Pipes and cigars

Pipes and cigars DEFAULT

Abstract

BACKGROUND: Because limited information is available on the quantitative association between consumption of tobacco products other than cigarettes and lung cancer risk, we undertook a case-control study of this relationship. METHODS: We investigated lung cancer risk among smokers of cigars and/or cigarillos only and of pipes only and compared these risks with the risk of smokers of cigarettes only in a case-control study conducted in seven European areas. Our study population consisted of 5621 male case patients with lung cancer and 7255 male control subjects. Each subject or his proxy was interviewed with respect to the subject's smoking history and other risk factors for lung cancer. RESULTS: The odds ratio (OR) for smoking cigars and cigarillos only was 9.0 (95% confidence interval [CI] = 5.8-14.1), based on 43 exposed case patients and 77 exposed control subjects, and the OR for smoking a pipe only was 7.9 (95% CI = 5.3-11.8), representing 61 case patients and 129 control subjects. The OR for smoking cigarettes only was 14.9 (95% CI = 12.3-18.1), based on 4204 case patients and 3930 control subjects. A dose-response relationship was present for duration of use and cumulative consumption both for cigars and cigarillos and for pipe tobacco. An effect was also suggested for inhalation of cigar and cigarillo smoke. The dose-response relationships between lung cancer risk and either duration of smoking or average and cumulative consumption were similar for cigar and cigarillo smoking, pipe smoking, and cigarette smoking. CONCLUSION: Our results suggest that smoking of European cigars, cigarillos, and pipe tobacco might exert a carcinogenic effect on the lung comparable to that of cigarettes.

The observation that cigar and pipe smoking may entail an elevated risk of lung cancer dates from the early epidemiologic studies (1) of the carcinogenic effect of tobacco smoke. Since then, a large body of evidence has been accumulated showing that smokers of pipes and cigars experience an increased risk of lung cancer as compared with nonsmokers; in most studies (2-4), however, they have been found to be at lower risk than cigarette smokers. This difference can either reflect a lower carcinogenic potency of smoke from cigars and pipes, as compared with cigarettes, or result from confounding by aspects of the smoking habit, such as the average amount smoked, duration of consumption, degree of inhalation, and age at start (4-6). A limitation of many previous studies has been the small number of pure smokers of products other than cigarettes participating, which hampers detailed quantitative analyses of the carcinogenic effect of such tobacco products on the lung.

We used data from seven case-control studies of lung cancer, including more than 5600 male case patients and 7200 male control subjects, for a detailed analysis of lung cancer risk following cigar and pipe smoking. These data were part of a pooled analysis of European case-control studies of lung cancer (7). We excluded women because of the very small number of cigar smokers and pipe smokers among them.

Cigars are products made of tobacco wrapped in tobacco leaves, as distinct from cigarettes, which are made of tobacco wrapped in paper (8). Most traditional cigars smoked in Europe weigh 2-8 g and are similar to American “small cigars.” Cigarillos are smaller than cigars, weighing 1.5-3 g; they are called “little cigars” in the United States.

Methods

We conducted a series of case-control studies among men in seven centers from Germany, Italy, and Sweden during the period from 1988 through 1994: Germany 1 (Bremen and Frankfurt metropolitan areas), Germany 2 (parts of North Rhine-Westphalia, Eifel, and Saarland), Germany 3 (Thuringia and Saxony), Sweden (Stockholm county), Italy 1 (Turin), Italy 2 (five areas of the Veneto region), and Italy 3 (patients from one hospital in Rome). Although not all of the studies were conducted using the same protocol, the procedures for selecting and interviewing case patients and control subjects and the questionnaires used to elicit information on lifetime history of tobacco smoking were comparable and enabled us to pool the data to increase the statistical power.

In Italy 3, control subjects were selected from hospital patients with diseases not related to tobacco smoking, while in the remaining centers, they were obtained from a random sample of the general male population. In the Swedish center, 51% of the study subjects were deceased at the time of the study, and proxies were interviewed. The response rate among case patients (or their proxies) was above 67% in all centers; that of control subjects was 63% or higher in all centers except Germany 2 (38%) and Germany 3 (45%).

A detailed interview concerning their lifetime history of tobacco smoking was obtained for each case patient and control subject: In particular, the dates at start and end and the detailed quantities (in the Swedish center: categories of tobacco used, without detailed amounts) were asked for each smoking period, defined by changes in either quantity or type of tobacco product. This enabled us to construct variables, such as total duration of smoking and average and cumulative consumption of cigarettes, cigars, cigarillos, and pipe tobacco. Information on inhalation was available for smokers from Germany and Italy.

