<h4>Background</h4>Cigars are a growing public health concern, given the changes in cigar use patterns in the US and elsewhere since the 1960s. We conducted a systematic review of published studies on current cigar smoking and all-cause and cause-specific mortality risks to inform potential regulatory approaches and future research that would strengthen the body of evidence.<h4>Methods</h4>Using 3 different databases and handsearching, we identified epidemiological studies published prior to June 2014 that examined the association between cigar smoking and all-cause mortality and smoking-related mortality. Detailed study characteristics as well as association-level characteristics, including effect estimates and 95% confidence intervals, were abstracted or calculated from each selected study.<h4>Results</h4>A total of 22 studies from 16 different prospective cohorts were identified. Primary cigar smoking (current, exclusive cigar smoking with no history of previous cigarette or pipe smoking) was associated with all cause-mortality, oral cancer, esophageal cancer, pancreatic cancer, laryngeal cancer, lung cancer, coronary heart disease (CHD), and aortic aneurysm. Strong dose trends by cigars per day and inhalation level for primary cigar smoking were observed for oral, esophageal, laryngeal, and lung cancers. Among primary cigar smokers reporting no inhalation, relative mortality risk was still highly elevated for oral, esophageal, and laryngeal cancers.<h4>Conclusions</h4>In summary, cigar smoking carries many of the same health risks as cigarette smoking. Mortality risks from cigar smoking vary by level of exposure as measured by cigars per day and inhalation level and can be as high as or exceed those of cigarette smoking. The body of evidence would be strengthened by future studies that focus on the health effects of primary cigar smoking and incorporate more contemporary and diverse study populations to better reflect the current patterns of cigar use in the US. Results A total of 22 studies from 16 different prospective cohorts were identified. Primary cigar smoking (current, exclusive cigar smoking with no history of previous cigarette or pipe smoking) was associated with all cause-mortality, oral cancer, esophageal cancer, pancreatic cancer, laryngeal cancer, lung cancer, coronary heart disease (CHD), and aortic aneurysm. Strong dose trends by cigars per day and inhalation level for primary cigar smoking were observed for oral, esophageal, laryngeal, and lung cancers. Among primary cigar smokers reporting no inhalation, relative mortality risk was still highly elevated for oral, esophageal, and laryngeal cancers. Conclusions In summary, cigar smoking carries many of the same health risks as cigarette smoking. Mortality risks from cigar smoking vary by level of exposure as measured by cigars per day and inhalation level and can be as high as or exceed those of cigarette smoking. The body of evidence would be strengthened by future studies that focus on the health effects of primary cigar smoking and incorporate more contemporary and diverse study populations to better reflect the current patterns of cigar use in the US. Ideally, these studies would also collect detailed information on cigar type, exposure level, and biomarkers of exposure and potential harm. Current cigarette smokers are excluded from this analysis to better isolate the effects of cigar smoking on disease risk. Past cigarette smoking patterns are likely to affect current cigar smoking patterns. CPS-I results suggest that secondary cigar smokers (current, exclusive cigar smoking with a history of previous cigarette or pipe smoking) are about twice as likely to report inhaling cigar smoke as primary cigar smokers (current, exclusive cigar smoking with no history of previous cigarette or pipe smoking) (42.0% vs. 