ABSTRACT Title of Dissertation: MEASURING THE SINGLE CIGARETTE USE PHENOMENON: SCALE DEVELOPMENT AND VALIDATION Lilianna Phan, Doctor of Philosophy, 2019 Dissertation directed by: Associate Professor, James Butler III, Department of Behavioral and Community Health The practice of single cigarette use perpetuates normative smoking beliefs and increases smoking propensity among urban, African American smokers. Despite the 2009 Family Smoking Prevention and Tobacco Control Act’s ban of single cigarettes, there is a paucity of research to inform the public about the harms of single cigarettes and regulatory enforcement of their sales by the Food and Drug Administration. This dissertation utilized a mixed-method, three-phase design with primary data collection to: 1) examine the social context, beliefs, and attitudes of loosie use; and, 2) develop and validate two theoretically-based scales (i.e., social context and Health Belief Model) on the purchasing and use of loosies by urban, African American smokers. In Phase I, 25 semi-structured, in-depth interviews were conducted to understand the social context and underlying intrapersonal factors related to loosie use. Qualitative data, analyzed using the Framework Method, informed the development of potential scale items. During Phase II, three expert reviewers and 24 urban, African American loosie users provided feedback and pilot tested the items via the “Think Aloud” method. In Phase III, psychometric data were collected from 122 urban, African American loosie users from the District of Columbia Housing Authority public housing sites. Rigorous exploratory factor analysis and reliability and validity testing were conducted to determine the most parsimonious models for two scales: The Social Context of Loosies Scale (SCL-11) and the Health Belief Model for Loosies Scale (HBML-20). Both scales and their respective subscales demonstrated internal consistency and divergent and convergent validity. To our knowledge, this dissertation research is the first study to utilize semi- structured interviews (Phase I) to examine individualized patterns of loosie use by urban, African Americans and to develop valid scales designed by, and for, urban, African American loosie users (Phase II and Phase III). Given the strong psychometric properties of the scales, they may be used to identify meaningful targets for individual, social, and environmental intervention to prevent and reduce loosie use among this priority population. MEASURING THE SINGLE CIGARETTE USE PHENOMENON: SCALE DEVELOPMENT AND VALIDATION by Lilianna Phan Dissertation submitted to the Faculty of the Graduate School of the University of Maryland, College Park, in partial fulfillment of the requirements for the degree of Doctor of Philosophy 2019 Advisory Committee: Associate Professor, James Butler III, Chair Professor, Kenneth H. Beck Associate Professor, Craig S. Fryer Associate Professor, Mia A. Smith-Bynum Professor, Min Qi Wang © Copyright by Lilianna Phan 2019 Dedication To Mom For the warmth of your love, the strength of your resilience, and the value of your humble teachings. This is dedicated to my Mom, and all moms who are the true pillars of first generation college students. With love and gratitude. ii Acknowledgements To my mentor, committee chair, and advisor Dr. Butler, thank you. Thank you for your guidance, time, positivity, teachings, and for the opportunities you have provided me. I am humbled by the dedication you have put into my academic and research training. I am truly grateful. To my dissertation committee - Drs. Wang, Fryer, Beck, and Smith-Bynum, thank you. Because of your enthusiastic guidance and research expertise, I was able to turn a topic that I am passionate about into a robust, meaningful project to launch my independent research career. Thank you for your thoughtful and constructive feedback to further bolster my research training and skillset. To my baby sister, Jules - I don’t know what I did to deserve such a courageous, smart, and kind-hearted soul for a sister! I am so proud of you and am grateful to see you grow and blossom. I have no doubt that you will do amazing things in your life. May this show you that with hard work, passion, and perseverance, anything is possible. Thanks for helping and being with mom when I couldn’t. To my husband, David - Thank you for your selflessness and taking care of our family so that I could focus on my education. You are the G.O.A.T. To my Aunt Jackie - Thanks for always having my back and being my #1 supporter. To my aunts and uncles - I hope this PhD serves as a sweet culmination for coming to every academic milestone in my life! Thank you for your endless love and support. To all of my family and friends - thank you for your ongoing support and encouragement. Most of all, thank you for your understanding when I wasn’t able to be as present as I would like to be. To my cohort and dear friends - What an inspiration you all are to me, and I am so grateful for the friendships we have built! Thanks for the laughs, encouragement, camaraderie, and support. You were the special ingredient in my PhD experience and I’m so excited for what’s to come next ladies! Randi, “Together we can, my friend.” To community partners - thank you for your warm welcome and support of this research. To participants - thank you for entrusting this research with your experiences and thoughtful feedback. I am gracious for your participation and time. Funding Acknowledgement This research was supported by funding from University of Maryland Tobacco Center of Regulatory Science (P50CA180523, PI: Dr. Pamela I. Clark), the Department of Behavioral and Community Health at the University of Maryland School of Public Health, and Dr. James Butler III, Associate Professor in the Department of Behavioral and Community Health at the University of Maryland School of Public Health. iii Table of Contents Dedication ..................................................................................................................... ii Acknowledgements ...................................................................................................... iii Table of Contents ......................................................................................................... iv List of Tables ............................................................................................................... vi List of Figures ............................................................................................................. vii Chapter 1: Introduction ................................................................................................. 1 1.1. Problem Statement ................................................................................................. 1 1.2. Study Aims ............................................................................................................ 9 1.3. Dissertation Format .............................................................................................. 12 1.4. Study Justification ................................................................................................ 13 1.5. Theoretical Framework ........................................................................................ 15 1.6. Conceptual Model ................................................................................................ 18 1.7. Study Overview ................................................................................................... 21 1.8. Clarification of Terms .......................................................................................... 22 Chapter 2: Literature Review ...................................................................................... 24 2.1. Burden of Tobacco Use ....................................................................................... 24 2.2. The Black/African American Smoking Paradox ................................................. 26 2.3. Smoking and Urban, African Americans ............................................................. 32 2.4. Single Cigarettes – Loosies .................................................................................. 35 2.5. Social Context Scale Development and Validation ............................................. 45 2.6. Health Belief Model Scale Development and Validation .................................... 49 2.7. Positionality in Qualitative Research ................................................................... 50 2.8. Summary .............................................................................................................. 52 Chapter 3: Manuscript #1 ............................................................................................ 54 3.1. Introduction .......................................................................................................... 54 3.2. Methods................................................................................................................ 57 3.3. Results .................................................................................................................. 60 3.4. Discussion ............................................................................................................ 66 Chapter 4: Manuscript #2 ............................................................................................ 75 4.1. Introduction .......................................................................................................... 75 4.2. Methods................................................................................................................ 77 4.3. Results .................................................................................................................. 82 4.4. Discussion ............................................................................................................ 89 Chapter 5: Conclusions ............................................................................................... 98 5.1. Overview and Summary ...................................................................................... 98 5.2. Implications ........................................................................................................ 100 5.3. Strengths and Limitations .................................................................................. 102 5.4. Future Directions ............................................................................................... 104 Appendices ................................................................................................................ 106 Appendix A: Methods ............................................................................................... 107 Appendix B: IRB Application and Approval Letters ............................................... 133 Appendix C: Phase I Materials ................................................................................. 149 Appendix D: Phase II Materials ................................................................................ 172 iv Appendix E: Phase III Materials ............................................................................... 192 Appendix F: Additional Tables and Figures ............................................................. 212 Bibliography ............................................................................................................. 