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. 2023 Jun 9;25(10):1648–1658. doi: 10.1093/ntr/ntad088

Exploring Young Adults’ Beliefs About Cigar Smoking by Susceptibility: A Belief Elicitation Study

Lilianna Phan 1,✉, Christen Seyl 2,3, Julia Chen-Sankey 4,5, Jeff Niederdeppe 6,7, Mignonne C Guy 8,9, Kymberle L Sterling 10, Kelvin Choi 11
PMCID: PMC10445255  PMID: 37294098

Abstract

Introduction

Young adults are at risk for cigar smoking, which is associated with cancers and pulmonary and cardiovascular diseases. Little is known about young adults’ beliefs about smoking cigarillos, little filtered cigars, and large cigars, and how these beliefs may vary across cigar types and by cigar susceptibility.

Aims and Methods

The larger study surveyed a U.S. sample of young adults (18–30 years old) who never used tobacco products (n = 948) through Qualtrics online panel services in August 2021–January 2022. We assessed participants’ susceptibility to using different cigar types. Participants were randomly assigned to open-ended questions about one of the three cigar types to elicit behavioral, normative, and control beliefs. We conducted thematic analysis to code emergent themes within each belief and examined the frequency of reported themes at the intersection of cigar type and cigar susceptibility.

Results

Cigar susceptible participants reported positive behavioral beliefs (eg, anticipated relaxation, mood regulation, being cool), friends as supportive referents, and easy-to-smoke control beliefs (eg, high accessibility, low cost) more frequently than non-susceptible participants. Varied frequency by cigar type also emerged. For example, cigarillo and little filtered cigar features were mentioned more frequently as easy-to-smoke control beliefs, while low accessibility was reported more frequently as a hard-to-smoke control belief for large cigars.

Conclusions

Findings identify salient beliefs about cigarillo, little filtered cigar, and large cigar smoking among young adult tobacco never-users. Future research should investigate the potential importance of these beliefs in cigar smoking susceptibility and initiation among young adults, and their potential utility in prevention research.

Implications

This thematic analysis identified salient beliefs about cigarillos, little filtered cigars, and large cigars among a U.S. young adult sample, and differentiated emergent beliefs by cigar susceptibility status and by cigar type. Given the lack of cigar smoking prevention media campaigns, identifying these beliefs is the one of the first steps in developing effective cigar smoking prevention strategies. Future quantitative studies are needed to confirm the relationships between these beliefs and smoking initiation of each cigar type to further inform the types of beliefs to be targeted in strategic communication and help prevent cigar smoking initiation among susceptible young adults.

Introduction

Cigar smoking is associated with multiple cancers and pulmonary and cardiovascular diseases.1 Cigars comprise of three types of tobacco products including cigarillos, little filtered cigars, and large cigars.1 These cigar types vary in product size, features (eg, filtered tip, flavors), and use behaviors (eg, frequency and intensity of use).2 For example, cigarillos and little filtered cigars are smoked more frequently and at a higher intensity than large cigars, leading a consensus study report to suggest that the health risks of these cigar types are worse than large cigars and are similar to those of cigarettes.3 Additionally, the prevalence of cigar smoking varies by cigar type and by sociodemographic characteristics.2 While the prevalence of cigar smoking was 3.5% in 2020 overall,4 Black young adults having the highest prevalence of current little filtered cigar and cigarillo use (2.7% in 2019), and Black adults are about three times more likely to use these cigar types throughout adulthood than not smoke cigars at all.5 The risk of establishing past-30-day cigar smoking also markedly increases at around 18 years old6 further emphasizing young adulthood as a critical developmental period to prevent the initiation and established use of cigars and help prevent cigar smoking-related racial disparities.5,6 While some previous studies have examined health communication strategies to address cigarillo smoking among young people,7,8 there is a lack of cigar smoking prevention interventions and formative research to inform such efforts.9,10 Previous research has shown that psychosocial factors are associated with cigar smoking behaviors among young adults.11–14 Therefore, understanding these psychosocial factors will help fill this research gap. With the variation in cigar-type features, use behaviors, and prevalence,2,5 it is important to identify beliefs related to smoking each of these cigar types and assess how these beliefs may overlap or vary across cigar types. These formative research efforts are needed to inform cigar-type specific prevention interventions to prioritize populations that experience cigar smoking-related racial disparities.5 While effective cigarette smoking health communication strategies can inform cigar smoking prevention interventions,15 young adult beliefs (eg, absolute and relative harm and nicotine addictive risks, outcome expectations, social norms) and reasons for initiating cigar smoking versus cigarette smoking vary,14,16,17 which suggests the need to examine cigar-type specific beliefs to appropriately develop corresponding prevention interventions.

