(71) VOS-BUT, C., RUMKE, P. IrnmunoglobuIin concentrations, PHA reac- tions of lymphocytes ilr vitro, and certain antibody titers of healthy smokers. Jaarboek Karkerondenoek Kankerbestruding 19: 49-53, 1969. (72) WFARY, P. E.. WOOD, B. T. Allergic contact dermatitis from tobacco smoke residues. Journal of the American Medical Association 208(10): 1905-1906. June 9, 1969. (75) WESTCC~~~, F. H., WFUGHT, I. S. Tobacco allergy and thromboangiitis obliterans. Journal of Allergy 9: 555-564, 1938. (74) YEAG~ H., JR Alveolar cells: Depressant effect of cigarette smoke on protein synthesis. IN: Proceedings of the Society for Experimental Biology and Medicine 131: 247-250. December 26, 1968. (75) ZUSSM~, B. Ed. Atopic symptoms caused by tobacco hypersensitivity. Southern Medical Journal 61(11) : 1175-1179, November 1968. (76) ZUSSMAN. B. M. Tobacco sensitivity in the allergic patient. Annals of Allergy 28(8) : 3713'77, August 1970. Chapter 9 Tobacco Amblyopia Source: 1971 ReDOrl, Chapter 7, ,,ages 431 - 438. 527 Contents Summary and conclusions . _ . _ . . . . _ . . . . . . _ . . . . . . . . . . . . 532 References . ..___._.__.............................. 532 529 TOBACCO AnmLyom Tobacco amblyopia (tobacco-alcohol amblyopia) is that syn- drome of visual failure occurring in association with the use of tobacco, with or without the concurrent use of alcohol, and with or without concurrent nutritional deficits. The disease has a subacute onset, leading to a loss of visual acuity and coIor perception (12). It is characterized by centrocecal scotomas which are bilateral but not necessarily symmetrical and which have sloping diffuse edges and by the presence of nuclei of denser visual loss within the large scotomas (22,~`). Such visual impairment is not unique to tobacco amblyopia. as it is also seen in neurodegenerative disorders, such as Leber's hereditary optic atrophy (7, 25). Clinical information on tobacco amblyopia has appeared in nu- merous articles throughout the past century. This information has been reviewed by Silvette, et al. (17) and, more recently, by Dunphy (5) _ Pure tobacco amblyopia (TA), that is amblyopia unassociated with excessive alcohol intake or the exposure to other toxins, is rarely seen in the United States today (12). Walsh, et al. (23) have observed that when TA is found it is usually present in association with nutritional or idiopathic vitamin deficiencies. Victor (29) recently observed that the type of visual defect seen in tobacco amblyopia may be found in clinical circumstances in which tobacco is clearly not a causative factor. He questions whether TA is distinguishable from other forms of ambIyopia. The prevalence of this disorder has been variously estimated in the past at from 0.5 to 1.5 percent of all eye clinic patients (20,23). However, currently in the United States, it appears to be a rare condition. Silvette, et al. (17) have observed that the incidence of ~~ tobacco amblyopia appears to have decreased substantially during the past decades. Other authors (3, 15) have also commented on this trend. Although reference has been made to the increased fre- quency of certain types of tobacco usage in patients with this dis- order, adequate popuiation studies with proper controls have yet to be performed. The association of this disorder with the use of tobacco is strengthened by the frequent clinical observations of improvement following the cessation of smoking although improve- ment has been noted by some to occur without cessation. Research into the pathogenesis of tobacco amblyopia has cen- 531 tered upon the interrelationships of cyanide metabolism, vitamin B II, and other vitamin deficiencies. Three reviews of this material have recently appeared (I, 12, ~`2 ). Xumerous studies reviewed in these articles suggest that tobacco amblyopia may result from the incomplete detoxification of the cyanide present in tobacco smoke. This failure of detoxification may stem from or be intensified by inadequate dietary intake of necessary nutritional factors. This may be the reason for the association of this disorder with exces- sive alcohol intake and with its related nutritional deficits (2, A, 6, 8,9,10,11,13,1~,16,1S, 19,91,2:,96,27,"8). SUMhIARY AND CONCLUSIONS Tobacco amblyopia is presently a rare disorder in the United States. The evidence suggests that this disorder is related to nutri- tional or idiopathic deficiencies in certain detoxification mechan- isms, particularly in handling the cyanide component of tobacco smoke. REFERENCES (I) CASADIXG MEDICAL XSSOCI~TION JOURNAL. Tobacco amblyopia. (Edi- torial) Canadian hIedica1 Association Journal lOZ(4) : 420, February 28. 