Abstract
Introduction
Many people remove the tobacco leaf from cigars and replace it with cannabis (ie, blunts), but few studies have examined whether messages about the risks of cigars, like warnings on cigar packages, can affect blunt use.
Methods
Participants were 438 U.S. adults who reported past 30-day cigar use and ever blunt use, recruited from a probability-based national panel to take an online survey. In a 2 × 2 experiment with a between-subjects design, we manipulated two cigar warning characteristics: (1) warning type: text-only versus pictorial (ie, text + image) and (2) warning size: 30% (smaller) versus 50% (larger) of the product package. Participants then viewed six different warnings on a fictious cigarillo package, within their randomly assigned condition. After evaluating all stimuli, participants were asked the extent to which the warnings discouraged them from wanting to use cigars to smoke cannabis (ie, blunt perceived warning effectiveness). Response options ranged from “not at all” (1) to “a great deal” (5).
Results
We observed no main effects of warning type or size on blunt perceived warning effectiveness. However, a significant interaction existed between the two experimental manipulations (p = .009). Whereas adding images made no difference to blunt perceived warning effectiveness when warnings were smaller (simple effect: −0.22, p = .28), images mattered for larger warnings. Specifically, adding images increased blunt perceived warning effectiveness when warnings were 50% of the product package (simple effect: 0.52, p = .008).
Conclusions
This experiment provides preliminary evidence that larger pictorial cigar warnings may discourage blunt use relative to larger but text-only warnings.
Implications
Blunts, which are hollowed out cigars with tobacco leaf wrappers that are filled with cannabis leaf, are one of the most common ways in which tobacco and cannabis are used simultaneously, yet few studies have examined whether messages about the risks of cigars can affect blunt use. We conducted an online experiment concerning the perceived effectiveness of cigar warnings among people who use blunts recruited from a probability-based panel. Results provide novel, preliminary evidence that larger pictorial cigar warnings may discourage blunt use, relative to larger but text-only warnings. More research evaluating cigar warnings on blunt use is needed.
Introduction
Tobacco and cannabis are two of the most commonly used substances in the United States and the world, and their use is often intertwined with one another.1 For instance, cannabis use is more common among people who use tobacco, and tobacco use is common among people who use cannabis.1 In some groups of people, like young adults, co-use of tobacco and cannabis is more common than exclusive use of each substance.1 People can use tobacco and cannabis concurrently (eg, both are used separately within the past 30 days) or simultaneously (eg, used at the same time within the same product). Blunts, which are hollowed out cigars with tobacco leaf wrappers that are filled with cannabis leaf, are one of the most common ways in which tobacco and cannabis are used simultaneously. In 2019, 7.0% of people aged 12 or older in the United States reported smoking blunts in the past year,2 with higher prevalence rates among Black/African Americans and young adults.3
Because of the difficulties in measuring and assessing tobacco and cannabis co-use, the long-term health effects of blunt use are unknown.1 However, as combustible cannabis products, blunts likely have adverse health consequences, including chronic bronchitis.4 Blunts also expose people to nicotine (in the cigar leaf wrappers)5 and are associated with increased nicotine dependence.6 Concerningly, research shows people who smoke blunts are at higher risk of initiating use of cigarettes, e-cigarettes, and cigars compared with people who do not smoke blunts.7 Blunt use has also been shown to be associated with greater exposure to carbon monoxide than other forms of cannabis use8 and increased risk of cannabis dependence.6 Despite these risks, many people believe that blunts are more natural, pose less harm, and are less addictive than unmodified cigars9,10; however, it is still important to note that people who use blunts do acknowledge some level of harm from using cigarillos for blunts.11
An important question is whether regulatory actions designed to reduce cigar use, like cigar warnings, may also discourage blunt use. In 2016, the Food and Drug Administration (FDA) proposed new warnings for cigars that would comprise 30% of the principal display panels on packages. While this was vacated in 2020 due to a court decision, some cigar manufacturers have voluntarily complied with this regulation.12 While cannabis is not under the regulatory purview of the FDA’s Center for Tobacco Products, given the high prevalence of blunt use among people who smoke cigars13 and the associations between blunt use and tobacco use initiation,7 examining the effects of cigar warnings on blunt use is important.
