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¹ Note that quotations are used at 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.

² 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.

with the increasing popularity of cigarettes (NCI, 1998). By mid-century, events impacting the use of cigarettes, such as the first Surgeon General’s Report on Cigarette Smoking in 1964 and the Tobacco Control Act in 2009, which banned flavors in cigarettes but not cigars, often produced notable, concomitant changes in cigar consumption (for more information, see Delnevo et al., 2017b). For example, sales restrictions and price increases aimed at cigarettes often resulted in increases in cigar sales (however, when the discount market for cigarettes grew, little cigars lost their appeal).

As shown in Figure 3-1, large cigars have been the dominant cigar type (versus little cigars) for much of the last century, although a few notable spikes merit attention. First, sales of little cigars, which resemble cigarettes, quadrupled between 1971 and 1973 when the federal Public Health Cigarette Smoking Act banned cigarette ads on TV but allowed on-air marketing of little cigars (Delnevo and Hrywna, 2007). During this period, consumption of large cigars was declining annually. Both little and large cigar consumption began declining in the mid-1970s and reached the lowest annual level in 1993. However, in the late 1990s cigar consumption began to rise again, for the first time in decades. Many believe the revival of cigars was caused by the cigar lifestyle magazine Cigar Aficionado, along with endorsement of premium cigars by celebrity “connoisseurs” (see Chapter 4 for more on this topic) (Delnevo and Hrywna, 2007). Between 1993 and 1998 the fastest growing cigar product was the large cigar, increasing in consumption 66 percent. Little cigars soon became more prominent with an increase of 259 percent compared to 55 percent for large cigars between 1998 and 2008. In 2009 legislation expanded the State Children’s Health Insurance Program (S-CHIP), which increased taxes on cigarettes and little cigars. This increase caused the consumption of little cigars to decline 95 percent from 2008 to 2020, however, the consumption of large cigars increased almost 129 percent.³ This increase is almost exclusively due to little cigar manufacturers “converting” their products into heavier filtered cigars to take advantage of the lower federal excise tax on large cigars (Delnevo et al., 2017b; Wang et al., 2016). Despite this marked divergence in sales patterns, overall consumption has continued to make modest annual gains every year since the release of the National Cancer Institute’s (NCI’s) cigar monograph in 1998 (approximately 145 percent from 1998 to 2020).⁴

While actual consumption of premium cigars was not explicitly detailed in the 1998 NCI monograph (the only comprehensive review of cigars), it noted that according to the Maxwell Reports (a trade publica-

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³ Calculated using Alcohol and Tobacco Tax and Trade Bureau’s (TTB’s) data on taxable cigars, see Figure 3-1.

⁴ Calculated using TTB data on taxable cigars, see Figure 3-1.

tion that provides cigar sales data), from 1993 to 1996, premium cigars experienced greater growth than little or large cigars. As shown in Figure 3-2, data abstracted from the 1996, 2003, and 2012 Maxwell Reports highlight the increase in premium cigar consumption in the early 1990s, which peaked in 1997, but the reports’⁵ data suggest that premium cigars have made up a small percentage of the total cigar market since then. The last year of production of the Maxwell Report was 2017, with the last report released in early 2018.

This trend is further confirmed with Alcohol and Tobacco Tax and Trade Bureau (TTB) data, which can be used as a proxy for nonpremium and premium cigar consumption, with some caveats (TTB, 2019). For taxation purposes, large cigars (which include cigarillos) are reported in two groups, those with a pretax value below $763.222 per 1,000 units and those above; these groupings correspond with federal excise tax structures. Prior to 2003, these two groups were referred to as Classes A–G and Class H cigars, respectively⁶ (Treasury Department and ATF, 2002; TTB, 2011). While these designations are no longer used, historically, the cigar industry has referred to premium cigars as Class H (Hoyt, 2008), although all Class H cigars may not be premium (e.g., they could include machine-made cigars). Nonetheless, as shown in Table 3-1, these data are consistent with prior reports from the industry (e.g., Maxwell Reports) and others

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⁵ The Maxwell Report of the Cigar Industry defines premium cigars as (1) being hand-made; (2) made entirely of natural, long filler tobacco; and (3) retailing between $1 and $25 each.

⁶ Personal communication with T. Baston, Alcohol and Tobacco Tax and Trade Bureau on May 14, 2021. Available in the project’s public access file and upon request from the National Academies Public Access Records Office at PARO@nas.edu.

that premium cigars have made and continue to make up a small percentage of the U.S. cigar market. These findings are inconsistent with Soneji et al. (2021), which commingled the terms “premium” and “large” when examining cigar imports—and considered all large cigar imports, which are indeed growing over time, to be premium.

