The Public Health Impacts of Flavored Cigar Bans: A Systematic Review and Meta-Analysis

INTRODUCTION: This review summarizes research on the public health impacts of flavored cigar bans, which are policies that restrict the sale of cigars containing characterizing flavors. METHODS: A systematic literature search was conducted using PubMed, Scopus, PsycINFO, Cumulative Index to Nursing and Allied Health Literature, and Applied Social Sciences Index and Abstracts. Studies were included if they evaluated the impact of a real-world or hypothesized flavored cigar ban. The primary outcome was tobacco use behavior. Secondary outcomes included retailer compliance, sales, and the tobacco industry response to flavored cigar bans. Two reviewers independently screened articles for inclusion, extracted data, and assessed study quality. We also conducted a meta-analysis using random effects models to pool estimates on tobacco use behavior after a flavored cigar ban. This review was registered with PROSPERO (CRD42023481603). RESULTS: Of 2,399 articles identified in the preliminary search, 55 were included in the review. Many real-world studies found declines in cigar use post-ban, specifically among youth. However, other studies found no significant changes in cigar use. Among studies examining sales, there were declines in flavored cigar sales but increases in sales of non-flavored cigars and other tobacco products. Among studies assessing hypothesized tobacco use behavior, pooled results indicate that 8% (95% CI: 2%, 27%) of flavored cigar users intend to quit tobacco altogether, 45% (95% CI: 39%, 50%) would switch to non-flavored cigars or cigarettes, and 41% (95% CI: 32%, 51%) would switch to other tobacco products. CONCLUSIONS: Flavored cigar bans may reduce cigar use and improve public health when policies are comprehensive and well-enforced. IMPLICATIONS: Overall, findings from this review suggest that flavored cigar bans may reduce tobacco use and have the potential to improve public health, but not all research is consistent. Several studies examining the impacts of flavored cigar bans on tobacco use found a decrease in cigar use among youth, but some found that there was no significant change in cigar use. Research on policy impacts among adults is limited. To maximize intended policy impact, monitoring of retailer compliance and the tobacco industry's response to flavored cigar bans is needed.