Premium Cigars Patterns of Use, Marketing, and Health Effects (2022) / Chapter Skim
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5 Health Effects of Premium Cigars
5 Health Effects of Premium Cigars
Pages 205-278
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From page 205... ...
" or "cigars in general" are used in this report, they refer to all cigar types (filtered cigars, little cigars, cigarillos, and large/traditional cigars [which include premium cigars]
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From page 206... ...
Thus, upper respiratory tract and esophageal disease can occur even in tobacco users who do not inhale, which is typical of some premium cigar smokers. While products of combustion are thought to be responsible for most of the disease caused by smoking, nicotine may also contribute.
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Thus, the health effects of HPHCs per gram of premium cigar tobacco smoked are expected to be very similar to those observed from nonpremium cigar smoking. The carcinogenic and other health effects of tobacco smoking can be expected to follow a dose–response relationship: health risks will depend on the total toxicant and carcinogen exposure.
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From page 208... ...
pyrene, 5-methylchrysene • Aromatic amines and heterocyclic aromatic amines. 4-aminobi phenyl, 1-aminonaphthalene, 2-aminonaphthalene, o-anisidine, o-to luidine, 2,6-dimethylaniline, 2-amino-6-methyldipyrido[1,2-a:3',2'-d]
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From page 209... ...
. Some evidence exists for abuse potential of the minor tobacco alkaloids nornicotine and anabasine, which could play a role in abuse potential of tobacco products, including premium cigars (Hoffman and Evans, 2013)
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. IARC considers NNK and NNN, which always occur together in tobacco and tobacco smoke and are present in all tobacco products, carcinogenic to humans (IARC, 2012b)
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However, given the conclusive data on tobacco products including cigars in general, and the absence of any important threats to validity, the committee extrapolated these findings to premium cigars.
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This section provides an overview of the evidence from epidemiologic studies examining risk of all-cause mortality with primary cigar smoking (exclusive cigar smoking with no previous history of other combustible tobacco use) and secondary cigar smoking (current exclusive cigar smoking with previous history of use of other combustible tobacco products)
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From page 213... ...
Both studies found increased risk of mortality among current primary cigar smokers, though these findings were not statistically significant (incidence rate ratio (IRR) [95 percent CI]
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From page 214... ...
, but not nondaily (RRs, 95 percent CI: 1.04–1.12) cigar smoking was associated with significantly increased risk of all-cause mortality among current primary cigar smokers (Christensen et al., 2018; Corrigendum, 2019; InoueChoi et al., 2019)
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From page 215... ...
That is, these studies may include premium cigars but also other large cigars, little cigars, or cigarillos. Studies that distinguish premium from nonpremium cigar use as well as studies that distinguish primary and secondary cigar smokers would better isolate the effects of premium cigar smoking.
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From page 216... ...
Several studies provide data on primary versus secondary cigar smokers, and several provide data on self-reported depth of inhalation. Many from the British Regional Heart Study and other studies present data on a combined group of pipe and cigar smokers but not cigar smokers alone.
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From page 217... ...
increased risk of coronary heart disease in primary and secondary cigar users, with variability across studies. There was a trend for increased risk based on the number of cigars smoked per day for primary cigar smokers (1–2 versus 3–4 versus 5+ per day)
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(2019) studied morbidity associated with current primary cigar smokers age 35 or more using NHIS data between 2000 and 2015.
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Overall, primary cigar smoking appears to be associated with a small but significant increased risk of cardiovascular morbidity and mortality. Cardiovascular risk is generally higher in secondary cigar smokers but still much less than continuing cigarette smokers.
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The literature search found no studies evaluating the specific lung cancer risks from premium cigar use. Studies of the association between cigar use and lung cancer through 1997 were previously reviewed (NCI, 1998)
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. Exclusive current cigar smokers were found to have a lung cancer incidence HR of 3.9 (p < 0.05)
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(2012) conducted a meta-analysis of the relationships among cigarettes, pipes, and cigars and lung cancer and found a relationship with lung cancer risk for ever exclusive cigar smoking (random-effects RR: 2.92; 95 percent CI: 2.38–3.57)
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From page 223... ...
Like cigarette smoking, cigar smoking has been shown in multiple epidemiological studies to result in considerable lung cancer incidence and mortality risk and to have strong dose– response relationships with intensity, duration, and cumulative exposure. Risk for former cigar smokers is highest for those quitting use at older ages.
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From page 224... ...
