Reasons for Cigarillo Initiation and Cigarillo Manipulation Methods among Adolescents

Abstract

Objective

To understand reasons for cigarillo initiation and cigarillo manipulation methods among adolescents.

Methods

We conducted surveys in 8 Connecticut high schools to assess reasons for trying a cigarillo and cigarillo manipulation methods. We used multivariable logistic regressions to assess associations with demographics and tobacco use status.

Results

Among ever cigarillo users (N = 697, 33.6% girls, 16.7 years old [SD = 1.14], 62.1% White), top reasons for trying a cigarillo were curiosity (41.9%), appealing flavors (32.9%), because “friends use it” (25.3%), and low cost (22.4%). Overall, 40.3% of ever cigarillo users added marijuana (to create blunts) and 39.2% did not manipulate the product. Endorsement of these reasons for initiation and manipulation methods differed significantly across sex, age, SES and other tobacco use.

Conclusions

Cigarillo regulations should include restricting all appealing flavors, increasing the cost, monitoring the restriction of sales of cigarillos to minors, and decreasing the appeal of cigarillo manipulation.

INTRODUCTION

Cigarillos, which include little cigars, have gained popularity among youth recently.^1,2 When cigarillos were added to the assessment of past-30-day combustible tobacco use among adolescents in a national survey in 2015, the rate increased by 67% (6.7% to 11.2%).¹ Furthermore, although cigarette consumption in the US population decreased by 32.8% between 2000 and 2011, overall cigar consumption (which includes cigarillos) increased by 123.1%.³ This large increase in consumption parallels the tobacco industry’s response to stringent cigarette regulation and taxation, which resulted in the development and sale of inexpensive cigarillos and little cigars.^3,4

Cigarillos are short narrow cigars (3–4 inches) that usually do not include a filter, whereas little cigars are the same size as a cigarette and usually contain a filter. Both products are wrapped in tobacco leaf rather than paper.⁵ There are some similarities between cigarillos and little cigars (referred to as cigarillos from here onward) and cigarettes, such as a similar burn time, filters, tobacco pH, and size.^6,7 However, there are notable differences; cigarillos are sold in appealing flavors, whereas most flavors (with the exception of menthol) are banned from cigarettes.⁸ Cigarillos are also cheaper than cigarettes because they are taxed at a lower rate.⁹ They are widely available in local convenience stores, particularly in the low socioeconomic, racial minority communities,¹⁰ and they are heavily endorsed by hip-hop celebrities.¹¹ Another unique feature of cigarillos is that their content can be easily manipulated. For example, many users create blunts by removing some or all of the tobacco and replacing it with marijuana.^12–14 Some also remove the inner tobacco wrapper (ie, process referred to as “freaking”) because they believe that the wrapper increases cancer risk or believe that removing the wrapper creates a smoother and more pleasurable smoking experience.¹⁵ Many of these characteristics that are unique to cigarillos could be enticing to youth.

These cigarillo characteristics have not been subjected to regulations until recently. On August 8, 2016, the U.S. Food and Drug Administration (FDA) expanded their regulatory authority to include cigarillos.¹⁶ To inform the FDA’s regulatory efforts, understanding features that attract adolescents to cigarillos is important. For instance, if adolescents are initiating cigarillos because of appealing flavors, it would be important for the FDA to restrict appealing flavors from cigarillos.

Using a large cross-sectional survey in CT, we assessed reasons for cigarillo initiation among high school adolescents. We examined reasons related to 4 broad categories: interest, social reasons, product features, and harm perceptions, which were derived from previous evidence of adolescents’ reasons for initiating other tobacco products.^17,18 We also modified some reasons by adding cigarillo specific content areas for this study. We operationalized “interest” as curiosity and positive perceptions of the product, such as the view that the product is “cool,” based on previous research indicating that these reasons related to initiation of other tobacco products.^17,19 Second, we examined “social reasons,” such as peer and family cigarillo use, based on the evidence that peer and family use predict initiation of other tobacco products consistently.^20–23 Third, we examined product features (ie, appealing flavors, low cost, ability to manipulate) that are unique to cigarillos, which may be attractive to youth. Finally, we assessed whether lower harm perceptions of cigarillos relative to cigarettes may be a reason for initiation. Harm perceptions are important to examine because low harm perceptions of cigarettes have shown to be strongly associated with cigarette smoking among adolescents.²⁴ Existing evidence suggests that youth perceive cigar products as less harmful than cigarettes.^15,25,26 If adolescents are initiating cigarillos because they perceive cigarillos to have lower harm than cigarettes, then education and prevention campaigns can focus on informing youth about the health risks of cigarillos relative to cigarettes.

