Smokescreen

For the past few years, public health officials and anti-smoking activists have been pushing a false equation between cigars and cigarettes. Are reporters wising up?

In 1997, The New York Times claimed that cigars pose "higher risks" than cigarettes. A year later it reported that "smoking cigars can be just as deadly as smoking cigarettes." Last June it said "the disease risks are not as high as they are for cigarette smokers because cigar smokers usually do not inhale the smoke."

Are cigars getting safer? No, but reporters may be getting smarter. Once easily misled by the scare tactics of public health officials and anti-smoking activists, the mainstream press is starting to acknowledge something that medical studies have been finding for decades: The typical cigar smoker faces hazards far less serious than the typical cigarette smoker does.

This fact was clear from the data compiled by the National Cancer Institute (NCI) in its 1998 monograph on cigars. Overall, the NCI reported, daily cigar smokers get oral and esophageal cancers almost as often as cigarette smokers. But they face much lower risks of lung cancer, coronary heart disease, and chronic obstructive lung disease–the three main smoking-related causes of death. The upshot can be seen in mortality figures. In a 1985 American Cancer Society study cited by the NCI, men who smoked a cigar or two a day were only 2 percent more likely to die during a 12-year period than nonsmokers, a difference that was not statistically significant. By contrast, the mortality rate was 69 percent higher for men who smoked a pack of cigarettes a day.

The only really bad news for cigar smokers in the NCI report applied to a small minority. The NCI emphasized that the risk from cigars increases with the frequency of smoking and the degree of inhalation. Cigar smokers who inhale deeply face measurably higher risks of heart disease and emphysema (though still not as high as those faced by cigarette smokers), and the risk of lung cancer for a five-cigar-a-day smoker who inhales approaches the risk for a pack-a-day cigarette smoker. That sort of cigar smoker is quite unusual, however. "As many as three-quarters of cigar smokers smoke only occasionally," the NCI said, and "the majority of cigar smokers do not inhale." Since the available data apply only to people who smoke at least one cigar a day, "the health risks of occasional cigar smokers…are not known."

In other words, there is no evidence that smoking cigars in moderation–with moderation defined by the way most cigar smokers actually behave–poses a measurable health risk. That point was lost on many reporters. "In its fiercest indictment of cigars yet," reported Alec Klein in the Baltimore Sun, "the U.S. government concludes in a long-awaited report that they can be just as lethal as cigarettes." (Emphasis added.) This phrase and variations on it have appeared again and again in newspaper stories about cigars during the last few years. Though literally true, it tells us almost nothing about the risks associated with cigar smoking. It is like saying that taking a bath "can be just as lethal" as swimming over Niagara Falls. Both activities can kill you, but that does not mean they are equally dangerous.

Klein gave no indication that cigar smoking is less hazardous than cigarette smoking. In fact, he erroneously reported that "the difference between cigarette and cigar smokers is not whether one gets cancer more frequently than the other, but where the malignancy occurs." A few months before, Klein had written an article in which he asserted, without qualification, that "cigars are just as deadly" as cigarettes, citing unnamed "health authorities" as his source. A month after the NCI monograph appeared, Klein reported that insurers once believed "cigars were not as hazardous as cigarettes," but "that myth has been dispelled." These statements are not simply misleading; they are flat-out wrong. Klein, now a reporter at The Wall Street Journal, declined to be interviewed for this article, saying it would be inappropriate because he had written a review of my book on the anti-smoking movement. (It was not a positive review. One of the statements from the book that Klein cited as clearly absurd was my observation that all tobacco products are not equally hazardous.)

Other reporters wrote more or less accurate stories about the NCI monograph, only to be undone by headlines. "Cancer Institute's Warning on Cigars: Just As Bad As Cigarettes," the San Francisco Chronicle announced. "Cancer Institute Calls Cigars As Hazardous As Cigarettes," declared The Washington Post. John Schwartz, who wrote the Post article, says the headline "inaccurately reflected the story, which was carefully written." Still, Schwartz did write that "cigars can be as hazardous to health as cigarettes"–technically true but not very informative. In retrospect, Schwartz says he wishes he had made the difference between cigars and cigarettes clearer. "The problem is that peanut butter can also be as deadly as cigarettes, if injected directly into the bloodstream," he says. "The distinction that was rarely made and should have been made [is] that cigars smoked the way they are generally smoked by most people are not nearly as hazardous as cigarettes."

