The belief that cigars are harmless if the smoke is not inhaled is a dangerous misconception. A cigar is a roll of tobacco wrapped in tobacco leaf or a substance containing tobacco. The smoke from this product, regardless of whether it reaches the lungs, subjects the entire upper digestive and respiratory tract to a concentrated dose of toxic chemicals. Understanding how the body absorbs nicotine and the direct chemical exposure in the mouth reveals that the health risks of cigar smoking are significant and cannot be avoided by simply not inhaling.
Nicotine Absorption Without Lung Inhalation
Cigar tobacco is typically air-cured and fermented, a process that results in smoke with a higher alkalinity compared to the acidic smoke produced by most cigarettes. This elevated pH is the reason cigar smokers do not need to inhale to achieve a systemic dose of nicotine. The alkaline environment causes the nicotine to exist in its unprotonated, or “freebase,” form, which is readily absorbed.
This freebase nicotine is lipid-soluble, allowing it to easily pass through the buccal mucosa, which is the lining of the mouth, and enter the bloodstream directly. Nicotine enters the body just by holding the smoke in the mouth, similar to the absorption route used by smokeless tobacco products. A single large cigar can contain the nicotine equivalent of an entire pack of cigarettes, and a significant portion of this is absorbed through the mouth.
Once absorbed, nicotine is a powerful vasoconstrictor and central nervous system stimulant. The resulting physiological effects on the cardiovascular system are an immediate concern, independent of smoke inhalation. Nicotine causes an acute increase in heart rate and elevates blood pressure, contributing to the development of cardiovascular disease. The rapid delivery of nicotine through the oral mucosa is also sufficient to establish and maintain a powerful addiction.
Localized Cancer and Oral Health Damage
The primary health risk for the non-inhaling cigar smoker is the direct and prolonged exposure of the mouth and throat tissues to the smoke. This localized exposure leads to significantly elevated rates of cancer in the areas that come into constant contact with the smoke and the carcinogen-laden saliva that is swallowed. Regular cigar smokers face a risk of oral cavity, larynx, and esophageal cancers similar to that of cigarette smokers.
For daily cigar smokers who do not inhale, the risk of oral cancer can be seven times greater than for a non-smoker. The risk for cancer of the larynx is also substantially increased, often rising to more than 10 times that of a non-user. When the toxic substances from the smoke mix with saliva, they are swallowed, exposing the delicate lining of the esophagus to carcinogens and nearly doubling the risk of esophageal cancer.
Beyond cancer, cigar use causes numerous serious oral health problems. The chronic irritation from the smoke contributes to the development of leukoplakia, which are precancerous white patches on the gums or inside of the cheeks. Cigar smoking impairs the immune response and blood flow to the gums, increasing the risk for periodontitis, a severe gum infection that leads to gum recession and tooth loss. Many cigars also contain added sugars, and the combustion of these sugars creates an acidic environment that promotes tooth decay and enamel erosion.
The Unique Toxicity of Cigar Smoke Components
The inherent composition of cigar tobacco makes its smoke highly toxic, regardless of the route of absorption. The air-curing and fermentation process unique to cigar tobacco produces much higher concentrations of certain cancer-causing compounds than the flue-curing process used for most cigarette tobacco. Specifically, cigar tobacco contains significantly greater levels of tobacco-specific nitrosamines (TSNAs), which are among the most potent carcinogens known.
Studies show that the levels of TSNAs in cigar tobacco can be five to seven times higher than in commercial cigarettes. The non-porous nature of the tobacco leaf wrapper leads to a less complete burn of the tobacco, which generates a higher concentration of toxic combustion byproducts. This incomplete burning also produces higher levels of polycyclic aromatic hydrocarbons (PAHs) and more tar per gram of tobacco smoked.
Furthermore, the sheer quantity of tobacco in a large cigar and the typically longer smoking time result in a greater overall emission of toxic substances. Even without inhaling, the smoker is exposed to increased levels of carbon monoxide, which enters the bloodstream through the oral mucosa and impairs the blood’s oxygen-carrying capacity. The concentration of toxic agents like ammonia and carbon monoxide in cigar smoke is often higher than in cigarette smoke, exposing the user to a more chemically aggressive product.