Nicotine and carbon monoxide exposure from inhalation of cigarillo smoke

Effect of sweet flavouring on the rewarding and reinforcing value of cigarillo use among young adults

INTRODUCTION

Cigarillos dominate the US cigar market, and young adults largely drive use. While young adults prefer flavoured to non-flavoured cigarillos, especially those flavoured to taste like fruit or other sweets, the factors that underlie this preference have received little attention. We sought to determine if key indicators of abuse liability, the rewarding and reinforcing effects, are greater for sweet versus non-flavoured cigarillos.

METHODS

Young adults (18-24 years old) completed three laboratory visits assessing the subjective rewarding value (exposure paradigm), relative reinforcing value (computerised choice task) and absolute reinforcing value (ad libitum cigarillo smoking session) of sweet-flavoured versus non-flavoured cigarillos. General linear regression models were fit with the appropriate family link for each outcome measure.

RESULTS

Young adults rated sweet-flavoured cigarillos as more rewarding (estimated marginal mean (EMM) =4.52, 95% CI 4.00 to 5.03) than the non-flavoured cigarillo (EMM=3.31, 95% CI 2.80 to 3.83; B=1.20, 95% CI 0.80 to 1.60, p<0.001). The reinforcing value of sweet-flavoured cigarillos, measured by break point, was higher relative to non-flavoured cigarillos (6.34 out of 10), especially among young adults with a preference for flavoured cigarillos (B=1.94, 95% CI 0.71 to 3.18, p=0.003). Young adults took 1.9 times the number of puffs (35.75 vs 19.95) from sweet-flavoured cigarillos compared with non-flavoured cigarillos (Rate Ratio =1.94, 95% CI 1.30 to 2.90, p<0.001).

CONCLUSIONS

Sweet flavouring increases the abuse liability of cigarillos among young adults as reflected in greater liking, motivation to use and actual use. Banning sweet flavouring in cigarillos may diminish their use in young adults.Trial registration number CT.gov (NCT05092919).

The interacting effects of depression symptoms and sweet flavoring on the rewarding and reinforcing value of cigarillo use among young adults

Background

Young adults 18-24 years old have the highest prevalence of cigarillo use, exposing young adults to comparable or higher nicotine levels and many of the same toxicants as combustible cigarettes. Identifying individual and product characteristics that increase the potential for persistent use is warranted. We sought to examine the interacting effects of depression symptoms and sweet flavoring on the rewarding and reinforcing value of cigarillo use.

Methods

86 young adults (18-24 years old, 73.3 % male, 38.4 % White, 33.7 % Black, and 27.9 % Other) completed three laboratory visits assessing the subjective rewarding value (exposure paradigm), relative reinforcing value (computerized choice task), and absolute reinforcing value (ad libitum cigarillo smoking session) of sweet-flavored versus non-flavored cigarillos. Depression symptoms were measured with the 20-item Center for Epidemiologic Studies of Depression Scale and treated as a continuous variable.

Results

General linear models with the appropriate family link tested differences in depressive symptomology for each outcome. Irrespective of flavor, greater cigarillo subjective reward was reported across increasing depressive symptomology (B=.0.03 [95%CI=0.00, 0.05], p=.017). Across symptom levels, no significant differences were observed in the subjective reward and relative and absolute reinforcing values of sweet-flavored versus non-flavored cigarillos (p's >.05).

Conclusions

Young adults with elevated depression find cigarillos more rewarding but not more reinforcing. They are not more vulnerable than young adults with lower symptom levels to sweet cigarillo flavoring. Public health prevention campaigns and tobacco product regulations aimed at preventing the initiation and escalation of young adult cigarillo use may impact young adults broadly.

Patterns of use, perceptions, and cardiopulmonary health risks of cigar products: a systematic review

OBJECTIVE

A systematic review was conducted to evaluate the use patterns, health perceptions, and cardiopulmonary health effects of cigars.

DATA SOURCES

PubMed and Google Scholar were searched for peer-reviewed articles published between June 2014 and February 2021. Search keywords included cigars, cigarillos, little cigars, and cardiopulmonary health outcomes.

STUDY SELECTION

Of 782 papers identified, we excluded non-English articles, review articles, commentaries, and those without empirical data on cigars. Three coders independently reviewed all articles and compared codes to resolve discrepancies. 93 articles met the inclusion criteria and were included.

DATA SYNTHESIS

Cigars have evolved from premium cigars to encompass little cigars and cigarillos (LCCs). LCCs are available in an array of flavors and at a price advantage, and as a result, are used by different groups compared to premium cigars. LCCs are more frequently used by youth, young adults, and those who identify as Black/African American. LCCs are often used in combination with other tobacco products, alcohol, and cannabis. Despite limited regulation, cigars generate smoke of a similar composition as cigarettes. Among the studies identified, evidence suggests that cigar use is associated with cardiovascular and pulmonary toxicity. Higher all-cause and cancer-related mortalities are associated with cigar use, particularly with more frequent and deeper inhalation, compared to non-tobacco users.

CONCLUSIONS

LCCs are used more frequently by at-risk groups compared to premium cigars. Recent studies evaluating cigar cardiopulmonary health effects are limited but suggest cigars have similar health risks as conferred by cigarette smoking. With the use of LCCs and targeted marketing on the rise among high-risk groups, there is a critical need for continued research in this area.