Figure 3-1 and Table 3-1 also show the dominance of large cigars over much of the past two decades. As illustrated in Chapter 2, the term “large cigars” is a misnomer, as it includes filtered cigars, most of which resemble cigarettes; mid-size cigarillos, with or without a plastic or wood tip; and larger traditional cigars. The products in this category are extremely diverse, varying in terms of size, flavorings, packaging, and tip styles (see Chapter 2 for more information). Sales data are useful to understand features that are driving growth in nonpremium or machine-made cigars. An analysis of convenience store sales data from 2008 to 2015 found that cigar sales increased 23 percent (Delnevo et al., 2017a, 2021). Moreover, sales of flavored cigars increased by nearly 50 percent during this period and, in 2015, they comprised more than half of the cigar market. Inexpensive two- and three-packs, which were rare in 2008, were 40 percent of the market share in 2015. Two brands, Black & Mild and Swisher Sweets, dominated the convenience store channel; they alone were nearly two out of every three cigars sold (Delnevo et al., 2017a, 2021).

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⁷ See https://pathstudyinfo.nih.gov (accessed November 10, 2021).

⁸ See https://nsduhweb.rti.org/respweb/homepage.cfm (accessed November 10, 2021).

⁹ See https://www.cdc.gov/tobacco/data_statistics/surveys/nats/index.htm (accessed November 10, 2021).

¹⁰ See https://cancercontrol.cancer.gov/brp/tcrb/tus-cps (accessed November 10, 2021).

¹¹ The PATH analysis focused on adults because premium cigar use is very limited in youth. The supplementary data for Appendix D provides data for young adults (18–34) and is available upon request from PARO@nas.edu. In Appendix D, the authors reported Wave 4 data because it provides truly nationally representative numbers (as does Wave 1). However, in this chapter, the committee reports Wave 5 data because it is the most recent. Data for Waves 2, 3, and 5 are provided in the Appendix D supplemental materials, available upon request from PARO@nas.edu.

acterize their use based on self-reported brand data to classify large cigar users as premium or nonpremium users (Corey et al., 2014, 2018; Delnevo et al., 2015). The few studies available in the literature reporting national prevalence estimates of premium cigar use in the United States rely on this approach (Corey et al., 2014, 2018), which was also adopted in the two commissioned papers. Most data reported in this section on patterns of use for premium cigars are based on this methodology.

TTB consumption data highlight that premium cigars make up a small percentage of the total cigar market; this trend has been fairly stable over time. This is consistent with PATH data, which show that premium cigar use among adults was 0.6–0.8 percent from 2013 to 2018. Likewise, according to NSDUH data, past 30-day use of premium cigars is low and similar to that found in PATH, despite differences in study design and sampling (see Figure 3-3; see Table 3-2 for the prevalence of tobacco use from selected national surveys and the committee’s commissioned work).

Demographics

Published analyses of PATH and NATS data highlight differences in the demographic characteristics of users of premium cigars, cigarillos or machine-made cigars, filtered cigars, and cigarettes (Corey et al., 2014, 2018). Premium cigar users are overwhelmingly male, older, white, and more affluent (i.e., higher education and income) compared to those who smoke cigarillos or little filtered cigars. Cigarillo users are younger, more likely to report being non-Hispanic Black, and have lower levels of education and/or income. Also, while cigarillo use was more common among men, it was not inconsequential among women. Compared to users of other types of cigars, filtered little cigar users were most likely to be female. Filtered cigar users are also older and have lower levels of education or income. Lastly, nearly half of current cigarette users are female, and the majority of them are older and have lower levels of education and income. Two recent studies examined the 2018–2019 TUS-CPS with respect to demographic correlates of cigar smoking, but neither addressed premium cigar use despite the availability of brand data. Phan et al. (2021) chose to collapse little cigars and cigarillo smoking into a single category, whereas Azagba et al. (2021) reported large cigars, cigarillos, and little cigars separately. Unsurprisingly, findings from both studies are similar, since they used the same dataset and are consistent with demographic patterns reported in PATH and NATS. The authors of both papers highlight that non-Hispanic Black adults, in particular non-Hispanic Black young adults (Phan et al., 2021), are more likely to smoke little cigars and cigarillos (Azagba et al., 2021).

who reported smoking a premium cigar brand in the past 30 days were under 18 (see Table 1, Appendix C). Additionally, very few premium cigar users (2.5 percent) in NSDUH identified as lesbian, gay, or bisexual—in contrast, 9.7 percent of nonpremium cigar users did so. This is consistent with NATS data showing that the prevalence of premium cigars as a usual cigar was greater among heterosexual than among lesbian, gay, and bisexual adults (Corey et al., 2014).