1970. (2) CHI~HOLX, I. A., BROSTE-STEWART. J., FOULDS, W. S. Hydroxocobalamin versus cyanocobalamin in the treatment of tobacco amblyopia. Lancet 2(7513) : 450451, August 26, 1967. (3) DARBY, P. IV.. WILSON, .J. C>-anide, smoking, and tobacco amblyopia. Observations on the cyanide content of tobacco smoke. British Journal of Ophthalmology 51(5) : 336-338, May 196'7. (4) DREYFL'S, P. M. Blood transketolase levels in tobacco-alcohol amblyopia Archives of Ophthalmology 74(S) : 617-620, November 1965. (5) DU.VPHY. E. B. Alcohol and tobacco amblyopia: A historical survey. American Journal of Ophthalmology 68(4) : 569-578, October 1969. (6) FOULDS, IV. S., BROKTE-STEWART. J. M., CHIsHoLhl, I. A. Serum thio- cyanate concentrations in tobacco amblyopia. Nature 218(5141) : 586, May 11. 1968. (7) Foows. W. S.. CANT, J. S., CHISHOLM, r. A., BRONTE-STEWART J., WILSOS. J. Hydrorocobalamin in the treatment of Leber's hereditary optic atrophy. Lancet l(7548) : 896-897, April 27, 1968. (8) FOIXX. W. S., CHISHOLM, I. A.. BRONTE-STEWART, J., WILSON, T. M. Vitimin B ,:' absorption in tobacco antblyopia. British Journal of Ophthalmology 53 (6) : 393-397, June 1969. (9) FOULDS. W. S., CHisHoLhl, I. A., BRON?E-STEWART, J., WILSON, T. ai. The optic neuropathy of pernicious anemia. Archives of Ophthalmol- ogy 63(4) : X7-432, October 1969. (10) FE'JIAG, A. G., HEXTOS, J. 31. The aetiology of retrobrrlbar neuritis in Addisonian pernicious anaemia. Lancet l(7183) : 90%911, April 29, 1961. 532 (II) HEATON, J. M., MCCORMICK, A. J. A., FREE~IAY. A. C. Tobacco ambly* pia: A clinical manifestation of vitamin-B,, deficiency. I,ancet Z(7041) : 286290, August 9, 1958. (1") KNOX, D. L. Neuro-ophthalmology. Archives of Ophthalmology 83(l) : 103-127, January 1970. (13) LINDSTRAND, K., WILSON, J., Ma-rra~ws, D. M. Chromatography and microbiological assay of vitamin B,, in smokers. British Medical Journal 2 (5520) : 988-990, October 22, 1966. (14) LINNELL, 3. C., Sarrw. A. D. M., SMITH, C. I,.. WILSOS. J., MATTHEWS, D. M. Effects of smoking on metabolism and excretion of vitamin B,?. British Medical Journal Z(5599) : 215-216, April 27, 1968. (15) SCIIEPENS. C. L. Is tobacco amblyopia a deficiency disease- Transactions of the Ophthalmological Society of the United Kingdom 66: 309-331, 1946. (16) SCHIEVELBEIN, H.. WERLE, E., SCHULZ. E. K.. B~UMEJSTER. R. The influ- ence of tobacco smoke and nicotine on thiocyanate metabolism. Naunyn-Schmiedebergs Archiv fur Pharmakologie und Experimentelle Pathologic 262(3) : 358-365, February 5, 1969. (17) SILVEETTE, II., HUG, H. B., LARSON, P. S. Tobacco amblyopia. The evolu- tion and natural history of a "tobaccogenic" disease. American Journal of Ophthalmology 50(l) : 71-100, January 1960. (18) ShIITH. A. D. hr. Retrobulbar neuritis in Addisonian pernicious anae- mia. (Letter) Lancet l(7184) : 1001-1002, &lay 6, 1961. (19) S~SITH, A. D. BI., DUCKETT, S. Cyanide, vitamine B,Z. experimental demyelination and tobacco amblyopia. British Journal of Experimen- tal Pathology 46(6) : 615-622, December 1965. (20) TRAQUAIR, H. M. Toxic amblyopia, including retrobulbar neuritis. Trans- actions of the Ophthalmological Society of the United Kingdom 50: 351385, 1930. (92) VICTOR, M. Tobacco-alcohol amblyopia. A critique of current concepts of this disorder, with special reference to the role of nutritional deficiency in its causation. Archives of Ophthalmology 70(3) : 313-318, Septem- ber 1963. (22) VICTOR, M. Tobacco amblyopia, cyanide poisoning and vitamin B,, de- ficiency. A critique of current concepts. Chapter 3. IS: Smith, J. L. (Editor) Neuro-Ophthlamology. Symposium of the University of Miami and the Bascom Palmer Eye Institute. Hallandale, Florida, Huffman Publishing Co., 1970. pp. 33348. (23) VVUSH, F. B., HOYT, W. F. (Editors) Neurotoxic substances affecting - the visual and ocular motor systems. Chapter 15: IN: Clinical Neuro- Ophthalmology. Volume 3, 3rd Edition. Baltimore, The Williams & Wilkins Company, 1969. pp. 2613-2616. (fr) WATSON-WILLIAMS, E. J., BOTTOMLEY, A. C., AINL~Y, R. G., PHILLIPS, C. I. Absorption of vitamin B,3 in tobacco amblyopia. British Journal of Ophthalmology 53(8) : 549-562, August 1969. (25) WILSON, J. Leber's hereditary optic atrophy: A possible defect of cya- nide metabolism. Clinical Science 29 (3) : 5055515, December 1965. (26) WILSON, J.. MAnHEWS, D. M. Metabolic inter-relationships between cyanide, thioryanate and vitamin B,l in smokers and nonsmokers. Clinical Science 31(l) : l-7, January 1966. 533 (27) Woti~s. F.. PICARD. C. W. The role of \-itsmin R,, ill human nutrition. Clinical Nutrition 3(5) : 3X-390. September-October 1955. (28) WYSDFR, E. L... HOFFMASN. I). Certain constituents of tobacco products. Chapter 9. I<. Vapor phase of tobacco smoke. IS: \Vynder. E. I,., Hoffmann, 1). (I.:diton). `l`ol~~co ;LII~ To\~~co Smoke. Studies in FIX- perimental Caxinogenesis. New York, Academic Press, 1367. pp. 451453. 