Some alarming trends should be countered with strong patient education about the effects of the 'harmless' alternative to cigarettes.
by Margaret J. Fehrenbach, RDH, MS
Cigar smoking causes a variety of oral cancers, including cancers of the lip, tongue, and oral cavity, and also the associated cancers of the pharynx, esophagus, and larynx. Many of these types of cancers have extremely low cure rates. For example, only 11 percent to 14 percent of patients with esophageal cancers survive five years after diagnosis.
The health risks associated with cigar smoking are significant for daily cigar users (at least one cigar per day). This should eliminate any complacency that our cigar smoking patients may have enjoyed since they were told in the past by cancer experts and other health care professionals that they had less risk of lung cancer than cigarette smokers (still significantly higher than nonsmokers).
The role of the dental hygienist is first as an educator. The patient who smokes cigars or has questions about the risk of cigar smoking should be educated about these risks.
Smoking one to two cigars per day presents significant oral health risks, even though many would consider this "light" use. The risk for oral cancers is doubled compared to someone who has never smoked. And someone smoking at the same moderate level (one to two cigars daily) increases the risk of cancer of the larynx by more than six times that of a nonsmoker. Like cigarette smoking, the risks from cigar smoking increase with the number of cigars smoked per day. Smoking three to four cigars per day increases the risk of oral cancers to 8.5 times greater than the risk of a nonsmoker, and smoking more than five cigars daily raises the oral cancer risk to 16 times the level for nonsmokers.
Large cigars typically contain between 5 grams and 17 grams of tobacco. Therefore, it is not unusual for some premium cigars to contain the tobacco equivalent of an entire pack of cigarettes. This increase in the amount of tobacco exposure has health consequences. Large cigars can take between one and two hours to smoke, whereas most cigarettes take less than 10 minutes to smoke.
As for cigar smoking and periodontitis, records in the Veterans Affairs Dental Longitudinal Study showed that over the course of 23 years, cigar smokers had the same risk of alveolar bone and tooth loss as cigarette smokers. Not only are cigar smokers more at risk for various oral cancers than nonsmokers, but they also may find their teeth falling out. Another study showed that the cigar smokers had nearly three times the percent of moderate to severe periodontitis as non-smokers. In addition, they averaged four missing teeth.
The health risks associated with less than daily smoking (occasional smokers) are not known at this time. However, it is important to note that about three-quarters of cigar smokers smoke only occasionally. But, the trend for smoking cigars is growing and with it an increase in overall use. Sadly, education and regulation have not kept up with this social trend.
Review of associated cancers
Cancer of the esophagus occurs two to three times more often in men than women and its peak age of incidence is between 50 and 60 years. Difficulty in swallowing is the main symptom. Pain appears early in the condition and is related to swallowing. Pain in the chest can become constant in the late stages of the cancer. The cause of cancer of the esophagus is unknown but smoking and heavy use of alcohol appear significant. Most cancers of the esophagus are detected relatively late so that radiotherapy is the most common treatment. However, if the cancer is detected early, surgery or laser therapy is the best treatment. A new photodynamic therapy uses a fixed-frequency laser light in combination with a photosensitizing agent.
Cancer of the larynx is much more common in men than women. Smoking and heavy alcohol use are factors associated with this type of cancer. The main symptom is persistent hoarseness, which is often associated with the feeling there is a lump in the throat. A change in voice quality in an older person should always be investigated. There may be an associated persistent sore throat with pain referred to the ear, as well as difficulty in swallowing or breathing. A persistent cough may appear with blood-stained spit.
Treatment consists of surgery followed by radiation. Removal of the larynx (partial or total) also may be indicated, with speech rehabilitation to follow.
