American Cancer Society’s Combustible Tobacco Statement Contains Falsehood

The American Cancer Society’s new position statement offering a “bold new framework” for eliminating combustible tobacco use in the U.S. (here) contains a demonstrably invalid statement: “Cigarette smoking is the leading cause of cancer mortality in the United States (1), accounting for as much as 98% of all tobacco-related deaths (2) [emphasis added].

The problem with the highlighted phrase is that no estimate of “all tobacco-related deaths” in the U.S. has ever been produced by the government, academia or health organizations.  The percentage of deaths attributable to smoking, while undoubtedly large, is simply not known.

In reference 2 above, ACS attributes the false assertion to a New England Journal of Medicine article by tobacco researchers Michael Fiore, Steven Schroeder and Timothy Baker (here).  That article made virtually the same statement and cited a citizen petition submitted to the FDA in 2010 by Dr. Joel Nitzkin on behalf of the Tobacco Control Task Force of the American Association of Public Health Physicians (here).  Careful review of the Nitzkin filing reveals nothing to support the ACS or NEJM claim.

This falsehood can be corrected.  With some effort, the very small number of deaths from smokeless use and cigar/pipe smoking can be estimated from large federal datasets.  Government researchers and the ACS have the resources and should make this a priority, in order to provide a scientific foundation for FDA tobacco regulation.

Fabrication, or repetition of false statements, particularly by trusted authorities, organizations, and public figures, can result in widespread acceptance of myth as truth. Such cavalier inattention to fact is not acceptable in scientific discourse or public health policymaking, where actual lives are at stake (here).

FDA Cigar Study Part II: Heart & Lung Disease Nearly Zero for 1-2 Cigars Per Day

As noted in my last blog post (here), data presented in a recent FDA review of cigar health risks (here) showed that smoking up to two cigars per day, while not completely safe, is neither associated with significantly increased risks for death from all causes, nor smoking-related cancers.       

Now we examine the FDA data regarding cigar-related circulatory and lung diseases. Here are the overall results:

Table 1. Relative Risks for Mortality From Circulatory Diseases and Emphysema Among Men Who Smoke Cigars
Disease	Study, Year	Relative Risk (95% CI)
Coronary heart disease	Kahn, 1966	1.04 (0.96 – 1.13)
	Carstensen, 1987	1.16 (0.84 – 1.57)
	Ben-Schlomo, 1994	0.45 (0.17 – 1.22)
	Shanks, 1998	1.05 (1.00 – 1.11)
	Jacobs, 1999	1.30 (1.05 – 1.62) 1
	Jacobs, 1999	0.93 (0.72 – 1.21) 2
Stroke	Kahn, 1966	1.08 (0.91 – 1.28)
	Shanks, 1998	0.96 (0.87 – 1.06)
Aortic Aneurysm	Kahn, 1966	2.06 (1.32 – 3.07)
	Carstensen, 1987	5.10 (1.33 – 13.19)
	Shanks, 1998	1.76 (1.29 – 2.35)
Atherosclerosis	Kahn, 1966	0.97 (0.69 – 1.33)
Emphysema	Kahn, 1966	0.79 (0.25 – 1.86)
	Carstensen, 1987	1.30 (0.00 – 7.45)
	Lange, 1992	3.70 (1.10 – 12.00)
	Shanks, 1998	1.42 (0.96 – 2.03)

¹Age 30-74 years

²Age 75+ years

    

Compared with never smokers, cigar smokers in most studies had no elevated risks for coronary heart disease, which is one of the most common smoking-related causes of death in the U.S.; the single exception was a subgroup of men, age 30-74 years, in the Jacobs study.  Cigar smokers also did not have increased risks for two other frequent causes of death, stroke and atherosclerosis (hardening of the arteries).

Aortic aneurysm – a bulge in the heart’s main artery – is the only disease risk that is consistently elevated in cigar smokers.  It is a serious disorder but a distinctly uncommon cause of death; the mortality rate due to aortic aneurysm among those 45 and older dropped precipitously from 16 deaths per 100,000 in 2000 to 7.4 in 2014.

For men who smoke only one or two cigars a day, the health risks are even lower.

Table 2. Relative Risks for Mortality From Circulatory Diseases and Emphysema Among Men Who Smoke 1 or 2 Cigars Per Day
Disease	Shanks, 1998	Other Studies
Coronary heart disease	0.98 (0.91 – 1.07)	1.00 (0.90 – 1.10)1
		1.18 (0.76 – 1.82)2
Stroke	1.01 (0.88 – 1.17)
Aortic Aneurysm	1.82 (1.11 – 2.81)
Emphysema	1.39 (0.74 – 2.38)

¹Kahn 1966, fewer than 5 cigars per day.

²Jacobs 1999, 1 cigar per day.

No elevated risks for coronary heart disease, stroke or emphysema among men smoking 1-2 cigars per day.  The only disease that was significantly elevated was aortic aneurysm.

The Take-Home Message for Cigar Smokers

Puffing and/or inhaling the smoke of burning tobacco is not without risks.

The FDA, which now regulates tobacco products, seems inclined to treat cigars the same as cigarettes.  FDA staff wrote in their cigar study that “…cigar smoking carries many of the same health risks as cigarette smoking…We have observed that some risks associated with cigar smoking can be as high or higher than those associated with cigarette smoking, especially at the highest doses and levels of inhalation for cigar smoking.”

The problem with such a sweeping indictment is that it ignores scientific evidence and misleads cigar smokers who could substantially benefit from truthful harm reduction guidance.

Like any risky behavior, the degree of risk is proportional to dose and duration of exposure.  In other words, risk is based on frequency of cigar smoking and the degree to which smoke is puffed and/or inhaled.