摘要：Objectives. We examined the mechanisms by which living in a disadvantaged minority community influences smoking and illegal cigarette sale and purchasing behaviors after a large cigarette tax increase. Methods. Data were collected from 14 focus groups (n=104) that were conducted during the spring of 2003 among Blacks aged 18 years and older living in New York City. Results. A large tax increase led to what focus group participants described as a pervasive illegal cigarette market in a low-income minority community. Perceived pro-smoking community norms, a stressful social and economic environment, and the availability of illegal cigarettes worked together to reinforce smoking and undermine cessation. Conclusions. Although interest in quitting was high, bootleggers created an environment in which reduced-price cigarettes were easier to access than cessation services. This activity continues to undermine the public health goals of the tax increase. Raising cigarette prices is one of the most effective means of reducing tobacco use. 1 In 2002, 16 states increased their cigarette taxes; New York State was among this group. In April 2002, the state increased the cigarette tax from $1.11 to $1.50 per pack. In July 2002, on top of this increase, New York City (NYC) increased its local excise tax from $.08 to $1.50. At $3.00, NYC has the second highest excise tax in the United States. 2 Retail prices currently average $7.50–$8.00 per pack. Data from the 2003 NYC Department of Health and Mental Hygiene’s Community Health Survey (CHS), a telephone-based survey of 10 000 NYC residents, indicated an unprecedented 11% decrease in smoking prevalence that corresponded with the tax increases. Smoking rates fell from 21.6% in 2002 to 19.2% in 2003. Further, the CHS found that Black individuals and low-income persons were more likely than White individuals and higher-income persons to report that the tax increase had some impact on their smoking (e.g., reduced amount smoked, tried to quit, or succeeded in quitting). 3 However, immediately after the city and state cigarette tax increased, local newspapers reported a “flood” of cigarette smuggling into NYC and a rise in illegal street sales of untaxed cigarettes, particularly in low-income neighborhoods. 4 , 5 Popular brands, it was reported, could be bought on the streets from bootleggers for as little as $5.00 per pack. Moreover, the CHS showed an 89% increase in cigarettes purchased through alternative sales channels. The CHS did not directly ask smokers about cigarettes purchased illegally on the street, but the study did find that, of cigarettes purchased elsewhere, 29% were bought within New York State but outside NYC; 21.7% in a different state; 18.1% over the Internet; and 12.4% from another person. 3 Purchases of untaxed cigarettes from another person were more common among Blacks compared with all other ethnic groups 3 and were clustered in low-income neighborhoods (NYC Department of Health and Mental Hygiene, unpublished data, 2003). Although smoking in the United States has declined, in part because of effective statewide tobacco control programs and polices, disparities in smoking prevalence by socioeconomic status appear to be widening. 6 – 11 Adults living below the poverty line have higher smoking rates (29.1% vs 20.6%) and are less likely to quit successfully compared with those living at or above the poverty line. 7 , 9 , 10 , 12 Explanations for these phenomena include stress associated with poverty and isolation, lower levels of education, and targeting of low-income neighborhoods by the tobacco industry. 13 – 15 Disparities in health behaviors may also result from material and social characteristics of the neighborhood environment that shape the social context of people’s lives, which perhaps diminishes the predicted effect of polices such as tax increases in ways that are poorly understood. 14 , 18 – 22 Despite quantitative evidence of tax avoidance in response to cigarette tax increases 3 , 23 – 26 and a recent survey that found support for cigarette taxes among Blacks, 27 no studies have examined how living in a disadvantaged minority neighborhood shapes the impact of smoking policies on individual tobacco use. We responded to the gap in research on the differential consequences of tobacco policies in underserved neighborhoods 28 by conducting the first study using qualitative analysis to examine these issues among a primarily Black population in the United States. We offer explanations for the mechanisms by which living in a disadvantaged community may influence smoking and illegal purchasing patterns after a tax increase.