For the purpose of comparing and combining data on cigarette, cigar, cigarillos, and pipe smoking, we equated one cigarette to 1 g of tobacco, one cigar to 4 g, and one cigarillo to 2 g [ (8); Joeckel K-H: personal communication]; for pipe smoking, we requested the weight in grams of the pack of tobacco and the frequency of use. Subjects who reported a lifetime consumption of no more than 400 cigarettes (i.e., one cigarette a day during 1 year) or the equivalent amount of cigars, cigarillos, or pipe tobacco were classified as nonsmokers; “pure” smokers were considered those who smoked only one product. We classified as “mixed” smokers those who smoked cigarettes and cigars, cigarillos, or a pipe; among them, “predominant” smokers were those who smoked more than 80% of total tobacco as one product. Because of the relatively small number of pure smokers of cigars and cigarillos and the similarities between these two products in the traditional European market, we combined these two groups in most analyses.

We selected subjects aged up to 75 years, with a complete history of tobacco smoking. Nonsmokers of any tobacco product served as the reference category; the analysis was based on unconditional logistic regression, with terms for age and center, and was aimed to estimate odds ratios (ORs) and 95% confidence intervals (CIs) (9). In selected analyses, we adjusted for additional potential confounders, such as total amount of tobacco smoked, age at start of smoking, education level (in three categories), and occupational exposure to lung carcinogens. In the analysis of quantitative variables, such as duration of smoking and cumulative consumption, smokers were divided into quartiles based on the distribution of the variable among the control subjects. Ex-smokers were divided in two groups for duration of quitting, with a cut point at 15 years, corresponding to the median duration of quitting among control subjects. All P values are two-sided and are considered statistically significant for P<.05. We also conducted an analysis based on random-effects models (10), since the design of the study slightly differed among centers. Because the results of this analysis did not differ from those based on the pooled database, we present only results based on the latter approach.

Results

The study included 5621 case patients and 7255 control subjects. The German centers contributed 61.0% of case patients and 47.8% of control subjects; the contribution of the Italian centers was 21.2% and 20.2%, respectively, and that of the Swedish center was 17.8% and 32.0%, respectively. Case patients were slightly younger than control subjects (mean ages, 61.4 and 62.1 years, respectively). A total of 2712 (48.2%) case patients were diagnosed with squamous cell carcinoma, 1101 (19.6%) with small-cell carcinoma, and 1030 (18.3%) with adenocarcinoma. The remaining patients either had a different histologic type (large-cell carcinoma in approximately 7%) or were diagnosed with mixed cell type cancer.

A total of 117 case patients and 1750 control subjects were classified as nonsmokers: The OR for ever smoking any tobacco product regularly was 14.2 (95% CI = 11.7-17.2). ORs of lung cancer in different groups of pure smokers and in mixed smokers are shown in Table 1. Pure smokers of cigars and cigarillos include subjects who smoked cigarillos only (21 case patients and 31 control subjects), cigars only (16 case patients and 42 control subjects), or both cigars and cigarillos but not pipe tobacco or cigarettes (six case patients and four control subjects). The risk was higher for cigarette smokers (OR = 14.9; 95% CI = 12.3-18.1) than for smokers of other products. Among control subjects, mixed smokers (excluding 60 control subjects who smoked cigars, cigarillos, and pipe tobacco but not cigarettes) consumed 73.3% of their total tobacco as cigarettes, 4.7% as cigars, 5.2% as cigarillos, and 16.7% as pipe tobacco.

For ever smoking, the OR of pure cigar and cigarillo smoking was 9.0 (95% CI = 5.8-14.1), that of cigar smoking only was 5.6 (95% CI = 2.9-10.6), and that of cigarillo smoking only was 12.7 (95% CI = 6.9-23.7) (Table 1). A dose-response relationship was evident for duration of smoking as well as for average and cumulative consumption of cigars and cigarillos (Table 2). This pattern was present for smokers of cigars (e.g., OR = 20.2; 95% CI = 8.2-49.8 in the highest category of cumulative consumption) and cigarillos (OR = 35.2; 95% CI = 13.1-94.4) separately, although numbers of case patients and control subjects were small in some of the exposure categories. A strong effect of age at start was present, with a fivefold excess risk among smokers who started before age 20 years as compared with smokers who started after age 26 years. Information on inhalation was available for a total of 74 pure smokers of cigars or cigarillos. The ORs for ever smoking were 5.2 (95% CI = 2.7-10.0) among noninhalers and 28.1 (95% CI = 5.7-22.4) among inhalers.

