Cigar Smoking Patterns by Race/Ethnicity and Cigar Type: A Nationally Representative Survey Among U.S. Adults

Abstract

Introduction:

Racial/ethnic minorities have a higher prevalence of past 30–day cigar smoking than non-Hispanic Whites. Little is known, however, about racial/ethnic differences in advanced cigar smoking patterns by cigar types. This research explores whether cigar smoking patterns differ by race/ethnicity and cigar types.

Methods:

This study used a nationally representative sample of adults (aged ≥18 years; N=28,148) from the Wave 3 survey (2015–2016) of the Population Assessment of Tobacco and Health Study for analysis. Cigar smoking patterns included past 30–day use, daily use, established use, past 12–month blunt use, use within 30 minutes of waking, and the number of cigars used per day. Weighted multivariable regressions were conducted in 2019 to examine the associations between race/ethnicity and cigar smoking patterns by cigar types (traditional cigars, cigarillos, and filtered cigars), controlling for covariates.

Results:

Compared with non-Hispanic Whites, non-Hispanic Blacks were more likely to smoke cigars in the past 30 days (AOR=2.27, 95% CI=2.03, 2.54) and on a daily basis (AOR=2.65, 95% CI=1.89, 3.70), have established cigar smoking (AOR=1.95, 95% CI=1.66, 2.29), and smoke blunts in the past 12 months (AOR=2.30, 95% CI=1.84, 2.88). This pattern was generally consistent across cigar types and was especially pronounced for cigarillos. Compared with non-Hispanic Whites, Hispanics were more likely to smoke cigars within 30 minutes of waking (AOR=1.50, 95% CI=1.10, 2.06).

Conclusions:

This study finds that non-Hispanic Blacks and Hispanics have more advanced patterns of cigar smoking than non-Hispanic Whites. Interventions and policies for minimizing cigar smoking may differentially benefit these populations and reduce disparities.

INTRODUCTION

Although the use of cigarettes has declined over time in the U.S., the annual consumption of cigars doubled from 2000 to 2016 (6.2 to 12 billion sticks).¹ Cigar products in the U.S. come in 3 major types: traditional (premium or large) cigars, cigarillos, and filtered (little) cigars.² These cigar products vary in features including size, weight, characterizing flavor, and quantity sold per package.² Cigar use is associated with negative health consequences such as lung, oral, and esophageal cancer^3,4 and its risks may differ based on cigar type.⁵ Notably, cigarillos, the main cigar product type consumed in the U.S., contain more tobacco and higher levels of carcinogens per gram of tobacco than cigarettes.^3,6 Traditional cigars can also deliver as much as 10 times the nicotine, 2 times the tar, and 5 times the carbon monoxide of a cigarette.⁵

Mounting evidence suggests that racial/ethnic minority populations, especially non-Hispanic Blacks/African Americans, are at a higher risk of smoking cigar products.^7–11 In 2016, past 30–day cigar use prevalence was 9.0% among non-Hispanic Blacks aged ≥12 years, as compared with 6.9% of their non-Hispanic White counterparts.¹² Moreover, unlike other racial/ethnic groups, non-Hispanic Blacks did not have a significant decrease in past 30–day cigar use prevalence between 2002 and 2016.¹² This disproportionately and persistently high cigar smoking prevalence among non-Hispanic Blacks demonstrates significant racial/ethnic differences that may lead to worsened health outcomes among minority groups.

