The impact of cigar pack size and pricing policies on youth and adult cigar use in the US

Abstract

Background:

Over 250 US localities have adopted cigar pack quantity and price policies. No empirical studies exist on their impact on tobacco use.

Methods:

A quasi-experimental design was used to assess the impact of cigar policies on cigar and cigarette use among (1) Minnesota youth (n=569,528, triennially 2007–2019); (2) New York youth (n=111,236, annually 2000–2020), (3) New York adults (n=62,295, annually 2003–2019), and (4) District of Columbia (DC) adults (n=5,027, annually 2015–2019). We estimated the county-level policy coverage for 15 local policies in Minnesota. Differences-in-differences approach was used to compare the policy in NYC with the rest of the state (no policy). We examined changes in DC use before and after policy implementation. Analyses adjust for sociodemographic characteristics.

Results:

In Minnesota, youth in counties with a greater proportion of the population covered by a policy had lower odds of cigar use (AOR: 0.51; 95% CI: 0.38–0.69). Similarly, adult cigar use in DC declined following policy enactment (AOR: 0.65; 95% CI: 0.46–0.93). Cigarette use also decreased in both Minnesota and DC following policy enactment. However, in New York, the NYC policy did not have a significant impact on cigar use among youth (AOR: 0.95; 95% CI: 0.47–1.93) or adults (AOR: 1.98; 95% CI: 0.85–1.37) in NYC compared to the rest of the state. The only significant effect in NYC was reduced odds for adult cigarette use (AOR: 0.79; 95% CI: 0.68–0.92).

Conclusions:

Findings suggest regulating cigar packaging could decrease cigar consumption without increasing cigarette consumption, but effects may differ across jurisdictions.

1. INTRODUCTION

Cigar smoking is associated with increased all-cause mortality and increased risk of tobacco-related cancers, heart disease, and stroke, resulting in a significant health disparity among the populations that use these products.^1–4 In the United States (US), cigars are the combustible tobacco product most commonly used by high school students, and the second most common among adults.^5,6 Approximately 310,000 youth and 10.1 million adults in the US reported past 30-day cigar use in 2021, with rates highest among males and Black populations.^5,7

Amidst increasing restrictions on cigarettes in the US, the tobacco industry introduced and heavily marketed cigarillos and little cigars, products similar to cigarettes but not subject to minimum pack quantity regulations, flavor restrictions, or the same level of taxation.^8–10 This same strategy has been employed globally¹¹ and likely accounts for the high projected global growth of cigars. The global cigar market was estimated at over $40 billion in 2021, and is projected to more than double by 2030, representing a critical need for tobacco control efforts.¹²

As of 2016, the US Food and Drug Administration’s Center for Tobacco Products has regulatory authority over cigar manufacture, marketing, and distribution. This authority does not preempt (prohibit) state or local tobacco regulations across these areas, allowing localities to implement additional restrictions as appropriate for their jurisdictions. Local policies have the potential to impact use as well as generate momentum for state and federal policies. In the absence of federal restrictions, over 250 localities in five US states and the District of Columbia (DC) have adopted policies that establish minimum cigar pack quantities and prices.¹³ The first policy was implemented in Huntington Park, California in 2011, eliminating the sale of single cigars. Communities in Massachusetts followed, enacting policies with a minimum pack quantity of four.¹⁴ In response, the cigar industry shifted to selling larger packages at low prices to circumvent the policy. Subsequently this led to communities amending their policies to establish a minimum price alongside the minimum pack quantity.¹⁵ Today, there are three broad types of cigar pack quantity and price policies in the US (Supplemental Table 1): (1) minimum pack quantity policies that establish a minimum number of cigars that can be sold in a pack, (2) minimum pack quantity policies that include a minimum price at which cigars can be sold, and (3) minimum price policies that set minimum prices for various pack quantities.¹³ These policies are designed to eliminate access to inexpensive cigars as increasing price/tax is among the most effective ways to reduce use.¹⁶ Within each policy type, there is heterogeneity in minimum pack quantity and minimum pricing requirements and variability in policy exclusions and penalties, both within and between states.¹³ Minimum prices range from $0.35 to $10.00 per cigar, and the most prevalent minimum pack quantities require 2-packs or 4-packs, though nearly one in ten communities set the minimum pack quantity at ten or greater.¹³

