Abstract
Background:
In the US, cigar warning label standards are less stringent than cigarette warning requirements and are not uniformly required; research is needed about warning efficacy in promoting cigar risk beliefs, discouraging use and supporting public health.
Methods:
Using data from the PATH Study (Wave 5), we analyzed associations between noticing cigar warnings and perceived harm from cigar use, frequency of thinking about harms, and effects of warnings labels.
Results:
Among adults who smoke cigars, respondents noticing warnings at least sometimes (vs. never/rarely) had higher odds of thinking about harms of their tobacco use often/very often (cigarillos: 30% vs. 19%, p<.001, aOR 1.80 [1.27, 2.56]); filtered cigars: 43% vs. 16%, p<.001, aOR 3.81 [2.50, 5.82]) and of reporting that smoking cigars is very/extremely harmful (cigarillos: 59% vs. 46%, p=.001, aOR 1.45 [1.05, 1.99]). A substantial majority found cigar warnings to be very/extremely believable (cigarillos: 63%, filtered cigars: 59%, traditional cigars: 65%), with 16%, 24% and 12% respectively reporting past-30-day warning avoidance. Those noticing warnings at least sometimes (vs. rarely) had higher rates of reporting that warnings sometimes/often/very often stopped them from having a cigar in the past 30 days (cigarillos: 36% vs. 10%; filtered cigars: 50% versus 6%; traditional cigars: 30% versus 9%; p’s<.001) and that warnings made them somewhat/a lot more likely to quit smoking (cigarillos: 55% versus 37%, p<.01; filtered cigars: 55% versus 26%, p<.001; traditional cigars: 39% vs. 24%, p<.05).
Conclusions:
Results support potential public health benefits of mandating the presence and increasing salience of cigar warning labels.
Keywords: Cigar warning labels, cigar harm perceptions
1.1. INTRODUCTION
Despite scientific evidence (Chang, 2015; WHO, 2004) indicating cigars and cigarettes pose comparable health risks, the regulation of cigar marketing and packaging in the United States is less stringent than for cigarettes. In the U.S., cigarette packs have been required to carry health warnings for decades. While cigarette packs in many countries now display prominent pictorial warnings and/or plain packaging (Canadian Cancer Society, 2016), this is not yet the case in the U.S., due to legal challenges to the FDA’s proposed pictorial warning standards (Kraemer & Baig, 2013; Pierson, 2022). Nevertheless, current warning requirements are even less rigorous for cigars, which include cigarillos, filtered cigars, and traditional cigars. Specifically, only small warnings are required on cigar packaging/advertising to date, per a 2000 consent decree between the U.S. Federal Trade Commission and several large cigar manufacturers. Moreover, the consent decree warning statements are relatively weak and stale, and they are not required for manufacturers that were not parties to the consent decree. With the passage of a “deeming rule” in 2016, which extended the FDA’s regulatory authority to include additional tobacco products, the FDA issued a cigar warning standard that required larger, more prominent warning labels for cigar products, and it would have covered all cigars (U.S. Food and Drug Administration, 2020). Yet in July 2020, the cigar industry filed a lawsuit that successfully challenged this requirement in court, and the warning requirement was vacated (U.S. Food and Drug Administration, 2023a) for failing to project its potential impact on cigar smoking initiation or cessation. Cigar companies can voluntarily implement the larger, more prominent warnings outlined by the FDA in the 2016 Deeming Rule, but previous research suggests such voluntary implementation has been variable (Ganz et al., 2022; O’Brien et al., 2020; Wackowski, et al., 2020). For example, an examination of advertising for cigars in print magazines from 2018–2021 found that voluntary compliance with the larger FDA-recommended warnings on ads dropped and then ceased shortly after the July 2020 court decision (Ganz et al., 2022).
Like other tobacco warnings, cigar warning labels have the potential to be beneficial public health tools to enhance perceptions of product risks, which inversely associate with cigar use (Fong et al., 2019; Cornacchione Ross et al., 2022) and also associate with changes in use habits (Timberlake & Rhee, 2022). In prior research, cigarette warning labels have been associated with reduced smoking frequency (i.e., foregoing cigarettes) (Moodie, MacKintosh, & Hammond, 2010) and smoking intentions (White, Webster & Wakefield, 2008), increased cessation attempts (Borland et al., 2009; Hammond, 2011), discouraged initiation, and increased perceptions of smoking risks (Hammond, 2011). Research about specific effects of cigar warnings is limited, but emerging research suggests that different features may contribute to warning effectiveness (Kowitt et al., 2023a,b; Ross et al., 2023) and that strong cigar warnings can elicit emotional reactions and cognitive elaboration about risks (Cornacchione Ross et al., 2023b). Yet for warning labels to be effective, they must first be noticed (Noar et al., 2017; McGuire, 1989) (or seen) by those who use the product or are susceptible to use. Our prior study on noticing cigar warning labels (Anonymous, 2022) used data collected for the Population Assessment of Tobacco and Health (PATH) study between December 2018 and November 2019; we found that among US adults who smoked cigars, depending on the type of cigar, only approximately 21–34% of the respondents noticed warnings sometimes or more frequently.
