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has a ce in, nore an 3 even the igar lsti- ~ars rars r 01ng *e evi- bon ilexx igh ha- ,ndi ~lY~ 'as he pee a tSy Cs cigarettes. The extent to whichi these changes may alter the health consequences of smoking pipes and cigars can best be estimated by an analysis of the potentially harmful chemical constitutents found in the smoke of'these tobaccos; the tumorigenic activity of smoke conden- sates in experimental animals, andi a review ofl the epidem.iological data which has accumulated on the health effects of pipe and cigar smoking.. Cliemi'cal Analysis of C:gar Smoke Only a few studies have i been conducted that compare the chemical constituents of cigar smoke with those found in cigarette smoke. Hoffmann, et al. (43) compared the yields of several chemical com- ronentls, in the, smokefrom ai pl'a7n 85 mm: cigarette,, two types of cigars; and a pipe. The particulate matter, nicotine, benzo(a)pyrene, and phenols were determined quantitatively in the smoke of' these tobacco products: One: cigar tested was a 135'-mmi long„ 7.8-g.,, U.S''.- madie cigar. The other was a handmade Havanai cigar 147 mm. long weighing 8.6 g. The relative content of nicotine in the particulate matter produced by the cigars was similar to that of the cigarette tars. The benzo(a)pyrene and phenol concentrations in the cigar condensate was two to three times greater than in cigarette "tar''" (itable 4). f£uhn, (58) compared the alkaloid and phenol content in conden- sat!esfroman 80-mrn. Bright-blend cigarette sold comrnerciallyinAustria with, that obtained' from 103-mm. cigars. These were tested TABLE 4.-Amounts of se77erall components of Z' g: o f particulate material from mainstt eam smoke : of tobacco products Tobacco product I Standard' 8.5 mm. 8.5' mm. Compound U.S. Havana pipe Cigarette plain U.S. plain UiS. cigar A cigar B tobacco tobacco cigarette cigarette (b) (b) in pipe, in pipe, (a) (b) (b) IrTicotine: (mg.)---------- 46.2' 63'.6' Benzo(a)pyrene (µg.) ____ 3.9 3. 6' Phenol (mg.)_----------- 8.2 6.7 a-Ctesoll (mg.)---------- 1.6 1. 7 m+p-Ciesol (mg.)------- 4.8 3: 8 m-}°p-Ethylphenoli (mg.)-_ 1. 1 1.5 56:1 61.0 65:9! 77:4 6. 0 3.6 L 2 1.3 15.0 7.3 ' 2.9 4. 1 1.9 1.4 .6 .8 '' 5.6 3. 4 1.4 1.9 1L 1 1.3' .7, .7 177 I Smoking conditions: (a) 1 puff' per minute, duration 2'scc., puff volume 35' ml. L (b) 2 puffs~ per: minute, duration12 sec:,.puff volume 35 ml. Source: HoHmann, et al. (.r,.4).

with and -without the use of a~ celhzl'oseacetatefilter. Tli~econcentra-tions of'totall alkaloids andi phenol in the cigar smoke condensate were essentially the same as in the cigarette condlensate, but pyridine values were about 21/2 ti~meshicher in the cigar condensate., Campbell and, Lindsey (T7) measured' the polycyclic hydrocarbons levelsin thesmoke of'asmal'1lpopular-type cigar 8.8'cm8 long, weighing, 1.9 ~ g.Significant quantities of anthracene; pyrene, ft'uoranthene, and benzo(a)pyrene were detected in the unsmoked cigar tobacco, in con~- centrations much greater than: thosee found in Virginia cigarettes butt of the same order as those found in some pipe tobaccos: The smoking process contributed consi:derably: to the hydrocarbon content of the smoke. Table 5 compares the concentrations in the mainstream smoke of'cigarettes; ci'gars;and pipes of fourhyd!rocarbons frequently found in condensates. The authors reported! that the mainstream smoke from a popular brand of small cigar contained the polycyclic aromatic hydrocarbons; acenaplithylene, phenanthrene, anthracene, pyrene, flnoranthene, andl benzo(a) pyrene. Theconcentrationse ofthese hyd~o-carbons in the mainstream smoke were greater than those found in Virginia, cigarette smoke. Osman, et al. (69) analyzed the volatile phenol' content of cigar smoke collected from a 7-g. American-made cigar wit.h: domestic filler.. Afterquantitativeanalysisof'ph:enol', cresols, xylenols,and'meta and para ethyl phenol,, the aurt•horsconcluded that the levelsofthesecom- pound'sweregeneral'1y siiniilar to those reported for ciga:rettesmoke. O'sma:n and Barson (68) also analyzed cigar smoke for benzene, toluene, ethyl benzene, m-, p-;, and o-xylene„ m- and p-ethyltohiene, 1',2,4' triin.ethylbenzene; andi dipentlene, and generally found levels within the.range of't:liose previously reported for cigarette condensates.. In summary, available evidence suggests that cigar smoke contains mani- of the same chemicali constituents, including nicotine and; other alkaloids, phenols, and polycyclic aromatic hydrocarbons as are found TABLE 5.-A comparison of several' cliemical''compounds faund' in the mainstream smoke of cigars, pipes, and cigarettes Compound 1Vlicrograms per 100 g: o('tohiacco consumed Cigars Pipes I ' Ci@arettps Acenaphthylene--------------------------- 1.6 29. 1 5: o: Anthracene------------------------------- 11.9 110. 0 10.9 Pyrene----------------------------------- 17.6 75!5: 12;5 3;4-benzp_vrene---------------------------- 3.4 8. 5 . 9 I This is a light; pipe tobacco. Source: Campbell, 7: M., Lindsey, A. J: (17). 178