Previous studies that have already demonstrated racial/ethnic differences in cigar smoking behavior have several limitations. First, little is known about whether or to what extent racial/ethnic disparities in cigar smoking differ by specific cigar type used. Previous studies only examined cigar smoking generally or focused on one or two particular cigar types (e.g., cigarillos).^7–9,11,12 Therefore, it is important to examine cigar types separately owing to potential differences in consumer demographic characteristics (e.g., race/ethnicity); product use behaviors (e.g., puffing, inhaling, use frequency); and the ways in which products are packaged, marketed, and sold to individuals from various racial/ethnic backgrounds.^5,13–15 Second, racial/ethnic differences in advanced cigar smoking patterns that may be predictive of prolonged and addictive cigar smoking behavior have also not been examined previously. Daily cigar smoking, for example, increases the risk of developing heart disease and other types of lung disease as compared to non-daily smoking.⁵ Additionally, little is known whether racial/ethnic differences in cigar smoking persisted after accounting for known behavioral risk factors for cigar smoking, including cigarette smoking and cannabis use. Previous research only investigated weighted cigar smoking prevalence by race/ethnicity^7,9,12 or only controlled for respondents’ sociodemographic characteristics such as gender, age, income, and education.¹⁰

The aim of the current study is to fill these critical research gaps by examining a range of cigar smoking patterns (e.g., prevalence, frequency, quantity) according to race/ethnicity and cigar types (i.e., traditional cigars, cigarillos, filtered cigars), using a nationally representative U.S. sample of adults from the Population Assessment of Tobacco and Health (PATH) Study.

METHODS

Study Sample

This study used data from the Wave 3 adult survey public-use file (2015–2016) of the PATH Study, which includes nationally representative, longitudinal cohorts of civilian, non-institutionalized youth and adults in the U.S.¹⁶ The PATH Study survey collects information on tobacco use and health status through audio computer-assisted self-interviews in English and Spanish.¹⁶ For the adult survey of the PATH Study, the weighted response rates at Wave 1 were 74.0%, and its weighted retention rate for Wave 3 among Wave 1 respondents was 78.4%.¹⁷ More details about the PATH Study can be found elsewhere.^16,17 For this analysis, the authors used the sample of the entire U.S. adult population (aged ≥18 years; N=28,148).

Measures

Derived variables (e.g., tobacco use status) and imputed variables (e.g., sociodemographic characteristics) from the PATH Study survey were used for analysis when available.¹⁷ The use of 3 specific cigar types (traditional cigars, cigarillos, and filtered cigars) was asked by separate questions related to cigar smoking behavior. Respondents were first shown the definition of these 3 types of cigar products with multiple examples of cigar brands, followed by images of each cigar type.¹⁷

Variables measuring 6 cigar smoking patterns were used as outcomes for this analysis. Each cigar smoking pattern consisted of measures of using any cigars, traditional cigars, cigarillos, and filtered cigars. Past 30–day cigar smoking was calculated from 3 derived variables obtained from the question: In the past 30 days, have you smoked a [cigar type], even one or two puffs? Daily cigar smoking was obtained from the question: Do you now smoke [cigar type]? Response options included every day, some days, and no. Those who answered every day were considered daily cigar smokers. Established cigar smoking was obtained from three derived variables describing respondents who had ever smoked any types of cigar products fairly regularly and currently smoked such products every day or some days. Past 12–month blunt smoking described those who smoked blunts in the past 12 months among the sample of past 30–day cigar smokers. Smoking blunts in the past 12 months was measured by the question: In the past 12 months, have you smoked part or all of a [cigar type] with marijuana in it? with options of yes and no. Smoking cigars within 30 minutes of waking was obtained from the question: On the days that you smoke [cigar type], how soon after you wake up do you typically smoke your first [cigar type] of the day? Please enter the number of minutes or hours. This question was asked among the respondents who smoked the product every day or some days. Three derived variables indicating that the smokers smoked the first product within 30 minutes of waking were used with options of yes and no. Finally, number of cigars per day on days used was measured by the question: On average, on those [number of days cigars were smoked], how many [cigar types] did you usually smoke each day? The total number of cigars smoked among past 30–day cigar smokers was calculated as a sum of the 3 types of cigars.

