Tobacco Documents Online

ii Contents Page Introduction--------------------------------------------- 1711 Tl1ePtevalence of Pipe, C'igar„ and C'igaretteZTsage---------- 173~ The Definition and Processing of Cigars, Cigarettes,, and Pipe Tobaccos--------------------------------------------- 175 C'hemicai Analysis of'Cigar Sinoke------------------------- 177 \Iortality Oreralt Morta,lity=------------------------------------ 179 Mortality and Dose-Response Relationships. Amount Smoked-------------------------------- 180' Dn.lialation-------------------------------------- 183 Specific Causes of Mortalily--------------------------- 189 Cancer----------------------------------------- 189 Cancer of the Lip------------------------------- 190, Oral Cancer------------------------------------ 191. Cancer of' the Larvnx---------------------------- 193' Cancer of' the Esophagus------------------------- 1'97 Lung Cancer------------------------------------ 203 Tumorigeniic Act'ivity---------------------------- 210 Experimentlal Studiies---------------------------- 210 Cardiovascular Disease& -------------------------- 215 Chronic Obstructive Pulmonary D'iisease~~ (COPD) - - - - 216, Gastrointestinal D!isorders------------------------ 2M Little Cigars-------------------------------------------- 2'22' Conclusions--------------------------------------------- 229. References---------------------------------------------- 230. List ofFiguires, Figure L-1'nhal~tion among pipe smokers by age----------- 184 Figure 2.-Inhalatt'ion among cigar smokers by agE-Ham- mond------------------------------------------------ 1'85 Figure 3.-Depth of inhalation among, cigarette smokers by age-Hammond--------------------------------------- 185 Figure 4.-Percent distribution ofl 130 brands of cigarettes and. 25' brands of littlle cigars by tar content------------------ 22'5 167 O ~ Ca~ ~ CJl'

Page Figure~ 5'.-Percent~ distribution of' 130~ brands~~ of' cigarettes and 25brands of little cigars by nicotine content______________ 226'. LI isU of Tables Tab1ei.-Percent distribut'ion ofU.S'., males~aged 21 and older by type of tobacco usedl for the years 1964, 1966, and 197'0-_ 173 Table 2.-Percent distribution of U.S. males by type,of'tobacco used and agefor 1970---------------------------------- 174' Table 3.. Percent distribution~ of' British~ males aged 25 and older by type of tobacco used for the years 1965, 1968, and 1977i'------------------------------------------------- 174 Table 4.-Amounts of' several components of' 1 gram of' par- ticulate material frorn~ mainstream smoke of tobacco prod- ucts ------------------------------------------------- 177 Table 5.-A comparison of sev.eral chemical compounds found in the mainstream smoke of cigars, pipes, and ci'garettes-_-_ 178 Table 6'. Mortality ratlios for totall deaths by type of'smoking, (males only)------------------------------------------ 180 Table 7.-Mortalit'yratiosf'or tlotaldeathsofcigar andl pipe smokers byy amount smoked-Hammond and Horn-------- 181 Table 8.-Mortality ratios for total deaths of cigar and pipe smokers by amount smoked'-Best----------------------- 181 Table 9. M'ortality ratios for totall deaths: of ci$ar, and pipe smokers by age and amounti smoked-li:ahn-------------- 1182 Table 1Q.-Mlortality ratios f'or total deaths of cigar and pipe: smokers by amount smoked-Harnmond!----------------- 182' Table11.-The: extent ofinhalingpipes,c'igars; and' cigarettesby British males aged 16' and over in~ 1968 andi 1971 ------- 186 Table 12.-Inhalation among cigar, pipe, and cigarette smokers by age-D'olll and Hill---------------------------------- 1W Table 13.-Mortality ratios for total deaths of cigar and pipe smokers~by age and inhalation-Hammond--------------- 187 Table 114.-Percentage of British male cigar smokers who re- ported inhaling a lot or a fair amount by type of product smoked---------------------------------------------- 187 Ti able 15.-P'ercentage of individuals reporting, inhalation of "almost every pufF" of tobacco smoke by current and pre- vioustobaccolusage and type of'tlobacco usedi------------- 188' Table 16.-Percentage of British males who reported inhaling a lot or fair amount of cigar smoke: by current andi previous tobacco usage and type of tobacco previously smoked (1968)----------------------------------------------- 188 168