However, the prevalence of COPD and respiratory symptoms was higher in those reporting either current cigarette smoking, exclusively or dual, or in cigar smokers who used to smoke cigarettes, than in those reporting exclusive cigar use. Mannino et al.
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Similar risks were estimated for all tobacco products. Schneller et al.
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Moreover, additional studies of relevant respiratory diseases, such as COPD and asthma, are needed. PERIODONTAL DISEASES AND CANCERS OF THE ORAL CAVITY, HEAD, AND NECK While many premium cigar smokers may not inhale as much smoke as do smokers of cigarettes and other types of cigars, they do take smoke into their oral cavity and often hold it over long periods.
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From page 227... ...
Multiple lines of investigation exist on the biologic mechanisms involved in periodontitis due to cigarette smoking, although smoking-related periodontal pathogenesis is not yet fully understood. To the extent that smoke from combusted premium cigars contains similar agents to mainstream cigarette smoke, the mechanisms associated with cigar-associated periodontitis are likely to be similar to those involved in cigarette-related periodontitis.
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From page 228... ...
. Multiple studies have found that cigarette smoking affects the composition of the oral microflora (Apatzidou et al., 2005; Hanioka et al., 2000; Jiang et al., 2020; Kubota et al., 2011; Moon et al., 2015; van Winkelhoff et al., 2001)
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. Compared with nonsmokers, exclusive cigar smokers also experienced significantly higher rates of tooth loss (RR: 1.3; 95 percent CI: 1.2–1.5)
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. Periodontal Diseases Summary Very few human studies have estimated the risk of periodontitis associated with cigar smoking, and none explicitly studied premium cigars.
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One study reported a dose-dependent association among current cigar smokers (Garrote et al., 2001) , and another found that the odds of UADT cancers declined with the number of years since quitting cigar use (Schlecht et al., 1999)
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The risk of mortality due to cancer of the oral cavity or pharynx among primary cigar smokers increased consistently with reported depth of inhalation (IRR: 6.98; 95 percent CI: 4.13–11.03 among men who reportedly did not inhale to IRR 27.88; 95 percent CI: 5.60–81.46 among those who reported moderate to deep inhalation)
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From page 233... ...
The level of increased risk will likely depend on the frequency of premium cigar smoking, which is generally lower than that of smoking other types of cigars. OTHER CANCERS Cigar use is associated with the risk of other cancers.
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The study found that dual cigarette and cigarillo use is associated with higher risks of overall, smoking-related, and lung cancers than exclusive cigarette smoking but that dual cigar and cigarette smoking has similar risks as exclusive cigarette smoking. Engeland et al.
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Lung, UADT, and bladder cancer combined risk among exclusive cigar smokers increased by depth of inhalation, duration of use, and intensity (cigars per week)
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Based on data from CPS-I, the NCI monograph reported that cigar smokers who have never smoked cigarettes (primary cigar users) have an increased risk of developing and dying of esophageal cancer when compared with nonsmokers (NCI, 1998)
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Esophageal and oral cancers have similar mortality ratios for both, while cigarette users have higher mortality ratios for coronary heart disease, COPD, lung cancer, and laryngeal cancer. The association observed between cigar use and esophageal cancer is further supported by a dose–response relationship and biological evidence of carcinogenic agents in cigars affecting risk of esophageal cancer in both rats and humans. Finally, the NCI monograph noted that despite few data on occasional cigar smokers, the risks of esophageal cancer and other causes of death are likely to be greater than in those with no tobacco exposure and less than in regular users.
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From page 238... ...
were 0.94–2.50 for primary cigar smoking and 1.90–3.69 for cigarette smokers compared to never-smokers. Analyses of 8 The following studies identified in the literature search were excluded and not discussed in the review: Boffetta et al., 2008 (review article that only discussed one study of cigar use -- that study was discussed separately)
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for primary cigar smokers, 1.23 (0.56–2.33) for secondary cigar smokers, 3.17 (2.83–3.54)
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. Relative to other tobacco products, the risk of incident BC was higher for primary cigar smokers than for primary pipe smokers (RR: 1.90; 95 percent CI: 1.2–3.1)
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. In CPS-I, most primary cigar smokers did not inhale (78.4 percent)
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The literature search found no studies reporting specific risks for premium cigar users. However, based on the cigar literature, it is expected that daily or frequent long-term use of premium cigars would result in higher risk of these cancers.
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From page 243... ...
