Opinion: Cigar Smoking and Coronary Health
A doctor examines the links between coronas and coronaries.
From the Print Edition:
maduro issue, Winter 93/94
When it comes to smoking, I guess we cigar lovers constitute one of the last beleaguered minorities. Yet even among smokers, the habit has been a source of conflict.
I don't suppose anybody remembers who Graham Lee Hemminger was. Well, in 1915 he was the fellow who wrote, at the age of 19, these prescient words:
Tobacco is a dirty weed. I like it.
It satisfies no normal need. I like it.
It makes you thin, it makes you lean,
It takes the hair right off your bean.
It's the worst darn stuff I've ever seen.
I like it.
Today, the media, doctors, health politicians and even our wives, husbands or significant others keep telling us that tobacco is not only dirty, but just about all forms of it are dangerous. The important questions, of course, are: Compared to what? And exactly how dangerous?
There are hundreds of studies that attempt to define the specific degree of risk that smoking entails in relation to a variety of health problems. These studies date back at least 50 years, when the striking similarity between the increase of cigarette sales and the incidence of primary lung cancer were first noted.
After scanning the many subsequent investigations detailed in the scientific literature, only a simpleton or a self-deceiver could deny that cigarette smoking is implicated in the etiology of all sorts of nasty ills of the flesh: cancer of the mouth, pharynx, larynx, esophagus and lungs, other pulmonary problems Such as chronic bronchitis and emphysema, various disorders of the heart and vascular system, stomach ulcers and too many more to list. Of these, the effects of smoking on coronary heart disease and on lung cancer have been most extensively studied and appear to be the most serious from a public-health point of view.
But even here, the connection is hardly one to one. Not all who smoke develop these disorders, and not all who develop them smoke. In the United States four out of five deaths from heart disease occur among nonsmokers. The risk is more serious but still far from universal when one looks at lung cancer: 10 percent of the men and 30 percent of the women who get this disease have never smoked. The experts are reduced to saying that there are wide differences in susceptibility, but that doesn't explain the peculiar anomaly of Buerger's disease, an inflammatory disorder of the blood vessels. Although this disorder seems to occur only in smokers (primarily men), in recent years its frequency of occurrence has decreased drastically-far more than would be expected from any concurrent decrease in cigarette smoking.
Thus, many risk factors other than smoking have been implicated in almost all of these illnesses, including smog, industrial pollution, automobile emissions, wood and coal fires, carcinogens in building materials, poor diet, obesity, physical inactivity, stress, certain types of behavioral patterns and personalities, genetic history and whatever else might turn up in the New England Journal of Medicine.
Nevertheless, cigarettes pose a definite danger and, face it, they don't even afford that much pleasure. Oh, once in awhile after a hike or a good meal, or when you've been under unusual pressure, that first drag tastes like ambrosia. But mostly cigarette smoking is a bad habit, quite possibly a true addiction in many users. Even the lower-tar, low-nicotine, filtered variety just postpones eventual trouble. I gave up those coffin nails a decade ago. Yet I still enjoy the occasional pipe or cigar. Pipes are effective stress reducers, and cigars, like nothing else I know, unquestionably provide rare, sensual pleasure. After a great dinner, along with a Port, brandy, or B&B, there is nothing else that can add the right finishing touch-that fitting coda-but a fine cigar from Havana, Honduras or the Dominican Republic.
How much danger to health, then, does that after-dinner cigar entail? Well, a computerized review of all recent scientific investigations that consider cigar smoking as opposed to cigarette smoking-and there are only about two dozen good ones-clearly indicates that the risk factor is substantially lower for those who smoke pipes or cigars than for those who smoke cigarettes. The risk is not a great deal higher, in fact, than for nonsmokers-including those who never smoked.
It is true that much of this research has been undertaken in foreign lands, as diverse as Denmark and Brazil, England and China, where the environmental circumstances, lifestyles, situational stresses and hereditary influences are very different. Even the types of tobacco and methods of smoking may vary. In Asian countries, for instance, where those who do not smoke cigarettes often use water pipes, the risk of lung cancer appears to be only slightly higher than that for nonsmokers. In Italy, on the other hand, the risk of cancer of the oral cavity and esophagus is greater for cigar smokers than for cigarette smokers, a fairly unusual finding that may not be understood unless you have smoked a cheap Italian cigar.
