HEALTH EDUCATION RESEARCH

‘We’re not gonna have a big quit if loose ones are around’: urban, African American smokers’ beliefs concerning single use reduction Downloaded from https://academic.oup.com/her/advance-article/doi/10.1093/her/cyab014/6343133 by guest on 01 October 2021

Lilianna Phan1*, Charlene Chao-Li Kuo2, Craig S. Fryer2,3, Mia A. Smith-Bynum4, Pamela I. Clark2 and James Butler III2 1Cancer Prevention and Control Program, Lombardi Comprehensive Cancer Center, Georgetown University Medical Center, Washington, DC 20007, USA, 2Department of Behavioral and Community Health, University of Maryland School of Public Health, College Park, MD 20742, USA, 3Maryland Center for Health Equity, University of Maryland School of Public Health, College Park, MD 20742, USA and 4Department of Family Science, University of Maryland School of Public Health, College Park, MD 20742, USA *Correspondence to: L. Phan. E-mail: [email protected] Received on July 28, 2020; editorial decision on February 26, 2021; accepted on March 2, 2021

Abstract These findings can inform enforcement policies and health education interventions targeting Single cigarette use (i.e. , loose ones, single cigarette use among urban, African singles) poses risks for continuation American smokers who use singles. among urban, African American smokers. There is, however, limited research to inform health education interventions addressing this Introduction behavior. We conducted 25 in-depth interviews with urban, African American users (ages Overall, the smoking rate among U.S. adults has 20–58 years) from Baltimore, MD and the declined; however, racial and ethnic -related District of Columbia in June and July 2018 to as- disparities persist [1]. Despite similar smoking sess their beliefs about reducing single cigarette prevalence rates (15%), African Americans’ rate of use. Interviews were guided by the Health Belief mortality attributable to smoking is 18% higher than Model and its constructs of perceived benefits, that of white smokers [2, 3]. A smoking ‘paradox’ perceived barriers, perceived susceptibility, per- [4] exists where African Americans are less likely to ceived severity and self-efficacy. We analyzed achieve smoking abstinence than their white coun- qualitative data using framework analysis. terparts [2, 5] despite smoking fewer per Perceived benefits of reducing single cigarette day, [6] being highly motivated to quit smoking and use involved the avoidance of health risks, making more quit attempts [2, 5]. Consequently, including concerns about buying fake cigarettes African Americans disproportionately experience and exposure to unknown personal hygiene the deleterious health effects of smoking, such as practices from sellers. Perceived barriers heart disease, cancer, stroke, diabetes and mortality were the convenience of buying singles due to more than their white counterparts [1]. their availability, accessibility and low cost. The smoking-related health challenges of low- Participants shared they were willing to use cog- income African Americans living in urban areas are nitive behavioral strategies to reduce their pur- of particular concern as they face several unique chasing and use of singles. This study provides risk factors for smoking within their social and insights on potential intervention targets related physical environments. These factors include to beliefs towards reducing single cigarette use. poverty [6] and poverty-related stressors (e.g.

