“Cigars Just as Bad as Cigarettes, Study Finds.” Doubtless you have seen a headline like this before-probably many times. Since the anti-tobacco forces began their campaign against cigars well over a decade ago, dozens of scientific studies condemning cigar smoking have been reported in the press. Misgivings and reservations, if the scientists have any, are rarely evident. Uninformed readers would probably conclude that the jury is in on cigars, and that anyone still smoking them is cavalierly courting a premature death. Yet a careful examination of the available medical evidence reveals that cigar smokers probably face few additional health risks when compared with nonsmokers.
What is going on is a systematic, coordinated assault by members of the medical establishment on cigar smoking in America. Their weapon of choice is the ponderous “scientific study,” which, to the layman, carries a presumption of honesty and validity. Statistical shortcomings, study design flaws, and contradictions are undiscovered or glossed over to simply finish and print a story-any story. Opposing points of view from cigar manufacturers aren’t even offered, much less reported. “We came to realize that we can’t fight back. It’s us against doctors. We get into debates about science and we can’t win,” said Norman Sharp, former president of the Cigar Association of America (CAA). With the field of public opinion all to themselves, researchers freely hammer home their meta-narrative that, for all intents and purposes, cigars and cigarettes are the same.
The familiar comparison with cigarettes is especially misleading. There is no question that, in significant doses, both cigarettes and cigars can cause certain diseases, and there is no dispute that, in significant daily quantities, the same would be true for meat, dairy, alcohol, pork, and a host of other products. Because cigarettes and cigars are both made from tobacco, there are superficial similarities. But there are also important differences. Cigars, unlike cigarettes, are not uniform in size, and deliver a variable range of nicotine, tar, and carbon monoxide. Cigars are also used quite differently; they are typically not inhaled, they are smoked irregularly, and they seldom lead to addiction. Yet in their attempts to chase the cigar out of American life, researchers and anti-tobacco forces choose to ignore these distinctions.
Scientists Don’t Smoke
The most common tool scientists employ for analyzing the relationship between a given behavior and disease is the epidemiologic study. Such studies divide participants into two groups: an unexposed (control) group and an exposed (subject) group. Confounding variables that could distort the outcomes such as sex, age, diet, etc., are adjusted for using statistical techniques. After the data has been massaged, the incidence of disease in the unexposed population is compared with the incidence in the exposed population. The shorthand used by scientists to express this relationship is called relative risk (RR). An RR of 1.0 means the exposed group has an identical chance of developing a disease as the unexposed group; an RR of 2.0 represents twice the level of risk, and so on. Leading medical journals generally will not accept papers for publication that demonstrate an RR of less than 3.0. However, the cigar and secondhand-smoke studies published during the last two decades are replete with RRs well under 2.0 and considered by most epidemiologists to be an inadequate level of proof.
Marc J. Schneiderman, a Pittsburgh physician and keenly interested observer, has reviewed much of the medical literature connected with these studies and has blamed the lower standards on politics. “We had great studies from the ’50s on,” he’s noted. “It wasn’t until the ’90s that research became a political issue, and some of the studies took casual cigar smoking to the ridiculous.”
Space here does not permit a review of all medical literature concerning cigar smoking, but one document can be considered the encyclopedia of the medical case against cigars: “Smoking and Tobacco Control Monograph No. 9,” a comprehensive 250-page treatise published by the National Cancer Institute (NCI) in 1998.
The central evidence presented (which is largely consistent with subsequent studies) is data from a 12-year study of over one million people, conducted by the American Cancer Society (ACS). In the study, ACS researchers tracked both cigar and cigarette smokers, and analyzed the rate at which each group developed diseases of the lungs, mouth, throat, larynx, and pancreas, as well as pulmonary disorders and heart disease.
The results confirmed that cigars, used moderately, are relatively benign. For participants who smoked one or two cigars a day, none of the seven disease-related RRs even rise to the level of statistical significance. For light cigar smokers, the all-cause mortality risk is 1.02, meaning they face a slender, 2%-greater chance of dying early.
According to the study, a typical cigarette smoker (e.g., one who consumes a pack a day and moderately inhales) runs a whopping thirteen-times-greater risk of developing lung cancer than a nonsmoker. In contrast, a person who smokes one or two cigars a day and does not inhale actually runs a slightly lower lung cancer risk than a nonsmoker. Alas, “Cigars Protect Against Lung Cancer, Study Shows,” is not a headline you are likely to see anytime soon.
Moreover, the actual percentage of seriously at-risk cigar smokers (those consuming three or more a day and inhaling) is very small. According to the US Department of Health and Human Services (HHS), in 2003, out of 240 million adults, 12.8 million (5.4%) smoked cigars. Although HHS did not break down this data further, the California Tobacco Survey (CTS) does. A recent CTS shows that, of California cigar smokers, only 8.5% smoked cigars every day. Only 4.4% smoked three or more cigars a day on days when they did smoke (over 85% of respondents smoked just one), while those inhaling totaled 28.3%. By applying these percentages to the US cigar-smoking population (12.8 million x 8.5% x 4.4% x 28.3%), we can obtain a rough estimate of at-risk cigar smokers: 13,548. Let that number sink in for a moment. Now consider the possibility that the endless parade of studies, press releases, and dire pronouncements from the surgeon general, the NCI, the ACS, and scores of scientists and physicians are directed at fewer than 14,000 smokers—or 11/100ths of 1% of the cigar-smoking population. Not since the Skylab experiments on weightlessness in the `70s has so much medical attention been lavished on the behavior of so few.