lra- ere. ues ion 119 qid ~ Dn* but ~ ~ng :~ the ~ ~ke : nd ' ~ >rn ~ tiie ne, ~o- ; inn iar ~r. nd n* ke. sls . M ns ier id' !he in~ cigarette smoke: Most of these compounds are found in concentra- tions whicli equal or exceed levels found in cigarette "tar.'"' A more compl'ete picture: of the carcinogenic potential of cigar "tars"' is ob- tainedi from experimental data in animals., Mortality Overall MortalitySev.eral large prospective studies have examined the health conse- quences of' various forms of smoking. The results of' these investiga- tions have been reviewed in previous reports of the Surgeon General in~ which the major emphasis has been on cigarette smoking and its effect on overall and specific mortality and morbidity., The following pages present a current review of the health consequences of smoking pipes and cigars. Data~ from the prospective investigations of Dunny et al. (31), Buell,, et a1.(16)1,Hirayama(42),, and W"eir and Dunn (~105), are not cited, because in these studies a separate category for pipe and cigar smokers was not established.. The smoking habits and mortality experience of 187,783 white men between the ages of 50 and 69, who were followed for 44' months were reported by Hammond and Horn (~41) . The overall mortality rates of men who smoked pipes or cigars were slightly higher than the rates of men who never smoked. The overalll mortality rate of cigar smokers was slightly higher than that of pipe smokers. In a study of' 41,00(Y British physicians,, Doll and Hill (28, 27) re- ported the overall mortality of pipe and eigar smokers as being; only 1 percent greater than that among nonsmokers. Best (9),, in a study of 78;000 Canadian veterans, reported overall mortality rates of pipe andd cigar smokers slightly above those of nonsmokers. Kahn (50) exam- ined the death rates and smoking habits, of' more than 293,000: U.S.. veterans~ and Hammond (38) examined the smoking habits of and mortality rates experienced by 440;559 men. In these studies„ pipe smokers experienced mortality rates similar to t.hose of men who never smoked regularly;, whereas cigar smokers had death rates somewhat higher than men who never smokedi regularly. Table 6 summarizes the results of'these five studies., Thus, data from the major prospective epidemiological studies demonstrate that the use of'pipes and cigars results in a small but dlefi,- nite increase in overall mortality. Cigar smokers have somewhat higher death rates than pipe smokers, and mixed smokers who use cigarettes in addition to pipes and cigars appear to experience an inter- mediate levell of mortality that approaches the mortality experience of' cigarette smokers. 495-028,oL--73'-- 13 179