Perceived message effectiveness of cigar warning themes among adults in the United States

Most tobacco warnings focus on health harms to the consumer, but other message themes may be promising. We assessed perceived message effectiveness (PME) among adults who smoke cigars for 12 cigar warning statements to discourage smoking, and measured PME across four message themes: explicit health effects to the consumer, secondhand smoke effects, chemicals/constituents, and toxicity. Between April 23 and May 7, 2020, we conducted an online study with U.S. adults who used any cigar type in the past 30 days (n = 777). Participants were randomly assigned to view two out of 12 warnings and rate each one on PME. We analyzed PME mean ratings (range 1 [low] to 5 [high]). The warning statements for lung cancer (M = 3.91) and heart disease (M = 3.77) had the highest PME ratings; secondhand smoke (M = 3.50) and formaldehyde (M = 3.48) had the lowest PME ratings. Multilevel analyses showed that the explicit health effects theme was associated with higher PME ratings compared to other warning themes (ps < 0.05 for chemicals/constituents and secondhand smoke effects) except toxicity (p =.16). Higher awareness of consequences was associated with higher PME ratings (p <.001). Higher nicotine dependence was also associated with higher PME ratings (p = .004). Warning statements with information addressing the themes of health harms and toxicity could potentially inform those who smoke cigars about the broader harms of cigar use and should be considered in FDA labeling regulations for cigars.

Responses to pictorial versus text-only cigarillo warnings among a nationally representative sample of US young adults

BACKGROUND

The US Food and Drug Administration requires six text-only warnings for cigar products, including cigarillos. Research has demonstrated the superiority of pictorial over text-only cigarette warnings, yet the relative effectiveness of pictorial warnings for cigarillos has not been examined. We examined the impact of pictorial cigarillo warnings compared with text-only warnings.

METHODS

Data were collected from a nationally representative sample of US young adult (18-29) cigarillo users and susceptible non-users. Participants were randomised to one of three experimental conditions: text-only or one of two pictorial conditions (combined for analyses). For each warning, we assessed negative emotional reactions, cognitive elaboration (ie, thinking about cigarillo risks) and perceived message effectiveness (PME).

RESULTS

Participants (N=661) were 46.5% female, 64.7% white and 21.9% Hispanic; 34.1% reported past 30-day cigarillo use; 41.4% were lifetime users (excluding past 30-day use); and 24.4% were susceptible non-users. Pictorial warnings elicited more negative emotional reactions and higher PME than text-only warnings (p values<0.01), with interactions showing the largest effects for past 30-day users (emotional reactions: d=0.99, PME: d=0.63). For cognitive elaboration, there was no main effect of warning type, but an interaction revealed effects for past 30-day users (p<0.05, d=0.46).

CONCLUSIONS

Pictorial cigarillo warnings elicited greater negative emotional reactions and PME compared with text-only warnings. These effects and the effects on cognitive elaboration were strongest for past 30-day users. Our findings extend research on cigarette warnings to cigarillos, demonstrating that pictorial warnings are superior to text-only warnings for cigarillos in eliciting beneficial responses.

Carbonyl Yields in Cigars under Three Smoking Regimens Using a Linear Smoking Machine

This study used standard linear smoking machines and puffing protocols to generate data on carbonyl yields in mainstream smoke from 11 unfiltered sheet-wrapped cigars (SWC), seven leaf-wrapped cigars (LWC), and two Kentucky reference cigarettes (3R4F, 1R6F). Carbonyl yields in cigar and cigarette products were determined using three different smoking regimens: International Organization for Standardization (ISO), Canadian Intense (CI), and Cooperation Centre for Scientific Research Relative to Tobacco (CORESTA) Recommended Method (CRM) No. 64 (CRM64, Routine Analytical Cigar-Smoking Machine─Specifications, Definitions and Standard Conditions). Mainstream tobacco smoke was collected using a smoking machine fitted with an impinger containing 2,4-dinitrophenylhydrazine (DNPH) and carbonyl compounds quantified using liquid chromatography with an ultraviolet detector. Commercial SWC and LWC generated comparable formaldehyde yields (SWC, 9.4-28 μg/cigar [ISO], 8.2-43 μg/cigar [CI], 8.6-13 μg/cigar [CRM64]; LWC, 11-13 μg/cigar [ISO], 11-22 μg/cigar [CI], 16-21 μg/cigar [CRM64]) and acrolein yields; however, LWC generated higher acetaldehyde yields compared to SWC, using CI and CRM64 regimens. Reference cigarettes using standard puffing regimens generated carbonyl yields within reported ranges and 5-10% RSDs, whereas the CRM64 regimen generated lower carbonyl yields and 12-14% RSDs. Reference cigarettes generated higher formaldehyde yields using cigarette smoking regimens (21-28 μg/cigarette under ISO, 76-96 μg/cigarette under CI) but comparable formaldehyde yields under CRM64 (12-14 μg/cigarette). In addition, this study evaluated physical parameters (e.g., tobacco weight, length, diameter, circumference, tobacco rod density) that show the correlation between tobacco weight, tobacco rod density, and acetaldehyde yields under the three smoking regimens. Carbonyl yields in the mainstream smoke of cigar products using the three smoking regimens were highly variable; however, the CI smoking regimen may provide meaningful analytical information regarding cigar smoke constituents, with lower likelihood of self-extinguishment due to the short puffing intervals.

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.

Review of cigars and cigar-type products as potential sources of consumer exposure to heavy metals

The popularity of cigars, growing since 1993, has not gone hand in hand with the increased interest of researchers in these products. Although the literature widely describes the harmfulness of tobacco and the content of toxic substances in tobacco products, the topic is often treated selectively as relating primarily to cigarettes and rarely extends to other products of the broadly defined tobacco industry. However, there is no reason to marginalize the harmful effects of other nicotine products, (which include tobacco products such as cigars). The study analyzed the available literature on the content of selected heavy metals in cigar tobacco. Among the heavy metals, the following contents of elements in tobacco were recorded in cigars: Fe (420-2200 µg/g), Mn (100-370 µg/g), Zn (14-180 µg/g), Cu (15-140 µg/g), Pb (not detected-32 µg/g), Cd (nd-19 µg/g), Ni (nd-13 µg/g), Cr (nd-10 µg/g), Co (0.65-1.0 µg/g), As (nd-0.66 µg/g), Hg (18-25 ng/g). Importantly, the values often differ between cigars of different origins and types, indicating the need for more extensive research.

