Experts' perceptions of and suggestions for cigar warning label messages and pictorials.

INTRODUCTION Warning labels can be effective tools to inform the public about tobacco risks. However, tobacco warning research has been largely cigarette centric. This formative study explores potential directions for improving the current warnings for cigars. METHODS Between June and August 2019, we conducted interviews with ten experts about the current cigar warning statements and requirements, the inclusion of pictorials in cigar warnings, and legal issues. Additionally, experts viewed and discussed concept images to pair with existing warning statements, including realistic photographic images and symbolic images (e.g., icons, caution symbols). RESULTS Experts agreed that cigar warnings should be strengthened (e.g., by increasing their size and use of pictorials) to better leverage their potential impact and maintain warning parity with cigarettes. However, perceived challenges exist given the wide variety of cigar products, product terminology, and use patterns. Experts agreed that photographic pictorials of health effects are likely to be more salient, informative and effective for behavior change than symbolic ones, but may be vulnerable to legal challenges. Symbolic images used in warnings may obtain attention in a less "controversial" way, but may be considered less serious and "factually accurate", increasing legal risks. Experts indicate that cigar educational campaigns can complement warnings and address additional themes, especially aimed at youth, including exposure to chemicals and flavorings and misperceptions that cigars are "natural". CONCLUSIONS Additional consumer research is needed to examine the potential public health impact of improving cigar warnings and to support regulatory efforts. IMPLICATIONS This study provides feedback from tobacco control experts about the importance of cigar warning labels and directions for future research and improvements. Experts support increasing the size of cigar warnings and adopting pictorials to improve cigar warning impact and maintain warning parity with cigarettes. Experts agreed that photographic pictorials of health effects are likely to be more salient and effective for behavior change than symbolic ones. Given legal challenges, experts discussed potentially prioritizing warning improvements for those cigars used most frequently as cigarette alternatives and by youth. Overall, more cigar warning research is needed to support regulatory efforts.