They found no substantial association for primary pipe/ cigar smokers. However, their reference group included individuals who were former cigar smokers, which may have attenuated a true positive significant association.
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Based on the findings from epidemiologic studies evaluating the health effects of cigar use in general, as well as biological plausibility, the absence of any important threats to validity, generalizability of study inferences, and the smoking behaviors of premium cigar users, the committee concludes: Conclusion 5-3: There is strongly suggestive evidence that the health risks of premium cigar use (overall mortality; cardiovascular disease; lung, bladder, and head/neck cancer; chronic obstructive pulmonary disease; and periodontal disease) depend on frequency, intensity, duration of use, and depth of inhalation.
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From page 245... ...
Likewise, concurrent users of premium cigars and other combustible tobacco products would experience greater health risks than those smoking only premium cigars. Conclusion 5-8: There is insufficient evidence to draw conclusions on the health effects of premium cigars on • Youth or young adults, • Racialized and ethnic populations, • Pregnancy, • Those with underlying medical conditions, • People with occupational exposures to premium cigars (e.g., cigar lounges, manufacturing)
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From page 246... ...
; however, this designation applies to consumption and/ or topical use, and the criteria do not include an examination of inhalation risks. In fact, the flavor chemical profile for flavored tobacco products is similar to that for candy (e.g., Swisher Sweet grape small cigars versus Kool-Aid grape mix)
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From page 247... ...
to premium cigars could result in a greater appeal to nonusers and lead to more frequent use with potentially increased nicotine intake, increased addiction potential, and increased expo sure to harmful and potentially harmful constituents present in premium cigar smoke. HEALTH EFFECTS OF SECONDHAND CIGAR SMOKE Combusted tobacco product use produces smoke that is released into the environment, which presents a risk to health.
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From page 248... ...
For cigar smokers, exhaled smoke may contribute a smaller percentage to overall SHS due to small puff volumes in premium cigar smokers who do not inhale. The constituents of SHS from cigars are qualitatively similar to secondhand cigarette smoke.
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From page 249... ...
These could include increased risk of heart attack, respiratory symptoms, more severe respiratory infections in adults, lung cancer, lower respiratory tract infection, 11 The study says "equivalent for Ashton" and that "a Todo El Mundo cigar of similar size to the Ashton was used for measurement of physical characteristics." 12 Given this cigar's obscurity and size, it was likely a premium cigar. 13 This cigar meets the committee's definition of premium.
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From page 250... ...
is their addiction potential different from that of other cigar products and other noncigar tobacco products, and what is the reason for the presence or absence of cross-product differences in addictiveness? Because of the absence of direct empirical evidence for premium cigars, two approaches were taken.
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From page 251... ...
Empirical Evidence and Biologic Plausibility on Addictiveness of Premium Cigars and Other Tobacco Products Determining Biological Plausibility Risk of tobacco dependence onset, duration, and severity is a function of the inherent addictiveness of the product and by the extent of exposure to it (i.e., chronicity, frequency, and quantity of use)
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From page 252... ...
Inferences regarding whether premium cigars are addictive involved considering comparisons of nicotine yield and sensory profile to other tobacco products with known addictiveness. Evaluating Experimental Research on Addiction Potential Abuse liability/addiction potential assessment refers to a host of experimental and quasi-experimental research paradigms designed to examine the effect of exposure to a tobacco product on intermediate end points that are proxy outcomes indicative of addictiveness and likely to correlate with risk of dependence (Carter et al., 2009)
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From page 253... ...
To address that question and also their comparative addiction potential to other products, dependence symptom metrics were compared between populations of cigar users and users of other tobacco products. This approach was also used to compare premium to nonpremium cigar users.
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From page 254... ...
As noted in Chapter 2, premium cigar smoke emissions from a puffing machine contain nicotine at levels that appear to be at least equivalent to nicotine in smoke in nonpremium cigars and other combustible tobacco products (e.g., conventional cigarettes) (Fant and Henningfield, 1998)
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From page 255... ...
Given these results and the similar features of premium cigars to other tobacco products that are addictive, there is reason to believe that premium cigars have sensory aspects to contribute to their addiction potential. Given the absence of added characterizing flavors in premium cigars, their sensory profile may not be equivalent to nonpremium cigar and other noncigar products that are available in characterizing flavors.
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From page 256... ...
. Experimental Addiction Potential Assessment of Cigars The literature search identified seven total abuse liability studies of cigars, three of which examined large cigars and none of which examined premium cigars separately.
