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Cristine D. Delnevo, PhD, MPH, Eric S. Pevzner, MPH, Michael B. Steinberg, MD, MPH, Charles W. Warren, PhD and John Slade, MD

Cristine D. Delnevo, Michael B. Steinberg, and John Slade are with University of Medicine and Dentistry of New Jersey–School of Public Health, New Brunswick, NJ. Eric S. Pevzner and Charles W. Warren are with the Centers for Disease Control and Prevention, Office on Smoking and Health, Atlanta, Ga.

Correspondence: Requests for reprints should be sent to Cristine D. Delnevo, PhD, MPH, University of Medicine and Dentistry of New Jersey–School of Public Health, 335 George St, Liberty Plaza, Suite 2200, PO Box 2688, New Brunswick, NJ 08903-2688 (e-mail: delnevo{at}umdnj.edu).

	INTRODUCTION

TOP INTRODUCTION References

 
More than 3000 youths become daily smokers each day.¹ Millions of youths will die from a tobacco-caused disease,² and tobacco use remains the single leading preventable cause of death in the United States.³ However, recent data indicate that the prevalence of cigarette smoking among youths nationally has declined since 1998.⁴ Although the decline in cigarette use among youths is encouraging, the emergence of other tobacco products, such as cigars, as alternative forms of tobacco use by youths is alarming. The purpose of this report is to compare cigar use among adolescents and adults on the basis of data from New Jersey and the United States.

We used 3 sources of data in this report. For adolescents, data for New Jersey are from the 1999 New Jersey Youth Tobacco Survey, and national data are from the 1999 National Youth Tobacco Survey. For adults, data for New Jersey are from the 1998 Behavioral Risk Factor Surveillance System (BRFSS)⁵; cigar data were not collected in the 1999 BRFSS. Comparable adult cigar use data were not nationally available.

The methodology of the Youth Tobacco Survey, a school-based questionnaire, is described in detail elsewhere.⁶ In brief, the New Jersey Youth Tobacco Survey used a 2-stage cluster sample design to obtain a representative statewide sample of students (N = 15 871) in grades 7 through 12. Likewise, the National Youth Tobacco Survey used a 3-stage cluster sample design to produce a nationally representative sample of students (N = 15 061) in grades 6 through 12. Both surveys were conducted during the fall school semester. For the purposes of this report, we excluded sixth-grade students from the National Youth Tobacco Survey middle-school sample to standardize comparisons.

Operational definitions of "current cigar use" were comparable in the 1999 Youth Tobacco Survey (i.e., smoked a cigar on 1 day or more in preceding 30 days) and the 1998 BRFSS (i.e., smoked a cigar in past month), offering a unique opportunity to compare youth and adult cigar smoking prevalence. Differences between prevalence estimates were considered to be statistically significant if the 95% confidence intervals did not overlap.

Last, note that data from the Youth Tobacco Survey and the BRFSS are based on self-reports, which are subject to underreporting or overreporting. The extent of this response bias cannot be determined, but school-based surveys may tend toward overreporting, whereas telephone surveys like the BRFSS tend toward underreporting of tobacco use behaviors.

Comparisons across groups documented remarkably high levels of cigar use among youths in New Jersey and the United States (Table 1). Sex differences were apparent in both adolescents and adults, with males reporting significantly higher rates of ever and current cigar use than females. Rates of ever and current cigar smoking were similar in New Jersey and the United States among high-school students; however, the prevalence of current cigar smoking in New Jersey (18.4; 95% confidence interval (CI) = 17.1, 19.7) exceeded the national rate (15.3; CI = 13.9, 16.7) by 25%.

After decades of stagnant consumption, cigar use surged during the 1990s, coinciding with increased cigar marketing, most notably the use of cigars by celebrities. By featuring celebrities such as Madonna, Michael Jordan, and supermodel Elle McPherson using cigars, the cigar industry has successfully marketed their products to adult women and adolescents of both sexes. Advertising and promotional activities have increased the visibility of cigar smoking,⁷ thereby "normalizing" cigar use.^8,9 As is evident in New Jersey's data, the "new cigar users" are young people, including adolescent females. The effect of increased cigar marketing on young girls and women is considerable.