Comparison of Measurement Methods for Electronic Cigarette Puff Topography

Objectives

Measurement of electronic cigarette (ECIG) puff topography provides an understanding of how product characteristics and user behavior affect nicotine delivery. However, mouthpiece-based topography devices may affect natural puffing behavior. This study was designed to compare ECIG topography measured by mouthpiece-based eTop computerized device and mouthpiece-free video recordings.

Methods

ECiG-naïve cigarette smokers (N = 18) and ECIG-experienced users (N = 25) puffed on a standardized ECIG via eTop or conventionally; both sessions were videotaped. Following overnight abstinence, participants experienced one directed (10 puffs, 30 sec IPI) and 2 ad libitum puffing bouts. Heart rate and subjective response were measured throughout sessions.

Results

No statistically significant differences between methods were observed for topography, heart rate, or abstinence-related subjective effects, and both methods were accurate and reliable. Use of a mouthpiece was perceived to alter aspects of ECIG puffing (eg, "reduce enjoyment).

Conclusions

The mouthpiece-based eTop measures ECIG topography precisely as when no mouthpiece is used, and interferes minimally with subjective ECIG experience. Reliable and valid ECIG topography measurement methods are an important regulatory tool, as they can be used to understand the interplay between product design and user behavior to predict toxicant exposure.

Five-Day Changes in Biomarkers of Exposure Among Adult Smokers After Completely Switching From Combustible Cigarettes to a Nicotine-Salt Pod System

INTRODUCTION

This study examined changes in biomarkers of exposure (BoE) after 5 days of nicotine-salt pod system (NSPS) use, compared with continuation of usual-cigarette smoking and cigarette abstinence, among adult combustible cigarette smokers.

AIMS AND METHODS

A randomized, open-label, parallel-cohort, confinement study of healthy adult smokers, naive to NSPS use, was conducted. Participants (N = 90) were randomized to six cohorts (n = 15 each): exclusive ad libitum use of NSPS (four flavors: Virginia Tobacco, Mint, Mango, Creme), continuation of usual-brand cigarette smoking, or cigarette abstinence. Total nicotine equivalents and BoE (NNN, NNAL, 3-HPMA, MHBMA, S-PMA, HMPMA, CEMA, 1-OHP, and COHb) were measured.

RESULTS

Eight non-nicotine BoEs, measured in urine, were reduced by an aggregate of 85.0% in the pooled NSPS cohort; increased by 14.4% in the cigarette cohort (p < .001 for pooled NSPS vs. cigarette); and reduced by 85.3% in the abstinence cohort (p > .05; 99.6% relative reduction between pooled NSPS vs. abstinence). Similar changes in individual BoEs were also observed (p < .001 for each BoE between pooled NSPS vs. cigarettes; and abstinence vs. pooled NSPS; p > .05 for each BoE between pooled NSPS vs. abstinence). Blood COHb decreased by 71.8% in the pooled NSPS cohort and 69.1% in the abstinence cohort (p > .05) and increased by 13.3% in the cigarette cohort (p < .001). Mean total urine nicotine equivalents increased in the pooled NSPS and cigarette cohorts by 9% and 26%, respectively, and did not significantly differ (p > .05).

CONCLUSION

Complete switching from cigarettes to NSPS produced significant reductions in key non-nicotine BoEs associated with cigarette smoking.

IMPLICATIONS

The results of this study concorded with evidence that complete switching from combustible cigarettes to tobacco and nontobacco-flavored vapor products may reduce exposure to key carcinogens and other toxicants known to be associated with tobacco-related diseases. Future research is needed to assess the long-term health effects of NSPS use. These results should not be interpreted to mean that the use of NSPS is without any risk, particularly for nonusers of tobacco products.

Characterizing #Backwoods on Instagram: "The Number One Selling All Natural Cigar"

We sought to assess the proportion of Backwoods (Imperial Tobacco Group Brands LLC) cigar-related posts to Instagram that may contain misleading claims, nature-evoking imagery, and appealing flavors. Inclusion criteria for this study included an Instagram post with the hashtag "#backwoods" from 30 August to 12 September 2018. Rules were established to content analyze (n = 1206) posts. Categories included misleading packaging (i.e., the post contained an image of a Backwoods product with the descriptor "natural" on the packaging), misleading promo (i.e., the corresponding caption to the post contained hashtag(s) like "#natural", "#authentic", "#alwaystrue"), nature-evoking imagery (i.e., the post contained images of grass, water, and pastural views along with a Backwoods product), flavors (i.e., the post contained a Backwoods product with brand-specific flavors on the packaging), flavor promo (i.e., the corresponding caption to the post contained hashtag(s) of Backwoods' brand-specific flavors), marijuana-related (i.e., the post contained an image of marijuana next to a Backwoods pack, rolled cigars visibly contained marijuana, or hollowed-out cigars next to marijuana), smoking (the post contained an image of smoke or a lit cigar), brand-specific promo (i.e., the post contained an image of a Backwoods t-shirt, sweatshirt, hat, etc.), and perceived gender. Among the posts analyzed, 645 (53.5%) were marijuana-related, 564 (46.8%) were flavors, 463 (38.4%) were misleading packaging, 335 (27.8%) were flavor promo, 309 (25.6%) were misleading promo, 188 (15.6%) were nature-evoking imagery, 165 (13.7%) were smoking, 157 (13.0%) were brand-specific promo, and 239 (19.8%) were perceived male gender. Backwoods cigar-related posts to Instagram often contained misleading images and promotions of a "natural" tobacco product, images of marijuana use (in the form of blunt-making), brand-specific flavors, smoking, and promotional merchandise. Misleading images and the depictions of marijuana use in addition to the variety of flavor options may increase product appeal to consumers. These results underscore the need for comprehensive regulation of cigar products similar to cigarettes.