Considering the relative dearth of research on noticing and effects of cigar warning labels (in comparison to cigarette warning labels), and in light of the July 2020 court decision striking down the cigar warning requirement, there is a demonstrated need for cigar-specific warning label research. In particular, to justify potential regulatory efforts, it is important to examine how cigar warning labels may advance public health goals. Prior research has examined the prevalence of noticing cigar warnings among adults who smoke cigars (Gratale et al., 2022b); here, we sought to expand upon prior findings by assessing perceived effects of cigar warning labels and potential associations between noticing cigar warning labels and perceptions of cigar harm. We utilized data from the PATH study to address these questions for each cigar type – cigarillos, filtered cigars, and traditional cigars.
1.2. MATERIAL AND METHODS
1.2.1. Study Sample
Data are from the public-use file for Wave 5 of the adult PATH Study (December 2018 – November 2019). The PATH study utilizes nationally representative, longitudinal cohorts of youth and adults to assess tobacco use and health (Hyland et al., 2017). Wave 5 includes two cohorts of individuals, those recruited at Wave 1 and those recruited at Wave 4 for sample replenishment. Details about the PATH Study are published elsewhere (Hyland et al., 2017; U.S. Food and Drug Administration, 2023b). For the current study, we restricted the samples to adults who currently smoke (i.e., smoke every day or some days) cigarillos (n=1,385), filtered cigars (n=682), or traditional cigars (n=1,363), consistent with the approach used in our prior study (Anonymous, 2022).
1.2.2. Measures
Measures of focus are described below. Most response categories were dichotomized during analysis based on item response distribution patterns and previous research.
Noticing Cigar Warnings.
Respondents were asked how often they noticed cigar warnings in the past 30 days (separately for each cigar type). Respondents who indicated “Sometimes,” “Often,” or “Very often” were considered to have noticed the warnings, while those who chose “Never” or “Rarely” were considered not to have noticed the warnings (Anonymous, 2022).
Perceived Harm of Cigar/Tobacco Use.
Three questions assessed respondent perceptions of how harmful they think cigar use is and how often they think about such harm. Perceptions of absolute harm of cigar smoking were assessed with the question, “How harmful do you think [specific cigar products] are to health?”, with a five point likert-type scale; we collapsed responses into two categories (not at all/slightly/somewhat harmful versus very/extremely harmful). Perceived relative harm of cigar smoking was assessed using the question, “Is smoking [specific cigar product] less harmful, about the same, or more harmful than smoking cigarettes?”. We collapsed the response options into two categories (less harmful versus the same/more harmful). Additionally, respondents were asked how often in the past 30 days they thought about the harm their tobacco use might be doing, with five options from “never” to “very often.” We collapsed the responses into two categories (never/rarely/sometimes versus often/very often).
Opinions and Perceived Impacts of Cigar Warnings.
We examined additional questions assessed among those who noticed cigar warnings at least rarely (i.e, not “never”). These questions pertained to respondents’ opinions about the warnings themselves, as well as how the warnings influence them. Believability of cigar warnings was measured on a five-point likert-type scale. We collapsed response options into two categories (very/extremely believable versus not at all/a little/somewhat believable). Perceived impact on thinking about health risks (i.e., cognitive elaboration) was measured by asking “to what extent do the health warnings on packages of [specific cigar product] make you think about the health risks of smoking”; we collapsed responses into two categories (not at all/a little versus somewhat/a lot). Warning avoidance was assessed by asking whether the respondent (yes/no) had in the past 30 days “tried to avoid looking at or thinking about the health warnings on packages of [specific cigar product]– such as covering them up, keeping them out of sight, using a cigar case, avoiding certain warnings, or any other means”.
Two questions assessed perceived effects of warnings on behaviors. First, respondents were asked how often in the past 30 days health warnings stopped them from smoking a cigar, with five response choices from “never” to “very often.” Second, respondents were asked to what extent health warnings on packages of [specific cigar products] made them more likely to quit, with four response options from “not at all” to “a lot”. Responses were collapsed in the same manner as previously described for measures with the same response options.
Covariates.
We included the following socio-demographic variables as covariates in analyses: race/ethnicity, sex, age, annual household income, and highest educational attainment. We also included tobacco-related variables, including frequency of cigar use (use every day versus some days) by cigar product type, current cigarette smoking (i.e., every-day use or some-day use), current e-cigarette use (i.e., every-day use or some-day use), past-12-month use of a cigar as a blunt, and cigar purchasing behavior (categorized as purchasing cigars as singles, in a box/pack, or not purchasing their own cigars). When available, we used imputed or derived socio-demographic background measures and tobacco use measures from the PATH public data.
