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Cigar Smoking Among Teenagers -- United States, Massachusetts, and New York, 1996Cigar 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
* 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 Note: To print large tables and graphs users may have to change their printer settings to landscape and use a small font size.
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.
======================================================================================================================================================================================================================
Return to top. Table_2 Note: To print large tables and graphs users may have to change their printer settings to landscape and use a small font size.
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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