534 Chapter 10 Pipes and Cigars Source: 1973 Report, Chapter 6. pages 165 236 535 contents Introduction- ________ ____---- ____-_-_____-_ - __-__- _ ---_-- The Prevalence of Pipe, Cigar, and Cigarette Usage __-_-_____ The Definition and Processing of Cigars, Cigarettes, and Pipe Tobaccos_________________-____-__-_-____------------- Chemical Analysis of Cigar Smoke------------------------- hlortality Ocerall~~lortality-__- ________ --_-_--_-__-_- ____ - ______ Mortality and Dose-Response Relationships AmountSrnoked~~~~~~~---..--------------------.. Inhalation__--__--_-____________________-------- Specijic Causes aj;Ifortality------- ____ -___-_-- ______-_ Cancer__-__-__-_---_-_____-__---_-_----_---_-_- Cancer of the Lip--- _______ - ____ --__--_----___-- Oral Cancer----_--------- _____- - __________-_-__ Cancer of the Larq-nx_-__----_----_------ _-__ -___ Cancer of the Esophagus---------------- _____ -_-_ LungCancer_------- _____ -_------_--_-_-----____ Tumorigenic Activity---_------------------------ Experimental Studies _____ -_-_--- _________ -_-_-__ Cardiovascular Diseases_---_ -_-_- ____ -_ _-_ ____ -_ _ Chronic Obstructive Pulmonary Disease (COPD)-- _ _ Gastrointestinal Disorders--_-------------- __ -_-__ Little Cigars _____ - -_____ -___- ______ -----------___-_-_--- Conclusions-_--_________________________-~----~-~----~-- References -_________-_____ -_--____---_-_ ________________ List of Figures Figure I.--Inhalation among pipe smokers by nge- _______ -__ Figure 2.-Inhalation among cigar smokers by age--Ham- mond______--_____-.-____________________--~--------- Figure Z.--Depth of inhalation among cigarette smokers by age-~fammond-___-_____________________--------~---- Figure *%.-Percent distribution of 130 brands of cigarettes and 25 bmnds of little cigars by tar content------- _____ -__-_- Page 543. 543 545 547 549 550 553 559 559 560 561 563 567 573 580 580 585 s&i 592 592 599 600 554 555 s55 595 537 Figure 5.-Percent diatribtrtion of I30 brnnds of cigrrrcttes nnd 25 brands of little cigRr3 by nicotine content- .- __ _ _ _ _ _ _ __ _ List of TubIes TnbIe l.-Percent distribution of U.S. males nged 21 nnd older by type of tobrrcco used for the yenrs 196-1, 1966, and 1970-- Table Z.-Percent distribution of U.S. males by t>-pe of tobucco used nnd ngefor 1970___---_-_-__-__-_------------------ TftbIe 3.-Percent distribution of British males aged 25 nnd older by type of tobncco used for the years 1965, 196S, nnd 1971__________~___-__~--~---------------------------- Table 4.-Amounts of se\-ernl components of 1 grnm of par- ticulnte mfiteriul from mainstream smoke of tobacco prod- ucts________________~----:------------------------------ Table 5.--A comparison of se\-ernl chemicnl compounds found in the mainstream smoke of cignrs, pipes, nnd cigarettes---- Tnble 6.-AIortaIity ratios for totnl denths by type of smoking (mnles only) ___._______ ----___--__- __________--___---- Tnble 7.-AIortnIitv ratios for totnl denths of cigar nnd pipe smokers by amount smoked--Hammond and Horn- _ - - _ __- Tablr 8.--1Iortnlity ratios for total deaths of cignr and pipe smokers by nmount smoked-Best-__- - _ - - _- _ _ -__ _ _ _ _ _ _ _ _ Table 9.-Alortnlity rrrtios for totnl deaths of cigar and pipe smokers by age nnd nmount smokeci-~Rhn__---__------- Table lO.--;\Iortnlitp ratios for totnl deaths of cigar and pipe smokers by omount smoked-Hammond _ _ _ _ _ - _ _ _ - - - _ _ - - _ Tnble Il.-The extent of inhnling pipes, cignrs, nnd cigarettes by British moles aged 16 and over in 1968 and 1971- _ _ ___ _ Table 12.-Inhalation among cigar, pipe, and cigarette smokers by age--Doll and Hill _____. --_---_--__----_- ____ -_-___- Table I3.--JlortaIity ratios for total deaths of cigar and pipe smokers by nge and inhnlntion-Hammond__ _ - - _ _ ___ _ _ __ _ Tnble 14.-Percentage of British male cigar smokers who re- ported inhnling n lot or rr fnir amount by type of product smoked-_-._____._______________________------~--~-~ Table 15.-Percentage of individunls reporting inhnlntion of "almost every puff" of tobncco smoke by current and pre- vious tobacco usage and type of tobacco used-- - _ _ __ _ _ _ ___ Table !6.--Percentage of British males who reported inhaling n lot or fair amount of cignr smoke by current and previous tobacco usage nnd type of tobacco previously smoked (1963) ---__ ---_-- ____ - _--- - ----------------- -_- ______ 596 543 544 544 547 548 550 551 551 552 552 556 556 557 -. 557 558 558 538 Table 17.-Extent of reported inhnlation of cigar smoke by British male cignr smokers who lvere ex-cigarette smokers in 1968, analpzcd by extent of reported inhalation of cignrctte smoke when previouslp smoking cigarettes---_. _ _ _ _ _ __ _ _ _ _ _ Table 18.