Abstract
The prevalence of tobacco use among urban African American persons aged 18 to 24 years not enrolled in college is alarmingly high and a challenge for smoking cessation initiatives. Recent data from inner-city neighborhoods in Baltimore, Md, indicate that more than 60% of young adults smoke cigarettes. We sought to describe community-level factors contributing to this problem. Data from focus groups and surveys indicate that the sale and acquisition of “loosies” are ubiquitous and normative and may contribute to the high usage and low cessation rates.
Increasing rates of smoking and low rates of cessation in young adults (aged 18–24 years) have been identified as “growing health concerns.”1 Of particular concern are those young adults who are not enrolled in college; who are unemployed, underemployed, or economically disadvantaged; and who are a target market of the tobacco industry.2,3 The overall decline in smoking rates in most of the US population has been attributed to a comprehensive approach that includes environmental and policy approaches (e.g., cigarette taxes and smoking restrictions).4–8 However, because these approaches have not been implemented equally across all communities and population subgroups, some groups are more vulnerable and less likely to want to quit smoking.9–11
Currently, little is known about environmental factors in urban communities that either facilitate smoking or act as barriers to cessation. Access to cigarettes and sales of single cigarettes—“loosies”—may be 2 of these factors.12 We examined the (1) availability of cigarettes, (2) sales of single cigarettes, and (3) positive social norms toward smoking. We have described these factors in African American young adults who were attending employment training and educational programs in inner-city Baltimore, Md.
Participants were recruited by program directors. Four focus groups were conducted with 28 young adults (20 men and 8 women): 23 smokers and 5 nonsmokers who were attending employment training and educational programs in Baltimore. Focus groups were gender heterogeneous but homogeneous as to smoking status, with 3 groups of smokers and 1 group of nonsmokers. The low number of nonsmokers in the programs required that the nonsmoking group contained both former smokers and individuals who have never smoked. Written consent was obtained before starting the focus groups, and participants received an incentive of $20. Groups were led by an experienced African American focus group moderator. All focus group discussions were audiotaped and fully transcribed. Focus group domains included social norms around tobacco use, tobacco acquisition practices, smoking and socializing, smoking restrictions, and tobacco advertising.
The directors of the employment training and educational programs used flyers, word of mouth, and telephone calls to recruit a convenience sample from their roster of program participants. Program participants were required to reside in selected zip codes in the city that were designated as under-served communities. Focus group participants were excluded from taking the survey. The investigators administered the surveys in a group setting to ensure uniformity of data collection and to maximize survey completion rates. Written consent was obtained, and participants received $20. The survey instrument was adapted from several national survey instruments; additional topics and wording of questions were derived from an analysis of the focus group transcripts. The topics surveyed included prevalence of use by current and former smokers, age at initiation, smoking behaviors, buying behaviors, and attitudes and social norms. Of special interest was the purchasing and selling of single cigarettes.
We analyzed all focus groups with Atlas.ti version 3 (Atlas.ti Scientific Software Development GmbH, Berlin, Germany) qualitative software to ascertain emergent themes. We used SAS 9.1 (SAS Institute Inc, Cary, NC) to complete a statistical analysis of the survey data with χ2 tests and t tests to assess bivariate associations between gender or smoking status and demographic characteristics, smoking behavior, cigarette acquisition behavior, attitudes, and perceptions. Multiple logistic regression analysis was performed to assess the factors associated with being a current smoker and the acquisition of single cigarettes. These factors included demographic characteristics, cigarette acquisition behavior (places and people from whom participants bought cigarettes, including other behaviors such as bumming, pooling money, and selling cigarettes), and single cigarette acquisition behavior (where and from whom).
Emergent thematic patterns, which were consistent across all 4 groups, pertained to buying and sharing single cigarettes, smoking and socializing, and smoking as a normative behavior. Both smokers and nonsmokers perceived smoking as normal, very common, and essentially unproblematic. Participants described facing relatively few smoking restrictions and reported that single cigarettes were easily accessible.
The survey was completed by 156 young adults, 60% of whom were men; 70% reported less than high-school education. Sixty-two percent reported being current smokers, and 63% smoked 10 cigarettes or fewer per day; 15% smoked 1 pack a day. On average, current smokers had started smoking at age 13.6 years, and all reported smoking Newport cigarettes. Factors associated with being a current smoker were having less than a high-school education (odds ratio [OR] = 3.20; 95% confidence interval [CI] = 1.51, 6.74) and living in a home in which smoking was permitted (OR = 3.34; 95% CI = 1.65, 6.79). No statistically significant differences were observed by gender for any of the demographic or smoking status variables.
