Loose Cigarette Purchasing and Nondaily Smoking Among Young Adult Bar Patrons in New York City

Loose cigarette purchase and adolescent smoking in Indonesia: a mixed-methods study

OBJECTIVES

To investigate the relationship between purchasing loose cigarettes and adolescent smoking habits in Indonesia.

DESIGN AND SETTING

This study employed a mixed-methods sequential explanatory design. We analysed the secondary data from a national survey, the 2019 Global Youth Tobacco Survey, using multivariable logistic regression models to examine the association between loose cigarette purchase and smoking frequency and intensity and nicotine dependence. Based on the quantitative findings, we arranged focus group discussions (FGDs) in junior and senior high schools located in South Jakarta, Indonesia. The qualitative data were analysed using thematic analysis with an inductive approach to explore experiences in purchasing loose cigarettes and how it affected their smoking initiation and current cigarette consumption.

PARTICIPANTS

For quantitative study, we included 785 samples after excluding the non-current smokers and those who had missing responses. For qualitative study, a total of 49 eligible students who met inclusion criteria (ever or current smokers, buying loose cigarettes and living with parents) and agreed to participate in FGD were later divided into 12 FGD groups.

RESULTS

Most students who smoked in the past 30 days are male (95%). More than half of the students (68%) reported buying loose cigarettes in the past 30 days, including 36% who smoked 1-2 days in a month and 34% who usually consumed one cigarette a day. One-third of the students had nicotine dependence (30%), with an average smoking duration of 3 years. Purchasing loose cigarettes in the past 30 days was significantly correlated with smoking for <20 days in the past month (adjusted OR (AOR)=1.56; 95% CI=1.17 to 2.07), consuming ≤5 sticks per day (AOR=2.15; 95% CI=1.54 to 3.00) and having lower nicotine dependence (AOR=1.55; 95% CI=1.08 to 2.22). Our qualitative findings further reported that affordability and accessibility were the main reasons that encouraged current student smokers to opt for loose cigarettes over other types of cigarettes (packs, cartons or rolled tobacco). Students reported the extensive selling of loose cigarettes and such a situation persuaded them to buy tobacco products more frequently, thus spending at least half of their weekly allowance on tobacco products, ranging from 30 000 to 200 000 Indonesian rupiah or equivalent to US$2-13 per week. Finally, our study highlighted that only a few students in this study either had to show their identity card or were denied when purchasing loose cigarettes in informal retailers.

CONCLUSION

Our study demonstrates that students purchasing loose cigarettes is significantly associated with non-daily smoking, consuming five or fewer sticks per day, and lower addiction which could be interpreted as smokers in the experimental phase. They possessed a higher risk of becoming regular smokers. Our qualitative findings supported the quantitative study by shedding light on the role of loose cigarettes in smoking initiation and continuation among young people. In this case, we supported the notion of prohibiting loose cigarette sales in the country in order to reduce smoking uptake and tobacco consumption among the younger generation.

An overlooked market: loose cigarettes, informal vendors and their implications for tobacco taxation

OBJECTIVE

To examine the features of markets for loose cigarettes in several low-income and middle-income countries and their effects on tobacco control policies, particularly taxation.

DESIGN

An analysis of survey data targeting people who smoke in two African, one Southeast Asian and two South Asian countries and retailers across 16 African countries to study loose cigarette markets and examine how prices in these markets move relative to the prices for cigarette packs.

RESULTS

Markets for loose cigarettes are large, and their consumer base tends to differ from the wider population of people who smoke. Loose cigarette prices are on average higher than those of cigarettes bought in packs, and they respond differently to tax increases, at least partially due to a denomination effect.

CONCLUSIONS

The features of the loose cigarette markets present a challenge for tobacco control policy, especially tobacco tax policy. One way to overcome this challenge is to aim for large, rather than incremental, tax increases.

[The sale of single cigarettes in Brazil from 2008 to 2019: one more cause of concern?]

