The U.S. Secretary of Health and Human Services (HHS), U.S. Surgeon General, and Commissioner of the Food and Drug Administration (FDA) have all declared youth e-cigarette use to be an epidemic. E-cigarettes are the most used tobacco product among youth and, like any tobacco product, are unsafe. E-cigarette use is also most common among younger adults. Action is urgently needed to reverse these dangerous trends.
Excluding Cigars from Tobacco Control Laws Puts Everyone At Risk
Cigars pose a real danger to the long-term health of all Americans – and to young people especially – yet government regulation of cigars lags behind that of cigarettes and e-cigarettes. In January 2020, the FDA prohibited the sale of most flavors in cartridge-based e-cigarettes.1 Flavored cigarettes, except for menthol, have been largely illegal since 2009. However, similar regulations do not exist for flavored cigars, something that has helped the cigar industry stay attractive to younger customers. Similarly, cigars are not always taxed at the same rate as cigarettes. Excluding cigars from evidence-based tobacco control measures provides opportunity for the tobacco industry to take advantage of and aggressively market their deadly products to youth. In addition, some groups, such as Black middle and high school students, experience a disproportionate impact, exacerbating existing health disparities.2
An estimated 770,000 U.S. high school students (5.0 percent) and 180,000 middle schoolers (1.5 percent) were current cigar users in 2020, making cigars the second most popular tobacco product among youth.3 In addition, 4.5 percent of U.S. adults reported current cigar use in 2019, including 7.7 percent of young adults between the ages of 18 and 25.4
DISPARITIES IN YOUTH USE
According to CDC data, Black high school and middle school students are more likely to use cigars than their peers. In 2020, 6.5 percent of surveyed Black middle and high school students reported using cigars in the past 30 days, compared to 3.5 percent among all students.5 Cigars are currently the most popular tobacco product among Black youth, outpacing both cigarettes and e-cigarettes. Male students are also more likely than female students to be current cigar users (3.7 percent vs 3.4 percent). Clearly, the issue of youth cigar use is also an issue of health equity.
Cigars, cigarillos, and little cigars are all sold in many flavors that are appealing to young people, such as banana, mango, chocolate, and grape. These flavored products are commonly sold by cigarette retailers, such as convenience stores, but, unlike cigarettes, are not required to be placed behind the countertop. 6,7 This practice may make flavored cigars and cigarillos more appealing and accessible to young people.
Flavored cigars are very popular among children and young adults. A 2015 study found that 74 percent of youth who used cigars reported flavoring as a primary reason for using them.8,9 In 2019, 41.9 percent of high school and middle school current cigar users reported using flavored cigars in the past 30 days.10
Importantly, flavored cigars can also serve as a gateway for new tobacco users. A 2019 longitudinal study found that, among youth aged 12-17 who began using cigars during the study period, 45.2 percent reported that their first product was flavored.11 This same study found that young adults aged 18-24 who start with flavored cigars are more likely to become regular users compared to those who start with unflavored cigars.
Regular cigar smoking increases the risk of cancers of the lung, oral cavity, larynx, and esophagus.12 In fact, cigar smokers are four to ten times more likely to die from laryngeal, oral or esophageal cancers than non-smokers.13 Heavy cigar smoking also increases the risk of developing lung diseases, such as emphysema and chronic bronchitis.14 Cigars also produce secondhand smoke that is dangerous for non-smokers.
All tobacco products, including cigars, contain nicotine, which may induce dependence and harm health.15 And unfortunately, young people who use tobacco products are more likely to become addicted than adults.16
ACS CAN’S POSITION
Regulation of cigars is part of ACS CAN’s comprehensive approach to reducing tobacco use and exposure to secondhand smoke in the United States. Excluding cigars from comprehensive tobacco control laws provides the tobacco industry with an opening to target youth, who may be especially drawn to flavored products.. ACS CAN makes the following policy recommendations with respect to cigars:
- Prohibit flavored cigars: Congress or the FDA should prohibit the use of characterizing flavors, including menthol, in all tobacco products. Many states and localities are moving forward to end the sale of menthol cigarettes, cigars and all other flavored tobacco products and winning legal challenges to its laws. The Family Smoking Prevention and Tobacco Control Act does not permit a state or locality from requiring a product standard, such as the removal of a flavor, but the law does preserve the ability for states and localities to regulate the sales of tobacco products. States and localities should pursue policy options including ending the sale of all flavored tobacco products, including cigars and menthol cigarettes, while taking into consideration what is permitted in a specific jurisdiction.
- Tax cigars at the same rate as cigarettes: Like all other tobacco products, cigars should be subject to taxation as well as manufacturing and marketing rules to reduce the deadly and costly burden of tobacco use. All cigars, regardless of size, must be taxed at rates equivalent to cigarettes with no cap on tax rates.