Three studies have examined retail environment changes following cigar pack quantity and price policy enactment in the US: two studies in Massachusetts^14,17 and one in Minnesota.¹⁸ These studies identified increases in cigar sale prices and reductions in single cigar availability following policy implementation. One of the studies¹⁴ also examined whether the availability of single cigars differed across neighborhoods based on race and income, finding a reduction in disparities in single cigar availability by neighborhood. With a history of disproportionate and targeted cigar marketing,^19,20 examining policy impact among those most susceptible to use is critical. Thus far, there have been no studies on the impact of cigar packaging policies on cigar use. The intent of policies that increase pack quantity is to reduce use. However, as previous studies have shown, buying larger packs of cigars is associated with smoking more.^21,22 To prevent tobacco companies from exploiting this relationship, some countries have implemented or proposed limits on the maximum number of cigarettes per pack.²³ Additionally, policies restricting cigar use, such as through price increases, may increase cigarette use, as people who smoke cigars often use cigarettes.^24,25 Therefore, this study aimed to evaluate the effects of local policies regulating cigar pack quantity and price on cigar use. We also examined whether these policies had unintended consequences on cigarette use as a possible substitute for cigars.

2. METHODS

2.1. Study samples

Over 250 localities in five US states and the District of Columbia (DC) have adopted cigar pack quantity and price policies. For the present study, Minnesota (MN), New York (NY), and DC were selected based on policy implementation and data availability (Supplemental Table 2). In MN, as of 2018, cigar pack quantity and pricing policies were effective in 10 cities and 5 unincorporated counties, with the earliest effective in 2014. In NY, New York City (NYC) adopted a cigar pack quantity and minimum price policy which became effective in 2014, and increased the minimum prices in 2017, effective in May 2018. DC restricted sales of single cigars in gas stations and convenience stores in 2017.

Cigar and cigarette use data were obtained upon request from each state. For MN, we obtained triennial Student Survey data from 2007–2019 for middle and high school youth including the county of residence (N=569,528; Supplemental Table 2).²⁶ For NY, we obtained annual Youth Tobacco Survey data from 2000–2020 for youth in grades 6–12 (N=111,236) and 2003–2019 Adult Tobacco Survey data (N=62,295) that included residence in NYC or the rest of the state (ROS).²⁷ For DC, we obtained 2015–2019 annual Behavioral Risk Factor Surveillance System data (N=5,027).²⁸ The study protocol received an exemption determination from the University of Utah Institutional Review Board.

2.2. Measures

Policies were identified through a systematic approach, including reviewing municipal code and confirming lists obtained by state tobacco control staff. Additional details on policy identification are published elsewhere.¹³ For MN, the policy variable was operationalized as the percentage of each county population covered by a policy by year (range 0 to 61%) based on American Community Survey estimates.^29,30 For NY and DC, the policy variable was defined as policy presence or absence based on the latest stated effective or enforcement date as available. To account for potential overlap with data collection dates and/or delays in implementation and enforcement, all policies were designated as effective for the data year following the effective date (e.g., policies with an effective date in July 2020 were analyzed as effective in 2021 data).

