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Cigar Smoking Among Teenagers -- United States, Massachusetts, and New York, 1996

Cigar smoking can cause cancers of the oral cavity, larynx, esophagus, and lung (1) and chronic obstructive pulmonary disease (2). In addition, cigars contain substantial levels of nicotine, an addictive drug (3). Despite these health risks, total cigar consumption in the United States was approximately 4.5 billion cigars in 1996, and consumption of larger cigars increased by 44.5% from 1993 through 1996 (from 2,138 million cigars to 3,090 million cigars, respectively) (4). This report presents estimates of the prevalence of cigar smoking among youth based on analyses of data from the Robert Wood Johnson Foundation's (RWJF) 1996 National Study of Tobacco Price Sensitivity, Behavior, and Attitudes Among Teenagers and Young Adults; a 1996 survey by the Massachusetts Department of Public Health (MDPH) of high school and junior high school students; and the Roswell Park Cancer Institute's 1996 Survey of Alcohol, Tobacco, and Drug Use in two New York counties (5). The analyses indicate that, during the year before being surveyed, 26.7% of U.S. and 28.1% of Massachusetts high school students reported having smoked at least one cigar and that 13%-15% of ninth grade students in two New York counties reported having smoked cigars during the previous 30 days. National Survey

The RWJF survey employed a three-stage cluster sample design to produce a nationally representative sample of students in grades 9-12. Within the selected sample of 200 counties (primary sampling units), schools were randomly selected, with the probability of selection proportional to enrollment size. Four alternate high schools were simultaneously selected, matching the original school in size, type, location, and the race/ethnicity and socioeconomic status of the students. An alternate was substituted when the first school chosen for the study could not participate. A total of 202 schools (representing 146 {73%} of the 200 primary sampling units) participated in the study. Within each school, one class per grade was chosen randomly. All students in the selected classes were eligible to participate; 80% of the students enrolled in the sample of selected classes participated. A total of 16,556 students aged 14-19 years completed the survey; however, 139 were excluded from these analyses because of missing information on sex. Participants were asked, "How many cigars, if any, have you smoked in the past year?" Annual cigar smokers were defined as any student who reported smoking a cigar during the previous year; frequent cigar smokers were defined as any student who reported smoking greater than or equal to 50 cigars during the previous year. Data were weighted by age, race/ethnicity, sex, and region* to provide national estimates. Confidence intervals (CIs) were calculated using SUDAAN.

In 1996, an estimated 6.0 million (26.7% {95% CI=plus or minus 1.7%}) 14-19-year-olds reported having smoked a cigar during the previous year (4.3 million {37.0% (95% CI=plus or minus 2.4%)} males and 1.7 million {16.0% (95% CI=1.3%)} females) (Table_1). Cigarette smokers were more than three times as likely as noncigarette smokers to report having smoked a cigar (54.1% {95% CI=plus or minus 2.4%}, compared with 14.2% {95% CI=plus or minus 1.2%}, respectively). Among the 68.8% of students who did not smoke cigarettes, males were more likely than females to have reported smoking a cigar during the previous year (20.4% {95% CI=plus or minus 1.8%} versus 7.8% {95% CI=plus or minus 1.1%}, respectively). Users of smokeless tobacco were more than three times as likely as nonusers to report having smoked cigars (73.4% {95% CI=plus or minus 3.4%}, compared with 22.6% {95% CI=plus or minus 1.4%}, respectively). Cigar smoking did not vary substantially by region or race/ethnicity, although prevalence was greatest among white, non-Hispanic males (41.6% {95% CI=plus or minus 2.7%}). Massachusetts Survey

The MDPH survey sample comprised two subsamples of students in grades 6-12: a statewide random sample, proportionately stratified by area and grade, and a separate random sample of five urban areas in the state, stratified by percentage of nonwhite students in each grade. These five urban areas were selected to oversample communities with racial/ethnic minorities to ensure adequate representation for analysis. Of the 191 schools meeting eligibility criteria, 171 (90%) participated in this survey. Of the 8236 students eligible to participate in the survey, 6844 (83.1%) participated. Data were collected during November 1996-January 1997. School and class selection was random, participation was voluntary, and all responses were anonymous. The questionnaires were self-administered. All students were asked "How often have you smoked cigars in your lifetime?"; "How often have you smoked cigars during the last 12 months?"; and "How often have you smoked cigars during the last 30 days?" The response categories were never, one to two times, three to five times, six to nine times, 10-19 times, 20-39 times, and greater than or equal to 40 times.

