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The US cigar market is diverse, yet until recently most research studies and tobacco surveillance systems have not reported behavioral and related outcomes by cigar type. The 2013-2014 Population Assessment of Tobacco and Health Study collected data separately for filtered cigars (FCs), cigarillos, and traditional cigars, which were further distinguished as premium or nonpremium. Descriptive statistics for adult established current smokers of each cigar type and cigarettes were calculated for demographic characteristics, tobacco use patterns, purchasing behaviors and reasons for use. Adjusted prevalence ratios (APRs) using a marginal predictions approach with logistic regression assessed correlates of dual cigar and cigarette smoking. Age, sex, race/ethnicity, education level, and poverty status of smokers varied according to cigar type. Daily cigar smoking prevalence and number of cigars smoked per day were higher for FCs (37.3%; median: 1.6 cigars/day, respectively), than all other cigar types (6.7%-25.3%, all p < .01; 0.1-0.4 cigars/day, all p < .01, respectively); daily smoking and cigars per day were similar for nonpremium cigars and cigarillos (p = .11; p = .33, respectively). Cigarette smoking was twice as common among smokers of nonpremium cigars, cigarillos, and FCs (58.0%-66.0%) than among premium cigars (29.9%). Among current cigar smokers, FC smokers (APR = 1.23, 95% confidence interval [CI] = 1.09-1.39), other tobacco product users (APR = 1.27, 95% CI = 1.15-1.41), and those with a GED/high school diploma or less (APR = 1.20, 95% CI = 1.09-1.33) were more likely to also smoke cigarettes. User characteristics, cigar smoking patterns, and dual smoking with cigarettes varied by cigar type highlighting the importance of adequately describing the cigar type studied and, where appropriate, differentiating results by cigar type. Despite the diversity of the cigar market place, historically many research studies and tobacco surveillance systems have treated cigars as a single product type. This study describes similarities and differences in the user characteristics, tobacco use patterns, and purchasing behaviors of premium, nonpremium, cigarillo, and filtered cigar smokers. To enhance tobacco regulatory science, sufficient descriptions of the cigar type(s) studied and, where appropriate, differentiation of the particular cigar type(s) studied should be undertaken to improve the interpretation of study findings, understanding of cigar use patterns and related behaviors and future approaches to reducing cigar-attributable morbidity and mortality.

A “blunt” is a hollowed-out cigar/cigarillo from which much of the loose tobacco has been removed, and the remaining tobacco wrapper filled with cannabis. Although blunts contain significant levels of tobacco/nicotine, they are often treated as if they were exclusive cannabis products and omitted from surveys of tobacco products. Whereas the prevalence of virtually all other tobacco products is on the decline in the USA, available data suggest that the prevalence of blunt smoking is not — and in fact, it may be increasing. Blunts are most frequently used by people who self-identify as Black. As a result of misperceptions and perhaps biases, there is a dearth of scientific investigation, hence knowledge, surrounding the health effects associated with blunt smoking. Co-use of tobacco and cannabis has been reported to have additive and even synergistic adverse health effects. Lack of investigations into the health effects of tobacco products most frequently used by Black people may contribute to tobacco-related health disparities. We argue that the scientific and public health communities must treat blunts as the potentially lethal tobacco product that they are, studying their prevalence and use patterns, and investigating their adverse health effects, both short and long term.