1.2.3. Statistical Analysis
We conducted analyses using Stata 17.0 (Hamilton, 2012) in 2023. We utilized the recommended Adult-Wave 5 Cohort Single-Wave Weights with 95% confidence intervals, applying the balanced repeated replications (BRR) method with Fay’s adjustment of 0.3 (U.S. Food and Drug Administration, 2021). For our analyses, we first examined whether cigar harm perceptions and frequency of thinking about harms of one’s tobacco use differed by prevalence of noticing cigar warnings for each cigar product via Chi-square tests. When Chi-square results were significant, we ran multivariable logistic regressions to assess the strength of associations, adjusting for covariates.
Lastly, we examined the prevalence of specific perceptions of/reactions to cigar warnings and perceived behavioral effects of cigar warnings. We used Chi-square tests to further examine whether those perceptions differ by frequency of noticing cigar warnings (at least sometimes versus rarely), again by cigar product type. As these outcomes already asked respondents to directly reflect on their perceptions of the effects of the warnings, we did not run multivariable models here with noticing warnings as a predictor.
Respondents who refused to answer or indicated “don’t know” to the question regarding noticing cigar warnings were excluded. For all other questions, “don’t know” was coded as missing. When variables for the analysis had missing data for less than 5% of the sample, people with missing values were excluded by listwise deletion for those variables (Baum, 2009). When variables for the analysis had missing data for more than 5% of the sample (i.e., income), data were retained for people missing on the variable, and they were recoded to a category called ‘undetermined’ for that variable. This research only involved the use of de-identified data, which is not considered human subjects research as defined under the Department of Health and Human Services regulations 45 CFR 46.102(d).
1.3. RESULTS
1.3.1. Study Sample
We used the PATH Wave 5 sample of the US adult population. Table 1 presents demographic and use characteristics of every-day and some-day cigar users, by product type
Table 1.
Demographic and use characteristics of every-day, some-day cigar users, by product type
| CIGARILLO | FILTERED CIGAR | TRADITIONAL CIGAR | |
|---|---|---|---|
| Sex | (n=1383) | (n=673) | (n=1359) |
| Male | 70.65% | 66.72% | 86.97% |
| Age | (n=1385) | (n=675) | (n=1361) |
| 18–34 | 50.50% | 40.93% | 36.31% |
| 35–54 | 33.92% | 34.48% | 37.26% |
| 55+ | 15.57% | 24.60% | 26.43% |
| Race/Ethnicity | (n=1372) | (n=663) | (n=1342) |
| Non-Hispanic (NH) White | 47.78% | 50.23% | 66.40% |
| NH Black | 31.38% | 23.38% | 13.43% |
| NH Other | 5.48% | 6.49% | 6.88% |
| Hispanic | 15.37% | 19.90% | 13.29% |
| Education | (n=1379) | (n=673) | (n=1355) |
| Less than high school/GED | 23.46% | 30.69% | 12.53% |
| High school graduate | 27.93% | 32.80% | 20.12% |
| Some college (no degree) or Associates | 35.36% | 26.12% | 33.11% |
| Bachelor’s degree or advanced degree | 13.25% | 10.40% | 34.24% |
| Income | (n=1321) | (n=636) | (n=1317) |
| less than $24,999 | 46.95% | 62.36% | 21.65% |
| 25,000–49,999 | 23.32% | 21.85% | 21.01% |
| 50,000–99,999 | 18.75% | 11.41% | 24.97% |
| 100,000 or more | 10.98% | 4.37% | 32.37% |
| Type of user | (n=1384) | (n=674) | (n=1361) |
| Established | 59.46% | 59.90% | 42.89% |
| Experimental | 40.54% | 40.10% | 57.11% |
| Use frequency | (n=1385) | (n=675) | (n=1361) |
| Every day | 14.81% | 28.43% | 5.20% |
| Some days | 85.19% | 71.57% | 94.80% |
| Past-30 day product use | (n=1385) | (n=675) | (n=1361) |
| Yes | 85.28% | 84.11% | 70.45% |
| Current cigarette smoker | (n=1382) | (n=674) | (n=1359) |
| Yes | 59.54% | 78.58% | 35.72% |
| Current e-cig user | (n=1385) | (n=675) | (n=1361) |
| Yes | 28.81% | 30.08% | 19.33% |
| Past 12-month any cigar use as blunts | (n=1381) | (n=673) | (n=1359) |
| Yes | 47.71% | 43.21% | 26.85% |
| Cigar purchase type | (n=1378) | (n=667) | (n=1355) |
| Box | 42.69% | 59.51% | 21.66% |
| Single | 46.02% | 25.78% | 59.22% |
| Don’t by own cigars | 11.29% | 14.70% | 19.12% |
1.3.2. Associations Between Noticing Cigar Warnings and Perceived Harms
1.3.2.1. Cigarillos.
A greater proportion of respondents who smoke cigarillos and noticed cigarillo warnings at least sometimes (versus never/rarely) reported that cigarillos are very or extremely harmful (p=.001) and that they think about the harms of their tobacco use often or very often (p<.001) (see Table 2). Further, noticing cigarillo warnings at least sometimes was associated with greater odds of thinking that cigarillos are very or extremely harmful (adjusted odds ratio [aOR]: 1.45, 95% confidence interval [CI]: 1.05, 1.99) and greater odds of thinking about the harms of tobacco often or very often (aOR: 1.80, 95% CI: 1.27, 2.56) in the multivariable models1 (see Table 3).