216 v List of Tables Table 1.1. HBM’s Cognitive Factors Influencing the Use of Loosies....................21 Table 1.2. Definition of Key Terms........................................................................23 Table 3.1. Phase I: African American Loosie Users Demographics and Smoking History....................................................................................................69 Table 3.2. Phase I: Single Cigarette Acquisition Practices of African American Users.......................................................................................................70 Table 3.3. Phase I: The Social Context of Purchasing and Using Loosies..............71 Table 3.4. Phase I: The Health Belief Model Framework for Purchasing and Using Loosies.........................................................................................72 Table 4.1. Instrument Development and Testing Procedures..................................91 Table 4.2. Phase III: African American Loosie Users Demographics and Smoking History.....................................................................................92 Table 4.3. Phase III: Single Cigarette Acquisition Practices of African American Users.......................................................................................................93 Table 4.4. Retained Factors for the Social Context of Loosies Scale......................94 Table 4.5. Retained Factors for the Health Belief Model for Loosies Scale...........95 Tables in Appendices Table A.1. Outline of Study Phases and Procedures..............................................105 Table A.2. Timeline of Primary Data Collection...................................................108 Table A.3. Phase II: African American Loosie Users Demographics and Smoking History...................................................................................206 Table A.4. Phase II: Single Cigarette Acquisition Practices of African American Users Outline of Measures by Study Phase..........................................207 Table A.5. Phase III: Test Retest Reliability for Social Context of Loosies Scale........................................................................................208 Table A.6. Phase III: Test Retest Reliability for Health Belief Model for Loosies Scale........................................................................................209 Table A.7. Outline of Measures by Study Phase....................................................118 vi List of Figures Figure 1.1. Study Phases and Manuscripts..............................................................13 Figure 1.2. Conceptual Model for Loosie Use among Urban, African Americans..............................................................................................20 Figures in Appendices Figure A.1. Phase I Participant Flowchart..............................................................110 Figure A.2. Phase II Participant Flowchart............................................................112 Figure A.3. Phase III Participant Flowchart...........................................................115 Figure A.4. Exploratory Factor Analysis Model for the Social Context of Loosies Scale.......................................................................................125 Figure A.5. Exploratory Factor Analysis Model for Health Belief Model for Loosies Scale.......................................................................................126 vii Chapter 1: Introduction 1.1. Problem Statement One of our nation’s greatest public health achievements in the last 50 years has been reducing the overall adult smoking prevalence from 42% to 15.5% (U.S. Department of Health and Human Services [U.S. HHS], 2014). Today, as we near the year 2020, we continue this progress by striving towards Healthy People 2020’s goal to further reduce the overall smoking prevalence to ≤12% (Office of Disease Prevention and Health Promotion [ODPHP], 2016). In order to reach this overarching goal and make meaningful advancements in tobacco control, our continual attention must focus on racial and ethnic minorities who disproportionately experience greater smoking-attributable morbidity and mortality (Fagan et al., 2004). The health of African Americans residing in urban areas is of significant concern as this subgroup has a substantially higher smoking prevalence (43-58%) (LaVeist, Thorpe, Mance, Jackson, 2007; Lee, Turner, Burns, & Lee, 2007) than what is seen in the broader U.S. population (15.5%) (Centers of Disease Control and Prevention [CDC], 2016). This high smoking prevalence among urban, African Americans is related to several factors – e.g., stressful daily lives (Budescu, Taylor, & McGill, 2011), poverty (Baker, Palmer, & Lee, 2016), violence (Lambert, Brown, Phillips, & Ialongo, 2004), racism and discrimination (Baker, Palmer, & Lee, 2016), lack of social support (Lacey, Manfredi, Balch, Warnecke, Allen, & Edwards, 1993), positive pro-smoking norms (Stillman et al., 2007), the tobacco industry’s 1 geodemographic targeting tactics (Lee, Henriksen, Rose, Moreland-Russell, & Ribisl, 2015), inequitable distribution of tobacco outlet density in African American communities (Fakunle, Milam, Furr-Holden, Butler, Thorpe, LaVeist, 2016; Mennis & Mason, 2016), and perceptions of the inadequacy of evidence-based smoking cessation services (Warren & Catrona, 2013). The Impact of Tobacco Use and Smoking on African American Health While the smoking prevalence among white Americans and African Americans are now comparable (approximately 17% respectively), there remains a widening gap of racial disparities regarding smoking initiation and cessation (U.S. HHS, 2014). Research suggests that, compared to white Americans, African Americans tend to have a different smoking pattern across the age continuum (Freedman, Nelson, & Feldman, 2012). Specifically, during early adolescence, the smoking prevalence is lower among African Americans than white Americans; however, during late adolescence and early adulthood, smoking initiation rates among African Americans begin to rise (Freedman, Nelson, & Feldman, 2012; Kandel, Schaffran, Hu, & Thomas, 2011). By the time individuals are in their late 20s and early 30s, greater onset of smoking among African Americans and greater cessation among white Americans causes the prevalence of African American smoking to equal—and often exceed—that of their white counterparts (Chen, & Jacobson, 2012; Kandel, Schaffran, Hu, & Thomas, 2011; Moon-Howard, 2003). This pattern is varyingly referred to as a “crossover” (Arnett & Brody, 2008; Geronimus, Neidert, & Bound, 1993; Kandel, 1995) or “convergence” in smoking patterns (Keyes et al., 2015; Pampel, 2008). 2 Furthermore, a smoking cessation “paradox” exists (Alexander et al., 2016). That is, African Americans are less likely to successfully achieve smoking abstinence (CDC, 2016; U.S. HHS, 2014; Kulak, Cornelius, Fong, Giovino, 2016). Even though African Americans smoke fewer cigarettes, have more desire to quit smoking, and make more quit attempts than white Americans, white Americans are more likely to quit and remain smokefree (CDC, 2016). Consequently, African Americans experience the deleterious health consequences of tobacco use such as heart disease, cancer, stroke, and diabetes mellitus at a disproportionate rate (CDC, 2017a). The Single Cigarette Phenomenon A significant reason for tobacco-related health disparities among urban, African Americans that has received minimal attention is the sale and use of single cigarettes, commonly referred to as “loosies” (Latkin, Murray, Smith, Cohen, & Knowlton, 2013). The 2009 Family Smoking Prevention and Tobacco Control Act (Tobacco Control Act) prohibits the sale of cigarette packages with fewer than 20 cigarettes, of which, loosies fit into this category (FDA, 2018). This makes the sale of loosies illegal as they are sold as untaxed, unpackaged cigarettes for monetary gain by a tobacco retailer or by an individual (Hall, Fleischer, Shigematsu, Santillan, & Thrasher, 2015). Despite that, loosies are ubiquitous in urban areas throughout the U.S. (Smith et al., 2007; Stillman, Bone, Milam, Ma, & Hoke, 2014). For example, more than 70% of young adult, African Americans of Baltimore, MD have seen the selling of loosies and have purchased them every day in their neighborhood (Smith et al., 2007). The accessibility of loosies in urban areas is based on their availability and the positive perceptions surrounding them (Stillman, Bone, Milam, Ma, & Hoke, 3 2014). Survey results from the research conducted by Stillman et al. (2014) indicate that approximately 74% of urban, low-income, African American young adult smokers in Baltimore, MD agreed with the statement that loosies should be available in their community (Stillman, Bone, Milam, Ma, & Hoke, 2014). Moreover, purchasing loosies has been associated with light smoking [i.e., smoking 1 to 10 cigarettes per day (cpd) (Okuyemi et al., 2004; Schane, Ling, & Glantz, 2010)] and intermittent smoking behavior, which is described as smoking on a non-daily basis (Guillory, Johns, Farley, & Ling, 2015; Husten, 2009; Sacks, Coady, Mbamalu, Johns, & Kansagra, 2012; Stillman, Bone, Milam, Ma, & Hoke, 2014; Thrasher, Villalobos, Barnoya, Sansores, & O’Connor, 2011). These smoking patterns closely reflect that of African American smokers (Trinidad et al., 2009). Namely, African Americans have almost twice the proportion of light smoking (24%) and are 1.82 times more likely to be intermittent smokers in comparison to white Americans (17%) (Guillory, Johns, Farley, & Ling, 2015; Trinidad et al., 2009). Results from research conducted in New York City also indicate the use of loosies, or purchasing illegal cigarettes from an individual on the street, to be greater among racial and ethnic minorities and individuals who are low-income or have lower educational attainment (Coady, Chan, Sacks, Mbamalu, & Kansagra, 2013; Guillory, Johns, Farley, & Ling, 2015). Guillory and colleagues (2015) found that ever purchasing a loosie and the last cigarette purchased as a loosie were negatively associated with white race among young adult smokers recruited from New York City bars. Further, individuals with some college credits or less were also more likely to have ever purchased loosies in comparison to individuals who were currently enrolled 4 in college or had graduated from college. Coady and colleagues’ (2013) findings were similar to those of Guillory et al. (2015). That is, low-income, young African American and Hispanic individuals were more likely than their white counterparts to purchase illegal cigarettes, such as loosies, from an individual on the street (Coady, Chan, Sacks, Mbamalu, & Kansagra, 2013). Limited Loosies Research Exposure and access to loosies are well-documented risks for smoking initiation among individuals <18 years of age (FDA, 2018). Yet, there remains a paucity of research that specifically addresses loosies’ sales, distribution, and use among urban, African Americans. Importantly, a growing body of research does implicate loosies as being harmful by promoting smoking continuance and in turn impeding smoking abstinence (see: Sacks, Coady, Mbamalu, Johns, & Kansagra, 2012; Saenz de Miera, Thrasher, Chaloupka, Watters, Hernandez-Avila, & Fong, 2010; Smith et al., 2007; Stillman, Bone, Milam, Ma, & Hoke, 2014; Thrasher, Villalobos, Barnoya, Sansores, & O’Connor, 2011). Using loosies as a preferred harm reduction method and gradual cessation aid has emerged in the literature (Guillory, Johns, Farley, & Ling, 2015; Smith et al., 2007; Thrasher, Villalobos, Barnoya, Sanesore, & O’Connor, 2011). For example, a sample of low-income, African American smokers (ages 18 to 24) in Baltimore, MD noted significant