Cigar Harm Beliefs and Associations with Cigar Use among Young Adults

Background: Cigar use, including little cigars and cigarillos (LCCs) and large traditional cigars, continues to harm young adults. Research on harm beliefs about cigars, particularly large cigars, is sparse. The current study examined cigar harm beliefs and associations with cigar use. Methods: Data are from a 2019 survey of a young adult cohort study recruited in fall 2010. Participants were asked questions about their beliefs about the harm of LCC and large cigar use. Those reporting ever use of cigars were asked how frequently they inhale the smoke into their lungs. Results: Participants (N = 1910) were 51.9% female with a mean age of 26.7 (SD = 0.6). Ever cigar use was 44.2% for large cigars and 43% for LCCs. Compared to those who have never used large cigars or LCCs, those reporting ever use of large cigars or LCCs reported lower harm beliefs about inhaling harmful chemicals and becoming addicted (ps <.0001). Those who reported higher harm beliefs also reported inhaling the smoke into their lungs more frequently for large cigars and LCCs (ps<.05). Conclusions: Cigar use harm beliefs were lower among participants reporting ever use of cigars compared to those reporting never use. Contrary to predictions, those reporting greater harm beliefs were more likely to report inhaling smoke more frequently than those with lower harm beliefs.

Keywords: Cigars; tobacco; young adults

The use of cigars, including little cigars, cigarillos, and large cigars remains a public health concern (Stanton et al., [39]). Cigars, including little cigars, cigarillos, and large cigars, are common particularly among younger people compared to older adults (Cornelius et al., [11]; Edwards et al., [16]). A recent longitudinal analysis from the Population Assessment of Tobacco and Health (PATH) study demonstrated that cigar initiation from 2013 to 2016 increased most among young adults ages 18–24 compared to adolescents and older adults (Stanton et al., [39]). Cigar use is associated with use of other tobacco products and other substances, including marijuana (Cohn et al., [8]; Cornacchione Ross et al., [9]; Schauer et al., [36]; Strong et al., [42]). Cigar use may also result in progression to cigarette smoking. In a study of young adults, results showed that 16.4% of people who reported current cigarette smoking indicated cigars were their first tobacco product ever used (Sutfin et al., [44]).

Cigar smoking has significant health consequences. Those reporting former or current exclusive cigar use have a higher all-cause mortality rate than those reporting non-tobacco use (Christensen et al., [6]). Cigar use also heightens risks and death from several cancers (e.g., oral, esophageal, bladder), coronary heart disease, stroke, and chronic obstructive pulmonary disease (Chang et al., [5]; Christensen et al., [6]; National Cancer Institute, [26]). Many cigar smoke constituents cause health problems and exist at higher levels than in cigarette smoke, such as tobacco-specific nitrosamines (known carcinogens), hydrogen cyanide, ammonia, and carbon monoxide (Baker et al., [3]; Hoffmann & Hoffmann, [20]; Koszowski et al., [22]; [23]; Pickworth et al., [30]; [32]; Rosenberry et al., [34]).

However, misperceptions exist about the harms associated with cigar smoking. Because cigars are wrapped in a tobacco leaf rather than paper, many young adults erroneously believe they are more natural, pure, less dangerous, and addictive than cigarettes (Cohn et al., [8]; Cornacchione et al., [10]; DeSantis, [13]; Jolly, [21]; Sterling et al., [40]). Also, people may underestimate the harms of cigars because they believe that they do not smoke frequently enough to cause any health effects, that they can quit before becoming addicted, and that smoking infrequently is less harmful (Cornacchione et al., [10]; Sterling et al., [41]). Misperceptions about the risks of cigar use not only influences beliefs, but can also impact cigar smoking behavior (Cornacchione et al., [10]; Sterling et al., [40]; [41]). In fact, a nationally-representative longitudinal study identified that those who had lower harm beliefs about cigars at wave 1 were more likely to become cigar users at wave 2 (Elton-Marshall et al., [17]).