In general, the smoke from cigars and cigarettes contains many of the same toxins and irritants (including carbon monoxide, nicotine, hydrogen cyanide, ammonia and volatile aldehydes) and human carcinogens (including benzene, aromatic amines, the bladder carcinogens 2-naphthylamine and 4-aminobiphenyl, vinyl chloride, ethylene oxide, arsenic, chromium, cadmium, nitrosamines and polynuclear aromatic hydrocarbons). But because cigars usually contain a greater amount of tobacco than cigarettes and involve a longer smoking time, they generate greater amounts of tobacco smoke for the smoking individual. Additional differences between cigar and cigarette smoke are primarily due to the long aging and fermentation process for cigar tobaccos and lack of porosity of the cigar wrapper compared to cigarettes.
Cigar tobaccos contain high concentrations of nitrogen compounds (nitrates and nitrites) that during fermentation and smoking give rise to increased levels of several tobacco-specific nitrosamines, some of the most potent human carcinogens known. In addition, the nonporous cigar wrapper makes combustion of cigar tobacco even more incomplete than cigarette tobacco. As a result, compared to cigarette smoke, the concentrations of nitrogen oxides, ammonia, carbon monoxide and tar are higher in cigar smoke. Most consumers are unaware of these similarities and differences between cigarettes and cigars.
In recent studies it has been shown that secondhand cigar smoke is more poisonous than secondhand cigarette smoke. Cigar secondhand smoke contains more than 4,000 chemicals, including 200 poisons and carcinogens. A single smoking cigar in an unventilated room produces the equivalent air pollution of 43 burning cigarettes.
Unlike what consumers were told in the past by the tobacco companies, nicotine is the addictive agent in tobacco and even tobacco smoke is capable of producing addiction or nicotine dependence. Most cigars contain nicotine in quantities equivalent to several cigarettes and can deliver nicotine in concentrations comparable to those delivered by cigarettes and spit (smokeless) tobacco. For large cigars this can be up to 40 times more nicotine than just one cigarette. When cigar smokers inhale, nicotine is absorbed rapidly as it is with cigarette smoke inhalation. For those who do not actively inhale, nicotine is absorbed predominantly through the lining of the oral cavity, which leads to a slower rise and lower peak of nicotine in the blood compared to cigarette smokers who absorb nicotine primarily through the lungs.
However, both inhaled and noninhaled nicotine can be highly addictive. For example, the studies of the large number of people addicted to spit tobacco demonstrate that nicotine absorbed through the lining of the oral cavity is capable of forming a powerful addiction. Another emerging trend is that cigar companies are beginning to make their products easier to inhale by altering their pH value. This is alarming, especially considering figures showing that a younger age group is beginning to smoke cigars.
Studies documenting the frequency or intensity of nicotine dependence and withdrawal symptoms from cigar smoking have not been conducted. However, the pattern of cigar smoking in the population, infrequent use, low number of cigars smoked per day, and lower rates of inhalation compared to cigarette smokers, suggests that cigar smokers are less likely to be dependent on nicotine than cigarette smokers are.
Specifically, the fraction of adult cigar smokers who smoke daily appears to be smaller than the fraction of everyday cigarette or spit tobacco users. In addition, recent data show that increased cigar use among adults is largely an increase in occasional smoking, suggesting that the risk of addiction is lower for cigars than for cigarettes. However, this is not to say that cigar smoking is free of the risk of dependence; cigar smoking is only less of a risk for nicotine dependence than cigarette smoking. One researcher clearly states that there is no safe number of cigars you can smoke.
Even though there has been relatively little published research on nicotine dependence in cigar smokers, several startling observations are notable when looking at other tobacco studies. Addiction studies with cigarettes and spit tobacco show clearly that nicotine addiction occurs almost exclusively during adolescence and young adulthood when young people begin using these tobacco products. Some researchers are concerned that the current high rate of adolescent cigar use may result in a higher probability for nicotine dependence in this younger age group.
Trends in cigar smoking
According to the 2000 National Household Survey on Drug Abuse (NHSDA), 4.8 percent of persons aged 12 or older (more than 10 million individuals) were current cigar users (smoked cigars within the past month).