~age !'26 73'. 74 f7 Page Table 17.-Extent of' reported inhalation of' cigar smoke by British male cigar smokers who were ex-cigarette smokers in, 11968, analyzed by extent,of reported inhalation of cigarettiee smoke.ehenpreviouslysmokingcigarettes----------------- 189 Table 18'.-Niortality ratios for total cancer deaths in cigar and' pipe smokers. A summary of prospective epidemiologicall studies----------------------------------------------- 189 Table 19. Relative risk of lip cancer for men, comparing cigar, pipe, and cigarette smokers with nonsmokers. A summary of retrospectYvestudies----------------------------------- 192 Table 20.-Mortality ratios for oral cancer in cigar and pipe smokers. A suQnmaryof'prospective:epidemiol,ogical'studies-- T9~3Table 2I1.-Ro1'ativerisk of' oral cancer formen„ comparing cigar, pipe, and cigarette smokers wath~ nonsmokers. A sum- mary of retrospective studies--------------------------- 194 Table 22.-Mortality ratios for cancer of' the larynx in cigar and pipe smokers. A summary of'prospective epidemiological studies----------------------------------------------- 196 Table 23.-Relative risk of cancer of the larynx for men, com- paring cigar, pipe, and cigarette smokers with nonsmokers. A summary of retrospective studies---------------------- 198 Table 24.-Mortality ratios for cancer of the esophagus in cigar and pipe smokers: A summary of prospective epidemio- logicall studies----------------------------------------- 200 Table 25.-Relative risk of cancer of' the esophagus for mens comparing cigar, pipe, and cigarette smokers with non- smokers. A summary of'retrospectlive studies--------------- 201 Table 26.-Mortality ratios for lung, cancer deaths in male cigar and pipe smokers. A summary of prospective studiies---- 204 Table 27:-Lung cancer death rates for cigar and pipe smokers by amount smoked-IDoll and Hill---------------------- 204' Table 28.-Lung, cancer mortality rat'ios for cigar and pipe smokers by amount smoked-Rahn---------------------- 205 Table 29.-Relative risk of lung, cancer for men, comparing cigar, pipe, andl cigarette smokers with nonsmokers. A summary of retrospective studiies------------------------ 206 Table 30.-Changes in bronchial epi'theliumi of male cigar, pipe,, and cigarette smokers as compared to nonsmokers---_ 209 Table 31_-Tumorigenic activity of' cigar, pipe, and cigarette smoke condensates in skin painting experiments on animals-_ 213 Table 32.-Mortality ratios for cardiovascular deaths in male cigar and pipe smokers. A summary of prospective epi- demiological studies----------------------------------- 2116 169 I 0 ® ® 0 0 I t

Page Table 33.-Mortality ratios for chronic obsttlruetive pulmonary deathsin m~a1ecigar and pilpesmokers. Asu.mmary of pros- pective epidemiolbgical stludies-------------------------- 219 Table 34.-Prevalence of respiratory symptoms andi illness by type of smoking--------------------------------------- 220 Table 35. Pulmonary function val'ues for cigar and pipe smokers as compared to nonsmokers--------------------- 221 Table 36'. Mbrtalirt,y ratios for peptic ulcer disease in male cigar and pipe smokers. Summary of prospective studies--- 222 Table 37.-Shipment of small andl large cigars destined for domestic consumption (1970; 1971, 1972)----------------- 227' Table 38,-Selected compounds in mainstream smoke-------- 228 Table 39.-The pH of the mainstream smoke of selected tobacco productas-------------------------------------- 228, 170