- Include cigars in smoke-free laws: Secondhand smoke from cigars poses significant health risks to smokers and those around them and should be included as part of any smoke-free law. This includes prohibiting cigar use in cigar and tobacco shops, bars identified as “cigar bars,” gaming facilities and wherever else smoking is prohibited.
- Regulate cigars by the FDA: All types of cigars, regardless of their weight, should be regulated by the FDA and subject to the same requirements as cigarettes, smokeless tobacco and other tobacco products. In addition, FDA should use its enforcement authority against manufacturers selling cigarettes as little cigars.
1. FDA Finalizes enforcement policy on unauthorized flavored cartridge-based e-cigarettes that appeal to children, including fruit and mint. U.S. Food and Drug Administration. Published January 2, 2020. Accessed December 9, 2020. https://www.fda.gov/news-events/press-announcements/fda-finalizes-enforcement-policy-unauthorized-flavored-cartridge-based-e-cigarettes-appeal-children
2. Odani S, Armour BS, Agaku IT. Racial/Ethnic Disparities in Tobacco Product Use Among Middle and High School Students — United States, 2014–2017. MMWR Morb Mortal Wkly Rep. 2018;67(34):952-957. doi:10.15585/mmwr.mm6734a3
3. Gentzke AS, Wang TW, Jamal A, et al. Tobacco Product Use Among Middle and High School Students — United States, 2020. MMWR Morb Mortal Wkly Rep 2020;69:1881–1888. DOI: http://dx.doi.org/10.15585/mmwr.mm6950a1
4. 2019 NSDUH Detailed Tables. U.S. Substance Abuse and Mental Health Services Administration. Published September 11, 2020. Accessed December 9, 2020. https://www.samhsa.gov/data/report/2019-nsduh-detailed-tables
5. Gentzke AS, Wang TW, Jamal A, et al. Tobacco Product Use Among Middle and High School Students — United States, 2020. MMWR Morb Mortal Wkly Rep 2020;69:1881–1888. DOI: http://dx.doi.org/10.15585/mmwr.mm6950a1
6. Kong AY, Queen TL, Golden SD, Ribisl KM. Neighborhood Disparities in the Availability, Advertising, Promotion, and Youth Appeal of Little Cigars and Cigarillos, United States, 2015. Nicotine & Tobacco Research. Published online January 9, 2020. doi:10.1093/ntr/ntaa005
7. The Truth about Tobacco Industry Retail Practices. Truth Initiative; 2017. https://truthinitiative.org/sites/default/files/media/files/2019/03/Point-of-Sale-10-2017.pdf
8. Flavors. Truth Initiative; 2018. https://truthinitiative.org/sites/default/files/media/files/2019/03/Truth-Flavors-Fact-Sheet.pdf
9. Ambrose BK, Day HR, Rostron B, et al. Flavored Tobacco Product Use Among US Youth Aged 12-17 Years, 2013-2014. JAMA. 2015;314(17):1871. doi:10.1001/jama.2015.13802
10. Wang TW, Gentzke AS, Creamer MR, et al. Tobacco Product Use and Associated Factors Among Middle and High School Students — United States, 2019. MMWR Surveill Summ. 2019;68(12):1-22. doi:10.15585/mmwr.ss6812a1
11. Villanti AC, Johnson AL, Glasser AM, et al. Association of Flavored Tobacco Use With Tobacco Initiation and Subsequent Use Among US Youth and Adults, 2013-2015. JAMA Netw Open. 2019;2(10):e1913804. doi:10.1001/jamanetworkopen.2019.13804
12. Cancer Facts and Figures. American Cancer Society; 2017. https://www.cancer.org/research/cancer-facts-statistics/all-cancer-facts-figures/cancer-facts-figures-2017.html
13. Oral Cancer and Tobacco. Johns Hopkins Medicine. https://www.hopkinsmedicine.org/health/conditions-and-diseases/oral-cancer-and-tobacco#:~:text=Smokers%20are%20also%20at%20a,60%20known%20cancer%2Dcausing%20agents.
14. Cigars. Centers for Disease Control and Prevention. https://www.cdc.gov/tobacco/data_statistics/fact_sheets/tobacco_industry/cigars/index.htm
15. The Health Consequences of Smoking - 50 Years of Progress. U.S. Department of Health and Human Services; 2014. https://pubmed.ncbi.nlm.nih.gov/24455788/
16. A Report of the Surgeon General: Preventing Tobacco Use Among Youth and Young Adults. Centers for Disease Control and Prevention Office on Smoking and Health; 2012. https://www.cdc.gov/tobacco/data_statistics/sgr/2012/consumer_booklet/pdfs/consumer.pdf