VC The Author(s) 2021. Published by Oxford University Press. All rights reserved. doi:10.1093/her/cyab014 For permissions, please email: [email protected] L. Phan et al. inadequate housing) [7], exposure to neighborhood cessation among this priority, hard-to-reach popula- violence [8], experiences of racism and discrimin- tion. To date, urban, African Americans’ beliefs ation [6], positive social norms toward smoking [9] about reducing single cigarette use have received and inequitable distribution of tobacco outlets with- minimal attention in the extant literature. Thus, Downloaded from https://academic.oup.com/her/advance-article/doi/10.1093/her/cyab014/6343133 by guest on 01 October 2021 in their neighborhood [10]. Additionally, evidence- the present study, theoretically guided by the Health based services are perceived as Belief Model, aimed to qualitatively examine inadequate by urban, African American smokers as urban, African Americans’ beliefs about reducing these services do not resonate with their lived expe- single cigarette use. riences and tobacco use practices [11]. Method Single cigarette use The sale of single cigarettes was banned by the 2009 The health belief model as a theoretical Family Smoking Prevention and framework Act [12] in order to protect the public’s health, pre- The use of theory in qualitative research approaches vent youth smoking and discourage the purchase is appropriate and quite useful [23]. The Health and use of singles, commonly practiced by African Belief Model (HBM) postulates that in order for an American smokers in low-income, urban areas individual to reduce his/her/their purchasing of [13, 14]. ‘Singles’ are loose, unpackaged, untaxed singles, they must perceive themselves as being cigarettes sold individually [15]. Some cigarette personally susceptible to the harms of single cigar- users believe acquiring singles is an immediate cost ette use. This health threat perception coincides savings in comparison with purchasing a pack with with the belief that reducing single cigarette use 20 cigarettes [13, 15], and that this practice may would subsequently lead to health benefits (e.g. support reductions in overall cigarette consumption reducing smoking intensity, successfully quitting [15] and lead to gradual cessation [16]. Though sin- smoking and remaining smoke-free) [24]. gle cigarette use has been associated with intent to Accordingly, as a structure to guide our study, we quit smoking [13], prior research indicates single examined the HBM constructs of ‘perceived bene- cigarette use promotes the opposite of cessation by fits’, ‘perceived barriers’, ‘perceived susceptibility’, maintaining smoking behavior [9] and increasing ‘perceived severity’ and ‘self-efficacy’ towards the likelihood of a lapse or relapse during quit reducing the purchasing and use of singles among attempts [17, 18]. Further, recent studies found users. We define participants’ ‘perceived benefits’ 60–96% [17, 19] of single cigarettes purchased as beliefs about the ‘pros’ of reducing single were mentholated cigarettes. Consequently, access cigarette use. ‘Perceived barriers’ are participants’ to singles contributes to the preference of menthol- self-identified challenges they would face in chang- ated cigarettes [20], which are disproportionately ing their behavior. ‘Perceived susceptibility’ and used by 88% of African American smokers due in ‘severity’ are participants’ beliefs about their risk part to targeted marketing [21], and is associated of harm from single cigarette use and how with increased smoking initiation, greater nicotine serious these harms are to them, respectively. ‘Self- dependence and decreased cessation [22]. efficacy’ is participants’ belief in their ability to As noted, the well-intentioned use of singles is reduce their use of singles and to perform strategies supported by misperceptions that this behavior can they identify as helpful in reducing their single help with gradual smoking cessation presenting a cigarette use. critical opportunity for health educators and researchers to inform users about the risks of single Recruitment and study procedures cigarette use, the need to reduce their purchasing This study was advertised as an ‘in-person of singles, and methods to promote successful interview’ to discuss personal experiences with

2of12 Beliefs related to reducing single cigarette use purchasing and using singles. Participants were between 60 and 90 minutes. All study sessions and recruited using two purposive sampling techniques: related components were conducted by the first au- (i) ‘word-of-mouth,’ an oral and interpersonal thor and held in a private area of a public library or communication style preference among African community center located near the participant’s Downloaded from https://academic.oup.com/her/advance-article/doi/10.1093/her/cyab014/6343133 by guest on 01 October 2021 Americans [25–28] and (ii) recruitment flyers [25] residence. Light refreshments were served, and each posted in Baltimore, MD and the District of participant received $25 cash [31]. The study was Columbia (DC) convenience stores, gas stations, approved by the host institution’s Institutional take-out restaurants, stations of the Washington Review Board. Metropolitan Area Transit Authority, community centers and local public libraries. The first author Qualitative data analysis met with staff from the community centers to intro- All interviews were digitally recorded and tran- duce and explain the purpose of this research. scribed verbatim by the transcription service, RevVC Permission to post recruitment flyers at their center (https://www.rev.com), which guarantees 99% was given prior to posting flyers. These active and accuracy for each transcription. The first and second passive recruitment strategies have been effective authors iteratively developed a codebook with ini- with African Americans in previous research tial a priori nodes based on interview guide ques- [25–28]. Eligibility criteria included being 18 years tions focused on HBM constructs and themes that of age and older, self-identifying as African emerged from the transcripts. The codebook listed American, residing in either Baltimore or DC, and the HBM constructs (i.e. node), subthemes within having purchased and used singles at least once in each construct (i.e. code), a description of each sub- the past 30 days. theme and example(s) of qualitative raw data cate- Participation involved completing one study gorized under the subtheme [32]. The transcripts session. First, participants completed the informed VC were entered into NVivo 12 (QSR International). consent process, which allotted ample time for ques- The first and second authors independently ana- tions about the research and allowed them to make lyzed all transcripts by identifying the node and an informed decision about their study participation code for specific sentences. All coding discrepan- [29]. Second, a paper-based survey was adminis- cies were reconciled through discussion and inter- tered to assess participants’ demographic character- rater agreement [33]. Qualitative data analysis fol- istics, smoking history, cigarette acquisition lowed framework analysis outlined by Ritchie and practices and single cigarette use behavior. Lastly, a Lewis [34], which permits the retention of each par- semi-structured, in-depth interview was conducted. ticipant’s unique experience with singles and the This interview structure included unscripted dia- evaluation of key themes across participants. logue between the interviewer and participant and Framework analysis has been used in previous follow-up questions posed by the interviewer [30]. qualitative studies on tobacco use [35, 36] and stud- The interview guide was developed based upon the ies using semi-structured, in-depth interviews [37]. HBM constructs and focused on understanding par- ticipants’ perceptions regarding the benefits of reducing single cigarette use; susceptibility to per- Results sistent smoking patterns from using singles; severity of cigarette smoking and using singles to one’s We conducted 25 semi-structured, in-depth inter- health outcomes; barriers to reducing one’s single views with African American adult single cigarette cigarette use and one’s self-efficacy needed to users (mean age 37.2 6 13.3 years) from Baltimore, change this tobacco use behavior. Interviews were MD and DC. Participant characteristics are pre- conducted in June and July 2018 and ranged sented in Table I and their cigarette acquisition