Casual cigar use is often dismissed as a non–health issue. However, even moderate cigar use carries significant health risks, including increased risk for oral, oropharyngeal, and laryngeal cancers. And as is the case with other carcinogenic products, risk increases with consumption (i.e., number of cigars smoked) and depth of inhalation. Furthermore, cigars have higher total nicotine content than cigarettes do and can deliver nicotine both through smoke and through direct oral contact with the tobacco wrapper. Consequently, a special concern is that adolescent cigar use may increase vulnerability for nicotine dependence, predisposing youths to initiation of and continued use of cigarettes and other tobacco products.⁸

The emergence of widespread cigar use among adult women and among adolescents of both sexes—combined with cigar use among men—is a significant public health threat. As funding for tobacco control increases and national rates of cigarette use appear to be declining, we must remain diligent in monitoring all forms of tobacco use. The Youth Tobacco Survey allows states such as New Jersey to monitor multiple forms of tobacco use and to examine emerging patterns among youth. However, even the most responsive surveillance system is rendered ineffectual if data are not disseminated and translated into public health policies and programs. The higher-than-expected levels of youth cigar use in New Jersey and the United States indicate that effective tobacco control programs must focus on all tobacco products, not just cigarettes.

	Acknowledgments

 
Completion of this work was partially supported by a contract from the New Jersey Department of Health and Senior Services through funding from the Master Settlement Agreement.

We would like to thank Dawn Berney and Shyamala Muthurajah for their critical contributions to the 1999 New Jersey Youth Tobacco Survey. We also would like to thank Mary Hrywna for her review of an earlier version of the report.

	Footnotes

 
C. D. Delnevo directed the New Jersey Youth Tobacco Survey, wrote drafts of the brief, and conducted analyses. E. S. Pevzner provided technical assistance on the New Jersey Youth Tobacco Survey and wrote drafts of the brief. M. B. Steinberg formulated the concept for the brief and wrote drafts of the brief. C. W. Warren provided technical assistance on the New Jersey Youth Tobacco Survey and contributed to the interpretation of results and editing of the brief. J. Slade provided content expertise in cigar use, health effects, and marketing and contributed to the editing of the brief.

Peer Reviewed

Accepted for publication January 19, 2002.

	References

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1. Centers for Disease Control and Prevention. Incidence of initiation of cigarette smoking—United States, 1965–1996. MMWR Morb Mortal Wkly Rep.1998;47:837–840.[Medline]

2. Centers for Disease Control and Prevention. Projected smoking-related deaths among youth—United States. MMWR Morb Mortal Wkly Rep.1996;45:971–974.[Medline]

3. McGinnis MJ, Foege WH. Actual causes of death in the United States. JAMA.1993;270:2207–2212.[Abstract/Free Full Text]

4. Johnston LD, O'Malley PM, Bachman JG. The Monitoring the Future National Survey Results on Adolescent Drug Use: Overview of Key Findings, 2001. Bethesda, Md: National Institute on Drug Abuse; 2002:61. NIH publication 02-5105.

5. Centers for Disease Control and Prevention. State-specific prevalence of current cigarette and cigar smoking among adults—United States, 1998. MMWR Morb Mortal Wkly Rep.1999;48:1034–1039.[Medline]

6. Centers for Disease Control and Prevention. Youth tobacco surveillance—United States, 1998–1999, CDC Surveillance Summaries. MMWR Morb Mortal Wkly Rep.2000;49(SS-10):1–94.[Medline]

7. Wenger L, Malone R, Bero L. The cigar revival and the popular press: a content analysis, 1987–1997. Am J Public Health.2001;91:288–291.[Abstract]

8. National Cancer Institute. Cigars: Health Effects and Trends. Bethesda, Md: Public Health Service; 1998. Smoking and Tobacco Control Monograph, No. 9. NIH publication 98-4302.

9. Feit MN. Exposure of adolescent girls to cigar images in women's magazines, 1992–1998. Am J Public Health.2001;91:286–288.[Abstract]

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