Abstract Introduction Prevalence of cigar use has been increasing among youth. Research indicates that youth are modifying cigar products either by “freaking” (ie, removing the filter paper) or “blunting” (removing the tobacco and supplementing or replacing with marijuana), yet little is known about youth who engage in this behavior. Thus, this study examines demographic and concurrent substance use behaviors of youth who modify cigars. Methods Data from the 2013 Cuyahoga County Youth Risk Behavior survey were examined (n = 16 855). The survey collected data on demographics, cigar product use, cigar modification behaviors, and current cigarette, hookah and marijuana use. Responses to cigar product use items were used to create a composite to classify youth in one of eight unique user categories. Univariate and bivariate statistics were calculated using SPSS complex samples procedures. Results Overall, 15.2% reported current cigar product use, 11.0% reported current freaking, and 18.5% reported current blunt use; taken together, 25.3% of respondents reported any current use of a cigar product. When examined by user category, of those who endorsed any cigar product use, cigars, cigarillos, and little cigars use only was most endorsed (26.3%), followed by Blunt only (25.2%) and all three (ie, cigars, cigarillos, and little cigars, freaking, and blunting; 17.4%). Conclusion A substantial proportion of high school youth who report using cigar products are modifying them in some way, with nearly half freaking and nearly two-thirds blunting. Given the FDA Center for Tobacco products recent extension of its regulatory authority to include cigar products, it is imperative to understand more about the prevalence of and reasons for cigar modification behaviors. Implications Although the FDA has recently enacted regulatory authority over cigar products, little is known about cigar product modification. This is the first study to concurrently examine two unique cigar modification behaviors, “freaking” (ie, removing the filter paper) and “blunting” (removing the tobacco and supplementing or replacing with marijuana). A significant proportion of high school youth are modifying cigar products to be used as a tobacco product and as a mechanism to smoke marijuana. More research is needed to understand these behaviors to prevent and reduce the use of cigar products among youth.

Abstract Introduction This study examined the association of sociodemographic characteristics, tobacco and substance use behaviors, and reasons to use cigars in young adults’ flavored and non-flavored cigar use. Methods Participants were 523, 18- to 29- year-old young adult college students (60.4% male; 40.9% non-Hispanic white) who reported current (past 30-day) cigar use. Results Almost 75% of the sample regularly chose flavored cigar products. Multilevel logistic regression analyses indicated that younger, female, and racial/ethnic minority cigar users had significantly greater odds of using flavored cigars than their counterparts. Current marijuana smokers, ever-blunt smokers, and students who reported using cigars because they were affordable and/or available in flavors they liked had a greater odds of flavored cigar use compared to their counterparts. Moreover, among dual users of cigars and cigarettes, those who cited using cigars because they were cheaper than cigarettes and because cigars felt like smoking regular cigarettes had greater odds of using flavored cigars compared to their peers. Number of days cigars were smoked and current use of other tobacco products were not associated with flavored cigar use. Conclusions Appealing attributes of flavored cigars have the potential to contribute to the tobacco use and subsequent nicotine addiction of younger, female, and racial/ethnic minority young adults. The wide variety of cigar flavors, their attractive price, and similarity to cigarette smoking underscore the need for additional research that links these unique traits to sustained tobacco use, and underscore the need for regulation of flavored products. Implications This study extends the current literature by finding that younger, female, and racial/ethnic minorities have greater odds of flavored cigar use than their peers. Flavored cigars have characteristics that appeal to members of these populations, which can contribute to their long-term use and potential for addiction.

Background Cigar use among adults in the United States has remained relatively stable in the past decade and occupies a growing part of the tobacco marketplace as cigarette use has declined. While studies have established the detrimental respiratory health effects of cigarette use, the effects of cigar use need further characterization. In this study, we evaluate the prospective association between cigar use, with or without cigarettes, and asthma exacerbation. Methods We used data from Waves 1–5 (2013–2019) of the Population Assessment of Tobacco and Health Study to run generalized estimating equation models examining the association between time-varying, one-wave-lagged cigarette and cigar use and self-reported asthma exacerbation among US adults (18+). We defined our exposure as non-established (reference), former, exclusive cigarette, exclusive cigar, and dual use. We defined an asthma exacerbation event as a reported asthma attack in the past 12 months necessitating oral or injected steroid medication or asthma symptoms disrupting sleep at least once a week in the past 30 days. We adjusted for age, sex, race and ethnicity, household income, health insurance, established electronic nicotine delivery systems use, cigarette pack-years, secondhand smoke exposure, obesity, and baseline asthma exacerbation. Results Exclusive cigarette use (incidence rate ratio (IRR): 1.26, 95% confidence interval (CI): 1.03–1.54) and dual use (IRR: 1.41, 95% CI: 1.08–1.85) were associated with a higher rate of asthma exacerbation compared to non-established use, while former use (IRR: 1.01, 95% CI: 0.80–1.28) and exclusive cigar use (IRR: 0.70, 95% CI: 0.42–1.17) were not. Conclusion We found no association between exclusive cigar use and self-reported asthma exacerbation. However, exclusive cigarette use and dual cigarette and cigar use were associated with higher incidence rates of self-reported asthma exacerbation compared to non-established use. Studies should evaluate strategies to improve cigarette and cigar smoking cessation among adults with asthma who continue to smoke.