Cigar and cigarette use were defined as any past 30-day use for MN and NY youth and NY adults (no/yes) and “current” use for DC adults (no/yes). All cigar types were grouped due to variations in survey items by year. MN youth were asked the number of days they smoked cigars, cigarillos, or little cigars in the past 30 days, with categorical response options that changed during the duration of the study.²⁶ NY youth were asked about their past 30-day use of cigars, though the wording changed from one item asking about “cigars” to separate items on “large cigars,” “cigarillos,” and “little cigars” during the duration of the study.²⁷ NY adults were asked about their past 30-day use with response options everyday, some days, and rarely considered use.²⁷ Some survey iterations included separate items for cigars, cigarillos, and little cigars, which were combined for analysis. DC adults were asked whether they “now smoke” cigars or cigarillo (e.g., Black N Milds)” and “little cigars that look like cigarettes,” with response options everyday and some days considered current use.²⁸

2.3. Statistical Analyses

To account for the variation in data collection across states, we performed weighted multivariable logistic regressions for each state separately. For MN, where both city and county policies were in place, we calculated the proportion of each county population covered (ranging 0 to 61%). For NY, we used a difference-in-differences approach to compare the policy effects between NYC and the rest of the state over time. Our primary analysis focused on the impact of the policy implemented in 2014. We conducted a sensitivity analysis to explore the impact of the subsequent change in 2017. We assessed the parallel trend assumption of DID by examining pre-policy trends between NYC and the rest of the state. Results indicated both had similar trends before policy implementation. For DC, we measured the change in cigar use from before (2015–2017) to after (2018–2019) policy enactment. We controlled for time trends, sex, age/grade, race and ethnicity, marital status, and income/education as available (Supplemental Table 2), and set p<0.05 as the significance level. We also conducted stratified analyses by race and sex for each sample as available. Race was not available in the MN youth dataset. Analyses were completed using Stata 17, in 2022, and applied weights to account for complex survey procedures as recommended by each survey.

3. RESULTS

Across all analyses, cigar and cigarette use decreased during the time periods analyzed (Figure 1). Youth cigar use in MN ranged from as high as 7.5% in 2007 to 1.6% in 2018, which varied by county over time. In NY, youth cigar use ranged from 8.0% in 2000 to a low of 2.1% in 2016. Adult cigar use in NY ranged from as high as 6.3% in 2012 to a low of 1.9% in 2019. In DC, adult cigar use ranged from 3.9% in 2017 to 0.8% in 2015. The descriptive characteristics of each sample are presented in Supplemental Table 3.

Figure 1.

Cigar Use Prevalence by State

Among MN youth, the percentage of the county population covered by a cigar pack quantity or price policy was associated with significant decreases in the odds of cigar use (AOR: 0.51; 95% CI: 0.38, 0.69; Table 1). The percentage of the county population covered was also associated with significant decreases in the odds of cigarette use (AOR: 0.61; 95% CI: 0.46, 0.81). Decreased odds for cigar use were significant for both males and females (Table 2); race was not available.

Table 1.

Estimates of the Impact of Cigar Pack Quantity and Pricing Policies on Current Cigar and Cigarette Use

	Cigar Use AOR (95% CI)	Cigarette Use AOR (95% CI)
MN Youth (N=569,528)	0.51 (0.38, 0.69)	0.61 (0.46, 0.81)
NY Youth (N=111,236)	0.95 (0.47, 1.93)	1.17 (0.79, 1.73)
NY Adults (N=62,295)	1.08 (0.85, 1.37)	0.79 (0.68, 0.92)
DC Adults (N=5,027)	0.65 (0.46, 0.93)	0.83 (0.69, 0.99)

Notes: Boldface indicates statistical significance (p<0.05). AOR = adjusted odds ratio; CI=confidence interval; MN = Minnesota; NY=New York; DC = District of Columbia Separate multivariable logistic regressions assessed the impact of local cigar pack quantity and pricing policies by state. For MN, we estimated the percentage of each county population covered by a policy. For NY, we employed a difference-in-differences approach to detect policy effects between NYC and the rest of the state over time. For DC, change in cigar use was examined from pre-policy (2015–2017) to post-policy (2018–2019). Models control for year, age, sex/gender, race/ethnicity(unavailable for Minnesota youth), marital status (only in DC), and income.

