All Commentary
Monday, November 1, 1999

Just a Cigar

What Are the Health Risks to Moderate Cigar Smokers?

Jacob Sullum is a syndicated columnist, a senior editor at Reason, and the author of For Your Own Good: The Anti-Smoking Crusade and the Tyranny of Public Health (The Free Press).

In July the Federal Trade Commission recommended that Congress require warning labels on cigars. One of the warnings suggested by the FTC nicely illustrates the artful evasiveness of public health officials who seek to shape people’s behavior rather than inform them: “Cigars are not a safe alternative to cigarettes.”

By denying a claim that no one has made, this admonition avoids the question of just how risky cigars are. Public health officials who are alarmed by the recent increase in cigar consumption prefer to avoid that question, because the evidence clearly shows that the typical cigar smoker faces hazards far less serious than the typical cigarette smoker does. In their campaign to scare people away from cigars, tobacco’s opponents have deliberately obfuscated that point, with consequences that can be seen in press coverage of this issue.

Two years ago, the New York Times claimed that cigars pose “higher risks” than cigarettes. Last year it reported that “smoking cigars can be just as deadly as smoking cigarettes.” In June it said “the disease risks are not as high as they are for cigarette smokers because cigar smokers usually do not inhale the smoke.”

Are cigars getting safer? No, but reporters may be getting smarter. Once easily misled by the scare tactics of public health officials and anti-smoking activists, the mainstream press is starting to acknowledge something that medical studies have been finding for decades: Although cigars are not a safe alternative to cigarettes, they are a safer alternative.

This fact was clear from the data compiled by the National Cancer Institute (NCI) in its 1998 monograph on cigars. Overall, the NCI reported, daily cigar smokers get oral and esophageal cancers almost as often as cigarette smokers. But they face much lower risks of lung cancer, coronary heart disease, and chronic obstructive lung disease—the three main smoking-related causes of death. The upshot can be seen in mortality figures. In a 1985 American Cancer Society study cited by the NCI, men who smoked a cigar or two a day were only 2 percent more likely to die during a 12-year period than nonsmokers, a difference that was not statistically significant. By contrast, the mortality rate was 69 percent higher for men who smoked a pack of cigarettes a day.

The only really bad news for cigar smokers in the NCI report applied to a small minority. The NCI emphasized that the risk from cigars increases with the frequency of smoking and the degree of inhalation. Cigar smokers who inhale deeply face measurably higher risks of heart disease and emphysema (though still not as high as those faced by cigarette smokers), and the risk of lung cancer for a five-cigar-a-day smoker who inhales approaches the risk for a pack-a-day cigarette smoker. That sort of cigar smoker is quite unusual, however. “As many as three-quarters of cigar smokers smoke only occasionally,” the NCI noted, and “the majority of cigar smokers do not inhale.” Since the available data apply only to people who smoke at least one cigar a day, “the health risks of occasional cigar smokers . . . are not known.”

No Measurable Risk

In other words, there is no evidence that smoking cigars in moderation—with moderation defined by the way most cigar smokers actually behave—poses a measurable health risk. But this point was lost on most reporters. Indeed, many news organizations erroneously reported that the NCI had debunked the “myth” that cigars are safer than cigarettes. The headline in the San Francisco Chronicle read, “Cancer Institute’s Warning on Cigars: Just As Bad As Cigarettes.” An Associated Press story said the NCI report was “intended to equate dangers posed by the two products.” The article began, “Smoking cigars can be just as deadly as smoking cigarettes.” This is like saying that riding a bicycle “can be just as deadly” as riding a motorcycle. It’s true in the sense that both activities can result in fatal accidents. But that does not mean they are equally dangerous.

Still, it’s easy to see how journalists got the wrong impression. Calling the increase in cigar smoking since 1993 “disturbing” and “alarming,” the NCI report downplayed the differences between cigars and cigarettes. “Cigars are not safe alternatives to cigarettes,” said NCI Director Richard Klausner. The issue, of course, was not whether smoking cigars is completely risk-free but whether, on average, it is less risky than smoking cigarettes—something no reasonable person could deny after looking at the evidence.