The Theory of Planned Behavior (TPB) provides a relevant theoretical framework to investigate these psychosocial factors that promote cigar smoking initiation among U.S. young adults18 and help identify critical beliefs for health communication.19 According to TPB, cigar smoking behavior is a function of underlying salient beliefs and one’s perceived importance of these beliefs.20 Thus, according to TPB, one health communication strategy to promote behavior change such as preventing the initiation and escalated use of cigar smoking is to change underlying salient beliefs.21 These beliefs are characterized into three belief categories: (1) behavioral beliefs, which are one’s beliefs about anticipated outcomes from cigar smoking; (2) normative beliefs, which captures one’s perceived support for engaging in cigar smoking behavior; and (3) control beliefs, which describes factors that one perceives would make it easy or hard for them to smoke cigars. TPB further posits that these three belief categories, along with outcome evaluation, motivation to comply, and perceived power, respectively, influence one’s attitudes, subjective norms, and perceived behavioral control, determinants of one’s intention to smoke cigars, and ultimately their cigar smoking behavior. Attitudes is one’s positive or negative appraisal of cigar smoking and are conceptualized by the theory as reflecting the weighted sum and net valence of all behavioral beliefs held by an individual and their evaluation of the advantages and disadvantages of engaging in cigar smoking (ie, outcome evaluation). Subjective norms is one’s perceived social approval, or disapproval, of cigar smoking and are likewise conceptualized as the weighted sum and net valence of all normative beliefs and the extent to which one would like to comply with the perceived social approval (ie, motivation to comply). Perceived behavioral control, which is also postulated to both indirectly and directly influence behavior, is one’s perception of how well they can engage in cigar smoking behavior and are thought to be comprised of the weighted sum and net valence of all control beliefs and one’s perceived power of the factors involved with cigar smoking.20 Given that susceptibility is a strong predictor of subsequent cigar smoking among young people,22,23 we conceptualize intention to smoke cigars as cigar smoking susceptibility24 in this study. Specifically, susceptibility to smoking identifies which young adults who have never used tobacco products may be cognitively inclined to future cigar smoking behavior through their intentions and expectations of cigar smoking.24 Among U.S. young adults, positive attitudes towards cigar smoking are associated with susceptibility to cigar smoking and current cigar use (ie, cigarillo and little filtered cigar smoking).11 A previous study focusing on perceptions of flavored cigarillos and little filtered cigars also found emergent qualitative themes that capture behavioral beliefs including wanting to be cool, affluence, pleasure, and relaxation among young adults who currently smoked these cigar types and/or cigarettes.14 Overall, the TPB suggests that public health strategies that effectively modify salient beliefs can in turn help change determinants of susceptibility (attitudes, subjective norms, and perceived behavioral control) and ultimately help prevent the initiation of these cigar products. Previous research have also outlined rigorous methods for selecting belief themes that are likely to be effective and suggest that targeting beliefs in health communication can simultaneously reach multiple segments of the intended young adult audience.25

However, little is known about specific behavioral, normative, and control beliefs related to smoking each cigar type and how these underlying beliefs may differ by susceptibility status among those who have not started smoking cigars to inform choosing potential health communication themes. Thus, as an initial step within the TPB framework, we elicited these beliefs through an online belief elicitation exercise26,27 among young adult tobacco never-users and examined emergent beliefs across cigar types and by cigar smoking susceptibility status. These beliefs hold potential to resonate with susceptible young adults and can inform future research focusing on preventing cigar smoking initiation and established use among young adults.21 With the identification of these beliefs in the current study, future research can examine the corresponding outcomeevaluation of behavioral beliefs, motivation to comply with normative beliefs, and perceived power associated with control beliefs to further inform cigar smoking prevention efforts.

Methods

Study Design

Participants included in this qualitative analysis (n = 948) come from a larger cross-sectional sample of U.S. young adults ages 18–30 years old who had self-reported never previously using a tobacco product, including electronic cigarettes (e-cigarettes) or cigars, but are susceptible to e-cigarette use (n = 1329) to understand e-cigarette susceptible young adults’ perceptions of e-cigarettes. We recruited participants and collected data through Qualtrics online panel services. Qualtrics recruits panelists using a variety of strategies including website intercept recruitment, member referrals, targeted email lists, gaming sites, customer loyalty web portals, permission-based networks, and social media. Qualtrics panelists (18–30 years old) were invited via Qualtrics email to participate in this study without mention of study eligibility. Qualtrics implemented sampling quotas for race and ethnicity and education level. We then asked participants to report their tobacco use history and susceptibility to using e-cigarettes to confirm study eligibility. We characterized participants as tobacco never-users if they reported never using the following tobacco products (ie, not even one or two puffs/times): Cigarettes, e-cigarettes, cigarillos, little filtered cigars, large cigars, hookah tobacco, smokeless tobacco and heated tobacco products. E-cigarette use susceptibility was defined as self-report of a response other than “definitely not” to any of the four e-cigarette use susceptibility items (ie, “Do you think that you will use a vape soon?”; “Do you think that you will use a vape in the next year?”; “Do you think that in the future you might experiment with vapes?”; “If one of your best friends were to offer you a vape, would you use it?” Response options: “definitely yes”; “probably yes”; “probably not”; “definitely not”).24 Participants provided their informed consent, completed the online survey, and were compensated according to Qualtrics’ panel provider compensation systems including rewards, points, and gift cards. We restricted the qualitative analytic sample to participants who provided valid responses to the cigar type-specific belief elicitation exercises (n = 948). This study received an exempt determination from Institutional Review Board (IRB) review by the National Institutes of Health, Office of IRB Operations.

