Does Brand Choice Matter: Associations Between Usual E-Cigarette Brands and E-Cigarette Use Patterns Among U.S. Youth, 2021.

BACKGROUND.: To inform youth about e-cigarette use prevention, it is important to understand whether using e-cigarette products from certain brands is associated with youth's differential e-cigarette use patterns and willingness to quit e-cigarettes. METHODS.: Data for this study come from the 2021 U.S. National Youth Tobacco Survey (NYTS). The sample was current (past-30-day) e-cigarette users (unweighted n = 1,436). We examined the associations between users' usual e-cigarette brands (Puff, Vuse, Smoke, JUUL, and others) and e-cigarette use patterns (use frequency, use with nicotine, use with flavors) and willingness to quit, controlling for covariates. RESULTS.: In 2021, 25.6%, 9.7%, 8.1%, and 6.5% of users reported Puff, Vuse, Smok, and JUUL as their usual brands, respectively. Having Smok as a usual brand increased the odds of frequent e-cigarette use compared with other brands. Using Puff, Vuse, and Smok increased the odds of using e-cigarettes with nicotine. Using Puff and Smok increased the odds of using e-cigarettes with any flavors and fruit flavors, and using Smok and JUUL increased the odds of using mint flavors. Finally, using Vuse reduced the odds of having a willingness to quit e-cigarettes. CONCLUSION.: Puff products, which are likely to be used infrequently and with fruit flavors, were the most endorsed usual brand by youth users. Vuse and Smok brand users demonstrated problematic use patterns, including high-frequency use of nicotine and reduced willingness to quit. The high prevalence of using flavors, especially banned flavors (e.g., mint for JUUL products), suggests the need for tightened restrictions on youth's access to flavored e-cigarettes.

Cross-sectional Use Patterns and Characteristics of Premium Versus Non-Premium Cigar Smokers in the United States, 2010-2019.

INTRODUCTION: Few studies have addressed the use patterns and characteristics of the past 30 days of premium versus non-premium cigar smokers. AIMS AND METHODS: We pooled 10 years of data from the National Survey on Drug Use and Health (NSDUH; 2010-2019) to evaluate use patterns and demographic and tobacco use characteristics of premium and non-premium cigar smokers ages 12 years and older in the U.S. cigar-type was manually coded as premium or non-premium according to the brand used most often. RESULTS: Between 2010 and 2019, 4.7% (95% CI = 4.6-4.8) of individuals aged 12 and older currently smoked cigars (past-30-day use). Smoking premium cigars (0.9% [95% CI = 0.8-0.9]) was less prevalent than smoking non-premium cigars (3.0% [95% CI = 2.9-3.1]). Although current non-premium cigar smoking prevalence steadily declined over the years, current premium cigar smoking prevalence remained stable. Premium cigar smokers were more likely to be older (≥25 years), male, non-Hispanic white, heterosexual, college educated, living in a large metro area, and to have income above 200% of the poverty threshold compared to non-premium users (p < .05). Additionally, past-30-day premium cigar smokers were less likely than non-premium users to initiate cigar smoking before the age of 18 years, smoke cigars frequently or daily, smoke cigarettes, or use marijuana (p < .05). CONCLUSIONS: Overall, premium cigar smoking is less prevalent than non-premium cigar smoking, especially among populations such as youth, racial/ethnic and sexual minorities, and low socioeconomic individuals. Premium cigar smokers tend to smoke infrequently and initiate cigars later in life compared with non-premium smokers. Study results can inform recommendations for regulating premium cigars. IMPLICATIONS: This study found that between 2010 and 2019, there are meaningful differences in the use patterns and characteristics of past-30-day premium versus non-premium cigar smokers in the United States. Premium cigars comprise a small share of the market compared to other cigar types and are less likely to be used by youth and other tobacco control priority groups (eg, racial/ethnic minorities and individuals with low socioeconomic statuses) that bear a disproportionate burden of risk and harm from using tobacco products. Additionally, most premium cigar users smoke them only occasionally. However, it is important to continue to monitor premium cigar use, as these patterns could shift because of factors like changes in marketing practices, consumer awareness, and product prices. Tobacco policy changes may also alter the patterns and trends of premium cigar use over time. A greater, more comprehensive understanding of premium cigars' physical characteristics, patterns of use, user perceptions, tobacco industry marketing strategies, and health effects will together help to inform cigar-related regulations.