Respondents’ race/ethnicity background was categorized as non-Hispanic Black/African American (non-Hispanic Black), non-Hispanic White, Hispanic, and non-Hispanic Other. Covariates included in this analysis included sociodemographic backgrounds, past 30–day cannabis use, and past 30–day cigarette smoking. Specifically, sociodemographic backgrounds involved sex (female and male), age (18–24 years, 25–34 years, 35–54 years, and ≥55 years), annual household income (<$50,000, ≥$50,000, and undetermined), and highest educational attainment (≤high school and >high school). Past 30–day cannabis use was measured by the question: In past 30 days, have you used marijuana, hash, THC, grass, pot or weed? with the response options of yes and no. Past 30–day cigarette smoking was obtained from a derived variable describing respondents’ use of cigarettes during the past 30 days.

Statistical Analysis

The authors conducted the following statistical analyses using Stata, version 14.0 in 2019. The Wave 3 weights were sued when calculating proportions with 95% CIs, utilizing the balanced repeated replications method with Fay’s adjustment of 0.30.¹⁷ First, the weighted prevalence of 6 cigar smoking patterns was examined, stratified by race/ethnicity and cigar type. Then, chi-square tests were conducted to examine whether cigar smoking patterns differed by race/ethnicity, stratified by cigar types. Lastly, multivariable logistic and linear regressions assessed the associations between race/ethnicity and 6 cigar smoking patterns by cigar type, controlling for covariates. For the regressions, the authors excluded observations with missing values by listwise deletion for multivariable regression models.¹⁸ They did not adjust for multiple comparisons given the study’s prior hypotheses.¹⁹ This research only involved the use of de-identified data, which is not considered human subject research and therefore requires no IRB review or approval per the NIH policy or HHS regulations 45 CFR 46.

RESULTS

Table 1 presents chi-square results and weighted prevalence of cigar smoking patterns by race/ethnicity and cigar types. Among the overall U.S. adult population, in the past 30 days, 6.8% (~16.3 million) smoked any type of cigars, 3.7% (~8.9 million) smoked traditional cigars, 4.2% (~10.1 million) smoked cigarillos, and 1.8% (~7.6 million) smoked filtered cigars; 4.5% (~10.8 million) smoked 1 type of cigar, 1.9% (~4.6 million) smoked 2 types, and 0.6% (~1.4 million) smoked three types. Non-Hispanic Blacks had the highest past 30–day prevalence of smoking any cigar (13.8%), traditional cigars (5.9%), cigarillos (11.4%), and filtered cigars (3.3%), among all racial/ethnic groups. Non-Hispanic Blacks also had a higher weighted prevalence for all cigar smoking patterns (any cigars used) as compared with non-Hispanic Whites (p<0.05).

Table 1.

Weighted Prevalence of Cigar Smoking Patterns by Race/Ethnicity and Cigar Types (PATH Wave 3 Adult Survey 2015–2016)

