Exploring the Hypothetical Impact of Flavored Cigar Sales Restrictions Among Black Young Adult Cigar Smokers: A Semi-Structured In-depth Interview Investigation

Abstract

This study assessed the hypothetical impact of flavored cigar sales restrictions on cigar smoking among Black young adult cigar smokers (ages 21–29). Forty in-depth interviews were conducted in 2020. Interviews were independently coded and analyzed using thematic analysis. When asked how they would smoke cigars given a flavor sales restriction, half of participants reported they would smoke in the same way, a third would stop or reduce smoking, and a few were unsure of what they would do. Cigar smoking outcome expectancies, preference for flavors, and perceived addictiveness of cigar products may predict cigar smoking change given flavor sales restrictions.

INTRODUCTION

Cigar smoking, just like cigarette smoking, can lead to the development of cancer (e.g., lung, oral, esophageal, and larynx) and cardiovascular diseases (American Lung Association, 2010; National Cancer Institute, 2017). Cigar products can also contain higher levels of nicotine than cigarettes, and contribute to nicotine dependence (Blank et al., 2011). However, unlike cigarette consumption which has seen a large decline in recent decades, cigar product sales increased by 29% during 2012–2016 (Gammon et al., 2019). In the U.S. market, cigar product types include large/premium cigars, cigarillos, and filtered/little cigars (Centers for Disease Control and Prevention, 2020), and are often used as blunts (Sifaneck et al., 2006), defined as completely or partially hollowed cigars filled with cannabis.

Cigar smoking prevalence in the U.S. is disproportionately higher among Black or African American individuals when compared to White individuals. In 2017, Black adults (8.0%) were more likely to smoke cigars than U.S. adults in general (4.9%) (Substance Use and Mental Health Services Administration, 2019). Additionally, in 2015–2016, the prevalence of past 30-day cigarillo smoking was higher in Black adults (11.4%) when compared to other adults (4.2%) (Chen-Sankey et al., 2021). In line with this, the prevalence of cigar smoking has not declined for Black adults in the U.S. between 2002–2016 (Weinberger et al., 2020), and neither has the cigar smoking mortality rate when compared to other minoritized racial and ethnic groups (American Lung Association, 2010; CDC, 2004, 2020). Additionally, Black adults also have the highest prevalence of smoking blunts in the U.S. (24.2%) when compared to White and Hispanic adults (Mantey et al., 2021). Non-Hispanic Black young adults, in particular, have the highest prevalence of smoking cigar products across all population groups in the U.S. (Chen-Sankey, Broun, et al., 2020; Cullen et al., 2011; Phan et al., 2021; K. Sterling et al., 2013).

One prominent reason for initiating and regularly using cigar products for young adults, and particularly Black young adults, is the characterizing flavors in cigar products. Most cigar products, especially cigarillos and filtered/little cigars, come with various characterizing flavors that do not taste or smell like tobacco, such as menthol/mint, fruit, candy, and alcohol (Lawyer et al., 2019). Flavors in tobacco products have been found to contribute to curiosity and interest towards tobacco use (Persoskie et al., 2016), product initiation (Sterling et al., 2015), frequent use (Odani et al., 2020), and difficulty quitting (Boyle et al., 2019). Black young adults were also more likely to smoke flavored cigar products than non-flavored products (Delnevo et al., 2015; Hinds et al., 2018). Another study found that almost all (98.4%) Black young adult current cigar smokers who participated in the study used flavored cigars during the two-week assessment (Chen-Sankey et al., 2019). Therefore, one promising strategy to reduce cigar smoking and its associated health problems and disparities is to reduce the availability of cigars with characterizing flavors.