Since 1993, cigar use in the United States has increased nearly 50 percent. Small cigar consumption has increased modestly since 1993, about 13 percent, whereas consumption of large cigars has increased nearly 70 percent during this time period. Sales of premium cigars, most of which are hand-made and imported, has increased even more, by an estimated 250 percent. These trends are in sharp contrast to cigarettes where consumption has declined by 2 percent since 1993. According to the U.S. Department of Agriculture Economic Research Service, cigar consumption hit an estimated 3.8 billion in 2001. Cigar stores and tobacco shops have seen their numbers plunge by 40 percent since 1970 as millions of Americans have given up smoking. However, this decline was halted in recent years, perhaps as a result of the increased popularity of cigars among both men and women.
The increased use of cigars since 1993 marks the reversal of a sustained decline in cigar smoking over the past several decades. Until 1993, consumption of large cigars had declined each year since 1965. Total cigar consumption (large and small cigars) declined by about 66 percent from 1973 until 1993. Peak cigar sales in this country occurred in the decade following the first U.S. Surgeon General's report in 1964, warning about the health risks of smoking cigarettes. A loophole in the l969 law banning cigarette advertising on television and radio allowed the advertising of small cigars. Small cigars are the size of cigarettes and the most popular brands contain filters and look like cigarettes. Small cigar consumption increased rapidly in the early 1970s until television and radio ads for these products were banned by Congress in l973. After that, total cigar consumption began a steady decline, which lasted 20 years.
However, that decline has not lasted: cigar use began to increase in the early 1990s, coinciding with an increase in promotional activities for cigars. Some of these activities include the publication of Cigar Aficionado magazine beginning in 1992 and media coverage of highly publicized social events such as cigar banquets and cigar parties that featured expensive imported premium cigars and fine liquors sponsored by hotels, held in ballrooms and lounges, called "cigar bars." The sharp rise in the popularity of premium cigars parallels the interest in gourmet coffee and microbrewery beers. It is interesting that young women, as well as men, are now strutting their cigars.
Look also at the increased use of cigars by male celebrity role models on highly rated television shows such as Frazier and in the past Seinfeld, with its crazy cool Kramer. Even more important are the blockbuster movies involving strong, silent Sylvester Stalone and Arnold Schwarzenegger and smooth, smart men like the latest James Bond. Or the new action hero, Will Smith, saving the world or Wolverine (Hugh Jackman) kicking back with the rest of the X-men.
Gone are the funny old man images of George Burns and Groucho Marx. Sports figures also have been smoking off the field and court, such as Dennis Rodman and Michael Jordan. Never are any negatives discussed or shown. Therefore, it is easy to see why the current evidence strongly suggests that most new cigar users are teenagers and young adult males who smoke occasionally (less than daily) as per a Centers for Disease Control-based study. Teenage boys are twice as likely to smoke cigars as teenage girls, while adults males are about eight times more likely to smoke cigars, compared to adult females. However, among older males (65 and older), cigar use has continued to decline since 1992.
Cigar use also appears to be increasing among higher socioeconomic status individuals, a group that had, in recent decades, chosen not to use tobacco (either by quitting or not beginning). This picture is opposite to what is observed among cigarette smokers, where the proportion of smokers declines with increasing income and education.
There have been a number of reports of high rates of use among not only teens but also pre-teens. Furthermore, usage appears to be increasing among adolescent females, as well as males. Some school-based studies report that among adolescent boys the current level of cigar smoking exceeds their use of spit tobacco; in some cases these rates are double their reported use of spit tobacco.
After seeing a dramatic increase in teen cigar smoking throughout the 1980s and early 1990s, cigar smoking among teens has thankfully decreased 30 percent since 1997. However, in 2001, about 15 percent of U.S. high school students reported having smoked a cigar in the previous month. Male students (about 22 percent) were more likely than female students (about 8 percent) to smoke cigars. Spit tobacco use is virtually non-existent among adolescent girls, but there is an increased use of cigars by these girls. This may be directly tied to the fact that strong independent female celebrity role models, such as Whoopie Goldberg, Demi Moore and Sex in the City's women, are smoking cigars. Among U.S. college students, a recent Harvard study found that 23 percent had smoked cigars at some point in their lives and about 16 percent of men and 4 percent of women were cigar smokers at the time of the survey.
