Preference for flavoured cigar brands among youth, young adults and adults in the USA

Prevalence of Blunt and Hemp Wrap Use Among Young Adults in the United States, 2022

INTRODUCTION

Blunt and hemp wraps, as a means of consuming cannabis, have emerged into the retail space where the prevalence has been increasing since 2017. There is limited epidemiological research on the prevalence of use of these products across the U.S. particularly among young adults who are at greater risk of tobacco and cannabis use.

METHODS

This study draws from a U.S. national representative sample of young adults (n = 1178) captured in May 2022. Respondents participated in an online survey about their use of blunt and hemp wraps. Multinomial regression was used to examine differences in sociodemographic characteristics (gender, race/ethnicity, sexual orientation, educational attainment, and region) in relation to use of each wrap type.

RESULTS

One quarter (22.7%) of young adults reported ever having used a blunt wrap, 3.2% in the past 30-days. One in seven (14.3%) had ever used a hemp wrap, 2.3% in the past 30-days. Non-Hispanic Black young adults were 1.55 and 2.91 times as likely to have ever used blunt or hemp wraps, respectively, compared to non-Hispanic Whites. Similarly, participants who identified as gay or lesbian or bisexual similarly had greater odds of having ever used blunt or hemp wraps. Hispanic young adults were 2.49 times as likely to have used hempwraps compared to non-Hispanic Whites.

CONCLUSION

Blunt and hemp wrap use is prevalent among young adults, particularly among minoritized populations. Continued research and surveillance of use of these products is needed to fully evaluate the impact their use may have on the broader population.

Roles of cigar microbes in flavor formation during roasted-rice leachate fermentation

Roasted-rice leachate fermentation, a distinctive local tobacco fermentation method in Sichuan, imparts a mellow flavor and glossy texture to tobacco leaves, along with a roasted rice aroma. In order to find out the impact of roasted-rice leachate on cigar tobacco leaves, the physicochemical properties, volatile flavor profile, and microbial community were investigated. The content of protein significantly decreased after fermentation. The volatile flavor compounds increased following roasted-rice leachate fermentation, including aldehydes, alcohols, acids, and esters. High-throughput sequencing identified Staphylococcus, Pseudomonas, Pantoea, Oceanobacillus, Delftia, Corynebacterium, Sphingomonas, Aspergillus, Weissella, and Debaryomyces as the primary genera. Network and correlation analysis showed Debaryomyces played a crucial role in roasted-rice leachate fermentation, due to its numerous connections with other microbes and positive relationships with linoelaidic acid, aromandendrene, and benzaldehyde. This study is useful for gaining insight into the relationship between flavor compounds and microorganisms and provides references regarding the effect of extra nutrients on traditional fermentation products. KEY POINTS: • Volatile flavor compounds increased following roasted-rice leachate fermentation • Staphylococcus was the primary genera in fermented cigar • Debaryomyces may improve the quality of tobacco leaves.

Examining Demand and Substitutability of Usual Brand Little Cigars/Cigarillos and Cigarettes in Young Adults Who Dual Use

INTRODUCTION

Cigarette and little cigar/cigarillo (LCC) dual use is popular among young people and poses a substantial health risk. What remains unclear is the abuse liability of LCCs vs. cigarettes, LCCs' substitutability for cigarettes, and the influence of flavors on the abuse liability and substitutability of LCCs.

METHODS

Sixty-five young adults (18-34 years) who dual use completed hypothetical purchase tasks to measure consumption of usual brand cigarettes and LCCs in 24 hours at increasing prices (demand), and LCC consumption at increasing cigarette prices (substitution). Three demand indices were calculated from raw data: breakpoint (price after which consumption reaches 0), Omax (maximum daily expenditure), and Pmax (price at maximum expenditure). Two indices were estimated using nonlinear mixed-effects modeling: intensity (consumption when free) and price-sensitivity (rate of decline in consumption as price increases). Substitution, and associations of flavored use with demand and substitution, were estimated using linear mixed models.

RESULTS

Results indicated similar abuse liability for LCCs and cigarettes. Intensity was greater for cigarettes, but price-sensitivity was similar. Flavored LCC use was associated with lower price-sensitivity and greater intensity than unflavored. LCCs were significant substitutes for cigarettes, but the effect was small. Flavored use was not associated with substitution.

CONCLUSIONS

Among young adults who dual use, LCCs and cigarettes had similar abuse liability, and those who used flavored had higher demand for their LCCs. A flavored cigar ban, as well as targeted prevention and cessation services for those who smoke flavored LCCs, may be important for reducing dual use in young adults.

IMPLICATIONS

Cigarette and LCC dual use remains high among young adults. Using hypothetical purchase tasks with young adults who dual use, LCCs had abuse liability similar to cigarettes, but were only modest substitutes for cigarettes. Participants who used flavored LCCs reported greater abuse liability than those who used unflavored, but not greater substitution for cigarettes. Prevention and cessation services are needed to target LCCs in young people, particularly those smoking flavored products. A flavored cigar ban may help to reduce their demand.

Exploring the hypothetical impact of flavored cigar sales restrictions among black young adult cigar smokers: a semi-structured in-depth interview investigation

This study assessed the hypothetical impact of flavored cigar sales restrictions on cigar smoking among Black young adult cigar smokers (ages 21-29). Forty in-depth interviews were conducted in 2020. Interviews were independently coded and analyzed using thematic analysis. When asked how they would smoke cigars given a flavor sales restriction, half of participants reported they would smoke in the same way, a third would stop or reduce smoking, and a few were unsure of what they would do. Cigar smoking outcome expectancies, preference for flavors, and perceived addictiveness of cigar products may predict cigar smoking change given flavor sales restrictions.

The interacting effects of depression symptoms and sweet flavoring on the rewarding and reinforcing value of cigarillo use among young adults

Background

Young adults 18-24 years old have the highest prevalence of cigarillo use, exposing young adults to comparable or higher nicotine levels and many of the same toxicants as combustible cigarettes. Identifying individual and product characteristics that increase the potential for persistent use is warranted. We sought to examine the interacting effects of depression symptoms and sweet flavoring on the rewarding and reinforcing value of cigarillo use.

Methods

86 young adults (18-24 years old, 73.3 % male, 38.4 % White, 33.7 % Black, and 27.9 % Other) completed three laboratory visits assessing the subjective rewarding value (exposure paradigm), relative reinforcing value (computerized choice task), and absolute reinforcing value (ad libitum cigarillo smoking session) of sweet-flavored versus non-flavored cigarillos. Depression symptoms were measured with the 20-item Center for Epidemiologic Studies of Depression Scale and treated as a continuous variable.

Results

General linear models with the appropriate family link tested differences in depressive symptomology for each outcome. Irrespective of flavor, greater cigarillo subjective reward was reported across increasing depressive symptomology (B=.0.03 [95%CI=0.00, 0.05], p=.017). Across symptom levels, no significant differences were observed in the subjective reward and relative and absolute reinforcing values of sweet-flavored versus non-flavored cigarillos (p's >.05).

Conclusions

Young adults with elevated depression find cigarillos more rewarding but not more reinforcing. They are not more vulnerable than young adults with lower symptom levels to sweet cigarillo flavoring. Public health prevention campaigns and tobacco product regulations aimed at preventing the initiation and escalation of young adult cigarillo use may impact young adults broadly.

Does noticing cigar warnings associate with cigar harm perceptions and smoking behaviors? Analysis from Wave 5 of the population assessment of tobacco and health study

BACKGROUND

In the US, cigar warning label standards are less stringent than cigarette warning requirements and are not uniformly required; research is needed about warning efficacy in promoting cigar risk beliefs, discouraging use and supporting public health.

METHODS

Using data from the PATH Study (Wave 5), we analyzed associations between noticing cigar warnings and perceived harm from cigar use, frequency of thinking about harms, and effects of warnings labels.

RESULTS

Among adults who smoke cigars, respondents noticing warnings at least sometimes (vs. never/rarely) had higher odds of thinking about harms of their tobacco use often/very often (cigarillos 30% vs. 19%, p <.001, aOR 1.80 [1.27, 2.56]); filtered cigars: 43% vs. 16%, p <.001, aOR 3.81 [2.50, 5.82]) and of reporting that smoking cigars is very/extremely harmful (cigarillos: 59% vs. 46%, p =.001, aOR 1.45 [1.05, 1.99]). A substantial majority found cigar warnings to be very/extremely believable (cigarillos: 63%, filtered cigars: 59%, traditional cigars: 65%), with 16%, 24% and 12% respectively reporting past-30-day warning avoidance. Those noticing warnings at least sometimes (vs. rarely) had higher rates of reporting that warnings sometimes/often/very often stopped them from having a cigar in the past 30 days (cigarillos: 36% vs. 10%; filtered cigars: 50% versus 6%; traditional cigars: 30% versus 9%; p's < 0.001) and that warnings made them somewhat/a lot more likely to quit smoking (cigarillos: 55% versus 37%, p <.01; filtered cigars: 55% versus 26%, p <.001; traditional cigars: 39% vs. 24%, p <.05).

CONCLUSIONS

Results support potential public health benefits of mandating the presence and increasing salience of cigar warning labels.

Tobacco minimum packaging policy to reduce cigarillo use among young people: results of an experimental study

OBJECTIVE

The Food and Drug Administration has the authority to set a minimum for cigar pack size, a product feature linked to price. This study examined the effects of cigarillo package size and price on young adults' smoking and purchase intentions.

