Abstract
Objectives. We estimated annual mortality, years of potential life lost, and associated economic costs attributable to regular cigar smoking among US adults aged 35 years or older.
Methods. We estimated cigar-attributable mortality for the United States in 2010 using the Centers for Disease Control and Prevention’s Smoking-Attributable Mortality, Morbidity, and Economic Costs methodology for smoking-related causes of death. We obtained cigar prevalence from the National Adult Tobacco Survey, relative risks from the Cancer Prevention Studies I and II, and annual US deaths from the National Vital Statistics System. We also estimated the economic cost of this premature mortality using the value of a statistical life-year.
Results. Regular cigar smoking was responsible for approximately 9000 premature deaths and more than 140 000 years of potential life lost among US adults aged 35 years or older in 2010. These years of life had an economic value of approximately $23 billion.
Conclusions. The health and economic burden of cigar smoking in the United States is large and may increase over time because of the increasing consumption of cigars in the United States.
Cigar use and its accompanying health risks are a significant and growing public health problem in the United States. From 2000 to 2011, consumption of cigars more than doubled in the United States, from slightly less than 6.2 billion in 2000 to more than 13.7 billion in 2011.1 By contrast, cigarette consumption decreased by 33%, from 435.6 billion to 292.8 billion during this period.
The cigar category includes a variety of products, including little cigars, cigarillos, and large cigars. Small cigars such as little cigars and cigarillos are sold in a variety of packages and sizes, some of which resemble cigarettes.2 Many small cigars also contain characterizing flavors, such as fruit, chocolate, and alcohol,3 and are taxed at a lower rate than are cigarettes, which can increase their appeal to young people. Within the cigar category, some products are experiencing faster growth in use than are others. According to the Centers for Disease Control and Prevention (CDC),1 consumption of small cigars increased almost 240% between 2003 and 2008, from 2.47 billion to 5.88 billion units. Sales of large cigars increased by 25% during this period, from 4.53 billion to 5.66 billion units.
Cigar use is most common among young people. The CDC, on the basis of National Youth Tobacco Survey data, estimated that 12.6% of US high school students in 2012 had smoked a cigar in the past 30 days.4 Among high school males, an estimated 16.7% had smoked a cigar in the past 30 days compared with 16.3% who had smoked cigarettes during this period. Cigars were also found to be the most commonly used tobacco product among African American high school students. Results from CDC’s National Adult Tobacco Survey (NATS) for 2009–20105 showed that cigar smoking prevalence among adults was highest among those aged 18 to 24 years (15.9%) and 25 to 44 years (7.2%).
Cigars pose significant health risks to users. Cigar smoke contains many of the same toxic and carcinogenic compounds as does cigarette smoke and may have higher concentrations of some constituents, such as nitrogen oxide, ammonia, and tobacco-specific nitrosamines.6 Research has found that cigar smoking increases the risk of dying from causes such as cardiovascular disease, lung cancer, and oral cancer.7,8 In general, differences in risk between cigarettes and cigars are driven primarily by differences in smoking behavior such as frequency of use and depth of inhalation.
The risks of upper aerodigestive tract cancers such as oral and esophageal cancer are particularly elevated for cigar smokers and comparable to risks for cigarette smokers.7,8 The CDC has previously used its Smoking-Attributable Mortality, Morbidity, and Economic Costs methodology to estimate that cigarette smoking is responsible for approximately 480 000 deaths in the United States each year.9,10 Similar estimates, however, are currently unavailable for cigar smoking.
We employed an approach similar to the Smoking-Attributable Mortality, Morbidity, and Economic Costs methodology to quantify the population health burden of regular cigar smoking in the United States. In doing so, we have presented for the first time, to our knowledge, estimates of the overall mortality and economic costs owing to regular cigar smoking for the US population.
METHODS
We estimated the health and economic burden of regular cigar smoking in the United States by first estimating the cigar smoking–attributable fraction (SAF) of deaths. We estimated the SAF by cause for gender and age group (younger than 65 years and 65 years or older) using the standard population attributable risk formula11:
 |
where p1 is the proportion of current cigar smokers in the population, p2 is the proportion of former cigar smokers, RR1 is the relative risk (RR) for current cigar smokers relative to never smokers, and RR2 is the RR for former cigar smokers relative to never smokers.