"Phantom smokers": Young cigarillo users who do not identify as smokers

INTRODUCTION

Many young consumers of non-cigarette tobacco products, such as cigarillos, do not identify as smokers. These "phantom smokers" tend to underestimate risks to health and feel little urgency to quit. This study examines the prevalence and characteristics of phantom smoker status among young cigarillo users.

METHODS

An online survey was conducted among 14-28 year olds who smoke at least 2 cigarillos per week. Phantom smoker status was determined by a negative response to "Do you consider yourself a smoker?" Other variables included smoking frequency, group smoking and sharing, and confidence in ability to quit. Associations between smoker identity and these variables were tested using chi square, independent samples t-tests and multivariable logistic regression.

RESULTS

Of 1089 respondents, 242 (22%) were identified as phantom smokers. Phantoms smoked half as many cigarillos per week as identified smokers (M = 4.75, SD = 5.11 vs. M = 11.33, SD = 0.88, p < .001) and phantoms were more likely to smoke only when sharing (39.7% vs 21.8%, p < .001). While 59.5% of identified smokers also smoked cigarettes, only 33.5% of phantoms did so (p < .001). Most phantom smokers (83.8%) were unconcerned about addiction. Phantoms also expressed greater confidence in their ability to quit (M = 4.40, SD = 0.98) than did identified smokers (M = 3.72, SD = 1.25, p < .001).

CONCLUSIONS

Despite regular cigarillo use, over 20% of respondents did not identify as smokers. Cigarillo smoking, along with non-daily and shared use, should be routinely assessed among youth. Phantom smokers' lack of concern about addiction and high confidence in their ability to quit may render conventional messages about smoking risk ineffective.

Tobacco carcinogens and the methionine metabolism in human bladder cancer

Cigarette smoking is a strong risk factor for bladder cancer. It has been shown that the duration of smoking is associated with a poor prognosis and a higher risk of recurrence. This is due to tobacco carcinogens forming adducts with DNA and proteins that participate in the DNA repair mechanisms. Additionally, polymorphisms of genes responsible for methyl group transfer in the methionine cycle and dosages of vitamins (from diet and supplements) can cause an increased risk of bladder cancer. Upregulated DNA methyltransferase 1 expression and activity results in a high level of methylated products of metabolism, as well as hypermethylation of tumor suppressor genes. The development of a market that provides new inhibitors of DNA methyltransferase or alternatives for current smokers is essential not only for patients but also for people who are under the danger of secondhand smoking and can experience its long-term exposure consequences.

Systematic Review of Health Communication for Non-Cigarette Tobacco Products

The Food and Drug Administration, which now has regulatory authority over all tobacco products meeting the statutory definition, is tasked with communicating the risks of these products to the public through health warnings and public education. However, there have been no attempts to summarize what is known about non-cigarette tobacco product (NCTP) health messaging. We conducted a systematic review to examine the existing literature on health communication for NCTPs and identify key research gaps. A total of 45 unique studies were retrieved and coded, with the majority focused on messaging for smokeless tobacco (SLT, k = 32, 71.1%), followed by waterpipe tobacco (WT, k = 9, 20%), electronic nicotine delivery systems (ENDS, k = 2, 4.4%), cigars (k = 2, 4.4%), and a potentially reduced exposure product (k = 1, 2.2%). Studies most commonly examined tobacco product warnings (k = 26, 57.8%) and public education (k = 19, 42.2%), which included mass media campaigns. Most studies examined knowledge, attitudes, and beliefs as outcomes (k = 27, 60%), while behavior was an outcome in the minority of studies (k = 8, 17.8%). Pictorial warnings and public education about NCTPs demonstrated positive impact in some studies, although the literature is nascent. Given the increasing use of NCTPs such as ENDS, WT, and cigars, particularly among adolescents and young adults, more research is needed on effective ways to communicate product risk to those audiences most at risk.

Biomarkers of Exposure among U.S. Adult Cigar Smokers: Population Assessment of Tobacco and Health (PATH) Study Wave 1 (2013-2014)

BACKGROUND

Given the diverse cigar market and limited data on biomarker patterns by cigar type, we compared biomarkers of nicotine and tobacco toxicants among cigar smokers and other groups.

METHODS

Using Wave 1 urinary biomarker data from 5,604 adults in the Population Assessment of Tobacco and Health (PATH) Study, we compared geometric mean concentrations among cigar-only smokers (all cigars and separately for traditional, cigarillo, and filtered cigars), cigarette-only smokers, dual cigar/cigarette smokers, and never users of tobacco. We calculated geometric mean ratios comparing groups with never users adjusting for sex, age, race/ethnicity, education and creatinine.

RESULTS

Some day cigar-only smokers had lower biomarker concentrations than every day cigar-only smokers, but higher than never users. Every day cigar-only smokers (n = 61) had lower TNE-2 (cotinine+trans-3'-hydroxycotinine) compared to every day cigarette-only (n = 2217; P < 0.0001) and dual cigar/cigarette smokers (n = 601; P < 0.0001). Several biomarkers, including NNAL (NNK metabolite) and CYMA (metabolite of acrylonitrile), were comparable in these groups. In exploratory analyses, every day filtered cigar-only (n = 7) smokers had higher biomarker concentrations compared with every day traditional cigar-only smokers (n = 12) and cigarillo-only smokers (n = 24). Every day smokers of each cigar type were similar to exclusive cigarette smokers. For some biomarkers, particularly for every day filtered cigar-only smokers, concentrations were higher.