Frequency of Use

Current or Past 30-Day Use

Current or past 30-day use of cigars was 4.7 percent in the pooled 2010–2019 NSDUH analyses, and the majority of current cigar users reported a nonpremium brand. Overall, 0.9 percent of U.S. youth (aged 12–17) and adults reported current use of premium cigars (Bover Manderski et al., 2022). Past 30-day use of premium cigars was very rare (0.1 percent or less) among those under 18 and women. The prevalence of premium cigar use was higher (but still low) among men (1.7 percent), non-Hispanic white people (1.1 percent), adults aged 26–34 (1.4 percent), and college graduates (1.5 percent). Nonpremium cigar use was highest among young adults (7.5 percent), non-Hispanic Black people (6.5 percent), and those who identify as bisexual (6.3 percent). Youth nonpremium cigar use was 1.9 percent, with higher rates for boys (2.6 percent) than girls (1.2 percent) (Bover Manderski et al., 2022).

These patterns of use are consistent with those seen in data from PATH Waves 1–5 (Jeon and Mok, 2022). In particular, the prevalence of premium cigars in Wave 5 was 0.7 percent, in comparison with 0.5 percent for nonpremium cigars, 1.4 percent for cigarillos, 0.8 percent for filtered cigars, and 16.4 percent for cigarettes.

Despite limited data on youth and premium cigars, the findings from the NSDUH pooled analysis, are, unsurprisingly, consistent with analyses of 2010–2011 NSDUH data focused on flavored cigar use, where preference for premium cigar brands was rare for youth and more common for adults over the age of 25 (Delnevo et al., 2015).

Frequency, Intensity, and Duration of Use

In general, and in contrast to cigarette smoking, cigar use has historically been less frequent and referred to as an “occasional” behavior (NCI, 1998). In the NSDUH pooled analyses, for example, among all cigar users, 2 out of 3 reported smoking on 5 or fewer days in the 30 days preceding the survey, with 46 percent reporting they smoked only 1 or

2 days a month; only 1 out 10 cigar users report smoking daily (Bover Manderski et al., 2022). However, different patterns of use are noted for those who use premium versus nonpremium cigars. Among premium cigar users, 60.3 percent reported smoking on only 1 or 2 days in the 30 days preceding the survey compared to 38.1 percent of nonpremium cigar users. Moreover, frequent use (defined as 20 or more days in the past 30 days) was less common among premium (7.6 percent) compared to nonpremium (20.8 percent) users. Daily use was rare (3.5 percent) among premium cigar users, whereas 13.1 percent of nonpremium users reported daily use (Bover Manderski et al., 2022).

In the most recent PATH data (Wave 5), daily smoking was infrequent among premium cigar users (6.4 percent) but highest among filtered cigar users (42.1 percent percent), followed by cigarillo (22.7 percent) and nonpremium traditional cigars (14.1 percent) (Jeon and Mok, 2022). In comparison, daily cigarette smoking was frequent (75.5 percent). While the point estimates for daily smoking among cigar users by cigar type and among cigarette users varied slightly across all five waves, the relative daily smoking patterns between products were consistent across all waves (Jeon and Mok, 2022).

Likewise, the median number of days smoked in the past 30 days in Wave 5 was lowest for premium cigars (1 day), highest for filtered cigars (20 days), followed by cigarillos (5 days) and nonpremium traditional cigars (3 days) (Jeon and Mok, 2022). For comparison, the median number of days smoked for cigarettes was 30.¹² The median number of cigars smoked per day was 0.1 for premium cigars and nonpremium traditional cigars, 0.2 for cigarillos, and 1.7 for filtered cigars. The median number of cigarettes smoked per day was 10. While the estimates for number of days smoked and number of cigars or cigarettes smoked per day varied across the five waves, the lower frequency of use for premium versus other cigar types and cigarettes is consistent across all waves, suggesting that at least since 2013, the frequency and quantity of use for all cigar types has not notably changed (Jeon and Mok, 2022).

PATH Wave 5 data show that compared to cigarette and cigarillo users, premium cigar users were older at first regular use (median age was 25 compared to 17 for cigarette users and 19 for cigarillo users) (Jeon and Mok, 2022). They also had a shorter duration of use, a key determinant of health effects, since first regular use compared to cigarette users and nonpremium cigar users but a longer duration compared to cigarillo and filtered cigar users (median duration was 16, 19, 14, 10, and 26 years

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¹² The median was calculated using the methods by Corey et al. (2018): respondents reporting smoking less than one cigar per day on the days smoked were assigned as 0.5 cigars per day.

for premium cigar, nonpremium cigar, cigarillo, filtered cigar, and cigarette users, respectively) (Jeon and Mok, 2022).