When predominant (instead of pure) smokers of cigars and cigarillos were considered, 102 case patients and 123 control subjects were classified as exposed (OR = 12.4; 95% CI = 8.7-17.7). ORs were somewhat higher among predominant cigar and cigarillo smokers as compared with pure smokers of each of these forms of tobacco. For example, the OR for high cumulative consumption (>572 g/day × years) was 35.8 (95% CI = 21.5-59.5). Most pure cigar or cigarillo smokers (27 of 43 case patients and 47 of 77 control subjects) were from Germany. The OR for cigar and cigarillo smoking in the German centers was 8.1 (95% CI = 4.5-14.9).

The OR for ever pipe smoking was 7.9 (95% CI = 5.3-11.8) (Table 1) and the results were similar when predominant smokers were considered instead of pure smokers (OR = 8.7; 95% CI = 6.2-12.4, based on 89 exposed case patients and 172 control subjects). A clear dose-response relationship was shown for duration of pipe smoking and cumulative consumption, while there was no clear pattern in risk according to average consumption and age at start (Table 3). Most pure pipe smokers (51 case patients and 103 control subjects) were from Sweden. Because information on inhalation was not available for these subjects, results for lung cancer risk by pipe-smoke inhalation were limited by small numbers and are not presented in detail.

A protective effect of time since quitting was present for pure pipe smokers. Current smokers had an OR of 12.5 (95% CI = 7.7-20.2), while the OR was reduced to 10.3 (95% CI = 5.1-20.5) for 1-14 years and 1.4 (95% CI = 0.5-4.0) for 15 or more years since quitting. Among cigar and cigarillo smokers, a smaller decrease in risk was present after quitting (OR = 10.6, 95% CI = 5.9-19.1 among current smokers; OR = 8.8, 95% CI = 4.0-19.5 for 1-14 years; and OR = 6.9, 95% CI = 3.1-15.1 for 15 or more years of quitting).

The lack of exact correspondence between the categories used in the dose-response analyses for the different tobacco products limited the comparability of the results. We therefore conducted an additional analysis on pure smokers of cigarettes, cigars or cigarillos, and pipes based on continuous variables of consumption after restriction to smokers (Table 4). Although the risk estimates for cigar, cigarillo, and pipe smoking were less precise than those for cigarette smoking, the results showed a comparable carcinogenic risk for all types of tobacco products. Similar results were obtained when nonsmokers were retained in the analysis and the ORs were estimated for the increase in one log-unit of pack-years: 3.3 (95% CI = 3.1-3.6) for cigarettes, 3.3 (95% CI = 1.8-6.0) for cigars and cigarillos, and 2.4 (95% CI = 1.5-4.0) for pipe.

These results were only slightly modified by adjustment for education and exposure to occupational carcinogens: The OR in the highest category of cumulative cigar or cigarillo smoking was 25.4 (95% CI = 13.3-48.7) and that for pipe smoking was 19.3 (95% CI = 10.7-34.7).

When we conducted the analysis by histologic type, we found a significant trend in the risk of squamous cell carcinoma according to cumulative consumption of either cigars and cigarillos or pipe. The OR for the highest exposure category was 54.6 (95% CI = 22.6-132) for cigars or cigarillos and 46.0 (95% CI = 19.0-111) for pipe. The results for small-cell carcinoma and adenocarcinoma were based on relatively small numbers of pure smokers, but they suggested a higher risk for the former (OR = 87.0 [95% CI = 26.2-289] for heavy cigar and cigarillo consumption and 48.0 [95% CI = 11.2-206] for heavy pipe consumption) than for the latter (OR = 2.1 [ 95% CI = 0.3-17.1] and 6.3 [95% CI = 2.0-19.8], respectively).

Discussion

Our study suggests that the lower overall risk of lung cancer among smokers of cigars and pipes as compared with cigarette smokers might be due to lower consumption of tobacco in the former group of smokers. The slopes of the dose-response relations that we have estimated for duration of use and for average and cumulative consumption of cigars, cigarillos, and pipe tobacco are comparable to those for cigarette smoking.