Influence of cigarillo packaging characteristics on young adults' perceptions and intentions: findings from three online experiments.

OBJECTIVES: Packaging is an important component of tobacco marketing that influences product perceptions and use intentions. However, little research exists on cigar packaging. We leveraged variability in existing Swisher Sweets cigarillo packaging to extend the evidence base. METHODS: Between 2017 and 2019, we conducted three online experiments with 774 young adult past-year cigar smokers recruited via Amazon Mechanical Turk. After viewing Swisher package images that differed by flavour descriptor and/or colour, participants rated them on perceptions and purchase intentions. In study 1, participants viewed one of four cigarillos ('Wild Rush Encore', 'Wild Rush Limited', 'Twisted Berry' and 'Strawberry'). In study 2, participants viewed two different watermelon rum-flavoured cigarillos ('Boozy Watermelon' and 'Island Madness'). In study 3, participants viewed two of three 'Wild Rush' cigarillo versions ('Encore' with or without an explicit flavour descriptor or 'Limited'). RESULTS: In study 1, more participants perceived 'Twisted Berry' and 'Wild Rush Limited' as tasting good and less harsh tasting compared with 'Wild Rush Encore'. In study 2, compared with 'Island Madness', more participants perceived 'Boozy Watermelon' as tasting good, less harsh tasting and used by younger users but less by masculine users; female participants were more likely to purchase 'Boozy Watermelon'. In study 3, participants perceived 'Wild Rush Encore' with the explicit flavour descriptor as tasting better than packages without and being used by younger users but less by masculine users. CONCLUSIONS: Variations in cigarillo packaging, even among cigarillos with the same flavour, may have differential consumer appeal, suggesting packaging features should be considered in cigar product regulation.

Closing the loopholes on a flavored cigar ban: Anticipated challenges and solutions.

For the first time since Congress authorized the U.S. Food and Drug Administration (FDA) to regulate tobacco in 2009, FDA proposed two tobacco product standards on May 4, 2022. After a period of public comment and agency review, if the product standards are finalized in their current form, they will ban menthol cigarettes (U.S. Food and Drug Administration, 2022b), which comprised 37% of the U.S. cigarette market in 2019 and 2020 (Federal Trade Commission, 2021), and flavored cigars (U.S. Food and Drug Administration, 2022a), which have exceeded 50% of cigar sales since 2012 (Delnevo et al., 2021b). This commentary examines potential challenges to banning flavored cigars and highlights issues FDA and Congress should consider.

The importance of cigarillo product characteristics among young adult cigarillo users: Differences by demographics, cigarillo use and other tobacco/substance use behaviors.

INTRODUCTION: Cigar products, including cigarillos, have increased in popularity in the U.S. and are disproportionately used by young adults. Cigarillo product characteristics can influence consumer perceptions and the appeal of these characteristics can vary by subgroup. The goal of this study was to examine a) product characteristics important to young adult cigarillo users and b) differences based on demographics and cigarillo and other tobacco/substance use behaviors. METHODS: In 2016, a convenience sample of 628 past-year cigarillo users rated the importance of the following cigarillo product characteristics when choosing a cigarillo to smoke tobacco: brand, tobacco filler quality, tobacco wrap quality, flavors, price, package graphic design, and number of cigars in the pack. Differences in mean importance by demographic, cigarillo use and other tobacco/substance use characteristics were analyzed using t-tests and ANOVA tests. RESULTS: The most important cigarillo product characteristics were price, quality of tobacco wrap, and flavors. The least important was graphic design of packaging. There were differences in importance by demographics and/or cigar and other tobacco/substance use behaviors for all product characteristics. In particular, pack size was rated as more important among current cigarillo users, users of foil pouches (2-3 cigarillos) or cardboard/paper boxes or other packaging styles, and current users of cigarettes, blunts and marijuana. Price was rated as more important among Hispanic/Latino and lower income smokers, and current cigarette and blunt smokers. CONCLUSIONS: Findings suggest cigarillo users prioritize different product characteristics depending on their demographics or smoking behavior. Further research is needed to examine whether various cigar-related policies, such as those that ban flavors or set minimum pack sizes, could impact sub-populations of cigarillo users differently.