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cigarette(s) if they no longer purchased singles Table I. Participant characteristics (N ¼ 25) and purchased a packaged, sealed pack of ciga- Variable M (SD) N (%) rettes. Furthermore, participants noted how see- Downloaded from https://academic.oup.com/her/advance-article/doi/10.1093/her/cyab014/6343133 by guest on 01 October 2021 Gender ing the Surgeon General’s health warning label Male 16 (64.0) Female 9 (36.0) Age 37.2 (13.3) Table II. Participant smoking history and cigarette acquisi- Hispanic ethnicity (yes) 1 (4.0) tion practices (N ¼ 25) Place of residence Variable M (SD) N (%) Baltimore, MD 20 (80.0) District of Columbia 5 (20.0) Cigarette smoking status Marital status Daily 20 (80.0) Single 19 (76.0) Non-daily 5 (20.0) Married or living with a partner 4 (16.0) Number of cigarettes smoked daily Divorced or separated 2 (8.0) Daily 10.9 (5.5) Educational attainment Non-daily 2.9 (1.5) Less than high school 6 (24.0) Typical cigarette acquisition High school diploma 7 (28.0) Pack 12 (48.0) GED or equivalent 6 (24.0) Loosies 13 (52.0) Some college or higher 6 (24.0) Frequency of buying singlesa,b Employment Sometimes 7 (28.0) Full-time 3 (12.0) Often 5 (20.0) Part-time 6 (24.0) Very often 13 (52.0) Unemployed 14 (56.0) Frequency of seeing singles being solda,b Other 2 (8.0) Often 5 (20.0) Monthly household income Very often 20 (80.0) <$400 6 (24.0) Frequency of cravings to smoke after seeing singles being Between $400 and $799 7 (28.0) solda Between $800 and $1200 3 (12.0) Never 3 (12.0) $1200 8 (32.0) Rarely 4 (16.0) Sometimes 6 (24.0) Often 7 (28.0) practices are described in Table II. Themes within Very often 5 (20.0) each of the six HBM constructs that emerged are Frequency of buying singles to reduce cigarette consumptiona reported below. Never 3 (12.0) Rarely 3 (12.0) Sometimes 8 (32.0) Theme 1: perceived benefits Often 5 (20.0) We asked participants, ‘What are the pros to not Very often 6 (24.0) Number of singles purchased at one time using loosies?’ They expressed that the benefits Two loosies 16 (64.0) to reducing their single cigarette use would be More than two loosies 9 (36.0) lessening their physical contact and interaction Typical singles type with seller(s) during point-of-sale. Specifically, Menthol 24 (96.0) the primary perceived benefit from changing this Non-menthol 1 (4.0) Cost per single $0.50 (100.0) behavior would be reducing the participants’ ex- Intention to quit posure from coming into contact with potentially Within next 6 months 10 (40.0) infectious agents from the seller’s unknown per- Longer than 6 months 7 (28.0) sonal hygiene practices and others who may Not interested in quitting 8 (32.0) have touched the cigarette(s) before the sale. Quit attempt in the last year (yes) 10 (40.0) Similarly, participants believed they would re- aFrequency within the past 30 days. b duce their risk of buying fake or counterfeit Response categories not presented n ¼ 0.

