Cigarette use continues to decline in the United States, but, according to a recent CDC report(www.cdc.gov), that reduction was counterbalanced by a spike in the use of cigars and pipe tobacco.
Physical differences between combustible tobacco products
Although traditional cigarette smoking decreased nearly 33 percent in the United States between 2000 and 2011, "consumption of loose tobacco and cigars increased 123.1 percent over the same period," says the report.
The report suggests that the rise in cigar and pipe tobacco smokers comes partly as a result of the tobacco industry dodging the 2009 increase in the federal tobacco excise tax, which created tax disparities between cigarettes and other tobacco products (OTPs). Because cigars and the pipe tobacco used in roll-your-own (RYO) cigarettes are not taxed at the higher rate, they are marketed to consumers as a lower-priced alternative, a practice the CDC calls "a particular public health concern." Diminishing the public health impact of the excise tax, says the agency, curbs efforts to prevent youth smoking, reduce consumption and prompt quitting.
- A recent report by the CDC indicates that although traditional cigarette smoking decreased nearly 33 percent in the United States between 2000 and 2011, consumption of loose tobacco and cigars -- known collectively as other tobacco products (OTPs) -- increased more than 123 percent during the same period.
- Pipe tobacco, which often is used in so-called roll-your-own cigarettes, and cigars are not subject to the 2009 increase in the federal tobacco excise tax, which has prompted tobacco companies to market these OTPs to consumers as a lower-priced alternative.
- Two bills currently circulating on Capitol Hill are designed to permanently block the FDA from regulating high-end cigars.
A more recent report(www.cdc.gov) from the CDC brings the issue into even sharper focus, pointing out that although overall tobacco use among American middle- and high-school students continued to decline from 2000 to 2011, the rate of that decline slowed noticeably after 2003. Some of this deceleration, according to a CDC release(www.cdc.gov), can be attributed to the fact that tobacco use remains high among high-school students overall and, in fact, the prevalence of cigar use is rising among black high-school students, from slightly more than 7 percent in 2009 to almost 12 percent in 2011.
"In 2011, cigar use among high-school males (15.7 percent) was comparable to cigarette use (17.7 percent)," says the release. "Cigar use includes the use of cigarette-like cigars that can be packaged and smoked like typical cigarettes, but are taxed at a lower rate, making them more appealing and accessible to youth. While they contain the same toxic chemicals as cigarettes, no cigars are subject to restrictions on flavorings and misleading descriptors such as 'light' or 'low tar.'"
Family physicians need to be aware of this trend, says FP Thomas Houston, M.D., of Dublin, Ohio.
"You have to figure out what (your patients) are smoking," Houston says. "We don’t see a lot of pipe smoking compared to what we saw a generation ago, but what we are seeing is that shift that the CDC talked about … to cigars and roll-your-own (cigarettes) using pipe tobacco."
Houston, the current chair of the AAFP Commission on Health of the Public and Science and an ex officio member of the of the Academy's Tobacco Cessation Advisory Committee (TCAC), says that certain risks accrue to pipe and cigar smokers -- lip, tongue and esophageal cancers, for example -- because it's a heavier tobacco.
"Depending how much they smoke, an average pipe smoker will have an almost four times higher incidence of heart disease as compared to a nonsmoker," he says. "Interestingly, their lung cancer risks are not inconsequential, either, particularly if they switched from cigarettes to pipes. That becomes even more of an issue with cigar smokers."
That's because secondary cigar smokers -- those who switched from cigarettes to OTPs -- inhale more than primary cigar smokers, according to Houston, which increases their lung cancer risk. This population also carries an increased risk of heart disease.
The AAFP is on record saying that increasing taxes on tobacco "provides a major disincentive to potential buyers, especially youth," and encourages development of health education programs funded through the cigarette tax. Below are some of the smoking cessation programs the Academy offers, as well as related policies and clinical recommendations:
- Ask and Act: The AAFP's evidence-based tobacco cessation program encourages family physicians to ASK their patients about tobacco use, then ACT to help them quit.
- Office Champions(3 page DOC): The Academy's Office Champions Tobacco Cessation National Dissemination Project provides practical strategies through an online training module, live teleconferences and assorted materials for making system changes in medical practices to improve tobacco cessation activities.
- Tar Wars: Tar Wars works in schools to educate students about being tobacco-free, provide them with the tools to make positive decisions regarding their health, and promote personal responsibility for their well-being.
- AAFP Policy on Tobacco Use-Prevention and Cessation
- AAFP clinical recommendations regarding tobacco use
One particular at-risk population, says Houston, is young smokers who buy low-end cigar products, mainly for cost reasons. In urban African-American subculture, Black & Mild brand "little cigars" are particularly popular.
"That is a brand many of these kids prefer," Houston says. "They're cheap, they've got flavors and many of (these young smokers) don't think that the risk is very high because they aren't cigarettes.
"In fact, many epidemiologists think that we are undercounting adolescent smokers in this population because we are not asking them what brand they smoke or asking specifically about Black & Milds. We need to do that."
Although OTPs currently should be subject to the FDA's cigarette regulations, says Houston, those regulations are not enforced. And two bills currently circulating in the U.S. House of Representatives and Senate are designed to exempt OTPs from these regulations.
H.R. 1639(www.govtrack.us) and S.1461(www.govtrack.us) propose exempting "traditional large and premium" cigars from FDA regulation and from the percentage-of-price tax rates applied to cigarettes. The bills define these traditional and premium cigars as "any roll of tobacco that is wrapped solely in leaf tobacco, contains no filter, and weighs at least 6 pounds per 1,000 count." Passage of the legislation would ensure these products are assessed a simple weight-based tax, which the AAFP opposes.
TCAC chair Richard Feldman, M.D., of Indianapolis, who wrote the Academy's current position on the excise tax, says there is a "huge, gaping hole" in the federal regulations, and OTPs need to be taxed at rates parallel to those used for cigarettes.
Notably, there has been some movement in this direction at the federal level.
When President Obama signed the Surface Transportation Extension Act of 2012 -- H.R. 4348 -- into law on July 6, for example, a late amendment that defines retailers with RYO machines as tobacco manufacturers went into effect. These stores now must register with the federal government and are subject to the same requirements as traditional cigarette manufacturers.
Meanwhile, TCAC member Saria Carter Saccocio, M.D., of Danville, Va., tells AAFP News Now that the recent CDC report has opened her eyes a bit and that she will tweak her process to address the OTP issue with her patients.
"(OTP) isn't something that I deal with on a regular basis, but patients that smoke these 'cigarillos' are starting to be more common, and I would suspect that patients rolling their own tobacco are not far behind," she says. "As faculty at a family medicine residency program, OTP will certainly be a topic of discussion when precepting residents in the clinic."