Intiroductiiorr r22 i'2!7 ~28. I28 This~ eha.pter, is a review of' the epidemiological, pathological, and esperimental data: on the health conseqpences of smoking cigars! and'~ I)ipes, alone, together, and in various combinations with cigarettes. Previous reviews on the health consequences of'~ smoking have dealt primarilyy with cigarette smoking. Although some of the material on pipes:and cigars presented in this chapter has been, presented in previ- ous reports of'the Surgeon General, this is the first attempt to summa- rize what isInown about the health effects,ofpipe and, cigarsmoking:, Since the use of pipes and cigars is limited almost exclusively to men in the: United States; only data on, men are included in this review.. The influence of pipe and cig~r smoking on health~ is determined byexaminiRrgtheoverall and specific, mortalityandi morbidiityeg-perienced by users of these forms of tobacco compared to: nonsmokers. Epidemilogical evidence suggests that individuals who limit their smoking to only pipes or cigars have overall mortality rates that are slightly higher than nonsmokers. For certain specific causes of deathyhowever„ pipe andl cigar smokers experience mortality rates that are as great as or, exceed those e$perienced! by cigarette smokers. Thiss analysis becomes more complea when combinations of smoking forms ar~e, examinedL Theoveral2 rnortalityrates ofl thosew1v) smoke pipes, cigars,, or both in combination with cigarettes appear to be inter- mediate between the high mortality rates of' cigarette smokers and' the lower rates of those who smoke only pipes or cigars. This might seem to suggest that smoking pipes or cigars in combination with ciga- rettes diminishes the harmful eff'ects of cigarette smoking. However, an analyTsis of mortality associated vr ith smoking combinations of ciga- rettes, pipes, and cigars should be standardi'zedl for the level of con, sumption of each of' the prodhzcts smoked in terms' of the amount smoked, duration of smoking, and the depth and degree of inhalation. f' or example„cigar smokers who also smoke a pack of cigarettes a day might be egpectedito have mortality rates somewhat higher than those who smoke only cigaret'tiesat the level of apack a d'ay„assumingthat, both groups smoke their cigarettes in the same way. Mixed smokers', who inhale pipe or cigar smoke in ai manner similar to the way they smoke cigarettes might bee expected to have: higher mortality rates than mixed smokers who do1 not inhale their cigars and pipes and also 1z1 1

resist inhaling their cigarettes. ~,~nf!ortunately, little of the published material on~ mixed cigarette, pipe, and cigar smoking contains, these types of'analyses or controls:A paradox seems to: exist between the mortality rates of ex-smokers of pipes~and cigars and ex-smokers of cigarett'es. Ex-cigarette smokers experience a relative decline in overall and certain specific causes of mortality following cessation. This decline is important but indirect evidence that cigarette smoking is a ma jor cause of the elevat'ed mor- tality rates experienced by current cigarette : smokers. In contrast to this finding„ several prospective epidem.iological investigationsy Hammond and'H'orn (I0), Best (9)~„Kahn ('50), and H'ammond! (38), have; reported higher death rates for ex-pipe and ex-cigar smokers than for current pipe and cigar smokers.. This phenomenon was ana- lyzedl by Hammond and Garfinkel (3J). The development of ill healthh often results in a cigarette smoker giving up the habit, reducing his daily: tobacco consumption, switching, to pipes or cigars; or choosing a cigarette lbw in tar and nicotline. In many instances, a~ smoking- related disease is the cause of ill health. Thus, the group of ex-smokers includes some people who.are illl from smoking-related diseases, and d'eath; rates anehigh among personsin:ill health.As' a result„ ex-cigarette smokers initially have higher overalll and specific mortality rates than! continuing cigarette smokers, but be- cause of the relative d'ecrease in mortality that occurs in those who quit smoking for reasons other than ill health, andl because of the dwindling number of i11i ex-smokers, a relative: decrease in mortality is observed (within a few years) following cessation of' cigarette smoking. The beneficial effects of cessation «ouldi be obvious sooner were it not for the high mortality rates of those who quit smoking for reasons of illness. A similar principle operates for es-pipe and ex- cigar smokers, but because of't!he lower initial risk of smoking these forms! and thereforethe:smaller margin, of benefi't' following cessationythe effect producedl by the ill ex-smokers creates a larger and more persistent impact on the mortality rates than is seen in cigarette smoking. For the above reasons a bias is introduced into the mortality rates of current smokers and!es-smokers of pipes and cigars,,so that a more accurate pi'cture of' mortality might be obtained' by combining the ex-smokers with tlie current smokers and looking, at the: resultant mortality experience. Because of' a lack of data that would allow a precise analysis of mortality among ex-pipe and' ex-cigar smokers, a detailed analysis of'these groups could not be undertaken in this review. For each specific cause of' death, tables have been prepared which summarize the mortality and relative risk ratios reported in the major t7z

