Prevalence and Socioeconomic Disparities of Cigar Use in China: Findings from the China Health Literacy Survey with a Focus on the ‘Knowledgeable but Economically Marginalized’ (KEM) Population

<b>Background</b>: Cigar smoking poses significant public health challenges due to its rising prevalence and associated health risks. However, research on cigar use in China remains limited. This study investigates the prevalence, demographic characteristics, and key factors associated with cigar use among Chinese adults. <b>Methods</b>: We analyzed data from the 2018-2019 China Health Literacy Survey, including 86,701 participants aged 20-69 years. Multistage stratified sampling was employed, and logistic regression was used to estimate odds ratios (ORs) and 95% confidence intervals (CIs) for factors associated with cigar use. Weighted data were applied to ensure national representation. <b>Results</b>: Of the 86,701 respondents, 1025 participants reported having used cigars, including 248 exclusive cigar users and 777 dual users of cigars and other tobacco products. Cigar use was significantly higher among men (1.93%) than women (0.05%). Most users were aged 50-59, with a mean age of 49.3 years. Factors associated with cigar use among men included higher education (for college and higher, OR: 1.81; 95% CI: 1.42-2.30), lower household income (for income < 20,000, OR: 1.02; 95% CI: 1.08-1.53), poor self-reported health (OR: 1.45; 95% CI: 1.15-1.83), and severe nicotine dependence (FTND ≥ 7 points, OR: 2.09, 95% CI: 1.67-2.61). Cigar use prevalence showed notable regional variation, with the highest rates observed in northern and eastern provinces. <b>Interpretation</b>: The estimated number of cigar users in China is approximately 10.46 million. Male cigar users often represent a unique demographic: "knowledgeable but economically marginalized" individuals, characterized by higher education but lower economic status. Tailored tobacco control measures addressing regional disparities, socioeconomic factors, and marketing-driven misconceptions about cigars are essential to reduce public health impacts.