A cigar is a rolled bundle of dried and fermented tobacco leaves made to be smoked.

They are
produced in a wide variety of sizes and shapes. Since the 20th century, almost all cigars are made
up of three distinct components: the filler, the binder leaf which holds the filler together, and a
wrapper leaf, (which is often the best leaf used). Often the cigar will have a band printed with the
cigar manufacturer's logo. Modern cigars often come with 2 bands, especially Cuban Cigar bands,
showing Limited Edition (Edicion Limitada) bands displaying the year of production

Smoke is a collection of airborne solid and liquid particulates and gases[1] emitted when a material
undergoes combustion or pyrolysis, together with the quantity of air that is entrained or otherwise
mixed into the mass. It is commonly an unwanted by-product of fires (including stoves, candles, oil
lamps, and fireplaces), but may also be used for pest control (fumigation), communication (smoke
signals), defensive and offensive capabilities in the military (smoke screen), cooking,
or smoking (tobacco, cannabis, etc.). It is used in rituals where incense, sage, or resin is burned to
produce a smell for spiritual purposes. Smoke is sometimes used as a flavoring agent, and
preservative for various foodstuffs. Smoke is also a component of internal combustion
engine exhaust gas, particularly diesel exhaust.
Smoke inhalation is the primary cause of death in victims of indoor fires. The smoke kills by a
combination of thermal damage, poisoning and pulmonary irritation caused by carbon
monoxide, hydrogen cyanide and other combustion products.

Cigarette smoking is well established as a risk factor for numerous epithelial malignancies, including the lung, oral

cavity, kidney, pancreas, esophagus, and stomach.1 Prior studies of smoking and colorectal cancer (CRC) have

demonstrated either a weak or no association, and smoking is not currently listed as a risk factor for CRC by the
International Agency for Research on Cancer.

Adenomatous polyps are relatively common in the general adult population, with an estimated prevalence of 15%–

25%.2, 3 It is felt that most, if not all, CRCs develop along an adenoma–carcinoma pathway, with a well-defined set of

genetic alterations observed in the majority of tumors. 4 As a result, adenomas are frequently used as a surrogate
endpoint in epidemiologic studies of risk factors for CRC.

In this issue of GASTROENTEROLOGY, Botteri et al5 present the results of a meta-analysis of the association between

cigarette smoking and adenomatous polyps in the colon, and report a summary relative risk (RR) for current smokers

of 2.14 (95% confidence interval [CI], 1.86–2.46) and for ever smokers of 1.82 (95% CI, 1.65–2.00). As they show in

the forest plot, there have been many prior studies on this topic with relatively consistent findings. The authors should

be particularly commended for elements of their analyses that serve to shed light on the association between
smoking and colorectal neoplasia.

If adenomas are the precursors for virtually all CRC, then one would anticipate that the observed association between

smoking and CRC would be at least as large as the association between smoking and adenomas. If smoking confers
no increased risk on progression of a polyp to carcinoma, then the smoking/CRC association should be equal to that

observed for polyps. Curiously, numerous studies of smoking and colon cancer have demonstrated
a weaker association as compared with adenomas. 6, 7 Given the numerous carcinogenic effects of components of

cigarette smoke, it is hard to reconcile these observations.

Various explanations have been proposed to help us understand these epidemiologic findings. 8 Smoking may

preferentially increase the likelihood of developing “low-risk” adenomas, such as smaller polyps without villous

features. The extra polyps found in smokers would be less likely to progress to adenocarcinoma, and therefore the

risk of CRC in smokers, although still increased, would be less elevated than the observed risk for polyps. The

authors compared the effects of smoking on the likelihood of developing high-risk (ie, ≥1 cm in diameter) versus low-

risk adenomas. Current and ever smokers had a 2-fold increased odds of high-risk adenomas. This finding seems to
refute the above explanation.

