Cigars Health Effects and Trends PDF
Preview Cigars Health Effects and Trends
V ' TTffT>r\<f'i?? MONOGRAPH Cigars HealthEffects and Trends » 'i U.S.DEPARTMENTOFHEALTH ANDHUMANSERVICES PublicHealthService NationalInstitutesofHealth Preface Therecentincreaseincigarconsumptionbeganin1993andwasdismissed bymanyinpublichealthasapassingfadthatwouldquicklydissipate.Recently releaseddatafromtheU.S.DepartmentofAgriculture(USDA)suggeststhatthe upwardtrendincigarusemightnotbeastemporaryassomehadpredicted.The USDAnowprojectsatotalofslightlymorethan5billioncigarswereconsumed lastyear(1997)intheUnitedStates. Salesoflargecigars,whichcompriseabout two-thirdsofthetotalU.S.cigarmarlcet,increased18percentbetween1996and 1997.Consumptionofpremiumcigars(mostlyimportedandhand-made) increasedevenmore,anastounding90percentlastyearandanestimated250 percentsince1993. Incontrast,duringthissametimeperiod,cigarette consumptiondeclined2percent. Thisdramaticchangeintobaccouseraisesanumberofpublichealth questions:Whoisusingcigars?Whatarethehealthrisks? Arepremiumcigars lesshazardousthanregularcigars?Whataretherisksifyoudon'tinhalethe smoke?Whatarethehealthimplicationsofbeingaroundacigarsmoker? Inordertoaddressthesequestions,theNationalCancerInstitute(NCI) undertookacompletereviewofwhatisknownaboutcigarsmokingandis makingthisinformationavailabletotheAmericanpublic. Thismonograph, number9inaseriesinitiatedbyNCIin1991,istheworkofover50scientists bothwithinandoutsidetheFederalGovernment.Thirtyexpertsparticipatedin themulti-stagepeerreviewprocess(seeacknowledgments).Theconclusions presentedinthemonographrepresentthebestscientificjudgment,notonlyof theNCI,butalsoofthelargerscientificcommunity. Thereissufficientevidencetoconcludethatacausalrelationshipexists betweenregularcigaruseandcancersofthelung,larynx,oralcavity,and esophagus. Heavycigarsmoking,particularlyforthosewhoinhale,causesan increasedriskofcoronaryheartdiseaseandchronicobstructivepulmonary disease.Thereisalsosuggestiveevidenceforarelationshipbetweencigar smokingandcancerofthepancreas,buttheevidenceisinsufficientatthistime todrawacausalinference. Thedatainthismonographstrengthenandextend theconclusionsondiseaseriskscontainedinseveralreportsoftheSurgeon Generalonsmokingandhealth. Afteracarefulassessmentoftheavailablescientificevidence,thefollowing overallconclusionsarewananted: Cigarsmokingcancauseoral,esophageal,laryngeal,andlung cancers. Regularcigarsmokerswhoinhale,particularlythosewho smokeseveralcigarsperday,haveanincreasedriskofcoronary heartdiseaseandchronicobshnctivepulmonarydisease. i Regularcigarsmokershaverisksoforalandesophagealcancers similartothoseofcigarettesmokers,buttheyhavelowerrisksof lungandlaryngealcancer,coronaryheartdisease,andchronic obstructivepulmonarydisease. CigaruseintheUS.hasincreaseddramaticallysince1993.Adult prevalenceofcigaruseinCaliforniahasincreasedpredominantly amongoccasionalcigarsmokers.Asubstantialnumberofadult formerandneversmokersofcigarettesarecurrentlysmokingcigars. Incontrasttocigarettes,muchoftheincreaseduseofcigarsby adultsappearstobeoccurringamongthosewithhigherincomes andgreatereducationalattainment. Adolescentcigaruseisoccurringatasubstantiallevelandis currentlyhigherthanthatrecordedforyoungadultspriorto1993. Currently,cigaruseamongadolescentmalesexceedstheuseof smokelesstobaccoinseveralstates. Thisuseofcigarsisoccurring amongbothmalesandfemales. Someinthecigartradehavemadetheclaimthatcigarsmokersexperience littleornoincreaseddiseaserisk.Thisclaimisnotsupportedbytheavailable scientificevidenceandmisleadscigarsmokerstobelievethatcigarsmokeisless