Previous research has found that some people who use cigars to smoke blunts do not pay attention to cigar warnings because they do not think such warnings are personally relevant.9 It is unknown, though, whether cigar warnings—particularly strong warnings that are large and contain images depicting health effects, which have been shown to be more effective than small, text-only cigar warnings14—could possibly deter blunt use.15 Indeed, previous research has shown that warnings or messages about one tobacco product can spill over and affect perceptions of other nontargeted tobacco products.16 For instance, one study found that e-cigarette warnings reduced interest in smoking cigarettes compared with control warnings.17 Thus, the goal of this exploratory study was to examine whether cigar warnings are perceived as effective for discouraging blunt use.
Methods
Participants
NORC at the University of Chicago recruited participants for our online experiment in March 2022. This study was part of a larger experiment (“parent study”) examining the impact of larger, pictorial warning labels on cigar use. At the end of the parent study, we examined the impact of larger, pictorial warning labels to discourage blunt use among people who reported smoking blunts (“current study”). To be eligible for participation in the parent study, adults had to be a part of the AmeriSpeak probability-based panel, be 18 years or older, speak English, live in the United States, and report past 30-day use of little cigars or cigarillos. NORC randomly selected U.S. households using area probability and address-based sampling, with a known, nonzero probability of selection from the NORC National Sample Frame. The AmeriSpeak panel provides sample coverage of approximately 97% of the U.S. household population. The weighting process accounted for unequal probability of selection and nonresponse, with final weights aligning with population benchmark demographic distributions from the Population Assessment of Tobacco and Health (PATH) Study for adults 18+ who use little cigars or cigarillos in the United States. A total of 840 people were eligible for the study (12.5% of those completing the screener), and of those, 809 completed the study and met the standards of data quality review (ie, did not speed through the survey, answered most questions). Of these 809 participants, 443 reported ever smoking blunts (weighted prevalence rate: 56.7%), and 438 fully completed the experiment for the current study.
Procedures
We conducted a 2 × 2 between-subjects, online experiment in which we manipulated two cigar warning characteristics: (1) warning type: text-only versus pictorial (ie, text + image) and (2) warning size: 30% (smaller) versus 50% (larger) of the product package. Within their randomly assigned condition, participants then viewed six novel warnings on a fictious cigarillo package to minimize brand loyalty (Supplementary Materials A). For instance, if a participant was assigned to the 30% text-only warning condition, they saw six cigarillo packages that had different warnings that were all 30% of the product package and text-only. Participants viewed the six different packages one at a time in a random order. The six warnings discussed different health risks from smoking cigars (eg, WARNING: Cigar smoking causes pharyngeal and throat cancer). The selected images were either graphic or depicted personal suffering. We selected the novel warning statements and images because they performed well in previous experiments conducted by our study team.18 The University of North Carolina at Chapel Hill Institutional Review Board approved the study.
Measures
Before the experiment, we asked participants about ever and past 30-day little cigar, cigarillo, and large/traditional cigar use with questions adapted from the PATH Study. At the end of the experiment, after participants had seen all of the six different warnings, participants were asked about ever blunt use using one question adapted from the PATH Study: “Sometimes people take tobacco out of a little cigar, cigarillo, or large cigar and replace it or mix it with marijuana. This is sometimes called a ‘blunt’. Have you ever smoked part or all of any type of cigar with marijuana in it?” Participants who reported “yes” were then asked about the perceived effectiveness of all of the warnings they had just seen for discouraging blunt use, which we have labeled “blunt perceived warning effectiveness (PWE).” Blunt PWE was measured with one item adapted from a perceived message effectiveness scale19,20: “How much did the warnings that you saw in this survey so far discourage you from wanting to use cigars to smoke marijuana?” Response options ranged from “not at all” coded as 1 to “a great deal” coded as 5. At the end of the experiment, we also assessed nicotine dependence21 and demographics.
