What is your doctor's opinion on cigar smoking

[Peter11216]

Well I guess this day has been haunting me for years, as one of the physicians on our forum I finally must throw the gauntlet down and pitch in with my 2 cents. I hope my comments do not land me in court for a malpractice suit!! Here goes...

I have just completed a literature search with my main source being a physician resource known as UP-TO-DATE. This database compiles the latest studies and them summarizes the results. There have been hundreds of studies looking at the effects of cigarette smoking on the body, there have been exactly ZERO studies looking at Cigars. This means that there is NO Evidence Based Medical data that objectively looks at cigar smoking.

Thanks very much for the comments. I must comment, however, that I'm not sure you are correct about the number of studies looking at cigars. After reading your post, I thought I remembered seeing a study of cigar health effects, and did a google search. Several things came up, but probably the best page is hosted by http://www.cigargroup.com/

The Internet Cigar Group claims that its mission is to "is to provide a wealth of information for the cigar smoker in a complete and comprehensive format." They have a page listing many studies on the health effects of cigar smoking. I have yet to look at any in depth, but it does not appear correct that there is "NO Evidence Based Medical data that objectively looks at cigar smoking," as you claim above.

As of 2002, there is this compilation of research on cigars and health: CIGARS AND CANCER - SOME IMPORTANT PAPERS 2002 Update copyright 2002 by Marc J. Schneiderman, M.D. and the Internet Cigar Group

I have no idea whether this review is legit. However, it appears to have been compiled by individuals who support cigar smoking. It would be cool if you could look at what's here, and give your opinion. With respect to cancer, the page does say, "No perfect study has at yet been written.. Given the number of articles, however, and the general agreement in some of the findings, some conclusions can be drawn between the relationship of cigars and cancer."

I also noted that there are studies on cigars that have appeared in JAMA. Such as "Health risks associated with cigar smoking"

Best,

Pete

[Kangaroo495]

Haven't been to a doc in Australia for ages (obviously the docs in Russia are not going to tell you to quit smoking... morelike encourage you to continue). On the previous occasion in Oz, the doc seemed fine with the cigar smoking. Though she did mention that it was having some kind of effect on my eyes. She examined my eyes and immediately mentioned that I am a smoker.

[PigFish]

I tell him that I only smoke before my visit so he cannot smell cheese burger on my breath! -

[Stalebread]

I tell him that I only smoke before my visit so he cannot smell cheese burger on my breath! -

[El Presidente]

I tell him that I only smoke before my visit so he cannot smell cheese burger on my breath! -

We have a bet as to whether a "smoking/drinking illness" or "death by misadventure" is going to take me first

[laficion]

I'm not certain what my physician's opinion is of my cigar habits. I'll have to ask him the next time we're smoking cigars together.

I have 4 doctors, general physicians, that are members of our cigar club, so .........

[StumpyJoe]

TropicalDoc, fantastic post!

As for myself, about ten years ago I had to have a gum graft for my mouth for a problem that went unattended for too long. Asked my gum graft specialist dentist about the whole smoking cigars and the effect it might have on my gums. He asked how often I smoked and I replied 1-2 a week with an occassional bump of 5 a week. He chuckled. He said if I had five a day it would be an issue but five a week was no problem. He said it's a case of build up and an occasional cigar just didn't provide a build up the body couldn't remedy. He reminded me that brushing and flossing were important, especially some time after smoking, and that I should enjoy my cigars. He also recommended no cigars until after my gum graft fully healed. After the graft healed both my specialist and regular dentists said it was the best results of a graft they had ever seen. No problems with my gums since then and I rarely get cavities now (1 every ten years or so).

Smoke 'em if you got 'em!

[PigFish]

We have a bet as to whether a "smoking/drinking illness" or "death by misadventure" is going to take me first

Mate... with some of those stupid emails that you get from your customers, I am surprised that you have not killed yourself with a blunt object by now!!! -LOL I think you are a ******* stoic, pehaps invincible!!! -the Pig

[Nino]

My doctor smokes cigars,

Nuff said...

First : Thank you Tropical Doc for the well measured and credible post on cigars and health issues.