Our comparative analysis was based on weights of 1 g for cigarettes, 4 g for cigars, and 2 g for cigarillos, which represent reasonable averages for traditional European products (Joeckel K-H: personal communication). The consumption of pipe tobacco, on the other hand, was based on the direct amount of pipe tobacco consumed by the smokers. To test the sensitivity of our results to the value for the average weight of cigars, we conducted additional analyses using different assumptions. With an average weight of 5 g, there was a small decrease in the risk estimate for 1 unit of average consumption (OR = 1.041; 95% CI = 1.005-1.078) and cumulative consumption (OR = 1.048; 95% CI = 1.022-1.075). The use of an average weight of 3 g, on the other hand, resulted in an increase in the risk estimates (OR = 1.079 [95% CI = 1.019-1.142] for average consumption and 1.076 [95% CI = 1.038-1.114] for cumulative consumption). Therefore, the risk estimates for pure cigar and cigarillo smoking seem to be comparable to those for cigarette smoking no matter which weight we choose for cigars.

We controlled for the potential confounding effect of education and exposure to occupational carcinogens: These factors did not change appreciably the results. We could not assess the impact of other potential confounders, such as diet and family predisposition to cancer. The participating centers adopted slightly different methods to recruit and interview case patients and control subjects. An additional limitation is the relatively low response rate among control subjects in two of the German centers. We addressed these issues by performing a meta-analysis based on random-effects models, which provided results similar to those of the analysis of the pooled dataset, owing to the lack of significant heterogeneity of the results among centers. In addition, we repeated the analysis after exclusion of one center at a time. The ORs for smoking 1 g/day × year of cigars or cigarillos varied from 1.053 (exclusion of Sweden) to 1.080 (exclusion of Germany 1), those for pipe smoking varied from 1.062 (exclusion of Germany 1) to 1.074 (exclusion of Sweden), and those for cigarette smoking varied from 1.035 (exclusion of Germany 2) to 1.042 (exclusion of Italy 1 or Italy 2). Therefore, the inclusion or exclusion of individual centers did not systematically affect our results.

Although a large number of studies have estimated the risk of lung cancer among cigar and pipe smokers, most reports do not present results for pure smokers of these products because of small numbers. In general, American studies [(1-14) and reviewed in (4)] and a study conducted in seven European regions (15) show a moderately increased risk for cigar and pipe smokers, while studies conducted in Scandinavia provide high-risk estimates, which are comparable to ours (16-19). Only a few studies have included a sufficiently large number of pure cigar and pipe smokers to allow a detailed quantitative analysis. In the Seven Area Study, the risk of lung cancer was higher for smokers of cigarettes alone for 40 years or more (OR = 11.6) than among the comparable groups of pure cigar (OR = 3.0) and pipe (OR = 4.4) smokers (15). In a Swedish cohort study (18), the increase in lung cancer risk was similar for smokers of cigarettes, cigars, and pipes. Results on cigar smokers from the American Cancer Society Cancer Prevention Study I have recently been reported (4): The relative risk among “ primary” cigar smokers was 2.1 (95% CI = 1.6-2.7) and was 3.4 (95% CI = 2.3-4.8) among smokers of five or more cigars per day.

There are several possible explanations for these differences. Although we do not have direct information on the brand or weight of the cigars smoked by our study population, most cigars traditionally smoked in Europe are smaller than regular American cigars. In addition, smokers of cigarillos, corresponding to the American “little cigars,” represent an important group in our study. We are not aware of data on the composition of the tobacco or the smoke of traditional European cigars. The available data on the composition of mainstream smoke of American cigarettes and cigars suggest higher levels of tobacco-specific nitrosamines and tar in smoke from both little and regular cigars than in smoke from cigarettes (20). Different inhalation patterns may also contribute to the differences in the results. The proportion of pure cigar and cigarillo smokers reporting inhalation among the control subjects in our study was lower than that of a previous European study (15) but higher than the proportion found in an American study (13). An additional possible explanation is misclassification of occasional and weak smokers as nonsmokers in some studies.

Only limited information is available on the histologic type of lung cancer among cigar and pipe smokers. In the study in seven European areas, lung cancers from smokers of cigars, pipes, and cigarettes alone had a similar histologic distribution (15) as did cancers from pipe and cigarette smokers in a Swedish study (17), while in an American study, there was a higher proportion of small-cell and squamous cell carcinomas in cigar and pipe smokers than in cigarette smokers (13). In our study, cigar and pipe smoking exerted a nonsignificantly stronger carcinogenic effect on squamous and small-cell carcinomas than on adenocarcinoma. To our knowledge, the effect of age at start and time since quitting smoking on lung cancer risk has not been previously investigated among Western smokers of cigars and pipes.