Since 2018, in order to reduce tobacco use among young people, an increased number of localities in the U.S. have enacted restrictions on the sale of flavored tobacco products, including cigar products (Chen-Sankey et al., 2018; Rose et al., 2020; Kuiper et al., 2018). In April 2021, the U.S. Food and Drug Administration (FDA) announced its plan to restrict the sale of flavored cigar products in the country (Food and Drug Adminstation, 2021). Indeed, studies have found that flavored tobacco sales restrictions may be a promising strategy to reduce tobacco use. The 2009 national ban on flavored cigarette products (except menthol) in the U.S. was found to be associated with decreased cigarette smoking in youth and young adults (Rossheim et al., 2020). A 2020 scoping review found that about 25%–64% of U.S. cigarette smokers may quit smoking altogether if a menthol flavored cigarette sales restriction was instituted (Cadham et al., 2020). Another study found that the sales of flavored cigars declined by 22% in New York City after the city-wide implementation of flavored tobacco sales restrictions (Rogers et al., 2017).

Previous studies, however, did not conduct a qualitative investigation to understand cigar smokers’ perceptions of a flavored cigar ban and its potential impact on their behavior. Additionally, research is needed on the priority groups who are vulnerable to cigar smoking (i.e., Black young adults) and who, therefore, might benefit the most from flavored cigar sales restrictions. Therefore, this study aimed to explore the potential cigar smoking behavior change (and its rationale) given a hypothetical flavored cigar sales restriction among a purposive sample of Black young adult cigar smokers using in-depth interviews.

METHODS

Participant Recruitment and Study Procedures

In-depth telephone interviews (N=40) were conducted between May and June 2020 with individuals who self-identified as Black or African American. Participant recruitment took place on various social media platforms (e.g., Facebook, Instagram). Participant eligibility criteria were: (1) self-reporting as non-Hispanic Black or African American; (2) being between 21 and 29 years of age; (3) being current cigar smokers, defined as having smoked any type of cigar product (large cigars, cigarillos, filtered cigars) at least four times in the past two weeks (Chen-Sankey et al., 2019; Mead et al., 2018); and (4) being able to read and speak English. Almost all participants lived in the greater Washington, D.C., metropolitan area, where the sale of flavored tobacco products (including flavored cigars) was not restricted at the time of data collection. All participants were screened for eligibility via phone and then sent a link with an electronic informed consent form. After giving their consent, participants completed a brief online survey covering socio-demographic backgrounds and tobacco use history. The participants who completed the survey were then contacted to schedule their phone interviews. Participants received $100 in compensation upon completion of both the online survey and telephone interview. The study was approved by the National Institutes of Health Office of Human Subjects Research Protection.

In-depth Interview and Structure

All interviews were conducted by a researcher experienced in conducting in-depth interviews on tobacco use topics. The duration of the interviews ranged between 45 and 60 minutes. Participants were first asked to discuss their current cigar smoking behavior and the cigar products they currently smoked. Specifically, the participants described the frequencies of cigar smoking as well as the brands and characteristics (e.g., size, flavors, containing filters or cannabis) of the cigar products they currently used. They were further asked to describe the taste and smell of the cigar products if they did not recall the names of the cigar flavors they smoked. Since all participants were frequent cigar smokers (smoked ≥4 times in the past two weeks), almost all of them were able to answer those questions without the interviewer’s further explanations.

The interview data used for the current analysis was from participants’ responses to the interview questions related to their reactions to a hypothetical cigar flavor sales restriction. Specifically, the interviewer first introduced a hypothetical scenario where the sale of non-tobacco-flavored cigar products was restricted, and only tobacco-flavored or plain cigars were available to purchase. The interviewer then asked the participants to discuss how they would smoke cigar products given this scenario. The interview questions were tailored to match the type of cigar product type (large cigars, cigarillos, filtered cigars, blunts) currently smoked by the participants. If the participants were confused about what tobacco-flavored cigars or plain cigars meant, further explanations were given by the interviewer. Specifically, the interviewer asked, “Now, consider a scenario where only tobacco-flavored or plain cigars are allowed to be sold in stores and online. All other flavors are banned in the country. In this situation, how would you smoke [Cigar Type]? Would you smoke them in the same or different ways, and why?