In addition to understanding reasons for cigarillo initiation, understanding how adolescents are using these products is important. Qualitative study findings show that cigarillos are mainly manipulated and used as blunts by young adults.^13,27 Smoking blunts can expose users to high levels of nicotine, as well as to other toxicants, and increases the odds of being dependent on cannabis and nicotine.^28,29 Although half of U.S. adolescents who have used cannabis also have used blunts, there is limited information on how adolescents are manipulating cigarillos to create blunts.³⁰ Thus, research on how adolescents are using cigarillos is needed to inform the regulation of both product design and attributes to decrease youth appeal. For instance, if adolescents are manipulating cigarillos to create blunts and find this activity attractive, then the FDA can prohibit the product design used for this purpose (eg, prohibit easy-to-crack design on cigarillos) and develop prevention campaigns that target the use of cigarillos for blunting.

Therefore, we also aimed to provide quantitative information on how adolescents are using cigarillos. We hypothesized that many adolescents would manipulate cigarillos by adding marijuana to create blunts, based on the evidence that this manipulation method is also popular among young adults.^13,27

We further assessed whether each reason for cigarillo initiation and each manipulation method was related to the sample characteristics, such as sex, age, race, socioeconomic status (SES), past-30-day cigarillo use (ie, current cigarillo use), and ever use of hookah, smokeless tobacco, cigarettes, e-cigarettes, and blunts. We hypothesized that girls, relative to boys, would be more likely to report peer and family use as a reason for initiation, based on previous research showing that social sources influenced girls’ tobacco use behaviors,³⁰ and that girls were offered tobacco products by their peers more often than boys.²³ We hypothesized that low cost would be a reason for initiation among low SES adolescents, given that low SES communities have high exposure to tobacco marketing and sale of cigarillos.^10,31 Additionally, we explored whether reasons for initiation and manipulation methods differed by race, given that tobacco products are frequently sold and marketed in minority, urban communities.^32,33 We also examined how other tobacco use is associated with reasons for initiation and manipulation methods because dual and poly tobacco use, including cigarillo use, is common among adolescents.³⁴ Finally, we assessed whether current cigarillo users endorsed different reasons for cigarillo initiation than non-current users.

METHODS

Participants

We analyzed cross-sectional survey data from 8 high schools in Connecticut. Schools were a convenience sample selected from 7 of 9 district reference groups (DRGs).³⁶ The DRGs are school groupings based on indicators of socioeconomic status, financial needs, and school enrollment. Response rates calculated based on attendance on the day of the survey administration were high (83.8%).

Procedure

Detailed study procedures can be found elsewhere (ie,^17,18). In brief, the entire student body in each school completed paper-and-pencil surveys assessing various tobacco use behaviors and perceptions during homerooms. The teachers distributed the surveys and informed the students that participation was voluntary and surveys were anonymous. These instructions were also repeated on the cover sheets of the survey. Research staff were available at the school at the time of the survey to answer questions.