Such misperceptions could be partially attributed to the belief among people who use cigars that they do not inhale cigar smoke or inhale less frequently than those who smoke cigarettes, which may reinforce the belief that cigar smoking has reduced risk (DeSantis, [13]; Rait et al., [33]; Sterling et al., [40]). One reason for not inhaling could be because cigar smoke is harsher due to a higher pH relative to cigarette smoke (Lawler et al., [24]). Data from the American Cancer Society Prevention Study-I found that over 75% of men who smoked cigars reported not inhaling cigar smoke (National Cancer Institute, [25]; Shanks & Burns, [37]). In a qualitative study of cigarette and cigarillo users, participants also indicated that they and others do not inhale when smoking cigarillos compared to when smoking cigarettes, and, thus believe cigarillos to be less harmful than cigarettes (Sterling et al., [40]). However, recent laboratory studies of people who dual use cigar products and cigarettes may challenge these self-reports of inhalation behaviors (Koszowski et al., [22]; Pickworth et al., [31]; Rosenberry et al., [34]). Smoking topography studies show increases in carbon monoxide exposure and plasma nicotine levels after smoking large cigars, little cigars, and cigarillos due to inhalation. The authors of these studies cautiously concluded that among people who dual use cigar products and cigarettes, inhalation also occurs when smoking cigar products (Koszowski et al., [22]; Pickworth et al., [30]; Rosenberry et al., [34]). Similar findings have also been found in studies among cigar-only users, with levels of actual inhalation greater than self reported behavior (Claus et al., [7]). These differences in self-reported inhalation behavior versus smoking topography behavior may contribute to inaccurate harm beliefs. If people who use cigar products believe they are not inhaling smoke, then they may incorrectly believe that smoking cigars is less harmful or addictive compared to smoking cigarettes. If cigar users do not think they are exposing themselves to harmful tobacco constituents via smoke inhalation, then it reasonably follows they would believe cigar use is not as harmful as cigarette smoking. However, cigar smoking, regardless of whether inhalation occurs, still causes significant health harms (Chang et al., [5]).

Beliefs are central to several health behavior theories, including the health belief model and the theory of reasoned action/planned behavior (Ajzen, [2]; Rosenstock, [35]). These theories posit that beliefs about the severity and likelihood of harmful outcomes influence behaviors. Beliefs are a key target in persuasion and behavior change; one way to change behavior is through strengthening or weakening beliefs through targeted messaging (Brennan et al., [4]; O'Keefe, [29]; Yzer, [48]). If people hold beliefs that cigar smoking is not likely to result in harmful health outcomes, then they may be more likely to smoke cigars compared to those who hold beliefs that harmful health outcomes are likely. In fact, longitudinal data from the Poppulation Assessment of Tobacco and Health Survey has demonstrated that adult nonusers of cigar products who perceived the products as being less harmful were more likely to have initiated the product compared to those with higher harm beliefs (Elton-Marshall et al., [17]). Furthermore, positive experiences smoking cigars can also reinforce beliefs about the its harmfulness. In the same longitudinal study, harm beliefs did not change from Wave 1 to Wave 2 among cigar users (Elton-Marshall et al., [17]).

The goal of this paper was to examine harm beliefs about large cigars and LCCs among young adults and to examine their association with use and inhaling behaviors. We hypothesized that users of cigar products (large cigars and LCCs) would be more likely to perceive the products to be less harmful and less addictive compared to those reporting never using large cigars or LCCs. We also hypothesized that those who reported higher levels of harm and addiction perceptions would report lower inhaling frequencies.

Data were collected among a cohort of 3,146 students from 11 colleges in North Carolina and Virginia. Participants were recruited in the fall of their first year of college (2010) and surveyed through fall of their senior year (2013). We continued to follow participants during the transition to adulthood using online surveys. For the current analyses, we use data from the spring 2019 data collection wave; 1,910 participants completed the spring 2019 survey. To establish the cohort, we oversampled males and those reporting smokeless tobacco use or cigarette smoking. The data/analyses are weighted to adjust for oversampling and non-response. More detail on initial study recruitment is described elsewhere (Spangler et al., [38]; Wolfson et al., [47]). The study protocol was approved by the Wake Forest University School of Medicine Institutional Review Board, and additional privacy protection was provided by obtaining a Certificate of Confidentiality from the U.S. Department of Health and Human Services.

We asked all participants four questions about their beliefs about tobacco products (Sutfin et al., [43]). We asked participants to state their perceived level of harm with two items: "If I smoke [large cigars/LCCs], I will inhale harmful chemicals" and "If I smoke [large cigars/LCCs] regularly, it would be bad for my health." Response options ranged from 1 = strongly disagree to 5 = strongly agree. We also asked participants about perceptions of addictiveness with the item "If I smoke [large cigars/LCCs] regularly, I will get addicted." Response options ranged from 1 = strongly disagree to 5 = strongly agree. We also assessed the relative risk of using cigars (large cigars and LCCs, assessed separately) compared to cigarettes with the item "Compared to cigarettes, [large cigars/LCCs] are..." Response options ranged from 1 = much less harmful to 5 = much more harmful.

