ATL Artist and Psychic's blog: "Random Rantings"

By the end of the 19th century, physicians began recording an increase in the incidence of bronchogenic (lung) cancer cases. By 1900 lung cancer became the most common organ cancer in men. A landmark paper by Adler in 1912 implicated tobacco use in these cancers, although researchers at various hospitals began suspecting tobacco as a carcinogen as early as 1900. Thousands of articles on the relationship of various tobacco products to heart disease, respiratory disease, and cancer have been published since Adler. Most of these articles have focused on the outcome of cigarette use and lung cancer. By comparison, cigar use and its relationship to disease has only been documented by little over a 100 comprehensive research studies. These various articles fail to differentiate between processed tobacco as opposed to fermented leaf, or machine made vs. hand made cigars. One can argue differences between the quantity of tar and nicotine present in an American El Producto vs. a Dominican Davidoff. Few papers differentiate between grams of cigar tobacco smoked vs. numbers of cigars smoked daily (a 2 corona per day user certainly uses less cigar tobacco than a 2 double corona per day user.) No perfect study has at yet been written.. Given the number of articles, however, and the general agreement in some of the findings, some conclusions can be drawn between the relationship of cigars and cancer.

Much of the literature regarding cigars and cancer began with lung cancer risk studies. In the 1980's researchers began to look at cigars and oral cancer risk. Today research has expanded into various forms of oral cancers, esophageal and other gastrointestinal cancers, bladder, prostate, and biliary system cancers. One researcher even studied melanoma of the eye and outcomes with tobacco use following radiation therapy. Perhaps it is easier to summarize the various forms of cigar-related cancers that have been studied by the graph which follows. Confusion, however, still abounds. Not all research techniques have been standardized. Some papers do not differentiate pipe smokers from cigar smokers, or even attempt to quantify cigar tobacco amounts.

Political agendas further complicating the cigar research field abounded in 1998. The World Health Organization studied second hand tobacco smoke (ETS or "environmental tobacco smoke") and found a small, and statistically insignificant protective effect from ETS with regards to heart disease. The WHO chose not to release the report as these results did not coincide with their mission. In 1998 U.S. District Court Judge William Osteen overturned the 1993 Environmental Protection Agency's report on secondhand tobacco smoke. He ruled that the authors approached the study with a predetermined mindset, manipulated the research and analyses to reach a conclusion they deemed favorable to their cause. Judge Osteen felt the report was internally flawed. Unfortunately that original EPA report had already resulted in considerable damage by fueling many an anti-cigar engine and created untold havoc and fear among the non-smoking public.

The National Institutes of Health, with the National Cancer Institute, published its long awaited Monograph number 9, Cigars, Health Effects and Trends in February, 1998. This publication is to date the most complete compilation of cigar research and health risks. NCI's conclusions regarding cigars and health are easily contested. But the papers they present should interest any student of the heath risks of cigar smoking. This monograph is highly recommended.

The relative risk values are the relative risk of occurrence of a certain disease compared to the general non-smoking population (which is considered a standard of "1"). It should be emphasized that the National Cancer Institute states that a "relative risk of less than 2 are considered small and are usually difficult to interpret." The NCI report then is encouraging to the moderate cigar smoker. According to the NCI the relative risk ratios of death are all less than 2 for smokers limiting cigar consumption from 1 to 2 a day for: 1) all causes of death, 2) lung cancer, 3) pancreatic cancer, 4) emphysema, and 5) coronary artery disease. Cancers of the oral cavity and larynx have higher risk ratios but are intimately associated with heavy alcohol use.

Now apparently cigar smokers are starting younger and becoming more numerous. One study of high school students reported that 26.7% of U.S. students had smoked at least one cigar. Although any high school tobacco use is worrisome, there are no studies suggesting that these students continue to smoke cigars on a regular basis. And although nicotine is highly addictive, there are no studies suggesting cigars are addictive.