Measures

Demographic characteristics

We assessed age, sex (“male,” “female”), race/ethnicity (“White or Caucasian,” “Black or African American,” “Hispanic or Latino,” “Asian,” “Other”), and socioeconomic status (SES). SES was assessed using the Family Affluence Scale (FAS), which has shown to be a reliable and a valid measure of SES among adolescents.^37,38 The 4-items assessed: 1) whether an adolescent’s family owns a car, van, or truck (yes, two or more = 2; yes, one = 1; no = 0), 2) whether an adolescent has his/her own bedroom (yes = 1; no = 0), 3) the number of laptops/computers an adolescent’s family owns (more than 2 = 3; 2 = 2; 1 =1; none = 0), and 4) whether an adolescent’s family had vacationed in the past 12 months (more than twice = 3; twice = 2; once =1; not at all = 0). Responses were summed to create a total SES score, and a higher FAS score indicated higher SES.

Tobacco use

We assessed ever use of cigarillos, e-cigarettes, hookah, smokeless tobacco, cigars, and blunts with the question, “Have you ever tried [tobacco product]?” for each of these tobacco products. All tobacco products were described briefly and a picture was provided for each tobacco product. A response of “yes” to a tobacco product was coded as “ever use” of that product. Ever use of cigarettes was determined if an adolescent provided a valid age to a question asking the age at which they “tried a cigarette, even just 1 or 2 puffs.” We also categorized “cigarillo current use” if an adolescent reported at least 1 day of use to an open-ended question asking, “How many days out of the last 30 did you use cigarillos?”

Reasons for cigarillo initiation

Reasons for cigarillo initiation were assessed among ever cigarillo users using a question, “Why did you try a cigarillo (short narrow cigars, like Black and Mild)?” Adolescents could select all reasons that applied from the following response options: “good flavors,” “low cost,” “curiosity,” “my friends use it,” “my parents/family use it,” “it is healthier than cigarettes,” “it is cool,” “I can change the amount of tobacco,” “I can change the wrapper,” and “other.”

Cigarillo manipulation methods

Cigarillo manipulation methods were assessed among ever cigarillo users with a question, “How do you smoke cigarillos?” Adolescents could select all reasons that applied from the following response options: “I smoke them as they come in the package,” “I add more tobacco,” “I take out tobacco,” “I add marijuana,” “I take out some of the wrapper,” and “other.”

Data Analysis

Using SPSS version 21, descriptive analyses characterized study variables and multivariable logistic regression analyses examined how demographic factors and other tobacco use variables were associated with each reason for cigarillo initiation and each cigarillo manipulation method. Specifically, we conducted nine separate multivariable logistic regression models for each reason for initiation and five separate multivariable logistic regression models for each manipulation method among ever cigarillo users. Each reason for initiation and manipulation method was a separate dependent variable. Sex, age, race (White vs. non-White [Race was characterized as White vs. non-White in the multivariable logistic regression models because race differences could not be interpreted due to low endorsement of other race categories: White 62.1%, Hispanic 13.2%, mixed race 12.2%, Black 7.2%, Asian 1.9%, other 2.6%), SES, current cigarillo use, ever use of cigarettes, e-cigarettes, hookahs, smokeless tobacco, cigars, and blunts were independent variables in all models. Because the questions assessing reasons for cigarillo initiation and manipulation methods were select all that apply, each model controlled for the number of other responses endorsed (ie, sum of all initiation responses in models examining reasons for initiation and sum of all manipulation method responses in models examining manipulation methods). We also controlled for school in all analyses. We applied Bonferroni corrections for multiple comparisons and p ≤ .004 was considered statistically significant.

RESULTS

Among the total sample (N = 7045), 9.9% of adolescents (N = 697, 33.6% girls, 16.7 years old [SD = 1.14], 62.1% White) reported ever trying a cigarillo and were included in the current analyses. The top reasons for trying a cigarillo were curiosity (41.9%), appealing flavors (32.9%), friends (25.3%), and low cost (22.4%). See Figure 1 for rates of all reasons for trying a cigarillo.

Figure 1. Reasons for Trying a Cigarillo among Adolescent Ever Cigarillo Users (N = 697).

Note: More than one response could be selected so the percentages do not add to 100%. *“Other” responses included adding marijuana.

Among ever cigarillo users, the top two cigarillo methods of use were to add marijuana (40.3%) and to use them without manipulation, as they come in the package (39.2%). See Figure 2 for rates of all other manipulation methods.