CONCLUSIONS

For some biomarkers, every day cigar-only smokers were comparable with every day cigarette-only smokers. Exploratory analyses suggest that biomarkers vary by cigar type with every day filtered cigar-only smokers having the highest concentrations.

IMPACT

High exposure to harmful constituents among cigar smokers is a continuing health issue.

Triangulating abuse liability assessment for flavoured cigar products using physiological, behavioural economic and subjective assessments: a within-subjects clinical laboratory protocol

INTRODUCTION

In the USA, Food and Drug Administration regulations prohibit the sale of flavoured cigarettes, with menthol being the exception. However, the manufacture, advertisement and sale of flavoured cigar products are permitted. Such flavourings influence positive perceptions of tobacco products and are linked to increased use. Flavourings may mask the taste of tobacco and enhance smoke inhalation, influencing toxicant exposure and abuse liability among novice tobacco users. Using clinical laboratory methods, this study investigates how flavour availability affects measures of abuse liability in young adult cigarette smokers. The specific aims are to evaluate the effect of cigar flavours on nicotine exposure, and behavioural and subjective measures of abuse liability.

METHODS AND ANALYSES

Participants (projected n=25) are healthy smokers of five or more cigarettes per day over the past 3 months, 18-25 years old, naive to cigar use (lifetime use of 50 or fewer cigar products and no more than 10 cigars smoked in the past 30 days) and without a desire to quit cigarette smoking in the next 30 days. Participants complete five laboratory sessions in a Latin square design with either their own brand cigarette or a session-specific Black & Mild cigar differing in flavour (apple, cream, original and wine). Participants are single-blinded to cigar flavours. Each session consists of two 10-puff smoking bouts (30 s interpuff interval) separated by 1 hour. Primary outcomes include saliva nicotine concentration, behavioural economic task performance and response to various questionnaire items assessing subjective effects predictive of abuse liability. Differences in outcomes across own brand cigarette and flavoured cigar conditions will be tested using linear mixed models.

ETHICS AND DISSEMINATION

The Virginia Commonwealth University Institutional Review Board approved the study (VCU IRB: HM20007848). Dissemination channels for study findings include scientific journals, scientific meetings, and policy briefs.

TRIAL REGISTRATION NUMBER

NCT02937051.

Nicotine pharmacokinetics of electronic cigarettes: A review of the literature

E-cigarettes are battery-powered electronic devices from which users can inhale nicotine following its aerosolisation from a liquid solution. Some regulators and public health bodies consider e-cigarettes as potentially playing a major role in tobacco harm reduction. Their ability to provide nicotine to smokers in both amount and in a manner and form generally similar to cigarette smoking have been proposed as key components to help smokers reduce or cease the use of combustible cigarettes. Nicotine pharmacokinetic studies of e-cigarettes have been performed for a number of years and are beginning to show how nicotine delivery is evolving as the products themselves evolve. In this review, we provide a critical overview of the literature to describe what is known about nicotine delivery from e-cigarettes. We will discuss how the progression of e-cigarette design, development, and user familiarity has allowed increases in nicotine availability to the user, in the context of how much and how rapidly nicotine is delivered during acute-use periods. This review will also provide insight into current research gaps and highlight the potential utility of modelling and the standardisation of methodologies used to assess nicotine delivery to facilitate identification of products that are best suited to displace cigarette smoking among adult smokers.

Marijuana use predicts onset of current little cigar use in a national sample of US young adults

BACKGROUND

This study examined whether young adult marijuana use increases risk of subsequent large cigar (LC) and little cigar/cigarillo (LCC) use among naïve users.

METHODS

Data were from 8 waves of the Truth Initiative Young Adult Cohort, a national sample of US young adults aged 18-34 assessed every 6 months. Discrete-time survival analyses examined whether baseline ever marijuana use among never cigar users predicted onset of past 30-day LC and LCC use and whether baseline ever LC and LCC use among never marijuana users predicted onset of past 30-day marijuana use. Models adjusted for demographics, past 30-day alcohol use, past 30-day tobacco product use, and menthol tobacco use.

RESULTS

In adjusted models, baseline ever marijuana use predicted onset of past 30-day LCC but not LC use. Cumulative risk ratios showed that 23% of ever marijuana users at baseline reported past 30-day use of LCCs by the end of wave 8 compared to just 3% of baseline never marijuana users. Race and past 30-day use of specific tobacco products also predicted onset of past 30-day LC and LCC use. Past 30-day use of alcohol uniquely predicted onset of past 30-day LCC use but not LC use. Baseline ever LC and LCC use did not predict onset of past 30-day marijuana use in models that adjusted for demographics, alcohol, and specific tobacco product use.

CONCLUSIONS

Ever marijuana use among US young adults may be an important predictor of onset of regular LCC use. Findings suggest different pathways linking marijuana to different cigar sub-types.

Cigarettes, Little Cigars, and Cigarillos: Initiation, Motivation, and Decision-Making

Introduction

Cigarettes and little cigars and cigarillos (LCCs) are the most prevalent dual-use tobacco combination; one-third of cigarette smokers use LCCs. Risk factors for multiple tobacco product use have been reported; however, there is little understanding of why some individuals transition to and maintain multiple product use. In this study, we examine narratives of tobacco product initiation and decision-making among LCC-only and LCC-cigarette smokers.

Methods

We audio-recorded in-depth interviews with 60 individuals, aged 14-28, who reported smoking more than or equal to 1 cigarillo per week; half also smoked cigarettes. Transcribed interviews were coded using a phenomenological approach to examine themes about smoking initiation, motivation, and product decision-making.

