Biomarkers of exposure among U.S. cigar smokers: an analysis of 1999-2012 National Health and Nutrition Examination Survey (NHANES) data.

BACKGROUND Cigar consumption is increasing in the United States, but little information is available about exposure to toxic constituents from cigar smoking. METHODS We conducted a cross-sectional analysis of biomarkers of tobacco exposure among 25,522 participants from the National Health and Nutrition Examination Survey (NHANES, 1999-2012). The biomarkers analyzed were serum cotinine, urinary 4-(methylnitrosamino)-1-(3-pyridyl)-1-butanol (NNAL), blood lead, blood cadmium, and urinary arsenic. We calculated geometric mean concentrations for each biomarker by tobacco use category and geometric mean ratios controlling for demographic factors. RESULTS Cigar smokers had higher cotinine, NNAL, and lead concentrations than nontobacco users. The geometric mean concentration [95% confidence interval (CI)] of cotinine for primary cigar smokers (i.e., current cigar/never cigarette smokers) was 6.2 (4.2-9.2) ng/mL versus 0.045 (0.043-0.048) ng/mL for nontobacco users, and the NNAL concentration was 19.1 (10.6-34.3) pg/mg creatinine for primary cigar smokers versus 1.01 (0.95-1.07) pg/mg creatinine for nontobacco users. Secondary cigar smokers (i.e., current cigar/former cigarette smokers) and dual cigar/cigarette smokers had higher cadmium concentrations than nontobacco users. Cigar smoking was associated with significantly higher concentrations of cotinine, NNAL, cadmium, and lead, after adjusting for demographic factors. Secondary cigar smokers had significantly higher cotinine and NNAL concentrations than primary cigar smokers. The NNAL concentrations in daily cigar smokers were comparable with those in daily cigarette smokers. CONCLUSIONS Cigar smokers have higher concentrations of several toxic and carcinogenic substances than nontobacco users. IMPACT Our results are consistent with epidemiologic evidence demonstrating cigar smoking as a cause of disease and premature death.