Premium
CIGARS
Patterns of Use,
Marketing, and
Health Effects
Steven M. Teutsch, Amy B. Geller, and Aimee M. Mead, Editors
Committee on Patterns of Use and Health Effects of
“Premium Cigars” and Priority Research
Board on Population Health and Public Health Practice
Health and Medicine Division
A Consensus Study Report of
THE NATIONAL ACADEMIES PRESS
Washington, DC
www.nap.edu
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This activity was funded in whole with federal funds from the National Institutes of Health and the Food and Drug Administration, Department of Health and Human Services, under contract/task order number HHSN263201800029I/75N98 020F00022. Any opinions, findings, conclusions, or recommendations expressed in this publication do not necessarily reflect the views of any organization or agency that provided support for the project.
International Standard Book Number-13: 978-0-309-09106-0
International Standard Book Number-10: 0-309-09106-3
Digital Object Identifier: https://doi.org/10.17226/26421
Library of Congress Catalog Number: 2022935876
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Suggested citation: National Academies of Sciences, Engineering, and Medicine. 2022. Premium cigars: Patterns of use, marketing, and health effects. Washington, DC: The National Academies Press. https://doi.org/10.17226/26421.
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Consensus Study Reports published by the National Academies of Sciences, Engineering, and Medicine document the evidence-based consensus on the study’s statement of task by an authoring committee of experts. Reports typically include findings, conclusions, and recommendations based on information gathered by the committee and the committee’s deliberations. Each report has been subjected to a rigorous and independent peer-review process and it represents the position of the National Academies on the statement of task.
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COMMITTEE ON PATTERNS OF USE AND HEALTH EFFECTS OF “PREMIUM CIGARS” AND PRIORITY RESEARCH
STEVEN M. TEUTSCH (Chair), Adjunct Professor, University of California, Los Angeles; Senior Scholar, University of Southern California Leonard D. Schaffer Center for Health Policy and Economics
WEI BAO, Assistant Professor, Epidemiology, College of Public Health, University of Iowa1
NEAL BENOWITZ, Professor Emeritus of Medicine, Zuckerberg San Francisco General Hospital, University of California San Francisco
CRISTINE D. DELNEVO, Director, Rutgers Center for Tobacco Studies, Rutgers University; Professor, Department of Health Behavior, Society & Policy, Rutgers School of Public Health
PEBBLES FAGAN, Professor, Department of Health Behavior; Health Education Director, Center for the Study of Tobacco, Fay W. Boozman College of Public Health, University of Arkansas for Medical Sciences
MACIEJ GONIEWICZ, Professor, Nicotine and Tobacco Product Assessment Resource (NicoTAR), Roswell Park Comprehensive Cancer Center
STEPHEN S. HECHT, Wallin Professor of Cancer Prevention, University of Minnesota
MIRANDA R. JONES, Assistant Professor, Epidemiology, Bloomberg School of Public Health, Johns Hopkins University
GRACE KONG, Assistant Professor, Department of Psychiatry, Yale School of Medicine
ADAM LEVENTHAL, Director, USC Institute for Addiction Science; Professor, Preventive Medicine and Psychology, Keck School of Medicine, USC Norris Comprehensive Cancer Center, University of Southern California
DARREN MAYS, Associate Professor, Department of Internal Medicine, College of Medicine; Center for Tobacco Research, Comprehensive Cancer Center, The Ohio State University
RAFAEL MEZA, Professor, Department of Epidemiology, School of Public Health, University of Michigan