Flavored Cigar Use

Flavors are common in the nonpremium cigar market (CounterTobacco.Org, n.d.; Delnevo et al., 2017a, 2021). One component of this report’s operational definition for premium cigars is that the cigar or brand does not have a characterizing flavor other than tobacco. A few brands, such as Acid, resemble premium cigars (they are large, handmade, wrapped in whole tobacco leaf with long filler tobacco, and lacking tips) but do offer flavored varieties. Understanding the role of flavors in cigar use is important because of the stark differences in the mass-produced versus premium cigar marketplace. See Chapters 2 and 5 for more information about flavored cigar manufacturing and potential health effects.

In recent years, cigars with characterizing flavors, such as menthol,¹³ fruit, alcohol, or candy, have become increasingly popular. For example, flavored cigar sales in convenience stores increased from $801.2 million in 2008 to $1,173.7 million in 2015 (Delnevo et al., 2017a, 2021).¹⁴ Research has found that fruit and sweet tasting flavors capture greater than 60 percent of the national market share of flavored cigar sales (Delnevo and Hrywna, 2015). Alcohol-flavored cigars that include wine, beer, spirits, liquors, and mixed drinks have significantly gained U.S. market shares of flavored cigar products during the past decade (Delnevo et al., 2017a, 2021; Jackler et al., 2018). Reporting use of a flavored usual brand occurred less frequently by premium cigar users (11.9 percent) compared with all other cigar types (53.0–61.0 percent, all p < .01) (Corey et al., 2018); commissioned analysis of PATH Wave 4 data found a similar pattern (Jeon and Mok, 2022). Availability of cigars in flavors (48.6–71.9 percent) was a common reason given by at least half of cigar users regardless of type. Specifically, 48.6 percent (43.2–54.1) of premium cigar users endorsed the reason “They come in flavors I like” for cigar smoking (Corey et al., 2018). Rostron et al. (2020) found that in 2016–2017 across all cigar types, greater than 50 to almost 75 percent of users reported that flavors were a reason to select particular cigars.

Flavored tobacco products are generally known to appeal to young people, but flavored cigars are especially popular among youth (Chen-Sankey et al., 2019; Corey et al., 2015; Delnevo and Hrywna, 2015; HHS,

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¹³ Menthol makes up a small percentage of the cigar market and is exclusively limited to little or filtered cigars.

¹⁴ Adjusted for inflation to 2015 dollars.

2012; King et al., 2014; Kong et al., 2019).¹⁵ Importantly, users report that cigar products are appealing for reasons such as palatability, and this factor also predicts their use (Soldz and Dorsey, 2005; Wray et al., 2012). A multivariate analyses of NSDUH data found that youth, young adults, women, Black people, cigarette users, blunt users, and daily cigar users are significantly more likely to report a usual cigar brand that is flavored (Delnevo et al., 2015). Additionally, preference for a usual brand that produces flavored cigars decreases significantly with age. A study of Texas college students found that among past 30-day cigar users, three out of four reported that they regularly chose flavored cigars, and younger, female, and racial and ethnic minority cigar users had significantly greater odds of using flavored cigars than their counterparts (Hinds et al., 2018). Another study found that smoking flavored cigars, especially alcohol flavors, is prevalent among young adult Black dual users: about 70 percent of study participants smoked at least one alcohol-flavored cigar, and alcohol was the most frequently smoked flavor type (34.4 percent, followed by sweet [23.4 percent] and mint [5.7 percent]) (Chen-Sankey et al., 2019). Additionally, a study of PATH data found that among Wave 4 (2016–2017) youth, 22.2 percent of traditional cigar users reported “I don’t know” regarding flavor use. Rostron et al. (2020) hypothesized that these responses could reflect the growing use of nonspecific concept descriptors, such as “tropical” for flavored cigars.

Research has also shown that women are more likely than men to smoke flavored tobacco (Glasser et al., 2017; King et al., 2013). Chen-Sankey et al. (2019) found that women had nearly three times greater odds of smoking alcohol-flavored cigars. Flavor options may also appeal to pregnant women who have sensitivities to tobacco smell and flavor (King et al., 2013). Potential reasons for sex-based differences in flavor preference include women’s sensitivity to the sensory effects of smoking (Perkins, 1996) and marketing strategies that target women (Brown-Johnson et al., 2014).

Geographic and Seasonal Differences

Data are scant on geographical differences in cigar use, premium or otherwise. Analysis of NATS found that premium cigars were more commonly used in the Northeast than little filtered cigars among cigar users, in contrast to other census regions, where premium cigars were

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¹⁵ Vargees, C., Stroup, A. M., Niznik, T., Dunn, D., Wyatt, R., Hoetger, C., Ben Taleb, Z., Cohn, A. M., Cobb, C. O., Fetterman, J .L. 2022. Patterns of Use, Perceptions, and Cardiopulmonary Health Risks of Cigar Products: A Systematic Review. Unpublished. Submitted to the committee by A. Stroup and available upon request at PARO@nas.edu.