TnBLE 6.-M'orta:l'ity ratios for total deatJis by type of' smoking (males only) Smoking type A uthor„reference Non- smoker Cigar only Pipe only Cigar and pipe Cigarette and cigar Cigarette and pipe Mixed (cigarette and other) Cigarette only Hammond and Horn 1 (4o)---, 1. 00 1. 22' ll 12' 1. 10 1.36 ' 1. 50 1., 43' 1. 68 IDoTl and Hill (2s)--------- 1.001 ---- ---- 1.01 ------ ------- 1. llli 1.28 Best (9)'----_--- 1. 00 1.06 1.05 .98' 1.22' ll 26 1.13 1.54 Kahn (dQ)------ 1. 00 1. li0 1. 07 1. 081 ------ ------- 1.51 1.84 Hammond 2 (3&)--------- 1.00 1.25 1. 19 1.01 ------ ------- 1. 57 1.86 "Only mortality ratios for ages 50 to 69 are presented! = Only mortality ratios for ages 8.5 to 64, are presentedl Mortality and Dbse-Response R'elat'ionsliiPs A consistent association existls between overall mortality and the total dose of smoke a cigarette smoker receives. The methods most frequently used'o to measure dosage of tobacco products are : Amount smoked, degree of inhalat'ion, duration of smoking experience, age at initiation,, and the amount of tar in a given tobacco product. Forr cigarette smokers, the higher the dose as measured by any of tihese parameters, the greater the mortali'ty.The significance of the small'i increase in overall mortality that occurs for the entire group of pipe and cigar smokers can be analyzed by examining the mortality of subgroups defined by si¢niIar measures ~ of dosage as used in the study of cigarette smokers, A3TOUIr fr SMOKED H!ammond and' Horn (40) reported' an increase in the overall mor- tality of pipe and cigar smokers with an increase in, the amount smoked. lndiv iduals who smoked more than four cigars a day or more. than 10 pipefuis a day had deathi rates significantly higher than men who never smoked (P<0.05 for cigar smokers and P'<0.05 for pipe smokers) (t~able 7):. Cigar and pipe users who smoked less than thiss amount experienced an overall mortality similiar to men who never 160'

qales rette iy ..68 .28 54 L 84 186 '. he St rLt re Ir se Ie srnokedl Thestludyof Canadian veterans (9)al'so~conta.ined evidenceof' a dose-response in mortality by amount smokedl for cigar smoker5. No dose-response relationship was observedl among pipe smokers (table. 8). Kahn (50) reported a consistent increase in overall mortality with an increase in the amount smoked for both pipe and cigar smokers (table 9). Hammond (38) found' no consistent relationship bet«een overall mortality and the number, of cigars or pipefuls smokedl (table 10). TABLE 7~.-1Vlortality~ratios~for totat deaths of'cig,ar and~pipc smokers by, am:aunt smoked-Hammond' and Horn. Amount smoked' Number of d@aths Observed Expected 14lortalityratio Nonsmoker----------------------------- 1,664 1,664 1. 00! Cigar only: Total,-----,------,------------------- 653 598' 1.09' 1 to 4 cigars------------------------ 410 400 1. 03' >4 cigars-------------------------- 229 185 1L, 24 Pipe only: Total------------------------------ 609 560' ll 09 1 to 10'pipef'uls---------------------- 391 374' 1L 05 >10 pipefuls--------------,---,------- 204 172' 1'. 19 Source: Hammond, E. G., Horn, D. (40). TABLE 8.-Mortality ratios for tatal' deaths of cigar and pipe' smokers by amount smoked-Best Amount smoked Number of deaths Observed Expected Modality ratio S'. Nonsmolter------------------------- ---------- ---------- Cigar only: Total-------------------------- 90 821 0'7 I 1 to 2' cigars-------------------- 64 56! 05 3 to 10 cigars. ------------------ 23' 19: 40 > 1'0 1 cigars--------------------- 1 1. 59 t Pipe only: Tota1--------------------,------ 570 566.99' 1 to 1o1pipefuls------------------ , 374 370.09 10 to 20'pipefuls---------------- _-, 141 140.84 I >20: pipefuls------------------- 36 35.90 ~ Source: Best„E. W. R. (9). 1. U0 1: , 1'0 1L 14 !' 1.19 ' .63 1.00 1.01 1.00, 1.00,