In Brazil, the sale of cigarettes is only allowed in closed packages with 20 units. The evolution over time of the proportion of adult smokers who purchased single manufactured cigarettes in their last purchase was evaluated. Data from the Global Adult Tobacco Survey conducted in 2008 and the Brazilian National Health Survey conducted in 2013 and 2019 were used. A generalized linear model was used to calculate the differences in the proportion of single cigarette purchases between the survey years, adjusted for sociodemographic and smoking behavior variables. Considering 2013 as the reference year, the relative differences in the proportions were, respectively, -15.3% (adjusted p-value ≤ 0.05) when compared to 2008, and +13.3 (adjusted p-value = 0.08) when compared to 2019. Approximately 20% of young adult smokers reported buying single cigarettes in 2019 and the difference in the proportion of single cigarette purchases between individuals aged 18 to 24 and those older likely increased from 2013 to 2019 (adjusted interaction p-value = 0.08). There are reasons for concern, as the strengthening of tax policy from 2008 to 2013 was accompanied by an increase in the proportion of purchases of single cigarettes. Despite the decrease in the real price of cigarette packs from 2017, a context of low effectiveness of implementation of other anti-smoking measures likely accentuated the difference in the proportion of purchase of single cigarettes between young people and adults. The continued presence of single cigarettes as a mode of acquisition contributes to economically vulnerable population subgroups becoming and/or remaining dependent on smoking behavior.

The State of Norm-Based Antismoking Research: Conceptual Frameworks, Research Designs, and Implications for Interventions

This synthesis review examined 189 qualified studies on norms and smoking in terms of conceptual frameworks, types of social norms, research designs, dependent variables, independent variables and covariates, and findings related to norms. Results show that 7.9% were experimental, and the remaining were cross-sectional. By far, the reasoned action approach (RAA) was the most-cited theory, but RAA was not used to guide experimental designs. The social norms approach, norm focus theory, social cognitive theory guided the intervention experiments. Harmful norms were more frequently examined than healthful norms. Pro-smoking norms positively predicted smoking intentions and behaviors, whereas antismoking norms positively predicted antismoking intentions and behaviors. The over-application of RAA in cross-sectional antismoking research has yielded repetitive findings. Norm-based experiments can adopt other theoretical perspectives to offer insights into antismoking interventions. The RAA constructs are still applicable and can be integrated into intervention designs.

Impact of Health Warning Labels on Cigarette Packs in India: Findings from the Global Adult Tobacco Survey 2016-17

Two rounds of Global Adult Tobacco Survey (GATS) were conducted in 2009-10 and 2016-17 in India. These two surveys provide national comparable data on tobacco usage and its related aspects in India. This study used the data from GATS 2016-17 to examine the salience and impact of cigarette pack pictorial health warnings (PHWs) on quit intention among current cigarette smokers in India. The nationally representative survey interviewed 74, 037 respondents aged ≥15 years with an overall response rate of 92.9% using a multi-stage sampling method. Results of multivariate analysis showed that the strongest predictor for quit intention because of health warnings was "ever made a quit attempt in the past 12 months" and buying cigarette packs instead of loose cigarettes. Compared to GATS 2009-10, GATS 2016-17 observed an increase in salience of cigarette health warnings by 16% and increase in the impact of PHWs on quit intention by 50%. PHWs have a significant impact on intention to quit among cigarette smokers in India with a rising trend. The efforts of Government of India in terms of periodic introduction of new PHWs and increase in the size of warning labels to 85% of the cigarette packs is laudable. The study results support ban on loose cigarettes and warrants stricter implementation of the act prohibiting sale of loose cigarettes.

'We're not gonna have a big quit if loose ones are around': urban, African American smokers' beliefs concerning single cigarette use reduction

Single cigarette use (i.e. loosies, loose ones, singles) poses risks for smoking continuation among urban, African American smokers. There is, however, limited research to inform health education interventions addressing this behavior. We conducted 25 in-depth interviews with urban, African American users (ages 20-58 years) from Baltimore, MD and the District of Columbia in June and July 2018 to assess their beliefs about reducing single cigarette use. Interviews were guided by the Health Belief Model and its constructs of perceived benefits, perceived barriers, perceived susceptibility, perceived severity and self-efficacy. We analyzed qualitative data using framework analysis. Perceived benefits of reducing single cigarette use involved the avoidance of health risks, including concerns about buying fake cigarettes and exposure to unknown personal hygiene practices from sellers. Perceived barriers were the convenience of buying singles due to their availability, accessibility and low cost. Participants shared they were willing to use cognitive behavioral strategies to reduce their purchasing and use of singles. This study provides insights on potential intervention targets related to beliefs towards reducing single cigarette use. These findings can inform enforcement policies and health education interventions targeting single cigarette use among urban, African American smokers who use singles.