We obtained current cigar smoking prevalence from NATS data for 2009–2010. The CDC conducted the survey as a nationally representative, random-digit-dial household survey of more than 100 000 US adults during these years. NATS was used as the source for cigar smoking prevalence because the assessment of cigar use included large cigars, cigarillos, and little cigars and provided information on number of days used. We estimated current cigar smoking prevalence on the basis of response to the following question: “During the past 30 days, that is, since [DATE FILL], on how many days did you smoke cigars, cigarillos, or very small cigars that look like cigarettes?”
We restricted our main analysis to current cigar smokers who reported smoking cigars on at least 15 of the past 30 days to estimate cigar smoking–attributable mortality (SAM) among regular cigar smokers. We chose this threshold because it is generally consistent with the RRs we used in our analysis, which we calculated for regular cigar smokers. It is also possible that occasional cigar smokers have increased mortality risks, so we have included SAM estimates from prevalence estimates on the basis of smoking cigars on at least 1 of the past 30 days as a sensitivity analysis, as well as a more conservative estimate with prevalence on the basis of smoking cigars on all the past 30 days.
We estimated cigar smoking prevalence by gender and age group using the appropriate NATS sample weights and stratum information. Former cigar smoking prevalence data were not available in NATS, so we estimated this prevalence on the basis of the ratio of former to current cigar smoking prevalence from 2010 National Health Interview Survey data, calculated for persons who reported smoking at least 50 cigars in their lifetimes.
We obtained estimates of mortality RRs for cigar smokers from the American Cancer Society’s Cancer Prevention Studies (CPS) I and II. CPS-I was conducted between 1959 and 1972 and included more than 1 million participants.7 CPS-II began in 1982 and included more than 1.2 million participants, with follow-up through 1994.12 When mortality RR estimates were available from CPS-II, we used these data in preference to those of CPS-I, because CPS-II relative risks are more recent and representative of current cigar smoking risks than are CPS-I data. CPS-II relative risks are also used in the CDC’s Smoking-Attributable Mortality, Morbidity, and Economic Costs methodology.9
We estimated CPS-II relative risks from mortality follow-up for regular cigar smokers who had never regularly smoked cigarettes or a pipe (“primary cigar smokers”), compared with never smokers, who had never regularly smoked cigarettes, cigars, or a pipe. The CPS-II questionnaire defined regular smoking as previously having smoked a cigarette, cigar, or pipe at least once per day for 1 year.12,13 We estimated CPS-II relative risks as hazard ratios, adjusting for age, alcohol consumption, and smokeless tobacco use for men aged 30 years or older.
CPS-I relative risks, although less recent, have the advantage of coming from a study with a larger number of current cigar smokers who had never regularly smoked cigarettes or a pipe (n = 15 191) compared with those of CPS-II (n = 7888). CPS-I relative risks come from data from primary cigar smokers compared with never smokers.7 We estimated the CPS-I relative risks as age-standardized rate ratios from data for White men aged 35 years or older.
CPS-II relative risks have been reported for lung, oral, laryngeal, esophageal, pancreatic, and bladder cancers12 and coronary heart disease.13 CPS-I relative risks have been reported for lung, oral, laryngeal, esophageal, pancreatic, and bladder cancers as well as chronic obstructive pulmonary disease (COPD), cerebrovascular disease, and aortic aneurysm.7 We used CPS-II relative risks for lung, oral, and laryngeal cancer as well as coronary heart disease, which were statistically significant and elevated for current cigar smokers. We also included CPS-II relative risks for esophageal and pancreatic cancer. These risks just missed statistical significance in CPS-II data, with the lower bound of the 95% confidence intervals (CIs) for each cause being 0.9, and were statistically significant in CPS-I data.
The International Agency for Research on Cancer has linked all these cancers to cigar smoking.8 Increased RR for aortic aneurysm was also statistically significant in CPS-I data, and we included this cause. The RR for COPD was elevated but not statistically significant in CPS-I data (RR = 1.42; 95% CI = 0.96, 2.03), so we did not include COPD in our main analysis but did conduct a sensitivity analysis that included this cause.