Innovative promotional strategies and diversification of flavoured mass merchandise cigar products: a case study of Swedish match.

In 2009, the Family Smoking Prevention and Tobacco Control Act (TCA) granted the U.S. Food and Drug Administration (FDA) regulatory authority over tobacco products, although initially this only included cigarettes, smokeless tobacco and roll-your-own tobacco. In 2016, the deeming rule extended regulatory authority to include all tobacco products, including cigars. The deeming rule prohibited the introduction of new tobacco products into the marketplace without proper marketing authorisation and laid out pathways for tobacco companies to follow. The deeming rule should have frozen the cigar marketplace in 2016. In this paper, we describe how the cigarillo marketplace, nevertheless, continues to diversify with new brands, flavors, styles and packaging sizes entering the market regularly. As an example, we highlight recent promotional efforts by Swedish Match North America (Swedish Match) for their popular cigarillo brands, including White Owl, Night Owl and Garcia y Vega's Game brand. We argue that ambiguities in the TCA make it unclear whether Swedish Match's seemingly new cigarillos fit the definition of new tobacco products and, if so, whether they are on the market legally. Swedish Match and other cigarillo companies may be taking advantage of these ambiguities to promote a variety of cigarillo flavors and styles in innovative ways. Given that cigars are combustible tobacco products that pose many of the same risks as cigarettes, this business practice raises significant concerns regarding the protection of public health, particularly among young people.

Flavored cigar availability in Oakland after a partial ban.

OBJECTIVES: We report the continued availability of flavored cigars based on our analysis of discarded cigar wrappers collected in February 2019, after a partial flavor ban in Oakland, CA. METHODS: We collected 1,501 discarded cigar wrappers in a stratified random sample of census tracts (n = 15). Collected packages were cleaned, photographed, and coded for product type, brand name, pack size, flavor descriptor, and pricing details. RESULTS: More than half (58.5%, CI 95% = 50-67.1%) of the cigar wrappers collected were flavored. When controlling for product type, pack size, and brand, there were statistical differences in the presence of flavored tobacco products that align with census tract racial and ethnic demographics. The odds of finding flavored cigars in black/African American tracts census tracts were significantly higher (AOR = 2.13, p < .05) than in white (non-Hispanic) census tracts. We also found that wrappers for larger cigar packs (containing three or more cigars) (77.7%) were the most likely to be flavored. CONCLUSIONS: Flavored cigars continued to be wide available despite Oakland's partial ban on flavored tobacco products. Serious consideration is warranted for comprehensive bans on the sale of flavored tobacco products and ongoing surveillance to assess their availability.

Adoption of Tobacco 21: A Cross-Case Analysis of Ten US States.

Despite the recent push for Tobacco 21 legislation in the US and the national adoption of Tobacco 21, there is a paucity of data on the process of policy adoption. To explore the key factors that served as facilitators or challenges to the passage of state T21 laws that apply to the sale of all tobacco products to anyone under 21 years of age, we conducted a comparative, cross-case study in ten states that adopted Tobacco 21 between 2016 and 2019. Stakeholders from selected states were identified via snowball sampling, and interviews were conducted from November 2018 to March 2020. Three primary factors emerged as facilitators to the passage of state T21 laws: (1) increased attention on e-cigarettes as the product driving an overall increase in youth tobacco use and depiction of an "e-cigarette epidemic", (2) having at least one influential policy entrepreneur or champion, and (3) traction from other states or local municipalities passing T21 legislation. Challenges to T21's success included (1) influence of the tobacco industry, (2) the bill's low ranking among legislative priorities, and (3) controversy among advocates and policymakers over bill language. As e-cigarette rates spiked, T21 bills became legislative priorities, traction from other successful efforts mounted, and ultimately, the tobacco industry flipped from opposing to supporting T21 laws. Despite these favorable headwinds, advocates struggled increasingly to pass bills with ideal policy language.

Experts' Perceptions of and Suggestions for Cigar Warning Label Messages and Pictorials.