21.6%) [ 31 ]. Therefore, secondary cigar smokers may have different disease risks compared with primary cigar smokers not only due to past cigarette use, but also due to differences in cigar use, particularly with inhalation. Thus, for studies that assessed this information, we present results for primary and secondary cigar smokers separately as well as separate studies that combine cigar and pipe use from studies of cigar use only. Results In total, there were 22 selected studies that examined cigar smoking and mortality from 16 cohorts (Table 1 ). Table 2 Current cigar smoking and all-cause mortality Study Cohort name Sex Cigar smoker deaths Effect estimate 95% CI Measure Primary/secondary* Adjustment Current Cigar Best1966 Canadian Study of Smoking and Health 196 1.06 (0.92, 1.22) SMR Age Kahn1966 Dorn study 1532 1.1 (1.05, Shanks and Burns and Shapiro, Jacobs, and Thun both found significantlyelevated risk of Table 4 Current cigar smoking and oral cancer Study Cohort name Cigar smoker deaths Effect estimate 95% CI Measure Primary/secondary* Adjustment ICD codes Current Cigar Kahn1966 Dorn study 9 4.11 (1.86, 7.84) SMR Age ICD 7: 140-150 Shanks1998 CPS-I 25 7.92 (5.12, 11.69) IRR Primary Age Shanks1998 CPS-I 8 6.58 (2.83, 12.97) IRR Secondary Age Shapiro2000 CPS-II 6 4 (1.50, 10.30) HR Primary Age, alcohol, smokeless tobacco ICD 9: 140–141, 143-149 *Primary cigar smoking: current, exclusive cigar smoking with no previous history of cigarette or pipe smoking; secondary cigar smoking: current, exclusive cigar smoking with previous history of cigarette or pipe smoking. Conclusions In summary, cigar smoking carries many of the same health risks as cigarette smoking, which is consistent with the fact that the two products share similar levels of many of the same harmful constituents. Mortality risks from cigar smoking vary by level of exposure as measured by cigars per day and inhalation level. We have observed that some risks associated with cigar smoking can be as high or higher than those associated with cigarette smoking, especially at the highest doses and levels of inhalation for cigar smoking.

Background A growing proportion of tobacco users in the United States use non-cigarette products including cigars, pipes, and smokeless tobacco. Studies examining the disease and mortality risks of these products are urgently needed. Methods We harmonized tobacco use data from 165 335 adults in the 1991, 1992, 1998, 2000, 2005, and 2010 National Health Interview Surveys. Hazard ratios (HRs) and 95% confidence intervals (CIs) for overall and cause-specific mortality occurring through December 31, 2015, were estimated by exclusive use of cigarettes, cigars, pipes, or smokeless tobacco using Cox proportional hazards regression with age as the underlying time metric and never tobacco users as the referent group. Results Current use of cigarettes (HR = 2.23, 95% CI = 2.13 to 2.33) and smokeless tobacco (HR = 1.36, 95% CI = 1.17 to 1.59) were each associated with overall mortality. Relative to never tobacco users, higher risks were observed both in daily (HR = 2.34, 95% CI = 2.24 to 2.44) and nondaily (HR = 1.69, 95% CI = 1.54 to 1.86) cigarette smokers, with associations also observed across major smoking-related causes of death. Daily use of smokeless tobacco was also associated with overall mortality (HR = 1.41, 95% CI = 1.20 to 1.66) as was daily use of cigars (HR = 1.52, 95% CI = 1.12 to 2.08). Current smokeless tobacco use was associated with a higher risk of mortality from heart disease and smoking-related cancer, with strong associations observed for cancers of the oral cavity and bladder. Conclusions Exclusive daily use of cigarettes, cigars, and smokeless tobacco was associated with higher mortality risk. Tobacco control efforts should include cigars and smokeless tobacco.