--Slortality ratios for total cancer denths in cigar nnd pipe smokers. A summary of prospective epidemiological studies_-_______________________________-------------- Table lg.--Kelative risk of lip cancer for men, comparing cigar, pipe, and cigarette smokers with nonsmokers. A surnmnry of retrospective studies-`------- ___________________________ Table PO.->Iortality ratios for oral cancer in cigar and pipe smokers. A summary of prospective epidemiological studies- - Table 21.--Relative risk of oral cancer for men, comparing cigar, pipe, and cigarette smokers with nonsmokers. X sum- mary of retrospective studies-- _ _- ________________ -_-_-- Tnble 22.--XIortality ratios for cancer of the larynx in cigar and pipe smokers. A summary of prospective epidcmiological studies.-_--_-_____----------------~---------~-----~-- Table 33.--Relative risk of cancer of the larynx for men, corn- paring cigar, pipe, nnd cigarette smokers with nonsmokers. A summary of retrospectire studies--- _- -- -_ _ _ _ __ _ - __ _ _ __ Table 24.--Jfortality ratios for cancer of the esophagus in cignr and pipe smokers. A summary of prospective epidemio- logical studws _____ -_-_-_____-_- ____ _ ___-_ -_---- _______ Table "S.-Relative risk of cancer of the esophagus for men, comparing cigar, pipe, and cigarette smokers \\ith non- smokers. ri summary of retrospective studies .____ - _-_______ Table 26.-A\Iortality ratios for lung cancer deaths in male cigar and pipe smokers. A summary of prospective studies---- Table 27.-Lung cancer death rates for cigar and pipe smokers byamountsmoked-DollandHill------ ______ -_- _____-- Table Pg.-Lung cancer mortality ratios for cigar and pipe smokers by amount smoked-Kahn- ____ __-__-_-__- ____-- Table 29.-Relative risk of lung cancer for men, comparing cigar, pipe, and cigarette smokers with nonsmokers. A summary of retrospective sbudies-__-_---------- ____----- Table 30.-Changes in bronchial epithelium of male cighr, pipe, and cigarette smokers as compared to nonsmokers- _ -- Table 31.--Tumorigenic activity of cigar, pipe, and cigarette smoke condensates in skin painting experiments on animnls-- Table 32.--Xlortalit_v ratios for cardiovascular deaths in mnie cigar and pipe smokers. A summary of prospective epi- . . demlologlcal studies _______ -_-_- ___-_______-..- --------- Page 559 559 562 563 564 566 568 570 571 574 574 575 576 579 583 586 539 Table 33.--Iiortnlity rntios for chronic obstructi\-e pulmonnry deaths in mnle cigar and pipe smokers. X summary ol pros- pective epitlemiolopicnl studies- - - - _ _ _ _ _ _ _ _ _ _ _ _ _ __ _ _ __ _ _ _ Table ?A.---Prey-alencc of respiratory symptoms and illness by type of smoking--- ___________ - ______ - _______________ Table 35.--Pulmonary function values for cigar and pipe smokers as compnretl to nonsmokers.- __- ________________ Table 36.-Jlortality rntios for peptic ulcer disense in male cigar and pipe smokers. Summary of prospective studies__- Table 37.4hipment of small nnd large cigars destined for domestic consumption (1970, 1971, 1972) ____ ---___-_- ____ Table 38.-Selected compounds in mainstream smoke-------.. Table 39.-The pI1 of the mainstream smoke of selected tobacco products_-----____---------------------------- 589 590 591 592 597 598 598 Introduction This chapter is a review of the epidemiological, pathological, and experimental data on the henlth consequences of smoking cigars and pipes, alone, together, and in varicus combinations with cignrettes. Previous reviews on the health consequences of smoking have dealt primarily with cigarette smoking. Although some of the material on pipes and cigars pwsented in this chapter has been presented in preti- ous reports of the Surgeon General, this is the first attempt to summ- rize what is known about the health effects of pipe nnd cigar smoking. Since the use of pipes nnd cigars is limited almost exclusively to men in the United States, only dnta on men are included in this revieff. The influence of pipe and cigar smoking on health is determined by examining the overall and specific mortality and morbidity ex- 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 death, however, pipe and cigar smokers experience mortality rates that are as great as or exceed those experienced by cigarette smokers. This analysis becomes more complex when combinations of smoking forms are examined. The overall mortnlity rates of those who 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 thw who smoke only pipes or cigars. This might seem to suggest that smoking pipes or cigars in combination with ciga- retteS diminishes the harmful effects of cigarette smoking. However, an analysis of mortality associated with