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Less than 10 years ago, a monograph on the health effects and trends in consumption of cigars would have seemed unnecessary. Until 1992, in the United States at least, cigar consumption had been declining for many decades and cigars accounted for only a small fraction of tobacco consumed. But in 1993, a large and sustained increase occurred in cigar consumption. Given this trend, it is time for an authoritative analysis of the health effects of cigars, which is provided by this National Cancer Institute monograph. It dispels any myths that cigar smoking is not harmful.
The monograph also covers trends in consumption and prevalence of smoking cigars, toxicology and pharmacology, indoor air pollution, marketing and promotion, and regulatory policies in the United States. It is a scientific report, written with a high level of scientific expertise, and covers the various topics in some detail. All chapters were peer reviewed. Nevertheless, it is easy to read; the chapter on marketing and promotion gives a fascinating account of how cigar manufacturers have promoted their products using high-profile personalities and by promoting a luxurious lifestyle associated with cigars.
The chapters on the chemistry, toxicology, and pharmacology of cigar smoke provide useful information on the constituents of smoke and their effects. For example, cigar smoke is more alkaline than cigarette smoke, and thus nicotine from cigars is more readily absorbed by the oral mucosa. Nicotine content of cigars is high. These findings probably explain the tendency of cigar smokers not to inhale. Not surprisingly to anyone who has had to endure cigar smoke, another chapter shows that cigar smoke can be a major contributor to indoor air pollution.
The monograph contains detailed analyses of trends in consumption and in prevalence of cigar smoking. It draws together surveys on prevalence and consumption data from many American sources. Most of the increase in cigar smoking appears to be from occasional rather than frequent smoking and sales of premium cigars have had the largest increases. Of concern are the recent surveys that show cigar smoking is reasonably common among adolescents.
Although the health effects of cigarettes have been estimated precisely, fewer data exist on the effects of cigars. In most epidemiological studies, insufficient subjects smoked cigars for precise analysis. Cigar smokers have often been grouped with pipe smokers and, sometimes, former cigarette smokers have been included with those who smoked cigars only (these people are called “secondary” cigar smokers). As a result, identifying effects due to cigars alone has been difficult. The most detailed data come from the Cancer Prevention Study I of the American Cancer Society, a large prospective study that began in 1959. The monograph presents extensive new analyses of a number of fatal outcomes among the 442 455 white, male subjects in that study. Results are presented according to the number of cigars smoked daily and the depth of inhalation. Results of other studies with information on cigars are also presented.
The authors’ conclusions that “cigar smoking can cause oral, esophageal, laryngeal, and lung cancers” and “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” are soundly based on the evidence. They argue persuasively that the risks for oral and oesophageal cancers among regular cigar smokers are similar to those of cigarette smokers, whereas the risks of other diseases are lower, partly because few cigar smokers inhale. The studies of cigarette smokers who turn to cigars show that they have higher disease risks than those who quit, indicating that the beneficial effect of quitting is diminished if a person takes up cigar smoking.
Why did the sudden upsurge in cigar smoking begin? Definitive answers to this question cannot be found in the monograph. The question is not merely of historical interest, because if we understand the causes, we might be able to act to prevent similar occurrences.