Among the 1020 students in grade 6, 9.9% (95% CI=plus or minus 1.8%) reported having ever smoked a cigar, 5.0% (95% CI=plus or minus 0.8%) smoked a cigar during the previous year, and 2.0% (95% CI=plus or minus 0.9%) smoked a cigar during the previous month. Among 1942 students in grades 7 and 8, 22.3% (95% CI=plus or minus 1.8%) reported having ever smoked a cigar, 14.1% (95% CI=plus or minus 1.5%) smoked a cigar during the previous year, and 7.6% (95% CI=plus or minus 1.2%) smoked a cigar during the previous month. Among the 3873 high school students in grades 9-12, 38.9% (95% CI=plus or minus 1.5%) reported having ever smoked a cigar, 28.1% (95% CI=plus or minus 1.4%) smoked a cigar during the previous year, and 14.5% (95% CI=plus or minus 1.1%) smoked a cigar during the previous month.

High school students who had used other tobacco products during the previous month were also more likely to have smoked cigars during the previous month. Among students in grades 9-12, 30.3% (95% CI=plus or minus 2.5%) of those who had smoked cigarettes during the previous month also reported having smoked a cigar, compared with 3.4% (95% CI=plus or minus 6.6%) of those who had never smoked a cigarette; among those who had used smokeless tobacco during the previous month, 60.7% (95% CI=plus or minus 6.6%) also reported having smoked a cigar during the previous month, compared with 8.3% (95% CI=plus or minus 1.0%) of those who had never used smokeless tobacco. New York Survey

The Roswell Park Cancer Institute survey was conducted in Erie (predominantly urban) and Chautauqua (predominantly rural) counties in New York during the fall of 1996. The survey was administered to 9916 ninth grade students in 57 of the 60 public and parochial high schools in Erie County (81% of the 12,216 ninth grade students in the 60 schools) and to 1677 ninth grade students in 16 of the 18 public schools in Chautauqua County (80% of the 2102 ninth grade students in the 18 schools). Of the students who participated in the survey in Erie County, 79% were non-Hispanic white, 12% were non-Hispanic black, 3% were Hispanic, and 5% were of other racial/ethnic groups. Of those students who participated in the survey in Chautauqua County, 89% were non-Hispanic white. The median age of all students was 14 years. Students completed a self-administered questionnaire with three questions on cigar use and purchasing: "In the past 30 days, did you smoke a cigar?"; "Have you ever bought cigars for yourself?"; and "When you try to buy cigars, how often are you asked about your age?"

Response patterns were similar for the two counties (Table_2). In Erie County, of the 9916 students, 1253 (12.7%) of 9862 students who responded to the question reported having smoked a cigar during the previous 30 days (937 {19.5%} of 4810 boys and 304 {6.1%} of 4983 girls). In Chautauqua County, of the 1677 students, 246 (14.8%) of 1657 students who responded reported having smoked a cigar during the previous 30 days (201 {24.0%} of 836 boys and 43 {5.3%} of 809 girls). In comparison, 29.0% of students in Erie County and 30.6% of students in Chautauqua County reported having smoked cigarettes during the previous 30 days. Cigarette smokers also were more likely than noncigarette smokers to report having smoked a cigar during the previous 30 days (Table_2). The prevalence of reported smokeless tobacco use during the previous 30 days was 3.5% in Erie County and 7.3% in Chautauqua County. Among smokeless tobacco users, reported rates of cigar smoking were 62.4% (217 of 348 students who responded) in Erie County and 63.0% (75 of 119 students who responded) in Chautauqua County (Table_2).