<h4>Importance</h4>Cardiovascular health outcomes associated with noncigarette tobacco products (cigar, pipe, and smokeless tobacco) remain unclear, yet such data are required for evidence-based regulation.<h4>Objective</h4>To investigate the association of noncigarette tobacco products with cardiovascular health outcomes.<h4>Design, setting, and participants</h4>This cohort study was conducted within the Cross Cohort Collaboration Tobacco Working Group by harmonizing tobacco-related data and conducting a pooled analysis from 15 US-based prospective cohorts with data on the use of at least 1 noncigarette tobacco product ranging between 1948 and 2015. The analysis for this study was conducted between September 2023 and February 2024. The median (IQR) follow-up time for the all-cause mortality outcome was 13.8 (10.2-19.2) years.<h4>Exposure</h4>Current, sole, and exclusive use of noncigarette tobacco products. Sole use refers to using a noncigarette tobacco product without currently smoking cigarettes. Exclusive use means using only the noncigarette tobacco product and never having smoked cigarettes.<h4>Main outcomes and measures</h4>Myocardial infarction, stroke, heart failure, atrial fibrillation, total coronary heart disease, total cardiovascular disease (CVD), coronary heart disease mortality, CVD mortality, and all-cause mortality.<h4>Results</h4>Of 103 642 participants (mean [SD] age, 55.7 [13.2] years; 49 550 female [47.8%] and 54 092 male [52.2%]), current use rates were 26 962 participants (26.3%) for cigarettes, 1147 participants (2.1%) for cigars, 530 participants (1.2%) for pipes, and 1410 participants (2.1%) for smokeless tobacco. Current cigar use was associated with stroke (hazard ratio [HR], 1.25; 95% CI, 1.01-1.55), atrial fibrillation (HR, 1.32; 95% CI, 1.13-1.53), and heart failure (HR, 1.29; 95% CI, 1.10-1.51) compared with never using cigars in the model adjusted for demographic and socioeconomic factors, cardiovascular risk factors, and cohort. Sole (HR, 1.34; 95% CI, 1.12-1.62) and exclusive (HR, 1.53; 95% CI, 1.20-1.96) cigar use was associated with stroke compared with never using cigars or cigarettes. Current pipe use was associated with heart failure (HR, 1.23; 95% CI, 1.01-1.49) compared with never using pipes, and sole pipe use was associated with myocardial infarction (HR, 1.43; 95% CI, 1.17-1.74) compared with never using pipes or cigarettes. Current use of smokeless tobacco was associated with coronary heart disease mortality (HR, 1.31; 95% CI, 1.08-1.59) and myocardial infarction (HR, 1.20; 95% CI, 1.03-1.39) compared with never using smokeless tobacco. Sole and exclusive smokeless tobacco use demonstrated associations with total CVD (HR, 1.34; 95% CI, 1.19-1.50 and HR, 1.34; 955 CI, 1.13-1.59, respectively), total coronary heart disease (HR, 1.41; 95% CI, 1.21-1.64 and HR, 1.36; 95% CI, 1.08-1.70, respectively), heart failure (HR, 1.41; 95% CI, 1.22-1.64 and HR, 1.70; 95% CI, 1.40-2.06, respectively), and cardiovascular (HR, 1.41; 95% CI, 1.20-1.65 and HR, 1.54; 95% CI, 1.24-1.91, respectively) and all-cause (HR, 1.46; 95% CI, 1.34-1.60 and HR, 1.39; 95% CI, 1.22-1.58, respectively) mortality compared with never using smokeless tobacco or cigarettes.<h4>Conclusions and relevance</h4>In this study, there were distinct risk patterns associated with the use of noncigarette tobacco products. These findings may carry implications for public health and regulation of noncigarette tobacco products.

Objective A systematic review was conducted to evaluate the use patterns, health perceptions, and cardiopulmonary health effects of cigars. Data sources PubMed and Google Scholar were searched for peer-reviewed articles published between June 2014 and February 2021. Search keywords included cigars, cigarillos, little cigars, and cardiopulmonary health outcomes. Study selection Of 782 papers identified, we excluded non-English articles, review articles, commentaries, and those without empirical data on cigars. Three coders independently reviewed all articles and compared codes to resolve discrepancies. 