Consumption of cigars, cigarillos, and pipe tobacco has declined in most European countries during the last decades (21). This trend paralleled a similar decrease that occurred in North America until the 1980s (21). In recent years, this trend has reversed in the United States and cigar smoking is becoming increasingly popular (22,23), in particular among teenagers (23,24), and a similar pattern might be expected in Europe. The same pattern does not seem to take place for pipe smoking (25). The results of our study suggest that the lower risk of lung cancer among cigar and pipe smokers that has been reported in many studies might be explained by a lower cumulative consumption and a later age at start in the former group of smokers and not to a lower carcinogenic potency of cigar and pipe smoke as compared with cigarette smoke. With respect to cigars, our results reflect the experience of smoking traditional European products and might not reflect the current pattern of cigar smoking in the United States. Regardless, control of cigar and pipe smoking is as important as cigarette smoking control for the prevention of lung cancer.

Table 1.

Odds ratios of lung cancer for various categories of tobacco use among ever smokers, adjusted for age and study center

Category of tobacco use*
No. of case patients
No. of control subjects
Odds ratio
95% confidence interval
Nonsmokers 117 1750 1.0 Referent 
Cigars, pure smokers 16 42 5.6 2.9-10.6 
Cigarillos, pure smokers 21 31 12.7 6.9-23.7 
Cigars and cigarillos, pure smokers†43 77 9.0 5.8-14.1 
Pipe, pure smokers 61 129 7.9 5.3-11.8 
Cigarettes, pure smokers 4204 3930 14.9 12.3-18.1 
Mixed smokers‡1182 1309 12.7 10.3-15.6 
Category of tobacco use*
No. of case patients
No. of control subjects
Odds ratio
95% confidence interval
Nonsmokers 117 1750 1.0 Referent 
Cigars, pure smokers 16 42 5.6 2.9-10.6 
Cigarillos, pure smokers 21 31 12.7 6.9-23.7 
Cigars and cigarillos, pure smokers†43 77 9.0 5.8-14.1 
Pipe, pure smokers 61 129 7.9 5.3-11.8 
Cigarettes, pure smokers 4204 3930 14.9 12.3-18.1 
Mixed smokers‡1182 1309 12.7 10.3-15.6 

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Table 1.

Odds ratios of lung cancer for various categories of tobacco use among ever smokers, adjusted for age and study center

Category of tobacco use*
No. of case patients
No. of control subjects
Odds ratio
95% confidence interval
Nonsmokers 117 1750 1.0 Referent 
Cigars, pure smokers 16 42 5.6 2.9-10.6 
Cigarillos, pure smokers 21 31 12.7 6.9-23.7 
Cigars and cigarillos, pure smokers†43 77 9.0 5.8-14.1 
Pipe, pure smokers 61 129 7.9 5.3-11.8 
Cigarettes, pure smokers 4204 3930 14.9 12.3-18.1 
Mixed smokers‡1182 1309 12.7 10.3-15.6 
Category of tobacco use*
No. of case patients
No. of control subjects
Odds ratio
95% confidence interval
Nonsmokers 117 1750 1.0 Referent 
Cigars, pure smokers 16 42 5.6 2.9-10.6 
Cigarillos, pure smokers 21 31 12.7 6.9-23.7 
Cigars and cigarillos, pure smokers†43 77 9.0 5.8-14.1 
Pipe, pure smokers 61 129 7.9 5.3-11.8 
Cigarettes, pure smokers 4204 3930 14.9 12.3-18.1 
Mixed smokers‡1182 1309 12.7 10.3-15.6 

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Table 2.

Odds ratio of lung cancer from cigar and cigarillo smoking, adjusted for age and center


No. of case patients
No. of control subjects
Odds ratio
95% confidence interval
P for trend*
Nonsmokers 117 1750 1.0 Referent 
Duration of tobacco use, y 
 0.1-13.0 21 3.1 1.0-9.4 
 13.1-26.0 20 4.3 1.6-11.9 
 26.1-39.0 12 17 10.3 4.7-22.7 
 ⩾39.1 22 19 20.7 10.5-41.1 .0003 
Average consumption of tobacco, g/day 
 0.1-5.0 22 3.4 1.3-9.5 
 5.1-12.0 10 25 6.2 2.8-13.7 
 12.1-15.0 11 7.8 2.6-23.4 
 ⩾15.1 23 19 21.1 10.7-41.7 .01 
Cumulative consumption of tobacco, g/day × y 
 1-82 19 2.4 0.7-8.5 
 83-210 20 3.2 1.1-9.8 
 211-504 19 6.0 2.5-14.6 
 ⩾505 28 19 26.9 14.1-51.3 <.0001 
Age at start of tobacco use, y 
 ⩽19 20 20 17.0 8.6-33.4 
 20-26 16 23 10.5 5.3-21.1 
 ⩾27 34 3.4 1.5-8.0 .002 

