In 1998, the National Cancer Institute undertook a review of available knowledge about cigars. A new National Academies consensus study report provides a comprehensive update to the 1998 report. It examines premium cigar characteristics, health effects, and marketing and perceptions, and makes prioritized recommendations for future federally funded research on premium cigars.

Steven Teutsch, the chair of the committee that wrote the report and adjunct professor at the Fielding School of Public Health, University of California, Los Angeles, shared some of the report’s key findings and research recommendations to move the field forward. 

Q: Why did the U.S. Food and Drug Administration (FDA) and National Institutes of Health (NIH) ask for this report?
Teutsch: In 2016, FDA’s authority was extended to regulate all products meeting the definition of a tobacco product, including cigars. For several years, the agency has been considering how best to fulfill that responsibility. Since there has been no systematic assessment of cigars since a 1998 NIH report, FDA and NIH commissioned the National Academies’ report to assess the current state of knowledge of the health effects and patterns of use of premium cigars — meaning, how they are used, and by whom. The aim of this report is to provide FDA with the best available scientific information and to identify priorities for federally funded research on premium cigars.

Q: Does the report provide regulatory recommendations?
Teutsch: The committee does not make regulatory recommendations, and it was not charged with doing so. The committee was charged with reviewing the literature and providing an assessment of current knowledge about the health effects and patterns of use of premium cigars and to make research recommendations.

Q: How widely used are premium cigars?
Teutsch: Currently, about 1 percent of the U.S. adult population smoke premium cigars, and this percentage has remained stable over time.

Q: What are the health risks of premium cigars compared to other cigar products and cigarettes?
Teutsch: Because of their ingredients, premium cigars are intrinsically as harmful as cigars and cigarettes. The actual health effects, though, are a combination of their intrinsic characteristics and how they are used (duration, frequency, depth of inhalation). Since only a small proportion of the population smokes premium cigars — and of those who do, most smoke only a small number each month — the aggregate health effects in the population are modest.

Q: The committee provided a definition of premium cigars in the report. What is the purpose of that definition, and how should others use it?
Teutsch: The committee provided this definition to inform its literature review. Since there is no single agreed-upon definition, the committee reviewed definitions used in legal proceedings, tax policy, and definitions used by others and then developed an operational definition.

While other stakeholders may consider the committee’s definition for other purposes, additional factors that the committee did not emphasize would need to be considered. For example, the tobacco industry has altered its products so that they no longer fit existing regulatory definitions (or [they] now meet the definition of a different tobacco product), and this factor was not a major consideration for the committee.

Q: What are the features of premium cigars that differentiate them from other cigar types?
Teutsch: While there is no single characteristic that differentiates premium from other cigars, the committee identified a set of characteristics to guide its work. These characteristics are similar to those that have been used for research, administrative, taxation, and legal purposes. By the committee’s definition, a premium cigar would meet all six criteria:

• Handmade

• Filler composed of at least 50 percent natural long-leaf filler tobacco

• Wrapped in whole leaf tobacco (i.e., not reconstituted tobacco)

• Weight of at least 6 pounds per 1,000 units (i.e., 2.72 grams per stick)

• No filters or tips

• No characterizing flavor other than tobacco

The committee noted that most premium cigars on the market today far exceed the weight criterion noted above.

Q: How did the committee reach its conclusions, given the lack of studies on premium cigars specifically?
Teutsch: Just because there is a lack of studies, that does not mean one cannot assess the health effects of premium cigars. We know a great deal about the patterns of use of premium cigars. To reach its conclusions, the committee reviewed the toxic and carcinogenic constituents of premium cigar smoke and determined these were substantially identical to those of cigar and cigarette smoke. There is also an extensive body of literature on the health effects of tobacco smoke. The committee was therefore able to assess the health effects of premium cigars based on the biologic plausibility of the known health effects of tobacco smoke and the pattern of use of premium cigars.

Q: What does the report say about the effects of flavors on premium cigar use? Is there evidence that the use of flavoring could lead to addiction, or make them more appealing to younger audiences? 
Teutsch: Cigars with flavorings would not meet the committee’s definition of premium. Based largely on studies of flavorings in other tobacco products, the committee found the addition of flavorings to premium cigars could result in greater appeal to nonusers and lead to more frequent use with potentially increased nicotine intake, addiction potential, and exposure to harmful and potentially harmful constituents present in premium cigar smoke. 

Q: What are the priority research gaps that must be addressed so we can more fully understand the health effects of premium cigars?
Teutsch: The report presents a number of research gaps. The highest priority are: 

• The need for FDA to develop formal categories and definitions for all cigars, for research purposes.

• The need for the U.S. Department of Health and Human Services (HHS) to implement a strategic plan to develop surveillance and evaluation systems that regularly monitor patterns of use, product characteristics, and related knowledge and perceptions by cigar type.

• The need for HHS to ensure the tobacco research it supports measures frequency of cigar use (ever use, ever regular use, and past 12-month use) to better understand lifetime use of each type of cigar product. HHS should also ask participants about brands they have used.