Buying and Selling “Loosies” in Baltimore: The Informal Exchange of Cigarettes in the Community Context

Abstract

Since the release of the first Surgeon General’s report, the proportion of adult smokers in the U.S. has been reduced by half (U.S. Department of Health and Human Services, 2004). This success has not, however, been equally felt across all social strata. Recent survey data from Baltimore show considerably elevated smoking rates within urban, African-American communities. Of particular concern was that in some communities, over half of the young adults (18–24 years old) smoke cigarettes. As yet, there has been little focus on understanding or preventing cigarette smoking among young adults, particularly for those seeking entry into the workforce rather than being engaged in higher education. In this paper, we explore community factors contributing to high young adult smoking prevalence. Our analysis is based on data from four focus groups conducted in 2004 as part of a community-based participatory research project with two urban education and job training organizations. The focus group data reflect the experiences and opinions of 28 young adult program participants (23 smokers and 5 nonsmokers). The data highlight a normalized practice of buying and selling single cigarettes (“loosies”) within the community, with participants describing buying loose cigarettes as a preferred acquisition practice. We apply theories of informal economy and suggest that this alternative purchasing option may influence the smoking behavior of these young adults. We argue that public health efforts need to more closely consider the impact of community structures on program implementation. Overlooking key community characteristics such as the availability of single cigarettes may serve to intensify health disparities.

INTRODUCTION

Tobacco Use As A Health Disparities Issue

Cigarette smoking remains the leading preventable cause of both morbidity and mortality in the United States, with 20.9% of American adults continuing to smoke.² The geographic variation in smoking prevalence across the U.S. implies a considerable influence of contextual factors on individual smoking behaviors,^3,4 as does the variation in smoking rates between racial/ethnic groups.^5,6 Smoking prevalence is currently reported as 22.2% for whites (non-Hispanic), 20.2% for blacks (non-Hispanic), 15% for Hispanics, and 11.3% for Asians.² Smoking has declined disproportionately for people who are more educated, have skilled jobs, better health, and higher household income than for people who are not already advantaged by these factors,^7–9 such that prevalence is higher for those living in poverty (29.1%) than those who are at or above the poverty level (20.6%). For individuals with a General Education Development (GED) diploma, smoking prevalence is 39.6%, whereas for adults with either a college degree or graduate degree, it drops to 11.7 and 8%, respectively. There is even a marked difference in smoking between adults with a GED and those with a high school diploma (24%).² In the U.S., as in other Western countries, smoking is now associated with low socioeconomic status, with higher rates among those with the fewest resources.¹⁰ Moreover, some researchers are beginning to examine whether there may be an “area effect” of living in a disadvantaged neighborhood,¹¹ such that being a part of a community that is economically, culturally, or physically isolated from mainstream society may serve to foster smoking.

The first step to eradicating disparities in cigarette use is documenting racial and ethnic differences.⁴ To better protect those more likely to smoke, however, it is also necessary to understand why such disparities exist.¹² In particular, there is a need for research on the role that community context plays in exacerbating such differences.⁴ Israel et al.¹³ (p. 525) argue that “[t]he extent to which neighborhood conditions contribute to the health disparities above and beyond the effects of individual or household social status is a matter of considerable interest.” In particular, with ever increasing urbanization, there is a need for greater understanding as to the impact of the urban environment on the health of its residents.¹³

Tobacco Use in Young Adults—A Vulnerable and Understudied Population

The concentration of smoking within vulnerable populations is evident in terms of socioeconomic, ethnic, and geographic differences, but vulnerability to tobacco use is also concentrated within particular age groups. In 2004, 23.6 % of individuals ages 18–24 were current smokers, with young men being slightly more likely to smoke than young women (25.6 vs. 21.5%).² Traditionally, efforts to reduce tobacco use have been divided between preventing youth initiation and helping long-term (usually conceptualized as in middle or old age) smokers to quit.^14,15 As a result, researchers and practitioners have largely overlooked the tobacco control needs of young adults.^15,16 Analysis of tobacco industry documents reveals, however, that young adults have been an important target market for tobacco companies since the mid-1980s.¹⁷ The importance of young adults to comprehensive tobacco control is becoming increasingly recognized,¹⁸ with recent studies indicating that up to one-fifth of smokers begin as adults.^16,19 Moreover, early adulthood (between the ages of 18 and 24) is often the period when the transition is made from initiation to established smoking status.^17,20