Results

Among dual users, 60% began smoking LCCs before or at the same time as cigarettes, and 40% began smoking cigarettes first. Reasons for smoking cigarettes in addition to LCCs included easier access when experiencing craving and less time to smoke the product. Cigarette smokers reported first smoking LCCs in social contexts when sharing LCCs with other smokers, or when they could afford a single LCC but not a pack of cigarettes. LCC-only smokers reported not smoking cigarettes because of their expense, unpleasant taste and/or smell, and fear of becoming addicted.

Conclusions

In this sample of current LCC users, half also used cigarettes. Product initiation order was almost evenly split, but reasons for initiating the second product differed, with immediacy of reducing cravings as a key reason for LCC users to smoke a cigarette and social and financial reasons for cigarette users to smoke an LCC.

Implications

Understanding how and why dual use is initiated and sustained can inform policies to help prevent increased nicotine dependence and initiation of additional tobacco products. This study demonstrates that the beliefs, perceptions, and practices of LCC-only and dual users inform their product selection. Our findings point to the need to apply the strategies that have been effective at decreasing cigarette consumption to LCCs.

An Ecological Momentary Assessment of Cigarette and Cigar Dual Use Among African American Young Adults

Introduction

The dual use of cigarettes and cigars among African American young adults is a significant public health issue. Patterns of and reasons for dual use are difficult to capture using traditional self-report methods. This study used ecological momentary assessment (EMA) to characterize patterns of dual smoking and examine the personal and environmental predictors of cigarette and cigar smoking among African American young adult dual users (ages 18-29) in real-time.

Methods

For 14 days, 64 participants smoked ad libitum and were prompted four times daily to record their smoking, craving, emotions, social smoking, and environment via text message on their mobile phones. The odds of single product and dual use were examined using adjusted generalized estimating equations.

Results

Participants smoked an average of 7.9 cigarettes and 4.2 cigars per day. Cigarettes and cigars were smoked as frequently during periods of dual use as they were during periods of single product use. Cigarette craving was positively associated with cigarette-only smoking (OR: 1.07), whereas cigar craving was positively associated with cigar-only smoking (OR: 1.43) and dual use (OR: 1.08). Cigars had the greatest odds of dual use when with others (OR: 4.69) and in others' homes (OR: 4.33). Cigarettes had the greatest odds of being smoked while alone (OR: 1.57).

Conclusions

EMA was useful for capturing variable smoking patterns and predictors. In this study population, cigarettes and cigars appeared to be smoked additively, and cigars smoked socially. These findings can inform future interventions addressing dual use in this high priority population.

Implications

This is the first study to use EMA to examine naturalistic patterns and predictors of multiple tobacco use in real-time. African American young adults smoked cigarettes and cigars during periods of dual use as frequently as during periods of single product use. This suggests that most use was additive (one product smoked in addition to another) and less often as substitution (one product smoked instead of another). Social smoking and craving were strongly associated with cigar smoking in single and dual use periods. This study suggests the need for cessation messaging specifically targeted to reduce dual use in this population.

Cigarillo and Little Cigar Mainstream Smoke Constituents from Replicated Human Smoking

Little cigar and cigarillo smoking is increasing in popularity in the U.S., but little is known about the topography and mainstream smoke (MSS) constituents of these types of cigar products. This report describes the quantity of selected MSS toxicants generated from puff-by-puff replication of human laboratory smoking. Participants were dual users of cigarettes and either little cigars ( n = 21) or cigarillos ( n = 23). In the laboratory smoking session, participants of the little cigar group smoked a filtered unflavored Winchester Little Cigar; those in the cigarillo group smoked an unfiltered, unflavored Black & Mild cigarillo. MSS components included both volatiles and semivolatile compounds. The MSS of five representative U.S. domestic cigarettes was generated using smoking topography profiles of the participants smoking their own brand of cigarettes. Machine smoking accurately replicated individual puff profiles as indicated by a high correlation between lab and machine smoked: time to smoke, number of puffs, and total puff volume. There was wide variability in smoking patterns across subjects of both little cigars and cigarillos. For example, total puff volume ranged from 84 to 732 mL after the little cigar and from 270 to 2089 mL after the cigarillo. Qualitatively, cigar smoke from little cigars and cigarillos were similar and resembles cigarette smoke. All analytes (VOC and SVOCs) were greater in cigarillo smoke compared to that of little cigars and cigarettes. However, when the toxicants were adjusted for grams of tobacco burned, little cigar smoke contained more nicotine, tobacco-specific nitrosamines, acetonitrile, and acrylonitrile compared with cigarillo smoke. When the constituents were adjusted for nicotine content, cigarillo MSS contained more of all toxicants compared with little cigar. Cigarillos and little cigars, like cigarettes, deliver nicotine and other toxicants known to be harmful to health; their regulation by the FDA is appropriate for their public health risk.

Urine Cotinine level with smoking history predicts a risk of coronary artery calcification

We investigated whether urine cotinine level, alone or combined with smoking status and cumulative smoking amount, could predict coronary calcium (CAC) score increase over time. The study population included 10,980 subjects. We analysed an association between CAC score increase over time and single or combined smoking-related factors. Urine cotinine level of ≥100 ng/mL, current or ex-smokers, and cumulative smoking amount of ≥1 pack-years (PY) showed significantly higher odds ratios (ORs) for CAC score increase over time. A combination of current smokers with >10 PY and urine cotinine level of ≥100 ng/mL showed the highest OR. Irrespective of smoking status and cumulative smoking amount, all combinations with urine cotinine of ≥100 ng/mL showed higher ORs than other combinations with urine cotinine level of <100 ng/mL. Urine cotinine levels can be useful to predict coronary artery calcification and encourage smokers to quit smoking.