Participants were asked whether they had ever used large cigars or LCCs (separately) with the questions: "Have you ever smoked a [large cigar/LCC], even one or two puffs?" They were considered ever users of large cigars or LCCs if they reported using each product at least once. Participants who had never smoked a large cigar or LCC were classified as never users of large cigars or LCCs. Cigarette smoking was measured with "have you ever smoked a whole cigarette", "have you smoked at least 100 cigarettes in your lifetime", and "do you now smoke cigarettes every day, some days, or not at all?" Participants were classified as current established smokers if they reported smoking at least 100 cigarettes and smoking some days or every day; participants were classified as former established cigarette smokers if they reported smoking at least 100 cigarettes, but now smoke cigarettes "not at all." Participants were classified as experimental cigarette smokers if they reported ever smoking cigarettes but have not smoked 100 cigarettes in their lifetime.

We also assessed frequency of large cigar and LCC use using items adapted from the Population Assessment of Tobacco and Health survey. For those reporting past 30-day use, participants were asked "which of the following choices best describes your [large cigar/LCC] smoking? Usually I smoke [large cigars/LCCs], everyday, weekly, monthly, every couple of months, about once a year, less than once a year. For ever use, participants were asked "which of the following choices best describes your former [large cigar/LCC] smoking?" with the same response options. Due to small cell sizes, we combined everyday, weekly, and monthly into one category; about once a year and less than once a year were also combined into one category.

Participants who reported using large cigars or LCCs were asked about their inhaling behaviors when smoking large cigars or LCCs with the items: "when you smoke [large cigars/LCCs], how often do you inhale the smoke into your lungs?" Response options ranged from 1 = never to 5 = always.

Demographic characteristics included sex (male, female), race (coded as White, Black, other), ethnicity (coded as Hispanic vs. Non-Hispanic), and mother's highest level of education as an indicator for socioeconomic status (coded as at least a college degree vs. less than a college degree). Age was collected by asking participants "how old are you?"

Descriptive statistics on demographic characteristics and tobacco use prevalence were conducted. Demographic statistics are unweighted in order to describe the sample. Tobacco prevalence rates are weighted in order to take into account the oversampling of males and tobacco users at baseline. Demographics and tobacco prevalence rates were compared between those reporting ever cigar use and never use for both large cigars and LCCs using chi-squared tests. Next, we examined differences in harm beliefs between ever and never cigar users using linear regression analyses. Among ever cigar users, we also examined the association between harm beliefs and frequency of inhalation (outcome) using linear regression analyses. For all analyses, models were fit for each of the four harm beliefs and cigar type (large cigars, LCCs) separately. Adjusted models adjusted for any statistically significant demographic differences between ever and never cigar users. Models predicting frequency of inhalation additionally adjust for frequency of use and test for an interaction between frequency of use and harm beliefs. Regression coefficients, standard errors, and p-values are reported. Observations with any missing data were not included in the models. All models used sampling weights and were constructed using SAS v 9.4.

Participants (N = 1910) were 51.9% female, 84.5% White, 7.5% Black, 6.5% Hispanic, with a mean age of 26.7 years (SD = 0.6). Less than half (44.2%) of participants reported ever use of large cigars, and 42.0% reported ever use of LCCs. Most (60.4%) reported never cigarette smoking. We identified some significant differences between those reporting ever vs. never use of large cigars or LCCs, including sex, race, and cigarette smoking behavior. See Table 1 for demographics and tobacco use behaviors.

Table 1. Sample characteristics (N = 1.910).

1 Note. Unweighted N and demographics %, weighted % for tobacco use.

• 2 Ever Use includes any use of cigars, including in the past 30 days.
• 3 M = Mean; SD = Standard Deviation.
• 4 Statistical significance at p<.05.