DESIGN

Young adults (n=1032) 18-30 years old who smoked cigarillos in the past 12 months completed an online 3×2 within-subjects experiment testing the effects of cigarillo pack size (1, 2, 5) and price (actual price, standardised price per stick) on intentions to purchase and smoke cigarillos. We modelled the main effects and interactions of pack size and price on intentions to buy and smoke cigarillos overall and by cigarillo use frequency.

RESULTS

Intentions to buy and smoke were strongest for lower priced singles and two packs compared with higher priced five packs. Under standardised price conditions, participants preferred larger packs, but under actual pricing conditions smaller packs, especially two packs, were preferred. Participants who smoked cigarillos less than monthly were more likely to buy and smoke the least expensive products (buy: singles actual price adjusted OR (aOR)=4.51, 95% CI 3.76 to 5.42; two packs actual price aOR=9.76, 95% CI 8.11 to 11.75; five packs standardised price aOR=3.17, 95% CI 2.89 to 3.48) with the strongest preference for two packs and singles.

CONCLUSIONS

Young adult cigarillo smokers prefer smaller packs in conditions where pricing incentivises smaller packs. Minimum pack size policies may reduce the appeal of cigarillos among young adults, especially less frequent cigarillo smokers. Pack size policy should take into consideration price, and ideally these two factors should be addressed together.

The Impact of Modest Price Increases and Single Cigar Restrictions on Youth Cigar Use

INTRODUCTION

In 2011, Boston restricted cigar sales to packages of at least 4 cigars unless sold at a minimum of $2.50 per cigar. Nearly 200 localities in Massachusetts have since adopted policies establishing minimum pack quantities of 2-5 or minimum prices of $2.50-5.00 per cigar. The objective of this study was to examine the impact of these policies on youth cigar use.

METHODS

Biennial data from 1999 to 2019 were obtained from the Massachusetts Youth Risk Behavior Survey and analyzed in 2023. Final analytic samples included 15,674 youth for the Boston analyses and 35,674 youth for the statewide analyses. For Boston, change in use was examined from prepolicy (1999-2011) to postpolicy (2012-2019). For statewide analyses, the percentage of the state covered by a policy was estimated. Multivariable logistic regressions examined the impact of cigar policies on cigar and cigarette use. Analyses were adjusted for sociodemographic characteristics and stratified by sex and race.

RESULTS

Policy enactment was associated with significant decreases in the odds of cigar use in Boston (AOR: 0.28; 95% CI: 0.17-0.47) and statewide (AOR: 0.98; 95% CI: 0.98-0.99), with similar findings for cigarette use. Results were consistent among males and females statewide but only among males in Boston. By race statewide and in Boston, odds of cigar use decreased significantly among White, Black, and Hispanic youth, but not youth of other races.

CONCLUSIONS

These findings indicate small increases in the quantity and price of cigar packs could discourage young people from purchasing and using cigars, providing significant benefits for local tobacco control efforts.

Effect of sweet flavouring on the rewarding and reinforcing value of cigarillo use among young adults

INTRODUCTION

Cigarillos dominate the US cigar market, and young adults largely drive use. While young adults prefer flavoured to non-flavoured cigarillos, especially those flavoured to taste like fruit or other sweets, the factors that underlie this preference have received little attention. We sought to determine if key indicators of abuse liability, the rewarding and reinforcing effects, are greater for sweet versus non-flavoured cigarillos.

METHODS

Young adults (18-24 years old) completed three laboratory visits assessing the subjective rewarding value (exposure paradigm), relative reinforcing value (computerised choice task) and absolute reinforcing value (ad libitum cigarillo smoking session) of sweet-flavoured versus non-flavoured cigarillos. General linear regression models were fit with the appropriate family link for each outcome measure.

RESULTS

Young adults rated sweet-flavoured cigarillos as more rewarding (estimated marginal mean (EMM) =4.52, 95% CI 4.00 to 5.03) than the non-flavoured cigarillo (EMM=3.31, 95% CI 2.80 to 3.83; B=1.20, 95% CI 0.80 to 1.60, p<0.001). The reinforcing value of sweet-flavoured cigarillos, measured by break point, was higher relative to non-flavoured cigarillos (6.34 out of 10), especially among young adults with a preference for flavoured cigarillos (B=1.94, 95% CI 0.71 to 3.18, p=0.003). Young adults took 1.9 times the number of puffs (35.75 vs 19.95) from sweet-flavoured cigarillos compared with non-flavoured cigarillos (Rate Ratio =1.94, 95% CI 1.30 to 2.90, p<0.001).

CONCLUSIONS

Sweet flavouring increases the abuse liability of cigarillos among young adults as reflected in greater liking, motivation to use and actual use. Banning sweet flavouring in cigarillos may diminish their use in young adults.Trial registration number CT.gov (NCT05092919).

Flavored Cannabis Use and Cannabis-Tobacco Co-use: Patterns In U.S. States With Legalized Nonmedical Adult Use

INTRODUCTION

Little is known about inhaled flavored cannabis use. This study aimed to investigate the prevalence and patterns of flavored cannabis use and cannabis-tobacco co-use.

METHODS

This study surveyed adult past 30-day cannabis users in U.S. states and districts that have legalized cannabis for nonmedical/adult use (n=9) (November 2018; n=2,978). By product/behavior (any cannabis, cannabis extract vaporizers, mixed cannabis-nicotine vaporizers, blunts, chasing), the association between flavored (versus non-flavored) use and sociodemographic characteristics, cannabis use disorder symptoms, and tobacco use was estimated using weighted multivariable logistic regression in January 2022.

RESULTS

Almost half of adult cannabis users reported using at least one flavored cannabis product (46.5%). Flavored cannabis use was more likely among respondents who were female (AOR=1.2, CI=1.0, 1.4), were Black (ref: White; AOR=2.2, CI=1.5, 3.1), were Hispanic/Latino/a/x (ref: White; AOR=1.6, CI=1.2, 1.9), had cannabis use disorder symptoms (AOR=2.0, CI=1.6, 2.4), or were currently using tobacco (AOR=2.4, CI=2.1, 2.9). Use was less likely among middle-aged/older adults (ref: ages 21-34 vs 35-49 years; AOR=0.6, CI=0.5, 0.7).

CONCLUSIONS

Observed differences in flavored cannabis use are concerning if flavors raise appeal or dependence. Integrating flavored cannabis and tobacco research and practice is warranted.

Estimating Prevalence of Premium or Traditional Cigar Use and User Characteristics Based on Varying Definitions of Use

BACKGROUND

Premium cigar use is infrequent compared with the use of other tobacco products, including other cigar types (eg, cigarillos), though current measurement methods for premium cigar use have limitations. Accordingly, prevalence estimates from existing surveillance studies likely underestimate the true prevalence of premium cigar use.

AIMS AND METHODS

Using an online convenience sample of adults (ages 18-45 years) surveyed in February 2022, we examined premium or traditional cigar prevalence and characterized users based on four definitions of use: (1) past-year use, (2) past 30-day use, (3) use every day or some days, and (4) use every day, some days, or rarely, using a novel, one-item measure. We examined demographics, cigar use behaviors, and other tobacco product use for each definition and conducted sensitivity analyses using cigar brands.

RESULTS

Prevalence estimates ranged from 1.8% using Definition 3 to 11.6% using Definition 1. Regardless of definition, premium or traditional cigar users were largely male, white, and aged 25-45 years. A large proportion of users based on Definition 3 were aged 25-34 years, had a regular premium cigar brand, smoked cigars on more than one day in the past month, used cannabis in the past month, and reported perceiving premium cigars as less harmful compared with cigarettes.

DISCUSSION

Prevalence estimates of premium or traditional cigar use varied by more than fivefold based on the definition of use and user characteristics varied by definition. Existing national surveys are likely underestimating the prevalence and patterns of premium cigar use.

IMPLICATIONS

Given that the negative health effects of premium cigars vary based on how the cigars are used (eg, frequency or duration), as well as co-use with other tobacco products and substances (eg, alcohol and cannabis), accurate measurement of these products is important for understanding patterns of use and their impact on public health.

Examining Racial/Ethnic and Income Disparities on Tobacco Product Use Among US Adults Within Wave 5 of the PATH Study

OBJECTIVE

The aim of this study was to examine the interactions between race/ethnicity and income across different types of tobacco products.

METHODS

The prevalence of past 30-day use of cigarettes, traditional cigars, cigarillos, filtered little cigars, and electronic nicotine delivery systems (ENDS) among adults was examined by race/ethnicity and income levels based on wave 5 (2018-2019) data of the Population Assessment of Tobacco and Health study.

RESULTS

Multivariate analysis across race/ethnicity and income showed that, although non-Hispanic Blacks (NHBs) were significantly more than likely to smoke cigarettes than non-Hispanic Whites (NHWs) at low- and high-income levels, such disparity only applied to low-income Hispanics compared with low-income NHWs. NHBs were significantly more likely to smoke traditional cigars, cigarillos, and filtered little cigars than NHWs at low and high incomes. No differences were found between Hispanics and NHWs with regard to traditional cigars and cigarillos. However, low-income Hispanics were significantly less likely to smoke filtered little cigars than NHWs, whereas high-income Hispanics were more likely to do so than NHWs. With regard to ENDS, significant differences were only found at the low-income bracket with NHBs and Hispanics being less likely to smoke these products than NHWs.

CONCLUSIONS

Our findings highlight significant interactions between race/ethnicity and income in the use of tobacco products, suggesting that income should be taken into account when designing interventions targeting different racial/ethnic groups.