Data Coding

Analysis of the online survey data was conducted via Stata 16.0 (College Station, TX: StataCorp LLC). Audio recordings of all phone interviews were transcribed verbatim. All interview transcripts were de-identified and labeled by participant identification numbers. Transcripts were coded using Dedoose® (Los Angeles, CA: SocioCultural Research Consultants), a qualitative data management application. The research team created the initial codebook largely based on the interview questions. A group of three coders (AA, AB, and DAD) received qualitative data coding training and applied the codes to five randomly selected interview transcripts. The research team added new codes based on other emerging themes from reading these transcripts in detail and thoroughly discussed in the meetings to finalize the coding scheme. Pairs of two coders then independently coded each transcript. Next, the third coder and the senior author (JCS) went through all coded data to resolve any coding inconsistencies and reach an agreement in coding. The percentage agreement for the codes used in this current analysis was moderate to high (85%–96%), suggesting satisfactory intercoder reliability (Golafshani, 2003).

Thematic Data Analysis

Thematic analysis (Guest et al., 2011) was used to analyze the interview data organized by relevant codes. The first and senior authors read through the coded data relevant to this study’s research questions, independently generated emerging themes and subthemes, and compared and contrasted the content related to the cigar product type most frequently used within the same theme and subtheme. The two authors then met to discuss the findings related to the themes and subthemes generated from the independent analysis. Disagreements were discussed and reconciled during the meetings with coders before reaching an agreement on the final set of themes and subthemes to be reported in the study. Reporting of themes and subthemes for the current manuscript was based on the frequencies of relevant content discussed by the participants using the following words: “all” (100%), “most” (70–99%), “more than half” (51–69%), “half” (50%), “some” (20–49%), “a few” (1–19%), and “none” (0%) (Berg et al., 2021; Sandelowski et al., 2009). Themes related to filtered cigar smoking were not analyzed or included in this current analysis due to the small amount of data specifically related to filtered cigar smoking.

RESULTS

Participant Characteristics and Cigar Products Most Frequently Smoked

Table 1 presents participants’ socio-demographic characteristics and tobacco use history. Slightly over half of the participants were female (57.5%), and the average age of the participants was 26.0 years (Standard Deviation=2.4). Most participants (90.0%) smoked cigarillos in the past 30 days, and more than half smoked large cigars (60.0%) or blunts (57.5%) in the past 30 days. The participants were also categorized by the products they most frequently smoked: blunt smokers (45.0%), cigarillo smokers (40.0%), large cigar smokers (10.0%), and filtered cigar smokers (5.0%). Additionally, over half of the participants also used e-cigarettes, cigarettes, and hookah (65.0%, 57.5%, and 67.5%, respectively) in the past 30 days.

Table 1.

Participant Characteristics (n=40)

	n	%
Age (mean, SD)	26.0	2.4
Biological Sex
Male	17	42.5%
Female	23	57.5%
Education Level
≤GED or high school	7	17.5%
Some or completed technical school	9	22.5%
Some college	15	37.5%
≥Bachelor’s degree	9	22.5%
Financial Situation
Live comfortably	13	32.5%
Meet needs with a little left	15	37.5%
Just meet basic expenses	12	30.0%
Employment Status
Full time	19	47.5%
Part time	7	17.5%
Unemployed	11	27.5%
Others	3	7.5%
Cigar Smoking in the Past 30 Days
Large cigars	24	60.0%
Cigarillos	36	90.0%
Filtered cigars	7	17.5%
Blunts	23	57.5%
Number of Cigar Products Smoked in the Past 30 Days
One product	4	10.0%
Two products	16	40.0%
Three products	11	27.5%
Four products	9	22.5%
Most Frequently Smoked Cigar Product in the Past 30 Days
Large cigars	4	10.0%
Cigarillos	16	40.0%
Filtered cigars	2	5.0%
Blunts	18	45.0%
Use of Other Tobacco Products in the Past 30 Days
Cigarettes	23	57.5%
E-cigarettes	26	65.0%
Hookah	27	67.5%