This 2001 update continues to confirm that cigars are associated with lung, gastrointestinal, pharyngeal and laryngeal cancers. Alcohol continues to remain as a cofactor in the genesis of oral and gastrointestinal cancers. Some new studies implicate cigars with the development of bladder, prostate, and colon cancer although the associations with these is still weak in my opinion. It should be noted that previous research has failed to significantly associate cigars with colon, bladder or prostate cancers. More research is certainly needed.

TYPE OF CANCER CIGARS IMPLICATED? PAPER/RELIABILITY

Lung Cancer yes with >5 cigars/day/inhaled Wynder, 1972/good
for longtime smokers
yes Abel, 1967/poor (no
inhalation practices studied)
yes/if inhaled >20g/day Gsell, 1972/good
yes if inhaled Wynder, 1977/good

yes if inhaled Joly, 1983/poor
yes if inhaled Lublin, 1984/good
not significant Chow, 1992/poor
yes 5+/day + inhaled Higgins, 1988/good
yes Wald and Watt, 1997/good;
yes (esp. inhaled) Boffetta, 1999 (good)
yes (+ other factors) Nakachi, 1999 (good)
yes Iribarren, 1999 (good)

Oral Cancer: yes (alcohol was not Gsell, 1972/good
studied)
yes + alcohol Wynder, 1977/good
not significant but Franceschi, 1992/poor
suggestive + alcohol
yes + alcohol Sorrall, 1995/poor
not significant Chow, 1993/good
yes Garrote, 2001/poor

Larynx Cancer: suggestive + alcohol Wynder/good
none Franceschi, 1992/good
not significant Freudenheim, 1992/good
yes: 5+/day+inhaling Muscat, 1992/poor
Esophageal Cancer: yes + alcohol Wynder, 1961/good
suggestive + alcohol Wynder, 1977/good
yes with dark tobacco
(alcohol/inhalation not studied) de Stefani, 1993/poor
(pure cigars not studied)
Biliary and
Extra biliary Cancers: minimal (sample size Wong-Ho, 1993/poor
too small)
no conclusions Chow, 1994/good
(small sample size)

Pancreas: possible/inhalation + Muscat, 1997/poor
ingestion.
none Farro, 1990/poor
none Bueon de Mesquita, 1991/poor

Colon none Slattery, 1997 (good)/
Nyren, 1996 (good)

Renal Cancer: none McLaughlin, 1995/good, Yuan, 1998

Bladder Cancer: minimal if any Wynder, 1977/not strong for bladder
none Burch, 1989/good
none Kunze, 1992/good
none Najem, 1982/good
none Morrison, 1984/good
none Slattery, 1988/good

yes Pitard, 2001/good

Pancreatic Cancer: none Farrow, 1990/good

Prostate Cancer: none Hedin, 1996/good
yes Sharpe, 2001 (weak)

Eye/Melanoma
spread after treatment: none Egan, 1992/good

Presented here are some of the finer points relating to cigars and cancer from articles which seem to demonstrate the least problematic methodology. In an attempt to decrease personal bias, most articles were directly quoted from rather than summarized. The reader's own interpretations hopefully will fill in here. Papers which were duplicative were not presented. For those who would like to study the literature more thoroughly, please refer to the references. Also, some papers presented did not focus primarily on cigars, but may have made important statements about cigars of interest to cigar smokers.

Any incorrect interpretation of specific findings was not intentional. No authors presented infer that any tobacco use is safe. Personal conclusions based upon the available research that moderate/non inhaled cigar use poses no significant health threat, hopefully have not colored this presentation. These studies demonstrate that inhalation habits play an important role in the genesis of tobacco related disease. Some cancers also appear to be related to tobacco use and abusive alcohol consumption. Future studies must take this into account when authors interpret results. If the current wave of increased cigar usage continues we will undoubtedly see more health issues surface. Future studies should further clarify the relationship between cigar usage and cancer.