Tobacco advertising exposure and product use among young adults: An ecological momentary assessment approach

INTRODUCTION

Tobacco-related content is prevalent on social media, yet many methods of measuring exposure are inadequate due to the personalized nature of online marketing. The purpose of this paper is to examine the association between exposure to pro-tobacco messages (both industry-sponsored and user-generated) and the use of tobacco products, as reported via ecological momentary assessment (EMA).

METHODS

Young adults (n = 175) were instructed to record all sightings of marketing (both in-person and online) related to tobacco for 28 days. Tobacco product use and recall of message encounters were assessed daily using app-initiated EMA.

RESULTS

Participants who reported exposure to tobacco messages were significantly more likely to report using tobacco, adjusting for gender, age, race/ethnicity, baseline use of any tobacco product, and having friends who use tobacco and e-cigarettes (p <.001). For each industry-sponsored message viewed, the odds of using tobacco or e-cigarettes in a given day increased by a factor of 1.77 (95 % CI = 1.41, 2.23). For each user-generated message viewed, the odds of using tobacco or e-cigarettes in a given day increased by a factor of 1.52 (95 % CI = 1.27, 1.83).

DISCUSSION

To our knowledge, this is the first study to specifically examine the association between exposure to user-generated messages and daily tobacco use. The findings suggests that there is a unique element to user-generated messages that distinguishes them from both traditional marketing and from simple peer influence.

Mouth Level Intake of Nicotine from Three Brands of Little Filtered Cigars with Widely Differing Product Characteristics Among Adult Consumers

Little filtered cigars are tobacco products with many cigarette-like characteristics. However, despite cigars falling under the U.S. Food and Drug Administration regulatory authority, characterizing flavors, which are still allowed in little filtered cigars, and filter design may influence how people use the products and the resulting exposure to harmful and potentially harmful constituents. We estimated nicotine mouth level intake (MLI) from analyses of little cigar filter butt solanesol levels, brand characteristics, carbon monoxide boost, and puff volume in 48 dual cigarette/cigar users during two repeat bouts of ad lib smoking of three little filtered cigar brands. Mean nicotine MLI for the three brands was significantly different with Swisher Sweets (0.1% ventilation) Cherry at 1.20 mg nicotine, Cheyenne Menthol (1.5%) at 0.63 mg, and Santa Fe unflavored (49%) at 0.94 mg. The association between nicotine MLI and puff volume was the same between Cheyenne Menthol and Santa Fe unflavored. However, these were different from Swisher Sweets Cherry. At least five main factors─flavor, ventilation, filter design, nicotine delivery related to tar, and user puff volume─may directly or indirectly impact MLI and its association with other measures. We found that users of little filtered cigars that have different filter ventilation and flavor draw dissimilar amounts of nicotine from the product, which may be accompanied by differences in exposure to other harmful smoke constituents.

Impact of tobacco flavoring on oral nicotine consumption in C57BL/6J mice

BACKGROUND

The continued use of flavors in tobacco products has been a prominent factor in their popularity, yet little is known regarding their role in nicotine dependence. This study aimed to investigate the impact of tobacco flavoring on oral nicotine consumption in mice using the two-bottle choice (2BC) test and assessed the potential impact of age and sex in their interactions.

METHODS

Adolescent and adult male and female C57BL/6J mice were used. First, voluntary consumption of tobacco flavor concentrate from a commercial electronic cigarette liquid vendor (Avail Vapor LLC) was measured; then, the effects of tobacco flavoring in combination with nicotine were examined. In one approach, tobacco flavor concentration was kept constant while nicotine concentration varied, and in the second, nicotine was kept constant while the tobacco flavor concentration varied.

RESULTS

Overall, tobacco flavoring decreased oral nicotine consumption in mice, and its effects were sex- and age-dependent. Although females consumed the tobacco-flavored solution at a slightly higher rate than males, male mice were more sensitive to the effects of the combination (nicotine + tobacco). Furthermore, adolescent mice showed a starker reduction in nicotine consumption in the presence of tobacco flavoring compared to adult mice. This attenuation was most likely due to a basal aversion to the tobacco flavoring itself, thus, creating a negative synergistic effect with nicotine.

CONCLUSIONS

Tobacco flavoring increases aversion to nicotine in the 2BC test in C57BL6J mice, suggesting that some flavors may diminish rather than enhance oral nicotine consumption in rodents.

Impact of a reduced nicotine standard on young adult appeal for menthol and non-menthol cigarettes

INTRODUCTION

The Food and Drug Administration (FDA) announced its intention to reduce the nicotine content in cigarettes as a strategy to promote cessation and reduce smoking-related harm. A low nicotine product standard will apply to all cigarettes on the market, including menthol cigarettes. In December 2021, the FDA approved a modified risk tobacco product application for menthol and non-menthol flavoured very low nicotine cigarettes (VLNC) from the 22nd Century Group. Notably, experimentation with menthol cigarettes is linked to smoking progression, as well as greater nicotine dependence relative to non-menthol cigarette use. If menthol VLNCs are perceived as more appealing than non-menthol VLNCs, this would indicate that some aspect of menthol may maintain smoking even in the absence of nicotine and FDA's regulatory authority to ban or restrict the sale of menthol cigarettes should apply to reduced nicotine content of cigarettes. In April 2022, the FDA announced proposed rulemaking to prohibit menthol cigarettes, however it is unclear if a menthol prohibition would apply to VLNCs.

METHODS AND ANALYSIS

This study will recruit 172 young adult menthol smokers (with a specific subsample of n=40 sexual and gender minority young adults) and measure appeal for smoking experimental menthol and non-menthol VLNCs, and the impact of proposed product standards on tobacco product purchasing behaviour using an Experimental Tobacco Marketplace. Appeal across product standards will be assessed in a controlled laboratory and using ecological momentary assessment.

ETHICS AND DISSEMINATION

The protocol was approved by the University of Oklahoma Health Sciences Center Institutional Review Board (#11865). Findings will examine the effects of a reduced nicotine standard and a menthol ban on young adult smoking and will be disseminated through peer-reviewed journal articles and presentations at scientific conferences.

TRIAL REGISTRATION NUMBER

NCT04340947.

Substitution of flavored cigarillos with menthol cigarettes among young adults in the U.S

BACKGROUND

Young adult cigarillo users often cite flavor as a primary reason for initiating and sustaining product use and are more likely to concurrently use other tobacco products such as menthol cigarettes. This study examines substitution with menthol cigarettes among cigarillo users facing a hypothetical ban on flavored cigarillos.

METHODS

Current young adult (21-28 years) cigarillo users were recruited from October 2020 to April 2021 for an online survey about cigarillo and other tobacco use behaviors. Participants (n = 500) self-reported past or current menthol cigarette experience, and if they would switch to menthol cigarettes if they could not get flavored cigarillos. Logistic regression was used to test differences in switching behaviors by level of experience with menthol cigarettes.

RESULTS

Most young adult cigarillo users (76.8 %) had ever used a menthol cigarette and 46.6 % reported current use of menthol cigarettes. No participant who had never used menthol cigarettes reported they would switch to menthol cigarettes. Current users were 4.2 times as likely to say they would switch after controlling for demographic characteristics and nicotine dependence.

CONCLUSION

Most young adult cigarillo users reported they would not switch to menthol cigarettes if flavored cigarillos became unavailable. However, participants who currently use or have used menthol cigarettes were more likely to report their intention to switch products than those who had never used menthol cigarettes. There may be a subsequent increase in menthol cigarette use among past menthol cigarette users if policies restricting flavored tobacco products exclude menthol cigarettes, diluting these policies' intended population health impact.

Perceptions of Game cigarillo packaging among young adult tobacco users: The effect of package color and the "natural leaf" descriptor

INTRODUCTION

Tobacco packaging elements have been shown to influence product perceptions and use intentions. Garcia y Vega's Game cigarillos are distinct from other brands in their use of "natural leaf" on packaging. The term "natural" has been linked to misperceptions about lower risk in the context of cigarettes. This study examines the impact of the "natural leaf" descriptor and pack color on young adults' cigarillo perceptions and intentions.

METHODS

In April-June 2020, we conducted an online experiment with 1,063 young adults (ages 18-34) that were past year users of cigars, vaping products, or marijuana. Subjects were randomly assigned to view one of eight images of Game cigarillo packs that varied in color and presence of the "natural leaf" descriptor.

RESULTS

Purple packaging increased perceptions that the product tasted good, smelled nice, was flavored, and that a typical user was young. "Natural leaf" increased beliefs that the product contained high quality tobacco and that a typical user was trendy. When on grey packs, it increased favorable perceptions compared to when on brightly colored packs, including perceptions that the product tasted good, was fresh, that a typical user was trendy, and that the product was flavored.

CONCLUSIONS

This study is the first to present quantitative evidence on the impact of the "natural leaf" descriptor on cigarillo perceptions and intentions, extending work that has been done in the context of cigarettes. Utilizing highly realistic stimuli, findings demonstrate that both the term "natural leaf" and packaging color can increase favorable perceptions of cigarillos.

Where should I start? A scoping review about the publications on clove cigarettes

INTRODUCTION

The general lack of knowledge about the composition of clove cigarettes and the large number of terms that can be used to define different types of cigarettes that contain cloves makes it difficult to find scientific articles focused on the subject. We reviewed the publications that cited clove cigarettes to assess their relevance.

METHODS

We searched publications on Scopus, ScienceDirect, PubMed, and Portal CAPES during the first semester of 2021, without date restrictions. Through a quality assessment, the studies found were assorted in ten different categories.