No. of case patients
No. of control subjects
Odds ratio
95% confidence interval
P for trend*
Nonsmokers 117 1750 1.0 Referent 
Duration of tobacco use, y 
 0.1-13.0 21 3.1 1.0-9.4 
 13.1-26.0 20 4.3 1.6-11.9 
 26.1-39.0 12 17 10.3 4.7-22.7 
 ⩾39.1 22 19 20.7 10.5-41.1 .0003 
Average consumption of tobacco, g/day 
 0.1-5.0 22 3.4 1.3-9.5 
 5.1-12.0 10 25 6.2 2.8-13.7 
 12.1-15.0 11 7.8 2.6-23.4 
 ⩾15.1 23 19 21.1 10.7-41.7 .01 
Cumulative consumption of tobacco, g/day × y 
 1-82 19 2.4 0.7-8.5 
 83-210 20 3.2 1.1-9.8 
 211-504 19 6.0 2.5-14.6 
 ⩾505 28 19 26.9 14.1-51.3 <.0001 
Age at start of tobacco use, y 
 ⩽19 20 20 17.0 8.6-33.4 
 20-26 16 23 10.5 5.3-21.1 
 ⩾27 34 3.4 1.5-8.0 .002 

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Table 2.

Odds ratio of lung cancer from cigar and cigarillo smoking, adjusted for age and center


No. of case patients
No. of control subjects
Odds ratio
95% confidence interval
P for trend*
Nonsmokers 117 1750 1.0 Referent 
Duration of tobacco use, y 
 0.1-13.0 21 3.1 1.0-9.4 
 13.1-26.0 20 4.3 1.6-11.9 
 26.1-39.0 12 17 10.3 4.7-22.7 
 ⩾39.1 22 19 20.7 10.5-41.1 .0003 
Average consumption of tobacco, g/day 
 0.1-5.0 22 3.4 1.3-9.5 
 5.1-12.0 10 25 6.2 2.8-13.7 
 12.1-15.0 11 7.8 2.6-23.4 
 ⩾15.1 23 19 21.1 10.7-41.7 .01 
Cumulative consumption of tobacco, g/day × y 
 1-82 19 2.4 0.7-8.5 
 83-210 20 3.2 1.1-9.8 
 211-504 19 6.0 2.5-14.6 
 ⩾505 28 19 26.9 14.1-51.3 <.0001 
Age at start of tobacco use, y 
 ⩽19 20 20 17.0 8.6-33.4 
 20-26 16 23 10.5 5.3-21.1 
 ⩾27 34 3.4 1.5-8.0 .002 

No. of case patients
No. of control subjects
Odds ratio
95% confidence interval
P for trend*
Nonsmokers 117 1750 1.0 Referent 
Duration of tobacco use, y 
 0.1-13.0 21 3.1 1.0-9.4 
 13.1-26.0 20 4.3 1.6-11.9 
 26.1-39.0 12 17 10.3 4.7-22.7 
 ⩾39.1 22 19 20.7 10.5-41.1 .0003 
Average consumption of tobacco, g/day 
 0.1-5.0 22 3.4 1.3-9.5 
 5.1-12.0 10 25 6.2 2.8-13.7 
 12.1-15.0 11 7.8 2.6-23.4 
 ⩾15.1 23 19 21.1 10.7-41.7 .01 
Cumulative consumption of tobacco, g/day × y 
 1-82 19 2.4 0.7-8.5 
 83-210 20 3.2 1.1-9.8 
 211-504 19 6.0 2.5-14.6 
 ⩾505 28 19 26.9 14.1-51.3 <.0001 
Age at start of tobacco use, y 
 ⩽19 20 20 17.0 8.6-33.4 
 20-26 16 23 10.5 5.3-21.1 
 ⩾27 34 3.4 1.5-8.0 .002 

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Table 3.

Odds ratio of lung cancer from pipe smoking, adjusted for age and center


No. of case patients
No. of control subjects
Odds ratio
95% confidence interval
P for trend*
Nonsmokers 117 1750 1.0 Referent 
Duration of tobacco use, y 
 0.1-20.0 33 1.3 0.4-4.5 
 20.1-32.0 33 3.4 1.4-8.0 
 32.1-44.0 21 33 13.3 7.2-24.9 
 ⩾44.1 30 30 19.1 10.4-35.1 <.0001 
Average consumption of tobacco, g/day 
 0.1-3.5 10 2.2 0.5-10.4 
 3.6-5.0 22 54 7.9 4.3-14.3 
 5.1-10.7 18 4.8 1.9-12.6 
 ⩾10.8 31 47 12.4 7.2-21.4 .1 
Cumulative consumption of tobacco, g/day × y 
 1-71 31 1.3 0.4-4.4 
 72-157 13 34 7.6 3.8-15.4 
 158-382 15 32 8.0 4.0-15.7 
 ⩾383 30 32 18.3 10.2-32.8 .0006 
Age at start of tobacco use, y 
 ⩽19 27 48 9.6 5.6-16.7 
 20-26 20 52 6.3 3.5-11.2 
 ⩾27 14 29 8.2 4.1-16.3 .4 