Almost all studies emphasize the importance of dose dependence. That is, smoking five cigars daily doubles the risk of smoking just two or three, and smoking 10 or more cigars each day seriously increases the risk. But whether or not you inhale seems to be more important than how many cigars you smoke. One rigorous study shows that self-reports of inhalation are consistent and valid when measured by expired-air, carbon-monoxide levels, an excellent indicator of toxicity. Primary pipe and cigar smokers who report that they did not inhale had levels about the same as those of nonsmokers.
If you inhale, duration in years plays an important part. Obviously, the longer you have smoked, the higher the risk. But even here, it is clear that within two or three years after you quit smoking, your risk of heart attack declines to levels similar to those who have never smoked-regardless of the quantity smoked or the duration of the habit. Quitting is somewhat less effective for the various cancers, because years of inhaling tobacco smoke may affect delicate structures of the respiratory tract-but even so, the risk still declines significantly after you stop. And it has been demonstrated that the sales curve of cigars (unlike that of cigarettes) has never approached a strong statistical association with the incidence of these various health-related problems.
What it all comes down to is the risk/benefit ratio. As Sigmund Freud pointed out many years ago, all of us are constantly making decisions, consciously or unconsciously, trying to balance the risk of pain versus the benefit of pleasure in our behaviors. We consider the risk of failure versus the benefit of success, of punishment versus reward, of derogation versus approbation, of suffering discomfort or botching the job or eliciting negative response versus comfort, mastery or affection. The unwillingness to face any risk is, in the end, if not impossible, at least an acceptance of a zombielike existence and an abdication of challenge.
Most of us have mixed feelings about taking risks. In some areas, as the president of Princeton stated in his commencement address a couple of years ago, "American society has become too risk averse for its own good." Yet more than half of the men and a fifth of the women recently surveyed by Shearson Lehman and the Roper Organization said they have at some time actually risked losing their lives by driving too fast or recklessly, riding a motorcycle without a helmet, volunteering for hazardous military missions or engaging in dangerous sports.
Obviously, some reasonable degree of prudence in the choice of risk makes sense. But smoking cigars? That would certainly seem to fall in the acceptable category. My father-in-law, who lived to be 97 in marvelous health, attributed his longevity to the fact that he finally gave up smoking cigars-at the age of 90. If you, too, wish to continue smoking cigars for maximum pleasure and minimum health risk, buy those of decent quality, limit yourself to two or three a day and don't inhale.
But what about the rights of others? We are asked this question by all of our nonsmoking friends and relatives. Secondary tobacco smoke is clearly very bad for infants and young children, for the developing fetus and persons who are exposed in a confined space over a considerable period of time. Otherwise, any evidence that other people are seriously affected is still pretty questionable. Even the so-called allergy to tobacco is debatable. There is no scientific evidence at all to support the claim that the wisps of smoke left in the air by a cigar smoker can cause cancer or heart disease in nonsmokers.
As a professor from the Emory University Medical School in Atlanta wrote in the pages of the esteemed Journal of the American Medical Association, no hard data exists to demonstrate that secondary or side-stream smoke from cigars or pipes is dangerous. What the zealots who object really mean is that the sight and smell of other people smoking offends and irritates them morally, physically or emotionally.
Yet we are all irritated or offended by a lot of things in everyday life, some of them even dangerous. Think of crying babies in movie theaters. Drunks who spill wine on your new suit. Twilight joggers on the roadway. Crooked politicians. Companies that pollute our streams and forests. You get the idea.
Of course nonsmokers should have the right to limit my smoking to restricted areas, as long as those areas are reasonably convenient and comfortable. And I should have the right to continue smoking my pipe or cigar in those areas where it won't (or shouldn't) bother them. A recent English study showed that although a lot of people have given up tobacco, most who still smoke are quite willing to respect the rights of others, if their own rights are respected. Courtesy, friendship, the golden mean of moderation and, ah, a good cigar after the tournedos and the Chateau Lafite. That's civilization in its finest flower.
Dr. Weiss is professor emeritus of psychiatry and family and community medicine at the University of Missouri-Columbia Health Sciences Center.
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