___________________
1 Resigned from the committee on August 20, 2021.
KYMBERLE LANDRUM STERLING, Associate Professor, Health Promotion and Behavioral Sciences, School of Public Health—Dallas Campus, University of Texas Health Sciences Center
ANDREA VILLANTI, Associate Professor, Psychiatry, University of Vermont Larner College of Medicine
Study Staff
AMY GELLER, Study Director
AIMEE MEAD, Associate Program Officer
SOPHIE YANG, Research Associate (until January 2022)
MAGGIE ANDERSON, Research Assistant (from September 2021)
HARIKA DYER, Research Assistant (until July 2021)
GABRIEL E. AGU, Senior Program Assistant (from January 2022)
KATHLEEN STRATTON, Scholar
MISRAK DABI, Finance Business Partner
ROSE MARIE MARTINEZ, Senior Board Director
Y. CRYSTI PARK, Administrative Assistant
TASHA BIGELOW, Editor, Definitive Editing
Consultants
JULIA CHEN-SANKEY, Assistant Professor, Rutgers Center for Tobacco Studies, Rutgers University; Department of Health Behavior, Society & Policy, Rutgers School of Public Health
NICHOLAS FRANCO, Research Assistant II, Yale School of Medicine
OLLIE GANZ, Instructor, Rutgers Center for Tobacco Studies, Rutgers University; Department of Health Behavior, Society & Policy, Rutgers School of Public Health
JEREMY GIBERSON, Clinical Research Coordinator, University of California, San Francisco
JIHYOUN JEON, Associate Research Scientist, University of Michigan
AMANDA KONG, Assistant Professor, University of Oklahoma Health Sciences Center
MICHELLE T. BOVER MANDERSKI, Instructor, Rutgers Center for Tobacco Studies, Rutgers University; Department of Biostatistics & Epidemiology, Rutgers School of Public Health
YOONSEO MOK, Research Area Specialist, University of Michigan
SUNNY NAM, Intern, Yale School of Medicine
MICHELLE PAGE, Research Associate, Roswell Park Comprehensive Cancer Center
JONATHAN A. SCHULZ, Postdoctoral Fellow, Vermont Center on Behavior and Health, Department of Psychiatry, University of Vermont
SARAH SKOLNICK, Research Assistant, University of Michigan
CHARIS TANG, Intern, University of Texas Health Science Center at Houston
SCOTT TOMAR, Professor and Associate Dean for Prevention and Public Health Sciences, University of Illinois Chicago College of Dentistry
SUNDOS YASSIN, Clinical Research Supervisor, University of California, San Francisco
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Reviewers
This Consensus Study Report was reviewed in draft form by individuals chosen for their diverse perspectives and technical expertise. The purpose of this independent review is to provide candid and critical comments that will assist the National Academies of Sciences, Engineering, and Medicine in making each published report as sound as possible and to ensure that it meets the institutional standards for quality, objectivity, evidence, and responsiveness to the study charge. The review comments and draft manuscript remain confidential to protect the integrity of the deliberative process.
We thank the following individuals for their review of this report:
Although the reviewers listed above provided many constructive comments and suggestions, they were not asked to endorse the conclusions or recommendations of this report nor did they see the final draft before its release. The review of this report was overseen by Linda C. Degutis, Yale School of Public Health, and David A. Savitz, Brown University. They were responsible for making certain that an independent examination of this report was carried out in accordance with the standards of the National Academies and that all review comments were carefully considered. Responsibility for the final content rests entirely with the authoring committee and the National Academies.
3 PATTERNS OF USE AND PREVALENCE OF CIGARS
Prevalence and Trends of Premium Cigars versus Other Cigar Types and Cigarettes
Co-Use of Premium Cigars with Other Tobacco Products or Substances
Transitions in Cigar Use and Other Tobacco Products
Key Research Gaps and Findings
4 CIGAR MARKETING AND PERCEPTIONS
Awareness, Knowledge, and Beliefs
Chapter 4 Annex: Evidence Tables
5 HEALTH EFFECTS OF PREMIUM CIGARS
Health Effects of Exposure to Harmful and Potentially Harmful Constituents of Cigar Smoke
Health Effects of Premium Cigars
Lung Cancer and Respiratory Disease
Periodontal Diseases and Cancers of the Oral Cavity, Head, and Neck
Health Effects: Summary and Conclusions
Differences by Sociodemographic Characteristics
Potential Health Implications of Flavorings in Premium Cigars
Additional Priority Recommendations
B OVERVIEW OF LITERATURE SEARCH
C CROSS-SECTIONAL PATTERNS OF CIGAR USE BY TYPE IN THE NATIONAL SURVEY ON DRUG USE AND HEALTH
D CROSS-SECTIONAL PATTERNS AND LONGITUDINAL TRANSITIONS OF CIGAR USE BY TYPE IN THE PATH STUDY
E CIGAR BRANDS FROM PATH AND NSDUH ANALYSES
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Acknowledgments
The committee wishes to thank and acknowledge the many individuals and organizations that contributed to the study process and development of this report. To begin, the committee would like to thank the Food and Drug Administration (FDA) and National Institutes of Health (NIH)—the study sponsors—for their support of this work.
The committee found the perspectives of many individuals and groups immensely helpful in informing its deliberations through presentations and discussions that took place at the public meetings. Speakers provided presentations on the state of tobacco science and policy and consumer perspectives: Benjamin Apelberg, David L. Ashley, Benjamin Blount, Ann Boonn, Benjamin Chaffee, Mike Copperman, K. Michael Cummings, Neal D. Freedman, Mia Hashibe, Dennis A. Henigan, Bartosz Koszowski, Joelle M. Lester, Thomas Lindegaard, Gerald Long, Drew Newman, Scott Pearce, Barry S. Schaevitz, Barbara Schillo, Richard Voith, and Clifford Watson. The committee also appreciated feedback from individuals on the research questions provided to the committee by FDA and NIH and at its public comment sessions: Ann Boonn, Mike Copperman, Stacy Gagosian, Joshua Harbursky, Hasmeena Kathuria, and Ranjana Kodwani, and Drew Newman.