Figure 2. Cigarillo Use Patterns among Adolescent Ever Cigarillo Users (N = 697).

Note: More than one response could be selected so the percentages do not add to 100%.

See Table 1 for the odds ratios and the confidence intervals for the multivariable logistic regression models predicting reasons for cigarillo initiation. As hypothesized, we observed that girls, relative to boys, were more likely to report friends’ use (odds ratio [OR] = 2.79, 95% confidence interval [CI] 1.44, 5.41) as a reason for cigarillo initiation. Contrary to our hypothesis, we did not observe a significant association between SES and low cost as a reason for initiation. However, we observed that high SES adolescents, relative to low SES adolescents, were more likely to report friends’ use (OR = 1.29, 95% CI 1.09, 1.54) and less likely to report the ability to manipulate cigarillos as a reason for initiation (OR = .63 95% CI .48, .84).

Table 1.

Adjusted Logistic Regression Models Examining Reasons for Cigarillo Initiation among Adolescents (N = 442)

	Interest		Product Features			Social Reasons		Health Perceptions
	Curiosity	Cool	Good Flavors	Low Cost	Manipulate cigarillo	Friends	Family	Healthier than cigarettes	Other
Sex (ref: boys)	.94 (.55, 1.61)	.77 (.23, 2.63)	.49 (.26, .95)	.84 (.38, 1.86)	.61 (.19, 1.94)	2.79 (1.44, 5.41)	4.81 (1.47, 15.72)	.99 (.21, 4.60)	1.03 (.43, 2.47)
Age	1.19 (.70, 2.01)	.74 (.48, 1.13)	1.05 (.82, 1.35)	1.89 (1.35, 2.66)	.66 (.42, 1.04)	.98 (.76, 1.25)	.63 (.38, 1.06)	1.28 (.73, 2.26)	.70 (.50, .99)
Race (ref: white)	1.19 (.62, 1.99)	.32 (.10, 1.02)	.92 (.49, 1.72)	.80 (.36, 1.78)	.65 (.21, 2.02)	2.13 (1.08, 4.20)	.28 (.07, 1.07)	1.13 (.21, 6.16)	1.35 (.55, 3.30)
SES	.97 (.85, 1.10)	1.04 (.78, 1.39)	1.01 (.87, 1.17)	.98 (.81, 1.19)	.63 (.48, .84)	1.29 (1.09, 1.54)	1.03 (.74, 1.43)	.94 (.65, 1.36)	.90 (.73, 1.11)
Past month cigarillo use	.42 (.26, .68)	3.24 (1.08, 9.69)	1.45 (.82, 2.55)	2.02 (1.01, 4.03)	1.23 (.46, 3.27)	.79 (.44, 1.43)	.27 (.07, .95)	2.56 (.71, 9.23)	1.08 (.50, 2.36)
Cigarettes Ever	1.11 (.62, 1.99)	1.20 (.30, 4.86)	1.38 (.68, 2.80)	1.22 (.52, 2.88)	3.06 (.51, 18.39)	.52 (.27, 1.01)	1.53 (.41, 5.67)	.32 (.07, 1.57)	2.06 (.65, 6.48)
E-cigarettes Ever	1.81 (.83, 3.97)	.12 (.02, .71)	1.22 (.47, 3.18)	.27 (.08, .92)	***	1.05 (.43, 2.54))	1.93 (.32, 11.67)	.51 (.06, 4.65)	1.22 (.24, 6.08)
Hookah Ever	.85 (.50, 1.44)	3.48 (.93, 13.06)	1.15 (.60, 2.18)	.50 (.22, 1.11)	2.55 (.76, 8.62)	.86 (.45, 1.65)	.34 (.09, 1.34)	2.00 (.45, 8.86)	1.10 (.46, 2.65)
Smokeless Tobacco Ever	.81 (.48, 1.38)	2.39 (.70, 8.23)	.82 (.44, 1.54)	3.73 (1.67, 8.32)	.69 (.23, 2.08)	.79 (.40, 1.54)	.23 (.04, 1.22)	3.12 (.70, 13.77)	.74 (.31, 1.78)
Cigar Ever	.75 (.43, 1.34)	.82 (.20, 3.43)	1.35 (.68, 2.69)	2.44 (.94, 6.33)	.94 (.23, 3.83)	.82 (.42, 1.60)	1.39 (.41, 4.67)	.24 (.04, 1.49)	1.48 (.54, 4.08)
Blunts Ever	2.24 (1.13, 4.45)	1.42 (.24, 8.52)	.55 (.26, 1.18)	1.70 (.58, 4.97)	1.15 (.20, 6.69)	1.06 (.47, 2.38)	.09 (.02, .36)	1.03 (.14, 7.56)	2.26 (.59, 8.62)

