Cigars -- still tobacco, still dangerous to your health

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

Here we will 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 machine-made cigarettes, cigars do not usually have 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. This is what gives cigars a different taste and smell from cigarettes.

Cigars come in many sizes, some as small as a cigarette (called a cigarillo), others much larger. Large cigars may 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.

To blur the line between cigars and cigarettes, there are now cigarillos ("little cigars") that are the same size and shape of cigarettes. Many have filters. Other than the fact that they are brown, they look just like cigarettes, though some are just a bit larger. Studies suggest that many people treat them like cigarettes -- inhaling and smoking them every day.

Who smokes cigars?

Cigar smoking is still a popular trend in the United States where a "cigar culture" is supported by cigar magazines, shops, and bars or clubs. Many cigar smokers think of themselves as connoisseurs, much like wine experts. They may view cigars as a sophisticated, affordable luxury that represents success. Some see cigar smoking as a sign 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 open to this kind of cigar marketing. But in real life, a survey by the Substance Abuse and Mental Health Service Administration found that unemployed adults were almost twice as likely to smoke cigars as those who worked full or part time.

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 climbed by almost 70%. An estimated 5.3 billion cigars and cigarillos were consumed in the United States in 2006 -- a 9% increase from 2005.

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, although some are sold in packs of 8, 5, or even 1 to a pack. Some companies add strawberry, chocolate, and other sweet flavors, which appeal to younger smokers. Their size, shape, filters, flavors, and packaging make them look like cigarettes, except for their color. Because of the lower taxes, they cost much less than cigarettes in most states. That and the fact that they can be bought in smaller packages makes them easier for younger smokers to afford.

In fact, the selling of "little cigars" is so much like that of cigarettes that many US states decided to take action. In 2006, the Attorneys General of 39 states and Guam signed a petition to the Alcohol and Tobacco Tax Trade Bureau (the TTB). The petition asked that the loophole that allows "little cigars" to be sold as cigars be closed, since the Attorneys General believe that they are promoted and sold like cigarettes. As of October 2008, the TTB has not yet finalized their decision about this. Partly because "little cigars" are not well regulated and are taxed very little, they have made inroads as cigarette replacements for many smokers. It's working for the tobacco companies: sales are climbing. Teens and youth are some of their best customers.

Sales of premium cigars, most of which are hand-made and imported, have increased over much of the last decade. 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).

Cigar smokers in the past have been mainly males between the ages of 35 and 64 with higher education and income, but recent studies suggest new trends. Most new cigar users today are teenagers and young adult males (ages 18 to 24) who smoke once in a while (less than daily). According to the Substance Abuse and Mental Health Service Administration's 2006 survey, 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.

But the general rise in cigar smoking in recent years has not been limited to adults. According to surveys from the Centers for Disease Control and Prevention (CDC), the level of cigar use among teens in recent years has been higher than that of spit (oral or smokeless tobacco) tobacco use. As of 2006, about 4% of teens in middle school (grades 6-8) had smoked a cigar in the past month.

A 2007 CDC survey that looked only at high school students (girls and boys in grades 9 through 12) found that 8% of girls and 19% of boys had smoked a cigar in the past month. In boys, the numbers doubled between 9th and 12th grade, with 13% of 9th grade boys and 26% of 12th grade boys reporting smoking a cigar in the past month. After cigarette smoking, cigar smoking is the second most popular form of tobacco used by teens in the US overall. But in some states, more high school boys smoke cigars than cigarettes. Much of this surge is due to "little cigars."

Are cigars addictive?

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

Even though people smoke cigars for different reasons, the fact is, like cigarettes, cigars deliver nicotine. 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. The amount of nicotine a cigar delivers to a smoker varies a great deal even among people smoking the same type of cigar. How much nicotine is taken in depends on a number of things like:

• how long the person smokes the cigar
• how many puffs are taken
• whether or not the smoker inhales

Given these factors and the large range of cigar sizes, good estimates of the amounts of nicotine cigars deliver are almost impossible to make. That said, Health Canada estimates that the filtered "little cigars" that are the size and shape of cigarettes contain about the same amount of nicotine as a cigarette. If these are smoked like cigarettes (inhaled), they would likely deliver a similar amount of nicotine, but this has not been fully tested.

Cigar smoking raises your risk of cancer and death

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

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

Studies have shown that regular cigar smokers are 4 to 10 times more likely to die from cancers of the mouth, larynx, and esophagus than non-smokers. 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 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, in the past most cigar smokers have not. This may be because cigar smoke tends to irritate the eyes, nose, throat, and breathing passages. A new trend among cigar companies is to change the fermenting process to make cigar smoke 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 for cigar smokers who don't inhale 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 an 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 voice box (larynx)
• face more than twice the risk of death from cancer of the pancreas
• face more than 3 times the risk of death from bladder cancer

Cigars cause other health problems

Heart and lung disease

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

Heart and lung diseases can steal away a person's enjoyment of life long before they cause death. These problems may start when smokers are in their 40s, and tend to worsen with age. Smoking-related illness can limit a person's daily life by making it harder to breathe, get around, work, or play.