Federal regulations and the Internet link
Federal regulations have just started to catch up to the growing trend for cigar smoking. Cigars are subject to fewer federal regulations than are cigarettes and spit tobacco products. Until recently, health warnings required on other tobacco products were absent on cigars. However, warnings of proven health risks similar to those required for cigarettes are required for cigar packaging and ads as a result of a legal settlement in June 2000 between the Federal Trade Commission and the seven largest U.S. cigar companies (representing 95 percent of the U.S. market). Finally, higher taxes on cigarettes have been shown to reduce consumption; this difference in the tax structure needs to be examined further in regards to cigar smoking.
A recent study conducted at the University of California found more than 140 internet sites marketing cigars on the Internet, with almost one-third having elements considered to have potential youth appeal. Only about one-quarter of these sites 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 age identification of the buyer difficult.
Margaret J. Fehrenbach, RDH, MS, is a dental hygiene educational consultant. She has published oral biology textbooks with WB Saunders and presented continuing education courses in the area of oral biology and pain control. Ms. Fehrenbach presented this information on cigar smoking at panel discussion at a past ADHA Annual Session and has also presented a discussion on tobacco cessation at an ADA Annual Session. She has online case-based continuing education programs with DH Forum, which is affiliated with Marquette University Dental Hygiene Program in Milwaukee, as well programs with ArcMesa Educators (www.arcmesa.com). Her Web site is http://home1.gte.net/jonmarg.
A discussion about 'inhaling'
One of the major differences between cigar and cigarette smoking is the degree of inhalation. Almost all cigarette smokers report inhaling, while the majority of cigar smokers do not. Inhalation also plays a role with cigar smokers who have a history of cigarette smoking. This group of smokers is more likely to inhale cigar smoke. For these smokers, the disease risks are uniformly higher than among cigar smokers who have never smoked cigarettes.
In spite of these differences, cigar smokers and cigarette smokers have similar levels of risk for oral cancers. For example, the risk of oral cancers among daily cigar smokers (smoking one or more cigars per day) who do not inhale is seven times greater than for nonsmokers and laryngeal cancer risk is more than 10 times greater than that of nonsmokers. For non-inhalers, the larynx receives less exposure than the oral cavity. Thus, cancer of the larynx occurs at lower rates in cigar smokers than cigarette smokers.
The degree of inhalation of cigars does have a strong effect on disease risk. Compared to nonsmokers, cigar smokers who reported inhaling deeply had 27 times the risk of oral cancer, 15 times the risk for esophageal cancer, and 53 times the risk of cancer of the larynx. With regular use and inhalation, the laryngeal cancer risk of cigar smoking may approach that of cigarette smoking.
Oral health risks associated with both cigars and cigarettes are strongly linked to the degree of smoke exposure. Since smoke from cigars and cigarettes are composed of many of the same toxic and carcinogenic compounds, the differences in health risks appear to be related to differences in daily use and level of inhalation.
However, all tobacco smokers, whether or not they inhale, directly expose the lips, oral cavity, tongue, pharynx and larynx to smoke. In addition, smoke constituents in the saliva are swallowed into the esophagus. This exposure probably accounts for the fact that oral and esophageal cancer risks are similar in both cigar smokers and cigarette smokers.
Oral cancer/cigar smoking Web sites
Action on Smoking and Health
Web site: www.ash.org
American Cancer Society
Web site: www.cancer.org
American Lung Association
Web site: www.lungusa.org
American Dental Association
Web site: www.ada.org
American Medical Association
Web site: www.ama-assn.org
American's for Nonsmokers' Rights
Web site: www.no-smoke.org
Centers for Disease Control and Prevention
Office on Smoking and Health
Web site: www.cdc.gov
National Cancer Institute
National Institutes of Health (NIH)
Web site: http://rex.nci.nih.gov
Robert Wood Johnson Foundation
Web site: www.rwjf.org