The committee’s work was enhanced by the technical expertise, writing contributions, data evaluation, and other support provided by Julia Chen-Sankey, Nicholas Franco, Ollie Ganz, Jeremy Giberson, Jihyoun Jeon, Amanda Kong, Michelle T. Bover Manderski, Yoonseo Mok, Sunny Nam, Michelle Page, Jonathan A. Schulz, Sarah Skolnick, Charis Tang,
Scott Tomar, and Sundos Yassin, who served as consultants. The committee also received valuable assistance from Evelyn Jimenez-Mendoza, Noel Leigh, Eric Claus, and Megan Schroeder.
The committee thanks the National Academies of Sciences, Engineering, and Medicine staff who contributed to producing this report, especially the extraordinary, creative, and tireless study staff Amy Geller, Aimee Mead, Sophie Yang, Maggie Anderson, Harika Dyer, Crysti Park, Gabriel E. Agu, Kathleen Stratton, and Rose Marie Martinez. The committee thanks the Health and Medicine Division communications staff, including Devona Overton, Esther Pak, and Marguerite Romatelli. This project received valuable assistance from Stephanie Miceli (Office of News and Public Information); Misrak Dabi (Office of Financial Administration); and Clyde Behney, Monica Feit, Tina Seliber, Lauren Shern, Leslie Sim, and Taryn Young (Health and Medicine Division Executive Office). The committee received important research assistance from Christopher Lao-Scott, Senior Librarian (National Academies Research Center), including compiling the literature review details in Appendix B.
Finally, the National Academies staff offers thanks to committee members’ executive assistants and support staff, without whom scheduling the multiple meetings and conference calls would have been nearly impossible: April Norambuena and Carol Rayside.
Acronyms and Abbreviations
| aOR | adjusted odds ratio |
| APA | Administrative Procedure Act |
| BaP | benzo[a]pyrene |
| BC | bladder cancer |
| CAL | clinical attachment loss |
| CEJ | cemento-enamel junction |
| CI | confidence interval |
| CIR | Canadian intense regimen |
| CO | carbon monoxide |
| COPD | chronic obstructive pulmonary disease |
| CORESTA | Cooperation Centre for Scientific Research Relative to Tobacco |
| CPS | Current Population Survey |
| CTP | Center for Tobacco Products |
| CVD | cardiovascular disease |
| DTC | direct-to-consumer |
| ENDS | electronic nicotine delivery systems |
| EPIC | European Prospective Investigation into Cancer and Nutrition |
| ETS | environmental tobacco smoke |
| FDA | Food and Drug Administration |
| FEV1/FVC | forced vital capacity |
| FTC | Federal Trade Commission |
| GC-MS | gas chromatography-mass spectrometry |
| GEE | general estimating equation |
| HPHCs | harmful and potentially harmful constituents |
| HR | hazard ratio |
| IARC | International Agency for Research on Cancer |
| IRR | incidence rate ratio |
| ISO/FTC | International Organization for Standardization/U.S. Federal Trade Commission |
| LC-MS | liquid chromatography-mass spectrometry |
| LGB | lesbian, gay, and bisexual |
| MDE | major depressive episode |
| MRTP | modified risk tobacco product |
| NATS | National Adult Tobacco Survey |
| NCI | National Cancer Institute |
| NHANES | National Health and Nutrition Examination Survey |
| NHIS | National Health Interview Survey |
| NHL | non-Hodgkin’s lymphoma |
| NIH | National Institutes of Health |
| NLMS | National Longitudinal Mortality Study |
| NNAL | 4-(methylnitrosamino)-1-(3-pyridyl)-1-butanol |
| NNK | 4-(methylnitrosamino)-1-(3-pyridyl)-1-butanone |
| NNN | N’-nitrosonornicotine |
| NSDUH | National Survey on Drug Use and Health |
| OR | odds ratio |
| PAH | polycyclic aromatic hydrocarbons |
| PATH | Population Assessment of Tobacco and Health Study |
| PCA | Premium Cigar Association |
| RR | relative risk |
| RYO | roll-your-own |
| SD | standard deviation |
| SES | socioeconomic status |
| SHS | secondhand tobacco smoke |
| SPD | serious psychological distress |
| TDS | tobacco dependence score |
| TTB | Alcohol and Tobacco Tax and Trade Bureau |
| TUS | Tobacco Use Supplement |
| TUS-CPS | Tobacco Use Supplement to the Current Population Survey |
| UADT | upper aerodigestive tract |
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Abstract
At the request of the Food and Drug Administration (FDA) and the National Institutes of Health, the National Academies of Sciences, Engineering, and Medicine (NASEM) convened an expert committee to examine four premium cigar topics: product characteristics, patterns of use, marketing and perceptions, and health effects. The resulting report includes 13 findings, 24 conclusions, and nine priority research recommendations for federal support.