Background The mechanisms by which cigarette smoking increases the risk of respiratory disease have been studied. However, less is known about risks of respiratory symptoms and outcomes associated with smoking cigars, and risks by cigar types have not been previously explored. The aim of this study was to examine associations between cigar use, including traditional cigars, cigarillos, filtered cigars, and dual cigar and cigarette use, and functionally important respiratory symptoms (FIRS), lifetime asthma diagnosis, uncontrolled asthma, and new cases of FIRS. Methods Data from Waves 2–5 (2014–19) of the Population Assessment of Tobacco and Health (PATH) Study, a nationally representative longitudinal study, were analyzed in two ways. For cross-sectional analysis, the analytic sample included adults 18 and older at each wave, resulting in 44,040 observations. Separately, longitudinal analyses were assessed among adults 18 and older at Wave 2, resulting in 7,930 individuals. Both analyses excluded adults with chronic obstructive pulmonary disease (COPD) or non-asthma respiratory disease. Results Current established cigarillo smokers had higher odds of having FIRS (Adjusted odds ratio (AOR): 1.72; 95% CI: 1.08, 2.74) compared to never smokers of cigarillos and cigarettes, after adjusting for covariates. Current established filtered cigar smokers had higher odds of asthma diagnosis (AOR: 1.35; 95% CI: 1.10, 1.66) while current established dual smokers of filtered cigars and cigarettes had higher odds of uncontrolled asthma (AOR: 5.13; 95% CI: 1.75, 15.02) compared to never smokers of filtered cigars or cigarettes. Both current established cigar smokers and current established dual smokers of cigarettes and cigars had higher odds of new FIRS compared to never cigar or cigarette smokers (AORs: 1.62; 95% CI: 1.02, 2.60 for exclusive cigars and 2.55; 95% CI 1.57, 4.14 for dual smokers). Conclusions This study provides evidence that cigar smokers or dual smokers of cigars and cigarettes have greater odds of FIRS, asthma, and uncontrolled asthma and that new incidence of FIRS is higher among any cigar smokers compared to never cigar or cigarette smokers. Understanding health impacts associated with cigar use provides information for supporting policy development, as well as for designing clinical interventions focused on smoking cessation for cigars.

Abstract Introduction Cigars are a popular tobacco product of choice for youth and young adults. Despite growing interest in cigar research, there are gaps in the available literature limiting an ability to set evidence-based policies. Too small research samples, the heterogeneity of types of cigars when asking a single question about use, makes analyzing data difficult. Given the Food and Drug Administration’s (FDA’s) authority granted in 2016 to regulate cigars, and its popularity, data to better understand use and preference for cigars will help FDA set appropriate regulatory policies. Methods We harmonized cigar survey data previously collected by five independent tobacco regulatory science survey research projects. Data supplying participants included three Tobacco Centers of Regulatory Science, one Center for Tobacco Products grantee, and data from Population Assessment of Tobacco and Health (PATH) study’s public use dataset. Results Analyzing 92 data variables from across five studies, and applying a rigorous data harmonization protocol, we report findings on 24 key cigar use variables. The step by step protocol for harmonizing is presented. Selected findings showing strict reproducibility across all five studies reveal youth 17–19 years at highest risk for cigar initiation; relative reproducibility shows males more likely to try cigars than females but with significant differences in magnitude across studies; and areas of inconsistent reproducibility are revealed when evaluating brand preferences. Conclusion Harmonizing data from multiple sources fosters a broader view of the robustness and generalizability of survey data than that from a single source. These observations raise awareness to look for the highest degree of reproducibility among and across data sources to inform policy. Implications Harmonizing data from discrete datasets provides insights into cigar initiation and use and is presented showing opportunities, challenges, and solutions. Comparing observational data from PATH and four independent research studies provides a best-practices approach and example of data synthesis for the tobacco research community. The dataset of five studies offers a look at the degree of confidence in analyzing harmonized survey results. Variable conclusions raise the need to strive for the highest degree of reproducibility, to best understand the behaviors of cigar users, and allow for the future development of the most effective interventions to alter tobacco use patterns.