The Hypothetical Impact of the Flavored Cigar Sales Restriction

Participants were asked whether and how a hypothetical sales restriction on flavored cigar products would impact their future cigar smoking behaviors. Overall, about half responded that they would smoke cigars the same way as before (n=21). Some said they would stop or reduce smoking cigars (n=14). A few (n=5) said they were not sure of what to do given the flavor sales restriction. Figure 1 shows the percentages of participants reporting cigar smoking behavior change given the flavored cigar sales restriction by cigar products most frequently smoked. Representative quotes from the participants (marked by participants’ biological sex, age, and most frequent cigar product smoked) are provided below for each theme.

Figure 1.

Cigar Smoking Behavior Change Outcomes Given Flavored Cigar Sales Restrictions

Would smoke cigars the same way

More than half of the participants reported that they would smoke cigars in the same frequency or amount given the flavored cigar sales restriction. Among them, those who currently smoked flavored cigars stated that they would not have any problems transitioning to smoking plain cigars without any flavors or were willing to try smoking plain cigars.

“I like those [large cigars], so it wouldn’t bother me that much.” (Female, 25 years, Large cigars)

“I would have no problems just smoking just the original flavor.” (Male, 27 years, Cigarillos)

Most of the participants who frequently smoked blunts reported that since they used cigar products mainly to smoke cannabis (e.g., to get “high”), flavored cigar sales restrictions would not affect the way they smoke. Some added that they could not taste the cigar flavors anyway when smoking blunts, so the flavor sales restrictions would not matter to them at all.

“No, because the experience wouldn’t be gone for me. I’m a weed smoker, so for me, it’s really about the Backwoods. The Backwoods is like a cake, it [the flavor] is the icing. You might prefer buttercream but if it’s regular vanilla, it’s still good. It’s still a cake. It’s still delicious.” (Female, 28 years, Blunts)

“Honestly, it doesn’t really matter when it comes to the flavor of it when I am smoking marijuana because that’s just a secondary thing. The marijuana itself is already flavorful. It’s just the cherry on top if you could have your favorite leaf. If I have to have a plain one, it’s fine.” (Male, 29 years, Blunts)

“If you are throwing weed in it, it really doesn’t matter. At the end of the day, the truth is you really can’t taste the flavor in the cigarillo.” (Female, 23 years, Blunts)

Half of frequent cigarillo and large cigar smokers mentioned that they would continue to smoke cigars in the same way given the flavor sales restriction because plain cigars without flavors did not taste bad at all or they enjoyed the taste of plain cigars. Some explicitly said they preferred smoking cigars without flavors, as plain cigars are “original,” “natural,” and “organic” and may have fewer chemicals in them than flavored cigars. Some even mentioned that this new policy may make people think that cigars are becoming less harmful and healthier in general, and, therefore, may make them want to try cigars more than before.

“Yes, I would [smoke plain cigars], because sometimes I don’t like the sweet flavors because they can be a little harsh. The natural can sometimes be good.” (Male, 28 years, Cigarillos)

“With the ‘original’ ones that just makes me feel better I guess. When I smoke them, they don’t usually give me different types of effect, and I pretty much know what I’m getting with the ‘original’ cigars.” (Female, 23 years, Cigarillos)

“I probably would because that’s natural. Flavored ones have all that other stuff in it, but banana, grape, I wouldn’t. If it’s more natural, yes, I’m for the natural. I wasn’t for the chemicals in the flavors anyhow. I think that you have to be careful with that. That might make them want it more because then they’ll think, ‘Oh, all-natural. Organic movement.’” (Female, 27 years, Blunts)

“To be honest with you, I would. I think a lot of people would because it sounds like this no ingredient tobacco.” (Male, 29 years, Blunts)

Some participants reported that even though they did not like the taste of plain cigars, they would still smoke cigar products in the same frequency and amount given the flavor sales restriction because they were “addicted” to cigars, were smoking cigars for the feelings or the sensation (e.g., stress and anxiety relief), or would have a hard time giving up smoking cigars.