INTRODUCTION: Warning labels can be effective tools to inform the public about tobacco risks. However, tobacco warning research has been largely cigarette-centric. This formative study explores potential directions for improving the current warnings for cigars. AIMS AND METHODS: Between June and August 2019, we conducted interviews with 10 experts about the current cigar warning statements and requirements, the inclusion of pictorials in cigar warnings, and legal issues. Additionally, experts viewed and discussed concept images to pair with existing warning statements, including realistic photographic images and symbolic images (eg, icons, caution symbols). RESULTS: Experts agreed that cigar warnings should be strengthened (eg, by increasing their size and use of pictorials) to better leverage their potential impact and maintain warning parity with cigarettes. However, perceived challenges exist given the wide variety of cigar products, product terminology, and use patterns. Experts agreed that photographic pictorials of health effects are likely to be more salient, informative, and effective for behavior change than symbolic ones, but may be vulnerable to legal challenges. Symbolic images used in warnings may obtain attention in a less "controversial" way, but may be considered less serious and "factually accurate," increasing legal risks. Experts indicate that cigar educational campaigns can complement warnings and address additional themes, especially aimed at youth, including exposure to chemicals and flavorings and misperceptions that cigars are "natural." CONCLUSIONS: Additional consumer research is needed to examine the potential public health impact of improving cigar warnings and to support regulatory efforts. IMPLICATIONS: This study provides feedback from tobacco control experts about the importance of cigar warning labels and directions for future research and improvements. Experts support increasing the size of cigar warnings and adopting pictorials to improve cigar warning impact and maintain warning parity with cigarettes. Experts agreed that photographic pictorials of health effects are likely to be more salient and effective for behavior change than symbolic ones. Given legal challenges, experts discussed potentially prioritizing warning improvements for those cigars used most frequently as cigarette alternatives and by youth. Overall, more cigar warning research is needed to support regulatory efforts.

Availability of menthol cigarettes in Oakland, California after a partial flavor ban.

This study measures the availability of menthol cigarettes in Oakland, California where such products were banned from the majority of tobacco retailers, except for those who sold a significant amount of tobacco (e.g., 60% gross income). Out of a total of 385 retailers in Oakland, only forty-eight retailers were exempt from this ban at the time of data collection. In February 2019, seven months after the ban went into effect, we selected a stratified random sample of 15 census tracts, based on race/ethnicity. In pairs, data collectors walked on opposite sides of the street and collected all discarded cigarette packs (n = 641) from the streets and sidewalks on weekdays. Overall, we found almost half (46.0%; 95% CI = 32.6%-59.3%) of the packs collected were menthol, with Newport as the dominant brand. We found at least one pack of menthol cigarettes in 14 of the 15 sampled census tracts. In predominantly black/African American census tracts, the proportion of menthol cigarettes collected was significantly higher (70.1%; 95% CI = 62.6%-77.7%) when compared to mixed race/ethnicity (55.9%; 95% CI = 41.0-70.9%) and white tracts (35.1%; 95% CI = 13.2%-57.1%). Finally, there was a moderate and negative correlation between distance to exempt tobacco retailer and menthol availability (r = -0.66, p < .05). The proportion of menthol cigarette packs decreased the further away census tracts were from exempt tobacco retailers. Results from this study lend support that partial bans provide disproportionate availability of menthol cigarettes in black/African American census tracts. Complete bans may help eliminate disparities associated with menthol cigarette use across communities.

E-cigarette environmental and fire/life safety risks in schools reported by secondary school teachers.

BACKGROUND: To identify if e-cigarette usage is an on-campus problem for secondary schools and evaluate initial school survey responses. More specifically, this survey can aid in identifying where students are seen using e-cigarettes, if smoke alarms have been newly inserted on school property, if smoke alarms have been tampered with to allow for vaping without detection; and, if any e-cigarette fires or explosions have occurred on school property. METHODS: This survey, disseminated to New Jersey secondary school teachers across seven sessions January-July 2019, resulted in 104 complete responses of 109 respondents. The survey was conducted after fire prevention, exit/egress, and life safety portions of "OSHA 10 Plus for General Industry" courses. Survey questions included number of times teachers observed students vaping and location where vaping in last 12 months, fire alarm installation and tampering, and fires or explosions and injuries from vaping/e-cigarette devices. RESULTS: Many (63%) respondents reported very or moderately common rates of vaping within their schools; however, three of four questions regarding school fire and smoke alarm use specifically to detect vaping had a majority of unsure/I don't know responses. CONCLUSION: Results suggested concerns regarding student vaping and e-cigarette use inside and outside secondary schools. Improved school detection and response are warranted. TRIAL REGISTRATION: Not applicable.

