Small cigar smoking is a largely understudied, but emerging public health concern. Our sample of racially diverse young adult college students reported a 30-day small cigar smoking prevalence of 12.1%. Small cigar smokers in our sample were mostly nondaily users, with little cigar smokers reporting use on average 4 days per month and cigarillo smokers reporting use on average 3 days per month. Our study confirmed that college students from racial minority groups and those who are concomitant users of other tobacco products, marijuana, and alcohol, are more likely to smoke small cigars.
Our findings, and that of others,11,13,14,27,28
suggest that there is a racial disparity in small cigar smoking for black college student smokers and those from other racial minority groups. Though racial differences in small cigar smoking have been noted previously,11–13,27,28
these differences were not documented at the very high disparity as found in our sample. As hypothesized, an association between small cigar and menthol cigarette smoking was also found in our study. Though additional studies are needed to explore these findings, perhaps they can be explained by exposure to targeted marketing of both products.27,29,30
Exposure to pro-tobacco messages has been associated with cigarette smoking36,37
and may partially explain the high prevalence of small cigar use in blacks and other racial minorities. Further, small cigars come in a variety of flavors (eg, apple, strawberry, grape). Although the FDA has banned the use of characterizing flavors (other than menthol) in cigarettes, they are still permitted in other tobacco products, including small cigars. The association between smoking mentholated cigarettes and small cigars might reflect a preference among some college student smokers for flavored combustible tobacco products.
Concomitant use of other tobacco products (eg, cigarettes, smokeless tobacco, and hookah) and substances (eg, alcohol and marijuana) was associated with small cigar smoking in our sample. Concurrent use of tobacco products and other substances may increase the risk for developing nicotine dependence, increase the exposure to carcinogens and other toxins, and make tobacco use cessation more difficult for young adult college students.31
Individual-, group-, and institutional-level interventions are available on some college and university campuses to interaction assist smokers between with quitting cigarette smoking.35
Our study highlights the importance of addressing other forms of tobacco use, including small cigar use, in college-based smoking cessation programs. Respondents in our sample and those in other studies perceive small cigar smoking is a less-harmful behavior compared to cigarette smoking.13,14,27,28
Tobacco cessation counseling for college students should also debunk this myth and inform students of the health risks associated with small cigar smoking. Small cigar smoking in our sample was associated with higher levels of perceived stress and greater sensation seeking behaviors. Similarly for cigarette smoking, health care providers should discuss coping mechanisms for handling stress when counseling students about small cigar use. A commonly used strategy in smoking cessation counseling is that of gradually reducing the amount of cigarettes smoked. Though not reported in this study, reports from qualitative studies suggest that some young adult smokers use small cigars as a way to reduce their cigarette smoking.13,14
Health care providers administering smoking cessation programs in college health clinics must also discuss the importance of not
replacing cigarette smoking with small cigar smoking as a strategy to quit. In addition to communicating the harm associated with small cigar use, institutional-level antismoking messages that address the attitudes about and norms toward small cigar smoking are warranted for college students.
Alcohol and marijuana use were associated with small cigar smoking among our sample. About half of small cigar users also reported marijuana use in the past 30 days. Prior studies have found that some young adult smokers may not use small cigars as intended, but will remove the tobacco from small cigars and replace it with marijuana,13,28
in a process called “blunting” a small cigar. Other studies have reported participants smoking marijuana in conjunction with small cigars to height the effects of the marijuana.14
Taken together, our findings suggest that health care providers in college health clinics should discuss the concomitant use of alcohol and marijuana when counseling students about small cigar smoking.
Our study had limitations with regard to measurement, generalizability, and survey response rate. Though brand-specific items may estimate small cigar use more accurately,32
use of these items limits comparability to studies that used other measures to capture small cigar use (ie, single catchall question assessing cigar product use). Though national-based estimates of small cigar use are emerging (ie, Monitoring the Future), more specific measures of use of all cigars are needed. In terms of generalizability, the survey sample was largely female and drawn from southeastern US colleges and, thus, may not generalize to other college populations from other regions of the country or young adults in general, particularly those not attending college. However, the sample characteristics are similar to the demographics of the participants’ school populations, although there was a larger proportion of females who responded. It is also uncertain what other factors not measured differed between respondents and nonrespondents and between those randomly selected to participate versus those not selected. Nonetheless, a significant strength was the strong representation of white and black college students. Finally, the survey response rate was 20.1%. Previous online research has yielded similar response rates (29–32%) among the general population33
and a wide range of response rates (17–52%) among college students. Moreover, many participants likely did not open the invitation e-mail or had inactive accounts, and their removal from the “denominator” would increase our response rate. Prior work has demonstrated that, despite lower response rates, Internet surveys yield similar statistics regarding health behaviors compared to mail and phone surveys.34
Tobacco control efforts among young adults have typically focused on cigarette use. Findings from this study suggest that small cigar use is prevalent among young adult college students and highlight correlates of use. Our results, along with evidence from a growing number of studies, suggest that existing tobacco control efforts need to consider small cigar use among young adult college students.