Nicotine & Tobacco Research, Volume 12, Number 6 (June 2010) 669–673
Advance Access published on April 23, 2010
© The Author 2010. Published by Oxford University Press on behalf of the Society for Research on Nicotine and Tobacco.
All rights reserved. For permissions, please e-mail: firstname.lastname@example.org
declined (Connolly & Alpert, 2008; U.S. Department of Agricul-
ture, 2007). The sale of small cigars alone increased by 115%
between 2000 and 2007 (Connolly & Alpert). This is cause for con-
cern given the evidence that cigar smoking has been linked to
negative health effects (Baker et al., 2000; Shapiro, Jacobs, & Thun,
2000), including coronary heart disease, chronic obstructive pul-
monary disease (Iribarren, Tekawa, Sidney, & Friedman, 1999),
cancers of the lung, pharynx, esophagus, pancreas, and bladder,
especially among those who inhale the smoke (Shapiro et al.).
The U.S. Surgeon Generals and public health researchers
have sought to bring attention to cigar use as a serious risk to
public health (Baker et al., 2000; Satcher, 1999; Symm, Morgan,
Blackshear, & Tinsley, 2005), yet most state and national sur-
veillance surveys inconsistently collect cigar data and none reg-
ularly include small cigar or cigarillo-specific questions (Centers
for Disease Control and Prevention [CDC], 2007; Delnevo,
2006), limiting our understanding of the prevalence, profiles of
users, and patterns of use of these products (Terchek et al.,
2009). This study examines prevalence, demographic character-
istics of adult tobacco users, and patterns of multiple product
use for three categories of tobacco use: cigarette, cigar, and little
cigar (which includes cigarillos and small cigars).
The data were derived from 5 years (2003–2007) of the Cuya-
hoga County Behavioral Risk Factor Surveillance Survey (BRFSS),
a random digit–dialed telephone survey conducted by ORC
Macro, based on the survey and methods of the Ohio BRFSS
(CDC, 2006; Przepyszny, & Borawski, 2008). Cuyahoga County
is one of the largest counties in the state and includes the city
of Cleveland and 58 surrounding municipalities, villages, and
Introduction: Adult use of cigars, cigarillos, and little cigars has
increased over the past two decades; however, little is known
about the characteristics of the users.
Methods: The data were derived from 5 years (2003–2007) of
the Cuyahoga County Behavioral Risk Factor Surveillance Sur-
vey, a random digit–dialed telephone survey conducted by ICF
Macro International, based on the survey and methods of the
Results: Results indicate that the prevalence of current ciga-
rette smoking across the 5 years was 23.1%. Cigar use and little
cigar use were reported by 4.3% and 3.3% of respondents, re-
spectively. Compared with cigarette users, cigar and little cigar
users were far more likely to report multiple product use (12.8%
vs. 63.9% and 80.5%, respectively). Cigar and little cigar users
differed from cigarette smokers in demographic profile and pat-
terns of multiple product use.
Discussion: Black and lower income adults were significantly
more likely to report use of little cigars and use of multiple
products. These disparities potentially contribute to the dispro-
portionate rates of tobacco-related illnesses and underrepresen-
tation of low-income and minority populations in tobacco use
Over the past 10 years, annual cigar consumption in the United
States has incrementally increased as cigarette consumption has
Adult use of cigars, little cigars, and
cigarillos in Cuyahoga County, Ohio: A
Elaine A. Borawski, Ph.D.,1 Ashley Brooks, M.P.H.,2 Natalie Colabianchi, Ph.D.,3 Erika S. Trapl, Ph.D.,1
Kathryn A. Przepyszny, M.A.,4 Nichelle Shaw, M.P.H.,5 & Laura Danosky, M.P.H.1
1 Department of Epidemiology and Biostatistics, Prevention Research Center for Healthy Neighborhoods, School of Medicine, Case
Western Reserve University, Cleveland, OH
2 Department of Health Behavior and Health Education, Gillings School of Global Public Health, University of North Carolina at Chapel
Hill, Chapel Hill, NC
3 Department of Epidemiology and Biostatistics, Arnold School of Public Health, University of South Carolina, Columbia, SC
