Premium Cigars and their Potential for Nicotine Dependence and Addiction
by David "Doc" Diaz
Tuesday, June 3, 2014
[Author's note: The following article was submitted to the FDA in response to their request for public comment on their proposed rule for subjecting tobacco products (including premium cigars) to FDA oversight and restrictions. The first few paragraphs were provided as introductory comments to the FDA. What follows the introduction is the article that I wrote and submitted as an attachment.]
I am writing this brief essay in response to the FDA’s request for public comment on their proposed rule: Deeming Tobacco Products To Be Subject to the Federal Food, Drug, and Cosmetic Act, as Amended by the Family Smoking Prevention and Tobacco Control Act; Regulations on the Sale and Distribution of Tobacco Products and Required Warning Statements for Tobacco Products.
By way of introduction and background, I have served as a health educator at the college level for more than 35 years and have studied the effects of tobacco and tobacco use on public health. On numerous occasions and in countries throughout the Caribbean and Central America, I’ve visited the farms and factories to observe the processes used by the premium cigar industry to bring their product to market from seed to smoke. I have written articles in non-peer-reviewed web publications on the topic of premium cigars and health (Diaz, 2011) and on the difference between premium cigars and cigarettes (Diaz, 2007).
My statement below will be limited to a clarification of the potential for nicotine dependence and addiction as alluded to in the following statement by the FDA under their proposed Option 2: Restrict Rule to Covered Cigars...
It is my intent to show that, 1) the fundamental difference in tobacco chemistry between premium cigars and cigarettes leads to a lower risk of nicotine dependence in cigar smokers, 2) smoking premium cigars entails less potential for nicotine dependence (compared to cigarette smoking) due to the method of delivery, and 3) the rate of oral nicotine delivery by cigar smoking is slow relative to inhalation and, thus, represents a low risk for dependence and addiction.
David P. Diaz, Ed.D.
Premium Cigars: Potential for Dependence and Addiction
Submitted on Tuesday May 20, 2014
[Author's Note: I have made edits in the following narrative for the purpose of clarification and to broaden the scope of the discussion.]
Public interest in the dangers of cigar smoking has been spurred by many scientific publications, but none were more historic or groundbreaking than the first report to the Surgeon General on Smoking and Health (U.S. Public Health Service, 1964). The Surgeon General’s report declared that moderate cigar smoker’s who smoked less than 5 cigars per day would have nearly the same low risk of early death as non-smokers. This started a debate that rages to this day.
Of particular importance to this discussion is the role of nicotine in causing dependence and addiction. It is generally accepted that nicotine is not directly responsible for tobacco-related disease (Hukkanen, et. al., 2005). Instead, it is thought that nicotine is an addictive drug that keeps the user coming back to the tobacco product of choice, thereby continually exposing them to carcinogenic and other bioactive compounds (Ibid).
And yet, nicotine has been smoked or chewed (i.e., ingested) in the Americas for thousands of years. By itself, nicotine is a common, cheap and mostly safe drug that has been used to treat a variety of maladies for centuries (Powledge, T.M., 2004). In modern times, nicotine replacement therapies have aided smoking cessation by delivering nicotine in ways that are far healthier and safer than cigarettes (WebMD). Nicotine therapies also hold promise as treatments for diseases like Parkinson’s, Alzheimer’s, ulcerative colitis and others. Therefore, it seems reasonable to postulate that there are factors that may modulate the negative effects or outcomes of ingesting nicotine as regards dependence and addiction, as well as morbidity and mortality.
Research Question: What are the factors that make premium cigars different from cigarettes as regards nicotine delivery and the potential for dependence and addiction?
Differences between Premium Cigars and Cigarettes
A cigarette can be defined as “a tobacco product that is wrapped in paper or other substance that does not contain tobacco” (NCI, 2000). Cigarettes may include tobacco, reconstituted tobacco, expanded tobacco, reclaimed cigarettes and other additives. For the purpose of this discussion, I will define a premium cigar as one that is made from 100% tobacco and does not contain non-tobacco products like reconstituted tobacco, added color or flavoring. I will be referring only to long-filler cigars whose tobaccos have been fermented and aged naturally (i.e., without additives) and are hand-made products.
The typical US-made cigarette contains a blend of heat-cured and air-cured tobaccos, while premium cigars are traditionally made with 100% air-cured tobacco. Unlike cigarette tobacco, premium cigar tobacco always undergoes fermentation, which represents one of the fundamental differences between cigarettes and premium cigars. Changes that take place during the fermentation of cigar tobacco include a decrease of nicotine in the tobacco leaf and a reduction (off-gassing) of ammonia (Loew, 1899; Johnson, 1934). The reduction of both nicotine and ammonia may reduce the potential for nicotine dependence in premium cigars (versus cigarettes) if the total volume of tobacco smoked is similar (i.e., on a per weight basis).
