Introduction

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

The purpose of this document is to describe what cigars are, the recent trends in their use, and the possible health effects they may have on the people who smoke them and those around them.

How Are Cigars Different From Cigarettes?

A cigar is defined, for tax purposes, as “any roll of tobacco wrapped in leaf tobacco or in any substance containing tobacco,” while a cigarette is “any roll of tobacco wrapped in paper or any substance not containing tobacco.” Unlike most manufactured cigarettes, cigars do not usually include a filter.

Most cigars are made up of a single type of air-cured or dried tobacco. Cigar tobacco leaves are first aged for about a year and then fermented in a multi-step process that can take from 3 to 5 months. Fermentation causes chemical and bacterial reactions that change the tobacco and give cigars a different taste and smell from cigarettes.

Cigars come in different sizes, some as small as a cigarette (called a cigarillo), others much larger. Large cigars typically contain between 5 and 17 grams of tobacco. There are about 29 grams in an ounce, so a very large cigar can contain more than half an ounce of tobacco. This is as much tobacco as a whole pack of cigarettes. Large cigars can take between 1 to 2 hours to smoke.

Who Smokes Cigars?

Cigar smoking continues to be a popular trend in the United States where a “cigar culture” is supported by cigar magazines, shops, and bars or clubs. Many cigar smokers consider themselves to be connoisseurs, similar to wine experts. Cigars are viewed as a sophisticated, affordable luxury that represents success, and cigar smokers are portrayed to have a high degree of taste and refinement. This image is fueled in part by the efforts of the tobacco industry to glamorize cigars and the willingness of movie stars and athletes to be paid and photographed smoking cigars. Teenagers and young adults may be particularly vulnerable because of the mistaken idea that cigars are a safe alternative to cigarettes.

According to the US Department of Agriculture (USDA), cigar use has increased since the early 1990s. Most of this increase was between 1993 and 1999, when the use of both large cigars and cigarillos (little cigars) climbed an estimated 70%. An estimated 5.3 billion cigars were consumed in the United States in 2006 — a 9% increase from the previous year. The production of little cigars went from 1.5 billion in 1997 to about 5.1 billion in 2006. These “cigars” are often sold in packs of 20, just like cigarettes. Some companies add strawberry, chocolate, and other sweet flavors, which appeal to younger smokers. Because of the lower taxes, they are less expensive than cigarettes. This also makes it easier for younger smokers.

Sales of premium cigars, most of which are hand-made and imported, have increased over much of the last decade. The sharp rise in the popularity of gourmet coffee and microbrewery beers is thought to go along with the large increase in cigar smoking, particularly among young and middle-aged white men (ages 18 to 44) with higher than average incomes and education.

Cigar smoking occurs mainly among males between the ages of 35 and 64 who have higher educational backgrounds and incomes, but recent studies suggest new trends. Most new cigar users today are teenagers and young adult males (ages 18 to 24) who smoke occasionally (less than daily). In 2006, about 12% of Americans aged 18 to 25 had smoked a cigar within the last month, compared to the average of 6% from all ages.

The general rise in cigar smoking in recent years has not been limited to the adult population, however. According to surveys from the Centers for Disease Control and Prevention (CDC), the level of cigar use among adolescents and teenagers in recent years has been higher than that of spit (oral tobacco) tobacco use. As of 2006, about 4% of teens aged 12 to 17 had smoked a cigar in the past month.

Are Cigars Addictive?

Even though people smoke cigars for different reasons, the fact is, like cigarettes, cigars can become addictive. Nicotine is the substance in tobacco that causes addiction. Most cigars have as much nicotine as several cigarettes. One cigarette delivers about 1 to 2 milligrams of nicotine, while many popular brands of cigars contain between 100 and 200 milligrams, or as even many as 444 milligrams of nicotine.

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

Do Cigars Cause Cancer?

Cigar smoking increases your risk of death from many cancers, including:

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

Studies have shown that male cigar smokers are 4 to 10 times more likely to die from oral and laryngeal cancers than non-smokers. In addition, when saliva containing cigar smoke chemicals is swallowed, the esophagus is exposed to carcinogens (cancer-causing agents). The death rate from esophageal cancer is many times higher in male cigar smokers than in males who have never smoked. For those who inhale, cigar smoking appears to be linked to death from cancer of the pancreas and bladder, too.

How you smoke and how much you smoke are both important. Cigar smokers may spend up to an hour smoking a single large cigar that can contain as much tobacco as a pack of cigarettes. Smoking more cigars each day or inhaling cigar smoke leads to more exposure and higher risks. Studies have shown your risk of death is higher if you smoke 3 or more cigars than if you smoke 2 or fewer cigars a day. The health risks linked to occasional cigar smoking (less than daily) are not known.

