To our knowledge, our study is the first in the field to use survival analysis to estimate the distribution of the age of initiation of ever, past 30-day and fairly regular cigarillos use among young adults, between 2014 and 2017 who reported never cigarillo use at their first wave of adult participation (2013–2016) in the PATH study. By age 21, over 5% of young adults had initiated ever cigarillo use and 4% had initiated past 30-day use. Our data indicate that the estimated proportion of young adults who initiated past 30-day cigarillo use is more than doubled between ages 21 and 26. At the end of 2019, Tobacco 21 became law nationwide, rendering sales of tobacco products, including cigarillos, to anyone under the age of 21 illegal [35]. Future studies will be needed to examine if Tobacco 21 is effective in reducing underaged cigarillo and other tobacco product sales and use, as this law went into effect after our study period. While the impact of Tobacco 21 is promising, our data indicate that cigarillo ever, past 30-day and fairly regular use initiation persists beyond age 21 and that additional, sustained interventions and policy efforts are needed to curtail use among this group into early young adults.

Prior studies show that males and non-Hispanic Black young adults are at heightened risk for cigar product use [4–6]. Our data also show that young adult males, compared to females were more likely to initiate ever and past 30-day cigarillo use at younger ages. Compared to non-Hispanic Whites, non-Hispanic Blacks were more likely to initiate ever and fairly regular cigarillo use at earlier ages. Non-Hispanic Blacks and Hispanics were also more likely to initiate past 30-day cigarillo use at earlier ages than Non-Hispanic Whites. Self-identifying as non-Hispanic other appeared to be a protective factor for cigarillo initiation, as this group was less likely than non-Hispanic Whites to initiate ever and past 30-day cigarillo use at earlier ages. While identifying reasons for cigarillo use initiation is beyond the scope of this paper, evidence suggests that there is pervasive cigar product advertising in non-Hispanic Black and other communities of color and in young adult neighborhoods [36]. Cigarillo product advertisements targeted to young adults of color are also found online. For example, the official Swisher Sweets webpage (https://swishersweets.com/) includes several images of young adults, mostly male, who appear to be non-Hispanic Black and other ethnicities of color, giving the impression that these groups are representative of those who use and are attracted to the product. Content analysis of cigarillo mobile websites and social media accounts have documented the marketing tactics, such as using hip-hop and other influential cultural references, that are used by the industry to attract and appeal to young adults [37–39]. Tobacco product advertising and promotion exposure in young adults is associated with product initiation and continuation [40]. As noted previously, cigarillos are often used to smoke blunts [11–14]. Evidence suggests that use of cigarillo for blunt smoking is increasingly prevalent among non-Hispanic Black young adults [17, 41, 42]. The heightened risk of an earlier age of initiation of ever, past 30-day and fairly regular cigarillo use among non-Hispanic Black young adults may be due to blunt smoking. Moreover, our data indicate that young adults who had a history of marijuana or blunt use prior to cigarillo initiation were at heightened risk of an earlier age of initiation of ever, past 30-day, and fairly regular cigarillo use. Additional studies are needed to develop interventions that may reduce the transition from marijuana use to initiation of cigarillos during young adulthood. The targeted marketing of cigar products to young adults, particularly males and those who self-identify as people of color, use of cigarillos for blunt use, and with the lack of cigar prevention programs for young adults, may explain the heightened risk of initiation among this group.

Our study findings also highlight the risk of an earlier age of cigarillo initiation among those with other tobacco product use experience. Compared to non-tobacco product users, young adults with a history of cigarette and smokeless tobacco use were significantly more likely to initiate ever, past 30-day, and fairly regular cigarillo use at earlier ages than participants who did not use them after controlling for the other covariates. Filtered cigar users were more likely to initiate fairly regular cigarillo use at earlier ages than participants who did not use the products. However, those with a history of hookah use were less likely to report initiation of fairly regular cigarillo use at an earlier age than those who did not use hookah previously. Our findings are supported by other PATH study data that indicate that young adults with a history of previous use of other tobacco products were at increased risk of initiating past 30-day cigarillo use [22]. Although additional studies are needed to examine if young adults with a history of other tobacco product use are substituting with, switching to, or concurrently using cigarillo products, the use of multiple tobacco products among young adults is concerning. Prior studies suggest that cigar users who dual use with other tobacco products may be at increased risk of becoming addicted to nicotine and experience difficulty quitting smoking [43].

Our study has many strengths, including the use of a national (PATH) dataset, the precise measurement of the age of initiation across four waves of PATH data (within a week’s precision), use of the prospective design which avoids recall bias, and use of the interval-censored Cox proportional hazards models. Our study is not without limitations. PATH measures the cigarillo outcomes among users and non-users. We only included participants who were never users of cigarillos at their first wave of adult participation in PATH, leading to left-censoring subjects, which may lead to an overestimation of the age of initiation. However, our goal was to prospectively estimate the distribution of the age of initiation of cigarillo outcomes among never users of cigarillos who were aged 18–24 years old at their first wave of adult participation in PATH to study how these behaviors emerged over time among this age group. These never users of cigarillos did not initiate their use during adolescence and for that reason it is important that the public understand that young adults still initiate at later ages even if they did not initiate during their adolescent years. Another limitation, is the subjective measure of fairly regular use, as participants may interpret this question differently. Finally, we did not include other potential confounders, such as sociodemographic factors (e.g., household income, education level), intrapersonal factors (e.g., tobacco product knowledge, perception of harmfulness, perception of addictiveness, internalizing problems, externalizing problems), interpersonal (e.g., family history of tobacco product use, peer use of tobacco products), as well as environment factors (e.g., social media, advertisements, marketing). Investigating the impact of these risk factors on the age of initiation of cigarillo use will be important for future research.

In conclusion, our study documents the onset of cigarillo initiation among young adults–legal advertising targets for the tobacco industry. Our findings have important implications for intervention and tobacco control regulatory policy development. Most tobacco prevention interventions are developed for and implemented among adolescents, and primarily target cigarette or ENDS use. Our study findings highlight the importance of developing cigarillo-specific prevention interventions, including health communication campaigns, that address use among young adults and to educate the public domain. Prevention interventions should be targeted to young adults who identify as men, non-Hispanic Black and Hispanic, and have a history of marijuana/blunt, cigarette, and filtered cigar use as early as possible to reduce the initiation of cigarillo use.