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

Does noticing cigar warnings associate with cigar harm perceptions and smoking behaviors? Analysis from Wave 5 of the population assessment of tobacco and health study

BACKGROUND

In the US, cigar warning label standards are less stringent than cigarette warning requirements and are not uniformly required; research is needed about warning efficacy in promoting cigar risk beliefs, discouraging use and supporting public health.

METHODS

Using data from the PATH Study (Wave 5), we analyzed associations between noticing cigar warnings and perceived harm from cigar use, frequency of thinking about harms, and effects of warnings labels.

RESULTS

Among adults who smoke cigars, respondents noticing warnings at least sometimes (vs. never/rarely) had higher odds of thinking about harms of their tobacco use often/very often (cigarillos 30% vs. 19%, p <.001, aOR 1.80 [1.27, 2.56]); filtered cigars: 43% vs. 16%, p <.001, aOR 3.81 [2.50, 5.82]) and of reporting that smoking cigars is very/extremely harmful (cigarillos: 59% vs. 46%, p =.001, aOR 1.45 [1.05, 1.99]). A substantial majority found cigar warnings to be very/extremely believable (cigarillos: 63%, filtered cigars: 59%, traditional cigars: 65%), with 16%, 24% and 12% respectively reporting past-30-day warning avoidance. Those noticing warnings at least sometimes (vs. rarely) had higher rates of reporting that warnings sometimes/often/very often stopped them from having a cigar in the past 30 days (cigarillos: 36% vs. 10%; filtered cigars: 50% versus 6%; traditional cigars: 30% versus 9%; p's < 0.001) and that warnings made them somewhat/a lot more likely to quit smoking (cigarillos: 55% versus 37%, p <.01; filtered cigars: 55% versus 26%, p <.001; traditional cigars: 39% vs. 24%, p <.05).

CONCLUSIONS

Results support potential public health benefits of mandating the presence and increasing salience of cigar warning labels.

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.

The Landscape of Cigar Marketing in Print Magazines from 2018-2021: Content, Expenditures, Volume, Placement and Reach

Cigar consumption has increased in the U.S. over the past decade, yet gaps remain in research on cigar promotion in print magazines. This study examines ad placement, volume, ad characteristics, and associated expenditures for cigars from 2018-2021, and readership data for magazines containing cigar ads. We merged content analysis data with Kantar Media data on magazine placement and expenditures and used magazine readership data from MRI-Simmons. The only brand in print magazines was Black & Mild (B & M), a top cigar brand in the U.S. There were 30 unique B & M magazine ads and 284 occurrences (i.e., appearances in magazines), translating to $46,504,578 in expenditures. All ads featured the word "enjoy/enjoyment" and a warning label. Filtered cigars were the most featured cigar type (75%) and sweets was the most featured flavor (78%). Nearly half of the publications in which B & M were advertised in have substantial Black/African American readership and were featured in publications with disproportionate young adult and Hispanic/Latino readership. This study identified tactics used in print advertising for a top cigar brand. Future research should examine how these tactics impact consumer perceptions. Findings of cigar ads reaching vulnerable populations may inform the FDA's efforts to reduce health disparities through regulations and public education.

Young adults' cigarillo risk perceptions, attention to warning labels and perceptions of proposed pictorial warnings: a focus group study

OBJECTIVE

Although cigars pose similar health risks to cigarettes, they are not uniformly required to carry a warning label on their packaging in the USA. The US Food and Drug Administration's 2016 deeming rule established a cigar warning requirement, but it was challenged in federal court for failing to document warning effects on prevention/cessation, thus necessitating an evidentiary base for such requirements. We sought to explore young adult users' understanding of cigarillo risks and addictiveness, as well as their perceptions of current (voluntary) and proposed cigar warning labels.

DESIGN

In December 2020-January 2021, we conducted eight focus groups with young adult cigarillo smokers. We asked participants their first associations of cigarillos and beliefs about product harms/addictiveness, and then discussed existing warning labels and examples of potential pictorial warnings.

SETTING

Focus groups were conducted remotely via the Adobe Connect platform, with participants from 20 US states.

PARTICIPANTS

Participants included 42 young adults (ages 18-29; 50% male), who were recent cigarillo users (ie, past 30 days) or less frequent users (ie, past 12 months).

RESULTS

Participants frequently used cigarillos as blunts and often conveyed uncertainty about cigarillo risks and addictiveness, in general and relative to cigarettes. Participants typically paid little attention to current text warnings, but many expressed that pictorial warnings would more effectively promote knowledge of product risks and discourage use among prospective users.

CONCLUSIONS

US young adult cigarillo users may lack knowledge about product risks and addictiveness. Standardised warning requirements, particularly pictorial labels, may help address this knowledge gap and deter use.

Cigar Warning Noticing and Demographic and Usage Correlates: Analysis from the United States Population Assessment of Tobacco and Health Study, Wave 5

Although cigars pose health risks similar to cigarettes, their packaging/marketing is not subject to commensurate regulation in the US. In a 2000 agreement with the Federal Trade Commission, seven major manufacturers agreed to use some form of cigar warning. In 2016, the Food and Drug Administration passed a rule requiring larger standardized warnings, but the requirement was successfully challenged in court. Here, we examined U.S. population-level trends in noticing existing cigarillo, traditional and filtered cigar warnings. We analyzed Wave 5 Population Assessment of Tobacco and Health adult data to assess prevalence of past-30 day warning noticing and associations with socio-demographic and tobacco use variables. Noticing was higher among current users of cigarillos (27%), filtered (34%) and traditional cigars (21%), than non-users (8% for each product, p < 0.0001), and among every-day vs. some-day users, established vs. experimental users, and past-30 day users vs. those without past-30 day use. Results varied by product, but generally indicated lower noticing among non-Hispanic Whites and dual cigarette users, but higher noticing among those purchasing cigars by the box/pack (vs. not purchasing for themselves). Low overall noticing but higher prevalence among frequent users underscores a need for a stronger, uniform cigar warning label policy in the US.