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WASHINGTON -- Sometimes a cigar is just a cigar, except when it's a "premium cigar." But what does "premium" mean, and do premium cigars affect people's health differently than other cigars, or cigarettes?

These are just a few of the questions that the National Academies of Sciences, Engineering, and Medicine tried to tackle in its report on "." However, the 14-member committee that issued the report ran into some difficulties, one of which was determining what a "premium" cigar was.

"One of the challenges that we faced was that there was no single consistent definition of premium cigars," Steven Teutsch, MD, MPH, committee chair and senior scholar at the University of Southern California Leonard D. Schaeffer Center for Health Policy and Economics, said Thursday during a webinar marking the report's release. So, the committee developed its own definition, which is a cigar that:

• Is handmade
• Contains filler composed of at least 50% natural long-leaf filler tobacco
• Is wrapped in whole-leaf (not reconstituted) tobacco
• Weighs at least 6 lbs per 1,000 units
• Has no filters or tips
• Has no characterizing flavor other than tobacco

The committee considered also using high price as a characteristic, but decided against it because the price can be affected by taxation and changed by the industry, said Teutsch. However, he added, "it does serve as a proxy for the first three attributes of the committee's definition, and at times we turned to price as a proxy when the detailed information wasn't available." Under this definition, the committee determined that about 1% of the U.S. population smokes premium cigars, and they tend to be white, male, and older than average, with a higher income and education level, Teutsch said.

Lack of data was another problem the group faced. For example, "there was no information on minority populations and high-risk populations" in terms of the effects of premium cigars, said committee member Neal Benowitz, MD, professor emeritus of medicine at the University of California San Francisco. "These may include youth or young adults, racialized and ethnic populations, pregnant women, those with underlying medical conditions -- especially cardiovascular disease and respiratory disease -- and people with occupational exposure to premium cigars," such as those who work in cigar lounges.

The committee was able to draw a few conclusions, however. The health risk from premium cigars "is directly related to how often premium cigars are used, and inhalation patterns," Benowitz said, noting that cigar smoke is harsher than cigarette smoke, and therefore it's harder to inhale it deeply. While the vast majority of cigarette smokers smoke daily, "about 5% of premium cigar smokers smoke daily, and the others smoke only occasionally. Since most premium cigar users are smoking infrequently, and are less likely to inhale, the population health risks of such users are likely to be less than those who smoke other cigar types. This is not because the cigars aren't as dangerous; it's because of how they smoke and how often."

On the other hand, if cigars are used regularly, the health risk is likely to be similar to cigarette smoking, he said. "Another important thing is if you are a cigar smoker who has smoked cigarettes in the past or currently, because you've learned to inhale, you're more likely to inhale cigar smoke, leading to a greater health risk."

In terms of how cigars are marketed, the committee said in its report that "there is strongly suggestive evidence from survey data that consumers of premium cigars who buy in person typically purchase their cigars from cigar bars or smoke/tobacco specialty shops or outlet stores, whereas nonpremium large traditional cigar users typically purchase their cigars at convenience stores and gas stations. A lower proportion of premium cigar users buy their cigars in person than nonpremium large traditional cigar users."

The committee had several recommendations for the federal government, which included:

• The FDA and other federal agencies should develop formal categories and definitions for cigars to be used for research, to ensure consistency across studies
• Using this agreed-upon definition for the different types of cigars, the Department of Health and Human Services, the Alcohol and Tobacco Tax and Trade Bureau, and the Federal Trade Commission should establish a system to monitor the use patterns, product characteristics, industry marketing, promotion, and sales by cigar type, and make the data public
• The FDA, the NIH, and other federal agencies should conduct or fund research to determine the unique type of marketing, advertising, and promotional practices used by companies that manufacture, distribute, and sell premium cigars. These agencies should also identify strategies for tracking these activities, especially those that may appeal to youth

The federal government's response could significantly affect the trajectory of cigar smoking, said committee member Cristine Delnevo, PhD, MPH, director of the Rutgers University Center for Tobacco Studies. "What the patterns of use will look like in the future will depend on how the broad category of cigars are regulated -- taxation, marketing practices, etc," she said. "And so we recognize that those patterns can change."

However, tobacco trade and tax data for 2022 show that "the import of premium cigars is actually on an increasing trajectory. There are some data to point towards the fact that premium cigars -- the consumption of them has started to increase. Whether that is an indicator of more people using premium cigars or those using premium cigars smoking more of them, we do not know and we need the survey data to answer those particular questions," she added.

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