Flavored Tobacco Sales Prohibition (2009) and Noncigarette Tobacco Products in Retail Stores (2017), New York City.

Objectives. To assess explicit- (products clearly labeled flavored) and emergent concept- (products implying flavoring but not clearly labeled) flavored tobacco product availability following New York City's flavor restriction.Methods. We examined explicit- and concept-flavored tobacco product availability, with 2017 New York City Retailer Advertising of Tobacco Survey data (n = 1557 retailers). We assessed associations between block group-level demographic characteristics and product availability by using logistic regression.Results. Most retailers sold explicit-flavored (70.9%) or concept-flavored (69.3%) products. The proportion of non-Hispanic Black neighborhood residents predicted explicit- and concept-flavored product availability, as did having a high school within a retailer's block group for concept-flavored products.Conclusions. Explicit- and concept-flavored other tobacco products persisted throughout New York City, despite 2009 legislation restricting sales.Public Health Implications. Making local sales restrictions or federal production bans inclusive of all explicit and concept flavors would reduce retailer and industry evasion opportunities and protect the health of youths and others.

Has FDA abandoned its efforts to make fake-cigar cigarettes comply with federal tobacco control laws that apply to cigarettes but not cigars?

In the USA, legal definitions of cigarettes and cigars are critical to tobacco control policy because federal, state and local laws typically tax and regulate cigarettes more strictly than cigars. In 2016, near the end of the Obama Administration, the US Food and Drug Administration (FDA) sent warning letters to four filtered 'little cigar' manufacturers stating that their so-called 'cigars' were cigarettes and, therefore, subject to more stringent public health restrictions. Documents produced in response to a Freedom of Information Act request show that without explanation or public notice FDA has abandoned its prior determination that the manufacturers' 'little cigars' were actually cigarettes and, consequently, were violating the ban on flavoured cigarettes in the Family Smoking Prevention and Tobacco Control Act (TCA). The documents also present the manufacturers' arguments against FDA's original position. However, those industry arguments are inconsistent with the research, other evidence and legal analysis indicating that filtered 'little cigars' meet the legal definition of cigarettes under the TCA and other similar federal, state and local definitions. To protect the public health, FDA must renew its efforts to ensure that these filtered 'little cigars' do not continue to evade compliance with the many important restrictions and requirements that apply to cigarettes but not cigars. Other government regulatory and tax-collection agencies with similar definitions need to follow suit.

Ten Years of the Tobacco Control Act in New York City.

This article describes the impact of the 2009 Family Smoking and Prevention Tobacco Control Act (TCA) on local tobacco control through the lens of New York City's experience during the first 10 years after the TCA was enacted, highlighting one meaningful change and an opportunity that has failed to materialize. Much of the analysis regarding the TCA highlights the U.S. Food and Drug Administration's (FDA) new powers and the TCA's impact on a national level. However, the TCA also opened up opportunities for local governments to pursue sound tobacco control policies that previously seemed fraught with high legal risk. This article focuses on two aspects of the TCA. First, the TCA weakened one of the tobacco industry's most reliable litigation weapons-preemption. Second, the TCA authorized the FDA to combat the illicit trade of tobacco products. Despite clear language in the TCA, the FDA has not signaled an inclination to take action regarding illicit trade in the context of tobacco tax evasion.

Examination of Voluntary Compliance with New FDA Cigar Warning Label Requirements.

OBJECTIVES: The US Food and Drug Administration (FDA) issued new requirements to strengthen and increase the size of cigar warnings. Although these requirements were challenged in court by the cigar industry, and later struck down, cigar manufacturers had the option of voluntarily complying during the injunction. In this study, we examined voluntary warning compliance on a sample of discarded cigar wrappers. METHODS: Warnings were examined on a sample of 1352 discarded cigar wrappers and packs obtained from 15 census tracts in Oakland, California in February 2019. Warnings were coded for new requirement compliance (ie, sized at 30% or more on front and back of pack). RESULTS: Overall, 67.3% of wrappers displayed compliant warnings - other wrappers had smaller warnings only on the front (30.6%), only on the back (1.5%) or no warning (0.4%). Cigar warning placement was significantly associated with brand (p < .01), cigar type (p < .01), and unit size (p < .01). The prevalence of warning compliance was at least 90% for 6 brands but ranged from 0% to 65% for others. Compliance was lowest for cigarillos (62.1%) and packs of 3 (27.6%). CONCLUSIONS: Strengthening cigar warnings can help increase their effectiveness, but cigar manufacturers may not voluntarily implement changes fully. Continued surveillance and renewed regulatory efforts are warranted.