“Yes, it wouldn’t be as enjoyable, but yes I’d still do it. It’s an addiction.” (Male, 29 years, Large cigars)

“I don’t smoke it for the flavor. I smoke it for the sensation. If it doesn’t have flavor that doesn’t stop me from smoking it. (Male, 26 years, Cigarillos)

“It helps me relieve stress, it helps with stress, and it helps me be at peace sometimes. It might be temporary but that’s why I do it.” (Female, 25 years, Large cigars)

“I probably would honestly because I wouldn’t enjoy it as much as I do now, but it still would give me the same effect, relieve the stress and anxiety. It still does the same thing.” (Male, 22 years, Cigarillos)

“I probably would be very hesitant at first just because I know that it’s not my preferred thing. But after a while, like I said, once that craving might start to kick in, it really wouldn’t matter that much to me.” (Male, 22 years, Blunts)

“It still makes you feel the same way. I just wouldn’t enjoy the taste, so I would. I love how it calms me down.” (Female, 28 years, Cigarillos)

A few participants who enjoyed cigar flavors shared that they would be willing to transition to smoking plain cigars because they could be “creative” and add flavors from food sources or other substances (e.g., honey, syrup, flavored THC wax) to their cigar products. A few mentioned they were already trying those “add-on flavors” as desirable alternatives to cigar flavors not only because of their pleasant taste but also because adding them makes cigars burn slower.

“I will find another way. I try to do something crazy like get an apple and put some stuff in the apple and smoke the apple. I need some flavor. I need something interesting.” (Female, 22 years, Blunts)

“I would just probably use honey on it. I coat my Js with honey before I smoke them and it gives it an added flavor too. Honey, honestly, is the only thing you probably would need. I just like the taste of it because those are the flavors that it comes in and it’s just so good.” (Female, 26 years, Blunts)

“Now they have the wax that they add on top of it like THC wax that they use. Putting things onto blunts to make it taste better and burn slower, is a well-practiced tradition.” (Male, 28 years, Blunts)

“I’ve heard people use maybe a syrup like Aunt Jemima’s syrup. I even had someone use coconut oil on it, but usually, you want to use something that’s like syrupy. People have used Agave oil too, but I think syrup and honey are the two top ones.” (Male, 28 years, Blunts)

Would stop or reduce smoking cigars

Some participants, mainly frequent cigarillo smokers, mentioned that they would completely quit smoking cigars or smoke fewer cigars given the flavored cigar sales restriction. Most of those participants explicitly mentioned their strong preference for various cigar flavors (e.g., chocolate, fruits, alcohol). Some frequent cigarillo smokers explicitly stated that they would not smoke plain cigars at all given their preference for a variety of flavors and that flavors are an important reason for them to smoke cigars.

“No, I would not. I wouldn’t engage in smoking cigars anymore if they didn’t have that flavor. That’s what makes them good to me, especially the cigars that I smoke, the chocolate flavored ones, I really like the taste of them. (Female, 28 years, Cigarillos)

If they take the taste away, I don’t think I’d be interested in smoking them anymore. I feel like it does alter how you feel, and that feeling that it gives it is great.” (Female, 23 years, Cigarillos)

“Not really honestly because they’ve just bitter, and I am not the hugest fan of bitter-tasting things.” (Female, 21 years, Cigarillos)

“When I do smoke a cigar by itself, I do like it because it has the flavor. I wouldn’t smoke a regular, plain 1882. I would definitely want to have a flavored one to smoke by itself.” (Male, 28 years, Blunts)

“Probably not because it’s mostly about the flavor. Unless I’m just going to roll a cigarette, just taste the tobacco. No, probably not.” (Female, 29 years, Blunts)

Some said that they would not completely stop smoking but would smoke fewer cigars or slowly cut down cigars given the flavor sales restriction because they enjoyed cigar flavors.