Cigarettes smoked among daily and non-daily smokers following CVS Health's tobacco-free pharmacy policy

INTRODUCTION

In September 2014, CVS Health ceased tobacco sales in all of its 7700 pharmacies nationwide. We investigate the impact of the CVS policy on the number of cigarettes smoked per day among metropolitan daily and non-daily smokers, who may respond to the availability of smoking cues in different manners.

METHODS

Data are from the US Census Bureau Tobacco Use Supplement to the Current Population Survey 2014-2015 and the Blue Cross and Blue Shield Institute Community Health Management Hub. Adjusted difference-in-difference (DID) regressions assess changes in the number of cigarettes smoked per day among daily smokers (n=10 759) and non-daily smokers (n=3055), modelling core-based statistical area (CBSA) level CVS pharmacy market share continuously. To assess whether the policy had non-linear effects across the distribution of CVS market share, we also examine market share using tertiles.

RESULTS

CVS's tobacco-free pharmacy policy was associated with a significant reduction in the number of cigarettes smoked by non-daily smokers in the continuous DID (rate ratio=0.985, p=0.022), with a larger reduction observed among non-daily smokers in CBSAs in the highest third of CVS market share compared with those living in CBSAs with no CVS presence (rate ratio=0.706, p=0.027). The policy, however, was not significantly associated with differential changes in the number of cigarettes by daily smokers.

CONCLUSION

The removal of tobacco products from CVS pharmacies was associated with a reduction in the number of cigarettes smoked per day among non-daily smokers in metropolitan CBSAs, particularly those in which CVS had a large pharmacy market share.

Single cigarette purchasers among adult U.S. smokers

Cigarette smoking remains the leading preventable cause of morbidity and mortality. The purchase of single cigarettes, known as loosies, allows for a more affordable cost than a pack of cigarettes. Many of the existing studies on loose cigarettes have used a small non-generalizable sample. This study examined the sociodemographic characteristics of loosie purchasers among adult cigarette smokers in the United States. Data from the 2006/07-2014/15 Tobacco Use Supplement to the Current Population Survey were analyzed. The sociodemographic characteristics of loosie users were examined by multivariable logistic regression. In 2014-2015, approximately 5.4% of adult smokers reported purchasing loosies compared to 3.7% in 2006-2007. Men (OR 1.22, 95% CI 1.10-1.35), non-Hispanic Blacks (OR 3.30, 95% CI 2.89-3.77), Hispanics (OR 1.97, 95% CI 1.67-2.32), and those living in a metropolitan area (OR 1.16, 95% CI 1.02-1.33) had significantly higher odds of single cigarette purchase. Single cigarette use also varied by age, marital status, employment, and geographic region. Menthol cigarette smokers had higher odds of purchasing loosies compared to non-menthol smokers. Likewise, cigarette quit intention was significantly associated with odds of buying loosies. The prevalence of single cigarette purchases among smokers appears to be lower in a national sample compared to previous estimates reported in specific populations. However, certain subpopulations were more likely to purchase a single cigarette and may contribute to persistent disparities among racial and ethnic minorities. Preventing the sale of loosies may improve the health outcomes of underserved communities, specifically those with low socioeconomic status.

"I'm gonna get me a loosie" Understanding single cigarette purchases by adult smokers in a disadvantaged section of New York City

This study seeks to update and expand our understanding of the perceptions and purchasing patterns of smokers of single cigarettes (‘loosies’) in disadvantaged urban areas. Semi-structured guides were used in thirteen focus groups with 67 self-identified adult smokers from the South Bronx section of New York City in summer 2013.

There is wide availability of single cigarettes in the South Bronx, with legitimate stores overwhelmingly being the preferred venue for purchases. Single cigarettes are sold at higher per-unit prices than illicit packs. However, buyers of single cigarettes can achieve cost savings compared to legal, fully taxed cigarette packs. Apart from cost-savings, smokers opt for single cigarettes to reduce their personal cigarette consumption. There is a general perception of market resilience despite law enforcement intervention. However, law enforcement has a limiting effect on access to single cigarettes outside of an individual smoker's immediate neighborhood.