No. of case patients
No. of control subjects
Odds ratio
95% confidence interval
P for trend*
Nonsmokers 117 1750 1.0 Referent 
Duration of tobacco use, y 
 0.1-20.0 33 1.3 0.4-4.5 
 20.1-32.0 33 3.4 1.4-8.0 
 32.1-44.0 21 33 13.3 7.2-24.9 
 ⩾44.1 30 30 19.1 10.4-35.1 <.0001 
Average consumption of tobacco, g/day 
 0.1-3.5 10 2.2 0.5-10.4 
 3.6-5.0 22 54 7.9 4.3-14.3 
 5.1-10.7 18 4.8 1.9-12.6 
 ⩾10.8 31 47 12.4 7.2-21.4 .1 
Cumulative consumption of tobacco, g/day × y 
 1-71 31 1.3 0.4-4.4 
 72-157 13 34 7.6 3.8-15.4 
 158-382 15 32 8.0 4.0-15.7 
 ⩾383 30 32 18.3 10.2-32.8 .0006 
Age at start of tobacco use, y 
 ⩽19 27 48 9.6 5.6-16.7 
 20-26 20 52 6.3 3.5-11.2 
 ⩾27 14 29 8.2 4.1-16.3 .4 

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Table 3.

Odds ratio of lung cancer from pipe smoking, adjusted for age and center


No. of case patients
No. of control subjects
Odds ratio
95% confidence interval
P for trend*
Nonsmokers 117 1750 1.0 Referent 
Duration of tobacco use, y 
 0.1-20.0 33 1.3 0.4-4.5 
 20.1-32.0 33 3.4 1.4-8.0 
 32.1-44.0 21 33 13.3 7.2-24.9 
 ⩾44.1 30 30 19.1 10.4-35.1 <.0001 
Average consumption of tobacco, g/day 
 0.1-3.5 10 2.2 0.5-10.4 
 3.6-5.0 22 54 7.9 4.3-14.3 
 5.1-10.7 18 4.8 1.9-12.6 
 ⩾10.8 31 47 12.4 7.2-21.4 .1 
Cumulative consumption of tobacco, g/day × y 
 1-71 31 1.3 0.4-4.4 
 72-157 13 34 7.6 3.8-15.4 
 158-382 15 32 8.0 4.0-15.7 
 ⩾383 30 32 18.3 10.2-32.8 .0006 
Age at start of tobacco use, y 
 ⩽19 27 48 9.6 5.6-16.7 
 20-26 20 52 6.3 3.5-11.2 
 ⩾27 14 29 8.2 4.1-16.3 .4 

No. of case patients
No. of control subjects
Odds ratio
95% confidence interval
P for trend*
Nonsmokers 117 1750 1.0 Referent 
Duration of tobacco use, y 
 0.1-20.0 33 1.3 0.4-4.5 
 20.1-32.0 33 3.4 1.4-8.0 
 32.1-44.0 21 33 13.3 7.2-24.9 
 ⩾44.1 30 30 19.1 10.4-35.1 <.0001 
Average consumption of tobacco, g/day 
 0.1-3.5 10 2.2 0.5-10.4 
 3.6-5.0 22 54 7.9 4.3-14.3 
 5.1-10.7 18 4.8 1.9-12.6 
 ⩾10.8 31 47 12.4 7.2-21.4 .1 
Cumulative consumption of tobacco, g/day × y 
 1-71 31 1.3 0.4-4.4 
 72-157 13 34 7.6 3.8-15.4 
 158-382 15 32 8.0 4.0-15.7 
 ⩾383 30 32 18.3 10.2-32.8 .0006 
Age at start of tobacco use, y 
 ⩽19 27 48 9.6 5.6-16.7 
 20-26 20 52 6.3 3.5-11.2 
 ⩾27 14 29 8.2 4.1-16.3 .4 

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Table 4.