smoking combinations of ciga- rettes, pipea, and cigars should be standardized for the level of con- sumption of each of the products smoked in terms of the amount amoked, duration of smoking, and the depth and degree of inhalation. For example, cigar smokers who also smoke a pack of cigarettes a day might be expected to have mortnlity rates somewhat higher than those who smoke omy cigarettes nt the level of a pack a day, assuming that both groups smoke their cigarettes in the same way. Mixed smokers who inhale pipe or cigar smoke in a manner similar to the Kay they smoke cigarettes might be expected to have higher mortality rates than mixed smokers who do not inhale their cigars nnd pipes and also 541 resist inhaling tliejr cigarettes. Irnfortunately, little of the published material on mixed cignrrttt. pipe, ;III~ cigar smoking contains these types of nnal~33 or corltr0lS. ;\ P3r3dox :eems to esi?t bet\!-ern the mortality rates of ex-smokers of pipes and cigars and es-smokers of cigarettes. Ex-cigarettesmokers experience a reJati\-e decline ir! orernll and certain specific causes of mortality follo\ring cessation. This decline is important but indirect evidence that cigarette smoking is a major cawe of the elevated mor- tality rates experienced by current cigarette smokers. In contrast to this finding, several prospective epidemiological investigations, Hammond and Horn (.@a), Best (9), Kahn (50), and Hammond (38), ha\-e reported higher death rates for ex-pipe and ex-cigar smokers than for current pipe and cigar smokers. This phenomenon eras ann- lyzed by Hammond and Garfinkel (39). The development of ill health often results in a cigarette smoker giving up the habit, reducing his daily tobncco consumption, ssitching to pipes or cigars, or choosing a cigarette low in tar and nicotine. In many instances, a smoking- related disease is the cause of ill health. Thus, the group of es-smokeIs includes some people \vho.are ill from smoking-related diseases, and death rates are high among persons in ill health. As a result, ex-cig;lrette smokers initially have higher overall and specific mortality rates than continuing cigarette smokers, but be- cause of the relative decrease in mortality that occurs in those who quit smoking for reasons other than ill health, and hecause of the dwindling number of ill es-smokers, a relative decrease in mortality is observed (within a few years) follo\ving cessation of cigarette smoking. The beneficial effects of cessation nould 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 smokes, but because of the Iorrer initial risk of smoking these forms and therefore the smaller margin of benefit following cessation, the effect produced 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 R bias is introduced into the nlortality rses of current smokers and es-smokers of pipes and cigars, so that a more accurate picture of mortality might be obtained by combining the ex-smokers with the current smokers and looking at the resultant mortality experience. B~JXLUQ? 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 m-hi& summarize the mortality and relatire risk ratios reported in the major 542 prospective and retrospective studies which contained information nbout pipe and cigar smokers. The smoking categories used include: cigsr oni?, pipe only, total pipe and cigar, cigarette only, and mixed. The tot31 pipe and cigar category includes: thw 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 calculnted 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 CIearinghouse for Smoking and Health from population surveys conducted in 1961,1966, and 1970 (98, 99,100). In each survey, about 2,500 interviews Kere conducted on a national probability sample stratified by type of population and geographic area. The use of these products among adults 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, 196S, and 1971 is presented in table 3. TABLE I.--Percent a!is!ribution qf U.S. n&e smokers aged 21 and Older by type oj tobacco used jor the years 1964, 1966, and 1970 Forms wed (pAI% 1x3 1970 @t=PXW (psrcent) 1. Cigar only-- ____________ - ________-__--- 6. 8 5. 5 5. 6 2. Pipe only_----_-________-~~~-----~----- 1. 7 3. 0 3. 6 3. Pipe and cigar ___________________ - ______ 3. 9 S-9 4.4 4. Cigarette only--- ___________________ ____ 28. 6 31. 2 25. 9 5. Cigarette and cigar ____________________-- 11. 3 9. 9 6. 6 6. Cigarette and pipe ______________________ 5. 3 4. 9 5. 3 7. Cigarette, pipe, and cigar ________________ 7. 7 6. 3 4.6 8. Nonsmoker ______ ____ ____ ____ - - ____ ____ _ 34.7 34. 3 44.0 Total ______ - __________i_________--- 100.0 100.0 100.0 Number of Reasons in sample. ______________- 2,359 2,679 2,881 Total pipe users (2+3+6+7) __________-__- - 18. 