My doctor ( internist ) enjoys cigars as well, so I invited him in 2008 to one of our cigar dinners as a guest and he held a 30 minute seminar on "Cigar - a dangerous lover / Health aspects of cigar smoking" for us.

http://www.flyingcigar.de/smoking_cigars/2...meinem_arzt.php

He basically confirmed all points made by TropicalDoctor in his post and left us quite re-assured - with the advice of having specific chek-ups regularly on throat, mouth, stomach.

Besides that, my pharmacist provides us with one of the best cigar lounges in Germany so I guess we can enjoy cigars without much fear here and relax about the health aspect.

Everytime I visit my doctor I bring him nice stick or two - he's happy as a cat ...

[TankerT]

I have several close family members (brother, uncles, cousins) that are physicians. We've discussed this. Basically, their comments have been:

1- A doctor (in the US) is often going to tell you what is going to keep them from being sued.

2- It is called the practice of medicine for a reason. Doctors don't know nearly as much as people would like to think they do.

3- It wasn't long ago that physicians would recommend one brand of cigarette over another.

4- Most things in moderation are not really a serious danger to you.

5- None of them were aware of a reputable published study on cigar smoking.

[Professor Twain]

Thanks very much for the comments. I must comment, however, that I'm not sure you are correct about the number of studies looking at cigars. After reading your post, I thought I remembered seeing a study of cigar health effects, and did a google search. Several things came up, but probably the best page is hosted by http://www.cigargroup.com/

The Internet Cigar Group claims that its mission is to "is to provide a wealth of information for the cigar smoker in a complete and comprehensive format." They have a page listing many studies on the health effects of cigar smoking. I have yet to look at any in depth, but it does not appear correct that there is "NO Evidence Based Medical data that objectively looks at cigar smoking," as you claim above.

As of 2002, there is this compilation of research on cigars and health: CIGARS AND CANCER - SOME IMPORTANT PAPERS 2002 Update copyright 2002 by Marc J. Schneiderman, M.D. and the Internet Cigar Group

I have no idea whether this review is legit. However, it appears to have been compiled by individuals who support cigar smoking. It would be cool if you could look at what's here, and give your opinion. With respect to cancer, the page does say, "No perfect study has at yet been written.. Given the number of articles, however, and the general agreement in some of the findings, some conclusions can be drawn between the relationship of cigars and cancer."

I also noted that there are studies on cigars that have appeared in JAMA. Such as "Health risks associated with cigar smoking"

Best,

Pete

I'm glad to see TropicalDoc's comments and the reply by Pete. I've tried to look closely at the scientific literature on the health effects of cigar smoking and there is very little good quality research. Many studies create a category of "cigar smokers", or "cigar and pipe smokers" but fail to sort out important subgroups. For example it is important to separate out "primary cigar smokers" who do not have the additional risk of current or past cigarette smoking. It's also important to study the relationship of dose of exposure to possible health problems associated with cigar smoking.

The best review I have found is by Dr. David Burns, titled "Cigar Smoking: Overview and Current State of the Science". It was published in 1998 in Smoking and Tobacco Control Monograph No. 9. It is available at the following web site: Cigar Smoking State of the Science I'm going to provide a pretty detailed summary of the findings.

Figure 2 on page 5 provides a good comparison of the risks of all primary cigar smokers with cigarette smokers. You can see that the risks are much lower for cigar smokers.

The most important information is shown in Table 1 on page 6. You will see that, compared with nonsmokers, cigar smokers who smoke 1-2 cigars per day have NO SIGNIFICANT INCREASES IN ALL CAUSES OF DEATH, ANY KIND OF CANCER, COPD, OR CORONARY HEART DISEASE. These are relative risk statistics, comparing to nonsmokers. For example people who smoke 1-2 cigars per day have a risk ratio of 1.02 compared to nonsmokers, or 2% increase, but the 95% confidence interval crosses the number 1.0, indicating that the 1-2 cigar a day group's risk compared to nonsmokers is not statistically different. Note that the risk ratio for coronary heart disease for those smoking 1-2 cigars a day is .98, meaning a 2% LOWER risk of CHD. This is also not statistically significant. In sum, the differences between people smoking 1-2 cigars a day and nonsmokers can't be detected in this study. However, you can see that people smoking many more cigars have much increased risks. For example, smoking 5+ cigars a day is associated with a 17% increased risk of death, a 15.94 times risk of cancer of buccal cavity and pharynx. Even this risk pales compared to people smoking over a pack a day of cigarettes, who show an 88% increased risk of death, and 65% increased risk of heart disease. The bottom of this table, on page 7, shows that health risks of cigar smoking increase greatly with increased depth of inhalation.