reasons for using loosies: 1) helping with “cutting back” on cigarette smoking (44%); and, 2) preventing further nicotine dependence (21%) (Smith et al., 2007). Additionally, young adults (18 to 26 years old) from New York City who tried to quit smoking in the past year were more likely to have ever purchased loosies, and 5 those who had intention to quit within the next six months were more likely to have purchased their last cigarette as a loosie (Guillory, Johns, Farley, & Ling, 2015). Nonetheless, there is no clear evidence that using loosies can advance the quitting process (Thrasher, Villalobos, Barnoya, Sanesore, & O’Connor, 2011). In a longitudinal study using population-based data from Mexico, Thrasher and colleagues (2011) noticed smokers who most frequently purchased loosies, even when used specifically to control their cigarette consumption, were no more likely to attempt quitting than those who did not purchase loosies. Tobacco Control Policies Loosie sales and use can negatively impact the effectiveness of tobacco control policies (Saenz de Miera et al., 2010). Loosies hinder the reach of the Surgeon General’s health warning label (“Caution: Cigarette Smoking May Be Hazardous to Your Health”) (See [USC04] 15 USC Ch. 36: Cigarette Labeling and Advertising) on cigarette packs and enforcement of cigarette taxes because individuals who purchase loosies are not exposed to cigarette packaging and loosies are an unintended consequence of increased cigarette taxes (Saenz de Miera et al., 2010). The purchasing of loosies increased significantly by 12% in New York City (Coady, Chan, Sacks, Mbamalu, & Kansagra, 2013) and by 10% in Mexico (Saenz de Miera, et al., 2010) following an increase in cigarette taxes. Notably, African Americans were nine times more likely to purchase a cigarette off the street following the 2008 cigarette tax increase in New York City (Coady, Chan, Sacks, Mbamalu, & Kansagra, 2013). 6 Enforcement of the sale of single cigarettes has involved the inspection of retailers (Baker, Lee, Ranney, & Goldstein, 2016) and arrests of individuals who sell loosies (von Lampe, Kurti, Johnson, & Rengifo, 2016). Yet, the number of inspections has been few and varied substantially across states (Baker, Lee, Ranney, & Goldstein, 2016). For instance, in 2014, North Carolina conducted 107 inspections and 65% of the issued warning letters were specifically for the violation of the sale of single cigarettes. Other states such as Louisiana and Maryland had 669 and 137 inspections, respectively, and neither state issued warning letters regarding the selling of single cigarettes (Baker, Lee, Ranney, & Goldstein, 2016). The number of inspections and warning letters for the sale of loosies by state did not parallel nor were they predicted by correlates of loosie use (Baker, Lee, Ranney, & Goldstein, 2016). One important example of an individual’s arrest for selling loosies is the tragic and wrongful death of Mr. Eric Garner from the unlawful use of force by police officers during his arrest in Staten Island, New York (Kim, 2014). Mr. Garner’s death calls for the need to develop public health strategies within the context of social justice (e.g., ending police brutality against persons of color) to insure that all citizens, regardless of race or ethnicity, are entitled to the same rights and services. The socioecological model (Brofenbrenner, 1979; McLeroy, Bibeau, Steckler, Glanz, 1988) posits that health behavior (the use of loosies) is influenced by the contextual factors (e.g., personal circumstances, built environment, social relationships, social justice issues) that occur at and between the intrapersonal, interpersonal, organizational, community, and public policy levels. 7 This dissertation research argues for shifting the current enforcement approach of the sale and use of loosies, from a primarily law enforcement strategy to a public health approach. A public health perspective is necessary to expand the impact of the existing ban, which is designed to protect the wellbeing of the U.S. population (FDA, 2018). Thus, as a beginning point to address these gaps, this dissertation research developed two theoretically-based, valid scales to identify potential targets for preventing and reducing loosie use among urban, African American smokers. In summary, empirical evidence suggests that the well-intentioned use of loosies is potentially harmful to one’s smoking behavior. The availability and use of loosies promotes the initiation of smoking, continuance of smoking, light or intermittent smoking patterns, and lapses and relapse (Stillman, Bone, Milam, Ma, & Hoke, 2014; Sacks, Coady, Mbamalu, Johns, & Kansagra, 2012; Thrasher, Villalobos, Barnoya, Sansores, & O’Connor, 2011). The risks associated with exposure to loosies can be detrimental to an individual’s ability to be smokefree — be it through never initiating smoking or successfully quitting smoking and remaining abstinent. Purpose of the Study The purpose of this study was to examine loosie use among urban, African Americans residing in Baltimore, MD and the District of Columbia. Specifically, a mixed-method, exploratory sequential design (Creswell, Gutmann, & Hanson, 2003) was used to develop and validate two theoretically-based scales that measure the use of loosies among African American loosie users. The findings from this dissertation: 8 1) add to our understanding of the “loosies phenomenon” and 2) provide two valid measurement tools for use in future observational studies or interventions that target the use of loosies, which can contribute to eliminating tobacco-related health disparities. This dissertation research resulted in a more comprehensive understanding of urban, African American’s social context and intrapersonal factors for purchasing and using loosies. Additionally, in this dissertation, recommendations are made for developing multilevel interventions to improve the health of urban, African American loosie users that could lead to the elimination of tobacco-related health disparities. 1.2. Study Aims This dissertation was guided by two study aims across three research phases: Aim 1: To examine the social context and beliefs and attitudes of loosie use among urban, African Americans (users). This aim was addressed in Phase I of the research via semi-structured, in- depth interviews (n=25). The in-depth interview questions were guided by the theoretical frameworks of the social context (i.e., research question 1) and the Health Belief Model (HBM) (i.e., research questions 2 - 6). Among users, Aim 1 sought to answer the following research questions: 1. Social context: What are the personal circumstances and environmental and social factors that influence the purchase and use of loosies? • Why - what are the intrapersonal reasons for purchasing and using loosies? • Where - what are the types of geographical settings where individuals purchase loosies? 9 • When - 1) what time of day are loosies purchased? 2) What kind of psychological motives influence loosie use? • From whom - what types of sellers are individuals purchasing loosies from? • How - what are the mannerisms and etiquette associated with loosie purchasing and use? 2. Perceived susceptibility - How do users perceive that loosies will increase their chances of: • continuing to smoke? • lapse? • relapse? 3. Perceived severity - How serious do users perceive the health consequences of: • loosies to be? • smoking to be? 4. Perceived benefits - What are the perceived benefits of 1) using and 2) not using loosies? 5. Perceived barriers - What are the perceived barriers of 1) using and 2) not using loosies? 6. Self-efficacy - What are one’s beliefs about their ability to: • stop using loosies? • use self-identified strategies to reduce loosie use? Aim 2: To develop two valid, theoretically-based scales that measure the 1) social context of loosie use and 2) HBM-based beliefs and attitudes toward reducing the use of loosies. 10 This aim was addressed in Phase II and Phase III of the dissertation research. The initial pool of generated items was developed based on qualitative themes from Phase I and research findings found in the existing literature (Guillory, Johns, Farley, & Ling, 2015; Stillman, Bone, Milam, Ma, & Hoke, 2014; Sacks, Coady, Mbamalu, Johns, & Kansagra, 2012; Thrasher, Villalobos, Barnoya, Sansores, & O’Connor, 2011). In Phase II, an expert panel (n=3) (Berg, 2014) reviewed the potential items for their language, content, and quality (Worthington & Whittaker, 2006). Items were revised or removed from the pool as recommended by the experts. Twenty-four urban, African American loosie users then pilot tested the developed items. Pilot testing involved an iterative process to assess participants’ understanding, interpretation, and acceptability of the items’ language and content (Johanson & Brooks, 2010; Pernerger, Courvoisier, Hudelson, Gayet-Ageron, 2014). Revisions were made based upon participants’ feedback and the items were finalized for psychometric testing. With considerations for recruitment and data collection feasibility, the potential scale items were administered to 122 urban, African American loosie users from five District of Columbia Housing Authority public housing sites. The data were used to assess the psychometrics of the generated items, which included exploratory factor analysis and reliability and validity tests (Park, Kang, Jang, Lee, & Chang, 2017; Worthington & Whittaker, 2006). This aim sought to answer the following research questions: 1. To what degree do the developed scales measure their intended theoretical frameworks (construct validity)? 11 1a. How well does the Social Context of Loosies Scale (SCL-11) measure the social context (i.e., why, when, where, from whom, and how) of purchasing and using loosies? 1b. How well does the Health Belief Model for Loosies Scale (HBML-20) measure HBM constructs for reducing loosie use? 2. How reliable are the developed scales (reliability)? 2a. What is the general agreement between items within the subscale (internal consistency reliability)? 2b. How stable is the scale over time (test-retest reliability)? 3. To what extent does SCL-11 and HBML-20 demonstrate convergent validity? 4. To what extent does SCL-11 and HBML-20 demonstrate discriminant validity? 5. How well do the measured constructs in SCL-11 and HBML-20 behave as expected in relation to known group trends for loosie use (construct validity testing via group differentiation)? The research methods used in this dissertation research are located in Appendix A. 1.3. Dissertation Format The following sections of Chapter 1 include the justification for the study, the theoretical frameworks and rationale for the selected intrapersonal health behavior theory, the conceptual model, the study overview, and the definitions of terms used in this dissertation. Chapter 2 provides a review of the existing literature on the burden of tobacco use, the smoking paradox, smoking among urban, African Americans, literature on single cigarettes – loosies, and prior scale development projects that focus on the theoretical frameworks of the social context and Health Belief Model. 