7 19. 2 17. 9 Total cigar users (1-i-3+5+7) _________--_- - 29. 9 26. 7 21. 2 Total cigarette uverj (4+5+6+7) _________-- 52 9 52. 4 42 3 lkwcs: U.S. De>-cat of Health, Education. and Welfam (98. PO. 100). 543 TABLE 2.-Percent distribution of U.S. male smokers by type of tobac- co used and age for 1.970 Forma Uspd A@ *ouP_ ?I to 34 3.5 to44 4.31054 65 to M 65 to 3 + 1. Cigar only- -----__ -- _______ 2. Pipe only_--- __`.______ ____. 3. Pipeandcigar_- _____ -- _____ 4. Cigarette only--- _____ _____ - 5. Cigarette and cigar-- ________ 6. Cigarette and pipe- - ..______ 7. Cigarette, pipe, and cigar- - _ _ 8. Nonvmokcr __.___ ---_-__--_- 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 4. 4 6. 9 28. 8 29. 0 27. 1 24. 3 13. 6 6. 8 10. 4 5. 5 5. 2 4. 2 6. 6 4. 4 5. 6 4; 0 3. 8 5.8 48 5. 0 4. 0 1. 4 40. 2 38. 1 43. 9 48. 2 57. 2 Total- _____ --__-___-__- 100. 0 100.0 100.0 100.0 100. 0 Number of in sample- _ _ persons 1,009 525 523 405 388 ~ Total pipe users .__._____.___ -- 20. 5 16. 0 18. 8 15. 6 15. 7 Total cigar users. _ _____ --_- -__ 20. 1 25. 0 20. 4 20. 3 21. 8 Total cigarette usem-_---_---- 48. 1 48. 6 43. 3 37. 5 23. 0 Source: U.S. Deprtmeut ol Health, Education. and Welfare (100). TABLE S.-Percent distribution of British male smokers aged 15 and older by type of tobacco ?Lsed for the years 1965, 196S, and 1971 Forms wd 1985 1968 1971 1. Cigars only __________________ -._- _______ 1. 9 2. 8 3. 3 2. Pipeonly_--__-__-___-__-~-~-~~~-~--.~- 5. 1 5. 6 5. 9 3. Cigarettesonly__- _____ --.--_--_- _______ 46. 8 45. 7 40. 8 4. Cigarettesandpipe _____ --__-_-__-_- _.__ 8. 0 7. 0 6. 1 5. ~Iixedsmokers_--___--_~--_.- _______-__ 7. 5 9. 1 8. 4 6. Nonsmokers- .__________ -_---_-- ______ -- 30. 7 29. 9 35. 4 Total_-_.-_-_~__.-_--~.~~--~---..-- 100.0 100.0 loo. 0 Number of persons in sample-__-.--_-.-~-~- 3, 576 3, 566 3,594 - Total pipe users _______________.__.________ 13. 9 14. 3 13. 3 Totalcigar- ____.________ ~__-__-- _._._._._ 9. 0 11.7 11.3 Totalcigarette _____ - _____ - _____ -__- _____._ 67. 6 67. 6 61. 6 Bourcc: Todd. 0. F. (91). 544 The Definition and Proceseing of Cigm, Cigarettea, and Pipe Tobaccos The U.S. Government has defined tobacco products for tax pur- poses. Cigarettes are defined as "(1) Any roll of tobacco wrapped in paper or in any substance not containing tobacco, and (2) any 1~11 of tobacco Trapped in any substance containing tobacco which, &UW 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 (l)." Cigarettes are further classified by size, but virtually all cigarettes sold in the United Stati are "small cigarettes" which by definition weigh "not more than 3 pounds per thousand" which is not more than 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. In this process, tobacco leaves are cured in closed barns where the temperature is progressively raised over a period of several days. This results in "color setting," fixing, and dryirq of the leaf. The most conspicuous change is the conversion of starch into simpler sugars and suppression of oxidative reactions. Flue-cured tobaccos produce an acidic smoke of light aroma (35,rZZ). Cigara Cigars have been defined for ta'x purposes as: "Any roll of tobacco wrapped in leaf tobacco or in any substance containing tobacco (other than any roll of tobacco which is a cigarette within the meaning of subparagraph (2) of the definition for cigarette)" (112). In order to clarify the meaning of "substance containing tobacco" the Treasury department has stated that, "The wrapper must (1) contain a signs- 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, pH, taste, and aroma; and (1) not be so changed in the reconstitution process that it loses all the tobacco characteristics" {J&`j. Further, "To be a cigar, the filler must be substantially of tobaccos unlike those in ordinary cigarettes and must not have any added flavoring which would cause the product to have the taste or aroma genernlly attributed to cigarettes. The fact that a product does not resemble a cigarette (such as many large cigars do not) and has a distincti\-e cirnr taste and aroma is of considernblc si,pificance in making this determination" (IT/Z). Cigars arc also cln.ssified by size. "Small cigars" xvei,nh not more than 3 pounds per thousand and "large cigars" weigh more than 3 portnds per thousand. "Large cigars" are further divided into seven classes for tax purposes based on the retail price intended by the manufacturer for such cirars (96). Cigars are made of filler, binder, and n-rapper tobaccos. hfost cigar tobaccos are air-cured and then fermented. More recently, reconsti- tuted cigar tobaccos have been used as wrapper, binder, or both. Cigars are either hand-rolled or machine made. Some brands of small cigars are manufactured on