Among students who reported ever purchasing a cigar for themselves, most (63.7% in Erie and 77.0% in Chautauqua) also reported having smoked a cigar during the previous 30 days. Among those who had ever purchased a cigar, 76.6% in Erie County and 71.7% in Chautauqua County reported that they were "rarely" or "never" asked about their age when purchasing a cigar. In comparison, 59.0% in Erie County and 67.7% in Chautauqua County reported that they were "rarely" or "never" asked about their age when purchasing cigarettes.

Reported by: NJ Kaufman, SL Emont, CR Trimble, CT Orleans, The Robert Wood Johnson Foundation, Princeton, New Jersey. N Briton, T Clark, M Krakow, Health and Addictions Research, Inc, Boston; C Celebucki, D Cullen, G Connolly, Massachusetts Dept of Public Health. A Hyland, J Perla, KM Cummings, Roswell Park Cancer Institute, New York State Dept of Health, Buffalo; A Abdella, K Tippens, Chautauqua County Dept of Health, Mayville, New York. Epidemiology Br, Office on Smoking and Health, National Center for Chronic Disease Prevention and Health Promotion, CDC.

Editorial note: This report is the first to estimate the prevalence of cigar smoking among youth in the United States and documents the level of access to and use of cigars. The risk for several cancers is higher for cigar smokers than for nonsmokers. Therefore, if cigar consumption continues to increase (4), cigar-related morbidity and mortality can be expected to increase.**

Although the findings from New York and from Massachusetts were from local surveys, they are consistent with the results from the national survey. However, a potential limitation to these data is that they represent the cigar use of only those adolescents attending school and, therefore, may not be representative of all adolescents.

Although federal law requires states to enact laws prohibiting the sale of cigars and other tobacco products to minors (6), young persons in New York reported being able to purchase cigars easily. These findings, especially if replicated in other communities, may warrant actions to curtail youth access to cigars that are consistent with measures for limiting access to cigarettes and smokeless tobacco (e.g., Food and Drug Administration regulations) (7). The findings from the surveys in this report also indicate that cigar smoking, once primarily an activity among older men (8), is now an activity of both male and female teenagers. Therefore, priorities include the need to further characterize the use of cigars in the United States, determine the prevalence of cigar smoking among adults, and continue monitoring the prevalence of cigar use among youth. Although the Surgeon General's health warning is legally mandated for some tobacco products, the law does not include cigars (9). Therefore, teenagers and other users of cigars may be unaware of the health risks of cigar smoking. Immediate efforts should be made to publicize the health risks of cigar smoking; deglamorize the product in magazines, movies, and television programs; and protect nonsmokers from secondhand cigar smoke.

References

  1. US Department of Health and Human Services. The health consequences of smoking: cancer -- a report of the Surgeon General. Rockville, Maryland: US Department of Health and Human Services, Public Health Service, CDC, National Center for Chronic Disease Prevention and Health Promotion, Office on Smoking and Health, 1982; DHHS publication no. (PHS)82-50179.

  2. US Department of Health and Human Services. The health consequences of smoking: chronic obstructive lung disease -- a report of the Surgeon General. Rockville, Maryland: US Department of Health and Human Services, Public Health Service, CDC, National Center for Chronic Disease Prevention and Health Promotion, Office on Smoking and Health, 1984; DHHS publication no. (PHS)84-50205.

  3. Henningfield JE, Hariharan M, Kozlowski LT. Nicotine content and health risks of cigars. JAMA 1996;276:1857-8.

  4. US Department of Agriculture. Tobacco situation and outlook report. Washington, DC: US Department of Agriculture, Commodity Economics Division, Economic Research Service, April 1997; document no. TSB-238.

  5. Roswell Park Cancer Institute. Survey of alcohol, tobacco, and drug use: ninth-grade students in Erie and Chautauqua counties, 1996. Buffalo, New York: Roswell Park Cancer Institute, Department of Cancer Control and Epidemiology, May 1997.