Analysis
The analysis conducted for the current study was exploratory and not preregistered. We first conducted weighted second-order Rao–Scott chi-square tests to describe participant characteristics by ever blunt use.
For our experimental analysis, we then used unweighted linear regression models to estimate main effects of the two experimental conditions (warning type and size) on blunt PWE and an interaction between the two experimental conditions.22 To probe a significant interaction, we estimated and compared simple effects (ie, the conditional effect of one of the experimental conditions at specific levels of the other experimental condition). We also specified contrasts to compare all four experimental conditions against one another. Blunt use was balanced across the four experimental conditions (p = .67). Because this was an experiment, we did not control for demographic variables. As a sensitivity analysis, we also analyzed data using an ordinal regression model, which provided the same pattern of results (Supplementary Table B). We conducted analyses in SAS (version 9.4) and used two-tailed tests and a critical alpha of 0.05.
Results
Participants Characteristics
All participants in this study reported past 30-day use of little cigars or cigarillos. Participants who reported ever smoking blunts in addition to smoking cigars were significantly more likely to be younger, female, and have lower incomes compared with participants who reported never smoking blunts (Table 1). In addition, participants who reported ever smoking blunts were significantly more likely to report using cigarillos in the past 30 days and have higher nicotine dependence scores. No other significant differences emerged.
Table 1.
Participant Characteristics and Tobacco Use Variables for the Full Sample (N = 809) by Blunt Smoking Statusa
| Full sample, N = 809 | People who reported never smoking blunts, n = 355 | People who reported ever smoking blunts, n = 443 | ||
|---|---|---|---|---|
| Variable | n (weighted %) | n (weighted %) | n (weighted %) | p |
| Age, mean (SE) | 38.1 (0.7) | 40.1 (1.3) | 36.9 (0.8) | .03 |
| Gender | ||||
| Male | 382 (63.8) | 198 (73.2) | 181 (57.1) | .003 |
| Female | 419 (35.2) | 154 (25.2) | 257 (42.2) | |
| Transgender or other | 7 (1.0) | 2 (1.6) | 5 (0.6) | |
| Sexual orientation | ||||
| Lesbian, gay, or bisexual | 82 (9.3) | 33 (8.4) | 48 (10.0) | .37 |
| Straight | 713 (89.5) | 318 (90.3) | 385 (88.6) | |
| Something else/don’t know | 14 (1.2) | 4 (1.3) | 10 (1.2) | |
| Race/ethnicity | ||||
| White, non-Hispanic | 426 (46.4) | 219 (52.7) | 203 (41.5) | .19 |
| Black non-Hispanic | 155 (30.2) | 51 (27.2) | 100 (32.3) | |
| Hispanic | 139 (16.6) | 47 (14.0) | 90 (18.9) | |
| Other, non-Hispanic | 89 (6.8) | 38 (6.1) | 50 (7.4) | |
| Education | ||||
| Less than high school | 80 (16.5) | 30 (17.5) | 49 (16.1) | .49 |
| High school graduate or equivalent | 168 (37.2) | 65 (33.4) | 100 (39.5) | |
| Vocational/tech school/some college/associate’s | 325 (35.4) | 133 (35.9) | 186 (35.1) | |
| Bachelor’s degree | 147 (6.7) | 78 (8.1) | 68 (5.7) | |
| Postgraduate/professional degree | 89 (4.2) | 49 (5.1) | 40 (3.6) | |
| Income | ||||
| Below $30 000 per year | 302 (42.2) | 97 (32.4) | 199 (49.3) | .006 |
| $30 000 to $59 999 per year | 219 (27.1) | 91 (29.1) | 127 (26.1) | |
| $60 000 to $99 999 per year | 165 (16.9) | 92 (21.2) | 71 (13.9) | |
| Greater than $100 000 per year | 123 (13.9) | 75 (17.2) | 46 (10.7) | |
| Past 30-day use of cigarillos | 698 (88.0) | 278 (80.9) | 409 (93.1) | <.001 |
| Past 30-day use of little cigars | 415 (48.7) | 207 (54.9) | 205 (45.2) | .06 |
| Number of days used cigarillos in the past 30 days, mean (SE)b | 7.7 (0.6) | 6.7 (1.0) | 8.2 (0.7) | .18 |
| Number of days used little cigars in the past 30 days, mean (SE)b | 5.2 (0.6) | 5.4 (0.8) | 5.0 (0.8) | 0.70 |
| Nicotine dependence, mean (SE)c | 2.2 (0.1) | 1.8 (0.2) | 2.4 (0.1) | <.001 |
Standard error (SE); boldface denotes statistical significance at p < .05.