Note that the article itself does not highlight these conclusions that low levels of cigar smoking appear to be relatively safe. The conclusions shown on page 19 are relatively dire. I would say that the spin is pretty negative, given that most cigar smokers probably smoke only 1-2 cigars per day.

You will never read this information in an announcement from the American Cancer Society of Center for Disease Control, however. These groups are committed to a dogmatic view that any exposure to tobacco is harmful. They are not interested in informing the public about risk reduction strategies for tobacco and will never publish a document stating that smoking 1-2 cigars a day is not associated with significant health risks. The American Cancer Society and National Cancer Institute will also not be eager to fund research that identifies safe exposures to environmental smoke.

For anyone interested in this general issue I recommend you follow the blog published by Dr. Michael Siegal of the Boston University College of Public Health. He is NOT pro smoking but objects to the outrageous lies and misrepresentations of science put forth by the rabid anti tobacco groups. The blog is at http://tobaccoanalysis.blogspot.com/

There are lots of unanswered questions about this whole area. For example, people who take up cigar smoking later in life probably have much less risk due to less exposure. It's likely that people who smoke outdoors have less risk than those smoking in poorly ventilated environments where they take in lots of second hand smoke. It would be ideal if we had new knowledge about the health effects of primary cigar smoking, but it's not a top priority for research. Since no agency is going to fund research on these topics it will be very difficult to know the answers.

So, there is some good practical advice we can draw, even if the research in this article is could be improved on. People smoking less than 3 cigars a day are facing minimal health risk. People smoking larger amounts of cigars, those inhaling, and those who are current or former cigarette smokers have greater risks.

Hope this is useful.

[celsis]

My doctor asks me if I smoke every time I go to see him! He's got a worse memory than me and I'm on Simvastatin! I keep telling him I smoke cigars and he keeps going mmmhhhggggg.............

[asmith]

Well as my best mate is my doctor and he smokes more than I do, he drinks more than I do, and takes more drugs than I do. I feel he isn't going to be complaining about my cigar smoking.

[Stalebread]

There's good info here, Gentlemen.

Thanks!

[Rogers72]

I have never mentioned that I do smoke cigars to my Dr. I'm sure he has aksed if I "smoke" to which my reply is always "no". I only smoke 3-5 cigars per week and I refuse to throw myself into the same category as someone who inhales 2 packs of cigs per day. For me, it is an indulgence which i partake in moderation.

[Murri]

Some life Insurance companies ask about tobacco use and some specifically ask about cigarettes.

Not sure if it is relevant but no mention of cigars.

I would think the legal staff would have clarified this.

Guessing just an oversight on their part?

My current company asks about cigarettes, so my answer is no.

[drake2k]

Ironically, it was my cardiologist who first introduced me to Cuban cigars. I had been smoking NCs for years. We were at a party together and he offered me a SCH El Morro. It was the best cigar of my life. He says that smoking cigars in moderation (7 to 10 a week) has no health effects at all, including someone with a history of heart disease.

Frankly, I think it can be a net positive, taking into account the health benefits of a little relaxation.

Of course, my wife says I can justify anything.

[cigcars]

Some life Insurance companies ask about tobacco use and some specifically ask about cigarettes.

Not sure if it is relevant but no mention of cigars.

I would think the legal staff would have clarified this.

Guessing just an oversight on their part?

My current company asks about cigarettes, so my answer is no.

I don't wanna take any chances with my insurance company tryin' to pull a fast one and back out of paying up when I croak because of checking "No" on the "Do You Use Tobacco?" box...and they find a trace of nicotine from one or more of my fine Havanas on my remains! I wouldn't put it past them with big companies behaving the way they do these days.

[uk1]

I have purposefully chosen a doctor who is fatter than me, smokes and drinks whiskey. This has cured the problem.