ters Cers ;of ~ect lor- ,' to Ins, ~eIS ha- Lth his Xlg tg- nd kdd le- ho ke. by te Br 19 K- tI, re ~e, Ss ,e le lt f'. prospecti~--e and retrospective studies which contained' informationn about pipe and cigar smokers. The smoking categories used include: cigar only, pipe only, total pipe and cigar, cigarette only, and mixed. The total pipe and cigar category includes: those who smoke pipes only, cigars only;, and~ pipes and cigars. The mixed category includes : those who smoke cigarettes and cigars; cigarettes and pipes; and cigarettes; pipes, and cigars. 'Mortality and relative risk ratios were calculated relative to nonsmokers. The Prevalence of Pipe,, Cigar, and Cigarette Usage: The prevalence of pipe„ cigar, and cigarette smoking in the United States was estimated by the National Clearinghouse for Smoking and Health from~ population surveys conducted in 19641, 1966;,and 1970 (98; 99; 100). In each survey, about 2,500 intervieavs were conducted on a national probabilitysamp16 stratified bytyype of populationandl beographic area. The use of'these products among adult's aged' 21 and older is summarized in tables 1 and 2: The prevalence of pipe, cigar, and cigarette smoking in Great Britain for the years 1965, 1968i and 1971 is presented in tablu :;: TABLE L.-F~ercen;t distr~~ib'ution of ~TT.S::7>za,le smoke~rs~~ aged~ 21 andolder~ by type of tobacco used' for the years 1964, 1966„ and 1970 Forms used 1964 1968 1970 (percent), (percent) (percent) 1. Cigar only----------------------------- 2: Pipe only ------------------------------ 3'. Pipe and cigar-------------------------- 4. Cigarette only -------------------------- 5.~ Cigarette and cigar---------------------- 6: 8 1.7 3,9 28 6 11.3 ' 5.5 3.0 4. 9' 31.,2 9.9 5: 6 3: 6. 4.4 25. 9 6,6 6. 7. 8. Cigarette: and pipe:.--------------------- Cgarette; pipe, and cigar---------------- Nonsmoker-----------------------,------ 5j 3 7: 7 3417 4: 9: 61 3! 34. 3 5. 3 4 6 4410 Total------------------------------ 100.0 10010 100'.,0 Total pipe users; (2+ 3+6-}-7)--------------- Total cigar users (1+3'-{-5+7)-------------- Total' cigarette users (4-}-5+6-F7)----------- 18: 7 29. 9 52: T 1'9:, 2' 26. 7 52.41 17. 9 21. 2' 42: 3' Source: U.S. Department ot Healthi Education, and Welfare (98, 99,10n);. 173:

TABLE 2.-P'ercent dzstribution of U.S. male smokers by type of tobac= co used and' age for 1•970' Forms used' 1. Cigar only----------------- 2. Pipe only------------------ 3. Pipe and cigar-------------- 4. Cigarette,only-------------- 5. Cigarette:and'cigar---------- 6. Cigarette and pipe---------- 7. Cigarette;, pipe,, and' cigar---- E', Nonsmoker----------------- Tota1------------------ Number of persons in sample--- TataP pipe users--------------- Total cigar users-------------- Total cigarette users---------- Age groups 21to34 38to:44 45'to54, 55to64 65to75' + 3,7 6' 5 4.7 6.7 9.3 4 3' 3. 5 3.0 ' 3. 2 3.6 '. 3. 8 3.3 5. 2' 414 6'. 9: 28.8 29:0 27. 1 24:3' 13:61 6.8 : 10.4 5.5 5: 2' 41 2' 6.6 4.4 5.6 4! 0~ 3.8 . 5: 8 4.8 5.0 4. 0 1.4 40:2 38. 1 43:9 48:,2 57.2 100.0 100.0 100L 0 1M 0 100.10 1i, 0w 528 523 405 388 20. 5' 16. 01 18.8 15. 6' 15. 7 20. 1 25.01 20.4 20. 3' 21!. 8' 48. 1 48.6 43.3 37.5 ' 210 Source: M S. Department of'Health, Education, and Welfare (1A0). 11'AS1,E. 3,-Percent' distribution of British male smokers aged 25 and older by type of tobacco used for the years 1965, 1968, and 1971. Formsused: 1. Cigars only'----------------------------- 2. Pipe only------------------------------ 3. Cigarettes on1y----,--------------------- 4. Cigarettes and pipe~--------------------- 5. MixedIsmokers------------------------- 6. Nonsmokers'---------------------------- Total'---------------------------- Number of' persons in sample--------------- Total pipe users--------------------------- Total cigar------------------------------- Total cigarette~-------------------------,--- Source: Todd, G. F: (B!,). 1' 74 1965 1968 1971, 1.9 21 8 3.3 ' 5. 1 5.6 ' 5. 9'. 46.8 ' 45. 7' 40.8 '. 8: 0 7T 0 6: 1. 7. & 9. 1 8.4 30. 7' 29. 9' 35.4 100:0 100.0 100.0 3)576 3, 566' 3,594 13.9 14.3 13, 3 9.0 11.7 ' 11. 3 67,6 67.6 61. 6