The RR of COPD was found to be elevated (RR = 1.45; 95% CI = 1.10, 1.91) in cigar smokers in an analysis of participants in a Kaiser Permanente cohort study,14 and cigar smoking has been found to be associated with decreased lung function and increased airway obstruction.15 It is also possible that inhalation among cigar smokers may have generally increased over time. The use of little cigars and cigarillos has increased over time, and inhalation of these products may more closely resemble that of cigarettes.16 We therefore conducted a sensitivity analysis in which we used CPS-I relative risks for moderate to deep inhalation for the smoking-related causes included in our main analysis.
We used CPS-II relative risks for former cigar smokers for the causes for which we used CPS-II data. RRs for former cigar smokers are not available from CPS-I data. We calculated these risks on the basis of the ratio of excess RRs for current and former cigar smokers by cause from CPS-II data for the causes for which these data are available. We used the ratio of current to former cigarette smoker excess RRs from CPS-II data for aortic aneurysm, cerebrovascular disease, COPD, and all former RRs for moderate to deep inhalation.
We applied these RRs to all regular cigar smokers as an estimate of the mortality effects of cigar smoking. It is possible that RRs owing to cigar use may vary for cigar smokers who also currently or previously smoked cigarettes. We therefore also conducted a sensitivity analysis in which we excluded current dual cigar and cigarette smokers from cigar smoking prevalence estimates to assess the impact of this group of smokers on mortality estimates. We defined current cigarette smokers as survey participants who reported that they had smoked at least 100 cigarettes in their lives and currently smoked some days or every day.
We estimated SAM by multiplying the smoking-attributable fractions by the number of deaths for each cause by gender and age group. We obtained the number of deaths for cigar smoking–related causes for the United States in 2010 by gender and age group (35–44, 45–54, 55–64, 65–74, 75–84, and ≥ 85 years) from the National Vital Statistics System.17
We estimated years of potential life lost (YPLL) owing to cigar smoking by multiplying the SAM by the average estimated remaining years of life for each gender and age group. We obtained estimated remaining years of life for the midpoint of each age group from US life tables from the National Center for Health Statistics.18
Valuing the Economic Burden Associated With Cigar Smoking
We valued the burden associated with cigar smoking using 2 related approaches: the value of a statistical life-year (VSLY) and the value of a statistical life (VSL). The VSL and VSLY are commonly used to measure the economic benefits of reductions in the risk of premature death. We applied the VSL to each cigar-attributable death, whereas we applied the VSLY to years of life lost owing to cigar smoking. We have presented VSLY-based estimates in the main analysis because the VSLY approach factors in the age of death. We have also presented VSL-based estimates as a sensitivity analysis for purposes of comparison.19,20
To calculate VSLY, we calculated the present value for each year of potential life lost by age of death and then multiplied this quantity by the number of smoking-attributable deaths in each age group. We calculated these results using a life-year value of $200 000 (the midpoint of 3 VSLY estimates used in the literature),21–23 which was updated to $216 325 in 2010. We used a social discount rate of 3% in calculating the life-year value, consistent with Food and Drug Administration practice.22
To estimate the burden associated with lives lost owing to cigar smoking, we used a VSL of $8.23 million ($6.5 million updated to 2010 dollars)24,25 and multiplied this amount by the number of estimated cigar smoking–attributable deaths.
Sensitivity Analyses
We conducted a range of sensitivity analyses to examine the effects of differences in values for particular inputs on estimates of SAM. In particular, we examined the impact of different definitions of cigar smoking (any past 30-day use, daily use), the application of RRs for moderate to deep inhalation of cigars, the inclusion of COPD as a cigar-attributable disease, and the exclusion of dual cigarette and cigar smokers from the analysis. We intend results from these analyses to indicate the sensitivity of estimates to changes in input values in which considerable uncertainty exists; we do not intend them to represent lower or upper bounds of estimates.
RESULTS
Table 1 presents estimated cause-specific RRs for cigar smoking by smoking status and depth of inhalation. As expected, the RRs are greater for current cigar smokers than for former cigar smokers as well as for cigar smokers who inhale moderately to deeply than for those who do not.
