title: Systematic review of cigar smoking and all cause and smoking related mortality.
abstract: BACKGROUND
  Cigars are a growing public health concern, given the changes in cigar use patterns in the US and elsewhere since the 1960s. We conducted a systematic review of published studies on current cigar smoking and all-cause and cause-specific mortality risks to inform potential regulatory approaches and future research that would strengthen the body of evidence.
  
  
  METHODS
  Using 3 different databases and handsearching, we identified epidemiological studies published prior to June 2014 that examined the association between cigar smoking and all-cause mortality and smoking-related mortality. Detailed study characteristics as well as association-level characteristics, including effect estimates and 95% confidence intervals, were abstracted or calculated from each selected study.
  
  
  RESULTS
  A total of 22 studies from 16 different prospective cohorts were identified. Primary cigar smoking (current, exclusive cigar smoking with no history of previous cigarette or pipe smoking) was associated with all cause-mortality, oral cancer, esophageal cancer, pancreatic cancer, laryngeal cancer, lung cancer, coronary heart disease (CHD), and aortic aneurysm. Strong dose trends by cigars per day and inhalation level for primary cigar smoking were observed for oral, esophageal, laryngeal, and lung cancers. Among primary cigar smokers reporting no inhalation, relative mortality risk was still highly elevated for oral, esophageal, and laryngeal cancers.
  
  
  CONCLUSIONS
  In summary, cigar smoking carries many of the same health risks as cigarette smoking. Mortality risks from cigar smoking vary by level of exposure as measured by cigars per day and inhalation level and can be as high as or exceed those of cigarette smoking. The body of evidence would be strengthened by future studies that focus on the health effects of primary cigar smoking and incorporate more contemporary and diverse study populations to better reflect the current patterns of cigar use in the US. Ideally, these studies would also collect detailed information on cigar type, exposure level, and biomarkers of exposure and potential harm.
authors.affiliation: Office of Science, Center for Tobacco Products, Food and Drug Administration, Document Control Center, Building 71, Room G335, 10903 ,New Hampshire Avenue, Silver Spring, MD, 20993-0002, USA. Cindy.Chang@fda.hhs.gov.
authors.forename: Cindy M
authors.initials: CM
authors.lastname: Chang
authors.affiliation: Office of Science, Center for Tobacco Products, Food and Drug Administration, Document Control Center, Building 71, Room G335, 10903 ,New Hampshire Avenue, Silver Spring, MD, 20993-0002, USA. Catherine.Corey@fda.hhs.gov.
authors.forename: Catherine G
authors.initials: CG
authors.lastname: Corey
authors.affiliation: Office of Science, Center for Tobacco Products, Food and Drug Administration, Document Control Center, Building 71, Room G335, 10903 ,New Hampshire Avenue, Silver Spring, MD, 20993-0002, USA. Brian.Rostron@fda.hhs.gov.
authors.forename: Brian L
authors.initials: BL
authors.lastname: Rostron
authors.affiliation: Office of Science, Center for Tobacco Products, Food and Drug Administration, Document Control Center, Building 71, Room G335, 10903 ,New Hampshire Avenue, Silver Spring, MD, 20993-0002, USA. Benjamin.Apelberg@fda.hhs.gov.
authors.forename: Benjamin J
authors.initials: BJ
authors.lastname: Apelberg
mesh_terms: D001014:Aortic Aneurysm / Q000401:mortality*; D003327:Coronary Disease / Q000401:mortality*; D004305:Dose-Response Relationship, Drug; D006801:Humans; D008175:Lung Neoplasms / Q000401:mortality; D009369:Neoplasms / Q000401:mortality*; D011446:Prospective Studies; D012306:Risk; D012907:Smoking / Q000401:mortality*; D062789:Tobacco Products