harmfulthancigarettesmoke.Webelieveanaccuratestatementisthatthe risksoftobaccosmokeexposurearesimilarforallsourcesoftobacco smoke,andthemagnitudeoftherisksexperiencedbycigarsmokers isproportionatetothenatureandintensityoftheirexposure. Differencesintheintensityoftobaccosmokeexposurebetweencigaretteand cigarsmokersresultfromdifferencesintheInhalationofthesmokeand differencesintheproportionofsmokerswhosmokeeveryday.Whilealmostall cigarettesmokersinhale,themajorityofcigarsmokersdonot.Thismaybedue todifferencesinthepHofthesmokeproducedbythesetwoproducts. Cigar smokecontainsasubstantialfractionofitsnicotineasfreenicotine,whichcan bereadilyabsorbedacrosstheoralmucosa. Incontrast,cigarettesmokeismore acidic,andtheprotonatedformofnicotineitcontainsismuchlessreadily absorbedbytheoralmucosa.Asaresult,cigarettesmokersmustinhaletoget theirrequiredquantityofnicotine,whereascigarsmokerscaningestsufficient quantitiesofnicotinewithoutinhaling.Thisreductionininhalationisoneof thereasonsforthedifferenceindiseaserisksbetweencigaretteandcigarsmokers. However,eventhosewhodonotinhalehavediseaseriskshigherthanthose whohaveneversmokedanytobaccoproduct.Asthismonographclearly demonstrates,regularcigarsmokerswhohaveneversmokedcigarettes,even thosewhodonotinhale,experiencesignificantlyelevatedrisksforcancersofthe larynx,oralcavity(includingpharynx),andesophagus. FortheCaliforniasurvey,cunentprevalenceamongadultswasdefinedasapositiveresponseto: 1)Haveyoueversmokedcigars?and2)Doyounowsmokecigarseverydayorsomedays? SmokingandTobacwControlMonographNo.9 Anotherreasonforadifferenceinriskbetweencigaretteandcigarsmokersis adifferenceintiiefrequencywitliwliiciitlietwoproductsareused. Most cigarettesmokerssmokeeveryday. Incontrast,asmanyastliree-quartersof cigarsmokerssmokeonlyoccasionally,andsomemayonlysmokeafewcigars peryear.Thisdifferenceinfrequencyofexposuretranslatesintolowerdisease risks. Wedonotknowtheriskofaddictionposedbycigarsmoking.Butthe differenceinsmokingpatternssuggestsapotentialdifferenceinaddictive propertiesbetweencigarettesandcigars. Ofspecialconcernaretherisksforthoseindividualswhoaremixedsmokers (currentsmokersofbothcigarsandcigarettes),orwhoswitchtosmokingcigars fromsmokingcigarettes.Asizablefractionoftoday'scigarsmokersarecurrentor pastcigarettesmokers.Theseindividualsaremuchmorelikelytocontinueto inhalewhentheyswitchtosmokingcigars,andmaythereforeremainatmuch higherriskforallthemajorsmokingrelateddiseasesthanarecigarsmokerswho haveneversmokedcigarettes. is—Tdoont'hto.seCiignadrisviadruealnsotwhsaofemaaltyerbneattihviensktiongciagbaroeutttessmaonkdinmgacyigbaersa,ddoiucrtiavdev.ice Tothosecigarettesmokerswhoarethinkingofswitchingtocigars,don'tbe misled.Unlessyousubstantiallyreduceyourexposuretosmoke,yourriskswill remainunchanged. Tothosecunentlysmokingcigars,quittingistheonlywaytoeliminatethe documentedharmthatcanresultfromcigarsmoking. Onceregulartobaccouseisestablished,nomatterwhetherit'scigarettes, cigars,orsmokelesstobacco,quittingmaybecomeextremelydifficult. Toallsmokersandnonsmokers,tobaccosmokecontainsover4,000 compounds,includingdozensofcarcinogens. Becauseoftheirgreatermass, cigarsgeneratemuchhigherlevelsofmanyoftheseindoorpollutantsthando cigarettes. Smokefromasinglecigarburnedinahomecanrequire5hoursto dissipate,therebyexposingotherhouseholdmemberstoasizableinvoluntary healthrisk. Aspecialconcerngeneratedbythedatainthismonographistherateofcigar useamongadolescents. Priortothecurrentupswingincigaruse,mostcigar smokersweremiddleagedoroldermen,andtheybegansmokingcigarsasadults. Incontrast,severalstudiesnowreportcigarsmokingprevalenceratesamong