Ammonia is important to this discussion because cigarette companies have been known to add ammonia to their tobacco, usually in the form of diammonium phosphate, which de-protonates nicotine, making it cross through membranes in the body much more readily (AAAS Science News Service). This makes the drug more "bioavailable" to the lungs, brain and tissues. Because ammonia is also a base (negatively charged), it strips away protons from nicotine, turning it into "freebase" form. Freebasing nicotine is a way to increase the potency of nicotine without increasing the dose. This finding suggests that adding ammonia has a substantial effect on the amount of freebase nicotine contained in cigarette smoke (AAAS). But since cigar tobacco contains no added ammonia and since ammonia is reduced in fermented cigar tobacco, ammonia should have little or no effect on nicotine delivery in cigars compared to cigarettes.
Nicotine Delivery, Tolerance and Dependence
Delivery: According to the National Cancer Institute (NCI, 1998, pg. 183), the ability of cigars to deliver nicotine at a level capable of producing dependency is based on the degree of smoke inhalation, the rate of oral nicotine absorption, the development of tolerance to nicotine, the age of initiation, and the duration of exposure.
Smoke inhalation in cigar smokers is not likely a significant factor since most cigar smokers do not inhale the smoke. In smoking practice, cigarette smokers always inhale while cigar smokers rarely do. The reason for the difference in smoking patterns is likely due to the chemical composition of cigarettes versus cigars. Cigar smoke is alkaline (i.e., has a higher pH compared to cigarette smoke) and is difficult to inhale without severely irritating the respiratory airways. The nicotine produced in a high pH environment is termed “free nicotine” (i.e., unprotonated) and is a type that more readily absorbs through the mucous membranes of the mouth (NCI, 1998), but is difficult to inhale. Thus, cigar smokers can deliver a substantial amount of nicotine to the brain via transport through the oral mucosa, but the rate of delivery is much slower compared to inhaling cigarette smoke. Further, premium cigar smokers typically smoke only occasionally or in moderation (i.e., 1-2 cigars/day) with each cigar being savored slowly and in a relaxed setting. Thus, while a typical premium cigar may have more tobacco than a standard cigarette, the total volume of tobacco ingested per week is likely to be much less for premium cigar smokers who smoke only occasionally or in moderation.
On the other hand, Cigarette smoke is mildly acidic, making it much easier to inhale and produces a type of nicotine that is termed “protonated.” Protonated nicotine is not readily absorbed through the oral mucosa and must be inhaled to produce substantial nicotine delivery. As indicated earlier, adding ammonia to cigarette tobacco can deprotonate nicotine, which would increase delivery through all membranes including via the mouth and lungs. However, inhaling tobacco smoke causes the nicotine to move into the blood and to the brain very quickly, compared to delivery solely via the oral mucosa.
Tolerance: Tolerance is a physiological state characterized by a decrease in the effects of a drug with chronic use, thereby leading the user to consume higher levels of the substance to achieve the same, or similar, effects. Anyone who has developed an addiction or physical dependence to nicotine will also likely have developed a tolerance to the drug. However, chronic tolerance to nicotine has not been shown to be closely associated with tobacco dependence (Perkins, 2002). Since Perkins' study adressed cigarette smokers exclusively, the FDA have less reason to link dependence with tolerance in cigar smokers who smoke occasionally or moderately and do not inhale.
Dependence: Karl Fagerstrom (2013), a founding member of the Society for Research on Nicotine and Tobacco has noted that there is growing evidence that different nicotine products can produce varying degrees of dependence, an observation that he calls the “continuum of dependence” (Fagerstrom, 2013). He hypothesized that there is likely a “continuum of harm” that mirrors the continuum of dependence with nicotine replacement products (e.g., nicotine patch) on the least harmful side and tobacco cigarettes on the most harmful side. Thus, any tobacco product that reduces the delivery of nicotine relative to cigarettes would fall toward the less harmful side of the continuum. While Fagerstrom placed smokeless tobacco products in the middle of the continuum, I would hypothesize that premium cigars would fall to the left of smokeless tobacco products and to the right of nicotine replacement products on the Continuum of Dependence (Figure 1).
Fagerstrom (2012) also noted that nicotine containing products may be variously and uniquely related to nicotine dependency due to their "very different characterisitics both in terms of behavioral and sensory involvement and also in pharmacokinetic and pharmacodynamic effects" (Fagerstrom, 2012).