Notes: Values represent odds ratios and 95% confidence intervals. All analyses controlled for school (N = 8) and sum of endorsement of other reasons for cigarillo initiation. The reference group for all tobacco use comparisons was non-users of the respective product. Bonferroni correction for multiple comparisons was applied, and values in bold indicate results that were considered statistically significant, p ≤ .004.

^***Odds ratios could not be calculated because only 1 non-e-cigarette user reported manipulating cigars.

We did not observe any race or age differences in reasons for initiation, with the exception that older adolescents were more likely to report “low cost” than younger adolescents (OR = 1.89, 95% CI 1.35, 2.66). Although reasons for initiation did not differ between adolescents who were ever e-cigarette, hookah, and cigar users and non-users of these respective tobacco products, we observed that smokeless tobacco users, relative to non-smokeless tobacco users, were more likely to report cost as a reason for cigarillo initiation (OR = 3.73, 95% CI 1.67, 8.32), and ever blunt users, relative to never blunt users, were less likely to report family as a reason to try cigarillos (OR = .09, 95% CI .02, .36). We also observed that current cigarillo users were less likely to report curiosity as a reason for initiation than non-current cigarillo users (OR = .42, 95% CI .26, .68).

See Table 2 for the odds ratios and confidence intervals for the multivariable logistic regression models predicting cigarillo manipulation methods. The results showed that ever blunt users (OR = 6.50, 95% CI 2.07, 20.78), relative to never blunt users, were more likely to add marijuana in their cigarillos. We did not find that other demographic and tobacco use variables were associated with cigarillo manipulation methods.

Table 2.

Multivariable Logistic Regression Models Examining Cigarillo Use Patterns (N = 442)

	As they come in the package	Add Marijuana	Add More Tobacco	Take Out Tobacco	Take Out Some Wrapper	Other
Sex (ref: boys)	1.95 (1.16, 3.28)	.39 (.19, .81)	.96 (.08, 11.44)	.66 (.31, 1.39)	.56 (.05, 7.04)	2.23 (.36, 13.95)
Age	.86 (.71, 1.04)	1.06 (.81, 1.39)	1.79 (.56, 5.77)	1.04 (.79, 1.38)	1.14 (.41, 3.14)	1.86 (.87, 4.01)
Race (ref: white)	1.46 (.88, 2.42)	.92 (.48, 1.79)	4.08 (.21, 78.22)	.79 (.40, 1.60)	.12 (.01, 1.58)	1.59 (.23, 10.90)
SES	1.07 (.94, 1.21)	.90 (.76, 1.07)	.83 (.49, 1.40)	.89 (.75, 1.05)	.83 (.47, 1.44)	1.14 (.74, 1.77)
Past month cigarillo use	1.06 (.68, 1.66)	.90 (.49, 1.67)	***	1.12 (.59, 2.11)	1.08 (.15, 7.94)	.70 (.11, 4.56)
Cigarettes Ever	.56 (.32, .96)	2.86 (1.19, 6.86)	.79 (.06, 10.44)	1.40 (.55, 2.11)	38.27 (.54, 2711.29)	1.47 (.15, 14.15)
E-cigarettes Ever	.99 (.49, 2.01)	1.23 (.41, 3.74)	.04 (.01, 3.18)	5.67 (.70, 45.88)	***	.21 (.02, 2.30)
Hookah Ever	.56 (.34, .93)	2.43 (1.21, 4.88)	.37 (.02, 9.12)	1.42 (.67, 2.99)	12.44 (.41, 381.82)	.41 (.07, 2.39)
Smokeless Tobacco Ever	1.29 (.77, 2.17)	.81 (.41, 1.58)	1.51 (.12, 19.18)	.83 (.40, 1.71)	.44 (.04, 5.08)	.30 (.03, 2.80)
Cigar Ever	1.28 (.74, 2.24)	1.05 (.48, 2.29)	3.93 (.13, 115.21)	.95 (.42, 2.18)	.12 (.01, 3.52)	1.21 (.19, 7.79)
Blunts Ever	.49 (.27, .92)	6.50 (2.07, 20.78)	.08 (.01, 3.03)	2.99 (.84, 10.58)	.06 (.01, 2.96)	.87 (.09, 8.74)

