Cigar1 products exist on a spectrum with overlapping characteristics, with no clear distinction separating “premium”2 from other types. Premium cigars currently have a different pattern of use than other cigar products and therefore result in different health effects. However, premium cigars are not inherently less risky than other cigars. As discussed in Chapters 2 and 5, all cigars contain harmful and potentially harmful constituents, and the extent to which they negatively affect health largely depends on how they are used (e.g., frequency and duration, pattern of inhalation).
Since the comprehensive National Cancer Institute (NCI) monograph on cigars (NCI, 1998), little has changed regarding the state of knowledge on premium cigar characteristics or health effects. Some studies have expanded our knowledge about cigar characteristics or reinforced the findings and conclusions from the monograph regarding health effects. However, the monograph identified many research gaps that still exist today, such as the lack of data to fully understand how cigars, includ-
1 Note that 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.
2 Note that quotations are used at the first occurrence of the term “premium” in each chapter, as there is no formally agreed upon definition of what constitutes a premium cigar, and different entities might use this term differently. See Chapter 1 for more information.
ing premium cigars, are used by consumers. To advance the field, comparisons to other cigar types are needed; therefore, the committee offers priority recommendations that will advance knowledge of cigars as a whole—not only premium cigars.
Premium cigars have a small share of the cigar market compared to other types. Current evidence suggests that they are less likely to be used by youth, and most users smoke them only occasionally, rather than daily. However, these patterns of use could change due to factors that include changes in marketing, consumer awareness, or prices; taxes, or regulations of one or more tobacco products; or social shifts that result in a preference for premium cigars. A greater understanding of premium cigars’ physical characteristics, patterns of use, user perceptions, tobacco industry marketing strategies, and health effects will aid comparison over time and inform regulation. The committee identified many research gaps for premium cigars, and cigars in general, as highlighted in this report. This chapter provides nine priority recommendations that the federal government3 should support to advance the field, based on the report’s findings, conclusions, and research gaps.
It is important to consider why the prevalence of premium cigar use is lower than for other cigars and tobacco products. Many of the characteristics that distinguish them from other cigar types are affected by tobacco control policies (see Chapter 1 for the committee’s definition of a premium cigar). For example, when access to a tobacco product is restricted (due to tobacco control policies, manufacturer’s decisions, or retailer and consumer preferences [e.g., manufacturers could reduce the weight and/or price of the product]) and it is only available in limited locations, its use is generally lower. Premium cigars are not as widely available for purchase as other cigar types or tobacco products. In most definitions (see Chapter 1 Annex), including the committee’s for the purpose of this report, premium cigars do not have any added flavors, and restrictions (including bans) on flavors and menthol are a proven public health strategy to decrease tobacco product use. Premium cigars are also larger than other types and can take up to 2 hours to smoke. They have a considerably higher price point than other cigar types or tobacco products, and increasing taxes and prices are also known public health strategies to decrease use. However, all combustible tobacco products are inherently harmful if used as expected (i.e., burned and smoked) (see Chapters 2 and 5). Additionally, the tobacco industry also often changes products based on regulations and consumer preferences. If one or more premium cigar characteristics change (e.g., size, weight, price, added fla-
3 The committee was only asked in its statement of task to provide recommendations to federal agencies.
vor) and thus they become more appealing or easy to access, it is plausible that they would be used by a wider population and/or more frequently by the people who already use them.
Health equity is an important consideration for all public health issues (NASEM, 2017). While premium cigar users are largely adult, white, male, and of higher socioeconomic status (SES), users of other cigar types are more likely to smoke cigarettes, be of lower SES, be female, be young, be from racialized and ethnic populations groups, and have comorbid health (including mental health) conditions (Anderson, 2011; NCI, 2008; Rising and Alexander, 2011; Yerger et al., 2007). Targeted marketing of other tobacco products increased use in these populations; it is therefore possible that premium cigar marketing efforts could shift the demographics of users. It remains critical to balance the relative importance of premium cigars compared to other cigar types and other tobacco products in health equity research and interventions, given important disparities in use of nonpremium cigars (NCI, 2017).
To develop its research recommendations, the committee identified key research needs in each of the areas it was tasked with exploring—product characteristics, patterns of use, marketing and perceptions, and health effects. The committee reviewed the research gaps, which can be found in each chapter, and considered the following criteria in prioritizing them:
- public health impact,
- disease burden,
- health equity,
- implementation considerations (including feasibility, cost-effectiveness, time frame, measurability, and scalability),
- relevance to Food and Drug Administration (FDA) regulation,
- alignment with other research efforts, and
- whether the results would change the field’s understanding of the health effects and/or patterns of use of premium cigars.