Data sources: MN youth 2007–2019 triennial Student Survey; NY youth 2000–2020 annual Department of Health data, NY adults 2003–2019 annual Department of Health data; DC adults 2015–2019 annual BRFSS data.

Table 2.

Estimates of the Impact of Cigar Pack Quantity and Pricing Policies on Current Cigar Use Stratified by Sex

	Cigar Use AOR (95% CI)
	Male	Female
MN Youth (N=569,528)	0.52 (0.39, 0.70)	0.48 (0.35, 0.67)
NY Youth (N=111,236)	0.40 (0.12, 1.33)	1.26 (0.56, 2.81)
NY Adults (N=62,295)	1.06 (0.81, 1.39)	1.11 (0.69, 1.77)
DC Adults (N=5,027)	0.78 (0.50, 1.21)	0.49 (0.27, 0.88)

Notes: Boldface indicates statistical significance (p<0.05). AOR = adjusted odds ratio; CI=confidence interval; MN = Minnesota; NY=New York; DC = District of Columbia Models assess the impact of 15 city and county policies effective between 2014 and 2018 in MN, the NYC policy effective in 2014 and revised in 2017, and the DC policy effective in 2017. Models control for year, age, sex/gender, race/ethnicity (unavailable for Minnesota youth), marital status (only in DC) and income.

In NY, among the treatment group (NYC), the cigar policy was not significantly associated with youth cigar (AOR: 0.95; 95% CI: 0.47, 1.93; Table 1) or cigarette use (AOR: 1.17; 95% CI: 0.79, 1.73), compared with the control group (the rest of New York state with no comparable policy). The sensitivity analysis examining the impact of the 2017 policy update was not statistically significant for cigars (AOR: 0.98, 95% CI: 0.48, 2.00) or cigarettes (AOR: 0.96, 95% CI: 0.56, 1.67). Similar non-statistically significant results were found in analyses stratified by sex (Table 2) and race (Table 3). For NYC adults, the cigar policy was significantly associated with lower odds of cigarette use (AOR: 0.79; 95% CI: 0.68, 0.92).

Table 3.

Estimates of the Impact of Cigar Pack Quantity and Pricing Policies on Current Cigar Use Stratified by Race

	Cigar Use AOR (95% CI)
	White	Black	Hispanic	Other
NY Youth (N=111,236)	0.40 (0.10, 1.63)	0.38 (0.03, 4.18)	1.18 (0.39, 3.57)	2.36 (0.88, 6.32)
NY Adults (N=62,295)	0.79 (0.54, 1.16)	0.88 (0.51, 1.52)	1.30 (0.71, 2.39)	1.24 (0.52, 2.94)
DC Adults (N=5,027)	0.22 (0.09, 0.55)	0.80 (0.53, 1.21)	0.64 (0.22, 1.92)	0.53 (0.17, 1.65)

Notes: Boldface indicates statistical significance (p<0.05). AOR = adjusted odds ratio; CI=confidence interval; NY=New York; DC = District of Columbia Models assess the impact of the NYC policy effective in 2014, and the DC policy effective in 2017. Models control for year, age, sex/gender, marital status (only in DC), and income.

In DC, following policy enactment, there was a significant decrease in the odds of adult cigar use (AOR: 0.65; 95% CI: 0.46, 0.94) and cigarette use (AOR: 0.83, 95% CI: 0.69, 0.99; Table 1). In stratified analyses, decreases in the odds of cigar use were significant for females (AOR: 0.49; 95% CI: 0.27, 0.88), but not for males (AOR: 0.78; 95% CI: 0.50, 1.21; Table 2). By race, significant decreases in the odds of cigar use were identified for White adults (AOR: 0.22; 95% CI: 0.09, 0.55), but not for Black adults, Hispanic adults, or adults of other races (Table 3).