RESULTS

Indonesian clove cigarettes-also known as kretek-are a mixture of tobacco and cloves rolled in a cigarette and sprayed with oils, plant extract, and food flavorings, in an unknown quantity and composition, different from each brand, which is usually kept in secret. Due to the relatively low prevalence of use in the general population, most publications on tobacco products tend to ignore clove cigarettes or place them in an existing category. Clove cigarettes can be hand-rolled, machine-made, filtered, unfiltered, and each form can be named differently. The interchangeable use of each term, sometimes grouping conventional cigarettes in the mix, can lead the researcher to consider a publication that should be excluded.

CONCLUSION

The existing regulations on flavored cigarettes, although well-intentioned, are still somewhat vague and broad, leaving possible loopholes that can be exploited by the tobacco industries. Fully understanding the precise effects caused by clove cigarettes can be an important tool in future discussions about tobacco control.

Factors associated with changes in flavored tobacco products used: Findings from wave 2 and wave 3 (2014-2016) of the population assessment of tobacco and health (PATH) study

INTRODUCTION

Flavored non-cigarette tobacco product use is widespread in the U.S. The availability of flavor options could be playing a role in recent increases in use, especially for non-cigarette tobacco products, among youth and young adults. Little is known about specific flavor preferences of youth and adult flavored tobacco product users, as well as how preferences may change over time.

METHODS

This study analyzes PATH Study data from completed Wave 2 (2014-2015) and Wave 3 (2015-2016) youth (12-17 years), and adult (18 + years) interviews to estimate the prevalence of flavored non-cigarette tobacco product use. We assess flavor switching by examining changes between flavors and characteristics of those who changed flavors between waves.

RESULTS

Across age groups, and at both waves, fruit-flavored products were the most frequently used flavor by past 30-day electronic nicotine delivery systems (ENDS), cigar, cigarillo, and hookah users. In the past 30 days, a higher proportion of youth and young adults used candy/sweets-flavored ENDS than adults. Among adult ENDS users, the odds of changing flavors were highest among younger users and decreased with increasing age.

CONCLUSIONS

Flavored tobacco product use is prevalent across non-cigarette tobacco products. Stability in the number of flavors used, as well as specific flavors, is higher among adult tobacco users, while the use of multiple flavors, and change in specific flavor, is more prevalent among youth tobacco users. Additional longitudinal research can further examine the role flavors play in appeal, product trial, and switching.

Innovative promotional strategies and diversification of flavoured mass merchandise cigar products: a case study of Swedish match

In 2009, the Family Smoking Prevention and Tobacco Control Act (TCA) granted the U.S. Food and Drug Administration (FDA) regulatory authority over tobacco products, although initially this only included cigarettes, smokeless tobacco and roll-your-own tobacco. In 2016, the deeming rule extended regulatory authority to include all tobacco products, including cigars. The deeming rule prohibited the introduction of new tobacco products into the marketplace without proper marketing authorisation and laid out pathways for tobacco companies to follow. The deeming rule should have frozen the cigar marketplace in 2016. In this paper, we describe how the cigarillo marketplace, nevertheless, continues to diversify with new brands, flavors, styles and packaging sizes entering the market regularly. As an example, we highlight recent promotional efforts by Swedish Match North America (Swedish Match) for their popular cigarillo brands, including White Owl, Night Owl and Garcia y Vega's Game brand. We argue that ambiguities in the TCA make it unclear whether Swedish Match's seemingly new cigarillos fit the definition of new tobacco products and, if so, whether they are on the market legally. Swedish Match and other cigarillo companies may be taking advantage of these ambiguities to promote a variety of cigarillo flavors and styles in innovative ways. Given that cigars are combustible tobacco products that pose many of the same risks as cigarettes, this business practice raises significant concerns regarding the protection of public health, particularly among young people.

Young adults' cigarillo risk perceptions, attention to warning labels and perceptions of proposed pictorial warnings: a focus group study

OBJECTIVE

Although cigars pose similar health risks to cigarettes, they are not uniformly required to carry a warning label on their packaging in the USA. The US Food and Drug Administration's 2016 deeming rule established a cigar warning requirement, but it was challenged in federal court for failing to document warning effects on prevention/cessation, thus necessitating an evidentiary base for such requirements. We sought to explore young adult users' understanding of cigarillo risks and addictiveness, as well as their perceptions of current (voluntary) and proposed cigar warning labels.

DESIGN

In December 2020-January 2021, we conducted eight focus groups with young adult cigarillo smokers. We asked participants their first associations of cigarillos and beliefs about product harms/addictiveness, and then discussed existing warning labels and examples of potential pictorial warnings.

SETTING

Focus groups were conducted remotely via the Adobe Connect platform, with participants from 20 US states.

PARTICIPANTS

Participants included 42 young adults (ages 18-29; 50% male), who were recent cigarillo users (ie, past 30 days) or less frequent users (ie, past 12 months).

RESULTS

Participants frequently used cigarillos as blunts and often conveyed uncertainty about cigarillo risks and addictiveness, in general and relative to cigarettes. Participants typically paid little attention to current text warnings, but many expressed that pictorial warnings would more effectively promote knowledge of product risks and discourage use among prospective users.

CONCLUSIONS

US young adult cigarillo users may lack knowledge about product risks and addictiveness. Standardised warning requirements, particularly pictorial labels, may help address this knowledge gap and deter use.

Dissonance in Young Adult Cigarillo Users' Categorization of Concept Flavored and Unflavored Products

This study asks young adult cigarillo users to categorize their preferred flavor in order to examine user consensus and potential methodological and regulatory implications of flavor name-based categorization systems. Young adult (21-28 years) cigarillo users (n = 426) named and categorized their favorite cigarillo flavor into one of seven categories: Fruit, Sweet and Candy, Mint, Alcohol, Menthol, Tobacco, and Other. Flavor responses were coded as characterizing (ex: Grape, Wine) or concept (ex: Jazz, Diamond) flavors. Variation within and between categories was assessed, including the presence of concept flavors and the placement of flavors in multiple categories. Of the 66 unique flavor names provided, participants placed 20 (30.1%) in more than one flavor category. Most of the Tobacco (76.9%) and Other (69.2%) flavor names appeared in multiple categories. The majority of flavor names in the Tobacco (69.2%) and Other (61.5%) categories were concept flavors. Concept flavors were placed in multiple categories (45.0%) twice as often as characterizing flavors (23.9%). This study has identified dissonance among cigarillo users' flavor categorizations, particularly for concept flavored and unflavored products. Flavor names may obscure how and whether a product is flavored. Research on and regulation of flavored tobacco products should classify products by flavor additives rather than by name alone.

The Impact of Influencers on Cigar Promotions: A Content Analysis of Large Cigar and Swisher Sweets Videos on TikTok

Little is known about the content, promotions, and individuals in cigar-related videos on TikTok. TikTok videos with large cigar and Swisher Sweets-related hashtags between July 2016 and September 2020 were analyzed. Follower count was used to identify influencers. We compared content characteristics and demographics of featured individuals between cigar types, and by influencer status. We also examined the association between content characteristics and video engagement. Compared to large cigar videos, Swisher Sweets videos were more likely to feature arts and crafts with cigar packages, cannabis use, and flavored products. In addition, Swisher Sweets videos were also more likely to feature females, Black individuals, and younger individuals. Both Swisher Sweets and large cigar influencers posted more videos of cigar purchasing behaviors than non-influencers, which was associated with more video views. None of the videos disclosed sponsorship with #ad or #sponsored. Videos containing the use of cigar packages for arts and crafts, and flavored products highlight the importance of colorful packaging and flavors in the appeal of Swisher Sweets cigars, lending support for plain packaging requirements and the prohibition of flavors in cigar products to decrease the appeal of cigars. The presence and broad reach of cigar promotions on TikTok requires stricter enforcement of anti-tobacco promotion policies.

Cigarillo Flavor and Motivation to Quit among Co-Users of Cigarillos and Cannabis: A Structural Equation Modeling Approach

Flavored cigar restrictions have the potential to benefit public health. Flavor availability facilitates cigarillo use, but it is unknown if flavor impacts patterns of co-use of cigarillos and cannabis, an increasingly prevalent behavior among young adults. Data were collected (2020-2021) in a cross-sectional online survey administered to a convenience sample of young adults who smoked cigarillos from 15 areas with high cigar use prevalence. We assessed the relationship between flavored cigarillo use and motivation to quit cannabis and cigarillo use among past 30-day co-users (N = 218), as well as several covariates (e.g., cigarillo price and flavor/cannabis policy). Flavored cigarillo perceived appeal and harm were hypothesized parallel mediators. Most co-users reported usually using flavored cigarillos (79.5%), which was not significantly associated with motivation to quit cigarillos or cannabis. Perceived cigarillo harm (β = 0.17, 95% CI = 0.00, 0.33), advertising exposure (β = 0.12, 95% CI = 0.00, 0.24), and income (among racial/ethnic minorities; β = -0.13, 95% CI = -0.25, -0.02) were significant predictors of motivation to quit cigarillos. There were no significant predictors of motivation to quit cannabis. Cigarillo flavor was not associated with motivation to quit, so findings could suggest that banning flavors in cigars may have a neutral impact on co-use with cannabis among young adults.

Characterizing tobacco and marijuana use among youth combustible tobacco users experiencing homelessness - considering product type, brand, flavor, frequency, and higher-risk use patterns and predictors

BACKGROUND

Cigarette smoking is three times more prevalent among youth experiencing homelessness compared with the general population. Co-use of tobacco and marijuana is also common. The aim of this study is to characterize tobacco and marijuana use among youth experiencing homelessness who use combustible tobacco in a Midwestern city to inform smoking cessation intervention.