Table 1 describes patterns of cigarette acquisition. Most respondents bought single cigarettes every day and also witnessed others selling single cigarettes on the street in many different locations throughout the community. Widely reported reasons for buying single cigarettes were convenience and lower cost. Women were more likely than men to buy cigarettes by the pack and to buy them near their residence, and women were less likely than men to buy from friends. Figure 1 represents the attitudes toward and perceptions of the availability of single cigarettes and smoking-related issues by smoking status and documents the acceptance of smoking and the availability of single cigarettes in this community. Factors associated with acquisition of single cigarettes were seeing people every day selling single cigarettes (OR = 3.89; 95% CI = 1.24, 12.19), buying cigarettes from a bar or club in the past month (OR = 4.39; 95% CI = 1.50, 12.88), and being likely to find single cigarettes sold outside corner stores (OR = 3.64; 95% CI = 1.06, 12.53).
Smoking cessation strategies need to take into consideration environmental influences, such as the sale of single cigarettes, particularly to inner-city African American young adults. This study found that the sale of single cigarettes was more pervasive than previously reported and that most of the sales occurred on the street. This easy and affordable way to purchase cigarettes from street vendors and stores undermines tax policies, promotes smoking as a normative behavior, and may contribute to high smoking rates in some inner-city communities.13 Although the US Food and Drug Administration attempted to eradicate the legal and illegal sale of single cigarettes in 1996, current laws differ from state to state, and enforcement is lax.14
Attitudes and behaviors of these young adults, both smokers and nonsmokers, regarding the sale of single cigarettes in the community and the perception that everyone smokes reflect the normative nature of tobacco use and may explain the lack of interest in quitting. Other influences associated with increased prevalence of smoking and lack of interest in quitting in this population are industry-targeted advertising as well as marketing and promotion campaigns that permeate the physical and social environments of these young adults, including special promotions at bars and clubs.3,15,16 The tobacco industry considers working-class young adults a critical market, especially to expand the sales of key brands such as Newport, a mentholated cigarette, and Black and Mild, a small cigar.1,17,18 Newport cigarettes are heavily advertised in African American communities.19,20 This may account for the brand loyalty found in our survey: 100% of the smokers indicated that they would smoke only Newport cigarettes. In addition to cigarettes, Black and Mild cigars are sold individually for less than $1 each; this may contribute to their use by young adults with modest available funds.18
The relation between environmental factors and smoking behavior needs more research because the evidence is of an ecological nature.16 The ultimate goal of this research is to design community-level initiatives promoting smoking cessation in partnership with the target population, community leaders, policymakers, and academia to reduce tobacco use communitywide.
aAmong the full population (smokers and nonsmokers). * P < .05 for the comparison by gender (χ2). FIGURE 1— Percentage of African American young adults (aged 18–24 years) who hold certain attitudes toward and perceptions of the availability of single cigarettes and smoking-related issues, by smoking status: Baltimore, Md, 2005–2006. * P < .05 for the comparison by smoking status (χ2).
Total, % (N = 96) Women, % (n = 37) Men, % (n = 59) Bought cigarettes by the pack during the last month* 74.7 91.9 63.8 Bought cigarettes near where they Live* 85.3 94.6 79.3 Socialize 75.8 86.5 69.0 Bought cigarettes at a Supermarket, drugstore, gas station 83.2 86.5 81.0 Convenience or corner store 85.1 91.9 80.7 Bar or club 56.8 56.8 56.9 Bought cigarettes from Friends* 33.7 21.6 41.4 Family 16.8 16.2 17.2 Borrowed or bummed cigarettes 71.6 64.9 75.9 Pooled money to buy cigarettes 53.1 51.4 54.2 Sold cigarettes 39.6 45.2 35.5 Bought single cigarettes during the last month 76.8 73.0 79.3 Reasons for buying single cigarettes Convenient 65.9 60.6 69.0 Less expensive 58.9 58.8 58.9 Did not have enough money 48.4 48.6 48.3 Trying to cut back 44.1 50.0 40.4 Prevents me from getting started or addicted 21.3 18.9 22.8 Saw people on the street selling single cigarettes every day during the last month (n = 156)a 71.8 64.5 76.6 Who they have seen selling single cigarettes on the street (n = 156)a Neighbors 43.5 39.3 46.2 Friends 38.2 37.7 38.5 Drug dealers 24.8 29.5 21.7 Relatives 23.7 18.3 27.2 Likely to find single cigarettes being sold (n = 156)a Near the subway 83.6 80.0 85.9 Outside of corner or grocery store 81.2 78.7 82.8 Outside of bars and clubs 71.3 64.4 75.8 Outside of schools 25.2 22.0 27.2 
This work was supported by the Maryland Cigarette Restitution Fund and the American Legacy Foundation (grant 5092).
We appreciate the assistance of the Community Building in Partnership Inc and the participants in the Employment and Training Programs. Special thanks to Priscilla Belen for her guidance in establishing the community advisory committee and Atanaska Dineva for her help with article preparation.
Human Participant Protection The study protocol was approved by the Johns Hopkins Bloomberg School of Public Health institutional review board.