Before the NCI report came out, reporters were primed to expect that it would show cigars are as dangerous as cigarettes, if not more so. Consider how Michael Eriksen, director of the Office on Smoking and Health at the U.S. Centers for Disease Control and Prevention, described the hazards of cigars in a May 1997 New York Times story: “Tobacco is tobacco is tobacco.” In February 1998, the NCI’s Donald Shopland told USA Today, “You’re smoking a whole pack of cigarettes” when you smoke a cigar. That same month, the addiction specialist Jack Henningfield, who contributed to the NCI report, told The Wall Street Journal “it will help explode some of the myths about cigars,” including the idea “that they are relatively safe.” Around the time the monograph came out, the California Department of Health Services started running a TV spot likening one cigar to 70 cigarettes.

The press may be starting to see through such misleading comparisons. The clear difference in risk between cigars and cigarettes was confirmed once again in a study published by The New England Journal of Medicine in June. But this time, reporters paid closer attention.

In the study, researchers led by Carlos Iribarren, an epidemiologist with the Kaiser Permanente Medical Care Program in California, tracked about 18,000 men—1,546 cigar smokers and 16,228 nonsmokers—from 1971 through 1995. Overall, the cigar smokers were about twice as likely to develop cancers of the mouth, throat, and lungs; 45 percent more likely to develop chronic obstructive lung disease; and 27 percent more likely to develop coronary heart disease.

As Iribarren and his colleagues noted, these risks are modest compared to those seen in cigarette smokers. Depending upon the study, cigarette smokers are four to 12 times as likely as nonsmokers to develop mouth and throat cancers; eight to 24 times as likely to develop lung cancer; nine to 25 times as likely to develop chronic obstructive lung disease; and 1.5 to three times as likely to develop coronary heart disease.

Furthermore, smoking-related diseases were concentrated among the heaviest cigar smokers in the Kaiser Permanente study. For those smoking fewer than five cigars a day—76 percent of the sample—only the difference in heart disease risk (20 percent) was statistically significant. Iribarren et al. did not ask the subjects about inhalation, which has been linked to higher risks in other studies, and they did not consider men who smoke a few cigars a month—the typical pattern, according to the NCI report—as a separate category.

More Accurate Coverage

Given the news media’s track record in this area, I expected reporters to hype the hazards found by the Kaiser Permanente study and ignore the differences between cigars and cigarettes. But for the most part, the coverage was much more accurate and responsible (though less conspicuous) than the stories that followed the NCI report, probably because the researchers themselves made it clear that cigars are not nearly so hazardous as cigarettes.

The Associated Press, whose story was picked up by several major newspapers, put the hazards of cigars in perspective, noting that “the risks aren’t as high as they are for cigarette smokers.” The Washington Post, which only last year said it was “probably a misconception” that “cigars are healthier than cigarettes because smoke is not inhaled to the same degree,” this time correctly cited that factor as the most likely explanation for the comparatively low risks found among cigar smokers.

My favorite story ran in The Hartford Courant under the appropriately reassuring headline, “Cigars’ Dangers Relatively Low/Moderate Users Face Only Slightly More Health Risks Than Nonsmokers.” The article quoted a local cardiologist who said: “If someone tells me they’re smoking one cigar a day, it would be hard for me to jump up and down and say you’re killing yourself and be intellectually honest. You are increasing your risk a little bit.”

Some reporters still don’t get it. “New findings give more weight to warnings that cigars can be at least as hazardous as cigarettes,” United Press International declared. If UPI’s science correspondent often leaps to such conclusions, she might do well in the long jump, but not in reading comprehension.

Unlike the UPI reporter, FTC Chairman Robert Pitofsky, who wants Congress to ban broadcast ads for cigars as well as require warning labels, seems to have taken a second, more careful look at last year’s NCI report. In an April 1998 comment to the Washington Post, he misinterpreted the monograph as saying that “regular cigar smoking is roughly as dangerous as cigarette smoking.” By contrast, when the FTC issued its recommendations in July 1999, he said, “We now know, based on the findings of the National Cancer Institute, that cigars, like other tobacco products, pose serious health risks.”

The significance of Pitofsky’s backpedaling did not register with everyone. According to the lead of an AP story on the FTC’s recommendations, “Federal regulators say they want to correct misperceptions that cigars are less dangerous than cigarettes.”

To be fair, it’s not surprising that reporters continue to make such mistakes, since public health officials are still pushing the false equation between cigars and cigarettes. Surgeon General David Satcher says the absence of federal warning labels (almost all cigars already carry California health warnings) “implies cigars are different and don’t carry the same risk.” They are, and they don’t.