Cigar warning labels are not equally believable among adolescents

Less than 50 percent of surveyed teens found it ‘very believable’ that cigars are not a safe alternative to cigarettes, according to a first-of-its-kind UNC School of Medicine study.

 A majority of adolescents in the United States report current cigar warning labels to be very believable, according to a new study conducted by doctors and researchers at the University of North Carolina-Chapel Hill. But significant differences exist in the believability of specific cigar warnings, suggesting that more work is needed to establish the best warnings to dissuade youth from smoking cigars.

The study, published in the Journal of Adolescent Health, included a national phone survey of 1,125 adolescents from ages 13 to 17. The survey presented individuals with one of three current cigar health warnings that specifically isolate the risk of cigar smoke:

• Cigar smoking can cause cancers of the mouth and throat, even if you do not inhale
• Cigar smoking can cause lung cancer and heart disease.
• Cigars are not a safe alternative to cigarettes.

The surveyors then asked a number of questions about the believability of the warnings. Three quarters (76.7 percent) of all respondents found it very believable that "cigar smoking can cause lung cancer and heart disease," while just 53.4 percent found it very believable that "cigar smoking can cause cancers of the mouth and throat, even if you do not inhale" and only 49.8 percent found it very believable that "cigars are not a safe alternative to cigarettes."

Respondents were classified as either susceptible – meaning they had used a cigarette or expressed interest in trying one – or non-susceptible. About 17 percent of those surveyed were classified as "susceptible." Adolescents susceptible to using cigarettes were significantly less likely to report the cigar warnings to be very believable. The potential source of the cigar warning (FDA, CDC, the Surgeon General, or none) did not impact surveyors' answers, nor did their race, age, or sex.

Studies have shown that cigars are one of the most common tobacco products among adolescents in the U.S., with one in 12 adolescents reporting current use of a cigar product.

"This is the first research that has been done to track how young people perceive cigars warning labels," said Sarah Kowitt, doctoral candidate at the UNC Gillings School of Global Public Health and lead author of the study.

"Adolescents may be misguided about the safety of cigar use," said Adam O. Goldstein, MD, MPH, study co-author, professor of family medicine, and member of the UNC Lineberger Comprehensive Cancer Center. "Many still believe that risks of cigars can be mitigated by not inhaling or inhaling less. But we know that cigar smoking can cause serious harm, including cancer and heart disease."

Historically, most tobacco prevention campaigns have been aimed at cigarettes. Some states, such as Maryland, have rolled out cigar-specific campaigns that may help dismantle cigar myths among youth.

While the current cigar warnings were mostly seen as believable, Goldstein said that further study is needed, especially on the impact of graphic cigar warnings in addition to text. Also, the UNC researchers suggest continued study to develop warnings that have the maximum impact on susceptible adolescents.

Some countries, such as Australia, have begun this work. "In Australia, warnings include pictorial representations, which may engage adolescents more effectively," Goldstein said.

Other UNC researchers on the study include Kristen Jarman, MSPH, and Leah Ranney PhD.

This research was supported by grant number P50CA180907 from the National Cancer Institute and FDA Center for Tobacco Products (CTP).