Sociodemographic Characteristics

Participants were asked to report their age (open-ended field; continuous variable), gender identity (coded as women; men; non-binary, transgender, or “other gender" [ie, “none of these describe me”]), ethnicity and race (coded as Hispanic [any race]; Black/African American; white; or another race [ie, Indigenous, Asian, multi-racial, Native Hawaiian or Pacific Islander, or “other” race]), education level (coded as ≤ high school or GED degree; vocational school or some college; or ≥ a college degree), total annual household income (coded as < $75000 or ≥ $75000 total annual household income), and sexual orientation (coded as heterosexual or LGBQ+ sexual orientation [lesbian or gay, bisexual, or “something else”]).

Belief Elicitation Exercise by Cigar Type

Participants were shown images and descriptions of cigarillos, little filtered cigars and large cigars adapted from previous research.2 After viewing these images, participants completed four susceptibility items for each cigar type with cigar type-specific susceptibility status determined similarly to e-cigarette use as described above (eg, “Do you think that you will use a cigarillo soon?”; “Do you think that you will use a cigarillo in the next year?”; “Do you think that in the future you might experiment with cigarillos?”; “If one of your best friends were to offer you a cigarillo, would you use it?” Response options: “definitely yes”; “probably yes”; “probably not”; “definitely not”).24 All participants (n = 1329) were then randomly assigned to one belief elicitation exercise about either cigarillos, little filtered cigars, or large cigars irrespective of their susceptibility status to that cigar type. Participants were instructed to think of only that cigar type for their responses. In total, n = 443 participants were randomized to receive each of the three possible cigar type-specific belief elicitation exercises. Each belief elicitation exercise included open-ended questions adapted from previous tobacco-related belief elicitation studies.28–30 Using cigarillo-focused questions as an example: Behavioral beliefs were elicited through (1) What emotions or feelings come to mind when you think of smoking cigarillos?; (2) What good or positive things come to mind when you think of smoking cigarillos?; (3) What bad or negative things come to mind when you think of smoking cigarillos?, normative beliefs were elicited through; (4) What individuals or groups of people in your life would be supportive of you smoking cigarillos?; (5) What individuals or groups of people in your life would be not supportive of you smoking cigarillos?, and control beliefs were elicited through (6) What would make it easy for you to try cigarillos?; and (7) What would make it difficult for you to try cigarillos?

Data Analyses

Descriptive statistics to describe the sociodemographic characteristics of the analytic sample were calculated using SPSS (IBM, SPSS Inc.: Armonk, NY, USA). We then used Dedoose, a web-based qualitative data management application (SocioCultural Research Consultants, LLC: Los Angeles, CA, USA), to conduct the thematic analysis. Overall, two study team members (LP and CS) trained in qualitative thematic analysis used an iterative process to develop the codebook and coded the data. The two study team members independently coded responses to determine which participant responses would be retained for this analysis. A total of 138 participants did not participate in this portion of the survey. Responses from 243 participants were also removed for being invalid (eg, keyboard smashing) or non-applicable responses (ie, responses that did not answer the question). Codebook development included ongoing discussions about codes, coding decisions, and independent coding of a subset of responses. One study team member then conducted 3–4 iterative rounds of coding for each question. A second trained study team member also independently coded 15% of responses within each question for each cigar type.31 The percentage agreement among the two coders was 87.2%. We examined emergent TPB-based construct themes at the intersection of cigar type andsusceptibility status. An estimated frequency count of responses reporting emergent themes was recorded as “very frequently” (30–46 responses), “frequently” (20–29 responses), “occasionally” (10–19 responses), “rarely” (1–9 responses), and “never” (0 responses) to help discern patterns of emergent themes, a method we adapted from previous tobacco-related qualitative research.32–35

Results

The qualitative analytic sample included 464 women (48.9%), 455 men (48.0%), and 29 (3.1%) individuals who self-identified with another gender identity (ie, non-binary, transgender, or “other” gender). The sample participants’ mean age was 24.44 years (SD = 3.53 years). About 60% of participants self-identified as white (n = 567), 15.6% (n = 148) as Hispanic (any race), 14.6% as Black (n = 138), and 10.0% as another race (n = 95; ie, Indigenous, Asian, multi-racial, Native Hawaiian or Pacific Islander, or “other” race). About one-thirds of the sample had ≤ high school or GED degree (n = 316; 33.3%), attended vocational school or some college (n = 262; 27.6%), or had ≥ a college degree (n = 370; 39.0%). About half of participants had < $75000 total annual household income (n = 466; 49.2%) or ≥ $75000 (n = 482; 50.8%) total annual household income. Most participants self-identified with heterosexual sexual orientation (n = 804; 84.8%) and 12.8% identified with LGBQ+ sexual orientation (n = 121; lesbian or gay, bisexual, or “something else”).

Among the qualitative sample, 70.5% were susceptible to ≥1 cigar type. Each subsample was also subdivided by susceptibility status to the cigar type corresponding to the belief elicitation exercise that the participant received. Overall, n = 327, n = 305, and n = 316 participants completed the belief elicitation exercise for smoking cigarillos (n = 209, 68.5% susceptible; n = 96, 31.5% non-susceptible), little filtered cigars (n = 222, 67.9% susceptible; n = 105, 32.1% non-susceptible), and large cigars (n = 210, 66.5% susceptible; n = 105, 33.2% non-susceptible).