Table 2.
Cigar harm perceptions/cognitions by level of warning noticing1 (among current product users)
| CIGARILLOS (%, CI) | FILTERED CIGARS (%, CI) | TRADITIONAL CIGARS (%, CI) | ||||
|---|---|---|---|---|---|---|
| Notice never/rarely | Notice at least sometimes | Notice never/rarely | Notice at least sometimes | Notice never/rarely | Notice at least sometimes | |
| Perceived absolute harm of [cigar] product | ||||||
| (n=1385), p= .001 | (n=675), p= .426 | (n=1361), p= 0.992 | ||||
| Very or extremely harmful | 46.15% (41.74, 50.62) |
58.87% (52.81, 64.67) |
46.09% (39.14, 53.19) |
50.61% (43.03, 58.15) |
38.77% (34.58, 43.14) |
38.73% (30.93, 47.14) |
| Not at all/slightly/ somewhat harmful | 53.85% (49.38, 58.26 |
41.13% (35.33, 47.19) |
53.91% (46.81, 60.86) |
49.39% (41.85, 56.97) |
61.23% (56.86, 65.42) |
61.27% (52.86, 69.07) |
| Perceived harm of [cigar] product relative to cigarettes | ||||||
| (n=1378), p= .12 | (n=672), p= .822 | (n=1359), p= .720 | ||||
| Less harmful | 14.55% (11.54, 18.18) |
10.30% (6.98, 14.96) |
9.81% (6.5, 14.53) |
10.49% (6.52, 16.45) |
35.10% (31.59, 38.79) |
33.12% (23.99, 43.73) |
| About the same/more harmful |
85.45% (81.82, 88.46) |
89.70% (85.04, 93.03) |
90.19% (85.47, 93.5) |
89.51% (83.55, 93.48) |
64.90% (61.21, 68.41) |
66.88% (56.27, 76.01) |
| Frequency of thinking about cigar use harms | ||||||
| (n=1359), p= 0.0002 | (n=665), p< .00005 | (n=1315), p= .703 | ||||
| Often/Very Often | 18.64% (15.44, 22.33) |
29.80% (24.78, 35.41) |
15.90% (12.36, 20.21) |
43.14% (36.23, 50.32) |
14.64% (11.43, 18.56) |
15.96% (11.16, 22.31) |
| Never/rarely/ sometimes | 81.36% (77.67, 84.56) |
70.20% (64.59, 75.22) |
84.10% (79.79, 87.64) |
56.86% (49.68, 63.77) |
85.36% (81.44, 88.57) |
84.04% (77.69, 88.84) |
- Warning noticing was assessed with the following question for each cigar type: “In the past 30 days, how often, if at all, have you noticed the health warnings on packages of [cigarillos/filtered cigars/traditional cigars]?”
Table 3.
Odds of reporting harm perceptions/cognitions (among current cigar product users)
| CIGARILLO USERS | FILTERED CIGAR USERS | |||||
|---|---|---|---|---|---|---|
| MODEL | Belief cigarillos are very/ extremely harmful (n=1344) | Think about tobacco harm often/very often (n=1327) | Think about tobacco harm often/very often (n=640) | |||
| Odds ratio | 95% CI | Odds ratio | 95% CI | Odds ratio | 95% CI | |
| Notice Warnings | ||||||
| No | 1 | 1 | 1 | |||
| Yes | 1.45 | (1.05, 1.99) | 1.80 | (1.27, 2.56) | 3.81 | (2.50, 5.82) |
| Sex | ||||||
| Male | 1 | 1 | 1 | |||
| Female | 1.22 | (0.89, 1.66) | 1.30 | (0.91, 1.85) | 1.39 | (0.93, 2.07) |
| Age | ||||||
| 18–34 | 1 | 1 | 1 | |||
| 35–54 | 0.64 | (0.47, 0.87) | 1.33 | (0.87, 2.04) | 0.85 | (0.43, 1.65) |
| 55+ | 0.65 | (0.42, 1.02) | 1.34 | (0.71, 2.53) | 0.75 | (0.38, 1.48) |
| Education | ||||||
| <HS/GED | 1 | 1 | 1 | |||
| HS | 0.92 | (0.57, 1.49) | 1.18 | (0.73, 1.92) | 0.56 | (0.28, 1.11) |
| College | 0.97 | (0.66, 1.43) | 1.09 | (0.74, 1.61) | 1.05 | (0.59, 1.88) |
| >=Bachelor | 1.09 | (0.61, 1.95) | 0.95 | (0.51, 1.79) | 1.34 | (0.49, 3.64) |
| Income | ||||||
| <25K | 1 | 1 | 1 | |||
| 25K-49,999 | 1.21 | (0.86, 1.70) | 1.01 | (0.62, 1.63) | 0.83 | (0.41, 1.66) |