“I would cut them down, because Black & Mild I particularly enjoy for the flavor.” (Female, 23 years, Cigarillos)

“I would probably smoke it less because, again, the flavor is what makes it more enjoyable.” (Female, 25 years, Cigarillos)

“Not really honestly, because they’re just bitter and I’m not the hugest fan of bitter-tasting things.” (Female, 27 years, Blunts)

A few frequent large cigar smokers mentioned that they would cut down on cigar smoking given the flavor sales restriction because it took a long time to smoke an entire large cigar and it would be too “boring” to smoke them without any flavors.

“Because cigars, they take so long to smoke. They’re so big. It takes a minute to finish them. I couldn’t imagine sitting there smoking a cigar for an hour and it doesn’t have a taste or any flavor. I don’t think I would engage in it anymore. (Male, 28 years, Large cigars)

Additionally, some of those who were not currently smoking blunts shared that they would probably transition to smoking cannabis if flavors were no longer available for cigar products. A few who were frequent blunt smokers reported that they would find other ways (e.g., bongs or papers) to smoke cannabis. A few participants who were also current cigarette smokers reported that they would smoke cigarettes more frequently if cigar flavors were no longer accessible. A few participants who smoked both cigarillos as-is and as blunts reported that they may smoke more blunts given the flavor restrictions as the only way they would smoke plain cigarillos is when smoking them as blunts.

“I probably would put marijuana in them to put it as a blunt just to make it taste and feel a little bit better.” (Female, 25 years, Cigarillos)

“Then the cigarillos, or whatever, if they did the same thing for cigarillos, I probably would stop smoking cigarillos and then maybe purchase something else to smoke marijuana out of papers, or even a bong, or something like that.” (Female, 28 years, Blunts)

“I’ll probably use my cigarettes a little more. I would try other cigarillo flavors and see if I would potentially get into those the way I’m into the ones I like now.” (Male, 28 years, Cigarillos)

Undecided or uncertain of what to do

A few participants reported that they were unsure what they would do given a flavored cigar sales restriction. Those participants mainly reported that they had not tried plain cigars before and were not sure what they tasted like or whether they would like them or not. They also mentioned that if they do not like plain cigars after their first trial, they would completely quit cigar products. A few participants also shared that whether they would quit cigar products or not depends on whether they would still be able to access flavored cigar products from other sources, such as going across the “border” to neighboring countries where flavored cigars are still available.

“I think with that, I would be willing to try the flavor that you mentioned and if I liked them then I would buy them. If I didn’t like them then I would quit.” (Female, 25 years, Cigarillos)

“I might cut down significantly, or I might just stop because I mainly do it for the flavor because it does taste pretty good. If it doesn’t taste good, I wouldn’t really…” (Male, 23 years, Large cigars)

“Maybe unless I travelled. If I booked a vacation or something, and the resort had them, sure. But if there was no immediate access for me to get them, I wouldn’t go out of my way to try to find them.” (Female, 25 years, Cigarillos)

DISCUSSION

Flavored cigar sales restrictions have been enacted in many local jurisdictions in the U.S. and were recently proposed by the FDA as a national policy (FDA, 2021). This study explored how Black young adult cigar smokers perceived this hypothetical policy and their potential behavior change in smoking various cigar products. We found that Black young adult cigar smokers’ responses to a ban varied by the cigar product type they predominately smoked, their subjective outcome expectancies of smoking cigars (e.g., relieving stress, consuming cannabis), their preferences towards flavored vs. plain cigars, and their perceived addiction to smoking cigar products. The results from this study provide important information about the potential impact of a ban on cigars with characterizing flavors among a high priority population (young adult Black smokers), and point to cigar smoker characteristics that may influence the outcomes of such policies.