Another plausible explanation relates to the selection of controls in the studies. Adenoma studies are generally based

on direct evaluation of the colon (eg, by colonoscopy). As a result, the controls in these studies are known to be polyp

free. In contrast, studies of risk factors for CRC generally use population-derived controls who have not generally

undergone evaluation of their colons. Thus, the polyp status is unknown in these controls, and therefore up to 25% of

the controls could have polyps. This could result in a significant attenuation of the observed associations between

smoking and CRC risk. In Botteri et al,5 the analysis was performed comparing studies in which the controls

underwent either full colonoscopy or partial examination. The association between smoking and adenomas was 1.6

times stronger in studies in which all the cases and controls underwent full colonoscopy, as compared with those

studies in which the controls underwent only a partial examination. In other words, there is a stronger association
between smoking and adenomas when controls are polyp free.

The common prevalence of adenomas also means that measures of association like odds ratios overestimate relative

risks.9 Thus, odds ratios for adenomas should be higher than odds ratios for CRC because the latter is still a relatively

rare outcome in which odds ratios are a good proxy for relative risk estimates (Figure 1). In this scenario, performing
relative risk regression as a means of estimating the relative risk for adenomas may be more appropriate. 10 If one

assumes that smoking only affects the development of adenomas and has no effect on the remainder of the

neoplastic pathway, then the odds ratio for the association with CRC should be smaller than that for adenomas. But

then why is this not observed with other risk factors for colorectal neoplasia, such as fiber? One possible explanation
is that other risk factors promote neoplastic progression throughout the entire neoplastic pathway.

Cigarette smoking harms nearly every organ of the body, causes many diseases, and reduces the
health of smokers in general.1,2

Quitting smoking lowers your risk for smoking-related diseases and can add years to your life.1,2
Smoking and Death

Cigarette smoking is the leading preventable cause of death in the United States.1

 Cigarette smoking causes more than 480,000 deaths each year in the United States. This is
nearly one in five deaths.1,2,3
 Smoking causes more deaths each year than the following causes combined:4
o Human immunodeficiency virus (HIV)
o Illegal drug use
o Alcohol use
o Motor vehicle injuries
o Firearm-related incidents

 More than 10 times as many U.S. citizens have died prematurely from cigarette smoking than
have died in all the wars fought by the United States.1
 Smoking causes about 90% (or 9 out of 10) of all lung cancer deaths.1,2 More women die from
lung cancer each year than from breast cancer.5
 Smoking causes about 80% (or 8 out of 10) of all deaths from chronic obstructive pulmonary
disease (COPD).1
 Cigarette smoking increases risk for death from all causes in men and women.1
 The risk of dying from cigarette smoking has increased over the last 50 years in the U.S.1

Smoking and Increased Health Risks

Smokers are more likely than nonsmokers to develop heart disease, stroke, and lung cancer.1

 Estimates show smoking increases the risk:

o For coronary heart disease by 2 to 4 times1,6
o For stroke by 2 to 4 times1
o Of men developing lung cancer by 25 times1
o Of women developing lung cancer by 25.7 times1
 Smoking causes diminished overall health, increased absenteeism from work, and increased
health care utilization and cost.1

Smoking and Cardiovascular Disease

Smokers are at greater risk for diseases that affect the heart and blood vessels (cardiovascular
disease).1,2

 Smoking causes stroke and coronary heart disease, which are among the leading causes of
death in the United States.1,3
 Even people who smoke fewer than five cigarettes a day can have early signs of cardiovascular
disease.1
 Smoking damages blood vessels and can make them thicken and grow narrower. This makes
your heart beat faster and your blood pressure go up. Clots can also form.1,2
 A stroke occurs when:
o A clot blocks the blood flow to part of your brain;
o A blood vessel in or around your brain bursts.1,2
 Blockages caused by smoking can also reduce blood flow to your legs and skin.1,2

Smoking and Respiratory Disease

Smoking can cause lung disease by damaging your airways and the small air sacs (alveoli) found in
your lungs.1,2

 Lung diseases caused by smoking include COPD, which includes emphysema and chronic
bronchitis.1,2
 Cigarette smoking causes most cases of lung cancer.1,2
 If you have asthma, tobacco smoke can trigger an attack or make an attack worse.1,2
 Smokers are 12 to 13 times more likely to die from COPD than nonsmokers.1
Larger infographic

Smoking and Cancer

Smoking can cause cancer almost anywhere in your body:1,2 (See figure above)