4of12 Beliefs related to reducing single cigarette use on a reminded them of the health Being reminded of the health risks of risks of smoking, which did not occur when pur- smoking from the surgeon general’s health chasing singles from individuals or retailers. warning label on packs Downloaded from https://academic.oup.com/her/advance-article/doi/10.1093/her/cyab014/6343133 by guest on 01 October 2021 Thus, a perceived benefit of reducing single cig- It’s [buying singles is] not a reminder... arette use was increased exposure to the Surgeon whereas...if they [single cigarette users] buy General’s health warning label on cigarette the pack, when they [single cigarette users] packs. go to take one out the pack, they can see it [Surgeon General’s health warning label]. Reducing the risk of exposure to germs (male, age 49) during single cigarette sales [I] don’t...get a chance to read the warning Sometimes I worry a little bit about health label to know how that stuff is killing me...not and hygiene...if it’s a pack of cigarettes you knowing how dangerous that these cigarettes open by yourself, you know it’s safe, it’s are, really, to our health. (male, age 49) hygienic, someone hasn’t meddled with it. But if you’re buying it from someone, some individual on the street, you don’t know Theme 2: perceived barriers where his hands have been...it [the pack of Participants were asked, ‘What are the cons to not cigarettes] keeps [getting] handled back and using loosies?’ with additional probes, including, ‘If forth...(female, age 40) you stopped using loosies, what would you miss about them?’ Participants reported singles’ high Because you don’t know where their hands availability, accessibility and immediate low cost [have] been at...and germs...I don’t want per unit as the main challenges they faced if they everybody or anybody touching [the sin- were to reduce their single cigarette use. Each day, gles] cause he’s selling them...so every- participants witnessed the high availability and ubi- body gonna touch it. So you don’t want quity of singles in their physical environment, mak- everybody touching your cigarette and then ing singles convenient to purchase. Furthermore, it goes right in your mouth. Bacteria...it’s singles were described as an affordable method to just basic stuff...it’s just, I don’t want it. acquire cigarettes. These factors make the purchas- (female, age 37) ing and use of singles preferable over purchasing packs; consequently, they are perceived barriers to Reducing the risk of buying fake or reducing single cigarette use among low-income, counterfeit cigarettes urban, African American smokers who engage in ...sometimes you worry too about an open this cigarette acquisition practice. pack. You didn’t break it open, no seal to it so you don’t know how original the cigarette High availability and accessibility of might be or maybe it’s some kind of fake singles cigarette you’re smoking. Maybe it’s been You can always get ‘em from anywhere. meddled with... You never can tell. You - sometimes you might not even have to (female, age 40) leave off your block or off your porch, or whatever. Versus buying a pack of cigarettes, I’d be concerned to see...if they put anything which you gotta go to a store. And they [the in the cigarettes that you don’t know about, store] gotta be open. (male, age 26) or they tamper with the cigarettes...so I [would] be pretty concerned and cautious Everywhere you go...there’s a guy that’s there about it. (female, age 37) everyday like clockwork. (female, age 49)