Emergent Theory of Planned Behavior Beliefs

Broadly, we observed emergent similar behavioral, normative, and control beliefs that spanned across cigar types (ie, cigarillos, little filtered cigars, large cigars), with more variability by susceptibility status than by cigar type. Thus, we report our findings organized by first emergent beliefs by susceptibility status across cigar types and then by specific cigar type(s) when applicable. Tables 1–3 presents emergent TPB belief themes, their descriptions, example responses, and frequency categories.

Table 1.

Emergent Positive and Negative Behavioral Beliefs

Beliefs/Themes Belief description Example responses Cigar type
Cigarillos Little filtered cigars Large Cigars
S NS S NS S NS
n (%) n (%) n (%) n (%) n (%) n (%)
208 (68.5) 96 (31.5) 222 (67.9) 105 (32.1) 210 (66.5) 105 (33.2)
Positive – – – – – – – –
Relaxation Feelings of relaxation and comfort “It would help me relax.”; “chill” VF R F R VF R
Cigar and smoking experience Positive smoking outcomes (brand, filters, taste, texture, smell, packaging) “It smells good.”; “Brand quality.” R R F R F R
Cigar flavors Positive feelings about cigar flavors “Cigarillo flavors are so good.” R R F R O R
Mood regulation Anticipated control over personal mood(s) “…it helps me to reduce stress.”; “It soothes the mood…think clearly.” O R O R O R
Being cool Socially admirable persona related to attitude, behavior, or appearance “Looking cool.”; “Stylish” O R O R O R
Happiness Feelings of happiness or joy “….happiness, make people forget about things.” R R O N F R
Satisfaction Feelings of satisfaction, pleasure, or enjoyment “Satisfied”; “It gives me pleasure.” R N R N O N
Affluence Classy, wealthy, or socially powerful persona “It makes me feel more royal and classy.”; “Being a boss or in charge…” R R R R F R
Energized Feelings of being energized or refreshed “…refreshed and a positive power.”; “Energized” R R R N R N
Confidence Increases self-confidence and socialization “…helps to socialize.”; “I feel more confident.” R R R R R R
Celebration Feelings of having fun or celebrating “Celebrating a big event.”; “Good for passing time.” N R N R R R
Negative – – – – – – – –
Disgust Feelings of disgust from smoking “They are kind of gross.”; “Disgust” O VF R F O VF
Cigar and smoking experience Negative smoking outcomes (brand, filters, taste, texture, smell, packaging) “Very harsh”; “Too big”; “Smelly” F O O O O O
Cigar flavors Negative feelings about cigar flavors “Flavor is so bad.” R R R R R R
Fear Feelings that cigar smoking is dangerous “Fear”; “Dangerous”; “Worried” R R R R R R
Sadness Feelings of sadness and depression “Sad”; “Very sad emotions.”; “Being depressed, hopeless, or sad.” R R R R R R
Boredom Feelings of boredom “Boring” R N R N N N
Stress Feelings of stress from cigar smoking “Stress”; “Stressful” R R R N R R
Being uncool Socially unadmirable persona related to attitude, behavior, or appearance “Pathetic”; “Cringe”; “Stupid” R R N R R N
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“S” indicates susceptibility to cigar type; NS indicates non-susceptible to cigar type; “VF” indicates very frequently (30–46 responses); “F” indicates frequently (20–29 responses); “O” indicates occasionally (10–19 responses); “R” indicates rarely (1–9 responses); “N” indicates never (0 responses); Themes are anticipated feelings and outcomes from cigar smoking.

Table 3.

Easy- and Hard-to-Smoke Control Beliefs

Beliefs/Themes Belief description Example responses Cigar type
Cigarillos Little filtered cigars Large cigars
S NS S NS S NS
n (%) n (%) n (%) n (%) n (%) n (%)
208 (68.5) 96 (31.5) 222 (67.9) 105 (32.1) 210 (66.5) 105 (33.2)
Easy-to-smoke – – – – – – – –
Accessibility and availability Easy to purchase or high availability of cigar type “Easy access”; “…available at stores around me.” O R O R O R
Cost The price of cigar type “Affordable prices.”; “It’s cheap.”; “Low price.” O R O R O R
Cigar features References to cigar features (e.g., filters, textures, and packaging) “Good brand”; “…packaging and texture.”; “Premium quality.” O R O R R R
Cigar taste References to cigar taste “I think it’s taste would attract me.” O R R N R R
Smoking experience References to the act and experience of smoking cigar type “…it is easy to inhale.”; “…easy to smoke.” O N O R R N
Cigar flavors References to cigar flavors “…good menthol flavor”; “If there’s a strawberry flavor, I’ll try it.” R R O R R R
Peer pressure Social pressures to smoke “Peer pressure”; “Recommendation from a friend.”; “When my friend forces me.” R R O R R R
Cigar offered Being offered the cigar type by a friend or someone else “If I was hanging out with a good friend who smoked and they offered me one.”; “Someone offered…” R R R R R R
Cigar smell References to cigar smell “It’s smell is good.” R R R R N N
Social norms References to supportive social norms for smoking “If I’m with my friends or co-workers it makes it easy to try…”; “I’ll smoke when I hang out at the bar.”; R N R R R R
Hard-to-smoke -- -- – – – – – –
Cost The price of cigar type “Expensive.”; “Its high cost.” O R O R O R
Accessibility and availability Difficult to purchase or low availability “I wouldn’t even know where to buy them.”; “Limited locations to buy.” R R R R O O
Cigar smell References to cigar smell “I don’t like the smell.” R R R R R R
Cigar taste References to cigar taste “I don’t think it tastes very good…” R R R R R R
Cigar features References to cigar features (e.g., filters, textures, and packaging) “I don’t think it’s comfortable to smoke with a filter.”; “…their look is unappealing to me.” R R R R R R
Personal identity Misalignment between one’s identity/values and cigar smoking “My life”; “My self-respect.”; It would be hard for me because I’m a college student.” R R R R R R
Smoking experience References to the act and experience of smoking cigar type “Puffing a smoke…”; “Smoking the first time is very hard…”; “Don’t know how to use them.” R N R N R R
Social norms References to social norms against smoking “Thinking what my parents would think of me.”; “Social backlash” N N N R N N
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“S” indicates susceptibility to cigar type; NS indicates non-susceptible to cigar type; “VF” indicates very frequently (30–46 responses); “F” indicates frequently (20–29 responses); “O” indicates occasionally (10–19 responses); “R” indicates rarely (1–9 responses); “N” indicates never (0 responses); Themes are anticipated feelings and outcomes from cigar smoking.

