HEALTH EDUCATION RESEARCH ‘We’re not gonna have a big quit if loose ones are around’: urban, African American smokers’ beliefs concerning single cigarette 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. loosies, loose ones, single cigarette use among urban, African singles) poses risks for smoking 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 tobacco-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 cigarettes 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 smoking cessation 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 Tobacco Control 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].