adolescentmalesthataremorethandoubletheratesofsmokelesstobaccouse. Ina1996surveyofMassachusettsschoolstudentsingrades6through12, prevalenceofcurrentcigaruseamongmalesrangedfrom3.2percentin6th gradersto30percentinhighschool.Adolescentgirlsalsoreportsurprisingly iii highratesofcigaruse,with6-7percentofgirlsinhighschoolreportingthey smokedcigarsinthepast30days. Similarfindingsarereportedinotherstudies. Thishighrateofcigaruseamongadolescentsraisessignificantpublichealth questionsandhasseriousimplicationsforpublichealthprogramming. Will thesehighratesofcigarusecontinueastheseyouthmoveintoadulthood?Will nicotineaddictiondevelopintheseadolescentusersandtherebyinfluencetheir inhalationandconsumptionpatterns?Willcigarsmokingtransitionlarge numbersofyouthintoregularcigaretteuselaterinlife?Ifregularcigaruse develops,willquittingproveasdifficultforcigarsasitisforcigarettes? Itisprematuretolabelcigaruseasthenexttobaccoepidemicinthemaking; butwewouldbewisetorememberthatasimilarproblemofsmokelesstobacco useconfrontedusinthelate1970's,anditwasanumberofyearsbeforethe publichealthcommunitybecameconcerned.Now,20yearslater,con—sumption ofsmokelesstobacco,especiallymoistsnuff,hasreachedrecordlevels 60 millionpoundslastyear,andshowsnosignofwaning.Thevastmajorityofall snuffusersareyounger-ageadultsandadolescents,apatternnotdissimilartothe cunentpatternofcigaruse. Thismonographprovidesuswithasnapshotofarapidlychangingpatternof behaviorwithimportantpotentialpublichealthconsequences.Icommendthe authorsforprovidingthenationwithclearandinvaluableinformationabout thisdisturbingchangeintobaccouse. RichardD.Klausner,M.D. Director NationalCancerInstitute ErratasheetforN MonographNo.9 Cigars:HealthEffectsandTrends Inputtingtogetheranytypeofscientificreport,itisinevitablethaterrorsaremade.Thisvolume isnodifferent. Below,wehavelistedthosewhichmaybearonhowsomefactsorinformationare interpreted. Weapologizeforanyinconveniencethismayhavecaused. Theseandothererrors willbecorrectedontheNCIWebversionofthemonograph. Pageviii SirRichardDoll,F.R.S.,F.R.C.P.,EmeritusProfessorofMedicine, RadcliflFeInfirmary,UniversityofOxford,Oxford,UnitedKingdom,was inadvertentlyleftofftheAcknowledgmentslist. Dr.Dollwasasenior reviewer. Page6Table1 ThemortalityratiovalueforCancerofLungforthosesmokingfiveor morecigarsdailyshouldread3.40not2.40. Page35Figure 5,andPage36Figure6 ThevaluesfortheYaxisareincorrect,theybothshouldread0to30in incrementsof5(seepage12forcorrectversionofFigure6). Page49 Thirdparagraph,lastline,changetoread"...cigarettesmokersat increasedriskofrelapse." Page51Table17 Titlecftableshouldread"PrevalenceofCigarSmokingAmong Adolos'^ontMalesinCalifornia..." Inthetable,2ndheadingwhichreads CigarSmokingStatusshouldinsteadreadCigaretteSmokingStatus. Page198Table1 SwisherSweetsmarketshareoflargecigarsshouldread19.4percentnot 9.4percent. Page231Table6 MississippiandMissourihavelawsspecificallygoverningyouthaccessto cigarsandshouldhaveanasterisk(*)notanXinthecolunrnlabeledType ofProhibition. Acknowledgments Cigars:HealthEffectsandTrendswasdevelopedundertheeditorialdirectionof DonaldR.Shopland,Coordinator,SmokingandTobaccoControlProgram (STCP),NationalCancerInstitute,Bethesda,Maryland. TheSeniorScientificEditorforthismonographwasDavidM.Burns,M.D., ProfessorofMedicine,SchoolofMedicine,UniversityofCaliforniaSanDiego,San Diego,California.TheConsultingScientificEditorswereDietrichHoffmann, Ph.D.,AssociateDirector, AmericanHealthFoundation,Valhalla,NewYorkand K.MichaelCummings,Ph.D.,M.P.H.,SeniorResearchScientist,RoswellPark CancerInstitute,Buffalo,NewYork.TheManagingEditorforthismonographwas