The findings suggest that single cigarette sales are an important element of the illicit cigarette market in disadvantaged communities which should not be ignored in future research on the nature and extent of cigarette tax avoidance and evasion.

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Local stores are the preferred venue for single cigarette (loosie) purchases.

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Some smokers report buying loosies when lacking the funds for buying packs.

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Some smokers report buying loosies to control their smoking habit.

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Single cigarettes are an integral part of the selling of bootlegged cigarettes.

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Single cigarettes tend to cost more per unit than illicit packs but less than legal packs.

Recruiting Hard-to-Reach Populations for Survey Research: Using Facebook and Instagram Advertisements and In-Person Intercept in LGBT Bars and Nightclubs to Recruit LGBT Young Adults

Background

Tobacco public education campaigns focus increasingly on hard-to-reach populations at higher risk for smoking, prompting campaign creators and evaluators to develop strategies to reach hard-to-reach populations in virtual and physical spaces where they spend time.

Objective

The aim of this study was to describe two novel recruitment strategies (in-person intercept interviews in lesbian, gay, bisexual, and transgender [LGBT] social venues and targeted social media ads) and compares characteristics of participants recruited via these strategies for the US Food and Drug Administration’s This Free Life campaign evaluation targeting LGBT young adults who smoke cigarettes occasionally.

Methods

We recruited LGBT adults aged 18-24 years in the United States via Facebook and Instagram ads (N=1709, mean age 20.94, SD 1.94) or intercept in LGBT social venues (N=2348, mean age 21.98, SD 1.69) for the baseline evaluation survey. Covariates related to recruitment strategy were age; race or ethnicity; LGBT identity; education; pride event attendance; and alcohol, cigarette, and social media use.

Results

Lesbian or gay women (adjusted odds ratio, AOR 1.88, 95% CI 1.54-2.29, P<.001), bisexual men and women (AOR 1.46, 95% CI 1.17-1.82, P=.001), gender minorities (AOR 1.68, 95% CI 1.26-2.25, P<.001), and other sexual minorities (AOR 2.48, 95% CI 1.62-3.80, P<.001) were more likely than gay men to be recruited via social media (than intercept). Hispanic (AOR 0.73, 95% CI 0.61-0.89, P=.001) and other or multiracial, non-Hispanic participants (AOR 0.70, 95% CI 0.54-0.90, P=.006) were less likely than white, non-Hispanic participants to be recruited via social media. As age increased, odds of recruitment via social media decreased (AOR 0.76, 95% CI 0.72-0.80, P<.001). Participants with some college education (AOR 1.27, 95% CI 1.03-1.56, P=.03) were more likely than those with a college degree to be recruited via social media. Participants reporting past 30-day alcohol use were less likely to be recruited via social media (AOR 0.33, 95% CI 0.24-0.44, P<.001). Participants who reported past-year pride event attendance were more likely to be recruited via social media (AOR 1.31, 95% CI 1.06-1.64, P=.02), as well as those who used Facebook at least once daily (AOR 1.43, 95% CI 1.14-1.80, P=.002). Participants who reported using Instagram at least once daily were less likely to be recruited via social media (AOR 0.73, 95% CI 0.62-0.86, P<.001). Social media recruitment was faster (incidence rate ratio, IRR=3.31, 95% CI 3.11-3.52, P<.001) and less expensive (2.2% of combined social media and intercept recruitment cost) but had greater data quality issues—a larger percentage of social media respondents were lost because of duplicate and low-quality responses (374/4446, 8.41%) compared with intercept respondents lost to interviewer misrepresentation (15/4446, 0.34%; P<.001).

Conclusions

Social media combined with intercept provided access to important LGBT subpopulations (eg, gender and other sexual minorities) and a more diverse sample. Social media methods have more data quality issues but are faster and less expensive than intercept. Recruiting hard-to-reach populations via audience-tailored strategies enabled recruitment of one of the largest LGBT young adult samples, suggesting these methods’ promise for accessing hard-to-reach populations.