The Impact of Modest Price Increases and Single Cigar Restrictions on Youth Cigar Use

Abstract

Introduction:

In 2011, Boston restricted cigar sales to packages of at least 4 cigars unless sold at a minimum of $2.50 per cigar. Nearly 200 localities in Massachusetts have since adopted policies establishing minimum pack quantities of 2–5 or minimum prices of $2.50–5.00 per cigar. The objective of this study was to examine the impact of these policies on youth cigar use.

Methods:

Biennial data from 1999 to 2019 were obtained from the Massachusetts Youth Risk Behavior Survey and analyzed in 2023. Final analytic samples included 15,674 youth for the Boston analyses and 35,674 youth for the statewide analyses. For Boston, change in use was examined from prepolicy (1999–2011) to postpolicy (2012–2019). For statewide analyses, the percentage of the state covered by a policy was estimated. Multivariable logistic regressions examined the impact of cigar policies on cigar and cigarette use. Analyses were adjusted for sociodemographic characteristics and stratified by sex and race.

Results:

Policy enactment was associated with significant decreases in the odds of cigar use in Boston (AOR: 0.28; 95% CI: 0.17–0.47) and statewide (AOR: 0.98; 95% CI: 0.98–0.99), with similar findings for cigarette use. Results were consistent among males and females statewide but only among males in Boston. By race statewide and in Boston, odds of cigar use decreased significantly among White, Black, and Hispanic youth, but not youth of other races.

Conclusions:

These findings indicate small increases in the quantity and price of cigar packs could discourage young people from purchasing and using cigars, providing significant benefits for local tobacco control efforts.

INTRODUCTION

In the past decade, cigars became the most popular combustible tobacco product among youth as cigarette use declined.¹ Cigars are perceived as safer than cigarettes² and subject to less stringent regulation,³ despite similar health effects.⁴ Cigars, often sold individually, offer a less expensive alternative to cigarettes, which are federally required to be sold in packs of 20 or greater.⁵ Additionally, unlike cigarettes which cannot contain nonmenthol flavors, cigars are often flavored, increasing their appeal to youth.⁶

In response to inexpensive cigar popularity among youth,⁷ in 2011, Boston became the first city in Massachusetts to adopt a cigar packaging policy, requiring cigars to be sold in packages of at least four cigars unless sold for at least $2.50 per cigar.⁸ Nearly 200 Massachusetts municipalities have since adopted regulations establishing minimum pack quantities of 2–5 and prices at $2.50–$5.00 per cigar.⁹ Two studies have assessed cigar availability and price following regulation. Kephart et al¹⁰ found single cigars became more expensive and less accessible across Massachusetts as more municipalities implemented regulations. Li et al¹¹ found disparities in access to inexpensive cigars narrowed but persisted across socioeconomically, racially, and ethnically diverse neighborhoods. With a history of targeted cigar marketing in low-income and Black communities,^12,13 examining impacts among those disproportionately impacted is critical. This study extends this work by investigating the effects of Massachusetts’ local cigar pack policies on youth cigar and cigarette use in Boston and statewide. The objectives were to (1) assess the relationships between local cigar pack quantity and price regulations and youth cigar and cigarette use and (2) examine whether findings differ by sex or race.

METHODS

Statewide and Boston city-level data were obtained from the Massachusetts Department of Health. Statewide data were collected using the Massachusetts Youth Risk Behavior Survey (YRBS).¹⁴ The Massachusetts YRBS is administered in spring odd-numbered years to randomly selected public high schools and represents Massachusetts public high school students. The Boston YRBS is administered following the same protocols and represents Boston high school students.¹⁵ Cigar use was first assessed in 1999, allowing for 11 years of analyses (completion rate 51.9%–69.1%). Cigar and cigarette use were defined as any past 30-day use. Analytic samples included 35,674 youth for the state analyses and 15,674 youth for the Boston analyses; the statewide dataset included Boston youth. The study was determined exempt by the University of Utah IRB.

Cigar pack quantity and price policies were identified by systematically reviewing municipal codes and verifying lists maintained by state tobacco control staff.⁹ For Boston, 1999–2011 was considered the prepolicy period, and 2012–2019 postpolicy. For statewide analyses, the percentage of the state population covered by regulations each year was calculated. Regulations effective after February 1 were assigned to the next year to account for policy implementation and varying data collection dates.