[PigFish]

I don't wanna take any chances with my insurance company tryin' to pull a fast one and back out of paying up when I croak because of checking "No" on the "Do You Use Tobacco?" box...and they find a trace of nicotine from one or more of my fine Havanas on my remains! I wouldn't put it past them with big companies behaving the way they do these days.

You are right on the money here Janet! If I believed in death insurance, I would not fib on the contract. A breach of contract is a breach of contract no matter how big or how small the player. If you want your intended beneficiaries to get what you have paid for and you have acted dishonestly while contracting, your loved ones will lose! In this case you can't cheat the hangman, and the hangman is the dishonest individual.

I highly doubt there are oversights on these contracts. If it asks tobacco use it means chaw to Old Toads and that includes your occasional use of Habanos. Some companies recognize that cigarettes are their nemisis and that is all they ask about, as a means to be competitive on these policies. While it looks like the insurance companie has got all the cards they make no money if they don't sell policies. In that right they need to be competitive and take some risk. They are in the risk/reward business, just as you and I are in smoking cigars. We weigh the risk of a few cigars a week with the knowledge that what we are doing might shorten our lives.

Lying about the risk in any case is stupid. Understanding the risk and recognizing that it may be a large or a small one depending on many factors, including genetics, is in my mind the sensible thing to do.

Frankly, I believe I risk more climbing on a horse, my Harley, or using a chain saw! I have a heart condition and have had a heart attack. While smoking could have played a part and I recognize it, I don't believe that it was a large role. I have never smoked a cigarette in my life. Even a lung full of cigar smoke will make me cough. Mine is genetics and poor diet for a guy with my genetics. I just can't eat what many others eat and have to take meds for my cholesterol. Mine was high before they invented statins. It was high when my diet consisted of less than 10 grams of saturated fat a day, I ate right and raced motorcycles every other weekend. It is just the way the Lord made me!

-Piggy

[ZAZ]

You are right on the money here Janet! If I believed in death insurance, I would not fib on the contract. A breach of contract is a breach of contract no matter how big or how small the player. If you want your intended beneficiaries to get what you have paid for and you have acted dishonestly while contracting, your loved ones will lose! In this case you can't cheat the hangman, and the hangman is the dishonest individual.

I highly doubt there are oversights on these contracts. If it asks tobacco use it means chaw to Old Toads and that includes your occasional use of Habanos. Some companies recognize that cigarettes are their nemisis and that is all they ask about, as a means to be competitive on these policies. While it looks like the insurance companie has got all the cards they make no money if they don't sell policies. In that right they need to be competitive and take some risk. They are in the risk/reward business, just as you and I are in smoking cigars. We weigh the risk of a few cigars a week with the knowledge that what we are doing might shorten our lives.

Lying about the risk in any case is stupid. Understanding the risk and recognizing that it may be a large or a small one depending on many factors, including genetics, is in my mind the sensible thing to do.

Frankly, I believe I risk more climbing on a horse, my Harley, or using a chain saw! I have a heart condition and have had a heart attack. While smoking could have played a part and I recognize it, I don't believe that it was a large role. I have never smoked a cigarette in my life. Even a lung full of cigar smoke will make me cough. Mine is genetics and poor diet for a guy with my genetics. I just can't eat what many others eat and have to take meds for my cholesterol. Mine was high before they invented statins. It was high when my diet consisted of less than 10 grams of saturated fat a day, I ate right and raced motorcycles every other weekend. It is just the way the Lord made me!

-Piggy

Well said.

[Peter11216]

Thanks so much for the response, and the reference. I skimmed it briefly.

There are a few things I think worth mentioning here:

1. There have been studies purporting to study (however lacking they may be in execution) the health effects of cigars. Although, one of the ways they may lack is by conflating sub-types of cigar smoker that we might be interested in. For instance, we may not have research on people who smoke Phillies Blunts out of addiction, rather than whatever flavour profile such things offer, compared with the Cuban cigar connoisseur, or just the avid cigar smoker of hand-rolled "premiums."

2. The research, however, does suggest that cigar smoking, even of one or two per day increases chances of getting various cancers. I take issue with the fact that the table on page 6 (of the study in Prof. Twain's response) shows "NO SIGNIFICANT" increase in various risk ratios. I don't think Prof. Twain's remark about significance is all that persuasive. The fact is, the study did find an increase. Whether something is or isn't "significant" is rather arbitrary, (and as far as I can tell, it is a tool for deciding whether or not it is worth publishing as a result). The elevated risk levels found still provide information you can act on, and this is the important point.