12 Chapters 3 and 4 are Manuscript #1 and Manuscript #2, respectively. Manuscript #1 reports the qualitative findings from the semi-structured, in-depth interviews. Manuscript #2 describes the scale development and validation methodology employed in this research. Lastly, Chapter 5 is a summary of this dissertation and its implications for future research. Figure 1.1. outlines the study phases and the generation of the two manuscripts. Figure 1.1. Study Phases and Manuscripts 1.4. Study Justification Tobacco control policies that are impactful among the general U.S. population are not necessarily as effective in racial and ethnic populations that are burdened by tobacco-related health disparities. For example, though pricing (i.e., increased cigarette taxes) is an overall effective strategy to prevent smoking initiation and/or promote smoking cessation, the use of loosies has increased as an unintended consequence of increased cigarette taxes, particularly among urban, African Americans (Coady, Chan, Sacks, Mbamalu, & Kansagra, 2013; Saenz de Miera et al., 2010). Special attention is given to them because of their high smoking prevalence 13 (43%) (Lee, Turner, Burns, & Lee, 2007) and certain factors, such as loosie use, cumulatively make smoking initiation likely to occur and cessation difficult for them to achieve (Smith et al., 2007; Stillman, Bone, Milam, Ma, & Hoke, 2014). African Americans are also specifically targeted by tobacco companies to purchase and smoke particular types of cigarettes (e.g., menthol) and specific cigarette brands (e.g., Newport), which are known to be more addictive (Balbach, Gaslor, & Barbeau, 2003). Urban areas, like Baltimore, MD and the District of Columbia, are challenged by social norms that are conducive to smoking behavior and high psychosocial stress from a substandard built environment (poor housing quality) (Hood, 2005), inadequate basic resources (recreational activities, access to healthcare) (Thomas & Quinn, 2008), exposure to stressful life events (crime and violence) (Gong, Palmer, Gallacher, Marsden, & Fone, 2016) and targeted marketing from tobacco brands and companies (Brown-Johnson, England, Glantz, & Ling, 2014; Schneider, Reid, Peterson, Lowe, & Hughey, 2005). There is also evidence that some accessible cessation strategies, such as free nicotine replacement therapy (NRT) from a local healthcare clinic, remain unappealing and unused by urban, African American smokers due to overall mistrust of the government (Baker, Palmer, & Lee, 2016) and skepticism about pharmacotherapy (Warren & Catona, 2013). This dissertation research suggests that our collective success in eliminating tobacco-related health disparities will remain limited if we do not first address the risk factors that impede the reach of our existing tobacco control programs and research. Loosies were the focus of this dissertation because of their high acceptability, availability, and use among urban, African 14 American smokers (Smith et al., 2007; Stillman, Bone, Milam, Ma, & Hoke, 2014). Furthermore, single cigarettes have been predominantly addressed through targeting their illegality; rather than their ubiquity and high prevalence of use. This dissertation research aimed to begin the shift in paradigm vis-à-vis how we address loosies by developing two valid scales that integrate the voice of urban, African American loosie users for potential use in future smoking prevention and cessation interventions. Concluding, the overarching goal of this research was to understand the social context within which the purchasing and use of loosies occurs and the important intrapersonal factors related to: 1) purchasing and using them, as well as 2) reducing this behavior, among urban, African Americans. This dissertation’s objective was to develop and validate two theoretically-based scales measuring: 1) the social context and 2) beliefs and attitudes surrounding loosie use. It is hoped that the findings from this study can be used to inform future interventions and programs by working directly with this priority population. 1.5. Theoretical Framework The inclusion of health behavior theory provides guidance and a framework with which we can understand the determinants of health and the process of health behavior change (Glanz & Bishop, 2010; Noar & Zimmerman, 2005). The goal of this dissertation research was to better explain the health problem and the cognitive processes involved with one’s decision to use loosies, in addition to identifying meaningful targets for reducing loosie use. The social context framework is useful in explaining diverse sources of resistance against tobacco control among marginalized groups (Poland et al., 2006). Specifically, the social context describes the 15 circumstances within which a phenomenon, such as the sale of loosies, takes place. However, the social context framework is to be explored in parallel to individual factors that influence a behavior and are important in reducing one’s purchasing and use of loosies. An explanatory, value expectancy theory focusing on the intrapersonal level of the Social Ecological Model (McLeroy, Bibeau, Steckler, Glanz, 1988) is therefore an appropriate complement to understanding the social context of purchasing and using loosies. Together, these two theoretical frameworks were applicable for this novel investigation of loosie use. Intrapersonal Theory Selection Two value expectancy theories that were evaluated for their appropriateness in describing loosie use in this scale development and validation study were the Theory of Planned Behavior (TPB) and the Health Belief Model (HBM). TPB posits that a strong determinant of a health behavior is one’s intention, which itself is influenced by one’s attitudes and perceptions of how others in one’s life view the health behavior (i.e., subjective norms) and one’s ability to perform the health behavior (i.e., perceived behavioral control) (Azjen, 1991). TPB has been used as a theoretical framework in research studies explaining smoking behavior and for smoking cessation interventions (Godin, Valois, Lepage, Deshainais, 1992; Hanson, 1997; Norman, Conner, & Bell, 1999). Nonetheless, TPB was not selected as the theoretical underpinning for this dissertation research because of the current understanding of the cognitive processes involved with the use of loosies and the intended use of the developed scales in future loosies-related programs and interventions. TPB’s construct of subjective norms has 16 been examined among users of loosies, including those who are African American and reside in urban U.S. neighborhoods. (Guillory, Johns, Farley, & Ling, 2015; Smith et al., 2007; Stillman, Bone, Milam, Ma, & Hoke, 2014; Stillman et al., 2007). Though user’s perceived behavioral control to avoid loosie use remains unknown, the culmination of what we do know infers that the intention to use loosies would be high, which would in turn predict actual use within a TPB framework. This prediction of the health behavior impedes this study’s goal to advance our understanding of loosie use and neglects the purposeful opportunity to contribute to future interventions targeting this health behavior. HBM, on the other hand, was specifically chosen as a complement to the social context framework for several important reasons. HBM is a theory that explains and predicts how individuals change a health behavior to prevent or to control health conditions based on their perceived threat of the condition and their expectations of the behavior (Rosenstock, Strecher, Becker, 1988). HBM’s outcome of the likelihood of behavior change or action was imperative in this study’s goal and provided a framework within which to explain and predict behavior change related to loosie use. Past research has identified general, overall attitudes towards loosies and the perceived benefits of using loosies among urban, African Americans (Stillman et al., 2007). This dissertation research aimed to extend these findings by illustrating a complementary, deeper understanding of urban, African Americans’ attitudes about the risk of using loosies and the perceived benefits and barriers of reducing loosie use. The primary HBM outcome has been revised from the uptake of a preventive 17 health behavior to the discontinuation of a harmful behavior to improve one’s health. Herewith, the theoretical framework of the study was underpinned and guided by the social context and an adaptation of HBM. The following section further describes the social context, HBM and its constructs, and the factors that impact the use of loosies. 1.6. Conceptual Model This dissertation research was guided by the theoretical frameworks of the social context and the Health Belief Model. The Social Context Framework The social context involves the understanding of one’s situational circumstances, physical environment, and social relationships that influence one’s use of loosies (Poland et al., 2006). Specifically, the social context framework describes the why, where, when, from whom, and how (Poland et al., 2006) urban, African American smokers purchase and use loosies. The social context is meaningful in describing the practice of single cigarette use and identifying potential targets connected with the sales and actual purchasing of loosies. The Health Belief Model The model was developed in the 1950’s by social scientists to explain the public’s failure to participate in screening programs to detect tuberculosis (TB) (Hochbaum, Rosenstock, & Kegels, 1952; Rosenstock, Stretcher & Becker, 1994). While there were numerous sites where individuals could obtain screening X-rays, few individuals took advantage of these opportunities, which caused the TB screening program to have limited success (Champion & Skinner, 2008; Hochbaum, 1958; Hochbaum, Rosenstock, & Kegels, 1952; Rosenstock, 1974). HBM was the resulting 18 theory that helped explain this lack of participation in preventive behaviors (Hochbaum, Rosenstock, & Kegels, 1952). Complementary to the social context framework, HBM focuses on modifying health behavior and postulates potential ways to reduce loosie use through targeting the perceived threat of purchasing and using loosies and the perceived benefits to be gained through behavior change. Overall, the Health Belief Model involves one’s perceptions of a health threat and one’s value in taking action to reduce the health threat. It is based on the assumptions that in order for an individual to make a positive health behavior change, the individual must perceive that he/she/they is personally susceptible to the health condition, the health condition would have at least a moderate degree of seriousness and effect on one’s life, and that taking action would indeed lead to benefits and reduction of the health threat (Rosenstock, 1974). In this study, the health threat was the use of loosies and its’ potential risk in increasing smoking intensity (number of cigarettes smoked daily), maintaining cigarette smoking, and increasing the likelihood of a lapse (also known as a “slip”) or relapse following a quit attempt. Specifically, the theoretical constructs that were examined were perceived susceptibility, perceived severity, perceived benefits, perceived barriers, and self-efficacy. The perceptions of susceptibility and severity of the health behavior (or health condition) are conceptually combined to describe this broader HBM construct of a perceived health threat. Namely, the degree to which individuals believe a specific health behavior is risky or they are personally in danger of having a health condition – i.e., developing a serious illness. Expectations is based upon the expectations of 19 one’s actions, which involves the weighing of perceived benefits and barriers to taking action with the former needing to outweigh the latter. In this study, perceived benefits is one’s avoidance of other health harms or the belief that reducing loosie use will significantly increase one’s chances of quitting smoking and remaining smoke free. Perceived barriers consist of one’s beliefs about the challenges he/she/they face in order to reduce his/her/their use of loosies. Cues to action involve internal or external cues to prompt engagement in a positive health behavior (Rosenstock, 1974). Since the focus of this study was disengagement with a negative health behavior (i.e., purchasing and use of loosies), cues to action was not included as a part of this conceptual model. The aforementioned theoretical frameworks are shown in the conceptual model (Figure 1.2). Figure 1.2. Conceptual Model for Loosie Use among Urban, African Americans 20 Table 1.1. HBM’s Cognitive Factors Influencing the Use of Loosies HBM Definition of HBM Adapted Definition Construct Construct for the Use of Loosies Perceived One’s belief about the User’s perceived risk of chances of getting a increasing smoking intensity, Susceptibility health condition.1,2 smoking continuance, lapse, and relapse due to loosie use.3 One’s belief of how User’s beliefs regarding the Perceived serious a health seriousness of using loosies Severity condition and its and health consequences of consequences are. 1,2 smoking. 