the least common (Corey et al., 2014). Analysis of the 2014–2015 TUS-CPS noted differences in state prevalence rates of current cigar use: from 1.0 percent in Utah to 3.5 percent in Alaska (Odani et al., 2018).¹⁶ The pooled NSDUH analyses found that 65.0 percent of premium cigar users reside in a large metro area versus 50.5 percent of nonpremium users, and only 6.5 percent of premium cigar users report residing in a nonmetro area versus 16.5 percent of nonpremium users. Similarly, findings from the 2018–2019 TUS-CPS showed that the prevalence (past 30-day use) of large cigar smoking was higher in the Northeast and the West and lower in the South compared to that of cigarillos or little filtered cigar smoking (Azagba et al., 2021). Compared to cigarette use, current cigar smoking was lowest in the Northeast and West and highest in the Midwest and South (Odani et al., 2018).

Anecdotal data raise questions about whether there are seasonal patterns in cigar use and, in particular, premium cigar use. This is plausible and is certainly the case for cigarette smoking in the United States; it declines in the winter and increases in the summer (Chandra and Chaloupka, 2003). However, no research literature is specific to cigars.

Secondhand Smoke Exposure

While some anecdotal data suggest that premium cigars may be used primarily outdoors (e.g., while golfing), premium cigars are also smoked indoors at cigar lounges. No data are published on secondhand smoke exposure to cigars overall or premium cigars in particular. An important data gap exists regarding secondhand exposure of nonusers, including children in the home and occupational risk for those who work in cigar lounges that are typically exempted from smoke-free air policies (see Chapter 5 for a discussion on health effects of secondhand cigar smoke).

CO-USE OF PREMIUM CIGARS WITH OTHER TOBACCO PRODUCTS OR SUBSTANCES

Co-Use with Other Cigar Types

No previous study examined prevalence of co-use of premium cigars with other cigar types. The commissioned analysis of the PATH study of adults addressed poly- or co-use of four cigar product types among current established cigar users (see Table 3-3). Premium cigar users across all survey waves were least likely to report co-use with another type of

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¹⁶ Current users were defined as persons who reported ever use and used cigars “every day” or “some days” at the time of survey.

cigar product, with less than one out of five reporting concurrent use with other cigar types. In contrast, users of nonpremium large cigars, cigarillos, and filtered cigars were significantly more likely to report using at least one additional cigar product compared to premium cigar users (Jeon and Mok, 2022). This is consistent with Kasza et al. (2017), who found that of adults who use more than one type of tobacco product, 12 percent used two or more cigar types.

Co-Use with Non-Cigar Tobacco Products

Co-use or poly-tobacco use is common (Baggett et al., 2016; Kasza et al., 2017; Spears et al., 2019), particularly among young people, and cigars are often one of the products that are co-used with other tobacco products (Frazier et al., 2000; Ishler et al., 2020; Pérez et al., 2020), most notably cigarettes. However, no research literature exists on co-use of premium cigars specifically with other tobacco products for youth.

Corey et al. (2014) analyzed data from the 2012–2013 NATS among U.S. adults who smoke cigars “every day,” “some days,” or “rarely.” Of the 7.3 percent who did so, more than half (52.5 percent) reported information that could be used to assign a usual cigar type. Premium cigar users were defined as those reporting that their usual cigar did not have a filter or tip and their usual brand was hand rolled or described by the manufacturer or merchant as containing high-grade tobaccos in the filler, binder, or wrapper. Current cigarette smoking among those who usually smoked premium cigars (35.1 percent) was lower than those who usually smoked cigarillos/mass-market cigars (58.3 percent) or little filtered

cigars (75.2 percent). Never cigarette smoking was highest among those who usually smoke premium cigars (41.9 percent) compared to cigarillos/mass-market cigars (26.4 percent) or little filtered cigars (12.4 percent).

Jeon and Mok (2022) replicated and extended Corey et al. (2018) for adults in the five waves (2013–2019) (see Table 3-4). Cigarette smoking was substantially less common among premium cigar users (range across waves: 20.7–30.1 percent) than adults who used nonpremium traditional cigars (50.1–58.8 percent), cigarillos (54.7–61.0 percent), and filtered cigars (66.0–72.7 percent) but more common than in the overall U.S. adult population (16.4–18.6 percent). The prevalence of current use of any noncigar/noncigarette tobacco product was comparable across current premium cigar (range across waves: 26.1–33.2 percent), nonpremium traditional cigar (28.8–38.6 percent), cigarillo (28.3–31.4 percent), and filtered cigar (27.1–33.5 percent) users.