Variable	Overall	Non-Hispanic White	Race and ethnicity Non-Hispanic Black	Hispanic	Non-Hispanic Other
	N=28,148 Weighted % (95% CI)	N=16,274 Weighted % (95% CI)	N=4,082 Weighted % (95% CI)	N=5,244 Weighted % (95% CI)	N=2,111 Weighted % (95% CI)	p-value
Past-30-day cigar smokinga
Any cigar smoking	6.8 (6.5, 7.2)	5.9 (5.5, 6.2)	13.8 (12.7, 14.9)	6.9 (6.2, 7.7)	4.7 (3.9, 5.6)	<0.0001
Traditional cigar smoking	3.7 (3.5, 4.0)	3.6 (3.3, 3.8)	5.9 (5.3, 6.7)	3.3 (2.8, 3.9)	2.6 (2.0, 3.4)	<0.0001
Cigarillo smoking	4.2 (3.9, 4.4)	3.0 (2.8, 3.3)	11.4 (10.5, 12.5)	4.5 (3.9, 5.2)	2.7 (2.2, 3.3)	<0.0001
Filtered cigar smoking	1.8 (1.7, 2.0)	1.5 (1.4, 1.7)	3.3 (2.7, 4.1)	2.1 (1.7, 2.5)	1.0 (0.8, 1.3)	<0.0001
Daily cigar smokinga
Any cigar smoking	0.7 (0.6, 0.8)	0.5 (0.4, 0.6)	1.9 (1.0, 2.0)	0.6 (0.4, 0.8)	0.5 (0.3, 0.7)	<0.0001
Traditional cigar smoking	0.2 (0.1, 0.2)	0.1 (0.0, 0.2)	0.4 (0.3, 0.6)	0.1 (0.0, 0.2)	0.1 (0.0, 0.3)	<0.0001
Cigarillo smoking	0.3 (0.2, 0.3)	0.1 (0.0, 0.2)	1.2 (0.9, 1.5)	0.3 (0.2, 0.4)	0.1 (0.0, 0.1)	<0.0001
Filtered cigar smoking	0.4 (0.3, 0.5)	0.3 (0.2, 0.4)	0.7 (0.4, 1.0)	0.4 (0.3, 0.5)	0.3 (0.2, 0.4)	0.0080
Established cigar smokingb
Any cigar smoking	2.7 (2.5, 2.9)	2.5 (2.3, 2.8)	5.4 (4.8, 6.1)	1.9 (1.6, 2.3)	1.7 (1.3, 2.2)	<0.0001
Traditional cigar smoking	1.4 (1.2, 1.5)	1.4 (1.3, 1.6)	2.0 (1.6, 2.5)	0.8 (0.6, 1.1)	0.9 (0.5, 1.4)	<0.0001
Cigarillo smoking	1.2 (1.1, 1.3)	0.9 (0.8, 1.1)	3.7 (3.3, 4.2)	0.9 (0.7, 1.2)	0.7 (0.5, 1.0)	<0.0001
Filtered cigar smoking	0.8 (0.7, 0.9)	0. ‘ (0.5, 0.8)	1.5 (1.1, 2.0)	0.8 (0.6, 1.1)	0.5 (0.3, 0.8)	<0.0001
Past-12-month blunt smokingc
Any cigar smoking	39.8 (37.4, 42.3)	31.6 (28.5, 34.8)	54.6 (51.0, 58.2)	47.6 (42.3, 52.8)	40.0 (32.2, 48.2)	<0.0001
Traditional cigar smoking	11.7 (10.1, 13.5)	8.8 (7.0, 11.1)	18.0 (13.9, 23.1)	16.6 (12.0, 22.6)	12.6 (7.2, 21.2)	0.0001
Cigarillo smoking	46.0 (43.4, 48.6)	40.2 (36.3, 44.3)	52.1 (47.8, 56.4)	50.1 (45.1, 55.0)	44.2 (34.6, 54.4)	0.0001
Filtered cigar smoking	5.2 (3.6, 7.5)	4.7 (2.9, 7.4)	2.3 (0.8, 7.3)	8.3 (3.5, 18.4)	13.9 (5.4, 31.7)	0.0620
Smoking cigars within 30 minutes of wakingb
Any cigar smoking	.3.0 (21.0, 25.0)	18.7 (16.4, 21.3)	30.7 (25.4, 36.5)	29.5 (24.0, 35.7)	21.8 (14.4, 31.6)	<0.0001
Traditional cigar smoking	14.9 (12.2, 18.0)	11.6 (9.00, 14.8)	26.2 (17.8, 36.8)	18.7 (10.9, 30.3)	12.0 (5.92, 23.1)	0.0021
Cigarillo smoking	20.7 (17.7, 24.2)	16.5 (12.9, 20.7)	23.2 (17.7, 30.0)	31.9 (24.0, 41.1)	19.0 (10.8, 31.2)	0.0043
Filtered cigar smoking	40.8 (36.7, 45.0)	38.8 (33.4, 44.5)	38.1 (30.4, 46.5)	40.7 (32.2, 50.0)	43.8 (28.3, 60.5)	0.9139
Number of cigars per day on days smoked,c weighted mean (SE)
Any cigar smoking	3.2 (0.2)	2.7 (0.3)	3.9 (0.3)	3.7 (0.5)	3.2 (0.5)	0.0290
Traditional cigar smoking	2.0 (0.2)	1.5 (0.2)	3.7 (0.6)	2.7 (0.4)	1.9 (0.3)	0.0002
Cigarillo smoking	2.4 (0.1)	2.3 (0.2)	2.5 (0.2)	2.5 (0.4)	2.9 (0.5)	0.3480
Filtered cigar smoking	6.2 (0.5)	7.8 (0.7)	4.0 (0.4)	3.4 (0.4)	8.2 (3.3)	0.0200