The committee ranked these needs via a voting process, informed by the above criteria. and identified four high-priority recommendations and five additional priority recommendations based on the findings, conclusions, and key research gaps identified throughout this report.
Definition of Premium Cigars
This report repeatedly points to the lack of formal definitions for not only premium cigars but also other cigar types. This has significantly hindered the research, with studies using a range of different definitions and terms (e.g., cigars on the larger end of the size spectrum are referred to as “large,” “traditional,” and “premium,” with large or traditional typically including premium). In addition, evidence is limited on consumers’ awareness of each type, the terms consumers use to describe each type, and its congruency with researchers’ nomenclature and operationaliza-tion of those types.
Recommendation 1: The Food and Drug Administration, in consultation with other federal agencies, should develop formal categories and definitions for cigars to be used for research to ensure consistency among studies.
These definitions should be, in part, informed by consumers’ use and experience with the products. Having standard definitions will advance research in many ways. For example, distinguishing premium cigars will help researchers capture awareness of them in the U.S. population and knowledge of the health risks associated with their use, track patterns of use (including when new regulations are implemented), and better assess health effects over time. As discussed in Chapter 4, the term “premium” itself has connotations about the products it represents (e.g., luxury) and can influence perceptions and use. These definitions could also be used for regulatory purposes.
When developing the definition, it will be important to consider that the weights of premium cigars reviewed in this report are much higher than the typically cited threshold of 6 pounds per 1,000 units. Moreover, other cigar types also commonly meet this criterion. Because this threshold is used in many definitions of premium cigars, the weight criterion merits re-examination, as it might need to be increased to be consistent with the current marketplace.
Experience with other tobacco products (e.g., e-cigarettes) has demonstrated that as definitions are delineated, new products arise that no longer fit into existing definitions. In addition, tobacco products are also sometimes altered to meet the definition or category of another product (e.g., small and large cigar weight as a category for tax purposes is a good example of tobacco industry success in adjusting to categories defined by government agencies—see Chapter 1 for more information). Furthermore, products can change for other reasons, such as advances in technology
(e.g., 3-D printing of biological substances), which could change both the health effects and the price of the product. Therefore, it is important that in addition to using consistent definitions for research purposes, as recommended by the committee, a series of product design criteria (e.g., length, weight, circumference, tobacco weight, tobacco type, flavors, filters) also be identified and reported consistently in all research studies so that as products evolve, they can still be characterized and compared. Lastly, these research definitions could be adapted for other purposes, such as regulation, but important factors that were not the focus of the committee’s deliberations need to be taken into account, such as the response of industry and consumers to any regulatory definition.
Strategic Planning and Data Collection
The 1998 NCI monograph identified significant gaps in data on cigar use and evaluation of cigars and made recommendations for improvement. Since that time, no coordinated federal surveillance and evaluation infrastructure has been established to support regular monitoring and tracking related to different cigar types. To conduct research on premium cigars and compare among cigar types, infrastructure to collect relevant data for cigars overall is needed.
Recommendation 2: The Department of Health and Human Services, in partnership with the Alcohol and Tobacco Tax and Trade Bureau and the Federal Trade Commission (FTC), should implement a strategic plan to develop surveillance and evaluation systems that regularly monitor patterns of use, product characteristics, and related knowledge and perceptions by cigar type. These systems should also measure exposure to cigar smoke; track health outcomes; monitor tobacco industry marketing and promotion strategies; track sales and marketing expenditures; track cigar prices by cigar type; make data available; and define other indicators of monitoring to inform public health research and practice. These efforts should include but are not limited to
- Agreed-upon definitions of each cigar type (see Recommendation 1), and
- Development of annual FTC sales and marketing expenditure reports on all cigar product types, as is done for cigarettes, smokeless tobacco, and electronic cigarettes.
Including all cigar types in this strategic plan will allow for comparisons in these areas over time—what the marketplace looks like today could change in the future. This recommendation will likely require funding from Congress; however, a similar structure is already in place for
cigarettes and smokeless tobacco.4 Parts of this recommendation can be implemented in the short term—for example, item b, which calls for annual FTC sales and marketing expenditure reports. Industry could be an important source for these data. This information will allow FDA to better assess how changes in policies (e.g., taxation) and regulation of premium cigars and other tobacco products could change use patterns.