The NSDUH analysis compared those who typically smoke premium and nonpremium cigars (Bover Manderski et al., 2022). Table 3-5 shows that current premium cigar users had substantially lower past 30-day cigarette smoking prevalence (23.3 percent) than current nonpremium cigar users (50.7 percent). Current premium cigar users had slightly lower past 30-day pipe use prevalence (4.8 percent) than current nonpremium users (6.8 percent). Current premium cigar users had similar rates of past 30-day smokeless tobacco use (12.9 percent) as current nonpremium users (12.5 percent). Rates of never established use of cigarettes were higher for premium (47.5 percent) than for nonpremium (35.1 percent) users but lower for never use of pipes (61.7 versus 70.5 percent).

Co-Use with Other Substances

In this report’s commissioned analysis of 2010–2019 pooled nationally representative U.S. data from NSDUH, premium cigar users had a higher prevalence of past 30-day alcohol use than nonpremium cigar users (89.0 vs. 74.9 percent) and lower prevalence of past 30-day cannabis use (16.8 vs. 40.7 percent) (Table 3-6) (Bover Manderski et al., 2022). The higher rates of cannabis use among nonpremium cigar users is not surprising, given that inexpensive cigars and cigarillos are often co-used with cannabis as “blunts.” This relationship between cannabis and cigar use, most notably among young people, has been well established in the literature (Cohn et al., 2018; Cornacchione Ross et al., 2020; Delnevo et al., 2015).

Comparisons of past-year alcohol, cannabis, and illicit (noncannabis) drug dependence in NSDUH are reported in Table 3-7 (Bover Manderski et al., 2022); past 30-day premium cigar users had a higher prevalence of each form of substance dependence than those who did not use any tobacco product in the past 30 days, with larger differences between these

two groups for alcohol dependence and smaller differences for cannabis or illicit drug dependence. Cannabis dependence prevalence was substantially lower among premium (1.3 percent) than nonpremium (7.4 percent) cigar users and slightly lower among premium cigar than cigarette (2.5 percent) users. Alcohol dependence was slightly lower in premium (7.3 percent) than nonpremium (9.6 percent) cigar users and the same as cigarette users (7.3 percent). It appears that, except for alcohol dependence, substance dependence was higher among premium cigar users than nontobacco users but lower than among nonpremium cigar and cigarette users.

TRANSITIONS IN CIGAR USE AND OTHER TOBACCO PRODUCTS

The committee found no studies on initiation and transition to use of premium cigars specifically; several studies reported data for cigars

more generally. This section also includes data from the committee-commissioned PATH analysis.

Youth Initiation of Cigars

A study using data from PATH Waves 1–3 (2013–2016) found that weighted cross-sectional prevalence of past 30-day cigar use was stable for adults 25+ but decreased in youth and young adults aged 18–24, raising questions as to whether cigar initiation might be decreasing (Edwards et al., 2020). Another study analyzed the age at initiation of cigarillos, filtered cigars, and/or traditional cigars among a longitudinal sample from PATH study youth (aged 12–17) at Wave 1 (2013–2014) followed until Wave 4 (2016–2017) (Chen et al., 2020). The study found that past 30-day use initiation for all three cigar products increases by age, with marked increases starting at age 17. In particular, the cumulative incidence of traditional cigars’ past 30-day use increased from 0.8 to 5.9 percent from ages 17 to 18, reaching 11.7 percent by age 20. Among men, the cumulative incidence of traditional cigar use increased from 1.3 percent at age 17 to 8.2 percent at age 18 and 17.4 percent at age 20. Among women, the cumulative incidence of traditional cigar use increased from 0.4 percent at age 17 to 3.2 percent at age 18 and 5.8 percent at age 20. Overall, men were 233 percent (HR: 3.33; 95 percent CI: 2.63–4.35) more likely to initiate past 30-day traditional cigar use at a younger age than women. Compared to

non-Hispanic white youth, non-Hispanic Black and Hispanic youth were 51 percent (HR: 0.49; 95 percent CI: 0.35–0.69) and 44 percent (HR: 0.56; 95 percent CI: 0.45–0.70) less likely to initiate past 30-day traditional cigar use at younger ages, respectively (Chen et al., 2020).