^aMeasured among the entire sample (n=28,148).

^bMeasured among “every day” or “some day” cigar smokers (n=2,582 for any cigars; n=1,435 for traditional cigars; n=1,309 for cigarillos; and n=776 for filtered cigars).

^cMeasured among past-30-day cigar smokers (n=3,586 for any cigars; n=1,774 for traditional cigars; n=2,436 for cigarillos; and n=984 for filtered cigars).

PATH, Population Assessment of Tobacco and Health.

Racial/ethnic differences related to smoking traditional cigars were consistent throughout all cigar smoking outcomes. Racial/ethnic differences related to smoking cigarillos existed across cigar smoking outcomes except for the number of cigars used per day on days used. Racial/ethnic differences related to smoking filtered cigars were present across cigar smoking outcomes except for past 12–month blunt smoking and smoking cigars within 30 minutes of waking. Higher prevalence of use for non-Hispanic Blacks, as compared with non-Hispanic Whites in particular, was consistent for 3 cigar smoking outcomes (past 30–day use, daily use, and established use) across all cigar types. Hispanics also had a higher weighted prevalence in some cigar smoking patterns. For example, 4.5% and 2.1% of Hispanics had smoked cigarillos and filtered cigars in the past 30 days, respectively, as compared with 3.0% (p<0.0001) and 1.5% (p<0.0001) of non-Hispanic Whites.

Table 2 presents results from the adjusted multivariable regressions, demonstrating the associations between race/ethnicity and cigar smoking patterns by cigar types after controlling for covariates. Non-Hispanic Blacks were more likely to report 4 cigar smoking patterns (past 30–day use, daily use, established use, and past 12–month blunt use) for any cigars used compared with non-Hispanic Whites. Similar differences between non-Hispanic Blacks and Whites were found for past 30–day, daily, established, and blunt smoking for traditional cigars and cigarillos, but no differences were found for filtered cigars.

Table 2.

The Adjusted Associations Between Race/Ethnicity and Cigar Smoking Patterns by Cigar Types (PATH Wave 3 Adult Survey 2015–2016)