METHODS

This study included 96 youth (ages 14-24 years; 52% male, 39% female, 5% transgender/non-binary) attending a homeless drop-in center who had used at least one combustible tobacco product in the past week. We assessed past-month use of tobacco products and marijuana, other product use characteristics (e.g., frequency, brand and flavor), and psychosocial predictors of more frequent (i.e., daily) use of combustible tobacco and marijuana.

RESULTS

Most youth experiencing homelessness with past-week combustible tobacco use had used cigarettes (n = 85, 88.5%), cigars (n = 89, 92.7%), and marijuana (n = 82, 85.4%) in the past month. One-third (n = 34) used electronic vapor products (EVPs), 19.8% (n = 19) smoked hookah, and 11.5% (n = 11) used smokeless tobacco (ST). Most marijuana users co-administered with tobacco (n = 67, 69.8%). Daily combustible tobacco smoking was associated with having a child and smoking out of boredom/habit. Daily marijuana use was associated with using substances to cope with one's housing situation. Newport (n = 66, 72.5%) and Black & Mild (n = 48, 51.1%) were the most popular brands of cigarettes and cigars among ever users. Most non-combustible tobacco ever users reported not having a usual brand (EVPs: n = 51, 73.9%; ST: n = 16, 57.1%). Cigar smokers reported the most varied selection of flavors.

CONCLUSIONS

Young combustible tobacco users experiencing homelessness engage in high-risk use patterns, including poly-tobacco use, co-use of tobacco with marijuana, and frequent combustible product use. Interventions that consider the full context of tobacco and marijuana use are needed to support smoking cessation in this population.

The importance of cigarillo product characteristics among young adult cigarillo users: Differences by demographics, cigarillo use and other tobacco/substance use behaviors

INTRODUCTION

Cigar products, including cigarillos, have increased in popularity in the U.S. and are disproportionately used by young adults. Cigarillo product characteristics can influence consumer perceptions and the appeal of these characteristics can vary by subgroup. The goal of this study was to examine a) product characteristics important to young adult cigarillo users and b) differences based on demographics and cigarillo and other tobacco/substance use behaviors.

METHODS

In 2016, a convenience sample of 628 past-year cigarillo users rated the importance of the following cigarillo product characteristics when choosing a cigarillo to smoke tobacco: brand, tobacco filler quality, tobacco wrap quality, flavors, price, package graphic design, and number of cigars in the pack. Differences in mean importance by demographic, cigarillo use and other tobacco/substance use characteristics were analyzed using t-tests and ANOVA tests.

RESULTS

The most important cigarillo product characteristics were price, quality of tobacco wrap, and flavors. The least important was graphic design of packaging. There were differences in importance by demographics and/or cigar and other tobacco/substance use behaviors for all product characteristics. In particular, pack size was rated as more important among current cigarillo users, users of foil pouches (2-3 cigarillos) or cardboard/paper boxes or other packaging styles, and current users of cigarettes, blunts and marijuana. Price was rated as more important among Hispanic/Latino and lower income smokers, and current cigarette and blunt smokers.

CONCLUSIONS

Findings suggest cigarillo users prioritize different product characteristics depending on their demographics or smoking behavior. Further research is needed to examine whether various cigar-related policies, such as those that ban flavors or set minimum pack sizes, could impact sub-populations of cigarillo users differently.

Taking global leadership in banning menthol and other flavours in tobacco: Canada's experience

Measures to ban or restrict menthol and other flavours in tobacco products are under consideration or newly implemented in an increasing number of jurisdictions across the world. As one of the world leaders, Canada's experience in successfully developing and implementing such measures can be instructive for other jurisdictions. This paper explores the history of how Canada was able to implement tobacco flavour bans including menthol, examines some of the challenges and presents lessons learnt for other jurisdictions. The crucial motivation for these bans emerged from surveillance data showing high rates of flavoured tobacco use by youth, including menthol cigarette smoking, that was publicised by non-governmental organisations. Further data showed that early legislation in 2009 contained loopholes (cigar size exemptions and menthol exemptions) that limited the benefits of the legislation. Leadership by the provinces created an environment in which the federal ban on menthol ingredients in 2017 was a clear and obvious step to ensure implementation across the country. The Canadian measures have been successful at reducing the use of flavoured tobacco including menthol cigarettes and facilitating smoking cessation. Lessons learnt include the downsides of exemptions, the lack of a contraband issue (despite an existing supply in Canada), the benefits of availability of youth flavour prevalence data and the success of subnational regulations to advance national regulation.

The Impact of Menthol Cigarette Flavor in the U.S.: Cigarette and ENDS Transitions by Sociodemographic Group

INTRODUCTION

A better understanding of how menthol cigarette flavoring and ENDS impact smoking initiation, cessation, and transitions between tobacco products could help elucidate the potential impact of a U.S. menthol ban on combustible tobacco products.

METHODS

A multistate transition model was applied to data on 23,232 adults from Waves 1-4 (2013-2017) of the Population Assessment of Tobacco and Health Study (analysis was conducted in 2020-2021). Transition rates among never, noncurrent, nonmenthol versus menthol cigarette, ENDS, and dual everyday/someday use were estimated, as were transition-specific hazard ratios for age, sex, race/ethnicity, education, and income.

RESULTS

Non-Hispanic Blacks who smoked menthol discontinued smoking at a much lower rate than those who smoked nonmenthol (hazard ratio=0.43, 95% CI=0.29, 0.64), but there was no statistically significant difference in the discontinuation rates among non-Hispanic Whites (hazard ratio=0.97, 95% CI=0.80, 1.16) or Hispanics (hazard ratio=0.81, 95% CI=0.56, 1.16). Non-Hispanic Whites who smoked menthol were more likely to become dual users than those who smoked nonmenthol (hazard ratio=1.43, 95% CI=1.14, 1.80). Young adults initiated menthol smoking at a higher rate than older adults (age 18-24 years versus ≥55 years: hazard ratio=2.45, 95% CI=1.44, 4.15) but not nonmenthol smoking (hazard ratio=1.02, 95% CI=0.62, 1.69). There were differences by sex in the impact of menthol flavor on smoking initiation and discontinuation but little difference by education or income.

CONCLUSIONS

Sociodemographic differences in product transitions should be accounted for when estimating the potential impact of a menthol ban.

Behavioral economic assessment of abuse liability for Black & Mild cigar flavors among young adults

Cigars are available in a variety of flavors that may impact uptake and use, but little is known about how different flavors affect abuse liability. This study used 3 behavioral economic tasks to examine abuse liability of Black & Mild cigars differing in flavor among young adult cigarette smokers. Participants were 25 cigar-naïve young adults (aged 18-25 years) who smoked ≥ 5 cigarettes/day. In 5 Latin square-ordered laboratory visits, participants completed 3 abuse liability tasks (drug purchase task, cross-price purchase task, and multiple-choice procedure) for each of 4 cigar flavors (original, cream, wine, or apple) and own-brand cigarettes. In the drug purchase task, relative to own-brand cigarettes, all cigar flavors were associated with lower abuse liability using most measures (intensity, breakpoint, maximum total tobacco expenditure for 1 day [ps < .05]), although only wine-flavored cigars scored significantly lower using 1 measure (price at maximum total tobacco expenditure for 1 day). When cigars and cigarettes were available concurrently in the cross-price purchase task, all cigar flavors functioned as substitutes for cigarettes. Using the multiple-choice procedure, crossover points for wine- (mean = $0.61) and apple-flavored cigars (mean = $0.71) were significantly lower than own-brand cigarettes (mean = $0.86) and original-flavored cigars (mean = $1.00); no significant differences existed between own-brand cigarettes and original-flavored cigars. Thus, whereas abuse liability may be highest for participants' own-brand cigarette, young adult smokers may be willing to use flavored cigars. Furthermore, abuse liability varies by cigar flavor, with original- and cream-flavored cigars appearing to have the highest abuse liability. Characterizing flavors and flavor additives in cigars represent an important tobacco regulatory target. (PsycInfo Database Record (c) 2022 APA, all rights reserved).

Impact of California's tobacco and cannabis policies on the retail availability of little cigars/cigarillos and blunt wraps

BACKGROUND

Recent changes in California's tobacco and cannabis policies could impact the retail availability of little cigars/cigarillos (LCCs) and blunt wraps that are used for blunt smoking. This study was intended to test whether tobacco flavor bans and minimum pack sizes of LCCs have reduced tobacco availability in California jurisdictions, whereas, permissive policies on sales and marketing of cannabis increased availability.

METHODS

Measures of retail availability of LCCs and blunt wraps were obtained from the 2016-2019 longitudinal sample of licensed tobacco retailers (LTRs, n = 4062) from California's Healthy Stores for Healthy Communities campaign. Additional data sources included the California Cannabis Local Laws database and geographic location of 1063 cannabis retailers used for constructing a spatial index of accessibility to the LTRs. Two-level generalized structural equation models were developed to assess effects of store- and jurisdiction-level predictors of change in tobacco availability (+, -, no change).

RESULTS

Neither permissive cannabis policies nor accessibility to cannabis retailers were associated with an increase in retail availability of the tobacco products. Enactment of a tobacco flavor ban, however, was associated with reduced availability of LCCs and blunt wraps, which was more pronounced in jurisdictions that had permissive cannabis policies (i.e. policy interaction).

