Cigars and Public Health

Editorial
In his historic 1964 report, Surgeon General Luther Terry concluded that "cigarette smoking is a health hazard of sufficient importance in the United States to warrant appropriate remedial action." Time and again since 1964, however, we have had to address additional threats to health from other tobacco products.

In the late 1960s, the major cigarette manufacturers introduced and widely promoted little cigars. Even though they were indistinguishable in appearance from standard filter cigarettes, they were exempt from the congressional ban on radio and television advertisements for cigarettes because their wrapping was made of tobacco, not paper. Consumption of little cigars increased dramatically. The next tobacco problem was smokeless tobacco. After the mass marketing of cigarettes began, smokeless tobacco had steadily declined in popularity. This trend changed in the mid-1980s, however, with the intensive marketing of a new form of smokeless tobacco called moist snuff, which was sold under such brand names as Skoal, Skoal Bandit, and Copenhagen. Consumption increased, particularly among young men and adolescent boys.

The effects on health of both little cigars and smokeless tobacco were quickly studied. My predecessors as surgeon general issued reports examining little cigars in 1973 and smokeless tobacco in 1986; they concluded that each product promoted cancer. Shortly after each report, Congress banned television and radio advertising of the products; in the case of smokeless tobacco, it also required health-related warning labels.

Cigars pose the most recent challenge. Between 1993 and 1998, sales of cigars in the United States increased by 50%. This increase was almost exclusively due to the rising sales of large cigars, which increased 75%, from 2.14 billion cigars in 1993 to 3.75 billion in 1998. Earlier this year, the Office of the Inspector General of the Department of Health and Human Services released two reports describing the widespread use of cigars, especially relatively cheap, machine-made cigars, among teenagers. Even in California, which has led the nation in reducing cigarette consumption, the percentage of men currently smoking cigars increased from 4.8% in 1990 to 8.8% in 1996. This corresponded to an unprecedented increase in promotional and product-placement advertisements for cigars in magazines, movies, and music videos. By comparison, cigarette consumption declined by 3% nationally over the same period. The increase in cigar smoking has taken place largely among relatively well educated people, who have traditionally eschewed cigarettes.

In 1998, in a comprehensive review of the scientific evidence on cigar smoking, the National Cancer Institute concluded that cigar smoking can cause oral, esophageal, laryngeal, and lung cancer. Regular cigar smokers who inhale, particularly those who smoke several cigars daily, have an increased risk of both coronary heart disease and chronic obstructive lung disease.

The report by Iribarren and colleagues in this issue of the Journal adds to the strong evidence that cigar smoking can have many adverse effects on health. In a study involving a cohort of nearly 18,000 men enrolled in the Kaiser Permanente health plan, including 1,546 cigar smokers, and several decades of follow-up, they found that, "independently of other risk factors, regular cigar smoking can increase the risk of coronary heart disease, COPD [chronic obstructive pulmonary disease], and cancers of the upper aerodigestive tract and lung." Iribarren et al. also found a possible synergistic effect of cigar smoking and alcohol consumption in terms of oropharyngeal cancers and cancers of the upper aerodigestive tract. Although such a relation has been documented for cigarette smoking, this is one of the first studies to demonstrate that the relation may also exist for cigars. Thus, the popularity of cigar bars where both cigar smoking and alcohol consumption are encouraged arouses special concern with respect to the public health.

What is the proper response of the public health community to the increase in cigar use in the United States? As a general guiding principle, restrictions on the sale of cigars (through the setting of excise-tax rates, for example) ought to be at least as stringent as those currently applied to other tobacco products. The current federal tax on large cigars is a maximum of 3 cents per cigar, which is considerably lower than the federal tax on cigarettes. It is critical that cigars not be construed as a safe or less costly alternative to cigarettes.

Cigars should carry warning labels similar to those now required on all cigarettes and smokeless-tobacco products. Cigar smokers should understand the increased risks of cancer and cardiovascular disease that are linked to cigar smoking. Equally important, people who do not smoke need to be informed that the passive smoke from cigars is toxic. Health warnings should appear not only on the product itself but also in all advertisements and promotional materials.

Manufacturers of cigarettes and smokeless tobacco are required by federal law to report annually to the Department of Health and Human Services all ingredients added to tobacco in their products. Cigar manufacturers should be required to do the same. Congress should lift arbitrary statutory restrictions on the disclosure of such information to the public. Such action would facilitate research and help educate consumers about the chemicals added to cigars as well as to other tobacco products. In addition, an accurate testing procedure should be developed to determine levels of tar, nicotine, carbon monoxide, and other harmful constituents in cigars. Tobacco smoke contains some 4,000 different substances, including about 60 that are known carcinogens. Information about the contents of tobacco smoke should also be routinely made public.

We must do a better job of educating the public, especially children and adolescents, about the risks to health associated with cigar smoking. We also need strong federal and state enforcement of existing tobacco-control laws that will make it as difficult for minors to purchase cigars as to buy cigarettes. This goal can be achieved, and lives can be saved. However, the states must allocate funds for effective tobacco-control programs from their multibillion-dollar settlement with the tobacco industry. Establishing such programs could well represent the most important public health initiative of the late 20th century.

Tobacco -- including tobacco in cigars -- is hazardous not only to the health of those who use it, but also to society. Tobacco use increases the risk of premature death and preventable illness for the user, and nonsmokers who inhale toxic smoke -- from a cigar or cigarette -- can have an increased risk of premature death and preventable illness. Passive smoking also contributes to respiratory and related illnesses in children and fetuses.

As we approach the new millennium, historians will record that we had the chance to eliminate tobacco as the nation's leading cause of preventable illness and premature death. It is time for government, the public health community, and parents and families to accept the challenge of making smoking history.

Editorial Note:
The current study helps establish that cigar smoking increases one's risk of coronary heart disease. Like previous studies the current study also found increased risks for cancer and chronic obstructive pulmonary disease.

The results suggest that strong policy measures should be taken to reduce cigar smoking. We would be well advised to follow the Surgeon General's advice.