There is now a growing body of research examining smoking among college students.²¹ However, despite data from the 1998–1999 Tobacco Use Supplement to the Current Population Survey (CPS-TUS) identifying an increase in the smoking rate among 18–24 year olds of low socioeconomic status, little research has been targeted towards understanding the tobacco control needs of populations, such as inner-city young adults who are not either in work or higher education.^12,22 Young adults may be particularly vulnerable to smoking when they move immediately into the workforce.^23–25 Subsequently, the lack of attention given to the “non-college” young adult population is particularly concerning in terms of lifetime smoking trajectories given the higher smoking prevalence among those employed in primary industry and trades than of those in higher education and clerical/professional positions.¹⁶ Recent research in Baltimore, Maryland found high adult smoking rates (52 %) in inner city, low SES neighborhoods.²⁶ The rates ranged even higher (55–62%) in studies that look at respondents between 18 and 24 years of age separately.^27,28 The majority of young adults surveyed reported buying loosies everyday and also witnessing others selling loosies on the street.²⁷

What is Being Done to Reduce the Tobacco Burden?

Prevention research has typically prioritized educating individuals to influence their knowledge of and attitudes towards unhealthy behaviors such as smoking. The centrality of structural interventions for effective tobacco control has, however, become well established, with environmental influences being seen as important factors in smoking initiation and maintenance.^29,30

Structural interventions include measures such as restrictions to the advertising and marketing environment around tobacco, restrictions on smoking in public (and increasingly private) spaces, and increasing the cost and limiting the availability of cigarettes through taxation and packaging restrictions.

In terms of tobacco control context in our study state, Maryland, as of 2006, ranked 21st (out of 52) for its level of tobacco tax, with a state tax of $1.00 per pack of 20 cigarettes (state taxes ranged from $0.07 in South Carolina to $2.58 in New Jersey).³¹ Maryland last increased its state cigarette tax in 2002, when it went from $0.66 to $1.00. The state tax is in addition to the federal tax of $0.39 per pack. Maryland state law prohibits all cigarette sales other than in a sealed package conforming to federal labeling requirements (with limited enforcement capabilities), and Baltimore City has a law that provides for the enforcement of the prohibition of sale of loose cigarettes. In 2004, Maryland restricted, but did not prohibit, smoking in most public places. There were no provisions at the state level, or in Baltimore City, to limit smoking in bars or clubs.³² In 2007, there is active discussion in Maryland of increasing cigarette taxes by $1.00 per pack to offset the cost of improving access to health care for all state residents and of introducing a comprehensive smoking ban in all public workplaces, including bars and restaurants.

Tobacco Use Among Young Adults in Baltimore

In this paper, we report findings from four focus groups conducted with young adults from one Baltimore community. These focus groups were conducted as formative research within a community-based intervention project seeking to reduce smoking prevalence among African-American young adults in Baltimore City. The research focused on identifying and understanding young adults’ perceptions of and experiences with social and contextual factors that contribute to tobacco use in their community.