regular cigarette making machines. The aging and fermentation processes used in cigar tobacco production produce chemical catalytic, enzymatic. or bacterial transformations as evi- denced by increased temperature. oxygen utilization, and carbon dioxide generation within fermenting cigar tobaccos. In this complex process. up to Xl percent of the dry xveipht of the leaf is lost through decreases in the concentration of the most readily fermentable ma- terials such as carbohydrates. proteins. and alkaloids. The flavor and aroma of cigar tobaccos are in large measure the results of precisely controlled treatment during the fermentation process (35,.X, 112). Pipe Tobnccos The definition of pipe tobacco used by the U.S. Government eras repealed in 1966 and there is no Federal tax on pipe tobaccos. The most popular pipe tobaccos are made of Burley; honever, many pipe tobaccos are blends of different types of tobacco. A fern contain a significant proportion of midrib parts that arecrushed betxveen rollers. "Saucing" material. or casings containing licorice, sweetening agents, sugars. and other flavoring materials are added to improve the flavo1, _ aroma. and smoke taste. These additives modify the characteristiZ of smoke components (112). ConclusiorL Because of the unique curin = and procrssing methods used in the production of cigar and pipe tobaccos. significant physical and chcmi- cal differences esist between pipe and cigar tobaccos and those used in 546 cigarettes. The cstcnt to \\-hich t&c chnnrcs mnr alter the hcnlth consequcnccs of sniokin~ l)ipcs n11(1 ciznrs rnn best be cstirnntcd lay nn nn:ll\sis of tlie potcntinll\ Iinrmflll cl~fnlic:~I constitntcrits fouri(l in the smoke of thcsc tobnccns. the turnorigcnic acti\-ity of srnnkc condcn- sntes in tzprrirnental nnirnnls. 2nd n review of the epidcmiological data n-hi& has nccumulntcd on the hcnlth effects of pip.2 and cigar smoking. Chemical Analysis of C&gar Smoke OnIy a few studies have been conducted that compnre the chemical constituents of cigar smoke x-ith those found in cigarette smoke. Hotfm:lnn, et 11. (43) compnrcd the yields of several chemical com- ponents in the smoke from 9 pklin 85 mm. cigxette, two types of cigars, 2nd a pipe. The pflrticulnte matter, nicotine, bcnzo(a)pyrene, and phenols were determined quantitatively in the smoke of these tobncco products. One cigar tested ~3s 5 lL%rnm.-long, 7.6-g., U.S.- made cigar. The other uxs n handmade Ilnvana cigar 147 mm. long -xeighing S.6 g. The relative content of nicotine in the particulate matter produced t.~y the cigars KE similar to that of the cigarette tars. The benzo(a)pgrene and phenol concentrations in the cigar condensnte xns tn`o to three times greater thnn in cigarette "tar" (t.ahle -1). Kuhn (58) compared the nlknloid and ~~henoi content in conden- sutes from nn SO-nun. Bright-blend cigarette sold commercially in A1ustria -with that obtnirnd from 103'mm. cigars. These were tested T.~BLE 4.-Amounts oj sewral components qf I g. qf pcrticulatx malerial from mainstream smoke of tobacco products Tobwco product 1 Compound Standxd @mm. 6.5 mm. u 8. II8vsns Pipe cigar h cigar B tobacco txy~;e plain U.S. plain U.S. cigarette cigarette (b) (b) In Pipe In pipe 03) w V-9 Skotine (mg.)_---- _____ 46. 2 63. 6 33. 1 61. 0 65. 9 77. 4 Benzo(a)pyrene (pg.). _. _ 3. 9 3. 6 6. 0 3. 6 1. 2 1. 3 Phenol (mg.)------------ 8. 3 6. 7 15. 0 7. 3 2. 3 4. 1 *Crcsoi (mg.)--- ____ -__ 1. 6 1. 7 1. 9 1. 4 .6 .8 n+p-Cresol (mg.).------ 4. 8 3. 8 5. 6 3.4 1. 4 1. 9 d-p-EthJ-lphenol (mg.).- I. 1 1. 5 1. 1 1.3 .7 .7 547 with and rrithout the use of a cellulose acetate filter. The concentm- tions of total alkaloids 3nd plicnol in the cigar smoke condcnsntc wre essentially the same as in the cigarette condensate, but pyridine values xvere about 21,1, times higher in the cigar condensate. Campbell and Lindsey (17) measured the polycyclic hydrocarbon levels in the smoke of a small popular-type cigar S.8 cm. long, n-eighing 1.9 g. Si?Tificnnt quantities of anthracene, pyrene, fluoranthene, nnd henzo(a) pvrene Kere detected in the unsmoked cigar tobacco, in con- centrations much ,Qater than those found in Virginia ciprettes but of the same order as those found in some pipe tobaccos. The smoking process contributed considerably to t.he hydrocarbon content of the smoke. Table 5 compares the concentrations in the mainstream smoke of cigarettes. cigars, and pipes of four hydrocarbons frequently found in condensates. The authors reported that t.he mainstream smoke from a popular brand of small cigar contained the polycyclic aromatic hydrocarbons; acenapht.hylene, phennnthrene, anthracene! pyrene, fluoranthene, and benzo(a.) pyrene.. The concentrations of these hydro- carbons in the mainstream smoke were greater than those found in Virginia cigarette smoke: @man. et al. (6.9) analyzed the volatile phenol content of cigar smoke collected from a 7-g. American-made cigar with domestic filler. :\fter quantitative anal?