Behavioral Beliefs

Behavioral beliefs about smoking each cigar type included anticipated outcomes from cigar smoking. These psychosocial outcome expectations included either positive or negative feelings about cigar flavors, cigar features, the experience of smoking them, personas, and emotions (see Table 1).

Positive Behavioral Beliefs

Overall, non-susceptible participants rarely mentioned the emergent positive behavioral beliefs. Among susceptible participants, anticipated relaxation was reported very frequently for cigarillo and large cigar smoking and frequently for little filtered cigar smoking. Regulating moods and perceiving being cool from smoking were also occasionally mentioned by susceptible participants for all three cigar types. Susceptible participants’ interest in cigar features and the anticipated smoking experience was reported frequently for little filtered cigars and large cigars, while it was rarely reported for smoking cigarillos. Interest in flavors was reported frequently by susceptible participants for little filtered cigars, occasionally for large cigars, and rarely for cigarillos. Among those susceptible to large cigar smoking, anticipated feelings of happiness (reported occasionally for little filtered cigar smoking and rarely for cigarillo smoking) and affluence (reported rarely for little filtered cigar and cigarillo smoking) were reported frequently. Satisfaction from little filtered cigar smoking was reported occasionally in comparison to being rarely reported for cigarillo and large cigar smoking by susceptible participants. Anticipated emotions of being energized or confidence were also mentioned rarely across the cigar types among susceptible participants. Finally, non-susceptible participants reported celebrations across the cigar types on a rare basis, while susceptible participants never mentioned celebrations for cigarillos and little filtered cigars, and rarely for large cigars.

Negative Behavioral Beliefs

Overall, disgust about cigar smoking was the most frequently elicited negative behavioral belief. Across cigar types, non-susceptible participants very frequently-to-frequently reported disgust in comparison to occasional-to-rare reports of disgust by susceptible participants. Negative anticipated outcomes related to cigar features and the smoking experience were reported frequently for cigarillo smoking among susceptible participants and occasionally by both susceptible and non-susceptible participants for other participant categories across the cigar types. Negative behavioral beliefs about cigar flavors and feelings of sadness and fear were rarely mentioned consistently across susceptibility status and cigar types. Anticipated feelings of boredom and stress and the persona of being uncool from cigar smoking also emerged, though patterns varied by susceptibility status and cigar type for these beliefs.

Normative Beliefs

Participants identified their significant other, friends, siblings, parents, grandparents, other family members, co-workers, and members of their broader community as individuals or groups of people whom they perceived would, or would not, be supportive of them smoking cigar products (see Table 2).

Table 2.

Emergent Supportive and Unsupportive Normative Beliefs

Beliefs/Themes Belief description Example responses Cigar type
Cigarillo Little filtered cigar Large cigar
S NS S NS S NS
n (%) n (%) n (%) n (%) n (%) n (%)
208 (68.5) 96 (31.5) 222 (67.9) 105 (32.1) 210 (66.5) 105 (33.2)
Supportive – – – – – – – –
Friends Friends or peers “…friends.”; “Friend circle”; “Friend group” VF R VF O F R
Significant other One’s partner/spouse/significant other “…boyfriend.”; “Husband…”; “Wife”; “Spouse” R R R R R R
Parents Father(s), mother(s), or parents(s) “Mom”; “Dad”; “Mother”; “Father”; “Parents” R R R R R R
Family Aunts, uncles, cousins, and other family members “…aunt.”; “…uncle.”; “Cousins” R R R R R R
Siblings Brother(s), sister(s), or sibling(s) “…brother(s).”; “…sister(s).”; “Siblings” R R R N R N
Grandparents Grandfather(s), grandmother(s), or grandparent(s) “Grandma(s)”; “Grandmother”; “Grandparents” R R N R R R
Co-workers Co-workers or colleagues “Co-workers”; “Colleagues” R N R N R R
Community Including neighbors, teachers, church families, healthcare workers, police officers, and family friends “Neighbors”; “Former teachers and professors”; “Coaches”; “Family friends” R R R N N R
Unsupportive -- -- – – – – – –
Family Aunts, uncles, cousins, and other family members “…aunt”; “…uncle”; “Cousins” VF VF VF F VF VF
Parents Father(s), mother(s), or parents(s) “Mom”; “Dad”; “Mother”; “Father”; “Parents” F O F O F O
Friends Friends or peers “…friends.”; “Friend circle”; “Friend group” O O O O O O
Significant other One’s partner/spouse/significant other “…boyfriend.”; “Husband…”; “Wife”; “Spouse” R R R R R R
Siblings Brother(s), sister(s), or sibling(s) “…brother(s)”; “…sister(s)”; “Siblings” R R R R R R
Community Including neighbors, teachers, church families, healthcare workers, police officers, and family friends “Neighbors”; “Former teachers and professors”; “Coaches”; “Family friends” R R R R R R
Grandparents Grandfather(s), grandmother(s), or grandparent(s) “Grandma(s)”; “Grandmother”; “Grandparents” R N R R R R
Co-workers Co-workers or colleagues “Co-workers”; “Colleagues” R R R N R R
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“S” indicates susceptibility to cigar type; NS indicates non-susceptible to cigar type; “VF” indicates very frequently (30–46 responses); “F” indicates frequently (20–29 responses); “O” indicates occasionally (10–19 responses); “R” indicates rarely (1–9 responses); “N” indicates never (0 responses); Themes are anticipated feelings and outcomes from cigar smoking.