Maryland’s population estimate is 5.6 million, and Baltimore is Maryland’s largest city, with a population of 635,000. The demographics of the city vary significantly from that of Maryland overall. Based on data from 2004, 65% of Baltimore’s population is black, and 31% is white. At the state level, the percentages are nearly reversed, with blacks accounting for 29% and whites for 64.5% of the total population. Educational achievement is lower inside city lines. Of Baltimore City residents 25 years of age and older, 68% are high school graduates compared to 83.8% statewide. Close to a third of Marylanders have at least a college education compared to 19% of individuals in Baltimore City. The median household income for Baltimore City residents in 2003 was estimated at $29,066; the state’s average was $54,302. The percentage of city residents living in poverty is more than double that at the state level (19.6% in Baltimore vs. 8.8% in Maryland).³³

Sandtown-Winchester is a residential community of 72 square blocks on the west side of Baltimore City, with a population of 17,495 that is almost entirely African American (97.9%). The community faces a high level of unemployment, low level of educational attainment, and considerable illicit drug problems.²⁶ Despite the adverse socioeconomic conditions in Sandtown-Winchester, there are ongoing transformation initiatives across all sectors—including the education and training programs that are partners in this research. Youth Build-Education and Job Training and Urban Youth Corp Education and Job Training are two locally developed programs organized around education, employment training, and community service. The programs are designed to be responsive both to the needs of the young adults in the local community and the employment needs and opportunities within the city of Baltimore, although Youth Build-Education and Job Training is no longer operating as a part of Baltimore’s Community Building in Partnership initiative. The program leaders from the training programs are partners in a community-based participatory research program with faculty from Johns Hopkins Bloomberg School of Public Health and Morgan State University with the objective of reducing tobacco use among African-American young adults in Baltimore City.

METHODS

In this paper, we explore community level factors that support tobacco use and potentially impede the effectiveness of tobacco control initiatives⁴ among young adults in one Baltimore community. Due to the lack of prior research around the smoking behaviors of young adults who are not in college, the team embraced not only a community-based participatory research approach³⁴ but also a qualitative methodology with a study design that intentionally prioritized exploration and discovery. The formative research component consisted of four focus groups with 28 young adults who were current participants in one of the partner organization programs. Data were collected between April and June 2004. We chose to anchor the project with initial focus group research because this would provide “researchers with access to the language and concepts participants use to structure their experiences and to think and talk about a designated topic.”³⁵ This research built upon a long-standing commitment to community-based participatory research³⁴ and existing partnership between two academic institutions (Johns Hopkins University and Morgan State University) and two community organizations (Youth Build-Education and Job Training and Urban Youth Corp Education and Job Training).

The investigators worked with community leaders to create an advisory board that, in turn, guided all phases of the research. Upon the advice of this board, we chose to conduct three focus groups with smokers and one focus group with nonsmokers. All of the focus group members were also active participants in one of the two job training programs. The advisory board helped plan recruitment and develop a moderator guide for the focus groups that included the following five domains:

1. community and social norms about tobacco use,

2. cigarette buying practices,

3. smoking and socializing,

4. smoking policies.

5. cigarette advertising and marketing.

The research team worked with an experienced focus group moderator. To begin the recruitment process, researchers provided a brief introduction to the project during a regular program meeting. During this time, researchers explained that the objective was to better understand why so many young adults in Sandtown-Winchester smoke and what might be done about it. Several individuals were eager to give responses at this stage and were encouraged to sign up to participate in a focus group. Researchers clarified the intention to include both smokers and nonsmokers and that participants would be compensated with $20 for their time. Formal, written consent was obtained the following week, before starting the focus groups. All research procedures were approved by the Committee on Human Research of the Johns Hopkins Bloomberg School of Public Health.

Focus groups included both men and women but were homogeneous as to current smoking status. All interested program members were invited to participate in the focus groups. Participants included 20 men and 8 women, and 23 smokers and 5 nonsmokers all of whom were between 18 and 24 years of age. All of the participants were African American, and all were full-time members of the education and employment programs (which provided a stipend and precluded them being formally involved in any other education or employment activity). Due to the low number of nonsmokers in the two programs, the nonsmoking group contained both former smokers and individuals who have never smoked. All focus groups were audio-taped, fully transcribed, and analyzed using Atlas.Ti qualitative software. The thematic analysis was primarily inductive and done in consultation with the advisory board. Analysis began with a collective formulation of codes, after which coding was implemented by a single individual (Smith), in constant consultation with the other authors. The emergent themes that were subsequently coded consisted of: cigarette acquisition, tobacco advertising, branding, kids and smoking, smoking restrictions, and reasons for smoking. This paper is focused on an analysis of discussions of cigarette acquisition. In addition to the general coding, more detailed coding involved identification of discussions of: places of acquisition, buying from friends, buying single cigarettes, buying by the carton or pack, bumming cigarettes, acquiring by borrowing or stealing, and buying for reasons of price or convenience. The thematic analysis of the data produced from this coding was again a collaborative process.