| 50k-99,999 | 1.28 | (0.81, 2.01) | 1.59 | (0.91, 2.77) | 1.29 | (0.62, 2.68) |
| >=100k | 0.84 | (0.45, 1.57) | 0.98 | (0.47, 2.08) | 0.30 | (0.04, 2.41) |
| Undetermined | 0.75 | (0.38, 1.50) | 0.57 | (0.24, 1.39) | 0.91 | (0.21, 3.92) |
| Race/Ethnicity | ||||||
| NH White | 1 | 1 | 1 | |||
| NH Black | 1.48 | (1.04, 2.10) | 1.38 | (0.88, 2.15) | 1.23 | (0.68, 2.23) |
| Hispanic | 1.50 | (0.90, 2.50) | 1.29 | (0.65, 2.58) | 0.81 | (0.39, 1.69) |
| NH Other | 1.26 | (0.73, 2.17) | 1.95 | (0.99, 3.85) | 1.30 | (0.46, 3.68) |
| Cigar Smoking Frequency | ||||||
| Nondaily | 1 | 1 | 1 | |||
| Daily | 1.09 | (0.71, 1.65) | 1.17 | (0.74, 1.86) | 1.00 | (0.50, 2.01) |
| Current Cigarette Use | ||||||
| No | 1 | 1 | 1 | |||
| Yes | 0.95 | (0.70, 1.28) | 1.78 | (1.20, 2.64) | 1.75 | (0.89, 3.42) |
| Current E-cigarette Use | ||||||
| No | 1 | 1 | 1 | |||
| Yes | 0.76 | (0.53, 1.10 | 0.85 | (0.55, 1.30) | 0.56 | (0.26, 1.20) |
| Past-Year Blunt Use | ||||||
| No | 1 | 1 | 1 | |||
| Yes | 1.08 | (0.81, 1.45) | 1.00 | (0.67, 1.50) | 1.03 | (0.56, 1.88) |
| Cigar Purchasing Behavior | ||||||
| Don’t buy own | 1 | 1 | 1 | |||
| Single cigars | 1.32 | (0.75, 2.31) | 1.92 | (0.96, 3.81) | 1.47 | (0.65, 3.31) |
| Box/pack | 1.16 | (0.62, 2.15) | 1.43 | (0.71, 2.88) | 1.16 | (0.53, 2.57) |
1.3.2.2. Filtered cigars.
Among those who smoke filtered cigars, the proportion of respondents who thought about the harms of their tobacco use often or very often was more than double for those who noticed filtered cigar warnings at least sometimes compared to those who never or rarely noticed these warnings (p<.001) (Table 2). Noticing filtered cigar warnings at least sometimes was also associated with nearly four times greater odds of thinking about the harms of tobacco often or very often (aOR: 3.81, 95% CI: 2.50, 5.82) in the multivariable models2 (see Table 3). Supplemental Table 1 presents logistic regression models for odds of perceiving filtered cigars as very/extremely harmful (which did not have significant bivariate associations with noticing warnings).
1.3.2.3. Traditional cigars.
There were no associations between frequency of noticing traditional cigar warnings and reported harm perceptions among respondents who smoke traditional cigars. Supplemental Table 1 presents logistic regression models for odds of perceiving traditional cigars as very/extremely harmful and odds of frequently thinking about the harms from tobacco use (which did not have significant bivariate associations with noticing warnings).
1.3.3. Prevalence of Cigar Warning Perceptions and Behavioral Effects, and Associations with Frequency on Noticing Cigar Warnings
Table 4 presents data on perceptions and perceived behavioral effects of cigar warnings among current users of each product type who reported any noticing of warnings for that product (i.e., at least rarely). In each product category, a substantial majority found the warnings to be very/extremely believable, and most said the warnings led them to think about the risks of smoking somewhat or a lot. Roughly one-third to one-half of respondents said the warnings make them more likely to quit smoking cigars. Detailed results by product type follow.
Table 4.