Does Inhaling Affect the Risk of Cancer?

While almost all cigarette smokers inhale, most cigar smokers do not. This may be because cigar smoke is generally more irritating to the eyes, nose, throat, and breathing passages. A new trend among cigar companies is to change the fermenting process of their products to make them easier to inhale. This same curing and fermenting process further enhances the flavor but also increases the levels of harmful ingredients.

For those who do not inhale, tobacco smoke does not reach the lungs in the same amounts as it does in cigarette smokers. As a result, the risk of death from lung cancer is not as high as it is for cigarette smokers. Still, it is many times higher than the risk for non-smokers.

Cigar smokers who have smoked cigarettes are more likely to inhale. According to a recent American Cancer Society study, those who inhale have an increased risk of death from lung cancer — 11 times greater than that of non-smokers.

The study also found that for those cigar smokers who inhale, the risks are increased for other types of cancer. Compared to non-smokers, cigar smokers who inhale deeply:

• are 6 times more likely to die from oral cancer
• are 39 times more likely to die from cancer of the larynx
• face more than twice the risk of death from pancreatic cancer
• face more than 3 times the risk of death from bladder cancer

Do Cigars Cause Other Health Problems?

Cigarette smoking is known to increase the risk of lung diseases such as emphysema and chronic bronchitis. Cigarette smokers have twice the risk of dying of heart attacks as do non-smokers. And smoking is a major risk factor for peripheral vascular disease, a narrowing of the blood vessels that move blood through the arms and legs.

While the link is not quite as strong as with cigarette smoking, cigar smoking (especially for people who inhale) increases the risk of heart disease and lung diseases, such as emphysema and chronic bronchitis.

At this time there are no studies that clearly show a link between cigar smoking and either peripheral vascular disease or stroke. However, a recent study found cigar smoking, as well as cigarette smoking, is linked to a man’s inability to achieve erection (a condition known as erectile dysfunction, or ED).

Taking Care of Yourself

Cigar Smoking

Introduction

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

The purpose of this document is to describe what cigars are, the recent trends in their use, and the possible health effects they may have on the people who smoke them and those around them.

How Are Cigars Different From Cigarettes?

A cigar is defined, for tax purposes, as “any roll of tobacco wrapped in leaf tobacco or in any substance containing tobacco,” while a cigarette is “any roll of tobacco wrapped in paper or any substance not containing tobacco.” Unlike most manufactured cigarettes, cigars do not usually include a filter.

Most cigars are made up of a single type of air-cured or dried tobacco. Cigar tobacco leaves are first aged for about a year and then fermented in a multi-step process that can take from 3 to 5 months. Fermentation causes chemical and bacterial reactions that change the tobacco and give cigars a different taste and smell from cigarettes.

Cigars come in different sizes, some as small as a cigarette (called a cigarillo), others much larger. Large cigars typically contain between 5 and 17 grams of tobacco. There are about 29 grams in an ounce, so a very large cigar can contain more than half an ounce of tobacco. This is as much tobacco as a whole pack of cigarettes. Large cigars can take between 1 to 2 hours to smoke.

Who Smokes Cigars?

Cigar smoking continues to be a popular trend in the United States where a “cigar culture” is supported by cigar magazines, shops, and bars or clubs. Many cigar smokers consider themselves to be connoisseurs, similar to wine experts. Cigars are viewed as a sophisticated, affordable luxury that represents success, and cigar smokers are portrayed to have a high degree of taste and refinement. This image is fueled in part by the efforts of the tobacco industry to glamorize cigars and the willingness of movie stars and athletes to be paid and photographed smoking cigars. Teenagers and young adults may be particularly vulnerable because of the mistaken idea that cigars are a safe alternative to cigarettes.

According to the US Department of Agriculture (USDA), cigar use has increased since the early 1990s. Most of this increase was between 1993 and 1999, when the use of both large cigars and cigarillos (little cigars) climbed an estimated 70%. An estimated 5.3 billion cigars were consumed in the United States in 2006 — a 9% increase from the previous year. The production of little cigars went from 1.5 billion in 1997 to about 5.1 billion in 2006. These “cigars” are often sold in packs of 20, just like cigarettes. Some companies add strawberry, chocolate, and other sweet flavors, which appeal to younger smokers. Because of the lower taxes, they are less expensive than cigarettes. This also makes it easier for younger smokers.

Sales of premium cigars, most of which are hand-made and imported, have increased over much of the last decade. The sharp rise in the popularity of gourmet coffee and microbrewery beers is thought to go along with the large increase in cigar smoking, particularly among young and middle-aged white men (ages 18 to 44) with higher than average incomes and education.