In reporting findings from our analysis, we first briefly discuss the social norms around tobacco use. We then focus specifically on the practice of buying and selling loose cigarettes outside of formal sales environments, namely, the practice of community members selling single cigarettes from their person or out of their home. We chose this focus for several reasons. First, the issue of loose cigarette sales in the community represents real discovery—it was not an element of the structure that we anticipated in planning the research, nor has this been adequately documented elsewhere. Existing research has focused solely on the sale of loose cigarettes within stores where packs of cigarettes are also legally sold.^36,37 Second, the issue of the availability of single cigarettes is directly applicable to key policy approaches to reducing tobacco use such as tobacco excise tax increases. Widespread availability of loose cigarettes may contribute to the explanation for the “failure” to reduce smoking prevalence among young adults in Sandtown-Winchester. The sale of “loosies” (single cigarettes) has been identified as problematic because it provides easier access to cigarettes.³⁸ Single cigarettes have also been thought to facilitate youth smoking and contribute to the addiction of young smokers.³⁹ Single cigarettes provide ease of access to tobacco through lowering the cost of a purchase, although the actual cost per cigarette is usually considerably inflated. Finally, understanding cigarette acquisition practices contributes to our understanding of these young adults’ smoking patterns and behavior, and it is therefore, directly relevant for planning future tobacco control research and programs.

FINDINGS

Smoking As A Normalized Behavior

“... wherever you go there are more smokers than there are non-smokers. I don’t care if you go to the grocery store and do a survey I’ll bet that 90% of people in that market smoke cigarettes sometimes.” (focus group 1, unknown speaker)

One of the most striking themes to emerge from the focus group discussions was the extent to which neither smokers nor nonsmokers perceived smoking as particularly problematic. Participants clearly perceived smoking to be generally pervasive. Smoking was seen as normative even by nonsmokers. Among smokers, smoking was seen as acceptable, as long as the smoker was willing to engage in tobacco use as a social or communal activity.

Male 1-2: “The majority of people you see nine times out of ten are smoking.” (focus group 1)¹

Female 3- 2: “Our peers they be smoking.” (nonsmoking focus group)

Moderator: “So, it’s ok if people smoke everywhere?”

(Unknown who is speaking): “Yes, as long as they sharing.” (focus group 2)

Not only did participants perceive that everyone smoked, they did not articulate resistance to either smoking or to being around smoke. Smokers did not indicate either contemplating quitting or having made attempts to quit previously. Rather, the young adults commented that there are prompts for smoking everywhere, without indicating that this was anything that they felt empowered (or compelled) to act against.

Male 4-3: “It’s just something that everybody see everyday. Everywhere you go you see Newport signs.”

Female 4-1: “You will walk in to any store and you see Newport, Kools, and Best Buys.”

Male ID unknown: “In our surroundings it’s like you must smoke.”

Although the participants were prevented from smoking within the building within which their programs were held, the discussions of smoking when socializing within the community also suggested that the participants faced relatively few smoking restrictions in their daily routine.

Male 1-4: “The thing about the clubs, they let you smoke cause when you in the clubs we all of age. When you drink, drinking makes you want to smoke. So you smoke more, they let you smoke cause as long as you’re drinking your going to smoke.”

Male 2-7: “Even the clubs that got signs that say you not supposed to smoke in there they let you smoke in there.”