The term "pharmacokinetic effects" refers to the characteristic interactions of a drug and the body in terms of its absorption, distribution, metabolism, and excretion, while "pharmacodynamic effects" refers to the relationship between drug concentration at the site of action and the resulting effects including the time course and intensity of effects. The delivery of nicotine via inhalation in tobacco cigarette smoking increases the rate of drug absorption through the membranes and to the brain and increases the magnitude of the nicotine stimulus, thereby increasing both the pharmacokinetic and pharmacodynamic effects. Due to the habitual and frequent use of cigarettes, behavioral and sensory aspects of cigarette smoking would likey be reinforced, making cigarette smoking fall on the harmful end of Fagerstrom's continuum of dependence. On the other hand, the characteristics of premium cigar smoking, including the manner in which the cigar is smoked, the frequency of use and the smoking dynamics, should modulate the interactions of nicotine and place cigar smoking well to the left of cigarette smoking on the continuum of dependence. I would also place cigar smoking to the left of smokeless tobacco use because of the constant contact of the smokeless tobacco with the oral mucosa.
The ability of any drug to bring on dependence and addiction appears to be, in part, related to the speed with which its chemical messages are delivered to the brain. The more quickly the brain 'feels' the effects of what the body takes in, the more easily it is able to connect or associate this action with the reaction of pleasure. Though cigarette and cigar smoking can both deliver substantial amounts of nicotine to the brain, the rate of delivery to the brain may be a more important factor when it comes to nicotine dependence and addiction. The practice of inhaling smoke has been shown to increase the rate of delivery of nicotine to the brain. However, nicotine absorption to the brain is slower when nicotine is absorbed through the oral mucosa. Armitage et al., (1978) noted that the peak levels of nicotine delivery during smoking cigars are similar to that of a cigarette, but the rate of rise for nicotine is slower in cigar smokers. If this is the case, then premium cigar smokers who do not inhale should be at a lower risk of suffering nicotine dependence and addiction.
Conclusion and Recommendations
Premium cigar smokers today are enjoying a tobacco that has not been chemically altered. They smoke it without inhaling (naturally, there are a few exceptions) and typically do not abuse it. In contrast, cigarettes provide a form of consumption of tobacco that is inconsistent with the moderate, non-abusive manner more often practiced by premium cigar smokers. Cigarettes are provided in a "dose pack" of 20. They burn quickly, are inhaled and provide rapid release of nicotine into the blood stream and to the brain. Cigarettes rapidly become addictive and are smoked in an addictive manner: frequently throughout the day and night and because of a physical need to smoke.
All tobacco products can be abused, but there are some simple recommendations that are exemplified by those who smoke only premium hand made cigars (Diaz, 2007). Following these recommendations will not necessarily prevent tobacco-related disease or addiction, but based on the evidence, they should greatly reduce the potential risk...
1. Smoke premium, handmade cigars that have been well cured, fermented and aged. Premium cigars have gone through extensive fermentation and aging and are not laced with harmful additives or flavorings. The fermentation process has been shown to reduce nicotine and ammonia.
2. Smoke in moderation. The total volume of tobacco consumed has been shown to be an important factor contributing to the risk of disease. Therefore, it would be wise to moderate the total number of cigars that you smoke to no more than 1-2 per day.
3. Don’t inhale. Cigar smoke is often partially inhaled by current and former cigarette smokers (Baker, 2000) who seem to be unable to break themselves of the habit of inhaling. Inhaling mainstream smoke will likely increase your risk of nicotine addiction and will increase your risk of suffering from coronary heart disease, lung cancer and COPD. Switching from cigarettes to cigars may not be a healthier alternative if the user continues to inhale.
4. Don’t chew your cigars. Chewing will cause a higher level of accumulated tars and nicotine to pass into the mouth where they can more substantially affect the oral mucosa and esophagus. Place your cigar down in your ashtray between puffs and take your time: enjoy the experience.
5. Smoke outdoors or in well-ventilated areas. Premium cigar smokers should take every opportunity to introduce fresh air into the smoking environment or remove smoke-filled air, or both. Those who must smoke indoors should provide plenty of air circulation. The use of fans, open windows, air-ventilation systems and/or air purifiers should help to reduce the concentration of environmental tobacco smoke.
1. To read the entirety of the Food and Drug Administration's (FDA) proposed rule, go to: Deeming Tobacco Products To Be Subject to the Federal Food, Drug, and Cosmetic Act, as Amended by the Family Smoking Prevention and Tobacco Control Act; Regulations on the Sale and Distribution of Tobacco Products and Required Warning Statements for Tobacco Products.
2. To submit your own public comment to the FDA go to Regulations.gov
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About the Author
David "Doc" Diaz is the publisher and the editor of the Stogie Fresh Cigar Publications. He has served as an educator, researcher and writer and has taught in the Health Education and Health Science field for over 30 years. He possesses an earned doctorate from Nova Southeastern University. Doc is a Certified Master Tobacconist (CMT), having received this certification from the Tobacconist University and is a member and Ambassador of Cigar Rights of America (CRA).blog comments powered by Disqus