Supportive Referents

Overall, both susceptible and non-susceptible participants reported that their friends would be supportive of them smoking cigars more frequently than other emergent supportive referent groups. However, frequency of supportive friends for cigar smoking varied by susceptibility status and cigar type. Susceptible participants mentioned having supportive friends very frequently for cigarillo and little filtered cigar smoking, and frequently for large cigar smoking. In comparison, non-susceptible participants mentioned having supportive friends rarely for cigarillo and large cigar smoking, and occasionally for little filtered cigar smoking. Having support from family, parents, and significant others were mentioned rarely by both susceptible and non-susceptible participants across the three cigar types. Supportive siblings, grandparents, and community members were also mentioned rarely across susceptibility status for cigarillo smoking, which was similarly observed for supportive grandparents and co-workers for large cigar smoking. Other patterns in the data varied and are shown in Table 2.

Unsupportive Referents

Both susceptible and non-susceptible participants very frequently-to-frequently mentioned that their family would not be supportive of them smoking cigarillos, little filtered cigars and large cigars. Across cigar types, susceptible participants frequently reported their parents were unsupportive referents, while non-susceptible participants occasionally mentioned their parents as unsupportive referents. Having friends who would not be supportive of cigar smoking was also occasionally shared by both susceptible and non-susceptible participants for all three cigar types. Across susceptible status and cigar types, unsupportive significant others, siblings, and community members were also rarely mentioned. Susceptible participants rarely reported having grandparents and co-workers as unsupportive referents, while this referent groups were mentioned rarely-to-never among non-susceptible participants.

Control Beliefs

Similar beliefs emerged as perceived factors that would either make it easy or hard for participants to smoke cigarillo, little filtered cigars, and large cigars. These factors included cigar features like their flavor, quality and whether or not they had filters (ie, “cigar features”), in addition to their price (ie, “cost”), accessibility and availability. Outcome expectations associated with the smoking experience, cigar taste and smell were also noted as control beliefs. Beliefs about social norms about cigar smoking, peer pressure, and being offered the cigar(s) were also mentioned (see Table 3).

Easy-to-Smoke Control Beliefs

Overall, the elicited easy-to-smoke beliefs were reported occasionally-to-rarely by susceptible participants and rarely-to-never by non-susceptible participants. Across cigar types, susceptible participants occasionally shared that high accessibility, high availability, and low cost were factors that would make it easier for them to smoke cigar products in comparison to these factors being rarely mentioned among non-susceptible participants. Among susceptible participants, interest in cigar features and the smoking experience was also mentioned occasionally for cigarillo and little filtered cigar smoking, and rarely for large cigar smoking. Experiencing social norms that support cigar smoking was also rarely noted by susceptible participants for all three cigar types. Interest in cigar flavors and experiencing social peer pressures to smoke were occasionally shared as easy-to-smoke beliefs for little filtered cigar smoking and were rarely mentioned for cigarillo and large cigar smoking. Additionally, interest in the taste of cigarillos was occasionally reported, while interest in the taste of little filtered cigars and large cigars were rarely mentioned. Across susceptibility status and cigar types, being offered the cigar from a friend or someone else was rarely reported. Both susceptible and non-susceptible participants rarely reported interest in the anticipated smell of smoking cigarillos and little filtered cigars, though it was not mentioned for large cigar smoking.

Hard-to-Smoke Control Beliefs

Susceptible participants occasionally perceived high cigar cost(s) as a factor that would make it harder for them to smoke cigarillos, little filtered cigars, and large cigars, while concerns about high cost of cigars was rarely noted by non-susceptible participants. Having low accessibility and low availability was occasionally elicited for large cigars and rarely elicited for cigarillos and little filtered cigars by both susceptible and non-susceptible participants. Across cigar types from both susceptible and non-susceptible participants, difficulty with the smell, taste, and other features of the cigar type were also rarely elicited as factors that would make it harder for participants to smoke cigars. Additionally, susceptible and non-susceptible participants alike rarely reported the belief that smoking cigarillos, little filtered cigars, and large cigars did not align with their personal values or identity.