Variable	AORs of cigar smoking patterns by race/ethnicitya (ref: non-Hispanic White)
	Non-Hispanic Black AOR (95% CI)	(Hispanic Non-Hispanic Other AOR (95% CI) AOR (95% CI)
Past-30-day cigar smokingb
Any cigar smoking	2.27 (2.03, 2.54)	1.09 (0.96, 1.25)	0.86 (0.70, 1.06)
Traditional cigar smoking	1.47 (1.26, 1.71)	0.93 (0.76, 1.12)	0.78 (0.59, 1.04)
Cigarillo smoking	3.75 (3.31, 4.25	1.30 (0.11, 1.51)	1.03 (0.81, 1.28)
Filtered cigar smoking	1.49 (1.16, 1.93)	1.12 (0.88, 1.43)	0.96 (0.68, 1.34)
Daily cigar smokingb
Any cigar smoking	2.65 (1.89, 3.70)	1.06 (0.73, 1.53)	1.22 (0.71, 2.11)
Traditional cigar smoking	2.39 (1.28, 4.45)	0.95 (0.42, 2.15)	2.09 (0.71, 6.19)
Cigarillo smoking	5.90 (3.44, 10.11)	1.58 (0.88, 2.84)	0.94 (0.28, 3.12)
Filtered cigar smoking	1.37 (0.80, 2.37)	1.09 (0.73, 1.67)	1.09 (0.53, 2.26)
Established cigar smokingc
Any cigar smoking	1.95 (1.66, 2.29)	0.79 (0.64, 0.96)	0.80 (0.62, 1.03)
Traditional cigar smoking	1.39 (1.07, 1.80)	0.77 (0.55, 1.06)	0.76 (0.50, 1.15)
Cigarillo smoking	3.47 (2.88, 4.19)	0.89 (0.67, 1.18)	0.90 (0.60, 1.36)
Filtered cigar smoking	1.49 (1.04, 2.12)	1.02 (0.69, 1.52)	0.11 (0.69, 1.78)
Past-12-month blunt smokingd
Any cigar smoking	2.14 (1.65, 2.77)	1.54 (1.09, 2.16)	1.04 (0.77, 1.65)
Traditional cigar smoking	1.51 (0.98, 2.78)	1.78 (1.15, 2.78)	1.23 (0.60, 2.78)
Cigarillo smoking	1.58 (1.15, 2.19)	1.07 (0.73, 1.57)	0.89 (0.54, 1.57)
Filtered cigar smoking	0.44 (0.10, 1.93)	1.84 (0.62, 5.48)	3.49 (0.94, 12.98)
Smoking cigars within 30 minutes of wakingc
Any cigar smoking	1.40 (0.97, 2.00)	1.50 (1.10, 2.06)	1.24 (0.72, 2.13)
Traditional cigar smoking	1.88 (0.84, 4.17)	1.60 (0.80, 3.23)	0.85 (0.31, 2.31)
Cigarillo smoking	1.30 (0.85, 2.00)	2.08 (1.29, 3.36)	1.17 (0.54, 2.52)
Filtered cigar smoking	0.93 (0.61, 1.41)	1.08 (0.67, 1.76)	1.70 (0.84, 3.43)
Number of cigars per days on days smokedd (ARC, 95% CI)
Any cigar smoking	0.23 (−0.83, 1.30)	0.24 (−1.01, 1.49)	−0.17 (−1.38, 1.04)
Traditional cigar smoking	1.41 (0.27, 2.55)	0.83 (−0.31, 1.99)	0.19 (−0.84, 1.23)
Cigarillo smoking	0.00 (−0.61, 0.61)	0.06 (−0.94, 1.06)	0.41 (−0.87, 1.68)
Filtered cigar smoking	−3.33 (−4.90, −1.76)	−3.39 (−5.24, −1.54)	0.50 (−6.35, 7.33)

Note: Boldface indicates statistical significance (p<0.05).

^aThe regression models controlled for sex, age, highest level of education, annual household income, past-30-day cannabis use, and past-30-day cigarette smoking.

^bMeasured among the entire sample (n=28,148).

^cMeasured among “every day” or “some day” cigar smokers (n=2,582 for any cigars; n=1,435 for traditional cigars; n=1,309 for cigarillos; and n=776 for filtered cigars).

^dMeasured among past-30-day cigar smokers (n=3,586 for any cigars; n=1,774 for traditional cigars; n=2,436 for cigarillos; and n=984 for filtered cigars).

ARC, adjusted regression coefficient.

The AORs were particularly high for cigarillo smoking outcomes (past 30–day use, daily use, established use, and past 12–month blunt use) comparing non-Hispanic Blacks with Non-Hispanic Whites. For example, non-Hispanic Blacks were more likely than non-Hispanic Whites to have smoked cigarillos in the past 30 days (AOR=3.75, 95% CI=3.31, 4.25) and on a daily basis (AOR=5.90, 95% CI=3.44, 10.11) as well as to report an established cigarillo smoking behavior (AOR=3.47, 95% CI=2.88, 4.19); the AORs for these relationships were 1.47, 2.39, and 1.39, respectively, for traditional cigar smoking.