4 Center for Clinical Investigation, School of Medicine, Case Western Reserve University, Cleveland, OH
5 Division of Community Health, Cuyahoga County Board of Health, Cuyahoga County, Ohio.
Corresponding Author: Elaine A. Borawski, Ph.D., Department of Epidemiology and Biostatistics, Prevention Research Center for
Healthy Neighborhoods, School of Medicine, Case Western Reserve University, 11430 Euclid Avenue, Cleveland, OH 44106, USA.
Telephone: 216-368-5913; Fax: 216-368-2610; E-mail: email@example.com
Received November 9, 2009; accepted March 17, 2010
by guest on January 11, 2011
Adult use of cigars, little cigars, and cigarillos
townships. In addition to identifying current cigarette users,
defined as having smoked at least 100 cigarettes in their lifetime
and smoking every day or some days, the survey also profiled
current cigar users and little cigar users. Individuals who
responded “every day” or “some days” to the following item
were categorized as cigar users, “Do you now smoke cigars every
day, some days, or not at all? Please do not include little cigars,
such as Black & Milds, when considering your answer to this ques-
tion.” Similarly, individuals who responded “every day” or “some
days” to the following item were categorized as little cigar users,
“Do you now smoke little cigars, such as Black & Milds, every day,
some days, or not at all?” These categories are not mutually exclu-
sive, such that a cigarette user could also be a cigar user and/or a
little cigar user; however, respondents were specifically asked to
exclude the other products in their reporting of each type.
The survey was completed by a total of 6,539 adults, aged
18 years and older, and weighted to reflect the population of adults
living in Cuyahoga County, Ohio, according to BRFSS methodol-
ogy that includes both sampling probability and poststratification
weighting (CDC, 2007). Cuyahoga County involves only one pop-
ulation sampling unit. The data were combined across years to
maximize the sample size of cigar and little cigar smokers. Signifi-
cant differences were determined based on nonoverlapping 95%
CIs surrounding the prevalence rates. SAS 9.2 survey procedures
were used to obtain weighed estimates and to account for differ-
ences in variance estimation resulting from the complex sampling
design. This study was approved by the Institutional Review Board
at Case Western Reserve University, Cleveland, Ohio.
Average prevalence of current cigarette smoking across the
5 years was estimated at 23.1%, higher than comparable state or
national estimates for the same time period, however, similar to
other Midwestern urban areas (CDC, 2010). As shown in Table 1,
cigar use and little cigar use were reported by 4.3% and 3.3% of
respondents, respectively. Compared with cigarette users, cigar
and little cigar users were far more likely to report multiple prod-
uct use (12.8% vs. 63.9% and 80.5%, respectively).
Multivariate examination of each type of product user and
multiple product use revealed different demographic profiles, as
shown in Table 2. As expected, when compared with older
adults (55 years and older), younger adults were more likely to
report use of all three tobacco products; however, the most
striking difference was among little cigars users, where adults
under age 35 years were nearly three times more likely to be little
cigar users than those 35–54 years (OR = 8.76 vs. 3.21) and nine
times more likely than those aged 55 years or older (reference
group). Age was not a predictor of multiple product use. While
men were more likely to use all three tobacco products than
women, they were significantly and substantially more likely to
be cigar (OR = 9.27), little cigar (OR = 4.00), or multiple product
users (OR = 4.77) than cigarette smokers. After controlling for
other socioeconomic status (SES) measures (education and
income), racial background of the respondent was predictive of
both little cigar and multiple product use but not cigarette or
cigar use. Compared with White adults, Black adults were nearly
two times more likely to be a little cigar (OR = 1.94) or multiple
product (OR = 1.98) user. Adults from racial backgrounds cat-
egorized as other (predominantly Asian/Pacific Islander, Native
American, and unidentified race in this sample) were signifi-
cantly less likely to be a little cigar user (OR = 0.12) compared
with White adults. Non–college-degreed adults were signifi-
cantly more likely to be both cigarette and little cigar users than
adults with college degrees. Lastly, adults in the lowest house-
hold income categories (<$25,000/years) were significantly
more likely to use any of the three tobacco products and to be a
multiple product user than those at the highest income category
(>$75,000/year). Little cigar users, in particular, were more
likely to be among the most economically challenged. For example,
adults making less than $25,000 were over four times more like-
ly (OR = 4.43) to be a little cigar user and nearly three times
more likely (OR = 2.80) to be a multiple product user than those
at the highest levels of income.