Lesser-known effects on the body

Cigar smoking, like cigarette smoking, is linked to gum disease, where the gums shrink away from the teeth. It also raises your risk that teeth will actually fall out. And a study completed in 2000 found cigar smoking, like cigarette smoking, is linked to sexual impotence in men (an inability to get an erection, known as erectile dysfunction).

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. 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. See your doctor or dentist right away if you have any changes or notice problems. The American Cancer Society recommends that medical check-ups should include oral cavity (mouth) exams. By doing this, cigar users may be able to find out about changes such as leukoplakia (white patches on membranes in the mouth) 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 phlegm or mucus than usual)
• a new cough
• coughing up blood
• hoarseness
• trouble breathing
• wheezing
• headaches
• chest pain
• loss of appetite
• weight loss
• feeling tired all the time (fatigue)
• frequent lung or respiratory infections (like pneumonia or bronchitis)

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 symptoms most people would notice until they are advanced and have spread to other parts of the body.

If you have any health concerns that you think may be caused by your cigar use, please see your health care provider right away. Taking care of yourself and getting treatment for problems before they get worse will improve your odds 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. This is also known as environmental tobacco smoke (ETS) or passive smoke. Secondhand smoke includes both the smoke from the end of the burning cigar and the smoke exhaled by the smoker.

In general, secondhand smoke from cigars contains many of the same toxins (poisons) and carcinogens (cancer causing agents) 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

Cigar smoke includes the following agents that cause cancer (carcinogens):

• 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 aging and fermenting of 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). When the fermented cigar tobacco is smoked, 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.

To compare cigar smoke with air pollution from car exhaust, researchers looked at the concentrations of carbon monoxide at 2 cigar social events in San Francisco. Carbon monoxide levels 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 and other health problems from long-term exposure to secondhand cigar 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. But warnings of proven health risks much like those required for cigarettes have been added to most cigar ads and packages. 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 on cigars made by these 7 companies 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 non-smokers.

Today cigars are exempt from federal tobacco regulations that limit advertising and restrict underage children from buying cigars. But all 50 states and the District of Columbia have laws that either clearly address children and teens' access to cigars or forbid underage children from buying any 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. But cigars are not required to go through these tests, 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 regular cigars, though "little cigars" are now included in the ban.

Despite the laws that forbid underage children from buying them, cigars are easy to get. A study done in 2000 at the University of California found more than 140 Internet sites that sold cigars, with almost 1 in 3 having potential youth appeal. Only about 1 out of 4 of these sites clearly 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.

Research and reduction in smoking is still needed

Tobacco in any form is a deadly product. Research keeps 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, point out the need for public awareness and a wide-ranging national policy to deal with this growing public health problem.

Additional resources

More information from your American Cancer Society

The following information may also be helpful to you. These materials may be ordered from our toll-free number, 1-800-ACS-2345 (1-800-ACS-2345).

• Guide to Quitting Smoking (also available in Spanish)

• Helping a Smoker Quit: Do's and Don'ts

• Questions About Smoking, Tobacco, and Health (also available in Spanish)

• Quitting Smoking -- Help for Cravings and Tough Situations (also available in Spanish)

National organizations and Web sites*

In addition to the American Cancer Society, other sources of patient information and support include:

American Heart Association
Toll-free number: 1-800-AHA-USA-1 (1-800-242-8721)
Web site: www.americanheart.org

American Stroke Association
Toll-free number: 1-888-4-STROKE (1-888-478-7653)
Web site: www.strokeassocation.org

American Lung Association
Toll-free number: 1-800-548-8252 (1-800-LUNG-USA)
Web site: www.lungusa.org

Centers for Disease Control and Prevention
Office on Smoking and Health
Toll-free number: 1-800-232-4636
Web site: www.cdc.gov/tobacco/quit_smoking/index.htm

National Cancer Institute
Toll-free numbers: 1-800-4-CANCER (1-800-422-6237) for cancer information
1-877-448-7848 (help with quitting smoking)
Web site: www.cancer.gov

Nicotine Anonymous
Toll-free number: 1-877-TRY-NICA (1-877-879-6422)
Web site: www.nicotine-anonymous.org

Smokefree.gov
(Online materials, including info on state telephone-based programs)
Toll-free number: 1-800-QUITNOW (1-800-784-8669)
Web site: www.smokefree.gov

*Inclusion on this list does not imply endorsement by the American Cancer Society.

No matter who you are, we can help. Contact us anytime, day or night, for information and support. Call us at 1-800-ACS-2345 (1-800-227-2345) or visit www.cancer.org.

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Last Medical Review: 10/28/2008
Last Revised: 10/28/2008