Female 1-1: “You can smoke in all restaurants I think just about all the ones I been to they ask you nonsmoking or smoking.”

We hypothesize that the completely normalized smoking environment has an impact on the smoking behaviors of young adults living in this community. For the purpose of this analysis, however, we call upon this normalized smoking environment primarily as it pertains to the practice of buying and selling loose cigarettes.

Buying Loosies

The participants in the smoking focus groups made reference to regularly buying loose cigarettes. In some instances, they described the availability of loosies as offering a choice. If you do not “feel like” buying a pack, then you simply buy loosies from someone in the street.

Male 2-5: “It’s both ways—like you can go to the store and get some, and if you don’t feel like paying for a pack—you catch the dude who’s selling loose ones and cop like three or four of them. Then you get like three or four of them and you go about your merry way.”

Other participants described the issue as being one of convenience. It may be that it is simply easier to buy a few cigarettes as part of the daily routine, rather than to make an additional effort to buy a pack.

Male 1-4: “If you like me, I get mine every morning from the newspaper lady; I get 4 for a dollar. She sells newspapers and she got her pack of cigarettes and she sell loose ones to. I be on my way to work ain’t got time to stop.”

Participants described sources of loose cigarettes in positive terms to the extent that they provide smokers with a choice. They commented that they frequently found buying loose cigarettes to be a matter of convenience. Participants did not commonly present the lower financial outlay associated with buying loose cigarettes both from street vendors and local stores out of necessity. Although the unit price of the cigarettes that was discussed in the focus groups (usually 25 cents each or three or four for one dollar) was potentially higher than the price at which a pack of cigarettes could be bought in a local store, the immediate cost of obtaining any cigarettes was far reduced.

Moderator: “Where do you go when you generally buy your cigarettes? Is it from people on the street or is it different kinds of stores where you get your cigarettes?”

Male 2- 7: “Anybody who selling them. Everywhere, you might catch a guy coming down the street selling like that two for five. Somebody might be selling a pack for three dollars. The loose man, you got stores selling loose ones and then you got people...”

Monetary issues were not, however, completely left out of the discussion of buying cigarettes, and loose cigarettes in particular.

Moderator: “So do you usually buy loose ones, packs, cartons?”

Male 4-4: “All depends on how much money you got to buy. You got change, you want a cigarette—go get a loose one. Got enough to get a pack you buy a pack. That’s how it is.”

The smokers did not report exclusively buying loose cigarettes. Instead, they reported regularly choosing the option to buy fewer than 20 cigarettes at one time. The availability of loose cigarettes in the community was seen to provide a choice or option regarding cigarette acquisition that is not necessarily available outside of this community environment.

Selling Loosies

Both smokers and nonsmokers described people selling loosies as being pervasive in the community.

Female 1-1: “Wherever you go at, somebody got cigarettes that you buy.”

Moderator: “You’ve got stores selling loose ones?”

Male 2-7: “Yes, even though it’s against the law, they selling loose ones too. Then you got people who got their personal houses who go out and stack up on cigarettes and you can go to their house and get them for a quarter. Running it like a store.”

Participants also described the ways in which these loose cigarette vendors solicited customers. One can therefore see the sellers as serving both as access points for and marketers of cigarettes in the community.

Male NS1- 1: “Yeah like everywhere you go you see these things going on. You could be walking down a busy place where everybody go shopping and you hear everybody saying ‘Loose ones, loose ones... got loose ones for twenty-five, thirty-five cents.’”

Moderator: “Is that in this community?”

Male NS1- 1: “Yeah.”

Male 2-7: “I wanted to say you can get cigarettes anywhere; guys sell cigarettes on the corner, loose ones, everybody selling cigarettes. Guy come up to, like... ‘I got loose ones, loose ones, loose ones; four for a dollar, three for a dollar.’”