Characterizing Blunt Use Among Twitter Users: Racial/Ethnic Differences in Use Patterns and Characteristics

BACKGROUND

Young adult Twitter users are exposed to and often participate in tweets that promote risky behaviors, such as blunt use. Blunts are hollowed out cigars or cigarillos that are filled with marijuana.

OBJECTIVES

The current study was designed to determine the use patterns and characteristics of African American, Hispanic and White young adult Twitter users who reported past month blunt use.

METHODS

Young adults (N = 753, 74% male) who reported past month blunt use were recruited via Twitter to participate in a brief anonymous online survey about their blunt use.

RESULTS

Findings revealed that African American young adults initiated blunt smoking at an earlier age (14.8 years), reported more days of blunt smoking in the past month (23.2 days) and smoked more blunts in the past month (27.2 blunts) than their Hispanic (16.5 years, 19.7 days, and 15.4 blunts) and White (18.1 years, 15.8 days, and 22.2 blunts) counterparts, p <.01. African American young adults were more likely than their White counterparts to report physical craving as an obstacle to quitting blunt smoking. Several racial/ethnic differences were also found on attitudes about blunt use and reasons for initiating and continuing to smoke blunts.

CONCLUSIONS

Findings suggest that blunt use patterns and attitudes about blunt use vary by race/ethnicity. Understanding racial/ethnic differences in blunt use patterns and characteristics offers opportunities to tailor future interventions and enhance outcomes among African American, Hispanic and White young adults.

Large Cigars: Smoking Topography and Toxicant Exposure

Background

Cigar smoking in the United States continues despite decreases in cigarette smoking and increased tobacco control efforts. We compared large cigar and cigarette smoking for use patterns, smoking topography, and toxicant exposure.

Methods

Dual users (n = 17, 94% men, 77% African American) smoked ad libitum either their usual cigarette brand or a study large cigar (Phillies Blunt) in two laboratory sessions. Plasma nicotine and exhaled carbon monoxide were collected before and after smoking. Smoking topography measures of puff volume, puff duration, puff velocity, and interpuff interval were also collected.

Results

Both cigarettes and large cigars significantly increased plasma nicotine and carbon monoxide and significantly decreased the urge to smoke. Cigarettes delivered more nicotine per gram of tobacco smoked and per 1000 mL of puff volume. Number of puffs, time to smoke, puff volume, and puff velocity were significantly larger and interpuff interval was significantly shorter in large cigar smoking. The temporal pattern of puffing more intensely at the beginning of smoking was similar for both large cigars and cigarettes.

Conclusions

People who regularly use both large cigars and cigarettes adapt their smoking pattern such that they are exposed to similar levels of nicotine from each product. The immediate increase in plasma nicotine and carbon monoxide suggest significant inhalation of large cigar smoke. These data call to question the assumption that cigar smoking is less toxic than cigarette smoking. By smoking large cigars, dual users expose themselves to toxic components that have been linked with the addiction risk, morbidity, and mortality of cigarette smoking.

Implications

This study found that dual users of large cigars and cigarettes inhale significant quantities of carbon monoxide, nicotine, and presumably other components of mainstream smoke. Large cigar smoke exposure may lead to or sustain nicotine addiction as wells as subject large cigar consumers to similar risks associated with cigarette smoking such as lung cancer and cardiovascular disease.

Use Behaviors, Dependence, and Nicotine Exposure Associated with Ad Libitum Cigar Smoking

Objectives

To examine factors important to cigar smoking and subsequent nicotine exposure, we evaluated the impact of cigar type, cigarette smoking history, and inhalation behaviors on nicotine dependence, smoking topography, and biomarkers of exposure in current exclusive cigar smokers.

Methods

Adult, exclusive cigar smokers (N = 77) were recruited based on cigar type, cigarette smoking history, and self-reported inhalation behaviors. Participants smoked their own brand product ad libitum for up to one hour; dependence symptoms, smoking topography, and biomarkers of exposure were assessed.

Results

Cigar smokers showed low levels of dependence. Cigar smoking alleviated withdrawal and craving symptoms, increased plasma nicotine concentration, and increased exhaled CO. Multiple regression analyses indicate that inhalation behaviors were associated with increased dependence and greater reductions in withdrawal symptoms upon cigar smoking. Large cigar smokers smoked longer and smoked more tobacco than small cigar and cigarillo smokers. Furthermore, large cigar smokers and self-reported inhalers were exposed to more nicotine than small cigar smokers and non-inhalers.

Conclusions

Our study suggests that cigar type and smoking behaviors affect dependence and nicotine exposure upon cigar smoking. These findings provide additional insight into the substantial risks associated with cigar smoking.

Beyond blunts: Reasons for cigarette and cigar use among African American young adult dual users

BACKGROUND

African American young adults are at high risk for dual use of cigarettes and cigars. Limited work has explored and characterized the reasons for use in this population and their relative importance for initiation and current smoking of these products.

METHOD

Reasons for cigarette and cigar use were systematically explored and categorized using a mixed methods participatory approach called concept mapping. A series of in-person group sessions were held with 30 African American young adult (ages 18-29) current smokers of both cigarettes and cigars in Prince George's County, MD and Washington, DC. Participants brainstormed, sorted, rated, and interpreted their reasons for initiation and past 30-day use of cigarettes and cigars. A cluster map was generated using multi-dimensional scaling, and t-tests were used to explore differences in ratings by background characteristics.

RESULTS

Participants generated 64 reasons for smoking cigarettes and cigars, and categorized these reasons into six groups: emotions, urges, access, product characteristics, lifestyle, and outside pressure. Emotions and urges were the most important motivations for initiation and current smoking of both products. Product characteristics were significantly more important for cigar initiation and smoking than for cigarettes, and outside pressure was more important for current smoking of cigars than cigarettes. Ratings differed by gender, socioeconomic status, and smoking characteristics.