We first examined the distribution of harm beliefs by use of large cigars and LCCs. As shown in Table 2, overall, participants tended to agree with beliefs that cigar smoking is harmful. In unadjusted models in Table 3, those reporting ever use of large cigars had significantly lower levels of agreement with the statement that they would inhale harmful chemicals while smoking large cigars (B=-0.16, SE = 0.04, p<.001) and would become addicted to smoking large cigars (B=-0.33, SE = 0.06, p<.001) compared to those reporting never use of large cigars. Similarly, those reporting ever LCC use had significantly lower levels of agreement with the statement that they would inhale harmful chemicals while smoking LCCs (B=-0.11, SE = 0.03, p<.001) and become addicted to smoking LCCs (B=-0.25, SE = 0.05, p<.001) compared to those reporting never LCC use. In adjusted models, these findings held for both large cigars and LCCs.

Table 2. Descriptive statistics for harm beliefs items by cigar use status (N = 1,910).

• 5 Note. Scales ranged from 1 = strongly disagree/less harmful to 5 = strongly agree/more harmful.
• 6 M = Mean; SE = Standard Error.

Table 3. Regression coefficients for cigar use predicting harm beliefs.

• 7 Note: Adjusted models control for demographic variables that were significant in Table 1.
• 8 Positive regression coefficients represent how much higher, on average, ever users are on the scale (more harmful / more agreement). Negative regression coefficients represent how much lower, on average, ever users are on the scale (less harmful / less agreement) compared to never users.
• 9 Statistical significance at p<.05.

We examined the association of harm beliefs with the frequency with which those who smoked LCCs or large cigars reported inhaling the smoke into their lungs (Table 4). Approximately half (53.7%) of those reporting large cigar use and 29.4% of those reporting LCC use stated that they "never" inhaled the smoke into their lungs (Figure 1). In fully adjusted models, among those reporting large cigar use, reporting that large cigars are more harmful than cigarettes was associated with inhaling cigar smoke more often (B = 0.13, SE = 0.04, p<.001). We also found that, among those reporting ever use of large cigars or LCCs, being more in agreement with the harm belief statement about inhale harmful chemicals was associated with reporting inhaling large cigar or LCC smoke into their lungs more often (large cigars: B = 0.12, SE = 0.05, p=.008; LCCs: B = 0.12, SE = 0.06, p=.04).

PHOTO (COLOR): Figure 1. Frequency of inhaling behavior by participants reporting use of large cigars and LCCs. Note: n = 998 for large cigars and n = 977 for LCCs.

Table 4. Regression coefficients for harm beliefs predicting inhalation frequency among cigar users.

• 10 Note: Adjusted models control for frequency of use and demographic variables that were significant in Table 1. Positive regression coefficients mean that a stronger belief that the product is more harmful is associated with more frequent inhalation of product into lungs. Negative regression coefficients mean that a stronger belief that the product is less harmful is associated with more frequent inhalation of product into lungs.
• 11 Statistical significance at p<.05.

Because the findings on the association between harm beliefs and inhaling behaviors were counterintuitive, we further explored whether the association between harm beliefs and inhaling behavior varied as a function of cigar smoking frequency. We speculated that this association may be impacted by the frequency with which people report smoking large cigars or LCCs. However, we did not detect significant interactions between harm beliefs and smoking frequency.

This study examined beliefs for large cigars and LCCs and their association with use and inhaling behaviors among a sample of young adults. As expected, those reporting ever use of cigar products were more likely to report lower harm beliefs compared to never users. Specifically, those reporting ever use of large cigars or LCCs were more likely to have weaker beliefs about becoming addicted to each respective product compared to those who have never used large cigars or LCCs. Similarly, those reporting ever use of large cigars or LCCs were more likely to have weaker beliefs that product use would result in inhaling harmful chemicals compared to those reporting never use.

These weaker harm beliefs associated with cigar use have important public health implications. To our knowledge, there have been no national efforts to educate the public about the harms of cigar use. Multiple campaigns have been implemented to educate people of all ages about the harms of cigarette smoking, smokeless tobacco use, and e-cigarettes, such as the Truth campaign, The Real Cost, and Tips from Former Smokers (Davis et al., [12]; Duke et al., [14]; Farrelly, [18]). As a result of these efforts, awareness and understanding about the risks of using these products have increased, contributing to declines in use and increases in cessation (Davis et al., [12]; Duke et al., [15]; Noar et al., [28]; Vallone et al., [45]). Similar efforts for large cigars and LCCs are needed. In particular, given the results of these studies, messages framed around educating consumers about the risks of inhaling harmful chemicals while smoking large cigars or LCCs may be a promising message theme, with particular focus on the harmful constituents that are consumed whether or not one inhales the smoke into their lungs. Study findings also support the need for more prominent warnings on cigar packaging and advertising to better help consumers understand the harms associated with cigar use.