Little cigar users who also smoked cigarettes (i.e., multiple
product users) smoked cigarettes on a comparable number of
days per month (24.1 days, SD = 10.0) and smoked a similar
number of cigarettes per day (11.61 cigarettes, SD = 10.3) as
compared with cigarette-only users (26.0 days, SD = 8.2 and
13.3 cigarettes, SD = 9.6, per day; data not shown). This is in
addition to the average of 1.9 little cigars smoked per day on an
average of 11 days per month that these multiple products users
also consume (data not shown).
In spite of the documented increase in other tobacco products
(e.g., cigars, little cigars, smokeless, roll-your-own) over the past
decade (Connolly & Alpert, 2008), current national surveillance
systems (e.g., Behavioral Risk Factor Surveillance System) do
not regularly assess the prevalence and patterns of tobacco
products other than cigarettes. As a result, we lack the ability to
track the use of these products, particularly cigars and little
cigars, as well as the profiles of users and patterns of use. Our
findings from a large urban population suggest that while the
overall prevalence may be lower, cigar and little cigar users have
Table 1. Prevalence of cigarette, cigar, and
little cigar usea and multiple product use
Multiple product use
Also smokes cigarettes
Also smokes cigars
Also smokes little cigars
Smoke both other products
Uses no other product
Note. Prevalence is mean prevalence across years of data (2003–2007);
results are weighted to reflect sampling and selection probability as well
as poststratification based on county population (n = 997,429–
1,017,345) depending upon the year.
aCurrent cigarette, cigar, and little cigar use is measured as reports
of smoking each tobacco product “every day” or “some days.” Each
product category is not mutually exclusive.
by guest on January 11, 2011
Nicotine & Tobacco Research, Volume 12, Number 6 (June 2010)
significantly different demographic profiles and engage in dif-
ferent patterns of multiple product use when compared with
cigarette users. Over half of cigar and little cigar users are also
concurrent cigarette users, potentially increasing their exposure
to tobacco and thereby increasing their risk for tobacco-related
illnesses. Moreover, it appears that cigars, and particularly little
cigars, are not alternatives to cigarettes for these users but rather
tobacco products that are used in addition to regular cigarette
use. This is especially concerning given the evidence that mul-
tiple product users are more likely to inhale cigar smoke than
cigar-only smokers (Shanks & Burns, 1998) and that inhalation
of cigar smoke has been linked to cancer (Shapiro et al., 2000).
While multiple product use is important, we also note that
approximately 20% of cigar and little cigar users are not concur-
rently using cigarettes. Since cigar smoking is inconsistently
assessed and little cigar smoking is not regularly assessed in any
U.S. state or national surveillance system, the exclusive use of cigars
and/or little cigars is being overlooked in tobacco use surveillance.