TABLE 1—
Mortality Relative Risks for Primary Cigar Smokers by Cause, Smoking Status, and Inhalation Depth: National Adult Tobacco Survey, United States, 2009–2010
| Overall |
Moderate to Deep Inhalation |
|||
| Cause (ICD-10 Code) | Current Cigar Smokers | Former Cigar Smokers | Current Cigar Smokers | Former Cigar Smokers |
| Malignant neoplasms | ||||
| Lip, oral cavity, pharynx (C00–C14)a | 4.0 | 2.4 | 27.9 | 13.6 |
| Esophagus (C15)a | 1.8 | 1.3 | 14.8 | 6.2 |
| Pancreas (C25)a | 1.3 | 1.1 | 2.3 | 1.4 |
| Larynx (C32)a | 10.3 | 6.7 | 53.3 | 33.1 |
| Trachea, lung, bronchus (C33–C34)a | 5.1 | 1.6 | 4.9 | 1.6 |
| Cardiovascular diseases | ||||
| Coronary heart disease (I20–I25)c | 1.4 | 1.0 | 1.4 | 1.0 |
| Aortic aneurysm (I71)b | 1.8 | 1.3 | 5.0 | 2.6 |
| Respiratory disease | ||||
| COPD (J40–J42, J43, J47)b | 1.4 | 1.4 | 4.5 | 4.2 |
Note. COPD = chronic obstructive pulmonary disease; ICD-10 = International Classification of Diseases, 10th Revision (Geneva, Switzerland: World Health Organization; 1992).
Overall relative risks ([RR] current and former) are from the Cancer Prevention Studies (CPS)-II, current smoker moderate to deep inhalation RRs are from the CPS-I, and former moderate to deep inhalation RRs are estimated.
Overall current RRs are from the CPS-I, and current moderate to deep inhalation RRs are from the CPS-I. Former estimates for both overall RRs and moderate to deep inhalation RRs are estimated.
Overall RRs (current and former) are from the CPS-II and are age-adjusted for those aged 35–74 years; the relative risk for those aged 75 years or older was not elevated.13 The current smoker moderate to deep inhalation RR is from the CPS-I and the former moderate to deep inhalation RR is estimated.
Table 2 presents cigar smoking prevalence estimates by gender and age for the United States in 2009 to 2010 by days smoked cigars in the past 30 days. Prevalence was consistently higher among men than among women by age group and prevalence definition.
TABLE 2—
Cigar Prevalence by Days Smoked Cigars in Past 30 Days: National Adult Tobacco Survey, United States, 2009–2010
| Gender and Age Group | ≥ 15 Days, % (95% CI) | ≥ 1 Days, % (95% CI) | 30 Days, % (95% CI) |
| Men | |||
| 35–64 y | 1.4 (1.1, 1.7) | 8.3 (7.6, 9.0) | 0.9 (0.7, 1.1) |
| ≥ 65 y | 1.0 (0.7, 1.3) | 3.4 (2.9, 3.9) | 0.8 (0.6, 1.0) |
| Women | |||
| 35–64 y | 0.4 (0.2, 0.5) | 2.3 (2.0, 2.6) | 0.3 (0.2, 0.4) |
| ≥ 65 y | 0.1 (0.0, 0.1) | 0.6 (0.4, 0.8) | 0.1 (0.0, 0.1) |
Note. CI = confidence interval.
Table 3 presents results from the main analysis of the mortality and economic burden of cigar smoking. In 2010, regular cigar smoking was responsible for approximately 9000 premature deaths among US adults aged 35 years or older. Cancer of the trachea, lung, and bronchus was the leading cause of premature death owing to regular cigar smoking, followed by cancers of the larynx and lip, oral cavity, and pharynx. Estimates are considerably higher for men than for women, reflecting the higher prevalence of regular cigar use among men. These deaths represented almost 140 000 YPLL (117 440 for men and 22 284 for women), representing an average of 15.1 years of life lost per death (14.3 for men and 22.0 for women). Table 3 also shows that the loss of these years of life represented a monetary loss of $22.9 billion ($19.5 billion for men and $3.4 billion for women), on the basis of VSLY.