Given the problems with research on cigars it is not save to say "People smoking less than 3 cigars a day are facing minimal health risk." Smoking three strawberry White Owls at your desk in a poorly ventilated office at the back of the shop may well cause a more than minimal increase in risk.

3. Those of us who are skeptical of the shoddy research, if it is shoddy, should not then rely on anecdotes about George Burns, or our great uncle Bill who lived to 101 drinking heavily and smoking 8 cigars a day. We all have a tendency to look for evidence that confirms and justifies our predilections.

4. I would again recommend looking into the work of Charles Whitebread, who studied how and why drugs get criminalized. His work suggests that while cigarettes may become illegal, "premium" cigars will remain legal, even if there use, or where the can be smoked, is regulated. Why has the "dogmatic" view on tobacco arisen, and why now? Why have cigar bars, however hampered by regulation, continued to be legal in the United States? Does the lack of research on cigars only reflect this "dogmatic" view, or is there also some hesitance to look into a habit that is predominantly taken up by a certain class of people?

5. My favourite response to this has been, "Maybe cigars aren't great for my health, but I'm going to not worry about it, and enjoy myself." I honestly think this is the best we can say, for now.

Thanks again, Prof. Twain, for the response and the reference, I appreciate it. I think this discussion is worth having.

Best,

Pete

I'm glad to see TropicalDoc's comments and the reply by Pete. I've tried to look closely at the scientific literature on the health effects of cigar smoking and there is very little good quality research. Many studies create a category of "cigar smokers", or "cigar and pipe smokers" but fail to sort out important subgroups. For example it is important to separate out "primary cigar smokers" who do not have the additional risk of current or past cigarette smoking. It's also important to study the relationship of dose of exposure to possible health problems associated with cigar smoking.

The best review I have found is by Dr. David Burns, titled "Cigar Smoking: Overview and Current State of the Science". It was published in 1998 in Smoking and Tobacco Control Monograph No. 9. It is available at the following web site: Cigar Smoking State of the Science I'm going to provide a pretty detailed summary of the findings.

Figure 2 on page 5 provides a good comparison of the risks of all primary cigar smokers with cigarette smokers. You can see that the risks are much lower for cigar smokers.

The most important information is shown in Table 1 on page 6. You will see that, compared with nonsmokers, cigar smokers who smoke 1-2 cigars per day have NO SIGNIFICANT INCREASES IN ALL CAUSES OF DEATH, ANY KIND OF CANCER, COPD, OR CORONARY HEART DISEASE. These are relative risk statistics, comparing to nonsmokers. For example people who smoke 1-2 cigars per day have a risk ratio of 1.02 compared to nonsmokers, or 2% increase, but the 95% confidence interval crosses the number 1.0, indicating that the 1-2 cigar a day group's risk compared to nonsmokers is not statistically different. Note that the risk ratio for coronary heart disease for those smoking 1-2 cigars a day is .98, meaning a 2% LOWER risk of CHD. This is also not statistically significant. In sum, the differences between people smoking 1-2 cigars a day and nonsmokers can't be detected in this study. However, you can see that people smoking many more cigars have much increased risks. For example, smoking 5+ cigars a day is associated with a 17% increased risk of death, a 15.94 times risk of cancer of buccal cavity and pharynx. Even this risk pales compared to people smoking over a pack a day of cigarettes, who show an 88% increased risk of death, and 65% increased risk of heart disease. The bottom of this table, on page 7, shows that health risks of cigar smoking increase greatly with increased depth of inhalation.

Note that the article itself does not highlight these conclusions that low levels of cigar smoking appear to be relatively safe. The conclusions shown on page 19 are relatively dire. I would say that the spin is pretty negative, given that most cigar smokers probably smoke only 1-2 cigars per day.