The above e'vidence'suggests that a dose-response relia.tionship may exist between the number of cigars and pipefuls smoked and overall mortality. FIowe'ver,becauseof'thehigh-mortalit'y rate ofex-sm~oke'rs: . of cigars and pipes, it is difficul't to interpret the data presented with- out out including this group with the continuing smokers. Without data which examines patterns of both daily rate of smoking and inhal'ationn at various age'leve]iS, no firm conclusions can be drawn as to the'nature of this dosage relat'ionship, 'Tl'Anr.E' 9.-Mortality ratios for t'o~tdl~, death,s~ of cigar and pipe smokers by age and' amount smoked=Kahn' Mortality ratio„age. Amountsmoked 58 Qo 84 6S'to 74' Pilbnsmoker-----------'-------------------------- 1.00 1.00 Cigar only: Total-------------------------------------- 1.01 1.08 11 to 4 cigars per day------------------------- .89 ll 00' 5 to 8'cigars per day------------------------- -, 1. 14 1L 23'. >8' cigars per day-----'---------------------- 1.65 ' 1L, 28 Pipe only: Total!-------------------------------------- - 1.08 ' v. 06, 1 to 4 pipefuls per day----------------------- 1. 16 .91 5 to 19 pipefuls per day'---------------------- 1.04 1. 10, }19 pipefuls per day'------------------------ ---------- 1. 18 Source: Kahn, H. A. (5q). TABLE 10.-Mortality ratios for total deaths of' cigdr and pipe smokers by amount smoked`Hammond' Amount smoked Mortality ratlu lwTonsmoker----------------- 1L, 00 Current cigar smokers:. Total-------------------- 1L 09, li to 4 cigars per day------- ll 03 >4 cigars per day--------- ll 18 Source: Hammond,,El. C. (18)'. 1' 82 Amount smoked M'ortalitip, ratio Current pipe smokers: Total-------------------- 1. 04! 1 to 9 pipefuls per day----- 1.08 > 9' pipefuls per'dax------- . 92'

Inhalation ofl tobacco smoke directly exposes the bronchi and the lungs to smoke and results in the absorption of'the soluble constituents of the gas and particulate phases. Without inhalation tobacco smoke only reaches the oral cavity and the upper digestive and respiratory tracts and does not reach the lungs where further direct effects and systemic absorption of various chemical compounds can occur.. Although the smoker has some voluntary control over the inhalation of smoke, the physical and chemical properties of' tobacco smoke to a degree determine its acceptability and "'inhaTability.7D' The ~ condensate of pipe andi cigar smoke is generally found to be alkaline when the pH is measured by suspending a Cambridge filter in COz-free water. Cigarette condensate is slightly acidic as measured by this method. Since alkaline smoke is more irritating to the respira- tory tract, it has been assumed that the more alkaline smoke of pipes and cigars was in part responsible for the lower levels of inhalation reported by pipe and cigar smokers. Brunnemann and Hoffmann (15) have analyzed the pH of whole, mainstream smoke of cigarettes and cigars on a puff-by-puff'basis using a pH electrode suspended in main- stream smoke: Smoke from several U.S. brands of'cigarettes was found to be acidic throughout the entire length of the cigarette. Of' interest was the findang, that cigar smoke also had an acidic pH for the first two-thirds ofl the cigar and became alkaline only ini the last 20, to 40 percent of the puffs f rom the cigar. Available epideniiol'ogical evidence indicates that most cigar smokers do not inhale the smoke and mostt cigarette smokers db. The fact that smoke from the first half' or more of a cigar is acidic, near the range of pH values commonly found in cigarette smoke, and becomes alkaline only toward the end of the cigar might suggest that the pH of the smoke of a tobacco product may not be the only factor thatinfluences inhalation patterns. Per- haps"`tar"' and nicotine levels as well as the concentration of' ok,her"irritating" chemicals also affect the degree to which a tobacco smokee will be inhaled. Nicotine is rapidly absorbed into the blbod stream from the lungss when tobacca smoke is inhaledl The amount of nicotine absorbed frorni the lungs is primarily a function of the nicotine concentration in the smoke and the depth of inhalation. Some nicotine may also be ab- sorbed through the, mucous membranes of' the mouth. This is moree likely to occur under alkaline conditions .chen nicotine is unprotonated (3, 15, 79). This suggests that cigar smokers mayy be able to absorbb some nicotine through the oralcauity without having to inhale, par- ticulkarly during the time that the smoke from the cigar is alkaline. 1ea ,