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Low cost of singles in comparison with a Single cigarette availability does not pack of cigarettes influence smoking cessation I would miss how much money I used to ...Ithinkifapersonreallywantedto[quit Downloaded from https://academic.oup.com/her/advance-article/doi/10.1093/her/cyab014/6343133 by guest on 01 October 2021 have in my pocket from just buying one cig- smoking] they could stop, or slack up. So arette [versus having to buy a cigarette pack]. being around a person that sells cigarettes, it (male, age 24) probably won’t bother [the person] much, especially if they have a strong mind or a Not having to spend a lot of money [to buy strong will. (male, age 31) cigarettes]. (female, age 26) Just the same way some people bum cigarettes off each other, you know. You’re Theme 3: perceived susceptibility still gonna get cigarettes to smoke even if loo- Participants were asked if they believed the sies aren’t out there on the streets. So I don’t availability and use of singles affected their think it has a direct effect on me quitting or smoking propensity and ability to successfully quit starting all over again. (female, age 40) smoking. We asked, ‘How worried are you that loosies will make you continue to smoke?’ and ‘If Risk factor for persistent smoking you quit smoking, how worried are you that behavior use could cause you to start smoking again?’ The majority of participants endorsed low-susceptibility I’m very worried about it because me buying beliefs from single cigarette use; they expressed loosies, let’s me know that I’m not even try- ... their use of singles supported, rather than hindered, ing to quit I’m saying, ‘Man, I’m buying cessation. Singles were viewed as a harm reduction loosies, at least I am not buying a pack. At least I’m cutting back.’ But it’s just the op- strategy, which allowed them to purchase fewer cigarettes at once, and subsequently smoke fewer posite. (male, age 55) cigarettes than if they had access to a pack of [My friend] has disillusioned himself to cigarettes. However, some participants also think, okay, he quit smoking but he’s still expressed how single cigarette use increased their smoking loosies and I’m like, no. So you smoking patterns and behavior and increased their kind of create that illusion that okay, as long risk of smoking while actively trying to quit. as I don’t buy a pack, [and just buy loosies], I Overall, participants shared the availability of quit smoking. (female, age 55) singles made it easier to have ‘just one more cigarette’ in scenarios where they did not want to purchase an entire pack. Risk factor for lapse or relapse I’m not the only one that goes through this, Single cigarette use as a harm reduction but every time I try and quit smoking, I go strategy through some type of dramatic event to where I need [a] cigarette. And I’m not gonna buy a I ain’t gonna buy a pack because...[if] I buy ... a pack, I’m gonna smoke more. When I buy pack pretty sure no one else [is] gonna buy loose ones, I smoke less. (male, age 55) a pack. They just promise themselves they’re gonna quit. You’re just gonna think to your- Because if I have a pack, I will smoke self...just one more cigarette...it’s just one- because they [are] mine, because I bought it’s just two, but eventually...youbackup ‘em, and I smoke. But if I have just one or [smoking more cigarettes]. We’re not gonna two [singles], I’ll take my time. (male, have a big quit and leave if loose ones are age 49) around at all. (male, age 24)

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I stop smoking for a period, until a loosie strategies specific to purchasing singles: (i) avoid come up. I mean, a single cigarette come up. contact with individual sellers or (ii) if they had Got singles, and I want one, so I get one. contact with the seller(s), to tell the seller they (male, age 58) quit smoking to avoid peer pressure from the sel- Downloaded from https://academic.oup.com/her/advance-article/doi/10.1093/her/cyab014/6343133 by guest on 01 October 2021 ler(s) to buy singles. Moreover, participants noted Theme 4: perceived severity other cognitive behavioral strategies similar to broader evidence-based cessation approaches To assess participants’ perceived severity of using [38] including distractions to avoid buying sin- singles, we asked questions including, ‘Do you think gles and using nicotine replacement therapy to loosies impacts your smoking?’; ‘How concerned manage nicotine withdrawal symptoms [39]. are you that using loosies could increase your smok- ing?’; ‘How serious is using loosies to you?’; ‘How Cognitive behavioral strategies serious is using loosies to your health?’ Participants associated the significance of purchasing and using ...where they are usually selling them, don’t singles with the serious health risks of cigarette go that route. (female, age 53) smoking. Notably, a ‘cigarette was a cigarette’, and Maybe I just lie to them [loosie sellers], I’ve cigarettes had a deleterious impact on the partici- quit smoking for awhile and I hope I can pant’s health irrespective of how they were acquired. keep it up. (male, age 40)

