-like bulge in the wall of the aorta).
  • Individuals who smoke cigars more frequently, or with increasing (or any) inhalation of cigar smoke, are at significantly higher risk of developing cancer of the oral cavity, esophagus, larynx and pharynx.  As an example, individuals who smoked three or more cigars per day have at least 7-times higher risk of oral cancer than individuals who have never smoked.  
  • Cigar smokers who reported no inhalation when smoking also had significantly elevated disease and mortality risks, including increased risk of oral cancer mortality.  

In the U.S. marketplace, cigar products vary widely in size, composition and flavors, and the systematic review demonstrates that all cigars, regardless of size, carry significant health risks.  Like other combustible tobacco products, cigars deliver a range of biologically active chemicals, including nicotine, carbon monoxide and other constituents.  Cigar smoking has been found to deliver equal or greater amounts of nicotine than cigarettes, depending on the duration of exposure and level of inhalation.  Free nicotine from cigar smoke can also be taken up directly through the oral mucosa.  

Cigar smoke has high levels of tobacco-specific nitrosamines due to the process used for cigar tobacco curing and fermentation.  Large cigars can be smoked over longer periods of time, and produce significant exposure to nicotine and other chemicals.  As shown in another recent study from the FDA Center for Tobacco Products,2 daily cigar smokers and daily cigarette smokers have similar levels of exposure to carcinogenic, tobacco-specific metabolites.

Concern has been expressed about the growing landscape of cigar products, including flavored cigars and cigarillos (small cigars), which are sold cheaply and marketed directly to youths, adolescents and young adults (often in smaller pack sizes).1  Many small filtered cigars, flavored cigars and cigarillos appear similar to cigarettes, and users of these products can inhale just as they do when smoking cigarettes.  As reported in the systematic review,1 a recent survey found that one in 8 high school students reported cigar smoking within the past 30-day period.

The ADA recently joined several health care organizations in calling for stronger regulatory oversight over all tobacco products, including cigars and little cigars (cigarillos), which are currently unregulated and heavily marketed to adolescents and young adults.  Dentists have an important role in advising patients of the dangers of exposure to tobacco smoke, including smoke from cigars, as well as the dangers of other forms of tobacco (e.g., smokeless tobacco).  The U.S. Public Health Service guideline Treating Tobacco Use and Dependence3 recommends the "5-A’s" behavioral counseling framework as a useful approach to engage patients in smoking cessation discussions: 1) ask about tobacco use; 2) advise to quit through clear personalized messages; 3) assess willingness to quit; 4) assist to quit; and 5) arrange follow-up and support.  Additional information about the health risks of cigar smoking can be accessed at the following websites:



Footnotes

1.    Chang CM, Corey CG, Rostron BL, Apelberg BJ.  Systematic review of cigar smoking and all cause and smoking related mortality.  BMC Public Health 2015 Apr 24;15(1):390. doi: 10.1186/s12889-015-1617-5.  Available at: “http://www.biomedcentral.com/1471-2458/15/390”.  Accessed April 27, 2015.

2.    Chen J, Ketterman A, Rostron BL, Day HR.  Biomarkers of exposure among U.S. cigar smokers: an analysis of 1999-2012 National Health and Nutrition Examination Survey (NHANES) data.  Cancer Epidemiol Biomarkers Prev. 2014 Dec;23(12):2906-15.  Abstract available at: “http://www.ncbi.nlm.nih.gov/pubmed/25380733?dopt=Abstract”.  Accessed April 29, 2015.   

3.    Fiore MC, Jaen CE, Baker TB et al.  Treating Tobacco Use and Dependence: 2008 Update.  Clinical Practice Guideline. Rockville, MD: US Department of Health & Human Services, Public Health Service; 2008.  Available at: “http://www.ahrq.gov/professionals/clinicians-providers/guidelines-recommendations/tobacco/index.html“.  Accessed May 4, 2015.

Resources

Cigars: Health Effects and Trends—Monograph 9 (National Cancer Institute)

Cigar Smoking (American Cancer Society)

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Science in the News is a service by the American Dental Association (ADA) to its members to present current information about science topics in the news. The ADA is a professional association of dentists committed to the public's oral health, ethics, science and professional advancement; leading a unified profession through initiatives in advocacy, education, research and the development of standards. As a science-based organization, the ADA's evaluation of the scientific evidence may change as more information becomes available. Your thoughts would be greatly appreciated.