Pipe and Cigar Smoking Linked to Decreased Lung Function and COPD

From Medscape Medical News
Fran Lowry

February 17, 2010 — Pipe and cigar smoking has been found to increase urine cotinine levels and is associated with decreased lung functio and increased odds of airflow obstruction, even in individuals who had never smoked cigarettes, according to the results of a large cohort study published February 16 in the Annals of Internal Medicine.

"Cigarette smoking is the main cause of chronic obstructive pulmonary disease [COPD]," write Josanna Rodriguez, MD, from Columbia University Medical Center, New York, NY, and colleagues, "but studies on the contribution of other smoking techniques are sparse."

The aim of this study was to determine whether pipe and cigar smoking resulted in absorption of tobacco smoke, as assessed by urine cotinine levels, as well as decrements in lung function and increased odds of airflow obstruction.

The investigators collected information on 3528 subjects aged 48 to 90 years, with no clinical evidence of cardiovascular disease, who were participants in the Multi-Ethnic Study of Atherosclerosis (MESA) trial.

They used self-administered items from the American Thoracic Society questionnaire to elicit participants' smoking histories for pipes, cigars, and cigarettes and measured cotinine levels from urine that was collected on the same day the questionnaire was administered.

Lung function was measured on spirometry according to American Thoracic Society and European Respiratory Society guidelines, and information on the following confounders was obtained: age; sex; race or ethnicity; educational level; medical history; occupational exposure to dust, fumes, or smoke; depth of inhalation of cigarettes; environmental tobacco smoke exposure; and family history of emphysema.

The study found that 9% of the participants reported pipe smoking (median, 15 pipe-years; interquartile range [IQR], 4 - 46 pipe-years), 11% reported cigar smoking (median, 6 cigar-years; IQR, 0 - 26 cigar-years), and 52% reported cigarette smoking (median, 18 pack-years).

Median cotinine levels were less than 10 ng/mL in never-smokers, 43 ng/mL in current cigar smokers, 1324 ng/mL in current pipe smokers, and 4304 ng/mL in current cigarette smokers (all P < .001 vs never-smokers). Median cotinine levels were also elevated in current cigar and current pipe smokers who reported never smoking cigarettes, the study authors report.

They also found that pipe-years were associated with decrements in forced expiratory volume in 1 second (FEV1), and cigar-years were associated with decrements in the FEV1-forced vital capacity (FVC) ratio. Furthermore, participants who smoked pipes or cigars had increased odds of airflow obstruction, whether they had also smoked cigarettes (odds ratio [OR], 3.43; 95% confidence interval [CI], 1.75 - 6.71; P < .001) or not (OR, 2.31; CI, 1.04 - 5.11; P = .039) vs participants with no smoking history.

"These results, together with the extensive literature on the effects of tobacco smoke on the development of COPD and the increase in cotinine levels among current pipe and cigar smokers in this cohort, suggest that pipe and cigar smoking produce a measurable increase in the risk for COPD," the study authors write.

Limitations of this study are the cross-sectional design, the retrospective ascertainment of cumulative pipe and cigar smoking, and the relatively small proportion of participants who smoked pipes or cigars but not cigarettes.

The study authors conclude that their findings suggest that long-term pipe and cigar smoking may damage the lungs and contribute to the development of COPD. "Physicians should consider pipe and cigar smoking a risk factor for COPD and counsel cessation of pipe and cigar smoking regardless of cigarette smoking history."

In an accompanying editorial, Michael B. Steinberg, MD, MPH, from Robert Wood Johnson Medical School, New Brunswick, New Jersey, and coauthor Christine D. Delnevo, PhD, MPH, from the University of Medicine and Dentistry of New Jersey, School of Public Health, New Brunswick, New Jersey, write that as long as the marketing of cigars and pipes remains under the radar of public health advocates and legislative bodies, their use will continue to increase.

"Rodriguez and colleagues have shown that smoke, whether from cigarette, pipe, or cigar, will result in absorption of one of the most addictive chemicals known, nicotine, and will produce measurable lung damage," they conclude. "Tobacco users and health care providers alike need to fully understand the true harms caused by all tobacco products and the role that these products play in a larger public health battle."

The National Heart, Lung, and Blood Institute, National Institutes of Health, supported this study. Disclosure information for the study authors and the editorialists can be obtained in the original article, available on the Annals Web site .

Ann Intern Med. 2010;152:201-210, 259-260. Abstract