Multivariate logistic regression models assessed the relationship between cigar regulations and youth cigar and cigarette use. Analyses adjusted for time trends, age, sex, and race/ethnicity with significance at p<0.05. Sub-group analyses were conducted by sex and race/ethnicity. Analyses incorporated weights to account for the complex design, school-, and student-level nonresponse, and poststratification adjustment for grade, sex, and race/ethnicity. Analyses were conducted in 2023, using Stata-MP version 17.

RESULTS

Among 15,674 Boston youth, 50.3% were male, and 12.7% White (Table 1). Cigar use declined from 9.4% in 1999, to 3.0% in 2019, with a biannual average decrease of 1.2% before and 4.4% after the policy (Figure 1). Following regulation, there were decreases in the odds of cigar use (AOR: 0.28; 95% CI: 0.17–0.47) and cigarette use (AOR: 0.12; 95% CI: 0.07–0.19; Table 2). In stratified analyses, cigar use odds decreased for males (AOR: 0.18; 95% CI: 0.10–0.31) but not females (AOR 0.56; 95% CI: 0.24–1.29; Table 2). By race, cigar use odds decreased among White youth (AOR: 0.16; 95% CI: 0.04–0.75), Black youth (AOR: 0.29; 95% CI: 0.12–0.68), and Hispanic youth (AOR: 0.33; 95% CI: 0.17–0.64), but not youth of other races (AOR: 0.35; 95% CI: 0.09–1.39).

Table 1.

Sample Characteristics

Characteristic	Boston 1999–2019 N=15,674	Massachusetts 1999–2019 N=35,674
Cigar use	7.6%	11.9%
Cigarette use	9.8%	15.7%
Age
14 years or younger	8.2%	10.4%
15 years	22.1%	24.4%
16 years	24.2%	26.0%
17 years	23.9%	24.3%
18 or older	21.6%	14.9%
Sex
Male	50.3%	50.6%
Female	49.7%	49.4%
Race/ethnicity
White alone	12.7%	70.5%
Black alone	38.2%	8.6%
Hispanic alone	32.7%	13.6%
Other	16.4%	7.2%

Figure 1.

Prevalence of cigar use in Boston and Massachusetts. The Boston regulation is indicated by a dashed vertical line. Statewide cigar pack size and price regulation (CPPR) coverage is indicated by a dashed line. The number of regulations for each data year were 3 for 2013, 78 for 2015, 136 for 2017, and 171 for 2019.

Table 2.

Estimates of the Impacts of Cigar Pack Quantity and Pricing Policies on Past 30-Day Youth Cigar and Cigarette Use in Boston and Massachusetts

	Cigar Use		Cigarette Use
Characteristic	Boston AOR (95% CI)	Statewide AOR (95% CI)	Boston AOR (95% CI)	Statewide AOR (95% CI)
Cigar pack policya	0.28 (0.17, 0.47)	0.98 (0.98, 0.99)	0.12 (0.07, 0.19)	0.97 (0.96, 0.97)
Sex (ref: male)
Female	0.46 (0.39, 0.54)	0.31 (0.28, 0.34)	0.90 (0.80, 1.02)	0.93 (0.86, 1.01)
Race/ethnicity (ref: White)
Black	0.56 (0.44, 0.71)	0.56 (0.46, 0.68)	0.30 (0.24, 0.38)	0.47 (0.40, 0.57)
Hispanic	0.69 (0.54, 0.88)	0.73 (0.65, 0.81)	0.46 (0.36, 0.58)	0.73 (0.65, 0.81)
Other	0.44 (0.34, 0.57)	0.74 (0.65, 0.83)	0.29 (0.23, 0.36)	0.80 (0.71, 0.89)
Age (ref: 14 or younger)
15 years	1.11 (0.83,1.50)	1.18 (0.99, 1.39)	1.25 (0.92, 1.70)	1.19 (1.07,1.33)
16 years	1.12 (0.82, 1.52)	1.56 (1.29, 1.88)	1.40 (1.04, 1.88)	1.62 (1.38, 1.89)
17 years	1.47 (1.07, 2.03)	2.07 (1.74, 2.42)	1.82 (1.34, 2.47)	2.07 (1.83, 2.34)
18 years+	1.55 (1.11, 2.18)	2.51 (2.02, 3.11)	2.03 (1.45, 2.85)	2.75 (2.37, 3.18)
Stratified Analyses by Sex and Race/Ethnicity
Policy effects by sex
Male	0.18 (0.10, 0.31)	0.98 (0.97, 0.98)	0.13 (0.07, 0.24)	0.97 (0.96, 0.98)
Female	0.56 (0.24, 1.29)	0.98 (0.97, 0.99)	0.09 (0.04, 0.23)	0.97 (0.96, 0.97)
Policy effects by race/ethnicity
White	0.16 (0.04, 0.75)	0.98 (0.97, 0.99)	0.01 (0.002, 0.12)	0.97 (0.96, 0.97)
Black	0.29 (0.12, 0.68)	0.96 (0.94, 0.98)	0.21 (0.09, 0.52)	0.96 (0.94, 0.97)
Hispanic	0.33 (0.17, 0.64)	0.99 (0.98, 0.996)	0.12 (0.07, 0.22)	0.97 (0.96, 0.98)
Other	0.35 (0.09, 1.39)	0.98 (0.97,1.001)	0.15 (0.04, 0.57)	0.97 (0.95, 0.98)