Since the late 1990s, overall cigar1 consumption has increased every year, with a total increase of 145 percent from 1998 to 2020. However, the committee found that premium cigars are consistently a small percent of the U.S. cigar market. Data from the Alcohol and Tobacco Tax and Trade Bureau suggest that the percentage of the cigar market that may be premium was 1.5–3.0 percent between 2010 and 2020. In addition, the committee found that 1 percent of the adult population uses premium cigars.
In 2016, FDA broadened its regulatory authority to include cigars. In 2018, FDA issued a call for additional information and comments on several aspects of premium cigars specifically, including the definition, patterns of use, and public health impacts, to further inform its regulatory actions. Since 2016, various cigar associations have filed several lawsuits against FDA regarding how it regulates cigars in general and premium
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1 When the terms “cigar(s)” or “cigars in general” are used in this report, they refer to all cigar types (filtered cigars, little cigars, cigarillos, and large/traditional cigars [which include premium cigars]). When discussing a specific cigar type, the type is noted in text.
cigars specifically; some are still ongoing. Members of Congress in both chambers have introduced legislation several times to exclude premium cigars from FDA regulation, most recently in June 2021.
There is not a single, consistent definition of premium cigars accepted by FDA, industry, courts, and the public. Consequently, there is no clear distinction between premium and large nonpremium cigars or even with other cigar types (e.g., filtered/little cigars and cigarillos). For the purposes of its work, the committee developed a working definition of premium cigars. The committee defined a premium cigar as having all of the following characteristics: (1) handmade, (2) filler composed of at least 50 percent natural long-leaf filler tobacco, (3) wrapped in whole leaf tobacco (i.e., not reconstituted tobacco), (4) weight of at least 6 pounds per 1,000 units, (5) no filters or tips, and (6) no characterizing flavor other than tobacco. The committee was not tasked with recommending a regulatory definition of a premium cigar. While other stakeholders may adopt or adapt the committee’s definition for other purposes, additional factors that the committee did not emphasize would need to be considered. For example, the tobacco industry has altered its products so that the products no longer fit existing regulatory definitions (or now meet the definition of a different tobacco product), and this factor was not a major consideration for the committee.
After reviewing the definitions of premium cigars used by different entities, the committee identified no material difference between products typically considered premium and other cigar types in terms of harmful or potentially harmful constituents. However, a meaningful difference currently exists in how products typically considered premium are used (e.g., frequency of use, depth of inhalation). The committee notes that tobacco products are inherently harmful, but their patterns of use are mutable, including how and by whom they are used, which ultimately determines their health effects.
The committee conducted a comprehensive literature search to identify publications on premium cigars. The literature on premium cigars specifically is limited, and most publications do not distinguish premium from other large cigars. With no agreed-upon definition of premium cigars, there is a lack of consistency regarding which brands are considered premium. In addition, study designs varied considerably (e.g., surveys and laboratory, epidemiologic, and toxicological studies). Because of the paucity of literature on premium cigars, studies of large, traditional cigars, cigars overall (including filtered cigars/little cigars and cigarillos), and other combustible tobacco products were included based on committee members’ assessment of the relevance and the potential generalizability of those studies’ findings to premium cigars. The committee also relied heavily on biological mechanisms and plausibility in its
framework, as well as threats to validity, particularly for the assessment of health effects. In addition, the committee commissioned several analyses to further inform its work.
The committee’s priority research recommendations for federal agencies include the following:
- Development of formal categories and definitions for all cigar types to be used for research to ensure consistency among studies;
- Implementation of a strategic plan to regularly monitor patterns of use, product characteristics, consumer knowledge and perceptions, and collection of sales and marketing data, among other data points;
- Improvement of survey data collection, such as measuring cigar ever use, ever regular use, and past 12-month use to better capture lifetime use of cigar products, and collecting data on self-reported inhalation patterns and how and when the cigars are smoked; and
- Research to assess specific aspects of premium cigars for:
- Cigar characteristics,
- Health effects (including priority populations),
- Addiction potential, and
- Marketing practices and consumer perceptions and knowledge.
If implemented, these recommendations will considerably advance the knowledge base of premium cigars and cigars in general and better inform policy and regulatory decisions.