This monitoring and tracking related to different cigar types would fill important information gaps on cigar use. Study participants have been classified based on relatively recent use (e.g., past 30 days) of each type of cigar, which may underestimate the total number of users, particularly for products not used daily or frequently, as is the case for premium cigars. Moreover, researchers, and the committee, relied on self-reported preferred brand data to classify large cigar users as premium or nonpremium, which may also underestimate the total users. Collecting data on the environments where premium cigars are smoked (e.g., homes, cigar lounges, outdoors), including by whom and smoking duration, will allow researchers to determine the real-life exposures to secondhand smoke, an area with a paucity of data. Given the potential seasonal and geographic variation in premium cigar use, including paradata (administrative data about the survey) could facilitate a better understanding of such potential variations and their implications for interpreting prevalence estimates.
Recommendation 3: The Department of Health and Human Services should ensure that the tobacco research it supports, including surveys such as the Population Assessment of Tobacco and Health Study, the Tobacco Use Supplement to the Current Population Survey, and the National Survey on Drug Use and Health:
- Measures ever use, ever regular use, and past 12-month use to better capture lifetime use of each type of cigar product.
- Asks participants about use of premium cigars, employing commonly used terminology (e.g., “Have you ever smoked premium cigars?”) in addition to asking about brands used.
- Asks participants about self-reported inhalation patterns, how cigars are typically smoked (e.g., in one session or partial/relighting), and where cigars are smoked (e.g., indoors at home) to assess secondhand smoke exposure.
- Includes paradata (administrative data about the survey), such as survey date and geographic location in publicly available datasets to improve understanding of patterns of use and/or exposure.
4 See, for example, https://www.ftc.gov/reports/federal-trade-commission-cigarette-report-2020-smokeless-tobacco-report-2020 (accessed November 10, 2021).
Most studies on health effects do not distinguish premium from nonpremium cigars (they may include premium cigars, other large cigars, little cigars, or cigarillos). Studies that distinguish premium from nonpremium cigar use would better isolate the health effects of premium cigar smoking. Since co-use of premium cigars is more likely for alcohol than any other substance (e.g., co-use of cannabis was low; see Chapter 3 for detailed analysis) and co-use of alcohol with tobacco products is directly related to cancer risk, data on alcohol use should be routinely collected.
Recommendation 4: The Food and Drug Administration (FDA), the National Institutes of Health, and other federal agencies should ensure that the research they support on the associations between cigar, including premium cigar, use and health effects
- Reports the frequency of use, duration, intensity, cumulative exposure, pattern of inhalation, and the number of years smoking cigars to inform potential dose–response relationship and modifying factors (e.g., co-use of alcohol, cannabis, and other substances);
- Distinguishes primary, secondary, and dual use cigar smokers;
- Examines co-use of alcohol and premium cigars;
- Estimates the associations between cigar use and specific lung cancer histological types;
- Includes questions on the type of cigar, including premium cigars, separated from large cigars and other cigar types; and
- Uses the definitions of cigar types provided by FDA (see Recommendation 1).
Methods are available to analyze harmful and potentially harmful constituents in premium cigar tobacco, but developing standardized conditions for quantifying the components of premium cigar smoke and executing studies on these components is a research priority.
Recommendation 5: To improve knowledge of premium cigar characteristics, the Food and Drug Administration, the National Institutes of Health, the Centers for Disease Control and Prevention, and other federal agencies should support
- The development of reproducible methods for machine smoking of premium cigars;
- Laboratory studies to measure nicotine, toxicants, and carcinogens in tobacco and smoke emitted from premium cigars;
- Studies to assess how the pH of premium cigar smoke affects puff topography and extent of inhalation;
- Comparative biomarker studies, both of toxicant exposure and of potential harm, in smokers of premium, large, and other cigar type smokers;
- Studies that precisely measure “real-life” puff topography and patterns of use;
- Studies that systematically evaluate how various premium cigar characteristics (e.g., size, shape, type of tobacco, added flavoring, sugar content, moisture, smoke pH) affect puffing topography; and
- Observational studies to assess patterns and intensity of secondhand smoke exposure to premium cigar smoke.
In studies of the impact of cigar pH, measurements should include nicotine absorption in premium cigar users. When studying premium cigar characteristics and users over time, the studies should examine use patterns, puffing topography, inhalation, relighting, and transitions. Studies of secondhand smoke exposure should include nonsmokers who may be regularly exposed to secondhand smoke from premium cigars (e.g., employees at cigar lounges).
Marketing and Perceptions
As noted in NCI Monograph 19, promotional activities for any tobacco product can normalize its use and increase its consumption, especially among new users (such as youth, young adults, and women) (NCI, 2008). Given the lack of research in this area for premium cigars, the committee recommends:
Recommendation 6: The Food and Drug Administration (FDA), the National Institutes of Health (NIH), and other federal agencies should conduct or fund research to determine the unique type of marketing, advertising, and promotional practices used by compa
nies that manufacture, distribute, and sell premium cigars. FDA, NIH, and other federal agencies should also identify strategies for tracking these activities, especially those that may appeal to youth.