Notes: Values represent odds ratios and 95% confidence intervals. All analyses controlled for school (N = 8) and sum of endorsement of manipulation method responses. The reference group for all tobacco use comparisons was non-users of the respective product. Bonferroni correction for multiple comparisons was applied, and values in bold indicate results that were considered statistically significant, p ≤ .004.

^***Odds ratios could not be calculated because no past month cigarillo users and only 1 never e-cigarette user reported adding more tobacco and taking out some of the wrapper, respectively.

Discussion

Understanding why adolescents initiate cigarillos and how they manipulate them is important to inform prevention and regulatory efforts targeting youth. Our evidence indicates that curiosity, appealing flavors, friends’ use, and low cost are frequently endorsed reasons for cigarillo initiation among adolescents. However, how these reasons predict continued use over time needs to be examined using prospective studies. It is possible that curiosity is a common reason for tobacco experimentation but not for current and continued use. Indeed, we observed that current cigarillo users were less likely to report curiosity as a reason for initiation than non-current users. Given that current cigarillo users did not differ on other reasons for initiation assessed in this study, future studies are needed to better understand the reasons for maintaining cigarillo use behaviors.

Our results showing that appealing flavors were the second highest reason endorsed for cigarillo initiation (following curiosity), adding to the existing literature showing that flavors in tobacco products are appealing to youth. Flavored tobacco products promote youth initiation by reducing the harshness of tobacco products and increasing their appeal.^39,40 In terms of cigarillos, youth commonly report good smell and flavors of cigarillos as attractive.¹⁴ U.S. national data indicate that cigar smokers, including youth and adults, prefer flavored cigar brands;⁴¹ however, flavored cigarillos are particularly popular among younger users;^42,43 more than two fifths of adolescent smokers endorsed using flavored cigarillos and cigarettes.⁴³ These findings have regulatory implications. While the FDA has extended their regulatory authority to cigarillos, they do not currently plan to restrict flavors in cigarillos. However, our evidence adds to the existing literature indicating the availability of appealing flavors is a reason for cigarillo initiation, which suggests appealing flavors should be restricted from cigarillos to protect youth.

The ability to manipulate cigarillos was endorsed infrequently as a reason for initiation; yet, 40% of adolescent cigarillo users reported that they manipulate cigarillos. It is possible that the ability to manipulate cigarillos is more important for maintaining use behaviors than it is for initiation; however, future studies should examine this potential association. Our survey methods could have underestimated the number of adolescents who initiated cigarillos because of the ability to manipulate the product. We did not assess specifically whether adding marijuana to a cigarillo is a reason for initiation. Nevertheless, many adolescents wrote about adding marijuana to their cigarillos into the “other” response option. In-depth qualitative research could shed light on why and how youth are manipulating cigarillos.