Our results reflect that about a third of Black young adult cigar smokers participating in our study would potentially quit or reduce cigar smoking given the flavored cigar sales restriction. This result may be encouraging for the FDA and other public health agencies to move forward with restricting flavored cigar products. Importantly, the study results showed that frequent cigarillo smokers might be most likely to be influenced by flavored cigar restrictions, given that this group highly prefers cigarillo flavors. This finding is significant given that cigarillos are the most popular type of cigar smoked in the U.S. (Chen-Sankey et al., 2021). Close to half (42%−46%) of cigarillo products sold in the U.S. convenience stores and all-outlets-combined are flavored, a proportion much higher than other types of cigar products and non-e-cigarette products (Kuiper et al., 2018). Additionally, research has shown that flavors in cigarillos are one of the most important reasons for young adults in general, and especially Black young adults, to initiate and regularly smoke cigarillo products (Kong et al., 2018; Nyman et al., 2018). Other studies with young adults have found that flavored cigarillo products are reported as more enjoyable and lower risk than unflavored cigarillo products (Kong et al., 2018; Nyman et al., 2018). Taken together, policymakers and public health practitioners may need to consider strategies to reduce and restrict the availability of flavored cigarillo products.

The study results also indicated that cigar flavor sales restrictions might have a limited impact on cigar reduction and cessation among those who frequently used cigars for consuming cannabis (e.g., smoking blunts), a group which represented over half of Black young adult cigar smokers in the current study and in a nationally representative sample of Black cigar smokers (Chen-Sankey et al., 2021). This finding warrants attention because blunt smoking can be addictive and harmful due to the presence of both cannabis and tobacco (Kong et al., 2018), and consuming both products can increase the risk of both cannabis and nicotine dependency (Timberlake, 2009) as well as physical and mental health risks from smoking tobacco (Peters et al., 2012). Therefore, other interventions and policies are needed to address cannabis use among Black young adult cigar smokers.

Our study also showed that potential behavior change outcomes from flavored cigar sales restrictions might largely depend on other individual factors such as smoking outcome expectancies (i.e., stress and anxiety relief), preferences for cigar flavors, and their perceived addiction to smoking cigar products. Specifically, those who reported more stress and anxiety relief outcome expectancies from cigar smoking, higher preference for cigar flavors, and heavier addiction to cigar products, may be less likely to reduce or quit cigar smoking given a flavored cigar sales restriction. Those particular subgroups, according to previous research, are also more likely to have used tobacco products for a longer period of time and less likely to reduce or eventually quit using tobacco (Ajith et al., 2021; Delnevo et al., 2015; Hinds et al., 2018). More evidence is needed to inform accompanying strategies to reduce cigar smoking among those particular groups, such as developing evidence-based, cigar-specific smoking cessation interventions (Ajith et al., 2021). These within-person factors could also be used to develop large-scale quantitative surveys to predict and evaluate the impact of flavored cigar sales restrictions on a population level.

Additionally, our results showed that restricting cigar flavors might inadvertently promote consumers’ perceptions that cigar products have become less harmful and “healthier” in general as cigar flavorings are considered harmful chemicals by some. The cigar industry’s use of “organic” and “natural” descriptions in their marketing practices on cigar products could intensify these misconceptions (Allem et al., 2017; Smiley et al., 2020). The literature examining “organic” and “natural” descriptors on cigarette products has found that these claims reduced young people’s harm and risk perceptions towards cigarettes (Byron et al., 2016; Pearson et al., 2019). Therefore, more research is needed to investigate the impact of cigar product descriptors, especially when appearing on packages of tobacco-flavored or plain cigar products, on consumers’ harm and risk perceptions towards cigar products.