By way of explanation for the press's mistakes in covering the NCI report, Schwartz notes that the monograph was released suddenly, late in the day, because a copy had already been leaked to the Sun's Klein. "You have to understand what that day was like," he says. "The NCI called in the afternoon and said, 'Somebody else has got it. We're releasing it broadly. We had planned to have briefings and walk people through the whole thing. And now, here it is. We're dumping it in your lap.' "

Then, too, the NCI report downplayed the differences between cigars and cigarettes. Calling the increase in cigar smoking since 1993 "disturbing" and "alarming," NCI Director Richard Klausner emphasized that "cigars are not safe alternatives to cigarettes." The issue, of course, was not whether smoking cigars is completely risk-free but whether, on average, it is less risky than smoking cigarettes–something no reasonable person could deny after looking at the evidence. But the NCI's spin seemed designed to obscure that point, so much so that the Associated Press concluded that the report was "intended to equate dangers posed by the two products."

Anti-smoking activists encouraged this interpretation. The day the monograph came out, John Banzhaf, executive director of Action on Smoking and Health, issued a press release in which he said FDA regulation of cigars was imperative "now that we know cigars are as dangerous as cigarettes." John Garrison, CEO of the American Lung Association, told the Los Angeles Times that cigars "are simply a more malodorous version of cigarettes."

Even before the NCI report was published, reporters were primed to believe that cigars are as dangerous as cigarettes, if not more so. Consider how Michael Eriksen, director of the Office on Smoking and Health at the U.S. Centers for Disease Control and Prevention, described the hazards of cigars in a May 1997 New York Times story: "Tobacco is tobacco is tobacco." In January 1998, former Surgeon General C. Everett Koop told the Baltimore Sun, "The health hazards of smoking cigars are the same as those of smoking cigarettes." A month later, the addiction specialist Jack Henningfield, who contributed to the NCI report, told The Wall Street Journal "it will help explode some of the myths about cigars," including the idea "that they are relatively safe." Later in the story, the Journal referred to "the widespread misconception that cigars are safer than cigarettes." That same month, the NCI's Donald Shopland told USA Today, "You're smoking a whole pack of cigarettes" when you smoke a cigar. "Cigar smoking indeed may be safer than cigarettes in some circumstances," the newspaper reported, "but overall the health risks are the same or worse."

Around the time the monograph came out, the California Department of Health Services started running a TV spot likening one cigar to three and a half packs of cigarettes. The ad showed a young man in a dark suit holding a cigar while sitting in a big leather chair. "Say, Chad," the narrator asked him, "any idea how many cigarettes you'd need to equal the nicotine in that big fat stogie?" After Chad repeatedly guessed wrong, the narrator said, "No, Chad, you'd have to smoke more than 70." Seventy cigarettes appeared in poor Chad's mouth as a slogan was displayed at the bottom of the screen: "CIGARS. The Big New Trend in Cancer." When the Chad ad was unveiled in March 1998, the Los Angeles Times described it as "comparing the effects of one cigar to smoking the equivalent of 70 cigarettes." According to the Sacramento Bee, "the television spot…points out that smoking cigars poses the same health risks as smoking cigarettes."

Ostensibly, the ad was talking about nicotine. But according to the NCI report, a premium cigar typically yields about as much nicotine as a dozen cigarettes, not 70. What's more, there is little evidence that nicotine contributes to smoking-related diseases (which is why pharmaceutical companies can sell nicotine gum and patches as safe alternatives to cigarettes). Yet the California spot clearly implied that a cigar's nicotine yield is something to worry about, and the tag line insinuated that nicotine, which is not a carcinogen, has something to do with cancer.

There are signs that journalists are beginning to see through such misleading messages. The clear difference in risk between cigars and cigarettes was confirmed once again in a study published by The New England Journal of Medicine last June. This time, reporters paid closer attention.

In the study, researchers led by Carlos Iribarren, an epidemiologist with the Kaiser Permanente Medical Care Program in California, tracked about 18,000 men–1,546 cigar smokers and 16,228 nonsmokers–from 1971 through 1995. Overall, the cigar smokers were about twice as likely to develop cancers of the mouth, throat, and lungs; 45 percent more likely to develop chronic obstructive lung disease; and 27 percent more likely to develop coronary heart disease.

As Iribarren and his colleagues noted, these risks are modest compared to those seen in cigarette smokers. Depending upon the study, cigarette smokers are four to 12 times as likely as nonsmokers to develop mouth and throat cancers; eight to 24 times as likely to develop lung cancer; nine to 25 times as likely to develop chronic obstructive lung disease; and 1.5 to three times as likely to develop coronary heart disease.