Purchasing and using single cigarettes are If I start craving a cigarette and...I’m tryna synonymous with cigarette smoking quit, I’m like okay I want a cigarette but I ...when you think of quitting, and loosies, don’t, I don’t wanna keep smoking so let me and packs of cigarettes, you have to put like distract myself. Let me go you know, go on the pack and the loosies [together], ‘cause it’s the computer, or go for a walk and not even all the same product. (female, age 55) think about a cigarette. (female, age 24)

It’s [loosies are] just as serious as a pack to Nicotine replacement therapy your health...100%...to my health, I think it I would say [I could] probably [use] some is very serious because I probably don’t smoke nicotine products, like nicotine patches or as much with loose ones as I would with a gum. (male, age 31) pack but smoking is smoking. (male, age 24) When I was reporting at the ... hospital, I It’s real serious...because whether you’re had the patches, had the gum, I did try those smoking loosies or the whole pack, it’s still a to help me, uh, kind of stop [smoking]. cigarette...it’s still dangerous to your (male, age 33) health... now [you] have the box [pack] to read the warning label, but that loosie came Theme 6: self-efficacy out of that same box with the warning label on it...(male, age 49) We asked participants how confident they felt in their ability to: (i) reduce their use of singles (i.e. ‘How confident are you that you can reduce your Theme 5: strategies to reduce single loosie use?’) and (ii) utilize strategies they identified cigarette purchase and use to reduce single cigarette use (i.e. ‘How confident ‘What can you do to reduce your use of loosies?’ are you that you can use these strategies?’). was asked to identify strategies participants Participants expressed a range of confidence from would be willing to utilize to support behavior ‘not confident at all’ (male, age 49), to ‘slightly change. They described two cognitive behavioral [confident]’ (female, age 55), to ‘very confident’

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(female, age 37). Similarly, self-efficacy beliefs their initial beliefs of low perceived susceptibility; towards identified strategies varied across partici- followed by their own experiences where buying pants, with some participants reporting ‘not [being] singles had increased their daily smoking pattern. confident at all’ (male, age 49) to others stating, Most of the participants believed they would smoke Downloaded from https://academic.oup.com/her/advance-article/doi/10.1093/her/cyab014/6343133 by guest on 01 October 2021 ‘I’m very confident’ (female, age 24). more cigarettes daily if they had access to a full pack of 20 cigarettes. The majority, however, stated Discussion they typically make many daily visits to sellers and purchase multiple single cigarettes per visit. This in- formation suggests users are smoking more from This study’s findings provide an initial understand- buying singles than they perceive. Users may be re- ing of beliefs related to reducing single cigarette use ceptive to novel health education curricula focused among low-income, African American smokers on the risks of maintained/increased smoking pro- residing in two urban U.S. cities. Prior studies pensity from single cigarette use. Health educators document single cigarette use and its associations can use these findings to motivate reductions in sin- with persistent smoking behavior [13, 15, 17, 18, gle cigarette use by: (i) educating users about these 40, 41, 42]. Our findings extend prior research by susceptibility risks supported by research findings identifying modifiable beliefs, including perceived and (ii) assisting users in identifying specific scen- benefits, perceived susceptibility and self-efficacy arios where buying singles have negatively that resonate with low-income, urban, African impacted their own daily smoking patterns. American smokers. These beliefs can be included in Perceived benefits from reducing single cigarette the development of future health education curricula use were immediate, short-term health benefits targeting single cigarette use designed for this prior- related to the point-of-sale of singles rather than ity, hard-to-reach population. We used the Health increasing the likelihood of quitting smoking. By Belief Model and its constructs as the theoretical reducing their single cigarette use, participants framework to guide our understanding of these perceived they would subsequently reduce their risk beliefs and to capture a promising pathway to of exposure to potentially poor, personal hygiene promote behavior change in future research. practices from sellers and other buyers who may Similar to susceptibility perceptions captured have handled the pack from which singles were herein, past studies have found single cigarette users being sold. This interesting finding can be used to to endorse gradual cessation and sustaining light develop health education messaging, which is dir- smoking behavior (i.e. non-daily smoking) [9, 15, ectly tied to the purchasing and use of singles (in 43] as reasons for use. Despite these perceptions, comparison with smoking cessation), and the need seeing singles sold can serve as a cue to smoke [16]. to focus on hygiene practices as a promising strategy Also, single cigarette use is associated with a higher for single cigarette users regardless of their motives likelihood of being a current smoker [40]andfailed for purchasing singles (e.g. financial constraints, quit attempts [18, 44]. Overall, the low perceived interest in gradual cessation). These perceived bene- susceptibility that single cigarette use perpetuates fits focusing on the potential spread of germs during persistent smoking behavior demonstrates the need point of sale may also indicate participants’ predom- to communicate these risks to single cigarette users, inantly low susceptibility beliefs that using singles especially those interested in quitting smoking. does not maintain/increase smoking behavior, The semi-structured, in-depth interviews we con- nor does it reduce opportunities for cessation. ducted allowed for interviewer/participant dialogue Approximately 32% of smokers in this study were that shed light on health education strategies to in- not interested in quitting smoking and may not have crease perceived susceptibility. When prompted by considered cessation as a benefit to reducing single interview questions related to the HBM construct of cigarette use for themselves. Additionally, cessation perceived susceptibility, some participants shared may be viewed as a long-term health benefit

