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.