What, it should be fair to ask, is the NCI’s guidance for the 10 million or so non-daily cigar consumers ignored by the monograph? “We say there is no safe level of use. We have clearly established cigars are a hazardous product,” an NCI medical officer has said, though she adds, “We’re not in the business of estimating how many cigars a year a person can have.” Yet a major cancer study from the NCI’s own publication, the Journal of the National Cancer Institute, has indirectly done just that. The study, published in 2000, classified any cigar smoker who had not smoked “at least one a day for one year’s time” as a “never smoker.” By this definition (which has been applied in other studies as well), perhaps 80% of all cigar smokers in America are in the same boat, health wise, as the surgeon general. “Cigars have the potential to do harm. But I think you can be a casual smoker with an acceptable level of risk,” the medical officer noted.
Apart from the cigar’s relationship to disease, its capacity to deliver potent levels of nicotine is presumed by medical researchers to be a major health risk in itself. There is some basis for this notion. Nicotine is a highly addictive drug whose presence is the main attraction in the usage of all forms of tobacco. And cigars, because of their physical characteristics, deliver nicotine in greater quantities and purity than cigarettes.
Yet if scientists are right, and nicotine is the devil in the cigar, then it is a decidedly underachieving one. Although physicians report anecdotal evidence of addicted cigar-only smokers, such cases are rare. (How often do you see cigar smokers puffing feverishly in front of nonsmoking office buildings?) Far more common are cigarette smokers who have switched to cigars and inhale, asserted Dr. Richard Hurt, director of the Nicotine Dependence Center at the Mayo Clinic. “Half the nicotine [from cigars] is in freebase form,” he has noted. “If you do inhale, it is really potent.” This point is crucial to understanding the health risks of cigars. The reason cigar smokers need not inhale is that the nicotine-containing smoke is alkaline and can therefore be absorbed through the lining of the mouth. Cigarette smoke, in contrast, is acidic, meaning it must be inhaled into the lungs for full absorption of nicotine.
Some anti-tobacco activists have attacked cigars on the basis of their potential to hook teenagers on nicotine. In a 2003 survey conducted by the Centers for Disease Control, 15% of high-school students reported smoking a cigar during the prior 30 days. (As a point of comparison, 22% had smoked marijuana.)
There is no tobacco issue more politicized now than secondhand smoke. The abolition of cigar-friendly venues in California, New York, and Boston is proof of the antismoking lobby’s effectiveness in influencing public policy through scientific studies. The “secondhand smoke causes cancer” train got rolling in 1992 with a 525-page epidemiologic study by the Environmental Protection Agency (EPA). Using computer modeling, the EPA calculated that, each year, 3,000 Americans died of lung cancer caused by passive smoke. The findings quickly caught fire with public officials who were looking for a reason to ban smoking or tax it more heavily.
In 1998, the tobacco company lawsuit objecting to these findings was finally decided by federal district Judge William L. Osteen. In finding for the tobacco companies, Osteen was devastating in his criticism of the EPA, charging the agency with manipulating data to conform to its political agenda. “In this case, EPA publicly committed to a conclusion before the research had begun,” Osteen wrote in his 94-page opinion. Noting that the EPA doubled its margin of error to make its results appear meaningful, he all but accused the agency of peddling junk science: “The record and EPA’s explanations to the court make it clear that, using standard methodology, EPA could not produce statistically significant results with its selected studies.”
Another effort to prove secondhand smoke causes cancer was commissioned by the World Health Organization (WHO) in the late 1990s. The study, one of the largest of its kind ever undertaken, encompassed 2,000 people in seven European countries, and was supposed to buttress WHO’s campaign against passive smoking. Instead, WHO received a black eye when researchers found no statistical linkage between secondhand smoke and lung cancer.
Additional large studies have since been undertaken with similarly inconclusive results and RRs barely exceeding 1.0. At such levels, concluding that passive smoking causes various diseases is as meaningful as saying pasta causes Italians to overeat.
Even if, as the NCI declared, the carbon monoxide levels in a poorly ventilated cigar-dinner venue occasionally reach a concentration similar to that of a parking garage, there is simply no evidence that cigar smokers pose an environmental risk to otherwise healthy adults. If the secondhand-smoking case against cigarettes is weak, the case against cigars is nonexistent.
Even Drs. Dildar Ahmad and W. Keith Morgan, formerly of the London (Ontario) Health Services Center (both of whom have supported public-smoking bans), have asserted researchers have put their political agendas ahead of professionalism, and that, “Many studies involving secondhand smoke are not convincing, and answers about whether it causes lung cancer are far from established.”