With the development of' sensitive measures of' serum nicotine levels (48) the extent to which nicotine is absorbed through the membranes of' the mouth in pipe and cigar smokers can be more accurately determinedl, Inhalation patterns of' smokers were determined in severaI of thee large prospective and some of the retrospective epidemiological studies. Inhalation was usually determined' by the administration of a ques- tionnaire that required a subjective evalhiationi of one''s own patterns ofinhalati~on. A1'thoughi the accuracy of t!heseqpestionnaiereshas not been confirmed by an objective measure of inhalationS such as carboxy- hemoglobin or serum nicotine levels, their reliability is supported by mortality data whichdemonstlratehigber, overall andl specific death rat'eswith self-reported increases~ in the depth of inhalation. Doll and Hill (26) andI'-Iammond (3&')presented information on inhalation patterns of pipe; cigar, and cigarette smokers (figs. 1, 2, 3i and table 12). Some 80: to 90 percent of' cigarette smokers reported inhaling, with the majority of' individ'uals inhaling moderately or deeply, whereas most pipe and cigar smokers denied inhaling at all.. Pipe smokers reported slightly more inhalation than cigar smokers., For each type: of' smoking,, less inhalation: was reported' by older smokers: This change may represent less awareness of inhalation, differences in smoking habit's of' successive cohorts of smokers, or it may reflect the: operation of'selectivefactorswhichfavor survival' of noninhalers. The Tobacco Research Council' of the United Kingdom hast since 1957i„periodi'eally reported the use of tobacco products by the British, Figure I.-Inhalation among pipe smokers by age. M'o inhalation Some inhalation Age 40 SOURCE: Hammond„ E: C. (38): 50 60' 70' 80 184

4els lnes !ely the ies. ies- rns not Ky- by ~th on !ed or ull. M ler bn, it ~ !o,f, tce >h. Figure 2.-lhhalation among cigar smokers by age-Hammond. SOURCE: Hammond, E. C. (38). Figure 3.-Depth of inhalation among cigarette smokers by age: HammondL None Slight inhalation Moderate inhalation Deep inhalation AVge 40 SOURCE: Hammond'y E. C. (38)., Recent reports edited by Todd have contained data on the inhalation pattern of cigar, pipe, andi cigarette smokers (92, 93, 94). Table 11'i shows that most cigarette smokers inhale a "lot" of "fair amount" whereas most pipe and cigar smokers donot'inhaTeatalll or "just alittle."' Little change is observed in the inhalatiion patterns of a given product since 1968. Best(9): reported inhalation data among, malie cigarette smoker&by smoking intensity and age group, but did not report the inhalation~ 60' 70 80' 185

pat'tlernsof' pipe andd cigarsmokers, The overall mortality ratesofs current pipe smokers who inhaled at least slightly were reported by Hammond'! (38) as being somewhat higher t'han for men who never smoked regularly. The overalll mortlalityy rates of current cigar smokers who reported inhaling at least slightly were appreciably higher than for men who never smoked regularly (table 13). Available: evidence indicates that cigarette smokers inhale smoke to agreaterdogree than smokers~of cigarsorpipes:Once a smokerhasllearned to inhale eigarettes,,hmRever, there appears to be a tendency to also inhale the smoke of' other tobacco products. For cigars,, this is evidently true whether one smokes both cigarettes and cigars or switches from cigarettes tlocigars (tables 1!4, 15;16). Bi-ossand Tidings (14): examined th:einhal'at'ion patt'ernsofs smokers of' large cigars, cigarettes, and those «•.ho switched from one tobacco product to another (table 15). Nearly 75 percent of those who: were currently smoking only cigarettes reported inhaling "almost every puff" and only 7 percent never inhaled. The opposite was true for per- sons who had always smoked' only cigars among whomi 4 percent re- TA$LE' 11~.-Th,e~ extent of' inhaling pipes;, cigars, d~~nd~~ cigarettes~ 8y, British; males aged 16' and over in 196'8' and 1971 V Tobacco product Amount of inhalation ~ Cigars Pipes Cigarettes ~ 1968 1971 1968 1971 1958 1971 Iilhale a lot------------------------ 23 19 8 8 47 47 C Inhale a f'air amount---------------- 16 19 1'0I 8 31 W Inhale just a lit'tle------------------ 27 27' 24 ' 26' 13' 15 Do not inhale at a11L---------------- 34 35 59 58 9 8 P; Total------------------------ 100~ 100~ 100 100~ 1001 100 Sourae: Todd, Ci. F. (91; 94). TABLE 12.-lniial'ation among cigar, pipe, and' cigdrette smokers by .lr age-Doll and Hill Percentage of [nhalers, age Smoking type. 26'.to.34~. 35to~44 4b~to64 b8~to164~~. &5~.to74: >74~, Cigar and pipe---------------- 12.00 10.00 ' 7. 00, 5:-00 4.00 4.00 Mixed (cigarette and other)----- 74. 00 60. 00 47. 00 36! 00 30. 00 26.00 Cigarette onlx---------------- 90. 00 85: 00' 75. 00 66: 00 58. 00 41.00 Source: Doll, R'., Hill, A. B: (P6)i 186'