Cigar smoking occurs mainly among males between the ages of 35 and 64 who have higher educational backgrounds and incomes, but recent studies suggest new trends. Most new cigar users today are teenagers and young adult males (ages 18 to 24) who smoke occasionally (less than daily). In 2006, about 12% of Americans aged 18 to 25 had smoked a cigar within the last month, compared to the average of 6% from all ages.

The general rise in cigar smoking in recent years has not been limited to the adult population, however. According to surveys from the Centers for Disease Control and Prevention (CDC), the level of cigar use among adolescents and teenagers in recent years has been higher than that of spit (oral tobacco) tobacco use. As of 2006, about 4% of teens aged 12 to 17 had smoked a cigar in the past month.

Are Cigars Addictive?

Even though people smoke cigars for different reasons, the fact is, like cigarettes, cigars can become addictive. Nicotine is the substance in tobacco that causes addiction. Most cigars have as much nicotine as several cigarettes. One cigarette delivers about 1 to 2 milligrams of nicotine, while many popular brands of cigars contain between 100 and 200 milligrams, or as even many as 444 milligrams of nicotine.

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

Do Cigars Cause Cancer?

Cigar smoking increases your risk of death from many cancers, including:

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

Studies have shown that male cigar smokers are 4 to 10 times more likely to die from oral and laryngeal cancers than non-smokers. In addition, when saliva containing cigar smoke chemicals is swallowed, the esophagus is exposed to carcinogens (cancer-causing agents). The death rate from esophageal cancer is many times higher in male cigar smokers than in males who have never smoked. For those who inhale, cigar smoking appears to be linked to death from cancer of the pancreas and bladder, too.

How you smoke and how much you smoke are both important. Cigar smokers may spend up to an hour smoking a single large cigar that can contain as much tobacco as a pack of cigarettes. Smoking more cigars each day or inhaling cigar smoke leads to more exposure and higher risks. Studies have shown your risk of death is higher if you smoke 3 or more cigars than if you smoke 2 or fewer cigars a day. The health risks linked to occasional cigar smoking (less than daily) are not known.

Does Inhaling Affect the Risk of Cancer?

While almost all cigarette smokers inhale, most cigar smokers do not. This may be because cigar smoke is generally more irritating to the eyes, nose, throat, and breathing passages. A new trend among cigar companies is to change the fermenting process of their products to make them easier to inhale. This same curing and fermenting process further enhances the flavor but also increases the levels of harmful ingredients.

For those who do not inhale, tobacco smoke does not reach the lungs in the same amounts as it does in cigarette smokers. As a result, the risk of death from lung cancer is not as high as it is for cigarette smokers. Still, it is many times higher than the risk for non-smokers.

Cigar smokers who have smoked cigarettes are more likely to inhale. According to a recent American Cancer Society study, those who inhale have an increased risk of death from lung cancer — 11 times greater than that of non-smokers.

The study also found that for those cigar smokers who inhale, the risks are increased for other types of cancer. Compared to non-smokers, cigar smokers who inhale deeply:

• are 6 times more likely to die from oral cancer
• are 39 times more likely to die from cancer of the larynx
• face more than twice the risk of death from pancreatic cancer
• face more than 3 times the risk of death from bladder cancer

Do Cigars Cause Other Health Problems?

Cigarette smoking is known to increase the risk of lung diseases such as emphysema and chronic bronchitis. Cigarette smokers have twice the risk of dying of heart attacks as do non-smokers. And smoking is a major risk factor for peripheral vascular disease, a narrowing of the blood vessels that move blood through the arms and legs.

While the link is not quite as strong as with cigarette smoking, cigar smoking (especially for people who inhale) increases the risk of heart disease and lung diseases, such as emphysema and chronic bronchitis.

At this time there are no studies that clearly show a link between cigar smoking and either peripheral vascular disease or stroke. However, a recent study found cigar smoking, as well as cigarette smoking, is linked to a man’s inability to achieve erection (a condition known as erectile dysfunction, or ED).

Taking Care of Yourself

If you have ever used cigars, now or in the past, tell your health care provider so he or she can be sure that you have the preventive health care you need. It is well known that cigar use puts you at risk for certain health-related illnesses. This means part of your health care should focus on related screening and preventive measures to help you stay as healthy as possible. For example, you will want to be certain that you regularly check the inside of your mouth for any changes and see your doctor or dentist if you have any changes or problems. The American Cancer Society recommends that periodic check-ups should include oral cavity (mouth) exams. By doing this cigar users may be able to find oral changes and leukoplakia (white patches on the mouth membranes) early. This may help prevent oral cancer.