TABLE 3—
Smoking-Attributable Mortality, Years of Potential Life Lost, Value of Statistical Life Years, and Value of Statistical Life Resulting From Regular Cigar Smoking: National Adult Tobacco Survey, United States, 2009–2010
| Men |
Women |
|||||
| Cause | SAM | YPLL | VSLY, $ Thousands | SAM | YPLL | VLSY, $ Thousands |
| Total | 8234 | 117 440 | 19 464 676 | 1012 | 22 284 | 3 405 408 |
| Malignant neoplasms | ||||||
| Lip, oral cavity, pharynx | 502 | 7528 | 1 224 637 | 44 | 1018 | 152 334 |
| Esophagus | 253 | 3626 | 599 998 | 11 | 239 | 36 684 |
| Pancreas | 148 | 1914 | 321 262 | 23 | 473 | 73 413 |
| Larynx | 765 | 11 151 | 1 843 728 | 43 | 956 | 145 636 |
| Trachea, lung, bronchus | 6062 | 84 016 | 14 023 126 | 810 | 17 577 | 2 699 599 |
| Cardiovascular diseases | ||||||
| Coronary heart disease | 362 | 7613 | 1 181 679 | 66 | 1711 | 250 594 |
| Aortic aneurysm | 142 | 1592 | 270 247 | 15 | 310 | 47 148 |
Note. SAM = smoking-attributable mortality; VSL = value of statistical life; VSLY = value of statistical life years; YPLL = years of potential life lost. Main analysis: smoked ≥ 15 days in past 30 days.
Table 4 presents similar results from a series of sensitivity analyses of the impact of varying a single data input at a time on SAM estimates. Changing prevalence estimates to include any cigar smoker who reported smoking at least 1 day in the past 30 days, while keeping the main set of CPS-II relative risks, increases estimates of SAM to more than 32 000 deaths, representing more than 545 000 YPLL. These years of life have an economic value of $87.7 billion on the basis of VSLY. Restricting cigar prevalence to everyday smokers reduces estimates of SAM to just more than 7000 deaths and just more than 100 000 YPLL with an economic value of $17.2 billion.
TABLE 4—
Sensitivity Analyses of Smoking-Attributable Mortality, Years of Potential Life Lost, Value of Statistical Life Years, and Value of Statistical Life Resulting From Cigar Smoking: National Adult Tobacco Survey, United States, 2009–2010
| Men |
Women |
|||||||
| Sensitivity Analysis | SAM | YPLL | VSLY $ Thousands | VSL $ Thousands | SAM | YPLL | VLSY $ Thousands | VSL $ Thousands |
| Main analysis | 8234 | 117 440 | 19 464 676 | 67 773 375 | 1012 | 22 284 | 3 405 408 | 5 781 843 |
| Smoked cigars at least 1 day in past 30 d | 27 462 | 431 306 | 70 045 606 | 226 037 457 | 5305 | 114 929 | 17 638 118 | 43 665 017 |
| Smoked cigars all 30 d in past 30 d | 6340 | 86 497 | 14 477 903 | 52 184 018 | 847 | 17 802 | 2 754 032 | 3 571 587 |
| Moderate to deep inhalation RR (smoked ≥ 15 d in past 30 d) | 16 471 | 224 391 | 37 081 369 | 130 451 812 | 1778 | 38 616 | 5 904 888 | 14 634 572 |
| Including COPD (smoked ≥ 15 d in past 30 d) | 9803 | 132 568 | 22 154 136 | 80 687 685 | 1230 | 26 055 | 4 013 815 | 10 124 029 |
| Excluding dual cigarette and cigar users | 5042 | 71 237 | 11 830 979 | 41 500 286 | 169 | 4168 | 620 432 | 1 391 025 |
Note. COPD = chronic obstructive pulmonary disease; RR = relative risk; SAM = smoking-attributable mortality; VSL = value of statistical life; VSLY = value of statistical life years; and YPLL = years of potential life lost.
Applying RRs for moderate to deep inhalation to regular cigar smokers increases estimated SAM to more than 18 000 deaths, representing more than 263 000 years of life lost with an economic value of $43.0 billion on the basis of VSLY. Including COPD as a cause increases estimates of cigar SAM to approximately 11 000 deaths and almost 159 000 years of life lost, representing an economic value of $26 billion. Excluding dual users results in a decrease in the estimate of cigar SAM to 5211 deaths and estimates of YPLL to about 75 405 years, representing an economic value of $12.4 billion. As an additional sensitivity analysis, we calculated the economic burden of each of the estimates of cigar smoking mortality using the VSL, for which the burden increased 3- to 4-fold across all analyses (Table 4).