93 articles met the inclusion criteria and were included. Data synthesis Cigars have evolved from premium cigars to encompass little cigars and cigarillos (LCCs). LCCs are available in an array of flavors and at a price advantage, and as a result, are used by different groups compared to premium cigars. LCCs are more frequently used by youth, young adults, and those who identify as Black/African American. LCCs are often used in combination with other tobacco products, alcohol, and cannabis. Despite limited regulation, cigars generate smoke of a similar composition as cigarettes. Among the studies identified, evidence suggests that cigar use is associated with cardiovascular and pulmonary toxicity. Higher all-cause and cancer-related mortalities are associated with cigar use, particularly with more frequent and deeper inhalation, compared to non-tobacco users. Conclusions LCCs are used more frequently by at-risk groups compared to premium cigars. Recent studies evaluating cigar cardiopulmonary health effects are limited but suggest cigars have similar health risks as conferred by cigarette smoking. With the use of LCCs and targeted marketing on the rise among high-risk groups, there is a critical need for continued research in this area. Higher all-cause and cancer-related mortalities are associated with cigar use, particularly with more frequent and deeper inhalation, compared to non-tobacco users. Conclusions LCCs are used more frequently by at-risk groups compared to premium cigars. Recent studies evaluating cigar cardiopulmonary health effects are limited but suggest cigars have similar health risks as conferred by cigarette smoking. With the use of LCCs and targeted marketing on the rise among high-risk groups, there is a critical need for continued research in this area. Cigar smoking is associated with a number of health outcomes including coronary heart disease [ 11 ] and chronic obstructive pulmonary disease (COPD); and confers similar cancer-related risks when compared to smoking cigarettes [ 12 , 13 ]. Dual and poly-tobacco use of cigars with other tobacco products likely increases exposure to harmful carcinogens and toxicants beyond the use of either product alone, which may exacerbate the health risks associated with combustible tobacco product use [ 13 , 14 ]. One possible reason for the lack of perceived harm is that youth endorse positive affect to LCCs, thus influencing their risk perception [ 18 , 85 ]. Although the perceived harm of cigar products among youth seems to increase with age, there remains a subset of individuals, especially those experiencing homelessness, who are less likely to perceive LCCs as harmful as cigarettes. Perceptions of cigar smoking related to specific health outcomes Three studies measured the perceived harmfulness of cigar products related to specific health outcomes. In a sensitivity analysis excluding dual cigar and cigarette users, both frequent (≥ 15 of the past 30 days) and less frequent (1 day in the past 30) use with moderate to deep inhalation more than doubled the smoking attributable mortality. Even less frequent cigar smoking was associated with an increased risk of mortality [ 91 ]. In a sample of White individuals of Dutch descent, the hazard ratios (HR) associated with cigar smoking for cardiopulmonary diseases were examined [ 92 ]. Individuals who also smoke cigarettes were not included in the pipe and cigar use group for this study. The product characteristics of the newer cigar products (little cigars, cigarillos) likely contribute to the inhalation and differences in smoking topography of these products compared to premium cigars. The mainstream smoke generated by LCCs contains similar levels of toxicants and carcinogens as cigarettes and LCC use is associated with similar levels of biomarkers of exposure as cigarettes, with a few exceptions, including CO [ 20 , 21 , 102 ]. Therefore, along with the data indicating inhalation of cigar smoke, it is reasonable to conclude that cigar products likely convey similar health risks as cigarettes. Emerging studies evaluating the cardiovascular and pulmonary health effects associated with LCCs are limited but suggest similar health risks are conferred by LCC smoking as cigarette smoking. Specifically, cigar use is associated with alterations in vascular function, heart rate, and spirometry, suggestive of cardiovascular and pulmonary toxicity [ 6 , 58 , 95 , 96 ]. Importantly, cigar smoking is associated with adverse health outcomes, most notably all-cause and cancer-related mortality, especially among individuals reporting more frequent and deeper inhalation [ 91 – 93 ]. We identified several limitations in the studies evaluated. Further, many of the studies demonstrating elevated cardiovascular and pulmonary disease risks associated with cigar smoking are based upon the evaluation of outcomes in individuals who report using both cigars and cigarettes, which confounds the ability to attribute the health risks solely to cigar use. Future studies evaluating the cardiopulmonary health effects of the different cigar products are needed, especially among diverse population samples that are more reflective of contemporary use patterns. Evaluation of the cardiopulmonary health effects of cigars is challenging due to product diversity.