Discussion

Our findings elucidate theoretical beliefs that may influence cigar smoking susceptibility and initiation among young adult tobacco never-users. We found that young adults in our sample who were susceptible to the cigar products consistently had more positive beliefs generally about the cigar type (eg, anticipated relaxation, mood regulation, being cool) than those who were non-susceptible. Interestingly, this differential pattern by susceptibility status was not observed for negative beliefs (eg, difficulty with cigar features, smoking experience, flavors), emphasizing the potential importance of positive beliefs in the psychosocial pathway to cigar smoking behavior, and the potential value of mitigating these beliefs to change intention to smoke and prevent initiation. Thus, these findings suggest that targeting positive beliefs may be one potentially impactful prevention messaging strategy. Future research should examine the potential influence of messages designed to reduce positive beliefs on cigar smoking intentions and initiation.

Among behavioral beliefs, emergent themes were about features of the cigar product (eg, flavors, filter, size), the anticipated smoking experience, personas, and emotions from cigar smoking. A previous study14 found similar perceptions about flavored cigar smoking including evoking the perceived personas of coolness and affluence as well as experiencing pleasure, satisfaction, and relaxation among young adults who smoked cigarillos, little filtered cigars, and/or cigarettes. Taken altogether, these findings lead us to speculate that perhaps young adults who are tobacco never-users susceptible to cigar smoking and those who are current cigar smokers may hold similar beliefs about cigar smoking. However, this speculation excludes the psychophysiological nature of nicotine dependence, which may change belief systems and reasons for continued use.35,36 Future research should examine the saliency of these beliefs and compare the potential effectiveness of health communication messages aimed to change positive behavioral beliefs among young adults of varying cigar smoking status such as those who are susceptible and have never smoked, those who have experimented with cigars, and those who experience nicotine dependence.

Although there were slight variations in reported frequencies across the cigar types, we found overlapping emergent themes for behavioral and control beliefs. For example, while interest in cigar features and the anticipated smoking experience were mentioned more frequently for little filtered cigars and large cigars as a positive behavioral belief, these themes were mentioned slightly more frequently for cigarillos and little filtered cigars as easy-to-smoke control beliefs. Despite the slight nuances, the overlap in emergent themes across types of beliefs may indicate the saliency of these beliefs for susceptible young adults. These findings also highlight the differentiation in beliefs between cigar susceptible and non-susceptible young adults. In addition to the higher frequency with which these themes were reported, these beliefs about anticipated outcomes related to the cigar product, the smoking experience, and the personas and emotions one perceives may be helpful communication targets for prevention messaging. These beliefs, in large part, may be shaped by cigar advertising,37,38 which is known to use descriptors highlighting the cigar products’ taste and smell,39 evoke glamorized personas such as being cool, affluent, and socially admirable,3,13,40 and expectations of feeling enjoyment and pleasure.41 Cigar smoking prevention messaging is needed to counter these cigar industry messages used to sell their products. While it was reported at a similar frequency across cigar types and by susceptibility status, the elicitation of personal norms, such as feeling that cigar smoking may be “wrong” due to one’s “self-respect” or misalignment with one’s personal identity (ie, hard-to-smoke personal identity theme) may be another potential messaging strategy. Future research should examine the potential association of these beliefs to cigar use intentions and harm perceptions that are also strongly associated with cigar use to further investigate their potential utility as messaging targets.21

Additionally, our findings build upon previous research by examining nuances in beliefs by cigar type. For example, while affluence and satisfaction were elicited positive behavioral beliefs for all cigar types, it was more frequently noted for large cigar smoking. This finding aligns with large cigar marketing and advertising, which aims to portray luxury, prestige, and a successful lifestyle.3,42 Similarly to little filtered cigar and cigarillo marketing strategies among young adults as well,10,43 easy accessibility and availability and low cost were mentioned more frequently among susceptible participants for little filtered cigars and cigarillos than for large cigars. These nuances provide rationale for cigar type-specific prevention messaging given that young adults may associate certain beliefs more strongly with one cigar type versus another, impacting the potential effectiveness of health communication to prevent cigar smoking, despite the overlap in emergent themes. Examining these beliefs with their corresponding TPB constructs of outcome evaluation, motivation to comply, and perceived power will be important to further investigate the utility of targeting these beliefs as a potential prevention messaging strategy. Cigarillo and little filtered cigar pack size, pricing, and marketing policies may also help prevent initiation of these cigar products among young adults.44,45

New findings from this study also include elicited normative beliefs. Overall, parents and other family members were mentioned most often as not being supportive of cigar smoking. In contrast, friends were named most frequently as a supportive group, with susceptible young adults naming their friends substantially more frequently than non-susceptible young adults. This strong perceived support from friends among susceptible young adults was also aligned with other elicited psychosocial factors that would make it easy-to-smoke cigars, including social norms, peer pressure from friends to smoke, and being offered a cigar. These findings suggest that educating young adults about behavioral cognitive strategies to avoid risky situations could be beneficial. These beliefs also shed light on the broader social context of cigar smoking susceptibility and use, including advertising cigars as a fun social activity,3 and how this may impact societal norms generally. Additionally, these normative beliefs suggest the potential utility in targeting perceived injunctive norms (ie, approval or disapproval of cigar smoking from referents) or descriptive norms (ie, perceived prevalence of cigar smoking) in health communication to prevent cigar smoking given the variation in elicited supportive referents by susceptibility status. Future studies should also examine TPB beliefs more comprehensively by sociodemographic characteristics and among priority sub-populations like Black/African American young adults who are at greater risk for cigarillo and little filtered cigar smoking5 due to targeted tobacco industry practices,12,46,47 unique risk factors like racial discrimination,48 and tobacco use disparities.5 Given that the U.S. prevalence of cigarillo and little filtered cigar smoking is highest among Black young adults (2.7% in 2018–2019) and large cigar smoking is highest among white young adults (1.5% in 2018–2019),5 future research may focus on understanding cigar-associated beliefs within these racial populations to further inform cigar type-specific prevention efforts.