a11 participants were missing on the ever blunt use question.
bNumber of days used was calculated among people who reported past 30-day use of the product.
cNicotine dependence ranges from 1 to 5, where 5 indicates highest possible nicotine dependence
Experiment
We observed no main effects of warning type or size on blunt PWE (Supplementary Materials B). However, there was a significant interaction between the two experimental manipulations (p = .009). Whereas adding images made no difference to blunt PWE when warnings were smaller (simple effect: −0.22, p = .28), it mattered for larger warnings. Specifically, adding images increased blunt PWE when warnings were 50% of the product package (simple effect: 0.52, p = .008) (Figure 1). Using contrasts to compare all four experimental conditions against one another, the pictorial warning at 50% size significantly increased blunt PWE more than the text-only warning at 50% size (p = .008) (Supplementary Materials C).
Figure 1.
Interaction between warning type and size on blunt perceived warning effectiveness, n = 438. Blunt perceived warning effectiveness (PWE) ranges from 1 to 5, where 5 indicates highest possible blunt PWE.
Discussion
Our exploratory study found that larger, pictorial warnings on cigarillo packages can potentially discourage blunt use, which is important for the millions of adults who smoke blunts.2 Importantly, we found that adding images only had an effect when the warnings were larger. We also found that pictorial warnings at 50% size increased blunt PWE, relative to text-only warnings at 50% and these were the only two warning conditions that significantly differed from one another. Our findings suggest that more evaluation of cigar warnings among people who use blunts is needed. This research becomes all the more important considering that participants who reported using blunts in our study and in others6 report higher nicotine dependence and may have more trouble quitting cigars than people not using blunts.
It is important to note that all participants in our study reported past 30-day cigar use. Previous research has shown that some people who smoke blunts do not identify as “tobacco users” or do not report smoking cigars.3,23 Therefore, our finding that cigar warnings can potentially discourage blunt use may not generalize to all people who smoke blunts. Indeed, it is possible that cigar warnings may have a smaller effect on people who use blunts and do not report using cigars. For example, some people who smoke blunts do not think the cigar wrapper contains nicotine,24 which may extend to their perceptions of the harms from smoking the wrapper. Hence, it may matter how warnings should be phrased. The six warnings used in our study started with the stem “WARNING: Cigar smoking…” Since this stem explicitly mentioned cigars, it may not be as relevant to people who do not report smoking cigars but do report smoking blunts.15 Future research could explore how cigar warnings are perceived among people who smoke blunts who do and do not report smoking cigars and how to phrase cigar warnings (eg, Cigar smoking vs. Smoking).