4. DISCUSSION

In examining the impact of US local cigar pack quantity and price policies on cigar and cigarette use in four separate analyses, we identified some support for an impact on use, though findings varied by state. In MN, 15 communities enacted cigar pack quantity or price policies between 2014 and 2018, and counties with a higher proportion of the population covered had lower odds for youth cigar and cigarette use. In DC, following policy adoption in 2017, there were significant decreases in adult cigar and cigarette use. In NY, the NYC policy adopted in 2014 and updated in 2017 was not associated with decreases in youth or adult cigar use when accounting for reductions in use in the rest of the state, though adult cigarette use did significantly decrease. The modest decrease in cigar consumption in NYC compared to the rest of the state could imply that policy interventions have spillover effects across regions. A deeper analysis of the retail landscape in NYC and other areas might reveal more insights. Moreover, the similar patterns of cigar and cigarette use in both regions suggest that adults who smoke cigars are not switching to cigarettes in response to changes in cigar access.

Cigar pack quantity and price policies are based on the premise that they will increase overall cigar pack price and ultimately reduce use, particularly among youth and low-income populations. Local policies are a critical opportunity to reduce tobacco use within a community as they are often more feasible to adopt and provide protections without waiting for state or federal action. Few cigar pack quantity and price policies have received industry pushback,³¹ suggesting this may be a feasible area for continued work. These findings suggest that adopting minimum cigar pack quantities as a product standard for cigars could be beneficial. At the US federal level, cigarettes are required to be sold in pack quantities of at least 20, and are explicitly restricted from being sold as loosies (individual cigarettes sold outside the original packaging).³² Restrictions on cigarette pack quantity provide precedent and may also may limit the product substitution from cigars to cigarettes following cigar pack quantity increases.

Treatment effect heterogeneity was identified for sex and race in DC, suggesting any identified policy effects may not extend equitably across sociodemographic populations. It is unclear what drives this finding, though other studies have noted differences in tobacco policy reach and impact by sex and race.^33,34 Decreases in cigar use were not identified in DC among those more likely to use cigars (i.e., males, Black adults). These findings should be examined more closely, and if needed, steps should be taken to ensure equitable policy impact.

Findings should be considered with respect to limitations. First, analyses did not control for other policy changes that may have affected cigar use. For example, local, state, and federal Tobacco 21 and flavor restrictions were adopted during the study period. Similarly, local cigar pricing and pack quantity policies were often part of a broader tobacco control strategy. The results may reflect the combined effect of these interventions. Second, analyses could not account for variations in pack quantity and price regulations across localities in Minnesota due to discordance between city policies and county data. More local data, particularly data that align with policy jurisdictions, are needed to examine the impact of local policies. Third, our analyses used a binary measure based on data availability for past 30-day use. Analyses using a continuous measure may detect additional important outcomes such as changes in the frequency of use. Finally, there is a lack of cigar use data by cigar type. Since patterns of use differ by cigar type, future research should explore impact by cigar type when possible.

Conclusions

This study provides evidence for the effectiveness of local cigar pack quantity and price policies in reducing the prevalence of cigar use among youth and adults, without increasing cigarette use. This study compared the changes in cigar and cigarette use in three jurisdictions (Minnesota, New York, and the District of Columbia) that implemented different policies regarding the minimum number of cigars sold in a pack and the minimum price per cigar. The results show that in localities in Minnesota and the District of Columbia, there were significant reductions in cigar use among youth and adults, respectively, while cigarette use remained stable or declined. There were no significant changes in cigar use in New York. Together, these findings suggest that cigar pack quantity and price policies may be an effective tobacco control approach, though additional studies should examine policy impact among those disproportionately affected by cigar use, such as Black youth and young adults. Additionally, further research is needed to understand the factors influencing these policies’ implementation, enforcement, and impact in different regulatory contexts.

Highlights.

• This study provides the first assessment of cigar pack policy impact on cigar use.

• Policies were associated with decreases in use among Minnesota youth and DC adults

• Minimum cigar pack sizes and prices appear to be promising approaches to reduce use