This research should include studies to examine:
- The various environmental (e.g., print and online media and platforms, social events, bars, lounges, etc.) and interpersonal channels (e.g., industry representatives, peers, online users, etc.) used to promote premium cigars;
- Premium cigar message effects, their framing, formatting, construction, and reach to better understand how they interact with audience characteristics (e.g., age, gender, race/ethnicity, socioeconomic background) to influence behavior;
- Advertising and audience segmentation practices that aim to recruit new users (including smokers who do not use premium cigars) versus advertising practices that target existing premium cigar users;
- If manufacturers are selling premium and large cigars in the same market, whether they are differentially marketed, and, if so, how; and
- Consumer cognitions, perceptions, and beliefs about advertising content, and how this content influences their motivation to use premium cigars and potentially other tobacco products.
Little is known about the addiction and addiction potential of premium cigars and how they compare to other cigar types. Premium cigars have nicotine levels similar to (or higher than) other cigars and conventional cigarettes. Premium and nonflavored cigars may also have similar sensorimotor characteristics that contribute to addiction potential (see Chapter 5). For these reasons, the conceptual and biological plausibility that premium cigars can be addiction promoting cannot be ruled out, given a sufficient level of exposure. However, more research is needed.
Recommendation 7: The Food and Drug Administration (FDA), the National Institutes of Health, and other federal agencies should support research that
- Provides data on the level of dependence in relation to patterns of premium and other cigar type use;
- Measures dependence on cigars and other tobacco products in dual and/or poly-tobacco users;
- Compares dependence on large cigars with flavors to dependence on premium cigars (which, by definition in this report, do not include flavors); and
- Studies the impact on dependence of reduced nicotine content in cigars, per proposed FDA policy to reduce nicotine to 0.4 mg/g for all cigarettes, to make them minimally addictive.
Regarding item d, FDA has issued an advance notice of proposed rule making that would require tobacco companies to lower the nicotine content in all cigarettes sold in the United States to levels at which they are no longer addictive (FDA, 2018). If this regulation progresses and cigars are excluded or other cigar types are included but premium cigars are not, premium cigars would provide an alternative source of nicotine for cigarette and cigar users, most likely resulting in significant changes in use patterns and undermining the aim of reducing the addictiveness of combusted tobacco products.
The literature about the health effects of large and premium cigars on specific populations has significant gaps; however, additional research is a high priority in certain areas.
Recommendation 8: The Food and Drug Administration, the National Institutes of Health, and other federal agencies should support research on the comparative health effects of cigar types, including premium cigars, in priority populations (as needed based on prevalence and trends), including
- Women, racialized and ethnic populations, sexual and gender minority groups, adolescents/young adults, and during pregnancy, including studies on the impact on nondaily users of cigars;
- People with vascular disease, including assessments of their cardiovascular risk, as this population would be especially vulnerable to the adverse effects of acute short-term smoke exposure;
- People with respiratory diseases, such as chronic obstructive pulmonary disease and asthma;
- Cancer survivors; and
- People with occupational exposures to premium cigars (e.g., in cigar lounges, manufacturing).
While it will be challenging to implement this recommendation, especially the first item (due to finding appropriate sample sizes), that does not obviate the need to obtain the best data possible for these populations over time.
Consumer Perceptions and Knowledge
As discussed in Chapter 4, no research examines whether consumers distinguish premium cigars from large cigars or other cigar types, their knowledge of what premium cigars are, what defines them, or their knowledge of specific health effects.
Recommendation 9: The Food and Drug Administration, the National Institutes of Health, and other federal agencies should support research to assess consumer knowledge and awareness of premium cigars in the U.S. population. Specifically, these studies should
- Develop and implement specific measures that capture awareness of premium cigars as a tobacco product category, perceived risks and benefits of using premium cigars, and knowledge of the risks of premium cigar use; and
- Gather data regarding consumer knowledge about different cigar types and how, why, and where people start, continue, and discontinue using premium cigars (including perceived benefits and harms).
The committee reviewed four premium cigar topics in this report: product characteristics, patterns of use, marketing and perceptions, and health effects. While research on premium cigars specifically is largely lacking, the committee drew conclusions in many areas based on studies on other cigar types, biological plausibility, and the absence of important threats to validity. The committee identified nine research priorities directed to federal agencies to expand the evidence on premium cigars and cigars in general. If implemented, these recommendations will result in better understanding premium cigar use (and cigar use overall), marketing practices and consumer perceptions, and health effects over time to inform evidence-based policies, programs, and regulations.
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