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Suggested Citation:"Front Matter." National Academies of Sciences, Engineering, and Medicine. 2022. Premium Cigars: Patterns of Use, Marketing, and Health Effects. Washington, DC: The National Academies Press. doi: 10.17226/26421.
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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

images

THE NATIONAL ACADEMIES PRESS
Washington, DC
www.nap.edu

Suggested Citation:"Front Matter." National Academies of Sciences, Engineering, and Medicine. 2022. Premium Cigars: Patterns of Use, Marketing, and Health Effects. Washington, DC: The National Academies Press. doi: 10.17226/26421.
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THE NATIONAL ACADEMIES PRESS 500 Fifth Street, NW Washington, DC 20001

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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Printed in the United States of America

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.

Suggested Citation:"Front Matter." National Academies of Sciences, Engineering, and Medicine. 2022. Premium Cigars: Patterns of Use, Marketing, and Health Effects. Washington, DC: The National Academies Press. doi: 10.17226/26421.
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The National Academy of Sciences was established in 1863 by an Act of Congress, signed by President Lincoln, as a private, nongovernmental institution to advise the nation on issues related to science and technology. Members are elected by their peers for outstanding contributions to research. Dr. Marcia McNutt is president.

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Learn more about the National Academies of Sciences, Engineering, and Medicine at www.nationalacademies.org.

Suggested Citation:"Front Matter." National Academies of Sciences, Engineering, and Medicine. 2022. Premium Cigars: Patterns of Use, Marketing, and Health Effects. Washington, DC: The National Academies Press. doi: 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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Suggested Citation:"Front Matter." National Academies of Sciences, Engineering, and Medicine. 2022. Premium Cigars: Patterns of Use, Marketing, and Health Effects. Washington, DC: The National Academies Press. doi: 10.17226/26421.
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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.

Suggested Citation:"Front Matter." National Academies of Sciences, Engineering, and Medicine. 2022. Premium Cigars: Patterns of Use, Marketing, and Health Effects. Washington, DC: The National Academies Press. doi: 10.17226/26421.
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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

Suggested Citation:"Front Matter." National Academies of Sciences, Engineering, and Medicine. 2022. Premium Cigars: Patterns of Use, Marketing, and Health Effects. Washington, DC: The National Academies Press. doi: 10.17226/26421.
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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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Suggested Citation:"Front Matter." National Academies of Sciences, Engineering, and Medicine. 2022. Premium Cigars: Patterns of Use, Marketing, and Health Effects. Washington, DC: The National Academies Press. doi: 10.17226/26421.
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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:

Suggested Citation:"Front Matter." National Academies of Sciences, Engineering, and Medicine. 2022. Premium Cigars: Patterns of Use, Marketing, and Health Effects. Washington, DC: The National Academies Press. doi: 10.17226/26421.
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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.

Suggested Citation:"Front Matter." National Academies of Sciences, Engineering, and Medicine. 2022. Premium Cigars: Patterns of Use, Marketing, and Health Effects. Washington, DC: The National Academies Press. doi: 10.17226/26421.
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Suggested Citation:"Front Matter." National Academies of Sciences, Engineering, and Medicine. 2022. Premium Cigars: Patterns of Use, Marketing, and Health Effects. Washington, DC: The National Academies Press. doi: 10.17226/26421.
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Suggested Citation:"Front Matter." National Academies of Sciences, Engineering, and Medicine. 2022. Premium Cigars: Patterns of Use, Marketing, and Health Effects. Washington, DC: The National Academies Press. doi: 10.17226/26421.
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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,

Suggested Citation:"Front Matter." National Academies of Sciences, Engineering, and Medicine. 2022. Premium Cigars: Patterns of Use, Marketing, and Health Effects. Washington, DC: The National Academies Press. doi: 10.17226/26421.
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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.

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Suggested Citation:"Front Matter." National Academies of Sciences, Engineering, and Medicine. 2022. Premium Cigars: Patterns of Use, Marketing, and Health Effects. Washington, DC: The National Academies Press. doi: 10.17226/26421.
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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
Page xviii Cite
Suggested Citation:"Front Matter." National Academies of Sciences, Engineering, and Medicine. 2022. Premium Cigars: Patterns of Use, Marketing, and Health Effects. Washington, DC: The National Academies Press. doi: 10.17226/26421.
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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
Suggested Citation:"Front Matter." National Academies of Sciences, Engineering, and Medicine. 2022. Premium Cigars: Patterns of Use, Marketing, and Health Effects. Washington, DC: The National Academies Press. doi: 10.17226/26421.
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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
Suggested Citation:"Front Matter." National Academies of Sciences, Engineering, and Medicine. 2022. Premium Cigars: Patterns of Use, Marketing, and Health Effects. Washington, DC: The National Academies Press. doi: 10.17226/26421.
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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

___________________

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.

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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

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Suggested Citation:"Front Matter." National Academies of Sciences, Engineering, and Medicine. 2022. Premium Cigars: Patterns of Use, Marketing, and Health Effects. Washington, DC: The National Academies Press. doi: 10.17226/26421.
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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.

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The early to mid-1990s saw a large surge in U.S. cigar consumption, including premium cigars. Based on recent import data, premium cigar use may be increasing, though they currently make up a small percent of the total U.S. cigar market. Premium cigars have also been the subject of legal and regulatory efforts for the past decade. In 1998, the National Cancer Institute undertook a comprehensive review of available knowledge about cigars - the only one to date. The resulting research recommendations have largely not been addressed, and many of the identified information gaps persist. Furthermore, there is no single, consistent definition of premium cigars, making research challenging.

In response, the Food and Drug Administration (FDA) and the National Institutes of Health commissioned the National Academies of Sciences, Engineering, and Medicine to convene a committee of experts to address this issue. The resulting report, Premium Cigars: Patterns of Use, Marketing, and Health Effects, includes 13 findings, 24 conclusions, and nine priority research recommendations and assesses the state of evidence on premium cigar characteristics, current patterns of use, marketing and perceptions of the product, and short- long-term health effects.

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