Notes: Year fixed effects are included in all regression models. Bold indicates statistical significance (p<0.05).

^aFor Boston, change in use was examined prepolicy (1999–2011) to postpolicy (2012–2019). Statewide analyses account for the percentage of the state population covered by a policy each year. Stratified analyses also adjust for year, sex, race/ethnicity, and age based on categories available from the state.

Of 35,674 Massachusetts youth, 50.6% were male and 70.5% White (Table 1). Cigar use ranged from 15.7% in 1999, to 3.9% in 2019 (Figure 1). The percentage of the state covered by a cigar pack regulation was associated with decreases in odds of cigar use (AOR: 0.98; 95% CI: 0.98–0.99; Table 2) and cigarette use (AOR: 0.97; 95% CI: 0.96–0.97). Decreased cigar use odds were consistent among males and females (Table 2). By race, cigar use odds decreased among White youth (AOR: 0.98; 95% CI: 0.97–0.99), Black youth (AOR: 0.96; 95% CI: 0.94–0.98), and Hispanic youth (AOR: 0.99; 95% CI: 0.98–0.996), but not youth of other races (AOR: 0.98; 95% CI: 0.97–1.001).

DISCUSSION

Massachusetts has a strong tobacco control history, once designated the highest per capita tobacco control expenditure in the world.¹⁶ The state remains progressive, with the first municipality to increase the minimum sales age to 21, and the first state to ban flavored tobacco.¹⁷ Regarding cigar pack quantity and price policies, Massachusetts again asserts itself as a leader, with nearly three-quarters of the state covered by regulation. Building on prior evidence that cigar pack policies are associated with changes in the retail environment¹¹ and decreases in cigar use,¹⁸ the present analyses indicate in Boston and statewide, policy enactment is related to decreases in youth cigar use without indication of cigarette substitution.

In Massachusetts, all pack quantity regulations require a minimum of 2, 4, or 5 cigars per pack. This represents a small shift in pack quantity compared to localities across the U.S. that have adopted requirements of 10, 20, or 25.⁹ Likewise, most policies require cigars to be sold for $2.50 or more. The findings indicate youth cigar use is sensitive to pack quantity and price changes, and small increases in these factors could reduce cigar consumption.

Declines in cigar and cigarette use were identified among males and females and among White, Black, and Hispanic youth. Given disparities in use, this provides some reassurance of equitable policy impact among those most susceptible to use, aligning with retail availability findings.¹¹ The lack of findings among youth of other races statewide and in Boston, and among females in Boston may be due to lower cigar use in these samples. Research is needed to comprehensively assess heterogeneous policy effects to ensure equitable impact.

Limitations

Several limitations should be considered. Findings represent public school students and may not generalize to youth at private or alternative schools or not in school. Massachusetts’ regulations cover municipalities, and available data cannot account for policy variability across cities. Due to the unavailability of data, there was no control group in the pre–post quasi-experimental design. While time trends account for other tobacco control initiatives across years, analyses could not separate specific policy components adopted simultaneously (e.g., flavor restrictions) or account for youth e-cigarette uptake. Therefore, study results may not capture all factors that contributed to the reduction in cigar use.

CONCLUSIONS

This study examined the impact of local policies on cigar use in Massachusetts, focusing on pack quantity and price regulations. Regulations were associated with lower cigar consumption among youth statewide and in Boston. These findings have important implications for tobacco control, as they indicate small increases in pack quantity/price could decrease youth cigar use. This study adds to the growing evidence base supporting policy interventions to reduce youth tobacco use.