You will never read this information in an announcement from the American Cancer Society of Center for Disease Control, however. These groups are committed to a dogmatic view that any exposure to tobacco is harmful. They are not interested in informing the public about risk reduction strategies for tobacco and will never publish a document stating that smoking 1-2 cigars a day is not associated with significant health risks. The American Cancer Society and National Cancer Institute will also not be eager to fund research that identifies safe exposures to environmental smoke.

For anyone interested in this general issue I recommend you follow the blog published by Dr. Michael Siegal of the Boston University College of Public Health. He is NOT pro smoking but objects to the outrageous lies and misrepresentations of science put forth by the rabid anti tobacco groups. The blog is at http://tobaccoanalysis.blogspot.com/

There are lots of unanswered questions about this whole area. For example, people who take up cigar smoking later in life probably have much less risk due to less exposure. It's likely that people who smoke outdoors have less risk than those smoking in poorly ventilated environments where they take in lots of second hand smoke. It would be ideal if we had new knowledge about the health effects of primary cigar smoking, but it's not a top priority for research. Since no agency is going to fund research on these topics it will be very difficult to know the answers.

So, there is some good practical advice we can draw, even if the research in this article is could be improved on. People smoking less than 3 cigars a day are facing minimal health risk. People smoking larger amounts of cigars, those inhaling, and those who are current or former cigarette smokers have greater risks.

Hope this is useful.

[baragh]

2. The research, however, does suggest that cigar smoking, even of one or two per day increases chances of getting various cancers. I take issue with the fact that the table on page 6 (of the study in Prof. Twain's response) shows "NO SIGNIFICANT" increase in various risk ratios. I don't think Prof. Twain's remark about significance is all that persuasive. The fact is, the study did find an increase. Whether something is or isn't "significant" is rather arbitrary, (and as far as I can tell, it is a tool for deciding whether or not it is worth publishing as a result). The elevated risk levels found still provide information you can act on, and this is the important point.

Given the problems with research on cigars it is not save to say "People smoking less than 3 cigars a day are facing minimal health risk." Smoking three strawberry White Owls at your desk in a poorly ventilated office at the back of the shop may well cause a more than minimal increase in risk.

I believe what Prof. Twain is referring to here is that the result is not statistically significant. This is often used term in statistics when interpreting results and implies that although there is an estimated effect, there is (in this case) a greater than 5% chance that the observed effect is simply by chance. I don't think that he is trying to downplay the risk, he is saying that from the evidence we cannot conclude that there is a linear relationship between smoking 1-2 cigars a day and an increased risk of any type of cancer.

[edameff]

Pete, I just want to make one more comment on the studies quoted. Remember anyone can do a study and publish it, since I have MD after my name I can do a study and even make is sound credible to non-physicians (maybe even to some not so astute physicians) just because I publish it. It will then be found through internet searches and quoted by all types of people because it confirms what they want to hear. When studies are done, then analyzed for validity multiple factors are scrutinized and something called a "p" value is assigned. This value objectively compares placebo to non-placebo, then helps determine just how valid the data are. These are the types of studies used by the FDA to approve or disapprove new medications. In short (too late) the studies you are citing are not correctly powered to answer the question with any level of confidence. When such studies are done appropriately they are then accepted by the medical community as "Evidence Based". Let me assure you just because something is published in JAMA, or New England Journal it meets these criteria, that is far from the truth, they publish the studies to stimulate discussion and thought in the medical community. Again at NO point in time am I saying that there is not a link between cigar smoking and cancer or other health problems, what I am saying is that to date there is no study that has been constructed and accepted as "Evidence Based". The choice to smoke cigars is a very personal one, and each person needs to weight the risks and benefits in their life and then make the decision that is right for them. The fact that I am a member of this forum should give everyone a bit of a hint as to which way the scales tip in my life.

Thanks so much for the response, and the reference. I skimmed it briefly.

There are a few things I think worth mentioning here:

1. There have been studies purporting to study (however lacking they may be in execution) the health effects of cigars. Although, one of the ways they may lack is by conflating sub-types of cigar smoker that we might be interested in. For instance, we may not have research on people who smoke Phillies Blunts out of addiction, rather than whatever flavour profile such things offer, compared with the Cuban cigar connoisseur, or just the avid cigar smoker of hand-rolled "premiums."