We also observed that few adolescents endorsed low harm perceptions (compared to cigarettes) as a reason for initiating cigarillos. This finding is unexpected given that other studies reported that youth perceived cigars to have lower health risks than cigarettes.^15,25,26 Although youth may hold beliefs that cigarillos are less harmful than cigarettes, our study findings show that these are not commonly endorsed reasons for initiation. For adolescents, avoiding long-term health risks may not be a compelling reason to initiate and/or discontinue tobacco use because they may believe that they can quit easily,⁴⁴ and that negative health effects from cigarillos are less likely to happen to them because they do not use it regularly.²⁶ Thus, future studies should evaluate a variety of perceptions related to benefit (eg, feel relaxed after use, become popular if using) and risk (eg, get bad breath, get into trouble, become addicted to nicotine) about cigarillos to identify perceptions that are most relevant to adolescents for initiation. Such relevant content areas that could be used in prevention campaigns.²⁴

We also examined whether reasons for cigarillo initiation differed by demographics or other tobacco use. Consistent with our hypothesis, we detected sex differences that showed that peer use affects girls more than boys, also seen in the cigarette smoking literature.^45,46 Given that social influences are salient for adolescents, particularly among girls, social influences should be considered when developing cigarillo prevention programs or campaigns.

Contrary to our hypothesis, low SES was not associated with endorsement of “low cost” for cigarillo initiation. In fact, we observed that high SES, rather than low SES, was associated with more frequent endorsement of cigarillo initiation because of friends’ use. Perhaps, high SES adolescents have more access to resources and have dispensable cigarillos to share with peers. Although studies on adults have shown that cigarillo use was more common among low SES adults,⁴⁷ studies among adolescents have shown that having more weekly spending money was associated with cigarillo use.⁴⁸ These findings suggest that the role of SES on cigarillo use differs between adults and adolescents. Future studies should assess how adolescent SES is associated with cigarillo use as well as other tobacco product use.

We also observed that other tobacco users (ie, smokeless tobacco users) were attracted to cigarillos because of the low cost. Although increasing cigarette pricing has been highly effective in reducing cigarette use among youth,⁴⁹ adolescents may be supplementing their tobacco use with cheaper alternative tobacco products, like cigarillos. Such compensatory tobacco use behaviors can have serious public health implications, such as perpetuating nicotine addiction and exposing adolescent users to tobacco-related health risks. However, we did not observe that other tobacco use, such as e-cigarettes and hookah were associated with the endorsement of “low cost” as a reason for cigarillo initiation.

It is also important to note that among reasons related to product features, appealing flavors and low cost were the top reasons for cigarillo initiation among adolescents. While these product features may entice youth to initiate or experiment with cigarillos, they may also maintain use. Thus, a comprehensive tobacco control strategy must restrict appealing flavors and increase the cost of cigarillos. Indeed, statistical models have shown that increase in cigarillo pricing would lead to a reduction in youth cigarillo use.⁵⁰ Increasing the cost of cigarillos may also prevent vulnerable youth, such as other tobacco users, from initiating cigarillos. Furthermore, future research should continue to examine how pricing affects co-use of other tobacco use.

Interestingly, we observed that low SES adolescents were more likely to endorse the ability to manipulate cigarillos as a reason for cigarillo initiation. The association between low SES and endorsement of manipulation of cigarillos as a reason for cigarillo initiation is consistent with the popularity of blunt smoking in low SES communities.^29,51 Future studies should examine whether adolescents in low SES communities are first being exposed to blunts, which then leads to cigarillo initiation. Lastly, we explored ways that youth reported using cigarillos. A commonly known cigarillo manipulation involves loosening the tobacco, removing the tobacco filler, removing the inner cigar binder, and adding back tobacco filler to be repackaged into the leaf wrapper.⁵² However, our findings showed that many adolescents reported adding marijuana but few reported manipulating the content of the tobacco wrapper or tobacco filler, so future studies should examine whether these manipulation patterns differ with the addition of marijuana and motivations for such manipulation. In terms of tobacco regulation, understanding the co-use of tobacco and cannabis among adolescents is an important research priority because of its potential to maintain nicotine addiction.²⁹ It is also important to note that many adolescents (39%) used cigarillos as they came in the package, without manipulation. Given the wide variety of cigarillos available, the brands and type of cigarillo products that adolescents manipulate versus use without manipulation needs to be examined. Future national studies also should examine specific strategies used to manipulate cigarillos.