  6. Substance Abuse and Mental Health Service Administration. Final regulations to implement section 1926 of the Public Health Service Act regarding the sale and distribution of tobacco products to individuals under the age of 18. Federal Register 1996;13:1492-500.

  7. Food and Drug Administration. Regulations restricting the sale and distribution of cigarettes and smokeless tobacco products to protect children and adolescents: final rule. Federal Register 1996;61:41,314-75.

  8. Giovino GA, Schooley MW, Zhu B-P, et al. Surveillance for selected tobacco-use behaviors -- United States, 1900-1994. MMWR 1994;43(no. SS-3).

  9. US Department of Health and Human Services. Reducing the health consequences of smoking: 25 years of progress -- a report of the Surgeon General. Rockville, Maryland: US Department of Health and Human Services, Public Health Service, CDC, National Center for Chronic Disease Prevention and Health Promotion, Office on Smoking and Health, 1989; DHHS publication no. (CDC)89-8411.

* The four regions were Northeast (Connecticut, Maine, Massachusetts, New Hampshire, New Jersey, New York, Pennsylvania, Rhode Island, and Vermont), Midwest (Illinois, Indiana, Iowa, Kansas, Michigan, Minnesota, Missouri, Nebraska, North Dakota, Ohio, South Dakota, and Wisconsin), South (Alabama, Arkansas, Delaware, District of Columbia, Florida, Georgia, Kentucky, Louisiana, Maryland, Mississippi, North Carolina, Oklahoma, South Carolina, Tennessee, Texas, Virginia, and West Virginia), and West (Alaska, Arizona, California, Colorado, Hawaii, Idaho, Montana, Nevada, New Mexico, Oregon, Utah, Washington, and Wyoming). 

** The National Cancer Institute has announced that it will publish a comprehensive monograph on cigar smoking by the end of 1997 titled "Cigar Smoking in the U.S.: Health Effects and Trends."