Few associations were observed for differential cigar smoking patterns among Hispanics compared with non-Hispanic Whites. For example, Hispanic past 30–day cigar smokers were more likely to have smoked blunts with any cigar type (AOR=1.50, 95% CI=1.10, 2.06) and cigarillos in the past 12 months (AOR=2.08, 95% CI=1.29, 3.36) than their non-Hispanic White counterparts. Hispanic every day and some days smokers were more likely to smoke any cigar type (AOR=1.50, 95% CI=1.10, 2.06) or cigarillos (AOR=2.08, 95% CI=1.29, 3.36) within 30 minutes of waking, respectively, compared with their non-Hispanic White counterparts. No differences were found for cigar smoking patterns between non-Hispanic Others and non-Hispanic Whites using the adjusted regression models.

DISCUSSION

This is one of the first studies to examine differential cigar smoking patterns by race/ethnicity and cigar types. This study highlights a higher prevalence and advanced patterns of cigar smoking, especially traditional cigar and cigarillo smoking, among non-Hispanic Blacks versus non-Hispanic Whites. The findings are consistent with the previous findings that non-Hispanic Blacks were more likely to smoke any cigar products within the past 30 days.^7,9,11,12 The current study adds to previous research by demonstrating that the racial/ethnic differences in past 30–day cigar smoking between non-Hispanic Blacks and non-Hispanic Whites are consistent across various cigar types and even more pronounced for cigarillos. Additionally, this study revealed that non-Hispanic Blacks are more likely to have more advanced cigar smoking behaviors (e.g., daily use and established use) as compared with their non-Hispanic White counterparts, even after controlling for known risk factors. These more advanced cigar smoking behaviors may lead to additional exposure to toxic and cancer-causing chemicals, which may translate into worse health outcomes among non-Hispanic Black smokers.

Previous studies suggested that non-Hispanic Blacks may be more likely to use cigars owing to concurrent use of cannabis and cigarette products.^10,20–22 This study found that even after controlling for past 30–day cigarette smoking and past 30–day cannabis use, differences for non-Hispanic Blacks persisted among a wide range of cigar smoking behaviors (e.g., past 30–day use, daily use, and established use). The authors suspect that additional multifaceted risk factors may explain the differences between non-Hispanic Black and White adults. They may include high levels of perceived stress and anxiety,^23–25 low harm perceptions about cigar and cannabis use,⁸ pro-cigar and a pro-cannabis use sociocultural environment,²⁶ and targeted marketing.^27,28 Longitudinal evidence is needed to investigate the development of more advanced cigar smoking patterns and its risk factors among non-Hispanic Blacks relative to non-Hispanic Whites.

The prevalence of smoking various cigar types in the past 30 days is the highest for cigarillos among the entire sample (4.2%), and especially among non-Hispanic Blacks (11.4%). Additionally, AORs for non-Hispanic Blacks were higher for cigarillos in terms of past 30–day smoking, daily use, and established use outcomes as compared to traditional cigars and filtered cigars. These findings suggest that cigarillos may be the cigar product that drives the high prevalence and more advanced patterns of cigar smoking among non-Hispanic Blacks. Recent research findings have indicated that the escalated use of cigarillos is one of the major factors for the growing prevalence of cigar smoking in the U.S.,^20,29 and cigarillo smoking may contribute to race/ethnicity differences in cigar smoking.^9,10,29 Specifically, cigarillos have become increasingly popular among non-Hispanic Blacks because of their affordability, compatibility with smoking cannabis, flavor variety, and targeted marketing and sales efforts aimed at Black communities.^{10,27,29–33} Public health efforts to combat cigar smoking and reduce cigar smoking disparities among non-Hispanic Blacks should focus particularly on the interventions and regulations that address cigarillo use and blunt use. Local- and national-level regulatory activities focused on increasing cigar prices through cigar taxing and packaging (increasing minimum pack sizes) as well as restricting the sales of flavored cigars may be especially impactful in preventing and reducing cigarillo use.