Abstract Introduction Among United States teens during the 1990s, increasing cigar use coincided with increasing use of tobacco cigar shells filled with cannabis, called “blunts.” Cigar smokers are more likely to use cannabis, and we hypothesized that starting to smoke cigars might be a probabilistic “trigger” of blunt smoking. We turned to the case-crossover approach to evaluate this hypothesis. Methods Within US National Surveys on Drug Use and Health, 2009–2013, we identified a nationally representative sample of newly incident blunt smokers aged 12- to 21-years-old (n = 4868) and compared month-of-onsets for smoking of cigars and blunts. Using the subjects-as-their-own-controls case-crossover design, we specified the first month prior to blunt use as a “hazard interval” and the second month prior to blunt use as a “control interval.” We used Mantel–Haenszel (MH) estimators to estimate the matched-pairs odds ratio (OR). Results The MH OR estimate was 1.7 (95% CI = 1.3, 2.3), with excess odds of cigar onsets during the hazard interval relative to the control interval. Two alternative control interval specifications yielded congruent estimates (OR = 2.7 and 2.9, respectively). Conclusions A short interval right after starting to smoke cigars may be one of increased risk of starting to smoke blunts. We discuss cigar, cigarillo, and “blunt wraps” control approaches that might reduce both tobacco and cannabis-related harms. Implications If this evidence is correct, increased market-targeting to promote youthful cigar and cigarillo smoking might be followed by increased rates of blunt smoking in a vulnerable population. As noted by others, enhanced risk of smoking-attributable harms might be a consequence of mixed tobacco-cannabis formulations.

Objectives: Cigar use in the United States is a growing public health concern because of its increasing popularity. We estimated health care utilization and expenditures attributable to cigar smoking among US adults aged ≥35. Methods: We analyzed data on 84 178 adults using the 2000, 2005, 2010, and 2015 National Health Interview Surveys. We estimated zero-inflated Poisson (ZIP) regression models on hospital nights, emergency department (ED) visits, physician visits, and home-care visits as a function of tobacco use status—current sole cigar smokers (ie, smoke cigars only), current poly cigar smokers (smoke cigars and smoke cigarettes or use smokeless tobacco), former sole cigar smokers (used to smoke cigars only), former poly cigar smokers (used to smoke cigars and smoke cigarettes or use smokeless tobacco), other tobacco users (ever smoked cigarettes and used smokeless tobacco but not cigars), and never tobacco users (never smoked cigars, smoked cigarettes, or used smokeless tobacco)—and other covariates. We calculated health care utilization attributable to current and former sole cigar smoking based on the estimated ZIP models, and then we calculated total health care expenditures attributable to cigar smoking. Results: Current and former sole cigar smoking was associated with excess annual utilization of 72 137 hospital nights, 32 748 ED visits, and 420 118 home-care visits. Annual health care expenditures attributable to sole cigar smoking were $284 million ($625 per sole cigar smoker), and total annual health care expenditures attributable to sole and poly cigar smoking were $1.75 billion. Conclusions: Comprehensive tobacco control policies and interventions are needed to reduce cigar smoking and the associated health care burden.

Although Black/African American populations have high cigar-smoking prevalence, little is known about cigar-smoking cessation among this group. This study explored the perceptions and experiences of cigar-smoking cessation and assistance received from healthcare providers among forty Black young-adult cigar smokers (ages 21–29). Semi-structured in-depth phone interviews were transcribed and coded. Qualitative data were analyzed by using thematic analysis. Participants mostly smoked cigarillos, large cigars, and blunts. Overall, many regular cigarillo smokers reported interest in quitting eventually, while large-cigar and blunt smokers shared less interest in quitting because they perceived low harm from smoking these products. The reasons for cigar-smoking cessation were health concerns and financial constraints. Most of the participants who attempted to quit cigars did not use any cessation aids. The reasons for relapse included nicotine withdrawal, stress, and easy access. Additionally, most participants reported their healthcare providers did not ask whether they smoked cigars, and even when they knew, little assistance for cigar-smoking cessation was provided. Informing Black cigar smokers of the harm of cigar smoking and encouraging healthcare providers to screen for and assist with cigar-smoking cessation may alleviate the health burden of cigar smoking in this population.