This study has limitations. Participants were recruited from an online panel using non-probability sampling approaches, and thus may not be representative of tobacco naïve young adults in the United States. It will be important for future research to validate our findings in a nationally representative sample of young adults. Additionally, eligibility criteria of the parent study included self-report of never tobacco use and susceptibility to e-cigarette use. Bioverification of tobacco use status would increase study validity..49 Eligibility criteria may also impact the generalizability of findings to other cigar susceptible and non-susceptible young adults. Given that there is a large degree of overlap in susceptibilities to various tobacco product use,50 our restricted sample included a higher proportion of susceptible participants than non-susceptible participants. However, the thematic analysis approach was based on number of excerpts rather than number of participants, lessening the concern for potential biases due to unequal sample sizes by susceptibility status. We were also unable to examine themes by sociodemographic characteristics, which will be important for future studies to understand how to best develop health communication strategies for prioritized populations and counter targeted cigar marketing practices, particularly towards Black young adults.12,13 Additionally, we did not include the TPB constructs of outcome evaluation, motivation to comply, and perceived power in this study that may be better measured quantitatively with these identified behavioral, normative and control beliefs.

Despite these limitations, this study is among the first to examine emergent beliefs about cigarillos, little filtered cigars, and large cigars. Our findings identify common beliefs that distinguishes susceptible young adults and non-susceptible young adults in the sample. Future directions may include quantitatively examining themes and beliefs through scale responses to determine the strongest beliefs that may be optimal for health communication25 and examine whether these beliefs are associated with intention to use cigar products, cigar-related harm perceptions, and cigar use behaviors. Future research is also needed to more comprehensively understand TPB-beliefs related to cigar smoking within priority populations.

Acknowledgments

This research was supported by the National Institute on Minority Health and Health Disparities Division of (NIMHD DIR), National Institutes of Health (NIH) Intramural Research Program and Food and Drug Administration’s Center for Tobacco Products (FDA CTP). Lilianna Phan was supported by the Pathway to Independence Award in Tobacco Regulatory Research from NIH/FDA (K99CA272919) and NIMHD DIR. Christen Seyl was supported by the AMGEN Scholars Program and Office of Intramural Training and Education, NIH. Julia Chen-Sankey is supported by the Pathway to Independence Award in Tobacco Regulatory Science from NCI/FDA (R00CA242589), Penn/Rutgers TCORS (U54CA229973), and Rutgers Cancer Institute of New Jersey Cancer Center Support Grant (P30CA072720). NIMHD DIR and NIH/FDA had no role in the study design, collection, analysis or interpretation of the data, writing the manuscript, or the decision to submit the paper for ­publication. The content was not reviewed by the FDA but underwent the standard manuscript clearance process for scientific papers published from the NIH Intramural Research Program. The opinions and comments expressed in this paper belong to the authors and do not necessarily reflect those of the U.S. Government, Department of Health and Human Services, National Institutes of Health, and National Institute on Minority Health and Health Disparities.

Contributor Information

Lilianna Phan, National Institute on Minority Health and Health Disparities, Division of Intramural Research, Bethesda, Maryland.

Christen Seyl, Department of Psychology, University of Nebraska-Lincoln, Lincoln, Nebraska; Department of Biological Sciences, University of Nebraska-Lincoln, Lincoln, Nebraska.

Julia Chen-Sankey, Center for Tobacco Studies, Rutgers Biomedical and Health Sciences, New Brunswick, New Jersey; School of Public Health, Rutgers Biomedical and Health Sciences, Piscataway, New Jersey.

Jeff Niederdeppe, Jeb E. Brooks School of Public Policy, Cornell University, Ithaca, New York; Department of Communication, College of Agriculture and Life Sciences, Cornell University, Ithaca, New York.

Mignonne C Guy, Department of African American Studies, Virginia Commonwealth University, Richmond, Virginia; Center for the Study of Tobacco Products, Virginia Commonwealth University, Richmond, Virginia.

Kymberle L Sterling, Department of Health Promotion and Behavioral Sciences, University of Texas Health Sciences Center School of Public Health, Dallas, TX.

Kelvin Choi, National Institute on Minority Health and Health Disparities, Division of Intramural Research, Bethesda, Maryland.

Declaration of Interests

The authors have no conflicts of interest to declare.

Data Availability

The datasets generated and/or analyzed during the current study are not publicly available due to the proprietary nature of the data.

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Associated Data

This section collects any data citations, data availability statements, or supplementary materials included in this article.

Data Availability Statement

The datasets generated and/or analyzed during the current study are not publicly available due to the proprietary nature of the data.

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