-sis of phenol. cresols, xylenols, ani meta and pnn ethyl phenol. the authors concluded that the IevclGf these com- pounds lvrcre generally similar to those reported for cigarette smoke. &man and Bar-son (63) aIso analyzed cigar smoke for benzene, toluene. ethyl benzene, m-, p-, and o-xylene, m- and p-ethyltoluene, I,",~-trinret~r~lbenzen~, and dipentene, and generally found levels within the range of those previously reported for cigarette condensates. In summary. available evidence sugpsts that cigar smoke contains man?- of the same chemical constit.uents, including nicotine and ot.her aIkaIoids, phenols, and polycyclic aromatic hydrocarbons as are found TABLE 5-A camparison oj sever& chemical compa~nds found in the mainstream smoke oj cigars, pipes, and cigarettes - COlIlpOUnd 1. 6 29. 1 5. 0 11.9 110.0 10. 9 17. 6 75. 5 12. 5 3. 4 8. 5. .9 548 in cigarette smoke. Most of these compounds are found in conrentra tions n-hic!l qua1 or exceed levels found in ci,rarcttc "tar." .\ more conlplete picture of the carcinogenic potential of cigar `it313" is ob- tained from experimental data in animals. Mortality OveraZ Xortdit y Several large prospective studies have examined the health conse- quences of various forms of smoking. The results of these invest.iga- tions have been reviewed in previous reports of the Surgeon General in which the major emphasis has been on cigar&to smoking and its effect on overall and specific mortality and morbidity. The follorring pages present a current review of the health consequences of smoking pipes and cigars. Data from the prospe&ive investigations of Dunn, et al. (31), Uuell, et al. (IG), Hirayama (&I), and \Veir and Dunn (105) are not cited, because in these studies a separate category for pipe and cigar smokers ~vas not established. The smoking habits and mortality experience of 157,783 white men betlveen the ages of 50 and 69 who were followed for M months were reported by Hammond and Horn (41). The overall mortality rates of men who smoked pipes or cigars nere slightly higher than the rates of men who never smoked. The overall mortality rate of cigar smokers was slightly higher than that of pipe smokers. In a study of 41,000 British physicians, Doll and Hill (26, 27) re- ported the overall mortality of pipe and cigar 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 and cigar smokers slightly nbove those of nonsmokers. Kahn (50) exam- ined the death rates and smoking habits of more than %93,000 U.S. veterans and Hammond (38) examined the smoking habits of and mortality rates experienced by 440,559 men. In t.hese studies, pipe-. smokers experienced mortality rates similar to those of men who never smoked regularly, whereas cigar smokers'had death rates somewhat higher than men who never smoked regularly. Table G summarizes the results of these five studies. Thus, data from the major prospective epidemiological studies demonstrate that the use of pipes and cigar-s results in a small but defi- 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 level of mortality that approaches the mortality experience of cigarette smokers. 495-0280--7J-13 549 TABLE 6.-&fortnlify TdiOS jar total deaths by fype of smoking (Inales oh) Smoking t,-pc Hammond and Horn ' (&I.__ 1. 00 1. 22 1. 12 1. 10 1. 36 1. 50 I. 43 1. 68 Doll and Hill (26)_-------- 1.00 ___- __-- 1.01 _-__-- _------ 1. 11 1. 28 B&(9)_------ 1.00 1.06 1.05 .98 1. 22 1. 26 1. 13 1. 54 Kahn (60) _.__ -_ 1.00 1. 10 1.07 1.08 _--___ _______ 1. 51 1. 84 Hammond * (38)-- _______ 1.00 1.25 1.19 1.01 _-___- _____ -_ 1. 57 1. 86 NortaMy and Dose-Response Relatiowhips A consistent association exists betrreen overall mortality and the total dose of smoke a cigar&to smoker receives. The methods most frequently used to meaSure dosage of tobacco products are: Amount smoked, degree of inhalation, duration of smoking experience, age at initiation, and the amount of tar in a given tobacco product. For cigarette smokers, the higher the dose as measured by any of these parameters, the greater the mortality. The significance of the small 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 similar measures of dosage as used in the study of cigarette smokers. hMOUXT .%lOKW Hammond and Horn (40) reported an increase in the orerall mor- tality of pipe and cigar smokers x4th an `increase in the amount smoked. Individuals who smoked more than four cigars a day or more than 10 pipefuls a day had death rates significantly higher than men xho never smoked (PcO.05 for cigar smokers and P