You should also be aware of any of the following:

• any change in a cough (for example, you cough up more mucus than usual)
• a new cough
• coughing up blood
• hoarseness
• difficulty breathing
• wheezing
• headaches
• chest pain
• loss of appetite
• weight loss
• general fatigue (tiredness)
• repeated respiratory infections

Any of these could be signs of lung cancer or a number of other lung conditions and should be reported to your doctor. While these can be signs of a problem, many lung cancers do not cause any noticeable symptoms until they are advanced and have spread to other parts of the body.

If you have any health concerns that may be related to your cigar use, please see your health care provider as quickly as possible. Taking care of yourself and getting treatment for small problems will give you the best chance for successful treatment. The best way, though, to take care of yourself and decrease your risk for life-threatening lung problems is to quit using any form of tobacco.

What About Secondhand Cigar Smoke?

Because cigars contain more tobacco than cigarettes, and because they often burn for much longer, they give off greater amounts of secondhand smoke, also known as environmental tobacco smoke (ETS) or passive smoke. Secondhand smoke includes both the smoke from the end of the cigar and the smoke exhaled by the smoker.

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

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

Carcinogens in cigar smoke include the following:

• benzene
• aromatic amines (especially carcinogens such as 2-naphthylamine and 4-aminobiphenyl)
• vinyl chloride
• ethylene oxide
• arsenic
• chromium
• cadmium
• nitrosamines
• polynuclear aromatic hydrocarbons

There are some differences between cigar and cigarette smoke, though. These differences are due to the long aging and fermentation process used for cigar tobacco and the fact that the cigar wrapper is not as porous as cigarette paper.

Cigar tobacco has a high concentration of nitrogen compounds (nitrates and nitrites). During fermentation and smoking, these compounds give off several tobacco-specific nitrosamines (TSNAs), some of the most potent human carcinogens known. Also, because the cigar wrapper is less porous than cigarette paper, the tobacco doesn’t burn as completely. The result is a higher concentration of nitrogen oxides, ammonia, carbon monoxide, and tar — all very harmful substances.

In a recent study, researchers found that the concentrations of carbon monoxide at 2 cigar social events in San Francisco were higher than the levels found on a busy California freeway. Had these indoor exposures lasted 8 hours, they would have exceeded the National Ambient Air Quality Standards for outdoor air established by the Environmental Protection Agency. While the health effects on non-smokers at cigar social events have not been studied, there is clearly an increased risk of lung cancer from long-term exposure to secondhand smoke.

Are There Laws Regulating Cigars?

Cigars have fewer federal regulations than cigarettes and oral tobacco products. Until recently, health warnings required on other tobacco products were not found on cigars. However, warnings of proven health risks much like those required for cigarettes have been added to cigar packaging and advertisements. This is a result of a legal settlement in June of 2000 between the Federal Trade Commission and the 7 largest US cigar companies (representing 95% of the US market). The labels carry 1 of the following 5 surgeon general warnings, on a rotating basis:

• Cigar smoking can cause cancers of the mouth and throat, even if you do not inhale.
• Cigar smoking can cause lung cancer and heart disease.
• Tobacco use increases the risk of infertility, stillbirth, and low birth weight.
• Cigars are not a safe alternative to cigarettes.
• Tobacco smoke increases the risk of lung cancer and heart disease, even in nonsmokers.

Today cigars are exempt from federal tobacco regulations that restrict youth access and limit advertising. However, all 50 states and the District of Columbia have laws that either clearly address youth access to cigars or limit youth access to all tobacco products.

Since the mid-1960s the Federal Trade Commission has overseen a testing program to report the amount of tar, nicotine, and carbon monoxide for most brands of cigarettes. Cigars, however, are not included, and makers of cigars do not have to report such levels to any federal agency.

Cigarettes and oral tobacco products cannot be advertised on television, radio, or any other form of electronic communication regulated by the Federal Communications Commission. At this point, this ban does not include cigars.

Cigars are easy to get, especially for youth. A study done many years ago at the University of California found more than 140 Internet sites marketing cigars, with almost one third having potential youth appeal. Only about one quarter of these sites prohibited sales to minors. On about one third of the sites, cigars could be purchased with money orders, cashier’s checks, or cash-on-delivery (COD) — options that make it hard to verify the age of the buyer.

Federal tax rates for cigars are going up, but they are still much lower than the federal tax on cigarettes. Small cigars have a federal tax rate of 4 cents per pack of 20. Large cigars have a federal tax of 5 cents maximum per cigar. Taxes on cigars are also collected by many (but not all) states at varying rates. This is good for the tobacco companies. They can sell packs of 20 “small cigars” at a final cost that is usually much less than that of cigarettes.

Conclusion

Tobacco in any form is a deadly product. Ongoing research is giving us more and more evidence that cigar smoking can cause a number of serious health problems. The rising rates of cigar smoking, especially among young people, indicate the need for public awareness and a wide-ranging national policy to deal with this growing public health problem.