Perceptions about cigar warnings and their impact, among cigar product users who notice warnings at all
| CIGARILLOS (%, 95% CI) | FILTERED CIGARS (%, 95% CI) | TRADITIONAL CIGARS (%, 95% CI) | |||||||
|---|---|---|---|---|---|---|---|---|---|
| All Partici pants (n=714 ) | Notice d Rarely (n=290 ) | Notice d At Least Sometimes (n=424 ) | All Partici pants (n=362 ) | Notice d Rarely (n=136 ) | Notice d At Least Sometimes (n=226) | All Partici pants (n=528) | Notice d Rarely (n=251) | Notice d At Least Sometimes (n=277) | |
| Extent to which warnings make you think about smoking health risks | |||||||||
| p< .00005 | p= 0.007 | p= 0.013 | |||||||
| Not at all/ a little | 45.45 % (40.73, 50.26) |
62.60 % (55.73, 69.00) |
32.29 % (27.02, 38.06) |
43.76 % (38.07, 49.61) |
61.43 % (50.00, 71.73) |
33.0 % (26.05, 40.87) |
49.80 % (44.61, 55.00) |
60.55 % (52.94, 67.68) |
41.02 % (33.11, 49.42) |
| Somewhat/a lot | 54.55 % (49.74, 59.27) |
37.40 % (31.00, 44.27) |
67.71 % (61.94, 72.98) |
56.24 % (50.39, 61.93) |
38.57 % (28.27, 50.00) |
67.0 % (59.13, 73.95) |
50.20 % (45.00, 55.39) |
39.45 % (32.32, 47.06) |
58.98 % (50.58, 66.89) |
| Warning label avoidance in past 30 days | |||||||||
| p= 0.015 | p= 0.335 | p= 0.174 | |||||||
| No | 83.83 % (79.57, 87.34) |
88.48 % (83.51, 92.10) |
80.24 % (74.07, 85.23) |
76.38 % (68.83, 82.57) |
80.84 % (65.91, 90.21) |
73.67 % (65.11, 80.74) |
88.12 % (83.12, 91.79) |
91.04 % (85.96, 94.40) |
85.73 % (77.28, 91.39) |
| Yes | 16.17 % | 11.52 % | 19.76 % | 23.62 % | 19.16 % | 26.33 % | 11.88 % | 8.96 % (5.60, 14.04) |
14.27 % |
| (12.66, 20.43) | (7.90, 16.49) | (14.77, 25.93) | (17.43, 31.17) | (9.79, 34.09) | (19.26, 34.89) | (8.21, 16.88) | (8.61, 22.72) | ||