Analysis of cigarette, cigar and cigarillo, and pipe smoking based on continuous variables*

Category of tobacco use
Duration of smoking†
Average consumption‡
Cumulative consumption§
OR
95% CI
OR
95% CI
OR
95% CI
Pure cigarette smokers 1.084 1.078-1.091 1.051 1.045-1.057 1.040 1.038-1.042 
Pure cigar/cigarillo smokers 1.058 1.019-1.098 1.057 1.010-1.105 1.061 1.030-1.092 
Pure pipe smokers 1.091 1.047-1.137 1.058 0.976-1.146 1.066 1.025-1.109 
Category of tobacco use
Duration of smoking†
Average consumption‡
Cumulative consumption§
OR
95% CI
OR
95% CI
OR
95% CI
Pure cigarette smokers 1.084 1.078-1.091 1.051 1.045-1.057 1.040 1.038-1.042 
Pure cigar/cigarillo smokers 1.058 1.019-1.098 1.057 1.010-1.105 1.061 1.030-1.092 
Pure pipe smokers 1.091 1.047-1.137 1.058 0.976-1.146 1.066 1.025-1.109 

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Table 4.

Analysis of cigarette, cigar and cigarillo, and pipe smoking based on continuous variables*

Category of tobacco use
Duration of smoking†
Average consumption‡
Cumulative consumption§
OR
95% CI
OR
95% CI
OR
95% CI
Pure cigarette smokers 1.084 1.078-1.091 1.051 1.045-1.057 1.040 1.038-1.042 
Pure cigar/cigarillo smokers 1.058 1.019-1.098 1.057 1.010-1.105 1.061 1.030-1.092 
Pure pipe smokers 1.091 1.047-1.137 1.058 0.976-1.146 1.066 1.025-1.109 
Category of tobacco use
Duration of smoking†
Average consumption‡
Cumulative consumption§
OR
95% CI
OR
95% CI
OR
95% CI
Pure cigarette smokers 1.084 1.078-1.091 1.051 1.045-1.057 1.040 1.038-1.042 
Pure cigar/cigarillo smokers 1.058 1.019-1.098 1.057 1.010-1.105 1.061 1.030-1.092 
Pure pipe smokers 1.091 1.047-1.137 1.058 0.976-1.146 1.066 1.025-1.109 

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Supported in part by a grant of the European Commission, DG-XII, Biomed-1 programme (contract No. BMH1-CT93-1047).

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Effect on mortality of switching from cigarettes to pipes or cigars

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Effects of type of smoking (pipe, cigars or cigarettes) on biological indices of tobacco exposure and toxicity

Although all forms of smoking are harmful, smoking pipes or cigars is associated with lower exposure to the lethal products of tobacco products and lower levels of morbidity and mortality than smoking cigarettes. Cytochrome P-450-1A (CYP1A) is a major pathway activating carcinogens from tobacco smoke. Our primary aim was to compare CYP1A2 activity in individuals smoking pipes or cigars only, cigarettes only and in non-smokers. We studied 30 smokers of pipes or cigars only, 28 smokers of cigarettes only, and 30 non-smokers male subjects matched for age. CYP1A2 activity was assessed as the caffeine metabolic ratio in plasma. One-day urine collection was used for determining exposure to products of tobacco metabolism. Nitrosamine and benzo[a]pyrene DNA adducts were measured in lymphocytes. CYP1A2 activity was greater (p<0.0001) in cigarette smokers (median: 0.61; interquartile range: 0.52-0.76) than in pipe or cigar smokers (0.27; 0.21-0.37) and non-smokers (0.34; 0.25-0.42) who did not differ significantly. Urinary cotinine and 1-hydroxypyrene levels were higher in cigarette smokers than in pipe or cigar smokers and higher in the later than in non-smokers. DNA adducts levels were significantly lower in pipe or cigar smokers than in cigarette smokers. In multivariate analysis, cigarette smoking was the only independent predictor of CYP1A2 activity (p<0.0001) and of 1-hydroxypyrene excretion in urine (p=0.0012). In this study, pipe or cigar smoking was associated with lower exposure to products of tobacco metabolism than cigarette smoking and to an absence of CYP1A2 induction. Cigarette smoking was the only independent predictor of CYP1A2 activity in smokers. However, inhalation behaviour, rather than the type of tobacco smoked, may be the key factor linked to the extent of tobacco exposure and CYP1A2 induction. Our results provide a reasonable explanation for the results of epidemiological studies showing pipe or cigar smoking to present fewer health hazards than cigarette smoking.

Sours: https://pubmed.ncbi.nlm.nih.gov/16884817/
Baraccini Pipes at P\u0026C

Mortality and life expectancy in relation to long‐term cigarette, cigar and pipe smoking: The Zutphen Study

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