Cigarette sellers were described as being a valuable community resource to the extent that they service the buying preferences of smokers. Furthermore, loose cigarettes were understood to be a semi-legitimate means by which sellers are able to meet economic needs. Participants accepted selling cigarettes as just one of many “hustles” that people might employ to get by.

Moderator: “Who are these people on the streets?”

Female 4-2: “Bums and drug addicts trying to make a dollar to get some money for some drugs for some food.”

Moderator: “So you are talking about homeless people?”

Female 4-2: “Not necessarily homeless, but addicts. People that get high they can’t support their habit they go steal cigarettes from the store and sell them as loose ones. Which is illegal but that’s the way they make their money.”

Male 4-2: “Or they’ll come up on three dollars and three dollars ain’t enough to get what they want to get so they buy a pack and sell loose ones.”

Male 4-2: “ That’s his job. He get it so he can eat. I mean that’s his job that’s way of living. I can’t knock him cause he sells loose ones. It’s just like that’s his hustle, you know what I mean.”

Moderator: “That’s his hustle.”

Male 4-2: “Yeah he might don’t want to get no job or can’t get no job so other than selling drugs he going to sell cigarettes. And that’s how he look at it is why would I you know what I mean stand out here and sell drugs and get a better chance of getting knocked off and catching more time for selling cocaine when I can sell cigarettes.”

The participants described both sides of the economic exchange of loose cigarettes as offering an opportunity to those involved in it. For the buyer, the loose cigarette vendor offers an option when one does not have enough money or is not interested in buying an entire pack. For the seller, the market for loose cigarettes provides a potential source of income, when few other options might be available.

DISCUSSION

One applicable theoretical perspective for understanding the widespread availability of loose cigarettes in Sandtown-Winchester as described by these young adults is that of the informal economy. Theories pertaining to informal economic exchange describe clusters of illegal or semi-legal activities by which people both earn income and acquire goods and services outside of formal economic structures.^40,41 These theories are typically applied to commerce within developing countries,^42,43 but also may be an appropriate model for understanding the sale of single cigarettes in Sandtown-Winchester. Previous research has applied theories of the informal economy to the exchange of cigarettes among school children when access to commercial sources was made increasingly restricted,⁴⁴ whereby markets emerged that were centered around so called “vending peers” who recognized the economic opportunity for selling cigarettes to classmates. In our study, vendors tend not to be schoolchildren, nor necessarily young adults, but rather, people in the community with a need for cash to meet daily living needs (including, but not limited to, money for illicit drugs). Exchange among peers is not fully explored here, but was largely described in terms of reciprocity, rather than economic exchange. Although the theory of informal economy is not explicitly called upon, Wiltshire et al. also linked tobacco control policy (tax increases) with routinized buying of smuggled cigarettes in Scottish communities of high deprivation.⁴⁵

Exchange via informal economic structures routinely means circumventing legal provisions, such as zoning codes, tax liability and business permits.⁴⁶ The success of informal economic activities such as loose cigarette selling can be at least partially attributed to the economic advantage that they yield to the purchaser due to avoiding restrictive and potentially expensive regulation and taxation.⁴¹ Thus, the more restrictive an economic environment, the more opportunities may arise from circumventing or breaking the rules.⁴¹ Based on the participants’ comments, the loose cigarettes routinely being sold in this community appear to either have been stolen or initially purchased legally in a store. The extent to which the cigarettes are offered to the buyers “tax free” is therefore not straightforward. Rather, the economic advantage is centered on the availability of loose cigarettes as a means of providing a quick, easy, and affordable way to purchase tobacco,⁴⁷ even though the actual unit cost is usually considerably inflated. Essentially, by purchasing single cigarettes, one is able to spread out the payment of taxation and vendor mark-up over a period of time.