Smoking is a known lung cancer cause, but no detailed quantitative systematic review exists. We summarize evidence for various indices. Papers published before 2000 describing epidemiological studies involving 100+ lung cancer cases were obtained from Medline and other sources. Studies were classified as principal, or subsidiary where cases overlapped with principal studies. Data were extracted on design, exposures, histological types and confounder adjustment. RRs/ORs and 95% CIs were extracted for ever, current and ex smoking of cigarettes, pipes and cigars and indices of cigarette type and dose-response. Meta-analyses and meta-regressions investigated how relationships varied by study and RR characteristics, mainly for outcomes exactly or closely equivalent to all lung cancer, squamous cell carcinoma ("squamous") and adenocarcinoma ("adeno"). 287 studies (20 subsidiary) were identified. Although RR estimates were markedly heterogeneous, the meta-analyses demonstrated a relationship of smoking with lung cancer risk, clearly seen for ever smoking (random-effects RR 5.50, CI 5.07-5.96) current smoking (8.43, 7.63-9.31), ex smoking (4.30, 3.93-4.71) and pipe/cigar only smoking (2.92, 2.38-3.57). It was stronger for squamous (current smoking RR 16.91, 13.14-21.76) than adeno (4.21, 3.32-5.34), and evident in both sexes (RRs somewhat higher in males), all continents (RRs highest for North America and lowest for Asia, particularly China), and both study types (RRs higher for prospective studies). Relationships were somewhat stronger in later starting and larger studies. RR estimates were similar in cigarette only and mixed smokers, and similar in smokers of pipes/cigars only, pipes only and cigars only. Exceptionally no increase in adeno risk was seen for pipe/cigar only smokers (0.93, 0.62-1.40). RRs were unrelated to mentholation, and higher for non-filter and handrolled cigarettes. RRs increased with amount smoked, duration, earlier starting age, tar level and fraction smoked and decreased with time quit. Relationships were strongest for small and squamous cell, intermediate for large cell and weakest for adenocarcinoma. Covariate-adjustment little affected RR estimates. The association of lung cancer with smoking is strong, evident for all lung cancer types, dose-related and insensitive to covariate-adjustment. This emphasises the causal nature of the relationship. Our results quantify the relationships more precisely than previously.

cannabis, in a pipe. It is the oldest traditional form of smoking. Regular pipe smoking is known to carry serious health risks including increased danger Pipe smoking is the practice of tasting (or, less commonly, inhaling) the smoke produced by burning a substance, most commonly tobacco or cannabis, in a pipe. It is the oldest traditional form of smoking. Regular pipe smoking is known to carry serious health risks including increased danger of various forms of cancer as well as pulmonary and cardiovascular illnesses. The overall health risks are 10% higher in pipe smokers than in non-smokers. However, pipe or cigar smokers who are former-cigarette smokers might retain a habit of smoke inhalation. In such cases, there is a 30% increase in the risk of heart disease and a nearly three times greater risk of developing COPD. In addition, there is a causal relationship between pipe smoking and mortality due to lung and other cancers, as well as periodontal problems, such as tooth and bone loss. However, all tobacco products deliver nicotine to the central nervous system, and there is a confirmed risk of dependence. Many forms of tobacco use are associated with a significantly increased risk of morbidity and premature mortality due to tobacco-related diseases. Pipe smoking is the practice of tasting (or, less commonly, inhaling) the smoke produced by burning a substance, most commonly tobacco or cannabis, in a pipe. It is the oldest traditional form of smoking. Regular pipe smoking is known to carry serious health risks including increased danger of various forms of cancer as well as pulmonary and cardiovascular illnesses. In the twentieth century, pipe smoking was adopted as a preferred method of inhaling a variety of psychoactive drugs, and some claim it is a more intense method of ingestion. Smokeable crack cocaine has a reputation for being more addictive than cocaine's insufflated form. Similarly, methamphetamine has gained popularity in a crystalline form which when smoked in a pipe lets the user avoid the painful nasal irritation of snorting. When not applied to a cigarette or joint, the liquid form of PCP is typically smoked in a pipe with tobacco or cannabis. Due in no small part to successful campaigning against