 Bladder
 Blood (acute myeloid leukemia)
 Cervix
 Colon and rectum (colorectal)
 Esophagus
 Kidney and ureter
 Larynx
 Liver
 Oropharynx (includes parts of the throat, tongue, soft palate, and the tonsils)
 Pancreas
 Stomach
 Trachea, bronchus, and lung

Smoking also increases the risk of dying from cancer and other diseases in cancer patients and
survivors.1

If nobody smoked, one of every three cancer deaths in the United States would not happen.1,2
Smoking and Other Health Risks

Smoking harms nearly every organ of the body and affects a person’s overall health.1,2

 Smoking can make it harder for a woman to become pregnant. It can also affect her baby’s
health before and after birth. Smoking increases risks for:1,2,5
o Preterm (early) delivery
o Stillbirth (death of the baby before birth)
o Low birth weight
o Sudden infant death syndrome (known as SIDS or crib death)
o Ectopic pregnancy
o Orofacial clefts in infants

 Smoking can also affect men’s sperm, which can reduce fertility and also increase risks for birth
defects and miscarriage.2
 Smoking can affect bone health.1,5
o Women past childbearing years who smoke have weaker bones than women who never
smoked. They are also at greater risk for broken bones.
 Smoking affects the health of your teeth and gums and can cause tooth loss.1
 Smoking can increase your risk for cataracts (clouding of the eye’s lens that makes it hard for
you to see). It can also cause age-related macular degeneration (AMD). AMD is damage to a
small spot near the center of the retina, the part of the eye needed for central vision.1
 Smoking is a cause of type 2 diabetes mellitus and can make it harder to control. The risk of
developing diabetes is 30–40% higher for active smokers than nonsmokers.1,2
 Smoking causes general adverse effects on the body, including inflammation and decreased
immune function.1
 Smoking is a cause of rheumatoid arthritis.1

Quitting and Reduced Risks

 Quitting smoking cuts cardiovascular risks. Just 1 year after quitting smoking, your risk for a
heart attack drops sharply.2
 Within 2 to 5 years after quitting smoking, your risk for stroke may reduce to about that of a
nonsmoker’s.2
 If you quit smoking, your risks for cancers of the mouth, throat, esophagus, and bladder drop by
half within 5 years.2
 Ten years after you quit smoking, your risk for lung cancer drops by half.2

References

1. U.S. Department of Health and Human Services.The Health Consequences of Smoking—50

Years of Progress: A Report of the Surgeon General. Atlanta: U.S. Department of Health and
Human Services, Centers for Disease Control and Prevention, National Center for Chronic
Disease Prevention and Health Promotion, Office on Smoking and Health, 2014 [accessed 2017
Apr 20].
2. U.S. Department of Health and Human Services. How Tobacco Smoke Causes Disease: What It
Means to You. Atlanta: U.S. Department of Health and Human Services, Centers for Disease
Control and Prevention, National Center for Chronic Disease Prevention and Health Promotion,
Office on Smoking and Health, 2010 [accessed 2017 Apr 20].
3. Centers for Disease Control and Prevention. QuickStats: Number of Deaths from 10 Leading
Causes—National Vital Statistics System, United States, 2010. Morbidity and Mortality Weekly
Report 2013:62(08);155. [accessed 2017 Apr 20].
4. Mokdad AH, Marks JS, Stroup DF, Gerberding JL. Actual Causes of Death in the United States.
JAMA: Journal of the American Medical Association 2004;291(10):1238–45 [cited 2017 Apr 20].
5. U.S. Department of Health and Human Services. Women and Smoking: A Report of the Surgeon
General. Rockville (MD): U.S. Department of Health and Human Services, Public Health
Service, Office of the Surgeon General, 2001 [accessed 2017 Apr 20].
6. U.S. Department of Health and Human Services. Reducing the Health Consequences of
Smoking: 25 Years of Progress. A Report of the Surgeon General. Rockville (MD): U.S.
Department of Health and Human Services, Public Health Service, Centers for Disease Control,
National Center for Chronic Disease Prevention and Health Promotion, Office on Smoking and
Health, 1989 [accessed 2017 Apr 20].