Our findings indicate that Black and low-income adults are
more likely to use other tobacco products, such as little cigars,
and to be multiple product users, potentially contributing to the
disproportionate rates of tobacco-related illnesses, particularly
lung cancer (Haiman et al., 2006; Schwartz & Swanson, 1997),
observed among racial and ethnic minorities and lower SES in-
dividuals (Delva et al., 2005; Fagan et al., 2004). Researchers
have identified several reasons why cigar consumption may
have increase among some segments of the population, includ-
ing price and tax incentives in the United States. (Connolly &
Alpert, 2008; Delnevo & Hrywna, 2007). State and federal taxes
on small cigars are less than a 10th of taxes applied to cigarettes,
resulting in much cheaper products (Connolly & Alpert). While
cigarettes must be sold in packs of 20, little cigars are sold in
smaller packs of 5 and are often sold as singles for pocket change
(Jolly, 2008). Marketing of tobacco products, particularly little
cigars, has been specifically targeted to low-income and minor-
ity populations (Moore, Williams, & Qualls, 1996). A number
of recent studies with adolescents have documented the grow-
ing preference of little cigars over cigarettes, particularly among
minority youth (Brooks et al., 2008; Jolly, 2008). Moreover,
these studies have found that youth, and particularly, Black
youth may perceive cigars more favorably than cigarettes and
consider cigars more natural, less harmful, cheaper, and better
smelling than cigarettes (Jolly, 2008; Malone, Yerger, & Pearson,
2001; Richter, Pederson, & O’Hegarty, 2006; Soldz & Dorsey,
2005; Symm et al., 2005; Terchek et al., 2009).
There are limitations to our study. We included cigarillos
(e.g., “Black & Milds”) in our classification of little cigars, which
is different from U.S. federal classification of these products.
According to federal regulations, cigars are classified in two cat-
egories: large cigars, weighing more than 3 pounds per thou-
sand and small cigars, those weighing not more than 3 pounds
per thousand and often packaged in a manner like cigarettes
(e.g., “Winchester Little Cigars”). We would argue that the fed-
eral classification of large cigars is overly broad, counting large
Table 2. Demographic characteristics of cigarette, cigar, little cigar, and multiple product
users: weighted multivariate resultsa
Little cigar useb
Multiple product usec
HS or less
Note. HR = high school; OR = odds ratio; bolded text identifies ORs that are statistically different (at least p < .05) from reference group.
aResults are weighted to reflect sampling and selection probability as well as poststratification based on county population (n = 997,429–
1,017,345) depending upon the year. Nonweighted samples were: 1412 (cigarette smokers), 219 (cigars), 139 (little cigars), and 177 (multiple
product users). For each analyses, multiple usage is not removed, that is, cigar users may also be little cigar or cigarette users and thus may be
included in more than one category.
bUser versus nonsmoker (n = 4,924): other product users excluded from each analyses. OR (95% CI).
cUses more than one product (cigarette, cigar, or little cigar) versus single product user OR (95% CI).
dReference group = 55 years and older.
eReference group = Caucasian adults.
fReference group = College graduate or higher.
gReference group = $75,000 or more.
by guest on January 11, 2011
Adult use of cigars, little cigars, and cigarillos
premium cigars with inexpensive manufactured cigarillos, ex-
emplified by brands, such as Black & Mild. Evidence suggests
that the increasing sales rate of cigarillos and small cigars are
more similar to each other than either category is to the sales
rate of large cigars (Kozlowski, Dollar, & Giovino, 2008). Thus,
we would argue that the federal classification is not a useful tool
in public health surveillance of tobacco use because it is unlikely
that survey respondents are aware of the U.S. federal classifica-
tion of cigars based on weight or use of the phrase “small cigar”
to refer to a specific agriculture product. Thus, our survey item
uses the phrase “little cigar” not as a legal definition but as a
description of the cigar, which includes both small cigars and
cigarillos. We attempted to further clarify our intent to the sur-
vey respondent by including the brand name (Black & Mild),
which is one of the most popular cigarillo brands.
There are other limitations to our study that are important
to note. First, we did not examine the prevalence and patterns
of the use of “blunts,” a term which commonly describes a
cigar containing some combination of tobacco and marijuana.