Discontinuing Use

In another study of PATH Waves 1–3 data, among adult past 30-day users of each type of tobacco product at baseline, the rate of discontinuing use of cigars at the following wave was 48.6 percent (95 percent CI: 47.0–50.2 percent), which was lower than the discontinuation rate of electronic nicotine delivery systems (ENDS) (52.6 percent; 95 percent CI 50.9–54.4 percent) and hookah (63.8 percent; 95 percent CI 61.6–66.0 percent) but higher than that of cigarettes (13.4 percent; 95 percent CI 12.8–14.1 percent) and smokeless tobacco (25.9 percent; 95 percent CI 24.2–27.7 percent) (Kasza et al., 2020). Individuals aged 40–54 and 55+ had lower odds than those aged 18–24 to discontinue cigar use (adjusted odds ratio [aOR]: 0.7; 95 percent CI: 0.6–1.0 and aOR: 0.4; 95 percent CI: 0.3–0.6, respectively). Male cigar users were less likely to discontinue use than female users (aOR: 0.8; 95 percent CI: 0.7–1.0). Non-Hispanic Black cigar users were less likely to discontinue use than non-Hispanic white cigar users (aOR: 0.7; 95 percent CI: 0.5–0.8). Those who identified as gay or lesbian were more likely to discontinue use than those who identified as straight/heterosexual (aOR: 1.6; 95 percent CI: 1.0–2.6). Lastly, hookah use (aOR: 0.8; 95 percent CI: 0.6–0.9) and frequent cigar use (aOR: 0.4; 95 percent CI: 0.3–0.5) were negatively associated with discontinuation (Kasza et al., 2020).

Among adult current established users of cigars at baseline, the rate of making a quit attempt at follow-up was 56.2 percent (95 percent CI: 53.6–58.7). This was lower than the rate of quit attempts for hookah users (61.5 percent; 95 percent CI: 58.6–64.3) but higher than that of cigarettes (35.6 percent; 95 percent CI: 34.6–36.7), ENDS (45.8 percent; 95 percent CI: 43.8–47.8), and smokeless tobacco (39.2 percent; 95 percent CI: 36.5–42.0) (Kasza et al., 2020). Factors associated with making a cigar quit attempt were younger age, Hispanic ethnicity, cigarette smoking, and higher dependence score. Factors negatively associated with a cigar quit attempt were having a Bachelor’s degree or more education, higher income, and daily cigar use.

Stability and Transitions in Use of Premium Cigars Across Time

In the commissioned analysis of PATH adults across the five waves (2013–2019) (see Appendix D), the prevalence of different types of within-

person changes in tobacco use patterns from one wave to the next wave 12 months later was analyzed (Jeon and Mok, 2022). This involved studying the change or stability in use and co-use patterns for premium cigars, other cigars (nonpremium traditional or large cigars, cigarillos, or filtered cigars), and cigarettes from Wave 1 to Wave 2, Wave 2 to Wave 3, Wave 3 to Wave 4, and Wave 4 to Wave 5. For each two-wave pairing, a transition probability was calculated that estimated the frequency of changing the type of tobacco used, and these were averaged across the four two-wave pairings to provide a mean 1-year transition probability.

For exclusive users of one of the three respective products, the probability of continuing to use the same product 1 year later was higher for premium cigar users (75.0 percent) than for other nonpremium cigar users (59.0 percent) but lower than for exclusive cigarette users (89.2 percent). Depicted in Figure 3-6 (Panel A), the approximately 75 percent of exclusive premium cigar users who continued to smoke them 1 year later included 69.2 percent who remained exclusive premium cigar users, 2.5 percent and 2.8 percent who became dual users with other cigar types and cigarettes, respectively, and 0.5 percent who became poly-tobacco users of premium cigars, other cigars, and cigarettes. For the 59.0 percent who smoked exclusively other (nonpremium) cigar types and continued to smoke other cigars, 46.9 percent remained exclusive users, 2.2 percent dual users with premium cigars, 9.6 percent dual users with cigarettes, and 0.3 percent poly-tobacco users of all three product types (Jeon and Mok, 2022).

For exclusive users of one of the three products, the probability of becoming a nonuser of any cigar or cigarette product was higher for premium cigar (18.8 percent) than cigarette (10.7 percent) users but lower than for exclusive users of other cigar types (32.1 percent). The probability of transitioning to cigarette smoking 1 year later was lower for exclusive premium (5.0 percent) than for exclusive nonpremium (15.7 percent) cigar users. Of dual users of premium and nonpremium cigars, only slightly greater than 40 percent remained so in the following year. About 34 percent of dual users of premium cigars and cigarettes became exclusive cigarette users within 1 year (Jeon and Mok, 2022).

Additional analyses comparing frequent and infrequent use of cigars found variable transition patterns as well (see Figure 3-6). About 68 percent of exclusive premium cigar users who smoked less than 6 days in the past 30 days continued smoking premium cigars in the following year either as exclusive users (63.0 percent) or dual users with other combustible tobacco products (5.2 percent) (Figure 3-6, Panel B). While only 4 percent of less frequent exclusive premium cigar users (less than 6 days in the past 30 days) increased use frequency within a year, about 20 percent of more frequent exclusive premium cigar users (6+ days in the past 30 days) decreased use frequency. Less frequent exclusive premium

cigar users were more likely to discontinue use within 1 year compared to more frequent users (22.7 versus 4.3 percent). Dual premium cigar use with other combustible tobacco products is relatively transient; only 44.5 percent of less frequent and 15.8 percent of more frequent premium cigar users remained dual users. About 35.2 percent of less frequent and 40.9 percent of more frequent dual premium cigar users discontinued premium cigar use and became exclusively other combustible tobacco product users within a year (Jeon and Mok, 2022).