CONCLUSIONS

Cigarette and cigar smoking have several overlapping motivations, but key differences were also found, most notably for product characteristics. The FDA's regulation of cigars and cigarettes should focus on addressing key characteristics appealing to young adults to curb dual use.

Surveillance of Nicotine and pH in Cigarette and Cigar Filler

OBJECTIVE

We examined differences between nicotine concentrations and pH in cigarette and cigar tobacco filler.

METHODS

Nicotine and pH levels for 50 cigarette and 75 cigar brands were measured. Non-mentholated and mentholated cigarette products were included in the analysis along with several cigar types as identified by the manufacturer: large cigars, pipe tobacco cigars, cigarillos, mini cigarillos, and little cigars.

RESULTS

There were significant differences found between pH and nicotine for cigarette and cigar tobacco products. Mean nicotine concentrations in cigarettes (19.2 mg/g) and large cigars (15.4 mg/g) were higher than the other cigars types, especially the pipe tobacco cigars (8.79 mg/g). The mean pH for cigarettes was pH 5.46. Large cigars had the highest mean pH value (pH 6.10) and pipe tobacco cigars had the lowest (pH 5.05).

CONCLUSIONS

Although cigarettes are the most common combustible tobacco product used worldwide, cigar use remains popular. Our research provides a means to investigate the possibility of distinguishing the 2 tobacco product types and offers information on nicotine and pH across a wide range of cigarette and cigar varieties that may be beneficial to help establish tobacco policies and regulations across product types.

Smoking Behavior and Smoke Constituents from Cigarillos and Little Cigars

OBJECTIVE

Although most cigarillos and little cigars smokers also smoke cigarettes (dual use), there are few studies comparing toxicant exposure and smoking behavior in cigars and cigarettes.

METHODS

Two groups of dual users smoked their usual brand of cigarette and either a Winchester unflavored little cigar (N = 21) or a Black & Mild cigarillo (N = 23). Acute exposure of nicotine and exhaled carbon monoxide (CO) and puffing topography parameters were collected. Individual cigar puffing data were used to machine-replicate smoking for analysis of volatile organic compounds (VOC) and semi-volatile organic compounds (SVOC) in mainstream smoke.

RESULTS

There were significant differences in puff topography, plasma nicotine and exhaled CO after cigarettes, little cigars, and cigarillos. Puff topography differences between cigarillos and cigarettes were due to the difference in the size of the article. Mainstream cigar and cigarette smoke was qualitatively similar; the yield was dependent on the smoking behavior. When smoke yield was adjusted for weight of tobacco burned or puff volume, exposure differences decreased.

CONCLUSIONS

There is a wide range of delivery of both SVOC and VOC components of cigar and cigarillo smoke. The difference in exposure is largely dependent on the article size and the amount consumed.

Does marijuana "blunt" smoking contribute to nicotine exposure?: Preliminary product testing of nicotine content in wrappers of cigars commonly used for blunt smoking

INTRODUCTION

An increasingly popular method of consuming marijuana is through the smoking of "blunts," cigar products in which some or all of the tobacco filler is removed and repacked with marijuana. Even if all tobacco filler is removed from the cigar product in the process of making blunts, nicotine may be present in the wrapper of the cigar product. This preliminary analysis quantified the nicotine content in wrappers of cigar products commonly used for blunt smoking.

METHODS

Five cigar products (3 large cigars, 2 cigarillos) were tested, yielding physical characteristics of cigar length, diameter, weight, and wrapper weight. Nicotine concentration in the wrapper of each cigar product was analyzed via gas chromatography/mass spectrometry. Total nicotine content in the wrapper of each cigar product was computed as the product of cigar wrapper weight and nicotine concentration in wrapper.

RESULTS

Depending on the product, the cigar wrapper contributed between 8 and 18% of the weight of the entire cigar article. Total nicotine content in the cigar wrapper ranged from 1.2 to 6.0mg per cigar.

DISCUSSION

All 5 tested cigar products had wrappers that contain quantifiable levels of nicotine, indicating that users of blunts may expose themselves to some degree of nicotine, the addictive component of tobacco. Future experimental studies that examine the efficiency of nicotine delivery from typical blunt smoking, as well as surveillance studies that quantify the number of blunts smoked by an individual per day, are needed to evaluate the contribution of blunt smoking to nicotine dependence.

Little Cigars and Cigarillos: Users, Perceptions, and Reasons for Use

OBJECTIVE

This study examines little cigar and cigarillo (LCC) adult user characteristics, perceived addictiveness, use and importance of flavors, intentions to continue use, and reasons for use to inform prevention efforts and regulatory policy.

METHODS

Data come from the 2014 Tobacco Products and Risk Perceptions Survey of a national probability sample of 5717 US adults, conducted online, June-November, 2014. The analytic sample consisted of 141 current LCC users.

RESULTS

Current LCC smokers were more likely to be male, younger, black or Hispanic, lower SES, current cigarette smokers, and to report poorer health than non-smokers. Perceived addictiveness was low overall, with 73.6% considering themselves "not at all" addicted, although female LCC users and dual users of cigarettes were more likely to consider themselves addicted to LCCs. Use of flavored LCCs was widespread. Flavors were cited as important reasons for use, especially among younger users, as were favorable comparisons with affordability and burn time of cigarettes.

CONCLUSIONS

Most LCC users do not perceive themselves addicted to LCCs. Users report being influenced most by flavorings and affordability, indicating that appropriate regulations and education to improve health perceptions could help reduce use of these harmful products.