Finally, we found that people who reported smoking blunts were more likely to be younger, have lower income, and be female compared with people who reported not smoking blunts, with no significant differences by race and ethnicity. Many previous studies on blunts have focused on young adults, males, and African Americans who tend to have higher rates of blunt use.6 However, research shows that blunt use appears to be increasing in other demographic groups, like Hispanic adults.25 Our findings suggests that up-to-date surveillance on blunt use prevalence by different demographic groups is needed for deciding how to tailor messages and warnings about the risks of blunt use.
Strengths of our study include our use of a probability-based panel and an experimental design. Limitations include that we only assessed potential effectiveness of cigar warnings on blunt smoking via an online study rather than actual warning effectiveness in the real world; we only measured ever blunt use and did not assess current blunt use; none of the warnings mentioned cannabis or blunts; and only people who reported ever smoking blunts were asked about blunt PWE, which limits our ability to determine whether cigar warnings could discourage potential blunt use among people who have not yet reported smoking blunts.
Conclusions
Among participants who reported smoking cigars and blunts, our experiment provides preliminary evidence that larger, pictorial cigar warnings can potentially discourage blunt use, relative to larger but text-only warnings. More research, including longitudinal research measuring behavioral outcomes, is needed to examine the impact of cigar warnings on blunt use.
Supplementary Material
Acknowledgments
None declared.
Contributor Information
Sarah D Kowitt, Department of Family Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC 27599, USA; Lineberger Comprehensive Cancer Center, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA.
Adam O Goldstein, Department of Family Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC 27599, USA; Lineberger Comprehensive Cancer Center, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA.
Jennifer Cornacchione Ross, Department of Health Law, Policy, and Management, Boston University School of Public Health, Boston, MA, USA.
Sonia A Clark, Lineberger Comprehensive Cancer Center, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA.
Kristen L Jarman, Department of Family Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC 27599, USA.
Paschal Sheeran, Lineberger Comprehensive Cancer Center, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA; Department of Psychology and Neuroscience, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA.
James F Thrasher, Department of Health Promotion, Education, and Behavior, Arnold School of Public Health, University of South Carolina, Columbia, SC, USA.
Leah M Ranney, Department of Family Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC 27599, USA; Lineberger Comprehensive Cancer Center, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA.
Funding
Research reported in this publication was supported by NCI and FDA Center for Tobacco Products (CTP) under award number R01CA240732. The content is solely the responsibility of the authors and does not necessarily represent the official views of the NIH or the Food and Drug Administration.
Declaration of Interests
None declared.
Author Contributions
Sarah Kowitt (Conceptualization [Equal], Data curation [Supporting], Formal analysis [Lead], Investigation [Equal], Methodology [Equal], Writing – original draft [Lead], Writing – review & editing [Lead]), Adam Goldstein (Conceptualization [Lead], Funding acquisition [Lead], Investigation [Equal], Methodology [Equal], Supervision [Equal], Writing – review & editing [Equal]), Jennifer Cornacchione Ross (Conceptualization [Equal], Investigation [Equal], Methodology [Equal], Writing – review & editing [Equal]), Sonia Clark (Conceptualization [Equal], Investigation [Equal], Methodology [Equal], Visualization [Lead], Writing – review & editing [Equal]), Jarman Kristen (Conceptualization [Equal], Data curation [Lead], Investigation [Equal], Methodology [Equal], Project administration [Lead], Writing – review & editing [Equal]), Paschal Sheeran (Conceptualization [Equal], Investigation [Equal], Methodology [Equal], Writing – review & editing [Equal]), James Thrasher (Conceptualization [Equal], Investigation [Equal], Methodology [Equal], Writing – review & editing [Equal]), and Leah Ranney (Conceptualization [Equal], Investigation [Equal], Methodology [Equal], Supervision [Equal], Writing – review & editing [Equal])
Data Availability
Data are available upon request to AOG (adam_goldstein@med.unc.edu).
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Associated Data
This section collects any data citations, data availability statements, or supplementary materials included in this article.
Supplementary Materials
Data Availability Statement
Data are available upon request to AOG (adam_goldstein@med.unc.edu).