8of12 Beliefs related to reducing single cigarette use whereas minimizing exposure to more immediate calculate the monetary costs related to purchasing health concerns may have more meaningful impli- singles to reduce beliefs about this barrier. Also, cations (e.g. ability to go to work, care for children) participants identified strategies they were receptive for this population. Furthermore, this health risk per- to using to increase their self-efficacy. These strat- Downloaded from https://academic.oup.com/her/advance-article/doi/10.1093/her/cyab014/6343133 by guest on 01 October 2021 ception regarding buying singles puts one at risk of egies included remaining busy and finding distrac- contracting infectious diseases (e.g. cold, flu) may tions to avoid buying singles, avoiding triggers to be particularly valuable with the emergence of purchasing singles and using nicotine replacement COVID-19 and its adverse prognosis associated therapy to manage withdrawal symptoms related to with smoking [42]. Smokers with greater beliefs of smoking. These health education topic areas align perceived benefits may reduce their purchasing and seamlessly with existing health education content in use of singles to minimize their exposure to broader, evidence-based smoking cessation pro- infectious diseases including COVID-19. Another grams. These topics could be easily integrated into perceived benefit that emerged was reducing the cessation programs serving African American risk of buying fake or counterfeit cigarettes. smokers who use singles. Potential health education curricula targeting these Importantly, other perceived barriers to reducing perceived benefits can illustrate (e.g. via vignettes) single cigarette use that emerged in this study were the transmission of infectious agents (e.g. bacteria, less modifiable targets for behavior change. The viruses) from person to person through sharing a convenience of purchasing singles because of their cigarette pack and the health risks associated with high availability and accessibility in the physical en- smoking a cigarette containing unknown ingre- vironment were characterized as perceived barriers dients. Nonetheless, given the nature of these topics andhavebeenreportedinpreviousresearchasthe within the social context of purchasing singles and top reasons for purchasing singles [40, 43]. These understanding singles’ role in the informal economy perceived barriers indicate how factors beyond the within specific communities [43, 45], development of individual level of the socioecological model (i.e. such health education content requires a community- community and interpersonal levels) affect single engaged approach involving African American single cigarette use. A comprehensive, multi-pronged solu- cigarette sellers/buyers, community members such as tion is needed. Understanding the social and commu- stakeholders from local organizations, as well as nity context associated with single cigarette use in researchers, health educators and smoking cessation future research is crucial to addressing these individ- counselors who serve this priority population. ual level perceived barriers and single cigarette Our findings suggest users who are motivated to use in low-income, urban communities of color. quit smoking may be most receptive to reducing sin- Enforcement approaches including educating gle cigarette use. Health education content about the retailers about tobacco control regulations regarding risks of single cigarette use, perceived benefits and single cigarettes may complement individual level benefits from quitting smoking altogether versus health education approaches targeting this behavior. light smoking, can be coupled with an individual- This study is among the first to examine beliefs ized cessation plan. Individualized plans to reduce related to reducing single cigarette use among low- single cigarette use, such as tracking how many sin- income, urban, African American smokers. gles are purchased and smoked daily, could help Nonetheless, our findings should be interpreted in users understand their actual patterns of smoking light of study limitations. While our findings only from singles. One perceived barrier to reducing represent this group of single cigarette users, we single cigarette use was the immediate low cost of believe there are common elements of their singles per unit compared with a pack of cigarettes. experiences that may be salient for other samples of Participants reported paying 50 cents per single, single cigarette users. Moreover, we demonstrate which is costlier than the per unit cost of a cigarette the feasibility and acceptability of utilizing within a pack. Individualized plans can help users community-based organizations and engaging with