| Believability of cigar warning labels | |||||||||
| p= 0.018 | p< .00005 | p= 0.221 | |||||||
| Not at all/a little/ somewhat | 37.49 % (32.63, 42.61) |
43.98 % (37.66, 50.51) |
32.51 % (26.47, 39.19) |
41.27 % (34.10, 48.83) |
53.15 % (41.06, 64.88) |
34.04 % (26.79, 42.13) |
34.68 % (29.49, 40.27) |
33.42 % (27.03, 40.48) |
35.70 % (27.83, 44.44) |
| Very/extremely | 62.51 % (57.39, 67.37) |
56.02 % (49.49, 62.34) |
67.49 % (60.81, 73.53) |
58.73 % (51.17, 65.90) |
46.85 % (35.12, 58.94) |
65.96 % (57.87, 73.21) |
65.32 % (59.73, 70.51) |
66.58 % (59.52, 72.97) |
64.30 % (55.56, 72.17) |
| Warnings prompted you to forgo a cigar in past 30 days | |||||||||
| p< .00005 | p< .00005 | p< .00005 | |||||||
| Never/rar ely | 75.58 % (71.41, 79.32) |
90.42 % (86.10, 93.50) |
64.18 % (57.46, 70.39) |
66.73 % (59.98, 72.85) |
93.81 % (88.83, 96.65) |
50.50 % (41.91, 59.06) |
79.65 % (75.07, 83.56) |
91.19 % (85.94, 94.61) |
70.21 % (62.45, 76.96) |
| Sometimes/ often/very often |
24.42 % (20.68, 28.59) |
9.58% (6.50, 13.90) |
35.82 % (29.61, 42.54) |
33.27 % (27.15, 40.02) |
6.19% (3.35, 11.17) |
49.50 % (40.94, 58.09) |
20.35 % (16.44, 24.93) |
8.81% (5.39, 14.06) |
29.79 % (23.04, 37.55) |
| Extent to which warnings make you more likely to quit smoking | |||||||||
| p= .0046 | p= 0.0001 | p= 0.042 | |||||||
| Not at all/a little |
52.92 % (48.11, 57.68) |
62.79 % (55.57, 69.47) |
45.34 % (39.28, 51.55) |
56.16 % (50.09, 62.05) |
74.44 % (65.38, 81.78) |
45.05 % (38.14, 52.15) |
67.93 % (62.26, 73.12) |
76.28 % (69.40, 82.01) |
61.11 % (52.14, 69.38) |
| Somewhat/a lot | 47.08 % (42.32, 51.89) |
37.21 % (30.53, 44.43) |
54.66 % (48.45, 60.72) |
43.84 % (37.95, 49.91) |
25.56 % (18.22, 34.62) |
54.95 % (47.85, 61.86) |
32.07 % (26.88, 37.74) |
23.72 % (17.99, 30.60) |
38.89 % (30.62, 47.86) |
1.3.3.1. Cigarillos.
Among respondents who smoke cigarillos and reported any cigarillo warning noticing, roughly 63% found the warnings to be very or extremely believable, and approximately 55% said the warnings make them think about the health effects of smoking somewhat/a lot. About 16% had avoided looking at the warnings in the past 30 days. A sizable minority also reported behavioral effects of warnings, with 24% of respondents indicating the warnings stopped them from having a cigarillo sometimes/often/very often in the past 30 days, and nearly half reporting that the cigarillo warnings make them somewhat/a lot more likely to quit smoking. Moreover, a greater proportion of those who noticed cigarillo warnings at least sometimes (versus rarely) reported that health warnings on cigarillo packages are very or extremely believable (67% versus 56%, respectively; p<.05), and that health warnings make them think about the health risks of smoking somewhat/a lot (68% versus 37%, respectively, p<.001). Similarly, those who noticed warnings more frequently (versus rarely) had higher rates of reporting that the warnings sometimes/often/very often stopped them from having a cigarillo in the past 30 days (36% vs. 10% respectively; p<.001) and that cigarillo warnings made them somewhat/a lot more likely to quit smoking (55% versus 37%, respectively, p<.01).
1.3.3.2. Filtered cigars.
Among filtered cigar users who noticed filtered cigar warnings, nearly 60% found the warnings to be very or extremely believable, about 56% said the warnings make them think about the health effects of smoking somewhat/a lot, and 24% reported past 30-day warning avoidance. About 33% indicated the warnings sometimes/often/very often prompted them to forgo a filtered cigar in the past 30 days, and 44% believed filtered cigar warnings make them somewhat/a lot more likely to quit smoking. There were also associations between frequency of noticing and perceived warning effects. A greater proportion of those who noticed filtered cigar warnings sometimes or more (versus rarely) reported that the warnings: are very/extremely believable (66% versus 47%, respectively, p<.001), prompt thinking about smoking health risks somewhat/a lot (67% versus 39%, respectively, p<.01), have sometimes/often/very often stopped them from having a filtered cigar in the past 30 days (50% versus 6%, respectively, p<.001), and make them somewhat or a lot more likely to quit smoking (55% versus 26%, respectively, p<.001).
1.3.3.3. Traditional cigars.
Lastly, approximately 65% of those reporting currently smoking traditional cigars and noticing those warnings characterized them as very/extremely believable, and roughly half stated that the warnings prompted them to think about health effects of smoking somewhat/a lot. Approximately 12% reported avoiding a warning within 30 days. Further, approximately 20% said the warnings sometimes/often/very often stopped them from having a traditional cigar in the past 30 days, and 32% said traditional cigar warnings made them somewhat/a lot more likely to quit smoking. A higher proportion of those noticing warnings at least sometimes (versus rarely) indicated that the warnings make them: think about the health risks of smoking somewhat/a lot (59% versus 39%, respectively, p<.05), forgo a traditional cigar sometimes/often/very often (30% versus 9%, p<.001), and more likely to quit smoking (39% versus 24%, p<.05).
1.4. DISCUSSION
This study presents important new evidence about the perceptions of and potential impacts of cigar warning labels on adults who use cigars, and the importance of the frequency of noticing warnings on these outcomes. Indeed, the findings here expanded on our prior work on the rates of cigar warning noticing and demonstrated, across multiple types of cigars, that the frequency of noticing cigar warnings is directly associated with the frequency of thinking about the harms of one’s smoking. Noticing warnings was also associated with the degree of perceived harm from cigarillo smoking specifically. These associational findings were strengthened by results from questions directly asking respondents to report how cigar warnings affect their behaviors and cognitions. Respondents generally found warning believability to be high, and respondents who reported more frequently noticing cigar warnings also more often indicated that the warnings make them think about cigar risks, forgo smoking cigars and increase their likelihood of quitting smoking. The fact that those with higher prevalence of noticing warnings more often report the desired behavioral effects of warnings is a promising result; it lends support to the idea that increasing the noticeability of cigar warnings may in turn help to promote more attention to the harms of cigar use and, potentially, more frequent forgoing of cigars, thus adding to the evidentiary base needed to justify regulatory action. This is important given that prior research has noted a low overall prevalence of noticing cigar warnings, thus representing an area for improvement (Gratale et al., 2022b; Kowitt et al., 2021).