We found that there were no statistically significant differences between those reporting ever use of cigars compard to never use about the relative risk of large cigars or LCCs compared to cigarettes. The current findings are promising as some research has highlighted that beliefs about the harms of cigar smoking could be based on a variety of reasons, including that they are perceived to be more natural than cigarettes or that they are not used as frequently as cigarettes, thus, subsequently resulting in believing they are less harmful than cigarettes (Cohn et al., [8]; Cornacchione et al., [10]; Sterling et al., [40]). One of the existing cigar warnings states that, "cigars are not a safe alternative to cigarettes", which may be an effective message for communicating the relative risk compared to cigarettes generally (Food and Drug Administration, [19]). However, given that there are risks to smoking large cigars and LCCs, it is important to communicate that cigars are are not safer than cigarettes and that infrequent use is still harmful, resulting in negative health effects, including nicotine addiction. This could be done both through communication campaigns as well as product warning labels.

Our study also explored the relationship between beliefs about harm and addiction with self-reported inhaling behaviors while using large cigars and LCCs. Contrary to our hypothesis, those who reported greater harm beliefs about cigar smoking reported inhaling the smoke into their lungs more frequently than those who reported weaker beliefs of harm. These discordant findings may be due to inaccurate beliefs that infrequent use (i.e., not daily) reduces risk and that they may not perceive themselves to be addicted smokers (Ajith et al., [1]; Cornacchione et al., [10]). It is possible that they do not think that harmful outcomes are likely given their frequency of cigar smoking, even though their self-reported behavior is more frequent compared to other participants in this study; monthly may still be perceived as infrequent compared to daily. Future studies are needed to disentangle our findings about cigar harm beliefs, frequency of use, and inhaling behaviors.

The findings of our study are also important when considering cigar warning requirements. Warnings are effective because they communicate the risks of the tobacco product. In 2016, the FDA mandated implementing new cigar warning requirements for all cigar packaging and advertising (Food and Drug Administration, 2016). These new warnings were proposed to be larger in surface area and font size (30% of pack surface area) than the existing Federal Trade Commission (FTC) cigar warnings from 2001. However, implementation of these warnings was delayed due to legal challenges from the tobacco industry and, ultimately, vacated in 2020 (Cigar Association of America et al. v. U.S. Food & Drug Administration et al.). The U.S. Court of Appeals for the D.C. Circuit ruling that the FDA did not provide evidence about the effectiveness of these warnings beyond the existing FTC-mandated cigar warnings, which are small and blend in with the packaging). Implementation of these new FDA proposed cigar warnings is important to ensure that the harms of cigars are accurately communicated to consumers to increase understanding and knowledge. Strengthened warnings, including increased size, are associated with increased knowledge and quit attempts and decreased smoking consumption and prevalence (Noar et al., [27]).

One limitation of this study is that we did not assess little cigars and cigarillos separately, but were instead combined into one item. They are distinct cigar products, but are frequently combined in research, including survey items and analyses. Little cigars and cigarillos may be used differently, be associated with different beliefs, and, thus, should be studied separately. However, a strength of the current study is that we were able to assess large traditional cigars, an area of research that is limited. Another limitation is that we were not able to conduct analyses with participants reporting current use of cigars because the sample sizes of current large cigar and LCC use was too small. Additional research examining differences in harm perceptions across cigar products and different levels of use are needed. Furthermore, our sample was not racially diverse, so we were unable to explore subgroup analyses. This is especially important given the higher rates of use of cigars, particularly LCCs, among those who identify as Black/African American (Weinberger et al., [46]). Future studies are critically needed to examine harm beliefs among priority populations to inform optimal intervention and messaging strategies.

Despite the limitations, this study contributes to our understanding of people's perceptions about the harms of cigar smoking, including LCCs and large cigars. Overall, those reporting ever use of large cigars or LCCs reported lower harm beliefs compared to never users, but, interestingly, those reporting greater harm beliefs were also more likely to report inhaling more frequently while smoking large cigars and LCCs. This study contributes to the growing literature to better understand beliefs about large cigars and LCCs.

The authors declare that they have no conflict of interest. The authors alone are responsible for the content and writing of the article.

Research reported in this manuscript was supported by the National Cancer Institute of the National Institutes of Health under Award Number R01CA141643. The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health.