Furthermore, smoking-related diseases were concentrated among the heaviest cigar smokers in the Kaiser Permanente study. For those smoking fewer than five cigars a day–three-quarters of the sample–only the difference in heart disease risk (20 percent) was statistically significant. Iribarren et al. did not ask the subjects about inhalation, which has been linked to higher risks in other studies, and they did not consider men who smoke less often than daily–who represent about nine out of 10 cigar smokers, according to recent survey data–as a separate category.

Probably because the researchers themselves made it clear that cigars are not nearly as hazardous as cigarettes, the coverage of this study was more accurate than the coverage of the NCI monograph. Stories in The New York Times, The New York Post, The Washington Post, and Time noted the difference in risk. But the most refreshing story ran in The Hartford Courant, under the appropriately reassuring headline, "Cigars' Dangers Relatively Low/Moderate Users Face Only Slightly More Health Risks Than Nonsmokers." The Courant's Hilary Waldman, who is completing a master's degree in public health and therefore knows something about statistics and epidemiology, reported the risks found in the study but was careful to put them into perspective. For example, she quoted a local cardiologist who said: "If someone tells me they're smoking one cigar a day, it would be hard for me to jump up and down and say you're killing yourself and be intellectually honest. You are increasing your risk a little bit."

Waldman says the Courant received complaints from readers who thought the story (especially the headline) was "irresponsible," but her colleagues were supportive. Though she has no particular interest in cigars, she says the study was an opportunity to show how the paper could improve its health coverage by calmly and accurately reporting research findings instead of hyping them. "I knew the minute I saw the study exactly how it would be spun," she says. "'Cigars are as deadly as cigarettes': I heard the TV news do that. The [New England Journal of Medicine] article didn't say that; the article said specifically that cigars are not as bad as cigarettes, although they contain the same toxins. And then they [the TV news] went ahead and said that cigars were as dangerous as cigarettes. That was just wrong."

In a similar vein, UPI reported that "new findings give more weight to warnings that cigars can be at least as hazardous as cigarettes." Elizabeth Manning, the stringer who wrote the UPI brief, says she did not spend much time on it and probably relied on press material from the journal or from Kaiser, rather than the study itself. But The New England Journal of Medicine does not issue press releases, and the Q&A sheet that Kaiser distributed to reporters explicitly notes that cigars are less dangerous than cigarettes. Manning says her gloss on the study was "consistent with what I've seen in the press….What the press seems to be reporting is that cigars are as dangerous as cigarettes."

At one point, Robert Pitofsky, the chairman of the Federal Trade Commission, seemed to believe this, too. In an April 1998 comment to The Washington Post, he misinterpreted the NCI monograph as saying that "regular cigar smoking is roughly as dangerous as cigarette smoking." By contrast, when the FTC issued its recommendations for federal warning labels on cigars last July, he said, "We now know, based on the findings of the National Cancer Institute, that cigars, like other tobacco products, pose serious health risks."

The significance of Pitoksky's backpedaling did not register with everyone. "Federal regulators say they want to correct misperceptions that cigars are less dangerous than cigarettes," the Associated Press reported. Similarly, New York Times reporter Stephen Labaton cited "a widespread misperception that cigars are safer than cigarettes." And in case you didn't get the point, Labaton added that "studies by the National Cancer Institute and others" have shown that "cigar smokers face increased risks of heart and lung diseases and that cigars are therefore not safer than cigarettes." These errors represented backsliding for both A.P. and the Times, since the Times had run an accurate A.P. story about the Kaiser study the previous month. On the other hand, the Reuters and Washington Post stories about the FTC's recommendations both noted the lack of evidence that occasional cigar smoking is harmful.

It's not surprising that some reporters continue to overstate the hazards of cigars, since their sources have not made much of an effort to clear up the matter. One of the cigar warnings proposed by the FTC nicely illustrates the artful evasiveness of public health officials who seek to shape people's behavior rather than inform them: "Cigars are not a safe alternative to cigarettes." This warning, which was also the NCI's take-home message when it released its monograph, assumes that people currently think cigars are risk-free. Yet the FTC itself reports, based on survey data, that "consumers generally are aware that cigar smoking poses health risks."

Meanwhile, public health officials continue to exaggerate those risks. "It's a very dangerous habit," Surgeon General David Satcher told Reuters last August. By any reasonable definition of "very dangerous," this is simply not true of cigar smoking as it is commonly practiced. Satcher has also complained that the absence of federal warning labels "implies cigars are different [from cigarettes] and don't carry the same risk." They are, and they don't.