Cigars carry lower overall mortality risk than cigarettes for people who smoke them occasionally and do not inhale, but they are not safe, and the gap narrows dramatically with heavier use. A large U.S. study found that exclusive cigar smokers had a 20 percent higher risk of dying from any cause compared with people who never used tobacco, while exclusive cigarette smokers faced roughly double the risk.1JAMA Internal Medicine. Association of Cigarette, Cigar, and Pipe Use With Mortality Risk in the US Population That difference has led many people to treat cigars as a relatively harmless indulgence, but the reality is more complicated and, in some respects, more hazardous than most cigar smokers realize.
How Cigar and Cigarette Smoke Differ Chemically
The smoke from a cigar and the smoke from a cigarette are not the same substance. Cigar tobacco is air-cured and fermented, which produces smoke with a pH around 8.5, well into alkaline territory. Cigarette tobacco is typically flue-cured, and the resulting smoke has a pH near 5.3, making it mildly acidic.2Nature. Absorption of Nicotine in Cigarette and Cigar Smoke through the Oral Mucosa That chemistry difference changes everything about how nicotine enters the body. The alkaline environment of cigar smoke keeps a higher proportion of nicotine in its uncharged form, which passes easily through the lining of the mouth and throat. Cigarette smoke, being acidic, does not deliver nicotine efficiently through oral tissue; smokers need to pull the smoke deep into their lungs to absorb it.3PubMed. Mouth versus deep airways absorption of nicotine in cigarette smokers
This is why most cigar smokers do not inhale, or at least report that they don’t. A study using radiolabeled particles in cigar smoke found that even among people who said they never or rarely inhaled, some smoke still reached their lungs. All nonsmoking volunteers in that study showed some degree of lung deposition, and about 58 percent of smoking volunteers maintained they did not inhale despite measurable particles in their airways.4PubMed. Deposition of cigar smoke particles in the lung: evaluation with ventilation scan using (99m)Tc-labeled sulfur colloid particles The claim “I don’t inhale” is often sincere but somewhat inaccurate. Some smoke gets in regardless.
Cancer Risks That Persist Even Without Inhaling
For lung cancer specifically, cigar-only smoking carries a meaningfully lower risk than cigarette smoking, though it is still elevated compared with not smoking at all. A European multicenter study found an odds ratio of 9.0 for cigar and cigarillo smokers getting lung cancer versus nonsmokers, compared with 14.9 for cigarette-only smokers. However, the dose-response curves for duration and amount smoked were strikingly similar across all product types, leading the researchers to conclude that the per-unit carcinogenic effect on the lung may be comparable.5JNCI: Journal of the National Cancer Institute. Cigar and Pipe Smoking and Lung Cancer Risk: a Multicenter Study From Europe A separate U.S. cohort study reported that current cigar smoking raised the risk of lung cancer death about fivefold compared with never smoking.6JNCI: Journal of the National Cancer Institute. Cigar Smoking in Men and Risk of Death From Tobacco-Related Cancers
But lung cancer is not where cigars do their worst damage. Cancers of the mouth, throat, esophagus, and larynx are sharply elevated in cigar smokers, and these risks remain high even among those who report no inhalation. A systematic review of cigar smoking and mortality found strong dose-response trends for oral, esophageal, laryngeal, and lung cancers, and critically noted that among cigar smokers reporting zero inhalation, relative mortality risk was still highly elevated for oral, esophageal, and laryngeal cancers.7PubMed Central. Systematic review of cigar smoking and all cause and smoking related mortality This makes intuitive sense: the smoke bathes the mouth and throat regardless of whether it reaches the lungs.
Pooled data on head and neck cancers tell a similar story. Among people who had never smoked cigarettes, exclusive cigar smoking was associated with roughly 3.5 times the odds of developing a head or neck cancer.8PubMed Central. Cigarette, cigar, and pipe smoking and the risk of head and neck cancers: pooled analysis in the International Head and Neck Cancer Epidemiology Consortium So while a cigar smoker may face a lower probability of lung cancer than a cigarette smoker, cancers from the lips to the voice box are a serious and independent concern.