This study found that non-Hispanic Black cigar smokers were more likely to smoke blunts in the past 12 months, even after controlling for their past 30–day cannabis use, as compared with their non-Hispanic White counterparts. The authors suspect that social and behavioral norms of blunt smoking and low harm perceptions toward smoking marijuana may contribute to this unique smoking pattern. Previous research has found that concurrent tobacco smoking and cannabis use are considered normative behavior among African American smokers²¹ and that music and cultural preferences heavily influence the use of blunts among Blacks in the U.S.^34,35 Moreover, although they had more advanced smoking patterns, non-Hispanic Blacks did not report higher levels of cigar dependence than non-Hispanic Whites. This finding is consistent with the previous research assessing cigarette smoking dependence,³⁶ which suggests that non-Hispanic Blacks reach similar levels of cigarette dependence by smoking fewer cigarettes per day compared with non-Hispanic Whites.

Little evidence is currently available regarding cigar smoking patterns among the Hispanic population in the U.S. This study found that after controlling for covariates, Hispanic past 30–day cigar smokers were more likely to have smoked blunts in the past 12 months compared with non-Hispanic White cigar smokers. This study also revealed that although few racial/ethnic differences were found in cigar smoking patterns between Hispanics and non-Hispanic Whites, Hispanics were more likely to smoke any type of cigar products, especially cigarillos, within 30 minutes of waking. This finding suggests that compared with non-Hispanic White cigar smokers, Hispanic smokers may be more likely to become dependent on cigar products given a similar level of consumption. More research is needed to further investigate the risk factors associated with Hispanics’ blunt use as well as the cigar smoking–related behavioral patterns (e.g., puffing typology, inhaling patterns) that may contribute to their increased cigar dependence.

Limitations

This study has some limitations. First, because of small sample sizes, the study could not examine racial/ethnic differences in cigar use among the subgroups of non-Hispanic Others. Future research that specifically examines the prevalence and risk factors of cigar smoking across the subgroups of non-Hispanic Others (e.g., Asians, Pacific Islanders, and American Indians) are critically needed to address potential racial/ethnic variations. Second, this study did not stratify the sample by young adults (usually defined as age 18–24 years) versus older adults (aged ≥25 years) given the current scope of analysis. Evidence has shown that young adults, especially Black young adults, have a much higher prevalence of smoking cigars alone and smoking cigars concurrently with cigarettes or cannabis.^8,11,37,38 Therefore, examining the relationship between race/ethnicity and cigar smoking patterns by age categories may add more insights to inform age-targeted preventive and intervention messages and programs.

Regardless of the limitations, this analysis contributes to the limited body of literature on racial/ethnic differences in cigar smoking behaviors across cigar types, providing a better understanding of the varying cigar product use profiles and contributing to the development of tailored strategies and policy efforts to improve best practices for cigar smoking surveillance, screening, and prevention/intervention to reduce health disparities.

CONCLUSIONS

This study presents a higher prevalence and advanced patterns of cigar smoking measured by a range of cigar smoking behavior and three cigar types among racial/ethnic minorities, especially non-Hispanic Blacks, as compared with non-Hispanic Whites. This study also highlights the finding that cigarillo smoking may drive the racial/ethnic differences in cigar smoking observed among non-Hispanic Blacks. Other intrapersonal, social, cultural, and environmental risk factors for cigar smoking that are unique to non-Hispanic Blacks need to be investigated to inform evidence-based strategies and regulatory activities for reducing cigar smoking among this group. Programs and regulations aimed at preventing and reducing cigar smoking may differentially benefit these racial/ethnic minority populations and reduce health disparities resulted from cigar smoking.