3 User’s beliefs about the One’s beliefs in the efficacy of reducing loosie use Perceived efficacy of the advised to avoid other health harms Benefits action to reduce risk. 1,2 associated with loosie purchasing and to quit smoking. 3 One’s belief of the User’s opinion of the tangible Perceived tangible and and psychological costs of Barriers psychological costs of reducing loosie use. 3 the advised action. 1,2 User’s confidence in their One’s confidence in ability to 1) reduce their use of Self-efficacy his/her/their ability to loosies and 2) perform perform a behavior. 1,2 cognitive behavior strategies to reduce their loosie use.3 1Rosenstock, Strecher, & Becker, 1988 2Glanz, Rimer, & Viswanath, 2015 3Maryland Resource Center for Quitting, 2018 1.7. Study Overview This dissertation research utilized a mixed-method, exploratory sequential design (Creswell, Gutmann, & Hanson, 2003) to develop and validate two scales measuring the use of loosies among urban, African Americans. The dissertation research consisted of three phases. Phase I involved semi-structured, in-depth interviews (n=25) to understand urban, African Americans’ social context and beliefs and attitudes regarding loosies. These in-depth interviews focused on answering the research questions guided by the social context and the Health Belief Model. The 21 interviews were transcribed verbatim and thematically coded using the Framework Method as outlined by Gale, Heath, Cameron, Rashid, and Redwood (2013). The qualitative data from Phase I, in conjunction with the existing literature on loosies, were used to generate the scale items for Phase II. The generated items were reviewed by an expert panel (n=3) and revised accordingly (Berg, 2014). The revised items were then pilot tested with individuals from the priority population (n=24) to further refine the scale for acceptability and feasibility (Johanson & Brooks, 2010; Pernerger, Courvoisier, Hudelson, Gayet-Ageron, 2014). Next, the survey was administered to a sample of 122 urban, African American loosie users (Phase III). Psychometric data were used for factor and item retention through exploratory factor analysis and the two developed scales were subsequently assessed for the strength of their reliability and validity. This dissertation research led to the development of two manuscripts describing the 1) Qualitative findings and 2) Psychometric testing of the developed scales. 1.8. Clarification of Terms Because certain words have different meanings from one group or culture, and from one academic discipline, to another, it was necessary for the purposes of this study to clarify and define the terms used herein (Table 1.2.). 22 Table 1.2. Definition of Key Terms Terms Definition African American The term African American refers to a person having origins in any of the Black racial groups of Africa or a person who self-identifies as Black or African American (U.S. Census Bureau, 2017). Evidence-based smoking EBSCT is the single or combined use of behavioral cessation treatment counseling, nicotine replacement therapy (NRT), (EBSCT) and/or pharmaceutical medication during a quit attempt (U.S. PSTF, 2016). Intermittent smokers Current smokers who do not smoke daily (Husten, 2009; Trinidad et al., 2009). Lapse or slip A lapse or slip is a puff or two on a cigarette, which may proceed to relapse, or abstinence may be regained (The Cochrane Collaboration, 2018). Light smoking Smoking 1 to 10 cigarettes per day (Okuyemi et al., 2004; Schane, Ling, & Glantz, 2010) Low-income Individuals who live at, near, or below the federal poverty level (FPL) (CDC, 2017b). Urban Geographical areas that include urbanized areas of 50,000 or more people and urban clusters of at least 2,500 and less than 50,000 people (U.S. Census Bureau, 2016). Single cigarettes – Loosies An illegal, untaxed, unpackaged, loose cigarette (Hall, Fleischer, Shigematsu, Santillan, & Thrasher, 2015). 23 Chapter 2: Literature Review 2.1. Burden of Tobacco Use More than fifty years after the initial Surgeon General’s report that affirmed the negative health effects of cigarette smoking, tobacco use remains the leading cause of preventable morbidity and mortality in the U.S. (U.S. HHS, 2014; Campaign for Tobacco Free Kids, 2017). Approximately 16 million people live with a tobacco- related disease, and nearly 480,000 individuals die from a tobacco-related cause each year (U.S. HHS, 2014). Tobacco use can cause cancer in almost all organs of the body, vascular disease (e.g., stroke, peripheral artery disease), and respiratory illness (e.g., chronic obstructive pulmonary disease). It can also cause life-threatening complications to the fetus (e.g., stillbirth, low birth weight, Sudden infant death syndrome – SIDS), and other diseases such as type 2 diabetes mellitus, tooth loss and decay, bone deterioration, and rheumatoid arthritis (CDC, 2017a; Das, 2003). Using data from the U.S. National Health Interview Survey (1997 to 2004), Jha and colleagues (2013) examined tobacco use and its effect on mortality from 216,917 adults between 35 to 69 years of age. Using an age-stratified Cox proportional-hazards model adjusting for educational attainment, alcohol consumption, and adiposity, they observed that the mortality rate was three times higher and life expectancy was shortened by more than 10 years for current smokers in comparison to never smokers. The differential mortality rates were primarily due to 24 neoplastic, vascular, and respiratory diseases such as lung cancer, ischemic heart disease, stroke, and chronic obstructive pulmonary disease. The results from Jha and colleagues (2013) were extended with specific relative risk estimates for tobacco-related causes of mortality among smokers by Thun et al. (2013). Thun and colleagues (2013) assessed trends for current, former, and never smokers across three time periods: 1959-1965, 1982-1988, and 2000-2010. Data were collected from the American Cancer Society’s Cancer Prevention Studies (ACSCPS) I (1959-1965) and II (1982-1988) and five contemporary cohort studies, which were the: 1) National Institutes of Health–American Association of Retired Persons Diet and Health Study, 2) ACSCPS II Nutrition Cohort, 3) Women's Health Initiative, 4) Nurses' Health Study, and 5) Health Professionals Follow-up Study. In comparison to their counterparts who have never smoked, current smokers between 2000 and 2010 had higher risks of all-cause mortality (RR=2.76 and RR=2.80, respectively). Specific health conditions resulting in smokers’ higher mortality rate were lung cancer (RR=25.66 and RR=24.97), chronic obstructive pulmonary disease (RR=22.35 and RR=25.61), ischemic heart disease (RR=2.86 and RR=2.50), and stroke (RR=2.10 and RR=1.92). It is important to note that there is no safe level of cigarette smoking; light and intermittent smokers (LITS) are burdened by the same detrimental tobacco-related health effects as heavy and daily smokers (Schane, Ling, & Glantz, 2010). Light smoking is described as smoking less than 10 cigarettes per day (cpd) (Husten, 2009). A literature review conducted by Schane, Ling, and Glantz (2010) focused on light and intermittent smokers to synthesize the existing evidence on health effects from 25 these smoking patterns. Their findings indicate that all smokers, irrespective of the amount of cpd, have the same amount of risk for cardiovascular disease. Though a dose-response relationship does exist for lung cancer, other cancers, and all-cause mortality, light and intermittent smokers have substantially greater odds of being diagnosed with tobacco-related diseases than individuals who have never smoked. Specifically, light and intermittent smokers have at least 3 times the odds for lung cancer and 1.5 times the odds for all-cause mortality relative to never smokers. Inoue-Choi and colleagues (2017) investigated the association between the long-term effects of smoking fewer than 1 or 1 to 10 cpd with all-cause and cause- specific mortality among current and former smokers ages 59 to 82 years. They used data collected from the 2004-2005 administration of the National Institutes of Health - AARP© Diet and Health Study. Overall, smokers who smoke fewer than 1 or 1 to 10 cpd over their lifetime had higher mortality risks than did never smokers, with even higher risks found among smokers who smoked a larger number of cpd earlier in their lives. Smokers of fewer than 1 cpd (RR=1.64; 95% CI 1.07, 2.51) and 1 to 10 cpd (RR=1.87; 95% CI 1.64, 2.13) had a higher all-cause mortality risk relative to never smokers. 2.2. The Black/African American Smoking Paradox The Black/African American smoking paradox (Alexander et al., 2016) is used to describe the contradiction between the smoking patterns and prevalence of tobacco-related diseases and mortality among African American smokers. African American smokers are less likely to achieve abstinence despite initiating cigarette smoking at an older age, smoking fewer cigarettes per day (cpd), having higher 26 motivation to quit smoking, and having made more quit attempts than white American smokers (CDC, 2016). The following sections describe evidence supporting African Americans’: 1) later age of smoking initiation; 2) light and intermittent smoking patterns; 3) low smoking cessation rate; 4) their use of menthol cigarettes; and, 4) low utilization of evidence-based smoking cessation services – all of which are factors that contribute to the smoking paradox. Later Age of Smoking Initiation Freedman, Nelson, and Feldman’s (2012) systematic literature review on smoking initiation consisted of 27 peer-reviewed research articles published between 1998 and 2010; of which, seven articles focused specifically on racial differences. The findings from this literature review indicate African Americans initiate smoking at an older age than white Americans. To determine the variations in age of regular smoking onset among racial groups, Trinidad and colleagues (2004) used data collected from the U.S. Census Bureau’s Current Population Survey and its supplement survey, the Tobacco Use Supplement, during the 1990’s. The study found that, in comparison to white Americans, smaller percentages of African Americans initiated smoking between the ages of 10 to 13 years old (8% versus 10%) and 14 to 17 years old (45% versus 60%). However, these trends reversed during young adulthood with approximately 54% and 43.4% of African Americans and white Americans having had initiated smoking between the ages of 18 to 25 years old, respectively. Light and Intermittent Smoking (LITS) Patterns 27 Husten (2009) summarizes that the definition of “light” smoking has varied substantially from 1 to 39 cpd. Though there remains a lack of consensus as to what constitutes “light” smoking, a majority of the research studies prioritizing African American smokers referenced by Husten (2009) characterized “light” smoking to be 1 to 10 cpd (Choi et al., 2004; Okuyemi et al., 2002; Okuyemi et al., 2004; Pulvers et al., 2015; Schane, Ling, & Glantz, 2010). The definitions of “intermittent” and “non- daily” smoking have been operationalized more consistently than “light” smoking, and are described as not smoking on a daily basis, but at least smoking weekly (Husten, 2009). Trinidad and colleagues (2009) used a more conservative definition of 1 to 5 cpd for “light” smoking to assess LITS behavior within and across racial groups. Their results demonstrate African Americans were more likely to be intermittent and light smokers than white Americans. Among African American smokers, women and younger smokers were more likely to be light or intermittent smokers than were men and older smokers. In a study conducted by Pulvers and colleagues (2015), light (i.e., 1 to 10 cpd) and intermittent smoking was examined among a sample of African Americans, Latino Americans, and white Americans in California (n=~50,000). Using data from the California Tobacco Surveys (1990 to 2008), results indicated that African Americans and Latino Americans were more likely to be LITS than white Americans over time. LITS also had higher odds of loosie use than heavy or daily smokers (Guillory, Johns, Farley, & Ling, 2015). 