Figure 3-7 shows individual trajectories across PATH Waves 1–5 for adult exclusive premium cigar users at Wave 1 who participated in all

waves. The figure shows that by Wave 5, about 56 percent of adult exclusive premium cigar users in Wave 1 remained as such, while about 35 percent discontinued all cigar and cigarette use. By Wave 5, less than 5 percent became cigarette users—exclusively or dual with premium or nonpremium cigars. Less than 10 percent of exclusive premium cigar users transitioned to other use categories at Wave 5 (Jeon and Mok, 2022). For comparison, about 23 percent of exclusive cigarette users in Wave 1 became noncurrent users of cigars and cigarettes by Wave 5.

KEY RESEARCH GAPS AND FINDINGS

Despite an overall paucity of data on premium cigars specifically (see Box 3-1 for key research gaps), based on the available data, the committee had some key findings.

Finding 3-1: Large, machine-produced cigars have been the dominant cigar type for much of the last century. Total cigar consumption began declining in the mid-1970s and reached its lowest level in 1993, when promotion of premium cigars reversed overall consumption trends for all cigar types. Since the release of the NCI’s 1998 monograph on cigars, overall cigar consumption has increased every year, with a total increase of 145 percent from 1998 to 2020.

Finding 3-2: Premium cigars are consistently a small, stable percent of the U.S. cigar market.

Finding 3-3: About 1 percent of the U.S. adult population smokes premium cigars, a frequency that has remained stable over time.

Finding 3-4: Cigarettes remain the most commonly used combustible tobacco product among adults in the United States. The prevalence of cigarette smoking among adults in 2018–2019 was 16.4 percent compared to 0.7 percent for premium cigars, 0.5 percent for nonpremium cigars, 1.4 percent for cigarillos, and 0.8 percent for filtered cigars.

Finding 3-5: The majority of premium cigar users are male, white, with higher income and education levels compared to those who smoke cigarillos, little filtered cigars, or cigarettes. Premium cigar users are on average 7–10 years older than those who smoke cigarillos or little filtered cigars. Premium cigar use is less common among youth, and only 0.6 percent of those who reported smoking a premium cigar brand in the past 30 days were under the age of 18. Premium cigar

use is also less common among women, non-Hispanic Black people, and people with less than a high school education.

Finding 3-6: The frequency and intensity of smoking is lower for premium cigars compared to other types of cigars and cigarettes. Only about 5 percent of premium cigar users smoke these daily, whereas 22 percent of nonpremium cigar users, 19 percent of cigarillo users, 40 percent of filtered cigar users, and 76 percent of cigarette users smoke those products daily. The median number of cigars or cigarettes smoked per day is about 0.1 for premium cigars, 0.2 for nonpremium cigars, 0.3 for cigarillos, 1.0 for filtered cigars, and 10 for cigarettes.¹⁷

Finding 3-7: Premium cigar users are less likely to smoke cigarettes or other cigar types concurrently than other cigar type users. Dual use with cigarettes was highest for filtered cigar users (~70 percent), followed by cigarillo users (~60 percent) and nonpremium cigar users (~50 percent), and lowest for premium cigar users (~26 percent).

Finding 3-8: Premium cigar users are more likely to be never or former cigarette smokers than users of other cigar products. They are also more likely than the general population to smoke cigarettes.

Finding 3-9: The prevalence of alcohol dependence among those who smoke premium cigars is similar to those who smoke nonpremium cigars or cigarettes. The prevalence of cannabis and illicit drug dependence among those who smoke premium cigars is lower than those who smoke nonpremium cigars or cigarettes. However, the prevalence of alcohol, cannabis, and illicit drug dependence among those who smoke premium cigars is higher than for those who do not use any tobacco products.

Finding 3-10: Population Assessment of Tobacco and Health Study analyses suggest that about three-quarters of exclusive premium cigar users continued smoking premium cigars in the following year. Among exclusive premium cigar users in Wave 1 (2013–2014), slightly more than half remained as exclusive premium cigar users in Wave 5 (2018–2019). About 35 percent discontinued use of cigars and cigarettes by Wave 5. Less than 5 percent became cigarette smokers

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¹⁷ The median was calculated, consistent with the methods used by Corey et al. (2018): respondents reporting smoking less than one cigar per day on the days smoked were assigned as 0.5 cigars per day.

(exclusive or dual with premium or nonpremium cigars) by Wave 5. Additionally, exclusive premium cigar users who smoked infrequently (i.e., less than 6 days in the past 30 days) were more likely to discontinue use within a year compared to those who smoked more frequently.

REFERENCES