Categorising characteristics of counterfeit Marlboro cigarettes: a systematic review of tobacco industry documents.

BACKGROUND: There is scant research on methods used to identify counterfeit Marlboro cigarettes. METHODS: Systematic analysis of internal tobacco industry documents characteristics of counterfeit Marlboro cigarettes. RESULTS: In the industry documents we identified as relevant, there were 42 characteristics of counterfeit Marlboro cigarettes. Overall, physical characteristics (88.1%) were the most commonly identified features across all locations, with the pack blank, cardboard shell of the cigarette pack, as the dominant site (30.9%). Some of the physical characteristics included offset lithography printing, incorrect font and colour. Overall, light microscopy was identified as the main method of forensic analysis for detecting counterfeits. CONCLUSION: Independent researchers employing litter pack and pack swap surveys are encouraged to use the characteristics identified in the study to gauge the prevalence of counterfeit Marlboro cigarettes and compare against industry estimates.

A discarded cigar package survey in New York City: indicators of non-compliance with local flavoured tobacco restrictions.

INTRODUCTION: In 2009, New York City (NYC) restricted the sale of flavoured tobacco products. We assessed product availability as a proxy for potential non-compliance by analysing discarded cigar, cigarillo and blunt wrap packages in New York City. METHODS: A discarded cigar package survey was conducted in 2016, in a stratified random sample of 94 block groups in NYC resulting in the collection of 886 discarded cigar packages. Each package was coded for brand name, flavour description (explicit and implicit) and size. FINDINGS: Overall, 19.2% of the cigar packages were explicitly flavoured. An additional 9.4% of the packages reflected implicit flavours. Explicit flavoured cigar packages were at increased odds of being found in Staten Island (adjusted OR (AOR)=3.96, 95% CI=1.66 to 9.46), in packaging size of two or three (AOR=8.49, 95% CI=4.24 to 17.02) or four or more (AOR=4.26, 95% CI=1.95 to 9.30). CONCLUSION: Nearly one out of three cigar packages were flavoured products suggesting a problematic level of non-compliance and continued availability. Potential non-compliance is likely fueled by licensed wholesalers and retailers who continue to sell restricted flavoured products. Some retailers may be unaware that implicitly named cigars are typically flavoured and are, therefore, illegal. This lack of awareness of implicit flavoured cigars may be exacerbated by NYC's lack of education or enforcement specific to implicitly flavoured tobacco products.

Increasing Price and Reducing Access to Tobacco in New York City.

This paper describes novel tobacco control laws passed in New York City in 2017. These laws are designed to improve the city's strategy of using price to decrease tobacco consumption, and over time, change the city's landscape by making tobacco less accessible.

Implementation of the New York City Policy Restricting Sales of Flavored Non-Cigarette Tobacco Products.

Flavored tobacco products appeal to youth, and jurisdictions have implemented policy interventions to reduce youth tobacco initiation. This study reviews the process, challenges, and compliance monitoring of a flavored tobacco sales restriction. New York City (NYC) passed a policy restricting the sale of flavored non-cigarette tobacco products in 2009. To describe the policy's passage, legal defense, implementation, and enforcement, we conducted stakeholder interviews, reviewed legislative and legal records, and analyzed administrative data on retailer inspections and violations. Extensive public and policy maker education efforts preceded this policy. Barriers included opposition to the policy's passage and a tobacco manufacturer's lawsuit that sought to halt the law's implementation and to establish that NYC lacked the authority to restrict the sale of flavored products. The city implemented the flavored tobacco policy as intended and it withstood legal challenges. NYC integrated enforcement into the city's retailer compliance monitoring infrastructure, and the violation rate is low. Our investigation of NYC's experience with flavored tobacco policy implementation and enforcement can provide policy makers and health professionals with insights relevant to policy implementation, expand understanding of the potential impact of these kinds of policies, and inform compliance monitoring efforts.