Heart Disease and Stroke
The cardiovascular picture is mixed, and researchers have gone back and forth on how large the effect really is. A well-known study in the New England Journal of Medicine found that cigar smokers had about 27 percent higher risk of coronary heart disease than nonsmokers, with dose-response effects as consumption increased.9PubMed. Effect of cigar smoking on the risk of cardiovascular disease, chronic obstructive pulmonary disease, and cancer in men A more recent cross-cohort analysis found that current cigar use was associated with higher risks of stroke, atrial fibrillation, and heart failure, with exclusive cigar users showing roughly 53 percent higher stroke risk compared to people who had never used cigars or cigarettes.10JAMA Network Open. Cigar, Pipe, and Smokeless Tobacco Use and Cardiovascular Outcomes From Cross Cohort Collaboration
One study using the PATH survey found that after adjusting for conventional cardiovascular risk factors like blood pressure and cholesterol, the elevated odds for cigar-only smokers were no longer statistically significant, while dual cigar-and-cigarette users and cigarette-only smokers still showed clear increases.11Preventive Medicine Reports. Cardiovascular disease outcomes among established cigar users 40 years and older That does not mean cigars are harmless for the heart. It may mean that the effect is more modest and harder to detect in studies, especially since cigar smokers tend to smoke less frequently than cigarette users. The overall pattern across studies is that cigar smoking does raise cardiovascular risk, but probably by a smaller margin than cigarettes for people who do not inhale and smoke infrequently.
Lung Function and COPD
Chronic obstructive pulmonary disease is strongly linked to cigarettes, and the picture for cigar-only smokers is less clear-cut. A longitudinal cohort study found that exclusive cigar use was not significantly associated with increased COPD risk after full adjustment, while exclusive cigarette use and dual use both were.12PubMed Central. Association between cigar use, with and without cigarettes, and incident diagnosed COPD: a longitudinal cohort study That might seem reassuring until you consider a cross-sectional study that measured lung function directly: people who smoked pipes or cigars and had never smoked cigarettes still had more than double the odds of airflow obstruction compared to people who had never smoked anything.13PubMed Central. The association of pipe and cigar use with cotinine levels, lung function, and airflow obstruction: a cross-sectional study The discrepancy likely reflects the difference between a clinical COPD diagnosis, which requires a doctor visit and symptoms severe enough to prompt one, and measurable airflow limitation picked up by a spirometer in a research setting. Cigar smokers may not end up with full-blown COPD at the same rate as cigarette smokers, but their lung function is not unaffected.
What Happens When Cigar Use Becomes Daily
Much of the relative safety case for cigars depends on how they are typically consumed: a few per week, not inhaled, often in a social setting. When that pattern changes to daily use, the toxicant gap between cigars and cigarettes shrinks considerably. An analysis of NHANES data found that primary cigar smokers had cotinine levels roughly 140 times those of non-tobacco users, and their levels of NNAL, a potent carcinogen marker, were about 19 times higher than in non-users. Among daily cigar smokers, NNAL concentrations were comparable to those in daily cigarette smokers.14Cancer Epidemiology Biomarkers and Prevention. Biomarkers of exposure among U.S. cigar smokers: An analysis of 1999-2012 National Health and Nutrition Examination Survey (NHANES) data
The mortality data reflect the same pattern. One study that looked specifically at primary cigar smokers who had never used cigarettes found no statistically significant increase in death from all causes, heart disease, cancer, or cerebrovascular disease. But dual users and former cigarette smokers who had taken up cigars had mortality patterns that looked essentially identical to exclusive cigarette smokers.15PubMed Central. Mortality among male cigar and cigarette smokers in the USA Frequency matters, history matters, and inhalation matters. The “occasional cigar at a barbecue” scenario and the “two cigars a day for 30 years” scenario belong in different risk conversations entirely.
The Switcher Problem
A common idea is that switching from cigarettes to cigars is a step toward harm reduction, a way to keep the ritual while cutting the risk. The evidence suggests this works far less well than people hope. A prospective study followed men who had switched from cigarettes to pipes or cigars more than 20 years before entering the study. These switchers consumed roughly the same amount of tobacco as lifelong pipe and cigar smokers, about 8 grams per day compared with 20 grams per day for cigarette smokers. But their blood carboxyhemoglobin levels were higher than those of lifelong cigar smokers, indicating they were inhaling more deeply. Their risk of dying from smoking-related diseases was 51 percent higher than that of lifelong cigar smokers, 68 percent higher than lifelong nonsmokers, and 57 percent higher than people who had quit cigarettes entirely over 20 years earlier.16PubMed Central. Prospective study of effect of switching from cigarettes to pipes or cigars on mortality from three smoking related diseases
The mechanism is straightforward: people who have spent years inhaling cigarettes do not easily stop inhaling just because the product in their hand has changed shape. The inhalation habit persists, and with it comes lung exposure to cigar smoke that a lifelong cigar smoker would typically avoid. Switching from cigarettes to cigars was still better than continuing to smoke cigarettes in this study, with about a 46 percent lower risk than continuing cigarette smokers. But it was substantially worse than quitting tobacco altogether.
Small Cigars and Cigarillos Are a Different Animal
When most people picture a cigar, they imagine a large, hand-rolled product smoked slowly over an hour. But the cigar category also includes little cigars and cigarillos, which are often indistinguishable from cigarettes in size and shape. Some have filters. Many are flavored. And their smoke chemistry is closer to cigarette smoke than to a traditional premium cigar.