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From page 257... ...
and the different demographic and behavioral profile of premium and nonpremium cigar smokers (Chapter 3) , there is a low certainty that the population of all cigar smokers is representative of premium cigar smokers.
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From page 258... ...
Comparisons were made between exclusive current users of seven different products, including premium cigars. The results of the commissioned analysis showed exclusive premium cigar users' reports of one or more tobacco dependence symptoms was 43–60 percent across waves (see Table 5-1)
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HEALTH EFFECTS OF PREMIUM CIGARS 259 TABLE 5-1 Tobacco Dependence among Current Established Exclusive Users of Four Cigar Types, Cigarette Smokers, Users of Smokeless Tobacco and Hookah in U.S. PATH Adults Premium Nonpremium Filtered Smokeless Cigars Cigars Cigarillos Cigars Cigarettes Tobacco Hookah Mean tobacco dependence symptom level score (95% CI)
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From page 260... ...
. In this report's commissioned analysis of PATH, exclusive premium cigar users had a prevalence and mean severity of tobacco dependence symptoms that was substantially lower than that of exclusive cigarette or smokeless tobacco users across waves (see Table 5-1)
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From page 261... ...
with dependence was comparable between exclusive premium cigar users and exclusive hookah users, and for some exposure metrics, it was comparable between exclusive premium cigar users and exclusive users of other noncigarette tobacco products. For Waves 4–5, the difference in dependence severity between users of <6 days versus 6+ days in the past 30 days was also comparable between exclusive premium cigar users and exclusive users of other products (except for cigarettes and smokeless tobacco, which produced stronger associations; see Table 5-2)
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38.0) Linear association between number of days used of respective product and dependence severity (95% CI)
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From page 263... ...
The prevalence evidence estimates only modestly altered the committee's conclusion regarding the addiction potential of premium cigars because these estimates are confounded with ease of accessing premium cigars versus other tobacco products and preexisting dependence vulnerability. Premium cigars are more difficult to access than other tobacco products because of their high cost and limited availability (e.g., at specialty retailers)
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From page 264... ...
A strong biological plausibility exists that premium cigars possess the features (i.e., rate/amount of nicotine delivery, pleasant stimuli) liable to make them as addictive as other tobacco products with known addiction potential (e.g., smokeless tobacco)
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From page 265... ...
Conclusion 5-11: There is moderately suggestive evidence to support the biological plausibility that regular cigar smoking in general can be addic tive. It is likely that this is also true for premium cigar smoking, based on nicotine delivery characteristics, abuse liability studies, and epidemiological data.
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From page 266... ...
• Studies do not identify dependence of large cigars with flavors compared to premium cigars. • Longitudinal data are absent on trajectories of dependence for premium cigar users to provide information on how quickly dependence is acquired.
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From page 267... ...
1994. What determines mortality risk in male former cigarette smokers?
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From page 268... ...
2009. Abuse liability assessment of tobacco products including potential re duced exposure products.
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From page 269... ...
2012. Harmful and potentially harmful constituents in tobacco products and tobacco smoke: Established list.
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From page 270... ...
2007. Passive smoking and the use of non cigarette tobacco products in association with risk for pancreatic cancer: A case-control study.
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From page 271... ...
1999. Cigar smoking and death from coronary heart disease in a prospective study of U.S.
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From page 272... ...
Paper commissioned by the Committee on Patterns of Use and Health Effects of "Premium Cigars" and Priority Research (Appendix D)
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From page 273... ...
2016. Immediate effects of cigar smoking on respiratory mechanics and exhaled biomarkers; differences between young smokers with mild asthma and otherwise healthy young smokers.
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From page 274... ...
2010. Impact of smokeless tobacco products on cardiovascular disease: Implications for policy, prevention, and treatment: A policy statement from the Ameri can Heart Association.
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From page 275... ...
2001. Cigar, pipe, and cigarette smoking and bladder cancer risk in European men.
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From page 276... ...
2020. Cross-sectional association between exclusive and concurrent use of cigarettes, ENDS, and cigars, the three most popular tobacco products, and wheezing symptoms among U.S.
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From page 277... ...
2017. The association between environmental tobacco smoke exposure and childhood respiratory disease: A review.
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From page 278... ...
2005. Associations between cigarette smoking, pipe/cigar smoking, and smoking ces sation, and haemostatic and inflammatory markers for cardiovascular disease.
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