CONCLUSIONS

A tobacco flavor ban may be an effective strategy to reduce retail availability of LCCs, blunt wraps and possibly other tobacco in California jurisdictions. This finding is of particular relevance as the tobacco industry has successfully petitioned for a referendum vote on California's statewide flavor ban in the 2022 election.

A longitudinal analysis of e-cigarette use and cigar, little cigar or cigarillo initiation among youth and youth adults: 2017-2019

PURPOSE

To examine whether youth and young adult e-cigarette use is associated with initiation of cigars, little cigars, or cigarillos (CLCCs) and current use of flavored CLCCs.

BASIC PROCEDURES

The sample is drawn from the Truth Longitudinal Cohort, a probability-based longitudinal cohort of youth and young adults recruited at ages 15-21 and surveyed every six months. The sample for this study was CLCC-naïve defined as those who had never used CLCCs as of 2017 (N = 5586). The outcomes were the odds of (1) initiating any CLCC use and (2) reporting current (past 30-day) use of flavored CLCCs from 2018 to late 2019. The main predictor was use of e-cigarettes by 2018.

RESULTS

The odds of initiating a CLCC was greater for those who had used ever used JUUL (OR: 3.30, p < 0.001) or were current users of another type of e-cigarette by 2018 (OR: 3.57, p < 0.001). Odds of CLCC initiation was also greater for those who had ever used combustible cigarettes (OR: 1.62, p < 0.05), were current smokers (OR: 3.12, p < 0.001) or had used marijuana (OR: 1.92, p < 0.001) by 2018. E-cigarette use that occurred by 2018 was associated with greater odds of current use of flavored CLCCs compared to non-flavored CLCCs (ever users of JUUL: OR: 2.57, p < 0.01; current users of some other e-cigarette: OR: 3.06, p < 0.05).

CONCLUSION AND RELEVANCE

This study raises new concerns about the effects of e-cigarette use on subsequent combustible tobacco use. Restrictions on CLCCs should be considered in conjunction with current policies designed to reduce the youth vaping epidemic.

Experts' Perceptions of and Suggestions for Cigar Warning Label Messages and Pictorials

INTRODUCTION

Warning labels can be effective tools to inform the public about tobacco risks. However, tobacco warning research has been largely cigarette-centric. This formative study explores potential directions for improving the current warnings for cigars.

AIMS AND METHODS

Between June and August 2019, we conducted interviews with 10 experts about the current cigar warning statements and requirements, the inclusion of pictorials in cigar warnings, and legal issues. Additionally, experts viewed and discussed concept images to pair with existing warning statements, including realistic photographic images and symbolic images (eg, icons, caution symbols).

RESULTS

Experts agreed that cigar warnings should be strengthened (eg, by increasing their size and use of pictorials) to better leverage their potential impact and maintain warning parity with cigarettes. However, perceived challenges exist given the wide variety of cigar products, product terminology, and use patterns. Experts agreed that photographic pictorials of health effects are likely to be more salient, informative, and effective for behavior change than symbolic ones, but may be vulnerable to legal challenges. Symbolic images used in warnings may obtain attention in a less "controversial" way, but may be considered less serious and "factually accurate," increasing legal risks. Experts indicate that cigar educational campaigns can complement warnings and address additional themes, especially aimed at youth, including exposure to chemicals and flavorings and misperceptions that cigars are "natural."

CONCLUSIONS

Additional consumer research is needed to examine the potential public health impact of improving cigar warnings and to support regulatory efforts.

IMPLICATIONS

This study provides feedback from tobacco control experts about the importance of cigar warning labels and directions for future research and improvements. Experts support increasing the size of cigar warnings and adopting pictorials to improve cigar warning impact and maintain warning parity with cigarettes. Experts agreed that photographic pictorials of health effects are likely to be more salient and effective for behavior change than symbolic ones. Given legal challenges, experts discussed potentially prioritizing warning improvements for those cigars used most frequently as cigarette alternatives and by youth. Overall, more cigar warning research is needed to support regulatory efforts.

Flavors And Implied Reduced-Risk Descriptors In Cigar Ads At Stores Near Schools

INTRODUCTION

Although the FDA prohibits using inaccurate, reduced-risk descriptors on tobacco product advertising, descriptors that imply reduced-risk or an enhanced user experience may be present on cigar product advertising in retail outlets near schools. Therefore, to inform the development of federal labeling and advertising requirements that reduce youth appeal of cigars, we conducted a content analysis of cigar ads in retailers near schools to document the presence of implied health claims and other selling propositions that may convey enhanced smoking experience.

METHODS

Up to four interior and exterior LCC advertisements were photographed in a random sample of licensed tobacco retailers (n=530) near California middle and high schools. Unique ads (n= 234) were coded for brand, flavor, and presence of implicit health claims, premium branding descriptors, and sensory descriptors. Logistic regressions assessed the association among flavored ads and presence of implicit health claims, premium branding, or sensory descriptors.

RESULTS

Seventeen cigar brands were advertised near schools; Black & Mild (20.1%) and Swisher Sweets (20.1%) were most common. Flavor was featured in 64.5% of ads, with explicit flavor names (e.g., grape) being more prevalent than ambiguous names (e.g., Jazz) (49.6% vs. 34.2%). Compared to ads without flavors, ads with ambiguous flavors were more likely to feature implicit health claims (OR=1.83, 95%CI=1.06, 3.19) and sensory descriptors (OR=2.64, 95%CI=1.39, 5.04); ads with explicit flavors were more likely to feature premium branding (OR=2.84, 95%CI=1.53, 5.41).

CONCLUSIONS

Cigar ads that featured implicit health claims and premium branding, and sensory selling propositions are present at retailer stores near schools.

E-cigarette and vaping product use-associated lung injury in the pediatric population: A critical review of the current literature

Use of electronic nicotine delivery systems (ENDS), also known as e-cigarettes, in the adolescent population has significantly increased over the past several years. This rise led to an outbreak of e-cigarette or vaping product use-associated lung injury (EVALI) in the summer of 2019. Since that time, numerous case reports and case series on vaping and EVALI have been published but the majority of literature highlights the adult population with few articles focusing on pediatric patients. Given the addictive nature of these products and the lack of full understanding of the human health effects, there is concern that use of ENDS may have lasting impacts on users, especially adolescents and young adults. The goal of this review is to critically assess published data on ENDS use in children, report our institutional experience, discuss the reasons why the use of ENDS have increased among young individuals, outline the current understanding of EVALI as it pertains to the pediatric population, and discuss future opportunities for health policy implementation.

Associations between Black and Mild Cigar Pack Size and Demographics and Tobacco Use Behaviors among US Adults

Pack size is an important pricing strategy for the tobacco industry, but there is limited data on how users differ based on preferred pack size for cigar products. Using data from Wave 4 of the Population Assessment of Tobacco and Health Study, this study identified differences in adult cigar user characteristics based on pack size purchasing behavior among users of a top cigar brand, Black and Mild. Weighted chi-square tests were used to examine the associations between Black and Mild pack size and sociodemographic, cigar and other substance use characteristics. Overall, our study found that users of Black and Mild cigars differ by demographic, cigar and other tobacco use characteristics based on preferred pack size, with smaller packs appealing to younger, female, less-experienced and less-established smokers, and larger packs appealing to older, male, more experienced, and more dependent cigar smokers. Dual use of cigarettes and cigars was also higher among users of smaller packs. While this study is cross-sectional, findings suggest that minimum packaging laws for cigars may impact younger adults who are purchasing smaller pack sizes and likely experimenting with new cigar products and styles.

The Effect of Cigarillo Packaging Characteristics on Young Adult Perceptions and Intentions: An Experimental Study

Research demonstrates that characteristics of cigarette packaging influence consumer product perceptions, yet the current literature on the impact of cigar packaging is limited. This study aims to examine how different cigarillo packaging features influence young adult cigar smokers’ perceptions. In 2016, we recruited past-year cigar users aged 18–34 from Amazon Mechanical Turk (N = 1260). We utilized a 2 × 2 × 3 × 2 between-subjects factorial design, randomly assigning participants to view one of 24 images of a cigarillo package that varied by brand (Black & Mild vs. Swisher Sweets), brand name (full vs. abbreviated), color (brown vs. green vs. purple), and price promotion (present vs. absent). Participants rated the product on several perceptions and purchase intentions, and they reported on cigar use and demographics. Overall, color and brand name influenced perceptions, but effects varied by brand. For Swisher Sweets, only price promotions influenced perceptions (e.g., taste, use for marijuana); for Black & Mild, all packaging features influenced perceptions (e.g., harshness, tobacco quality), and price promotions increased purchase intentions. Our findings also raise questions that product features may interact with one another, with certain features, such as color, overpowering other attributes. More research is needed to understand the impact of other packaging features, such as warning labels, on product perceptions across a variety of brands.

A Qualitative Study of Perceptions and Practices Related to Areca Nut Use Among Adolescents in Mumbai, India

INTRODUCTION

Areca nut, commonly known as supari, is widely used in India. In addition to tobacco and alcohol, it has been identified as one of the contributory factors for high rates of oral cancer in the country.

METHODS

This qualitative study explored perceptions and practices around the use of areca nut by conducting in-depth interviews and focus group discussions with 61 school-going adolescents in the city of Mumbai, India.