We acknowledge limitations of this study. First, the cross-sectional nature of the data precludes us from examining whether reasons for initiation contribute to future regular cigarillo use. For instance, youth may be attracted to cigarillos because of curiosity but their continued use may be associated with other appealing features, such as low cost and ability to manipulate them. Future longitudinal studies should examine reasons for continued use. Second, some adolescents may not have understood the cigarillo description used in the survey. While a strength of our approach was using the brand name (ie, “Black and Mild”), adolescents who use different cigarillo brands may not have recognized this brand. We also defined blunts as “cigars filled with marijuana” in our survey; however, we did not differentiate the use of large cigars, cigarillos, or both for this purpose. Qualitative evaluation may be needed to assess how youth are referring to various cigar products, including blunts, to better inform survey construction. Third, we examined Connecticut schools, so our findings may not generalize to other geographic regions. Fourth, we did not examine race differences among minority groups given the small number of race categories. Other studies have shown that cigarillo use is more prevalent among Black youth,^53,54 so future studies using a more diverse sample should examine whether reasons for cigarillo initiation and manipulation methods differ by race among adolescents. Fifth, although reasons for cigarillo initiation assessed in our surveys were derived from prior research, there could be other reasons for initiation not assessed in this study. Finally, some of the estimates have wide confidence intervals given the low prevalence of endorsement of several reasons, and larger studies are needed to provide more precise effect estimates. Despite these limitations, our findings provide initial evidence of reasons for cigarillo initiation and cigarillo manipulation methods among adolescents and underscore a need to develop a better understanding of these factors to inform cigarillo regulations.

The findings of this study have several regulatory implications. First, our data suggest that, restricting appealing flavors and increasing the cost may reduce youth initiation of cigarillos. In particular, the finding that low cost is a reason for initiation raises a concern that adolescents may be able to purchase cigarillos (either directly them from stores or by giving money to older individuals to purchase it for them) even with the law requiring a minimum age of 18 to purchase tobacco products. Regulations should also focus on continued surveillance and monitoring compliance of the restrictions of cigarillo sales to underage minors. Second, prevention efforts for cigarillos may need to focus on social skills, such as peer refusal skills as our data suggest certain youth (ie, girls and high SES youth) report friends’ use as a reason for initiating cigarillos. Third, our data demonstrate that many adolescents reported manipulating cigarillos by adding marijuana or using them as they came in the package, without manipulation, and few reported manipulating the content of the tobacco wrapper or filler tobacco. Future data is needed to understand the product features of cigarillos that are used for manipulation to inform the regulation of the product design and attributes to reduce youth appeal. Future studies should also examine co-use of tobacco and cannabis among adolescents contributes to health and nicotine dependence outcomes.

In sum, there is a critical need to develop and implement local and federal policies to prevent youth from initiating cigarillo use, which has serious health effects.⁵⁵ Our study findings contribute to the amassing literature demonstrating the youth appeal of cigarillos and provide specific policy suggestions to prevent youth cigarillo use (eg, eliminating appealing flavors, increasing the cost, and enhancing the surveillance of underage sale to minors).

IMPLICATIONS FOR TOBACCO REGULATION.

The development of regulations to prevent youth cigarillo initiation is an important public health goal given the changing tobacco use landscape among youth. Our evidence indicates that curiosity, appealing flavors, friends’ use, and low cost are important factors to consider when developing tobacco control strategies. These findings suggest that restricting appealing flavors, increasing the cost of cigarillos, and increasing surveillance and monitoring compliance of underage restrictions of sales to minors may be useful tobacco control strategies to prevent youth initiation. Many adolescents are either manipulating cigarillos to add marijuana or using them without manipulation. Research is needed to identify cigarillo product features that are used for manipulation purposes to determine how best to set product standards to prevent this behavior.