Research measuring actual smoke constituents from little cigars and cigarillos found that qualitatively, the smoke resembles cigarette smoke. Cigarillos delivered higher absolute levels of volatile organic compounds and semi-volatile compounds than either little cigars or cigarettes, while little cigars delivered more nicotine and tobacco-specific nitrosamines per gram of tobacco burned.17PubMed. Cigarillo and Little Cigar Mainstream Smoke Constituents from Replicated Human Smoking In a separate study comparing how people actually smoke these products, little cigars delivered significantly more nicotine per gram of tobacco consumed than cigarillos or large cigars, while large cigars and cigarillos produced higher absolute levels of carbon monoxide per smoking session because of the larger amount of tobacco burned.18PubMed Central. Dual Use of Cigarettes, Little Cigars, Cigarillos, and Large Cigars: Smoking Topography and Toxicant Exposure
People tend to smoke little cigars the way they smoke cigarettes: inhaling deeply, finishing them quickly. A study of large cigar smoking found that while cigarettes delivered more nicotine per gram of tobacco, large cigar sessions involved more puffs, longer smoking time, and larger puff volumes.19Nicotine & Tobacco Research. Large Cigars: Smoking Topography and Toxicant Exposure The upshot is that small cigars and cigarillos should not be thought of as a milder alternative. Regulatory agencies have increasingly treated them as cigarette-equivalent products, and the toxicant data supports that treatment.
Secondhand Smoke From Cigars
One area where cigars are unambiguously worse than cigarettes is the smoke they release into the surrounding air. A cigar burns for much longer, produces a larger volume of sidestream smoke, and does so at lower combustion temperatures that generate different chemical profiles. An analysis of volatile emissions found that cigars release levels of volatile organic compounds one to two orders of magnitude higher than conventional cigarettes.20E3S Web of Conferences. Volatile Emissions of Cigar Smoke and Their Predicted Impact on Indoor Air Quality That means 10 to 100 times more of certain airborne toxicants per cigar. For anyone sharing an indoor space with a cigar smoker, this makes the ambient exposure substantially greater than sitting near someone with a cigarette.
Oral Health
Even if a cigar smoker escapes cancer and heart disease, the effects on the mouth are hard to miss. A study examining periodontal disease across tobacco users found that cigar and pipe smokers had higher rates of moderate and severe gum disease, greater loss of the tissue attachment that holds teeth in place, and more gum recession than nonsmokers. On average, cigar and pipe smokers were missing four teeth. The estimated prevalence of moderate-to-severe periodontitis among current or former cigar and pipe smokers was about 18 percent.21PubMed. Cigar, pipe, and cigarette smoking as risk factors for periodontal disease and tooth loss One curious finding: smokers had less gingival bleeding than nonsmokers. That is not a sign of healthier gums but rather the opposite. Nicotine constricts blood vessels, masking one of the early warning signs of gum disease and potentially delaying diagnosis.
Why the Risk Gap May Be Partly a People Gap
Some of the apparent health advantage of cigars over cigarettes may reflect who smokes them rather than what the product does. Premium cigar smokers in the United States tend to be older, college educated, higher income, and more likely to be non-Hispanic white compared with non-premium cigar users. They are less likely to smoke cigars daily, less likely to also smoke cigarettes, and less likely to have started before age 18.22PubMed Central. Cross-sectional Use Patterns and Characteristics of Premium Versus Non-Premium Cigar Smokers in the United States, 2010-2019 These are precisely the characteristics associated with better health outcomes across the board: higher socioeconomic status, better access to healthcare, fewer co-occurring risk factors. When studies compare cigar smokers to cigarette smokers, they are partly comparing two populations with very different baseline health trajectories. Researchers try to adjust for these differences statistically, but no adjustment is perfect, and the “healthy cigar smoker” image is at least partly a reflection of privilege rather than product safety.
The Perception Problem
A systematic review of studies on cigar health perceptions found that recent research on cardiopulmonary effects is limited but suggests cigars carry similar health risks to cigarettes.23PubMed Central. Patterns of use, perceptions, and cardiopulmonary health risks of cigar products: a systematic review Yet public perception does not match the science. Many cigar smokers believe they are doing something fundamentally different from cigarette smoking. Warning labels make a measurable difference in closing that gap: among cigarillo smokers who noticed health warnings at least sometimes, 59 percent rated cigar smoking as very or extremely harmful, compared with 46 percent of those who rarely or never noticed warnings.24PubMed Central. Does noticing cigar warnings associate with cigar harm perceptions and smoking behaviors? That a warning label can shift the proportion of people recognizing harm by 13 percentage points suggests the baseline understanding is weaker than it should be. The idea that cigars are a gentleman’s indulgence rather than a tobacco product with real consequences is remarkably sticky, and the evidence accumulated over the past two decades should have eroded it more than it has.