The Definition and Processing of Cigars,, Cigarettes, and Pipe Tobaccos CigaretGes A. 3' B. 6 3. 6' L 2 3. 8 1.4 7. 2 10; ~ 388 The U.S+ Government has defined tobacco products for tax pur- poses. Cigarettes are definedl as "(1) Any roll of' tobacco wrapped in paper or in any substance not containing tobaccot and (12) any roll of tobacco wrapped in any substance containing tobacco which, because of its appearance, the type of tobacco used in the filler„or, its packaging and labeling, is likely to be offered to„ or purchased by, consumers as a cigarette described in subparagraph Cigarettes are further classified by size, but virtually all cigarettes sold in the United States are "`small ci'garettes"' whichl by definition weigh "not more~ than 3' pounds per thousand"' which is not more thani 1.361 grams per cigarette (',96). American brands of cigarettes contain blends of different grades of' Virginia, Burley, Maryland, and' oriental tobaccos. Several varieties of cigarette tobaccos are flue-cured. Ifn this process, tobacco leaves. are curedl in closed barns where the temperature is progressively raised over a period of several days. This results in "'color setting," fixing, and dry~-ing, of the leaf. The most conspicuous change is the conversionn of starch; into simpler sugars and suppression of oxidative reactions. Flue-cured tobaccos produce an acidic smoke of light aroma: (35,,112);. Cigars r Cigars have been defined' for tax purposes as:: "Any roll of tobacco ,vrapped in leaf tobacco or in any substance containing tobacco, (other than any roll of tobacco which: is a cigarette w ithin the meaning of subparagraph (2) of the definition for cigarette)"' (112). In order to clarify t!he meaning of' "substance containing tobacco" the Treasury d'epartment has stated that, "The wrapper must (1) contain a signi& cant proportion of natural tobacco;, (2) be within the range of colors normally found in natural leaf'tobacco; (3)': have some of the other characteristics, of the tobaccos from which produced;e.g:,nicotine content, pI-I,, taste,, and' aroma;, and (4)1 notbesochangedl in the reconstitution process that it loses a11 the tobaeco: characteristics" (102). Further, "To be: a cigar,thefilder, must besubstantial,'ly of' tobaccos unlike those in ordinary cigarettes and must not have any added flav.ori'ng which would cause the product to have the taste or aroma generallyattributed to cigarettes. The fact that a product dioes 1i75

not resemble a cigarette (suchas~ many large cigars do1 not~)and'has adistinetiv.e cigar taste and aroma is of considerable significance in making this determination" (102)1. Cigars are also classified bysiae, "Smalll cigars"' weigh notl more thani 3 pounds per thousandi and, "large cigars"' weigh more than 3 pounds per thousand. "Large cigars" are further divided intolseven classes for tax purposes based on the retail price intended by the manufacturer for such cigars (96). Cigarsaremad'eof'fi1d'er,, binder, andwrappert'obaccos. 'Mosti' cigar tobaccos are air-cured and then fermentedL Nfore recently; reconsti- tutedl cigar tobaccos have been used as wrapper, binder, or both. Cigars are either hand4ol'led or machine made. Some brands of'smalli cigars aremanufactured' on regular cigarettemakingmac;hines. 'Il'heaging, and fermentation processes used in cigar tobacco production producee chemical catalytic, enzymatic, or bacterial tiransformations as evi- denced by increased temperature, oxygen utlilizationy and carbon dioxide generation within fermenting ciYar tobaccos. ]fni this complex process, up to 20~ percent of'tlied~yweight of'theleaf is lost through decreases in theconcentlrat'ion ofthemostl readil'yfermentablema- terial's such as carbohydrates, proteins, and alkaloids. The flavor and aromaofeigartobaccosare iazi largemeasuretheresul~t'sof 'preciselycontrolled treatment d~uringtheferment'ation process(35; 36, 112). Pipe Tobaccos The definition of pipe tobacco used by the LT.S. Government was repealed in 11966 ' and there is no Federali tax on pipe tobaccos. The mostpopular pipetokiaccos~ are made of Burley; however, many pipe tobaccos are blends of different types of tobacco. A few contain a significant proportion of midrib parts that' are crushed between rollers. "Saucing" material, or casings containing licorice, sweetening agents, sugars, and other flavoring materials are added to improve the flavor, aroma, and smoke taste. These additives modify the characterist!ics of smoke components (112)'.. CancLu sian. B'ecauseof t!heuniquecuringand processing methods used in the production of cigar andl pipe~tobaccos; significant phy.si~cali and chemi- cal differences exist betweeni pipe and cigar tobaccos and thoseusedl i'n »b.