9of12 L. Phan et al. single cigarette users to learn about their experien- for their support. We thank the local community ces with single cigarette use, an illegal tobacco con- centers and libraries for providing space to conduct sumption behavior. We believe this study serves as study sessions. Importantly, we graciously thank a critical capacity-building step for future health the participants for their contributions to this Downloaded from https://academic.oup.com/her/advance-article/doi/10.1093/her/cyab014/6343133 by guest on 01 October 2021 education programs designed specifically to address research. single cigarette use among urban, African American smokers residing in low-income, underserved Funding communities. This study sample included a hard-to-reach, di- This study is supported by the National Cancer verse group of single cigarette users with varying Institute, National Institutes of Health (NIH) and smoking characteristics, including intent to quit the Food and Drug Administration (FDA) Center smoking from Baltimore, MD and DC. Our findings for Tobacco Products under grant number suggest how health education approaches to address P50CA180523. The research sponsors had no role single cigarette use may vary based on primary in the study design; in the collection, analysis, and reasons for use. For example, those who purchase interpretation of data; in the writing of the report; singles due to financial constraints and are inter- and in the decision to submit the paper for publica- ested in maintaining their smoking behaviors may tion. The content is solely the responsibility of the endorse HBM beliefs different from those interested authors and does not necessarily represent the offi- in cessation. Though we preliminarily examined cial views of the NIH or the FDA. self-efficacy as a modifiable HBM construct, we did not assess how one’s degree of self-efficacy impacts Conflict of interest statement her/his/their willingness to engage in a specific cognitive behavioral strategy to reduce their single None declared. cigarette use. Future research is needed to further explore self-efficacy for specific cognitive behavioral strategies and examine the influence of References nicotine dependence and preference of mentholated cigarettes on the HBM beliefs captured in this study. 1. CDCTobaccoFree. Centers for Disease Control and Prevention. Tobacco-Related Disparities. Available at: Overall, the purchase and use of singles among low- https://www.cdc.gov/tobacco/disparities/index.htm. Last income, urban, African American smokers warrant accessed: 3 February 2020. culturally appropriate health education campaigns 2. CDCTobaccoFree. Centers for Disease Control and Prevention. African Americans and Tobacco Use. Available and programs on single cigarette use to mitigate its at: https://www.cdc.gov/tobacco/disparities/african-ameri role in tobacco-related health disparities. Our find- cans/index.htm. Last accessed: 18 November 2019. ings describe potential health education targets to 3. CDCTobaccoFree. Centers for Disease Control and Prevention. Burden of Tobacco Use in the U.S. Available inform the development of such approaches. at:https://www.cdc.gov/tobacco/campaign/tips/resources/ data/cigarette-smoking-in-united-states.html. Last accessed: 21 March 2020. 4. Alexander LA, Trinidad DR, Sakuma K et al. Why We Must Acknowledgements Continue to Investigate Menthol’s Role in the African American Smoking Paradox. Nicotine & Tobacco Research : The authors would like to thank the Deputy Chief official Journal of the Society for Research on Nicotine and Tobacco 2016;18 Suppl 1:S91–101. 10.1093/ntr/ntv209 Executive Officer of the Community Wellness 26980870 Alliance/Fiscal Agent Representative of the D.C. 5. Kulak JA, Cornelius ME, Fong GT, Giovino GA. Tobacco Free Coalition for their insights regarding Differences in Quit Attempts and Cigarette Smoking Abstinence Between Whites and African Americans in the the sale of single cigarettes in DC and posting United States: Literature Review and Results From the study flyers. We thank the Agents of Change International Tobacco Control US Survey. Nicotine & Writing Group, Maryland Center for Health Equity Tobacco Research : official Journal of the Society for

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