RESULTS

Respondents used low-priced sachets of sweetened, flavored areca nut called supari. They perceived supari as harmless because it was sweet, it had a fresh after-taste as compared to bitter-tasting smokeless tobacco products. How can something sweet be harmful was a common argument offered by respondents. Respondents invariably compared and contrasted areca nut to more harmful and addictive tobacco products; perceiving supari to have milder or inconsequential health effects. Supari use was initiated with friends, a sibling, or a cousin. It was almost always used with friends. Respondents also reported difficulty in refusal to use when offered supari by friends. Parental response to finding out about the child's supari use was often muted in comparison to extreme reactions associated with the child's tobacco use.

CONCLUSIONS

Perceptions of low risk or relative harmlessness of the product, social influence, and the features of the product itself influence adolescents' use of areca nut. Although more research on perceptions of risk, with larger samples, is required, these findings are useful for school-based tobacco prevention and cessation programs and health policy-makers.

IMPLICATIONS

The study findings have implications for prevention and cessation programs, and policymakers. School-based health education programs should allocate special sessions on areca nut use. Focused mass media communication campaigns describing its harms and association with oral cancer are required for the larger community. As was done for tobacco, Indian policymakers will have to evaluate the marketing, commerce, and distribution of areca nut and create appropriate laws. More research, with larger nationwide samples, is required to examine perceptions of areca nut.

Volatile Organic Compounds in Mainstream Smoke of Sixty Domestic Little Cigar Products

The mainstream smoke yields of five volatile organic compounds (VOCs) were determined from 60 commercial U.S. little cigar products under ISO 3308 and Canadian Intense (CI) smoking regimens on linear smoking machines using a gas sampling bag collection. The five VOCs, 1,3-butadiene, acrylonitrile, benzene, isoprene, and toluene were analyzed using an automated GC/MS analytical method validated for measuring various VOCs in mainstream smoke. The VOCs range in amounts from micrograms to milligrams per little cigar. VOC deliveries vary considerably among the little cigar products under the ISO smoking regimen primarily due to varying filter ventilation. Under the CI smoking regimen where filter ventilation is blocked, the delivery range narrows, although individual and total VOC yields are approximately 2 fold higher than those under the ISO smoking regimen. Correlation analysis reveals strong associations between acrylonitrile and 1,3-butadiene or toluene under the ISO smoking regimen. Compared to cigarettes, little cigars delivered substantially higher VOC mainstream smoke yields under both ISO and CI smoking regimens. Moreover, little cigar smoke also contains higher VOCs than cigarette smoke when adjusted for mass of tobacco.

Cross-Sectional Associations of Multiple Tobacco Product Use with Depressive and Anxiety Symptoms among Young Adult E-Cigarette Users

BACKGROUND

Tobacco users with mental health conditions are a vulnerable population in tobacco research, yet few studies have evaluated the association of depressive and anxiety symptoms with multiple tobacco product (MTP) use among young adult electronic cigarette (ENDS) users.

METHODS

Cross-sectional survey data on U.S. young adult past 30-day ENDS users (N = 2348) were collected via Amazon MTurk from May-July 2019. Binary logistic regressions evaluated the association of tobacco use pattern (exclusive ENDS use, ENDS + one other tobacco product [OTP; dual use], ENDS + two or more OTPs [poly-use]) with depressive (PHQ-9) and anxiety (GAD-7) symptoms. Among MTP users (n = 1736), we evaluated the association of ENDS use relative to OTP use and same-day MTP use with depressive and anxiety symptoms.

RESULTS

The sample included 26% exclusive ENDS, 27% dual, and 47% poly-users. We observed a gradient-relationship for depressive and anxiety symptoms: poly-users had greater odds of depressive and anxiety symptoms compared to dual users (aOR = 1.86 [95%CI:1.50-2.30] and aOR = 1.61 [95%CI:1.30-2.01], respectively), and dual users had greater odds of depressive and anxiety symptoms compared to exclusive ENDS users (aOR = 1.42 [95%CI:1.11-1.81] and aOR = 1.56 [95%CI:1.20-2.02], respectively). MTP users who used ENDS more often than OTPs (vs. less often than OTPs) had greater odds of depressive (aOR = 1.38 [95%CI:1.06-1.80]) and anxiety (aOR = 1.37 [95%CI:1.04-1.79]) symptoms.

CONCLUSIONS

The majority of young adult past 30-day ENDS users in this sample reported OTP use. Future research on MTP use should distinguish between dual and poly-use. Tobacco prevention efforts for young adults with mental health symptoms are needed.

Cigarette and cigar sales in Hawaii before and after implementation of a Tobacco 21 Law

INTRODUCTION

On 1 January 2016, Hawaii raised the minimum legal age for tobacco access from 18 to 21 years ('Tobacco 21 (T21)') statewide, with no special population exemptions. We assessed the impact of Hawaii's T21 policy on sales of cigarettes and large cigars/cigarillos in civilian food stores, including menthol/flavoured product sales share.

METHODS

Cigarette and large cigar/cigarillo sales and menthol/flavoured sales share were assessed in Hawaii, California (implemented T21 in June 2016 with a military exemption), and the US mainland using the only Nielsen data consistently available for each geographical area. Approximate monthly sales data from large-scale food stores with sales greater than US$2 million/year covered June 2012 to February 2017. Segmented regression analyses estimated changes in sales from prepolicy to postpolicy implementation periods.

RESULTS

Following T21 in Hawaii, average monthly cigarette unit sales dropped significantly (-4.4%, p<0.01) coupled with a significant decrease in menthol market share (-0.8, p<0.01). This combination of effects was not observed in comparison areas. Unit sales of large cigars/cigarillos decreased significantly in each region following T21 implementation. T21 policies in Hawaii and California showed no association with flavoured/menthol cigar sales share, but there was a significant increase in flavoured/menthol cigar sales share in the USA (7.1%, p<0.01) relative to Hawaii's implementation date, suggesting T21 may have attenuated an otherwise upward trend.

CONCLUSIONS

As part of a comprehensive approach to prevent or delay tobacco use initiation, T21 laws may help to reduce sales of cigarette and large cigar products most preferred by US youth and young adults.

Neighborhood Disparities in the Availability, Advertising, Promotion, and Youth Appeal of Little Cigars and Cigarillos, United States, 2015

INTRODUCTION

Between 2012 and 2016, sales of cigars increased by 29% in the United States. In small local studies, greater little cigar and cigarillo (LCC) availability and marketing has been documented in neighborhoods with a greater proportion of Hispanic or Latino and black residents, and near schools. This national study of cigarette retailers assesses whether LCC availability and marketing at the point of sale is associated with neighborhood racial, ethnic, income, and percent youth demographics.

METHODS

In 2015, we collected LCC availability and marketing data through retailer audits of a nationally representative sample of 2128 cigarette retailers. Using 2011-2015 American Community Survey census tract estimates, we modeled associations of neighborhood demographics (in quartiles) with availability of LCC-flavored products, and presence of exterior advertisements, youth marketing, and promotions.

RESULTS

Nearly 90% of retailers sold LCCs, 83.0% sold flavored LCCs, and 30.9% had youth marketing. Controlling for retailer type and other neighborhood characteristics, neighborhoods with the highest proportion of black residents had significantly higher odds of flavored LCC availability (adjusted odds ratio [AOR] = 2.24, 95% confidence interval [CI] = 1.52, 3.30); exterior advertisements (AOR = 2.84, 95% CI = 1.94, 4.16); price promotions (AOR = 1.62; 95% CI = 1.07-2.45), and youth appeal (AOR = 1.49, 95% CI 1.08-2.08) compared to the lowest. Disparities in flavored LCC availability, exterior advertising, and youth appeal were also present for lower income neighborhoods.

CONCLUSION

Neighborhoods with a greater proportion of black or lower income residents have greater flavored LCCs availability and LCC marketing. Without stronger LCC regulation, residents of these neighborhoods may be at a greater risk of LCC use.

IMPLICATIONS

LCCs are harmful combustible tobacco products that are less regulated than cigarettes (eg, lower taxation, cheaper outlay due to small package sizes, availability of flavors), which makes them an affordable and appealing product to youth. This study documents greater availability, advertising, and marketing of LCCs in neighborhoods with a higher proportion of black or lower-income residents, potentially putting these populations at a greater risk of using or switching to these products in the face of increasing cigarette regulations. These findings underscore the need for local, state, and federal LCC regulatory action.

Age of initiation of cigarillos, filtered cigars and/or traditional cigars among youth: Findings from the Population Assessment of Tobacco and Health (PATH) study, 2013-2017

SIGNIFICANCE

Early age of initiation of tobacco use is associated with sustained tobacco use and lower rates of smoking cessation. Although much is known about age of initiation of cigarette use, much less is known about the age of initiation of cigar product use among youth.

METHODS

Survival analyses of the Population Assessment of Tobacco and Health youth annual datasets (ages 12-17) from 2013 to 2017 were conducted for any cigar product use, cigarillos or filtered cigars, and traditional cigars across four cigar use outcomes, age of initiation of: susceptibility to use, ever use, past 30-day use and "fairly regular" use. An interval censoring survival method was implemented to estimate the probability of each outcome for age of initiation of each cigar product overall. Differences in age of initiation by sex and race/ethnicity were assessed using weighted Cox proportional hazards models for interval-censored data.

RESULTS

For each outcome across the three cigar products, striking increases in the probability of initiation begin before 17 years old. For cigarillo or filtered cigars, males had a higher risk of onset of susceptibility to use, initiating ever use, and initiating past 30-day use at earlier ages than females. Compared to Non-Hispanic Whites, Hispanic and Non-Hispanic Other had lower risk of initiating ever use and past 30-day use at earlier ages. Non-Hispanic Black youth had higher risk of initiating past 30-day use and "fairly regular" use than Non-Hispanic White youth at earlier ages. Similar findings are reported for any cigar use and traditional cigar use.