RichardH.Amacher,ProjectDirector,KBMGroupInc.,SilverSpring,Maryland. TheeditorsandSTCPstaffmembersgratefullyacknowledgethe manyresearchersandauthorswhomadethismonographpossible. Attributionsforeachchapterareasfollows: Chapter1. CigarSmoking:Overview DavidM.Bums,M.D. andCurrentStateofthe ProfessorofMedicine Science SchoolofMedicine UniversityofCallfomiaSanDiego SanDiego,CA Chapter2. TrendsinCigar KarenK.Gerlach,Ph.D.,M.P.H. Consumptionand Epidemiologist SmokingPrevalence OfficeonSmokingandHealth CentersforDiseaseControlandPrevention Atlanta,GA K.MichaelCummings,Ph.D.,M.P.H, SeniorResearchScientist DepartmentofCancerControland Epidemiology RoswellParkCancerInstitute Buffalo,NY AndrewHyland,M.A. DataAnalyst DepartmentofCancerControland Epidemiology RoswellParkCancerInstitute Buffalo,NY ElizabethA.Gilpin,M.S. SeniorStatistician CancerPreventionandControl UniversityofCallfomiaSanDiego Lajolla,CA V Acknowledgments MichaelD.Johnson,Ph.D. Chief DataAnalysisandEvaluationUnit CaliforniaDepartmentofHealthServices TobaccoControlSection Sacramento,CA JohnP.Pierce,Ph,D. ProfessorandAssociateDirector CancerPreventionandControl SamM.WaltonProfessorforCancer Research UniversityofCaliforniaSanDiego Lajolla,CA Chapter3. ChemistryandToxicology DietrichHoffmann,Ph.D. AssociateDirector AmericanHealthFoundation ValhaUa,NY UseHoffmann,B.S. ResearchCoordinator AmericanHealthFoimdation Valhalla,NY Chapter4. DiseaseConsequencesof ThomasG.Shanks,M.P.H.,M.S. CigarSmoking PrincipalStatistician UniversityofCaliforniaSanDiego SanDiego,CA DavidM.Burns,M.D. ProfessorofMedicine SchoolofMedicine UniversityofCaliforniaSanDiego SanDiego,CA Chapter5. IndoorAirPollution JamesL.Repace,M.S. fromCigarSmoke RBoewpiaec,eMAsDsociates U.S.EPAOfficeofRadiationand IndoorAir(Retired) WayneR.Ott,Ph.D. VisitingScholar DepartmentofStatistics ConsultingProfessor DepartmentofCivilandEnvironmental Engineering StanfordUniversity Stanford,CA NeilKlepeis,M.S. SchoolofPublicHealth EnvironmentalHealthSciences UniversityofCalifornia,Berkeley Berkeley,CA vi SmokingandTobaccoControlMonographNo.9 Chapter6. Pharmacologyand ReginaldV.Fant,Ph.D. AofbuCsiegaProstential BPeitnhneesydaA,ssMocDiates,Inc. JackE.Henningfield,Ph.D. VicePresident ResearcliandHealthPolicy BPeitnhneesydaA,ssMocDiates,Inc. AssociateProfessor DepartmentofPsychiatryandBehavioral Sciences JohnsHopkinsUniversity SchoolofMedicine Baltimore,MD Chapter7. Marketingand JohnSlade,M.D. PromotionofCigars ProfessorofClinicalMedicine UniversityofMedicineandDentistryof NewJersey RobertWoodJohnsonMedicalSchool SaintPeter'sMedicalCenter NewBrunswick,NJ Chapter8. PoliciesRegulatingCigars GregoryN.Connolly,D.M.D.,M.P.H. DirectoroftheMassachusettsTobacco ControlProgram MBoasstsoanc,huMseAttsDepartmentofPublicHealth Wegratefullyacknowledgethefollowingdistinguishedscientists,researchers,and others,bothinandoutsideGovernment,whocontributedcriticalreviewsorassistedin otherways: AnthonyAlberg,Ph.D.,M.P.H. NealL.Benowitz,M.D. AssistantScientist ProfessorofMedicine JBoalhtnismoHroep,kMinDsUniversity DCihviiesfionofClinicalPharmacology andExperimentalTherapeutics DileepG.Bal,M.D. UniversityofCaliforniaSanFrancisco Chief SanFrancisco,CA CancerControlBranch CaliforniaDepartmentofHealthServices LoisBiener,Ph.D. Sacramento,CA SeniorResearchFellow CenterforSurveyResearch SteveBayard,Ph.D. UniversityofMassachusettsBoston Director Boston,MA OfficeofRiskAssessment HealthStandardsProgram MicheleBloch,M.D.,Ph.D. OSHA,DepartmentofLabor Chair Washington,DC TobaccoControlandPrevention Subcommittee AmericanMedicalWomen'sAssociation Alexandria,VA vii
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