28 Low Smoking Cessation Rates The inequitable burden of tobacco-related health consequences on African American lives is also related to differential smoking cessation rates between these smokers and their white counterparts. In 2010, white Americans (6.0%) had successfully quit smoking at about twice the rate of African Americans (3.3%) (CDC, 2011). This difference exists despite African American smokers having higher desire to quit smoking (74% versus 69.4%) and having tried to quit smoking (49.3% versus 40.9%) more often than white American smokers, respectively (U.S. HHS, 2014). Kulak, Cornelius, Fong, and Giovino (2016) conducted a comprehensive literature review to examine race as a predictor of smoking cessation. The review included four study designs (population-based, cross-sectional, population-based retrospective cohort, and clinic-based cohort) and reported the analyses from wave 7 (2008-2009) of the International Tobacco Control U.S. Survey. Nine of the 17 articles in the literature review reported African Americans being more likely than white Americans to have made a quit attempt in a given year. Yet, white Americans were more likely than African Americans to achieve prolonged abstinence. Menthol Cigarettes and Utilization of Evidence-based Services Historically, the high prevalence of menthol cigarette use among African Americans (Gardiner, 2004) and the low utilization of evidence-based smoking cessation treatment (CDC, 2011) are contributing factors to the low smoking cessation rate among African American smokers. Menthol is a flavoring agent and cigarette additive, and its cooling sensation permits more frequent, larger puffs, deeper inhalation, and prolonged breath holding of cigarette smoke (Clark, Gautam, 29 & Gerson, 1996; Strasser et al., 2013; Watson et al., 2017). With the tobacco industry’s unjust marketing and advertising tactics towards African Americans, more than 80% of adult African American smokers smoke menthol cigarettes (Caraballo & Asman, 2011). Gardiner’s (2004) publication summarizes the “African Americanization” of menthol cigarettes through key historical periods, which include: 1) the emergence of the African American urban market in the 1940s; 2) the marketing of Kool cigarettes with healthful benefits (e.g., “Throat raw?” [Smoke a Kool]); and, 3) the tobacco industry’s philanthropy in African American social issues such as the civil rights movement. Menthol cigarettes critically impact the “Black/African American smoking paradox” through its facilitation of smoking in older age due to the taste and feel of menthol, increased nicotine dependence, and profound difficulty with quitting smoking (Alexander et al., 2016). Single cigarettes are also most often sold from opened cigarette packs of mentholated cigarette brands (Wackowski et al., 2018). Evidence-based smoking cessation treatment includes the single or combined use of behavioral counseling (e.g., cognitive behavioral therapy, motivational interviewing counseling), Nicotine Replacement Therapy (NRT) (nicotine patch, gum), and/or pharmaceutical medication (Varenicline, Zyban). These aids are deemed efficacious in helping smokers from the general U.S. population achieve and maintain abstinence (U.S. Preventive Services Task Force [PSTF]), 2016). Still, the use of these aids by African American smokers remains low. Stahre and colleagues (2010) assessed the relationship between menthol smoking and the population-quit ratio, and whether menthol smokers differed in the 30 utilization of evidence-based smoking cessation aids. They analyzed data from the 2005 National Health Interview Survey (NHIS) conducted with current and former smokers. Several statistically significant findings were noted: 1) 49% of African Americans made a quit attempt in the last year versus 41% of white American smokers; 2) the quit ratio for white Americans (51%) was higher than for African Americans (38%); 3) the quit ratio was higher for African American non-menthol smokers (49%) than for African American menthol smokers (34%); and, 4) the utilization rate of cessation aids was higher for white American (34%) than for African American smokers (23%). Tobacco control initiatives have targeted the low utilization of evidence-based strategies among African Americans by increasing their access and availability and by testing the effectiveness of culturally-targeted smoking cessation interventions (Baker, Palmer, & Lee, 2016; Liu et al., 2013; U.S. HHS, 2017). One strategy to increase access to evidence-based services by African Americans is Smokefree.gov. Smokefree.gov is a federally-funded effort that provides motivated-to-quit smokers with texting programs, recommendations for using NRT, the capability of speaking to an expert via an online chat or by telephone (also known as the Quitline that provides free NRT), and mobile phone applications (U.S. HHS, 2017). Though the overall reach of state quitlines is limited (about 1% of U.S. smokers), there is promising evidence that African American smokers are accessing these state quitlines (.94%), and even more so than white American smokers (.74%) (Keller, Feltracco, Bailey, et al., 2010; Marshall, Zhang, Malarcher, Mann, King, & Alexander, 2017). A study comparing quit rates and satisfaction with quitline services between African 31 Americans and white Americans in Louisiana, Texas, and the District of Columbia demonstrated that there were no statistically significant differences between racial groups for smoking cessation and satisfaction rates (Rabius, Viatrex, & McAlister, 2012). In their literature review, Liu et al. (2013) synthesized the empirical evidence regarding the effectiveness of adapted, culturally-targeted smoking cessation interventions. It was determined that although culturally-targeted interventions were regarded with higher acceptability and satisfaction than standard interventions, there was no concrete evidence that culturally-adapted materials and interventions were more efficacious in helping African Americans achieve smoking abstinence. Furthermore, other investigators (Bader, Boisclair, & Ferrence, 2011) have indicated the low acceptability and utilization of evidence-based services, specifically among African Americans residing in urban areas. 2.3. Smoking and Urban, African Americans African Americans residing in urban, metropolitan areas are the focus of this dissertation research because this subgroup is inequitably challenged by a multitude of risk factors for smoking initiation and unsuccessful quit attempts. Several of these risk factors are described below. High Smoking Prevalence Romano, Bloom, and Syme (1991) described the determinants of smoking behavior among African Americans living in urban areas. As a part of a controlled community intervention trial to reduce cancer mortality among urban, African Americans in San Francisco and Oakland, California, the researchers surveyed 1,134 32 individuals in 1985 and 1986. Approximately 43% of female and 40% of male participants were smokers. Using a 10-item Hassles index, it was determined that individuals who reported more hassles and stress were more likely to smoke than those who had less hassles and stress. Smokers also had lower household incomes and were more likely to be unemployed relative to non-smokers. Other studies focusing on African American smokers report the effect of poverty, racism and discrimination (Baker, Palmer, & Lee, 2016), and lack of social support (Lacey, Manfredi, Balch, Warnecke, Allen, & Edwards, 1993) on smoking and cessation behavior. Low Utilization of Evidence-based Smoking Cessation Treatment Though cessation-related disparities exist between white Americans and African Americans, these disparities are even greater for African Americans residing in urban areas. Okuyemi and colleagues (2007) conducted a cluster-randomized trial with 20 low-income housing developments in Kansas and Missouri. The goal of the trial was to test the efficacy of nicotine gum and motivational interviewing (MI) counseling for smoking cessation among public housing residents. The trial was deemed ineffective. This was partly due to the low utilization of nicotine gum that was provided to the treatment group participants. That is, only 26% of the trial’s treatment group participants used “most” of the nicotine gum, while 62% of the treatment group participants used “some” of the nicotine gum that was provided. Research has shown there is a disconnect between evidence-based smoking cessation aids and their use by urban, African American smokers. For example, Warren and Catona (2013) conducted nine focus groups with urban, low-income, African American, light smokers (n = 57) to understand their perceptions of existing 33 smoking cessation services such as behavioral counseling and pharmacotherapy. Two prominent themes emerged: 1) dissatisfaction of existing evidence-based services; and 2) mistrust towards physician-prescribed pharmacotherapy. These results further underscore the low utilization of evidence-based smoking cessation treatment and pharmacotherapy among urban, African American smokers who would benefit the most from them (Baker, Palmer, & Lee, 2016). Similarly, Baker, Palmer, and Lee (2016) conducted focus groups and surveyed 71 urban, African American smokers. These investigators were interested in the: 1) specific reasons for smoking and barriers to quitting; 2) perceptions of existing smoking cessation interventions; 3) influence of the cultural environment on smoking; and, 4) cultural components to incorporate in a smoking cessation intervention. The study’s participants voiced their frustrations with current quitting recommendations. When discussing the recommendation of setting a “quit date,” one participant stated, “Sometimes that works, but after the date is over, then what happens? You go right back [to smoking].” Another participant said that the available resources for cessation were inadequate: “So I was like ‘I ain’t gon’ even try to fight the funk [and try to use the services].’” Only 44% stated they would use smoking cessation aids to quit smoking, and only 26% reported that they would try NRT that was being offered for free from a local healthcare clinic nearby. These findings illustrate that accessibility to evidence-based cessation services, alone, does not necessarily translate into high usage of cessation resources among urban, African American smokers. Interventions prioritizing African Americans in urban areas must integrate emotional support, stress management, and facilitate hope in order to engage 34 the priority population and increase their utilization of evidence-based smoking cessation treatment (Baker, Palmer, & Lee, 2016). This dissertation research also proposes the need to integrate a loosies-specific component in these evidence-based cessation strategies to strengthen their impact and relevance. 