Table_1
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TABLE 1. Percentage of students aged 14-19 years who reported having smoked at least one cigar during the previous year, by selected characteristics -- United States, National Study of Tobacco Price Sensitivity,
Behavior, and Attitudes Among Teenagers and Young Adults, 1996
======================================================================================================================================================================================================================
                                                                        Annual cigar use *                                                                                Frequent cigar use +
                                                     --------------------------------------------------------------------                  ------------------------------------------------------------------------
                                                             Female                    Male                  Total                                Female                  Male                 Total
                                                     ---------------------      -----------------       ----------------                     ----------------     ------------------      ----------------
Characteristic                                             %     (95% CI &)       %     (95% CI)         %     (95% CI)                       %     (95% CI)        %     (95% CI)         %     (95% CI)
----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
Race/Ethnicity
 White, non-Hispanic                                    16.0    (+/- 1.8%)      41.6    (+/-2.7%)      28.9    (+/-2.1%)                     1.2    (+/-0.4%)      3.4    (+/-0.8%)       2.3    (+/-0.5%)
 Black, non-Hispanic                                    13.4    (+/- 2.9%)      25.2    (+/-3.7%)      19.3    (+/-2.9%)                     1.6    (+/-0.6%)      5.6    (+/-2.0%)       3.6    (+/-1.1%)
 Hispanic                                               20.0    (+/- 3.0%)      32.3    (+/-3.0%)      26.2    (+/-2.1%)                     1.8    (+/-0.8%)      3.2    (+/-0.9%)       2.5    (+/-0.6%)
 Other @                                                14.5    (+/- 2.7%)      28.5    (+/-4.3%)      22.2    (+/-2.9%)                     0.5    (+/-0.7%)      5.8    (+/-2.4%)       3.4    (+/-1.3%)
Age group (yrs)
 14-16                                                  16.8    (+/- 1.8%)      32.1    (+/-2.4%)      24.4    (+/-1.7%)                     1.3    (+/-0.4%)      2.9    (+/-0.7%)       2.1    (+/-0.4%)
 17-18                                                  14.9    (+/- 1.8%)      43.9    (+/-3.2%)      29.8    (+/-2.4%)                     1.1    (+/-0.5%)      5.2    (+/-1.1%)       3.2    (+/-0.7%)
    19                                                  14.9    (+/- 6.7%)      35.5    (+/-7.8%)      27.5    (+/-5.3%)                     3.1    (+/-3.0%)      4.9    (+/-2.6%)       4.2    (+/-2.1%)
Region **
 Northeast                                              12.4    (+/- 2.1%)      33.7    (+/-5.2%)      23.2    (+/-3.4%)                     0.8    (+/-0.5%)      3.0    (+/-1.0%)       1.9    (+/-0.5%)
 Midwest                                                16.9    (+/- 2.6%)      42.3    (+/-4.2%)      29.8    (+/-3.4%)                     1.3    (+/-0.7%)      4.9    (+/-1.5%)       3.2    (+/-0.9%)
 South                                                  17.2    (+/- 2.2%)      37.1    (+/-3.7%)      27.3    (+/-2.4%)                     1.5    (+/-0.5%)      4.3    (+/-1.3%)       3.0    (+/-0.9%)
 West                                                   16.4    (+/- 3.4%)      34.5    (+/-5.4%)      25.6    (+/-4.2%)                     1.1    (+/-0.5%)      3.0    (+/-1.0%)       2.1    (+/-0.5%)
Education of parents ++
 Completed college                                      16.0    (+/- 2.0%)      38.7    (+/-3.1%)      27.9    (+/-2.2%)                     1.0    (+/-0.4%)      3.5    (+/-0.9%)       2.3    (+/-0.5%)
 Did not complete college                               16.0    (+/- 1.5%)      37.0    (+/-3.3%)      26.1    (+/-2.1%)                     1.3    (+/-0.4%)      4.0    (+/-0.8%)       2.6    (+/-0.5%)
School performance
 Better or much better than average                     12.5    (+/- 1.6%)      31.2    (+/-2.9%)      21.5    (+/-2.0%)                     0.7    (+/-0.3%)      3.2    (+/-0.8%)       1.9    (+/-0.4%)
 Average                                                19.2    (+/- 1.8%)      40.9    (+/-3.0%)      30.1    (+/-2.1%)                     1.6    (+/-0.5%)      4.3    (+/-1.0%)       3.0    (+/-0.6%)
 Below average                                          28.6    (+/- 6.0%)      54.7    (+/-5.4%)      45.1    (+/-4.2%)                     3.5    (+/-1.9%)      5.4    (+/-2.1%)       4.7    (+/-1.6%)
Household smoker
 Present                                                19.1    (+/- 1.7%)      41.2    (+/-3.1%)      30.1    (+/-2.1%)                     1.8    (+/-0.5%)      4.9    (+/-1.1%)       3.4    (+/-0.6%)
 Not present                                            13.0    (+/- 1.7%)      33.0    (+/-2.8%)      23.2    (+/-1.9%)                     0.7    (+/-0.4%)      3.0    (+/-0.6%)       1.8    (+/-0.4%)
Cigarette use
 Smoker&&                                               34.0    (+/- 2.6%)      73.9    (+/-2.6%)      54.1    (+/-2.4%)                     3.0    (+/-0.8%)      9.4    (+/-1.7%)       6.2    (+/-0.9%)
 Nonsmoker                                               7.8    (+/- 1.1%)      20.4    (+/-1.8%)      14.2    (+/-1.2%)                     0.3    (+/-0.2%)      1.5    (+/-0.4%)       0.9    (+/-0.2%)
Smokeless tobacco use
 User@@                                                 50.1    (+/-12.0%)      75.9    (+/-3.6%)      73.4    (+/-3.4%)                     3.3    (+/-3.5%)      8.4    (+/-2.4%)       7.9    (+/-2.2%)
 Nonuser                                                15.5    (+/- 1.3%)      30.6    (+/-1.9%)      22.6    (+/-1.4%)                     1.2    (+/-0.3%)      3.2    (+/-0.6%)       2.1    (+/-0.3%)
Total                                                   16.0    (+/- 1.3%)      37.0    (+/-2.4%)      26.7    (+/-1.7%)                     1.2    (+/-0.3%)      3.9    (+/-0.6%)       2.6    (+/-0.4%)
----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
*  Smoked one or more cigars during the previous year.
+  Smoked >=50 cigars during the previous year.
&  Confidence interval.
@  Numbers for other races were too small for meaningful analysis.
** Northeast=Connecticut, Maine, Massachussetts, New Hampshire, New Jersey, New York, Pennsylvania, Rhode Island, and Vermont;
   Midwest=Illinois, Indiana, Iowa, Kansas, Michigan, Minnesota, Missouri, Nebraska, North Dakota, Ohio, South Dakota, and Wisconsin;
   South=Alabama, Arkansas, Delaware, District of Columbia, Florida, Georgia, Kentucky, Lousiana, Maryland, Mississippi, North Carolina, Oklahoma, South Carolina, Tennessee, Texas, Virginia, and West Virginia; and
   West=Alaska, Arizona, California, Colorado, Hawaii, Idaho, Montana, Nevada, New Mexico, Oregon, Utah, Washington, and Wyoming.
++ Highest level of education of either parent.
&& Smoked during the previous 30 days.
@@ Used chewing tobacco or snuff during the previous 30 days.
======================================================================================================================================================================================================================

