Last year my colleague Nantaporn Plurphanswat and I published a study in the Harm Reduction Journal on causes of death among U.S. male smokeless tobacco (ST) users. We showed that exclusive ST users do not have significantly elevated mortality from any smoking-related diseases, although younger ST users had elevated deaths from all other causes.
While conducting that research, I testified (see here and here) at a field hearing convened by U.S. Senator Marco Rubio, then-chairman of the Senate Committee on Small Business & Entrepreneurship. The hearing focused on proposed FDA regulations’ likely effect on premium cigar production and marketing.
Subsequently, Dr. Plurphanswat and I conducted a cigar use mortality study. Our report has just been published in the Harm Reduction Journal. Our main finding:
“exclusive male cigar smokers age 40 + years had no statistically significant increased mortality from all causes, heart diseases, malignant neoplasms, cerebrovascular disease, smoking-related diseases or other causes. In contrast, the mortality experience of dual users of cigars and cigarettes and cigar smokers who formerly used cigarettes is similar to exclusive cigarette smokers.”
As with our ST study, our analysis of cigar users included only men age 40+ years, because it was designed to maximize the chance of producing significant results. Many previous studies included women, who rarely smoke cigars, and young men, among whom death is rare; those groups do not produce relevant information. Consider: Researchers aiming to measure breast cancer rates will likely not count men because while breast cancer does affect males, it occurs at such a minuscule rate that it would cut the rate among women in half, painting a grossly inaccurate picture.
Cigars are a complicated tobacco category, as we noted in our article:
“The cigar category consists mainly of two types of products: traditional, regular or premium cigars and cigarillos and little filtered cigars. The first type is larger and contains tightly rolled tobacco wrapped in a tobacco leaf. The second category has been described by the National Health Interview Survey questionnaires since 2015: ‘Cigarillos are medium cigars that sometimes are sold with plastic or wooden tips’ and ‘sold individually or in packs of 5 or fewer. Little filtered cigars look like cigarettes and are usually brown in color. Like cigarettes, little filtered cigars have a spongy filter and are sold in packs of 20.’ [reference here] These differences are important. It has been known for decades that exclusive users of traditional cigars and pipes tend to puff, not inhale, the smoke, thus limiting systemic exposure to toxic constituents compared with cigarette smoking…In contrast, users of cigarillos and small cigars generally inhale the smoke. These cigar types are more commonly consumed by adults under age 40 who are less educated and lower income than regular cigar smokers. They are also more likely to be consumed daily, in larger numbers, and also concurrently with cigarettes.”
However, National Health Interview Surveys (NHIS) data that we used to conduct our study does not distinguish between smokers of premium cigars and those who smoke products in the second category. The following figure from our HRJ article, which illustrates the hazard ratios (HRs, similar to relative risks) for cigar users, shows how we tried to overcome the NHIS deficiency. We coupled current, former and never cigar users with the same groupings of cigarette smokers. Cigar smokers in the red circles are likely to be in the cigarillos/little cigar group, whereas those in the green circle – who never smoked cigarettes – are likely to be premium users.
To be clear, neither puffing nor inhaling the smoke of burning tobacco is a healthy activity, but federal officials and others misrepresent the complex category when they make sweeping statements about how cigar smoking carries many of the same health risks as cigarette smoking.
All tobacco consumers deserve truthful information and guidance. The sweeping FDA indictment ignores scientific evidence and misleads cigar smokers. The following facts are indisputable: (1) In the U.S., the prevalence of cigar use, especially premium cigars, is very low; (2) premium products are used infrequently and in small numbers; and (3) they are puffed, not inhaled. Low prevalence, infrequent use and reduced exposure translates into minimal harm at the population level.
Conflation of cigarette smoking with dip and chew, vaping, cigar and pipe smoking falsely informs consumers that all tobacco products are equally dangerous. When Congress gave the FDA regulation of tobacco products 10 years ago, it did not direct the agency to treat all tobacco products as equally hazardous. Unfortunately, the FDA’s regulatory actions have done just that. The FDA’s current posture wastes government resources, undermines public health, and does nothing to address the 500,000 annual deaths caused by cigarette smoking.