2.4. Single Cigarettes – Loosies The use of single cigarettes, also known as “loosies” (Latkin, Murray, Smith, Cohen, & Knowlton, 2013), is a notable risk factor for tobacco use in urban communities (Stillman et al., 2007; Stillman, Bone, Milam, Ma, & Hoke, 2014). Though research is scant, the sale of single cigarettes in urban areas has been documented and persists due to their high acceptability (Stillman et al., 2007) and their role in the community’s informal economy (Latkin, Murray, Smith, Cohen, & Knowlton, 2013; Stillman et al., 2007). The Family Smoking Prevention and Tobacco Control Act The 2009 Family Smoking Prevention and Tobacco Control Act gave the FDA the authority to regulate the manufacture, distribution, and marketing of tobacco products (Husten & Deyton, 2013) – i.e., any product made or derived from tobacco that is intended for human consumption (Carvajal, Clissold, & Shapiro, 2009). FDA’s regulation covers six major categories: 1) regulation of tobacco products, 2) regulation of the advertising, marketing, and promotion of tobacco products, 3) regulation of the distribution and sales of tobacco products, 4) enforcement of tobacco regulations, 5) regulatory science research, and 6) public education about the harms of tobacco products. 35 In March 2010, the FDA released the final regulation restricting the sale and distribution of cigarettes, cigarette tobacco, and smokeless tobacco. One prohibition under this regulatory action was the sale of cigarettes in packets of fewer than 20 cigarettes (FDA, 2018). This description specifically refers to the illegal selling of single cigarettes or loosies. Loosies are sold as untaxed, unpackaged, loose cigarettes by a tobacco retailer or by an individual for monetary gain (Hall, Fleischer, Shigematsu, Santillan, & Thrasher, 2015). To enforce the prohibitions within the Tobacco Control Act, the FDA awarded contracts to primarily state agencies (e.g., local health departments, contracted organizations) in 40 states, three territories, and the District of Columbia to conduct compliance checks to assess tobacco retailer violations (Husten & Deyton, 2013). Violations resulted in warning letters, civil money penalties, and no-tobacco sale orders (Husten & Deyton, 2013). Baker, Lee, Ranney, and Goldstein (2016) assessed the sale of single cigarettes by tobacco retailers and aimed to identify predictors of differences of these violations by state. Using publicly available warning letters from advertising and labeling compliance checks, Baker and colleagues found that warning letters were not being evenly distributed across states. States such as Virginia, Ohio, and Vermont did not provide any warning letters; while North Carolina sent 107 warning letters to tobacco retailers for their first violation. Of these 107 warning letters, 64% were specifically for the selling of single cigarettes. Important implications of the findings from Baker, Lee, Ranney, and Goldstein (2016) are that the states’ number of compliance checks and warning letters for selling loosies at the retail store level did 36 not align with the increased availability of loosies in cities such as Baltimore, MD and New York City. In Maryland, there were 137 compliance checks and one warning letter, which was not in relation to single cigarettes. In New York, from 246 inspections, only six warning letters were issued, and none were for selling loosies. Research Conducted in Urban Areas of Baltimore, Maryland Smith and colleagues’ (2007) focus group research aimed to identify and understand young adult (18 to 24 years old) African American smokers and non- smokers’ perceptions of and experiences with social and contextual factors that contribute to smoking in their Baltimore, MD community. Participants (n=28) were recruited with the help of program directors from training and educational programs for young adults in the Sandtown-Winchester neighborhood of Baltimore. When discussing the social and contextual factors surrounding smoking, the sale of single cigarettes outside of the formal tobacco point-of-sale environments emerged as a theme across all focus groups. Three themes emerged from this study: 1) smoking is a normalized behavior, 2) the practice of buying and selling loosies, and 3) the sale of loosies as a part of the informal economy of the community as a survival strategy. Stillman and colleagues (2007) surveyed urban, African American young adults (n = 156) in 2005 and 2006. Their findings indicated that approximately 70% of urban, African American young adults saw loosies being sold every day during the last month, and the primary neighborhood locations to buy loosies were at corner stores (85%), supermarkets, drugstores, or gas stations (83%), at bars or clubs (57%), or from family members (17%) or friends (34%). The implications of the availability of loosies for smoking initiation and barriers to cessation are synthesized in their 37 findings. The likelihood of purchasing loosies was associated with seeing loosies being sold everyday (OR=3.89; 95% CI = 1.24, 12.19), seeing loosies being sold outside a corner store (OR=3.64; 95% CI = 1.06, 12.53), and buying cigarettes from a bar or club (OR=4.39; 95% CI = 1.50, 12.88). Stillman and colleagues (2014) reported the subsequent findings from a 110- item cross-sectional survey administered to 488 young adult African Americans smokers and non-smokers in Baltimore, MD. The participants were recruited from the same training programs used from the previous studies of Smith et al. (2007) and Stillman et al. (2007). Notably, there was high acceptability of loosies among 73.5% and 30.5% of smokers and non-smokers, respectively. These participants agreed with the statement that loosies should be available in their community. Males and those with lower educational attainment were more likely to support the sale of single cigarettes. In relation to the availability of loosies, 65% of respondents saw single cigarettes being sold everyday on the street. More than 30% reported seeing their family member(s) or friends selling loosies. Loosies were being sold near subway stations and outside of corner and grocery stores (80%), outside of bars and clubs (71%), and outside of schools (37.5%). Respondents who purchased loosies everyday (OR=2.49; p = .23) or several times a week (OR=3.86; p = 0.01) were more likely to have higher tobacco use in the past month than those who purchased loosies less often. Latkin and colleagues (2013) examined the selling of loosies by drug users via baseline data from a randomized controlled trial of a cognitive behavioral intervention, which was designed to decrease depressive symptoms and HIV risk 38 among drug users in Baltimore, MD. The ethnicity and race of respondents were not reported. The study sample was primarily unemployed (96%) and about half of the respondents had less than a high school education. Approximately 70% of respondents saw loosies being sold on their block and 58% reported selling single cigarettes themselves a few times in the past week. Research Conducted in the District of Columbia According to Mr. Charles Debnam, BA, MCHES, CTTS, CAC, the Deputy Chief Executive Officer of the Community Wellness Alliance and the past Chair of the DC Tobacco Free Coalition, the sale of single cigarettes is a significant issue affecting the lives of urban, African Americans residing in the District of Columbia (C. Debnam, personal communication, April 25, 2018). Following a comprehensive review of the published literature, there remains a lack of empirical evidence specifically documenting the use of loosies in this urban setting. However, Kirchner and colleagues (2015) found a higher rate of tobacco retailer sales to minors in predominantly African American neighborhoods in the District of Columbia than other non-African American areas in the district. It is also important to note that the use of single cigarettes has emerged in an ongoing study (focus groups and surveys) being conducted by the committee chair (Dr. Butler), a committee member (Dr. Beck), and the doctoral candidate. The purpose of the study is to examine the social context of smoking among African American public housing residents in the District of Columbia to inform the development and validation of a social context of smoking scale. Regarding loosies, one focus group participant noted, “[Loosies are a] good way to help you quit smoking because you don't have to buy a pack.” While another 39 participant stated the potential harm of loosies, “You need to know who you bought the singles from because they [can get] dipped in water, PCP...” The participants also shared that you can buy loosies “on the street” and they cost about “a dollar [per loosie].” We anticipate learning more about the unintended consequence of loosie use during future focus groups. Furthermore, the use of loosies has been referenced in relation to the District of Columbia culture through local news reports, music, and podcasts. Unfortunately, on May 14, 2016, two men argued over the selling of loosies, which resulted in a shooting in the northeast section of the city (Meehan, 2016). This notwithstanding, Tef Wesley, a local District of Columbia rapper, titled his extended play record, “Corner Store Loosies” (Wesley, 2012a). The record’s video was taped outside of a local corner store where Tef Wesley is presumed to be smoking a loosie (Wesley, 2012b). The last lyric of his song is related to a loosie, “You can light up one” (Wesley, 2012a). Another cultural reference to loosie use is the local “District Sentinel Radio” podcast series, which briefly discussed the issue of loosies in an episode entitled, “Selling Loosies for Snitches” (District Sentinel Radio, 2017). This notwithstanding, there remains limited research on loosie usage in the District of Columbia. Nonetheless, hearing from Mr. Debnam and some loosie users about the sale and use of loosies underscored the need for this dissertation research reported here. The dissertation research results add to our understanding of the loosie phenomenon among African Americans residing in the District of Columbia. 