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Table_2
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TABLE 2. Number and percentage of ninth grade students who reported having smoked cigars during the previous 30 days or who purchased cigars for their
own use, by selected characteristics -- Erie and Chautauqua counties, New York, Survey of Alcohol, Tobacco, and Drug Use, 1996
===========================================================================================================================================================
                                                                  Erie County *                                        Chautauqua County +
                                                  --------------------------------------------------         ----------------------------------------------
Category/Characteristic                            Total responses &            Smoked or purchased          Total responses &   Smoked or purchased
-----------------------------------------------------------------------------------------------------------------------------------------------------------
                                                                                   No.        (%)                                  No.        (%)
SMOKED CIGAR
Sex
  Male                                                   4810                      937     (19.5)                   836            201     (24.0)
  Female                                                 4983                      304     ( 6.1)                   809             43     ( 5.3)
Cigarette use
  Never smoked                                           6977                      323     ( 4.6)                  1147             56     ( 4.9)
  Occasionally smoked@                                   1708                      458     (26.8)                   288             91     (31.6)
  Regularly smoked **                                    1148                      469     (40.9)                   218             99     (45.4)
Smokeless tobacco use
  Not used during previous 30 days                       9469                     1032     (10.9)                  1532            170     (11.1)
  Used during previous 30 days                            348                      217     (62.4)                   119             75     (63.0)
Marijuana use
  Never used                                             6918                      360     ( 5.2)                  1126             58     ( 5.2)
  Ever used                                              2899                      885     (30.5)                   521            187     (35.9)
  Used during previous 30 days                           1523                      606     (39.8)                   293            134     (45.7)
  Total                                                  9862                     1253     (12.7)                  1657            246     (14.8)
PURCHASED CIGAR
Sex
  Male                                                   4800                      608     (12.7)                   831            114     (13.7)
  Female                                                 4969                      166     ( 3.3)                   813             21     ( 2.6)
Cigarette use
  Never smoked                                           6957                      210     ( 3.0)                  1147             31     ( 2.7)
  Occasionally smoked @                                  1705                      237     (13.9)                   288             35     (12.2)
  Regularly smoked **                                    1147                      331     (28.9)                   217             70     (32.3)
Total                                                    9839                      779     ( 7.9)                  1657            136     ( 8.2)
-----------------------------------------------------------------------------------------------------------------------------------------------------------
*  n=9916
+  n=1677
&  May not equal county totals because of missing data about cigar use and/or purchasing.
@  Smoked on 1-19 days during the previous 30 days.
** Smoked on 20-30 days during the previous 30 days.
===========================================================================================================================================================

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