Driving through Baltimore City, one sees numerous examples of an active informal economy in neighborhoods such as Sandtown-Winchester. People stand on intersections waving their hand in a particular way—known as ‘hacking’ to locals—to indicate that they are looking for a ride and will pay a dollar or two to the driver in return. In the summer months, “icee” stands appear outside the front steps of row houses. It would appear that loose cigarette selling may fit easily into such a model of a local, informal economic exchange. Focus group participants identified that selling single cigarettes shares some properties with selling illicit drugs (with far lower risks). We would also argue that the practice is compatible with the regular practice of street vending other forms of both legitimate and illicit consumer goods, such as newspapers, food items, counterfeit clothing, and accessories.

Informal economic practices such as street sales can be understood as survival strategies that are employed by people who are somehow excluded from the more formal sector.⁴⁶ To this end, the informal economy has frequently been conceptualized as a display of budding entrepreneurship and as a potential source of community strength. Unlike other forms of informal economic exchange, however, the existence of an informal economic structure that accommodates the demand for affordable cigarettes is potentially detrimental to community health.⁴⁶ In the case of loose cigarettes, not only do sellers serve as smoking prompts and symbols of the normalcy of smoking within the community, they are also likely to negatively influence cessation attempts by their prevalence and the relative affordability of single cigarettes.

LIMITATIONS

The decision to embrace a qualitative, exploratory approach to examining cigarette smoking among young adults shaped both the nature of the data and analytic approach. Conducting focus groups enabled us to gather the perspectives and experiences of young adults in one community pertaining to norms around cigarette acquisition and use. The inductive nature of our qualitative approach meant that the analysis was not predetermined via theories imposed on the data from the research team.³⁵ Our findings are, therefore, necessarily specific to the experiences of young adults within one urban, predominantly African-American community in Baltimore, Maryland. We would argue, however, that based upon the applicability of informal economy theory to existing structures in this one community, analogous structures are likely to exist in areas with a similar community context. The interaction between community context and policy interventions is an important area for future study.

Implications For Practice

“We should not make any assumptions that we know what economically rational behavior is in any given circumstance, nor that people would necessarily behave in this way, no matter how limited their resources are.” (p. 286)⁴⁷

Public health advocates have discussed and justified tobacco control efforts such as tax increase initiatives with particular reference to the potential impact on adult and youth smoking behaviors.^48,49 Studies have shown that a 10% increase in the price of cigarettes reduces overall adult consumption by 3–5% and reduces youth smoking by two to three times as much.^50–54 Economic price elasticity theory predicts that as cigarette costs increase, so people will tend to smoke less, with youth and young adults being more sensitive to cost changes due to both their lower income and shorter smoking histories.⁵⁰ While it was beyond the scope of this study to ask focus group participants about how their buying practices and smoking behaviors would be affected by state-based tax increases, it is clear that tobacco use was still very prevalent among young adults in the training programs in this one Baltimore neighborhood. We suggest that, in certain communities, existing economic structures and behavioral norms have considerable power to mediate the impact of price increases on demand for cigarettes.⁵⁵ Stead et al. called for research to identify “features of places” that contribute to elevated smoking rates among residents.¹¹ The community context may prevent reductions in consumption and quitting and therefore further exacerbate existing health disparities. This study suggests that the normalized practice of buying and selling loose cigarettes is one feature that public health advocates should seek to better understand and change.

Our core assertion is that the impact of policy interventions such as tax increases is dependent on the context into which they are introduced. Poland et al. argue that there is a need for social theory that can help to unpack the socially unequal distribution of smoking.⁴ In this paper, we argue that theories of the informal economy are precisely this. For some communities, when government regulation of the market sector is strong, the opportunity is either created or augmented for informal economic activity around single cigarettes.⁵⁶ We do not seek to undermine the appropriateness of tax initiatives as a central tobacco control strategy. Clearly, tax increases are very effective in reducing both prevalence and consumption.⁵⁷ Instead, we wish to draw attention to the need for careful consideration of how certain community structures may modify or mediate a policy’s intended effect and suggest that, in such communities, there is a need for complementary efforts to curtail community-specific practices that serve to undermine prevention and cessation strategies.