DISCUSSION
We estimated that regular cigar smoking was responsible for approximately 9000 premature deaths and almost 140 000 YPLL among US adults aged 35 years or older in 2010. The economic cost on the basis of years of life lost is estimated to be almost $23 billion annually. Lung cancer was the leading cause of premature death owing to regular cigar smoking, followed by oral cancers. Mortality estimates are considerably higher for men than for women, reflecting the higher prevalence of regular cigar use among men.
These estimates reflect only some of the health and economic costs of cigar smoking and exclude some important effects on the population. First, the analyses are restricted to regular cigar smokers, so the estimates do not account for the health and economic effects of less regular or occasional cigar use. Second, the estimates do not include the health and economic impacts of cigar smoking on disease and disability even though the causes of death included in our study are associated with a considerable morbidity burden from cigars.14 Third, the estimates we have presented correspond to regular cigar smokers themselves and do not include deaths or disease caused by secondhand smoke exposure from cigars.
Fourth, the analyses include causes for which RRs were statistically significant in CPS-I or CPS-II data, but there may be other causes of death attributable to cigar smoking. The International Agency for Research on Cancer8 has found evidence that additional cancers such as bladder cancer and stomach cancer are linked with cigar smoking, although the sample sizes of relevant cases can be small in studies. Finally, we did not attempt to estimate the economic impacts from increased health care costs and expenditures caused by premature morbidity and mortality.
Our results are subject to certain limitations. First, there are considerable uncertainties in the RR estimates for cigar smoking. The RRs, particularly those from the CPS-I, come from an earlier period, when patterns of cigar use, frequency, and duration may have differed from more recent trends. Because CPS-I and II risks come from regular users, we restricted our analysis to those who smoked cigars at least every other day on average. However, CPS-I data demonstrate that cigar RRs are most affected by differences in frequency of use and depth of inhalation.7 Changes in these factors among the population of regular cigar smokers in the United States will produce changes in RRs over time.
We also do not have separate cigar RRs by cigarette smoking status, which could vary. For example, current dual cigarette and cigar smokers may have lower excess risk from cigars, because they also smoke cigarettes and may therefore smoke fewer cigars on average, or they may have higher excess risk, because of their greater tendency to inhale when smoking cigars because of their experience with cigarette smoking. Similarly, studies have shown that cigar smokers who were former cigarette smokers (secondary cigar smokers) are more likely to report inhaling cigar smoke than are primary cigar smokers.26 This greater inhalation among secondary cigar smokers could increase their mortality risk and lead to downward bias in our mortality estimates.
Another limitation is the lack of information on use and RRs for little cigars and cigarillos compared with traditional, large cigars. This issue may have a greater effect on estimates over time, because small cigars tend to resemble cigarettes in size and shape and may be inhaled more deeply, like cigarettes, thus producing greater harm for the smoker.27,28 The design of cigars, particularly small cigars, may have also changed over time to make the products more toxic and thus more harmful to smokers.
RRs for some of the causes may also be imprecisely estimated because of small sample sizes, even in large cohort studies such as CPS-I and II. RRs are also only available for men, because of limited cigar smoking among women in the past, and we applied these risks to both men and women. The effect of any differences in RRs for women on population harm estimates, however, should be minimal, because of the low prevalence of regular cigar use in women. Finally, the CPS-I and CPS-II study populations were overwhelmingly White, but we applied the RRs to all regular cigar smokers, regardless of race/ethnicity.
Our findings indicate that regular cigar smoking is responsible for approximately 9000 premature deaths and 140 000 YPLL on an annual basis, representing an economic loss of $22.9 or $73.6 billion depending on the method used to value the burden. Cigar smoking thus represents an important public health issue that significantly affects the health and well-being of millions of Americans. Moreover, these health and economic costs could increase over time because of the increasing consumption of cigars in the United States, unless efforts to prevent cigar smoking initiation and increase cigar smoking cessation are implemented and successful.
Acknowledgments
This article was funded by the Food and Drugs Administration Center for Tobacco Products (contract HHSF223201110005B/HHSF22311006).
Note. The views and opinions expressed in this article are those of the authors only and do not necessarily represent the views or official policy or position of the US Department of Health and Human Services or any of its affiliated institutions or agencies.
Human Participant Protection
This study used aggregate secondary data and was thus exempt from institutional review board review.
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