2. The research, however, does suggest that cigar smoking, even of one or two per day increases chances of getting various cancers. I take issue with the fact that the table on page 6 (of the study in Prof. Twain's response) shows "NO SIGNIFICANT" increase in various risk ratios. I don't think Prof. Twain's remark about significance is all that persuasive. The fact is, the study did find an increase. Whether something is or isn't "significant" is rather arbitrary, (and as far as I can tell, it is a tool for deciding whether or not it is worth publishing as a result). The elevated risk levels found still provide information you can act on, and this is the important point.

Given the problems with research on cigars it is not save to say "People smoking less than 3 cigars a day are facing minimal health risk." Smoking three strawberry White Owls at your desk in a poorly ventilated office at the back of the shop may well cause a more than minimal increase in risk.

3. Those of us who are skeptical of the shoddy research, if it is shoddy, should not then rely on anecdotes about George Burns, or our great uncle Bill who lived to 101 drinking heavily and smoking 8 cigars a day. We all have a tendency to look for evidence that confirms and justifies our predilections.

4. I would again recommend looking into the work of Charles Whitebread, who studied how and why drugs get criminalized. His work suggests that while cigarettes may become illegal, "premium" cigars will remain legal, even if there use, or where the can be smoked, is regulated. Why has the "dogmatic" view on tobacco arisen, and why now? Why have cigar bars, however hampered by regulation, continued to be legal in the United States? Does the lack of research on cigars only reflect this "dogmatic" view, or is there also some hesitance to look into a habit that is predominantly taken up by a certain class of people?

5. My favourite response to this has been, "Maybe cigars aren't great for my health, but I'm going to not worry about it, and enjoy myself." I honestly think this is the best we can say, for now.

Thanks again, Prof. Twain, for the response and the reference, I appreciate it. I think this discussion is worth having.

Best,

Pete

[Professor Twain]

I believe what Prof. Twain is referring to here is that the result is not statistically significant. This is often used term in statistics when interpreting results and implies that although there is an estimated effect, there is (in this case) a greater than 5% chance that the observed effect is simply by chance. I don't think that he is trying to downplay the risk, he is saying that from the evidence we cannot conclude that there is a linear relationship between smoking 1-2 cigars a day and an increased risk of any type of cancer.

Pete and Baragh, thanks for your comments. It's difficult to explain this information, which is pretty complicated, in a brief way.

Baragh is correct in that when I said that the results were not "significant", it means that they were not statistically significant, which means they very well could have occurred by chance. An apparent difference can occur completely by chance. For example, if you flip a coin 100 times, it SHOULD come out 50 heads, and 50 tails, if the coin is fair. But in reality you could very easily get a finding that on 51 flips you get heads, and on 49 flips you get tails. This would be a 2% difference, but we shouldn't conclude that the coin is prone to produce heads. With another 100 flips you could get different results. So statisticians have produced tables of probability that are used to determine the likelihood that a given difference might be due completely to chance. Conventionally, researchers use a standard that there should be less than a 5% chance that the finding could occur by chance before we accept it as a "significant" difference.

In my commentary, I noted the following: "For example people who smoke 1-2 cigars per day have a risk ratio of 1.02 compared to nonsmokers, or 2% increase, but the 95% confidence interval crosses the number 1.0, indicating that the 1-2 cigar a day group's risk compared to nonsmokers is not statistically different. Note that the risk ratio for coronary heart disease for those smoking 1-2 cigars a day is .98, meaning a 2% LOWER risk of CHD. This is also not statistically significant." That 2% higher death rate in the 1-2 cigars per day group, just like the 2% LOWER risk of developing coronary heart disease, is such a small difference that it could have occurred by chance. If we don't use this kind of probability statement we would conclude from this article that smoking 1-2 cigars a day decreases rates of coronary heart disease.

While this study has limitations, it is the strongest study that I have found. The research finds no statistically significant differences between nonsmokers and people smoking 1-2 cigars per day on any of the indicators of death or cancer and other diseases. There may be such differences, but they must be very small, so small that this study could not detect them.

As I noted, there may not be better science produced on this topic, because funding agencies are not oriented toward finding out what constitutes a safe level of cigar smoking. From the available evidence I feel comfortable smoking cigars as a hobby but people smoking heavily, inhaling, or with a history of cigarette smoking should be very cautious.