CONCLUSION

Developmentally and culturally appropriate cigar use interventions and communication campaigns should be provided to youth before 17 years of age to prevent the onset and progression of cigar products. Regulatory policies that reduce appeal of all cigar products should be implemented to curb cigar initiation among youth.

Examination of Voluntary Compliance with New FDA Cigar Warning Label Requirements

Objectives

The US Food and Drug Administration (FDA) issued new requirements to strengthen and increase the size of cigar warnings. Although these requirements were challenged in court by the cigar industry, and later struck down, cigar manufacturers had the option of voluntarily complying during the injunction. In this study, we examined voluntary warning compliance on a sample of discarded cigar wrappers.

Methods

Warnings were examined on a sample of 1352 discarded cigar wrappers and packs obtained from 15 census tracts in Oakland, California in February 2019. Warnings were coded for new requirement compliance (ie, sized at 30% or more on front and back of pack).

Results

Overall, 67.3% of wrappers displayed compliant warnings - other wrappers had smaller warnings only on the front (30.6%), only on the back (1.5%) or no warning (0.4%). Cigar warning placement was significantly associated with brand (p < .01), cigar type (p < .01), and unit size (p < .01). The prevalence of warning compliance was at least 90% for 6 brands but ranged from 0% to 65% for others. Compliance was lowest for cigarillos (62.1%) and packs of 3 (27.6%).

Conclusions

Strengthening cigar warnings can help increase their effectiveness, but cigar manufacturers may not voluntarily implement changes fully. Continued surveillance and renewed regulatory efforts are warranted.

Age Verification and Online Sales of Little Cigars and Cigarillos to Minors

Objectives

In our cross-sectional study, we aimed to determine age verification and sales of little cigars and cigarillos (LCCs) online to underage teens.

Methods

We selected 100 popular Internet Little Cigar and Cigarillo Vendors (ILVs) for order attempts. From August to December 2015, we supervised 14 teens 14-17 years old making order attempts for LCCs.

Results

Of the 91 valid orders attempted, we received 89. For the valid orders attempted, 9.9% of ILVs used no age verification strategies at all, 84.6% used less effective forms of age verification, and 50.5% used more effective ones. Only one order was blocked during the order attempt and only one attempt was made to verify age at delivery. Most (79.8%) deliveries were left at the door and only 2 order attempts were rejected because of age verification strategies, resulting in a successful or valid buy rate of 97.8%.

Conclusions

Our study demonstrated that ILVs selling LCCs were not making adequate efforts to verify the age of their customers, at the point-of-sale or point-of-delivery, facilitating easy access by minors. Few ILVs utilized age verification strategies that prevented online sales of LCCs to underage teens.

History repeats itself: Role of characterizing flavors on nicotine use and abuse

The popularity of e-cigarettes has skyrocketed in recent years, and most vapers use flavored e-cigarette products. Consumption of flavored e-cigarettes exceeds that of combustible cigarettes and other tobacco products among adolescents, who are particularly vulnerable to becoming nicotine dependent. Flavorings have been used by the tobacco industry since the 17th century, but the use of flavors by the e-cigarette industry to create products with "characterizing" flavors (i.e. flavors other than tobacco or menthol) has sparked a public health debate. This review addresses the possibility that characterizing flavors make nicotine more appealing, rewarding and addictive. It also discusses ways in which preclinical and clinical studies could improve our understanding of the mechanisms by which flavors may alter nicotine reward and reinforcement. This article is part of the special issue on 'Contemporary Advances in Nicotine Neuropharmacology'.

Changes in Tobacco Product Advertising at Point of Sale: 2015-2018

OBJECTIVES

Tobacco point-of-sale advertising, particularly in retailers surrounding schools, is associated with youth tobacco use and must be monitored. This study examines how the point-of-sale environment surrounding youth changed over time with regard to diverse tobacco products.

METHODS

Each spring from 2015 to 2018, research staff visited the same tobacco retailers (n = 141) within a half-mile of New Jersey high schools. For cigarettes, cigars, electronic cigarettes, and smokeless tobacco, advertisement presence, volume, and share of advertising voice (SAV) were measured for both the exterior and interior of the store. Analyses examined changes over time by product, controlling for store type and poverty.

RESULTS

Over time, exterior cigarette advertisements declined in presence (61% to 49%) and SAV (50% to 40%), whereas interior advertisements maintained stable presence, volume, and SAV. In contrast, cigar advertisements increased in presence (exterior 11% to 23%; interior 19% to 30%) and volume (exterior mean 0.2 to 0.5; interior 0.3 to 0.8). For electronic cigarettes, exterior and interior advertising presence, volume, and SAV decreased from 2015 to 2017 but increased in 2018. Smokeless tobacco advertising was infrequent and stayed consistent except in volume in the interior of stores (mean 0.2 to 0.3). When there were any differences by store type, chain convenience stores had the most exterior and interior advertising for all products.

CONCLUSIONS

The longitudinal changes observed for each product's advertising reflect national youth use rates of the corresponding products. The point-of-sale environment around schools may be influencing youth tobacco use and must be monitored and regulated.

Flavored Tobacco Sales Prohibition (2009) and Noncigarette Tobacco Products in Retail Stores (2017), New York City

Objectives. To assess explicit- (products clearly labeled flavored) and emergent concept- (products implying flavoring but not clearly labeled) flavored tobacco product availability following New York City's flavor restriction.Methods. We examined explicit- and concept-flavored tobacco product availability, with 2017 New York City Retailer Advertising of Tobacco Survey data (n = 1557 retailers). We assessed associations between block group-level demographic characteristics and product availability by using logistic regression.Results. Most retailers sold explicit-flavored (70.9%) or concept-flavored (69.3%) products. The proportion of non-Hispanic Black neighborhood residents predicted explicit- and concept-flavored product availability, as did having a high school within a retailer's block group for concept-flavored products.Conclusions. Explicit- and concept-flavored other tobacco products persisted throughout New York City, despite 2009 legislation restricting sales.Public Health Implications. Making local sales restrictions or federal production bans inclusive of all explicit and concept flavors would reduce retailer and industry evasion opportunities and protect the health of youths and others.

Do tobacco industry websites target content to specific demographic groups?

BACKGROUND

Prior research has not examined whether tobacco brand websites vary content based on audience demographics. This study explored whether marketing content on tobacco brand websites varied by user ethnicity, gender or age group.

METHODS

Participants (n = 32) were adult smokers, representing equal numbers of eight demographic groups: user ethnicity (Non-Hispanic White, Hispanic, African American, Asian), gender (women, men) and age (age 21-35, age 36+). This study examined 12 tobacco brand websites representing four tobacco product categories (cigarettes, cigar/cigarillos, smokeless tobacco, and e-cigarettes). From January 2016 to January 2017, participants coded websites for themes, interactive activities, and links to social media sites (n = 874 website visits). Logistic regression was used to analyze observed content by participant ethnicity, age and gender.

RESULTS

All themes, all interactive activities and all links to social media were observed at least once for each demographic category. Male participants were more likely to observe Harm reduction themes, while female participants were more likely to observe Promotion themes. Older participants were more likely to observe website features allowing them to select music, and request coupons. Compared to Non-Hispanic White participants, African American participants were more likely to observe links to social media sites.

CONCLUSION

Tobacco brand website content varied across ethnic, age and gender groups. These findings suggest that other factors, such as tobacco use behaviors, may influence marketing strategies participants recall or find appealing. The findings from this study can inform future regulatory activities and communication strategies aimed at countering pro-tobacco content online.

Association Between Adolescent Blunt Use and the Uptake of Cigars

IMPORTANCE

Almost two-thirds of adolescents who smoke blunts also report using cigars. Although adolescent co-use of blunts and cigars is prevalent, whether adolescent blunt use is associated with progression to current cigar use (past 30-day use) and increased frequency of use is unknown.

OBJECTIVE

To determine whether adolescent use of blunts is associated with progression to cigar use (past 30-day use) and increased number of days used (in the past 30 days) across the subsequent 24 months compared with adolescents who have never used blunts.

DESIGN, SETTING, AND PARTICIPANTS

In this prospective cohort study of adolescents from 4 public high schools outside of Philadelphia, Pennsylvania, in-classroom surveys were administered at baseline (fall 2016, beginning of 9th grade) and at 6-month intervals for the following 24 months (fall 2018, beginning of 11th grade). Data analyses were conducted in September and October 2019.

EXPOSURES

Self-report of lifetime (ever) blunt use at baseline (age 14 years).

MAIN OUTCOMES AND MEASURES

Progression to current cigar use (use in the past 30 days) and escalation in the frequency of use (number of days used in the past 30 days) across the subsequent 24 months.

RESULTS

Of 1825 participants, 907 (49.7%) were female, 1330 (72.9%) were white, and 376 (20.6%) were Hispanic; the mean (SD) age at baseline was 14.38 (0.55) years. In all, 257 participants (14.0%) reported ever blunt use. Mixed-effects models revealed that ever blunt use at baseline vs never blunt use was associated with progression to current cigar use (past 30 days use: odds ratio, 22.66; 95% CI, 11.34-45.27) but not escalation in the number of days used across the following 24 months (β = 0.13; 95% CI, -0.17 to 0.43).

CONCLUSIONS AND RELEVANCE

These findings highlight the risk that blunt use may pose for subsequent cigar use among adolescents. Policies and public health campaigns addressing marijuana as well as cigars will be important to reduce adolescent blunt use and cigar use.