tobacco use, sales of pipe tobacco in Canada fell nearly 80% in a recent fifteen-year period to 27,319 kilograms in 2016, from 135,010 kilograms in 2001, according to federal data. By comparison, Canadian cigarette sales fell about 32% in the same period to 28.6 billion units. The overall health risks are 10% higher in pipe smokers than in non-smokers. However, pipe or cigar smokers who are former-cigarette smokers might retain a habit of smoke inhalation. In such cases, there is a 30% increase in the risk of heart disease and a nearly three times greater risk of developing COPD. In addition, there is a causal relationship between pipe smoking and mortality due to lung and other cancers, as well as periodontal problems, such as tooth and bone loss. However, all tobacco products deliver nicotine to the central nervous system, and there is a confirmed risk of dependence. Many forms of tobacco use are associated with a significantly increased risk of morbidity and premature mortality due to tobacco-related diseases. Sparky Anderson, American baseball manager. Vicente Battista, Argentine writer. Enzo Bearzot, manager of the 1982 FIFA World Cup Champion Italy national football team. Rómulo Betancourt (1908–1981), President of Venezuela. Clarence "Gatemouth" Brown, American blues musician. An avid pipe smoker, the Texas-blues guitarist often sold his own proprietary blend of pipe tobacco as well as autographed pipes at his concerts and shows. Abelardo Castillo, Argentine writer. Julio Cortázar, Argentine writer. Edward VIII, short-reigned (20 January – 11 December 1936) King of the United Kingdom. William Faulkner, American author, known to be an enthusiastic proponent of pipe smoking. Manuel Felguérez, Mexican artist. Gerald R. Ford (1913–2006), 38th President of the United States from 1974 to 1977. Che Guevara (1928–1967), Argentinian revolutionary, who was known to enjoy a pipe from time to time, in addition to his usual cigar. Herbert Hoover (1874–1964), 31st President of the United States (1928–1933). J. Robert Oppenheimer (1904-1967), American theoretical physicist who served as the director of the Los Alamos Laboratory of the Manhattan Project during World War II. Although more known for his chain-smoking of cigarettes, he enjoyed pipe tobacco. His blend of choice was Walnut, a discontinued blend of the John Middleton Co., named after Walnut Street (Philadelphia). Douglas MacArthur (1880-1964), US five-star General during World War II and the Korean War. He was often photographed smoking Missouri Meerschaum corncob pipes (he allegedly sent his own pipe design to the company). John N. Mitchell (1913–1988), 67th Attorney General of the United States (1969–1972) under President Richard Nixon. Charles Stewart Mott, GM executive, philanthropist, Flint Mayor. Pablo Neruda, Chilean poet. Helmut Schmidt (1918–2015), Chancellor of West Germany (1974–1982). Joseph Stalin (1878–1953), Premier of the USSR. He was frequently shown with a pipe: "Photos of him appeared daily in the Soviet press, now in genial pipe-smoking profile, now walking with his comrades..." J. R. R. Tolkien (1892-1973), English writer and philologist. He was the author of the high fantasy works The Hobbit and The Lord of the Rings. He favored a billiards pipe and was an aficionado of Capstan Medium Navy Cut. Mark Twain (1835–1910), American author, a.k.a. Samuel Clemens, writer of Huckleberry Finn favored Missouri Meershaum corncob pipes. He was notoriously partial to a special blend of "Cuban leaf" pipe tobacco, remarking once that "If I cannot smoke in heaven, then I shall not go." Harold Wilson (1916–1995), UK Prime Minister (1964–1970, 1974–1976). More examples can be found in the Pipe Smoker of the Year

often classified as Cameroon. Cigar smoking carries serious health risks, including increased risk of developing various types and subtypes of cancers A cigar is a rolled bundle of dried and fermented tobacco leaves made to be smoked. Cigars are produced in a variety of sizes and shapes. Since the 20th century, almost all cigars are made of three distinct components: the filler, the binder leaf which holds the filler together, and a wrapper leaf, which is often the highest quality leaf used. Often there will be a cigar band printed with the ciga When cigar smokers don't inhale or smoke few cigars per day, the risks are only slightly above those of never smokers. Risks of lung cancer increase with increasing inhalation and with increasing number of cigars smoked per day, but the effect of inhalation is more powerful than that for number of cigars per day. When 5 or more cigars are smoked per day and there is moderate inhalation, the lung cancer risks of cigar smoking approximate those of a…