The results from our study also revealed that flavored cigar sales restrictions might lead to other unintended consequences. For example, some participants, especially dual users of cigar and cigarette products, indicated that they would substitute cigar smoking with cigarette smoking if cigar flavors were no longer available. Policymakers and researchers need to take into account cigar smokers’ potential substitution with other types of tobacco products when evaluating the population health impact of flavored cigar sales restrictions. Additionally, some cigar users may find ways to adulterate with homemade flavoring agents for smoking cigar products. We suspect that the adoption of this practice might increase after the implementation of a cigar flavor sales restriction. Furthermore, according to our results, cannabis or blunt consumption might increase given the cigar flavor ban because they are used to offset the plain taste of tobacco-flavored cigars. Previous research has already shown that Black young adult tobacco users, in particular, might be more likely to transition to or concurrently use cannabis compared to their White counterparts (Chen-Sankey et al., 2020). Consequently, research is greatly needed to understand cross-product transition between cigar and cannabis as a potential unintended consequence of flavored cigar sales restrictions.

The intended and unintended policy consequences revealed in the study may inform policymakers regarding the strategies for implementing flavored cigar sales restriction policies at the local and national levels. First, policymakers may need to consider the population health impact of tobacco and cannabis use substitution and behavior transition after implementing the flavored cigar sales restrictions. In particular, the sales restrictions, especially those implemented in the localities that have decriminalized cannabis use, may need to accompany cannabis use prevention messages and programs to reduce the potential transition of flavored cigar smoking to cannabis initiation and escalated use. Local and national flavored cigar sales restrictions may be especially effective in reducing tobacco-related harm if the sale of all flavored tobacco products (including menthol cigarettes) is restricted to minimize consumers’ potential transition to using other flavored tobacco products. Similarly, new and effective cigar-smoking cessation messages and programs are greatly needed to support consumers’ potential trials in quitting and cutting down cigar smoking after flavors are restricted. Messages are also needed for reducing consumers’ potential adulteration of cigar products with homemade flavoring agents to avoid accidental harm and risks from using altered cigar products.

Limitations

This study has several limitations. First, the data were collected during the beginning of the COVID-19 pandemic when many participants experienced excessive stress and increased cigar smoking to relieve mental health and psychological burdens (Chen-Sankey, Broun, et al., 2020). Therefore, participants might be less likely to report reduced cigar smoking change given flavor sales restrictions when compared to the pre-COVID period. Second, this study investigated participants’ perceived behavior change given a hypothetical policy situation; thus, their actual behavior change might be different and influenced by other factors such as the level of policy enforcement and compliance and commercialized strategies to circumvent flavor ban policies. Third, participants were mainly recruited from the Washington D.C. metropolitan area, where the sale of flavored cigars was not restricted and recreational cannabis had been decriminalized (Segraves, 2021) at the time of data collection. Interview results might be different if participants resided in an area with existing flavored cigar sales restrictions or different cannabis-use-related policies. Lastly, this study did not further ask questions regarding the details of behavior change related to smoking or accessing cigars (e.g., whether and how to quit or cut down cigar smoking; how to transition to smoking plain cigars) given the flavored cigar sales restriction. Future research is recommended to investigate nuanced cigar smoking behavior change processes to gain further understanding on the policy impact.

CONCLUSION

Due to the disproportionately higher cigar smoking prevalence among Black (vs. White) populations in the U.S., strategies to reduce cigar smoking are needed to help alleviate health disparity outcomes associated with cigar smoking. This study found that restricting the sale of flavored cigar products may be one promising strategy to reduce cigar smoking among a portion of Black young adult cigar smokers. Future studies aimed at investigating the population health impact of flavored cigar sales restrictions in the U.S. may need to especially consider their differential impact on smoking various cigar product types as well as consumers’ cigar smoking outcome expectancies, preference for flavors, and perceived addiction to cigar products. Evaluating the impact of cigar control-related public health policies among the Black population may be particularly informative in assessing their influence on reducing cigar-related health disparities.