We excluded blunts to focus the attention on tobacco products
without the complexity of other substance use. Second, we did
not analyze the use of pipes or smokeless tobacco due to the
low prevalence of these products in the geographic region in-
cluded in this study. Third, as discussed above, it is difficult to
be certain if the respondents correctly classified their tobacco
use as either cigarette, little cigar, or cigar use. Little cigars are
frequently packaged similar to cigarettes, and some respon-
dents may not realize the differences. Similarly, there are varia-
tions in the size and packaging of cigarillos making it difficult
for some survey respondents to distinguish the various tobacco
products, although we did give popular specific examples (e.g.,
Black & Milds) in the question stem to assist respondents in
their classification. Fourth, as is the case with the BRFSS in gen-
eral, this survey relies on self-reported information, which may
lead to underreporting of socially unacceptable behaviors. Sim-
ilarly, because the survey is administered by telephone, there
may be a lack of representation of households without a tele-
phone. Finally, the individuals included in this survey were
sampled to be representative of the Greater Cleveland area, and
the findings may not generalize to other metropolitan areas or
This study found that low-income and minority adults were
disproportionately likely to use little cigars and multiple tobacco
products. These results add to the growing number of recent
studies highlighting the importance of including alternative
tobacco products, particularly little cigars, in national surveil-
lance and tobacco prevention and cessation policies. Surveil-
lance measures that group the use of all alternative tobacco
products together, or exclude items assessing cigar and little
cigars, may underestimate tobacco use prevalence among
minority and low-income populations and obscure disparities
in tobacco-related deaths.
This work was supported by the Ohio Tobacco Prevention
Foundation, Ohio Department of Health, and the Cuyahoga
County Board of Health through the Tobacco Master Settle-
Declaration of Interests
The authors wish to thank the Cuyahoga County Board of
Health and the Ohio Tobacco Prevention Foundation (no lon-
ger in existence) for their support for this project. We also thank
the concerned stakeholders in our community who were persis-
tent in their belief that our tobacco surveillance was overlooking
an important tobacco use indicator.
Baker, F., Ainsworth, S. R., Dye, J. T., Crammer, C., Thun, M. J.,
Hoffman, D., et al. (2000). Health risks associated with cigar smok-
ing. Journal of the American Medical Association, 284, 735–740.
Brooks, A., Larkin, E. M., Kishore, S., & Frank, S. H. (2008).
Cigars, Cigarettes, and Adolescents. American Journal of Health
Behavior, 32, 640–649.
Centers for Disease Control and Prevention. (2006). Behavioral risk
factor surveillance system: Operational and Users Guide, Version 3.
Retrieved 3 March 2010, from ftp://ftp.cdc.gov/pub/Data/Brfss
Centers for Disease Control and Prevention. (2007). Behavioral
risk factor surveillance system survey data. Atlanta, GA: U.S.
Department of Health and Human Services, Centers for Disease
Control and Prevention.
Centers for Disease Control and Prevention. (2010). SMART:
BRFSS City and County Data Selected Metropolitan/Micropolitan
Area Risk Trends. Retrieved 3 March 2010, from http://apps
Connolly, G. N., & Alpert, H. R. (2008). Trends in the use of
cigarettes and other tobacco products, 2000–2007. Journal of the
American Medical Association, 299, 2629–2630.
Delnevo, C. D. (2006). Smokers’ choice: What explains the steady
growth of cigar use in the US? Public Health Reports, 121, 116–119.
Delnevo, C. D., & Hrywna, M. (2007). “A whole ’nother smoke”
or a cigarette in disguise: How RJ Reynolds reframed the image
of little cigars. American Journal of Public Health, 97, 1368–1375.
Delva, J., Tellez, M., Finlayson, T. L., Gretebeck, K. A., Siefert, K.,
Williams, D. R., et al. (2005). Cigarette smoking among low-
income African-Americans: A serious public health problem.
American Journal of Preventive Medicine, 29, 218–220.