While it is promising that over half of respondents reported that noticing the warning labels resulted in cognitive elaboration about the risks of smoking somewhat or a lot, a substantial minority did not; similarly, a smaller minority did not rate the warnings as very/extremely believable. These findings, coupled with our prior findings (Anonymous, 2022) on relatively low overall noticing, indicate that there is a distinct opportunity for improving warning noticeability as well as impact. Making warning labels more attention grabbing and efficacious is both important and challenging, given the other competing, salient features on cigar packaging and in advertising (e.g., flavors, price promotions) (Cornacchione Ross et al., 2023a; Ganz et al., 2022; Giovenco et al., 2022). Strategies for increasing warning noticeability and efficacy may include those outlined by the FDA, such as increasing warning size to 30% of pack size, and placing warnings on the front and back of packs (U.S. Food and Drug Administration, 2020). Additional strategies may include the use of graphics/graphic images in the warning label (Strasser et al., 2012; Noar et al., 2016, 2017; Meernik et al., 2016; Peterson et al., 2010), new, more novel warning statements to broaden cigar risk knowledge and mitigate warning desensitization (Cornacchione Ross et al., 2021, 2023b; Gratale et al., 2022a; Kowitt et al., 2022; Wackowski et al., 2021; Meernik et al., 2016), and/or plain packaging (Meernik et al., 2016; Maynard, Munafo & Leonards, 2012).
Moreover, while some patterns were noted across cigar types, we most consistently observed associations between noticing warning labels and downstream variables of interest among respondents who use cigarillos. The consistent associations between noticing cigarillo warnings and cigarillo harm perceptions are important given the popularity of cigarillos among vulnerable populations including youth and young adults, racialized populations, and low-income groups; further, these products account for the majority of cigar sales in the U.S (Chen-Sankey et al., 2021; Corey et al., 2018; Delnevo et al., 2015, 2021; Weinberger et al., 2021). Future research should further probe differences in warning noticing and efficacy across product types, especially in light of the lack of association between noticing warnings and harm perceptions for traditional cigars.
Some limitations of our research should be noted. This is a cross-sectional analysis and thus, noticing warnings can drive harm perceptions or the reverse may be true, thereby limiting our understanding of the dynamic nature of the associations. Yet either directional influence is meaningful (and desirable from a public health standpoint) – whether the warnings themselves enhance perceptions of risk or individuals who are more concerned about potential harms in turn pay more attention to warnings, those warnings represent an important public health tool. Another potential limitation is that our analyses rely on self-report data, which can be subject to inaccurate recall and/or potential biases (e.g., social norms/desirability). Still, this is mitigated somewhat by using different types of questions (e.g., about perceptions and behaviors) and analyses, some of which are associational (e.g., between noticing and harm perceptions) and some based on direct reports (e.g., respondent assessments of whether warnings prompt them to think about smoking risks or to forgo a cigar product). The limitations of this study also point to future research directions. For instance, we identified a meaningful portion of respondents who chose to forgo a cigar due to a warning; future research could probe whether those individuals continue to smoke fewer cigars on average and/or progress to quitting, as well as what types of warnings or messaging best encourage them to do so.
1.5. CONCLUSIONS
Our findings suggest the potential of current cigar warnings to have meaningful effects on attitudinal and behavioral outcomes when noticed. Perhaps with requirements enhancing their prominence and noticeability, cigar warnings could potentially yield more consequential effects on cigar perceptions and behaviors. Still, even small associations/effects found here between warning noticing with harm cognitions, cigar forgoing, and likelihood of quitting are meaningful to public health, considering the severity of health effects of cigar smoking and the overall difficulty of changing habitual behaviors.
Supplementary Material
Highlights.
Cigar warning noticing associates with frequent thinking about harms from tobacco
Noticing cigarillo warnings associates with stronger perceived harm from cigarillos
Noticing cigar warnings prompts individuals to forgo cigar products (all types)
Results support potential public health benefits of cigar warning labels
Funding
This work was supported by the Food and Drug Administration Center for Tobacco Products (CTP) and the National Cancer Institute (NCI) [grant number U54CA229973, 2018-2023]. The content is solely the responsibility of the authors and does not necessarily represent the views of the NIH or FDA.
Footnotes
CRediT author statement
SKG: Conceptualization, methodology, validation, visualization, writing – original draft, writing – review & editing; JCS: Data curation, methodology, formal analysis, writing – original draft, writing – review & editing; OG: Methodology, writing – review & editing; AT: Conceptualization, formal analysis, validation, writing – review & editing; AAS: Writing – review & editing, funding acquisition; KS: Writing – review & editing; CDD: Writing – review & editing, funding acquisition; OAW: Conceptualization, writing – review & editing, supervision, project administration, funding acquisition
The only other variables that associated with greater odds of believing cigarillos are very/extremely harmful in the multivariable models were younger age (18–34 vs. 35–54) and race (Non-Hispanic Black vs. Non-Hispanic White); for the model on thinking about harms of tobacco use, current cigarette use increased odds of more frequent thinking relative to non-use.
No other variables were significant predictors in the multivariable models pertaining to filtered cigars.
Declaration of Interests: None
Conflicts of Interest
The authors have no conflicts of interest to disclose.
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