Psyche, Science, and Society

Are youth switching from cigarettes to cigars?

November 23rd, 2005

In preparation for an article, a reporter has asked for my comments on a recent letter in the American Journal of Public Health on the risks of young people switching from smoking cigarettes to smoking cigars. The letter cited data from the New Jersey Youth Tobacco Survey indicating that males had a higher rate of current cigar than of cigarette use. Further, they cited data from the 2003 National Survey on Drug Use & Health which indicate that youth and females constitute a large fraction of those initiating [starting use of] cigars.

I was asked to comment because I have done extensive research on youth use of alternative tobacco products, namely cigars, bidis [small hand-rolled cigarettes imported from India, and, in the US, often given kid-friendly flavors like “chocolate raspberry”] , and kreteks [tobacco cigarettes flavored with clove extract]. Those interested in reading my papers on this topic can find them on my publications page.

What follows are the reporters questions and my slightly edited replies:

1. What do you think of these study findings? Do they seem reasonable?

This study raises an important issue: whether declines in youth cigarette smoking are accompanied by an increase in alternative tobacco use, including most notably, use of cigars. I shared this concern when I did my work. As the authors point out, tax law currently facilitates this substitution process by making alternative tobacco cheaper than cigarettes.

As to whether this substitution is occurring, I don’t know. Examining the 2003 National Survey on Drug Use & Health: Results reference it isn’t as clear as the authors indicate. The authors refer to the following statement:

Initiation of cigar smoking more than doubled between 1990 and 1998, reaching a peak of 3.7 million new users in 1998. Between 2000 and 2002, cigar initiates declined from 3.6 million to 3.0 million. Since 1990, youths under 18 have constituted an increasingly greater proportion of the number of new cigar smokers, from 23 percent in 1990 to 46 percent in 2002. During that period, the proportion of cigar initiates that was female also increased, from 24 to 45 percent.

However, the same report states:

Current cigar use among the three age groups also was unchanged between 2002 and 2003. The rate was 4.5 percent in both years among youths aged 12 to 17; 11.4 percent in 2003 and 11.0 percent in 2002 among young adults aged 18 to 25; and 4.5 percent in 2003 and 4.6 percent in 2002 among adults aged 26 or older.

These prevalence rates are more in line with those usually seen in recent years in household surveys [school-based surveys, for methodological reasons, typically report higher rates for prevalence of most substances, making the two types of surveys not directly comparable.]. The higher initiation rates among youths under 18 are of concern and should be tracked. However, the overall prevalence rates do not suggest a mushrooming problem so far.

The rates reported in the letter for the New Jersey Youth Tobacco Survey are anomalous, as far as I am aware [I have not followed all the individual state prevalence reports.] In the 2004 National Youth Tobacco Survey they found:

In 2004, a total of 28.0% of high school students reported current use of any tobacco product (Table 2). Cigarettes (22.3%) were the most commonly used product, followed by cigars (12.8%), smokeless tobacco (6.0%), pipes (3.1%), bidis (2.6%), and kreteks (2.3%).

However, looking at the stats by gender in the New Jersey Youth Tobacco Survey Table 2, we see, for males: current cigarettes use — 22.1 (Confidence Interval 2.7); current cigar use — 18.4 (CI: 1.8) and A female cigar rate of 7.5 (CI: 1.4).

Thus, New Jersey has a much male lower cigarette use than nationally [great for them!], but little difference on cigars. This pattern is consistent with the authors’ argument in the letter. One would suspect that the cigarette tax there, perhaps accompanied by other tobacco control efforts, are responsible for the lower cigarette rate. So, efforts [taxes and other tobacco control efforts] may be necessary to reduce cigar use.

However, the authors don’t present their confidence intervals, a measure of the precision of their prevalence rates. It seems likely that the male cigarette and cigar rates are not in fact, significantly different. In other words, the higher rate for cigars is likely just a chance finding, not really higher. Of course, an equal rate for cigarettes and cigars could still be a serious problem.

In order to evaluate the New Jersey findings, we will need similar data from other states, or another year’s survey data from New Jersey.

2. Why is cigar use among teens a growing problem?

We don’t know. Originally, it was thought that the allure of cigars, a la, Cigar Aficionado magazine was the reason. My research suggested that this was a factor only among suburban kids.

An other factor [often ignored by tobacco control folks who don't think much about other types of substance abuse] include the fact that cigars are often hollowed out and used to smoke marijuana [called 'blunts']. Interestingly, I found that Philly’s blunts were the most frequently smoked cigar brand by kids, both when smoking cigars, and when making blunts.

Finally, there is the price factor, raised by these authors. They are perfectly correct that it makes no sense to tax alternative tobacco at lower rates than cigarettes are taxed.

3. In terms of danger to health, how do cigars compare to cigarettes?

Dangerous, but possibly somewhat less so. The National Cancer Institute, in their Cigar monograph: Cigars: Health Effects and Trends, found that cigars are associated with most diseases that cigarettes are, with the partial exception of lung diseases. The latter is because cigars are usually not inhaled.

However, there is some anecdotal evidence that some kids may inhale cigars. This was the issue I most regretted exploring in my own research on this. If kids inhale cigars, then cigars may be as, or even more dangerous than cigarettes, as cigars are less likely to be filtered.

A related issue that I have no data on is the relative addictiveness of nicotine as received from cigars as compared to cigarettes. The biggest reason tobacco use among teens is such a concern, is not the immediate health risks, but the fact that nicotine is highly addictive. Studies show that a fraction of teens start showing withdrawal symptoms within weeks of initiating smoking. Thus, youth tobacco use sets the young person up for a potential of many years of tobacco use, leading to the variety of chronic diseases.

Another issue we do not know the answer to is how much nicotine is absorbed when cigars are used as blunts to smoke marijuana. Is it enough to begin the addictive process? I wish we knew.

If cigars are as addictive as cigarettes, they would also hold the potential to create long-term smokers, whether of cigars or of other forms of tobacco. If youth inhale cigars, this likely would increase the addictive potential. There are a number of “ifs” here, but we should be finding out.

4. Do you think public health folks are doing enough about the cigar problem? What more could be done?

No. There has been very little attention to cigars among public health folks. When I conducted my study, it was virtually the first study focused on alternative tobacco use. Many health educators and others were completely unaware of issues around alternative tobacco use. This needs to change. I think it is starting to change, but more needs to be done. I also think we need to learn more about effective tobacco control strategies for reducing cigar use.

5. Might there be any benefit to teens smoking cigars instead of cigarettes? (i.e., less exposure to tobacco, they’re less socially acceptable in some parts, etc.)

As to the exposure to tobacco, see my comments above. We simply don’t know enough about how kids use cigars to know if they’re getting less nicotine. Same about the relative social acceptability and its effects. On the other hand, young people are often attracted to substances because they are “forbidden”. We don’t know enough to know how these relative factors work out.

Entry Filed under: Public Health, Social Issues, Tobacco Control