Fagan, P., King, G., Lawrence, D., Petrucci, S. A., Robinson, R. G.,
Banks, D., et al. (2004). Eliminating tobacco-related health dis-
parities: Directions for future research. American Journal of
Public Health, 94, 211–217.
Haiman, C. A., Stram, D. O., Wilkens, L. R., Pike, M. C.,
Kolonel, L. N., Henderson, B. E., et al. (2006). Ethnic and racial
differences in the smoking-related risk of lung cancer. New England
Journal of Medicine, 354, 333–342.
by guest on January 11, 2011
673 Download full-text
Nicotine & Tobacco Research, Volume 12, Number 6 (June 2010)
Iribarren, C., Tekawa, I. S., Sidney, S., & Friedman, G. D. (1999).
Effect of cigar smoking on the risk of cardiovascular disease,
chronic obstructive pulmonary disease, and cancer in men. New
England Journal of Medicine, 340, 1773–1780.
Jolly, D. H. (2008). Exploring the use of little cigars by students
at a historically black university. Preventing Chronic Disease.
5(3). Retrieved March 3, 2010, from http://www.cdc.gov/pcd
Kozlowski, L. T., Dollar, K. M., & Giovino, G. A. (2008). Cigar/
cigarillo surveillance: Limitations of the US Department of Agricul-
ture system. American Journal of Preventive Medicine, 34, 424–426.
Malone, R., Yerger, V., & Pearson, C. (2001). Cigar risk percep-
tion in focus groups of urban African American youth. Journal
of Substance Abuse, 13, 549–561.
Moore, D. J., Williams, J. D., & Qualls, W. J. (1996). Target
marketing of tobacco and alcohol-related products to ethnic
minorities. Ethnicity and Disease, 6, 83–98.
Przepyszny, K., & Borawski, E. (2008). Data Brief: Cuyahoga
County BRFSS Methodology, 2003–2007. Cleveland, OH: Center
for Health Promotion Research at Case Western Reserve Uni-
versity. Retrieved March 3, 2010, from http://www.case.edu/affil
Richter, P. A., Pederson, L. L., & O’Hegarty, M. M. (2006).
Young adult smoker risk perceptions of traditional cigarettes
and nontraditional tobacco products. American Journal of
Health Behavior, 30, 302–312.
Satcher, D. (1999). Cigars and public health. New England
Journal of Medicine, 340, 1829–1831.
Schwartz, A. G., & Swanson, G. M. (1997). Lung carcinoma in
African Americans and whites: A population-based study in
metropolitan Detroit, Michigan. Cancer, 79, 45–52.
Shanks, T. G., & Burns, D. M. (1998). Disease consequences of ci-
gar smoking. In Cigars: Health effects and trends (pp. 105–160).
(Smoking and Tobacco Control Monograph No. 9) (NIH Publica-
tion No. 98-4302). Bethesda, MD : Government Printing Office.
Shapiro, J., Jacobs, E., & Thun, M. (2000). Cigar smoking in
men and the risk of death from tobacco-related cancers. Journal
of the National Cancer Institute, 92, 333–337.
Soldz, P., & Dorsey, E. (2005). Youth attitudes and beliefs
toward alternative tobacco products: Cigars, bidis, and kreteks.
Health Education and Behavior, 32, 549–566.
Symm, B., Morgan, M. V., Blackshear, Y., & Tinsley, S. (2005).
Cigar smoking: An ignored public health threat. Journal of Pri-
mary Prevention, 26, 363–375.
Terchek, J. J., Larkin, E. M., Male, M. L., & Frank, S. H.
(2009). Measuring cigar use in adolescents: inclusion of
a brand-specific item. Nicotine and Tobacco Research, 11,
U.S. Department of Agriculture. (2007). Tobacco outlook
(Report No. TBS-263). Washington, DC: U.S. Department of
Agriculture, Economic Research Service.
by guest on January 11, 2011