40 Research Conducted in New York City, New York The Sacks et al. study (2012) used population-based data from 2002 (n = 2,113) and 2010 (n = 1, 141) to examine the characteristics associated with non-daily smoking and to compare non-daily, daily, and heavy daily smokers among New York City adults. Loosies were not a primary focus of this study, though some of the study’s findings are relevant to loosie users. For instance, purchasing loosies was associated with being a non-daily smoker (AOR = 3.5; 95% CI = 1.72, 7.08) and making a quit attempt in the last year (AOR = 2.3; 95% CI = 1.36, 3.96). Additionally, African Americans were more likely to be non-daily smokers than heavy smokers (25% versus 10%, p<.05). The highest rate of quit attempts was among non-daily smokers, while the percent of smokers advised to quit by a healthcare professional was lowest among non-daily smokers in comparison to light and heavy smokers (44% versus 60% and 65%; p < 0.01). New York City has the highest cigarette pack price in the nation due to city, state, and federal law tax increases over time. To examine the relationship between cigarette excise tax increases and tax-avoidant purchasing behaviors over time among New York City adults, Coady and colleagues (2013) analyzed data collected from 2003 to 2010 from the city’s annual Community Health Survey. Using multivariable logistic regression analyses, results showed that after the 2002 tax increase, the percentage of smokers engaged in tax-avoidant behavior decreased with time from 30% in 2003 to 13% in 2007. Yet, following the 2008 tax increase, 21% of smokers reported buying cigarettes from another person on the street. Low-income, younger, 41 African American, and Hispanic smokers were more likely to purchase cigarettes on the street. With an interest to assess tax-avoidant behavior in New York City, Guillory and colleagues’ (2015) examined loosie purchasing behavior among young adult smokers ages 18 to 26 years (n = 1,730). The average age was 23 years old (SD = 1.77), and a small proportion (16%) was African American and had less than a college education (18.6%). The participants were representative of all five New York boroughs (Manhattan = 42.3%; Brooklyn = 12.4%; Queens = 24.6%; The Bronx = 10.3%; and Staten Island = 9.0%). Regarding the acceptability of loosies, Guillory and colleagues observed that for every 1-unit increase in the approval of smoking, the odds of the last cigarette smoked being a loosie increased (AOR = 1.40; 95% CI = 1.09, 1.81; p <.01), as did the odds of having ever purchased a loosie (AOR = 1.30; 95% CI = 1.09, 1.55; p <.01). In addition, the last cigarette smoked being a loosie was significantly greater for non-daily smokers (AOR = 7.27; 95% CI = 2.35, 22.48; p <.01) than for daily smokers. Intention to quit within the next 6 months was associated with last smoking a loosie (AOR = 2.50; 95% CI = 1.41, 4.41; p <.01) and having made a quit attempt was also associated with ever purchasing a loosie (AOR = 1.70; 95% CI = 1.15, 2.50; p <.01). Research Conducted in Mexico Although the sale of single cigarettes has been banned in Mexico since 1999, their availability continues to rise within the context of increasingly high cigarette taxes (Hall, Fleischer, Shigematsu, Arillo-Santillan, & Thrasher, 2015). The use of single cigarettes in Mexico was initially addressed in the research of Thrasher and 42 colleagues (2009) who assessed the prevalence, perceptions and correlates of single cigarette use among adult Mexican smokers via focus groups (n = 75) and the 2006 administration of the International Tobacco Control Policy Evaluation Project (n = 1, 709). At least one participant in each focus group stated they had purchased single cigarettes as a method to quit smoking or to cut down to “keep from smoking too many cigarettes.” In addition, seeing the selling of loosies served as a cue to smoke. These qualitative findings reflect those from other studies conducted in Baltimore, MD (Smith et al., 2007; Stillman et al., 2007). Thrasher and colleagues’ (2009) results indicated that purchasing loosies was associated with certain demographic characteristics: younger age, less education, lower income, non-daily smoking, higher number of quit attempts in the last year, greater intentions to quit smoking, more frequent purchasing of loosies to reduce the amount of cigarettes smoked, and experiencing more frequent cues to smoke when seeing single cigarettes for sale. In multivariate models, those who most frequently purchased single cigarettes to reduce consumption were more likely to intend to quit smoking (OR = 3.71; 95% CI = 2.13, 6.48) than those who did not purchase loosies for the reason of keeping consumption low. To further explore the use of single cigarettes and the association between single cigarette use and cessation behavior among adult Mexican smokers, Thrasher and colleagues (2011) conducted an additional study using data from the 2008 (n = 1, 649) and 2010 (n= 1, 206) Mexican International Tobacco Control Policy Evaluation Survey. As observed in Thrasher et al. (2009), more frequent purchases of single cigarettes were made by those who were younger, lighter smokers (1 to 5 cpd), and 43 those who intended to quit in comparison to their counterparts. Despite the well- intentioned use of loosies as a means to quit smoking, the odds of being quit was only statistically significant when comparing those who had not bought loosies to reduce consumption with those who had done so on an irregular or infrequent basis (AOR = 2.30; 95% CI = 1.19, 4.45); whereas those who regularly purchased loosies were no more likely to be abstinent. These findings infer that frequent use and exposure to loosies supports persistent smoking behavior rather than promotes cessation. Hall and colleagues (2015) used data from the 2010, 2011, and 2012 Mexican International Tobacco Control Policy Evaluation Survey to determine trends in single cigarette availability and purchasing in Mexico and to assess the association between neighborhood access to singles and cessation behavior among adult Mexican smokers (n = 4,249). The findings suggest that a substantial cigarette tax increase in 2011 may have impacted the increasing prevalence of loosies in Mexico. Using trend analysis, the percentage of participants who saw singles sold daily (45.2% in 2010; 51.4% in 2011; 64.9% in 2012), who bought singles at least once a week (22.3% in 2010; 29.1% in 2011; 29.1% in 2012) and whose last cigarette purchase was a single (16.6% in 2010; 20.7% in 2011; 25.8% in 2012) increased significantly from 2010 to 2012 (all p<0.001). In adjusted analyses, smokers living in neighborhoods with higher access to singles were less likely to make a quit attempt (RR = 0.72; 95% CI = 0.46, 1.12) and also more likely to relapse (RR=1.30; 95% CI = 0.94, 1.82), though these results were not statistically significant. 44 2.5. Social Context Scale Development and Validation Social Context of Cigarette Smoking It has been proposed that understanding the social context of smoking may help bolster tobacco control research and practice for priority populations that face substantial barriers to living smokefree lives and who are less impacted by tobacco control policies designed for the broader U.S. population (Poland et al., 2006). Yet, there remains limited research that focuses on the social context of smoking (Gittelsohn, Roche, Alexander, & Tassler, 2001) and specifically explores single cigarette use. Importantly, the social context framework was included as part of this dissertation research’s theoretical framework. The social context includes the social, environmental, and situational circumstances (i.e., why, when, where, from whom, and how) surrounding loosie purchasing and use. This framework has been previously used to characterize tobacco (Gittelsohn, Roche, Alexander, & Tassler, 2001), alcohol (Beck, Summons, & Thombs, 1991; Beck, Thombs, Summons, 1993; Beck, Thombs, Mahoney, Fingar, 1995; Beck & Treiman, 1996; Thombs & Beck, 1994), hookah, (Sharma, Beck, Clark, 2013), and cannabis use (Beck et al., 2009) among adolescents college students. Gittelsohn, Roche, Alexander, and Tassler (2001) conducted qualitative interviews and focus groups to understand variations of the social context of smoking among white and African American adolescents in Baltimore, MD. In relation to the priority population of this dissertation research (i.e., urban, African American adults), African American adolescent males smoked due in part to social coercion and those 45 that did not smoke had stronger sentiments of parental sanctions against smoking, not wanting to disrespect parents, and greater displeasure of parental smoking. Social Context of Alcohol, Cannabis, and Hookah Use To gain an understanding of the social context of loosies, an examination of previous research focusing on the development and validation of social context measures (on alcohol, cannabis, and hookah use) was conducted. For example, Beck, Summons, and Thombs (1991) conducted exploratory factor analysis with survey data from high school students in a suburban area of the District of Columbia. From the generated 25 items designed to measure the social context of drinking, four distinct factors with 17 items emerged; however, only two of these factors demonstrated strong reliability and validity and were retained for subsequent analyses. The four scale dimensions described negative affect abatement (i.e., drinking to cope with stress), conviviality (i.e., social drinking), under parental control and supervision (i.e., in one’s home) and lastly, consuming alcohol at a bar, or in a dormitory. Associations between subscale scores for negative affect abatement and conviviality with categories of alcohol abuse explain that high school students who had been drunk drivers had higher scores for consuming alcohol to relieve stress and to be social than those who had never driven while drunk. Beck, Thombs, and Summons’ follow up work (1993) included another survey administration of 48 items on the social context of alcohol consumption with a different group of District of Columbia high school students. Among these high school students, consuming alcohol for social facilitation, for peer acceptance, to defy school restrictions, to control stress, and under parental control emerged in 46 exploratory factor analysis. Drinking for social facilitation, school defiance, and stress control significantly predicted binge-drinking patterns. Thombs and Beck (1994) subsequently conducted a replication study with adolescents enrolled at a suburban high school in Western New York State. The same social context factors were established in this sample as demonstrated previously by Beck, Thombs, and Summons (1993). In the replication study, findings indicated high intensity drinkers were more likely to consume alcohol in the context of social facilitation than light drinkers. To extend previous findings on alcohol use by adolescents, Beck and Treiman (1996) examined the social context of alcohol use in combination with perceived social norms and parental drinking behaviors. Results indicated the social context of consuming alcohol were better predictors for identifying binge drinking, those who ride in cars with drunk drivers, and high intensity drinkers than perceived social norms and parental drinking behaviors. In the college setting, the social contexts of alcohol, cannabis, and hookah tobacco use have been studied. Beck, Thombs, Mahoney, and Fingar (1995) explored the utility of the social context of alcohol consumption in relation to the Sensation Seeking Scale with college students from two public universities in New York and Maryland. The retained factors involved drinking alcohol for social facilitation, peer acceptance, emotional pain, sex seeking, and in the setting of family drinking and being in a motor vehicle. As established among adolescent drinkers, high intensity drinkers had higher scores of drinking to be social than those who drank alcohol less frequently. The social context dimensions were also more able to discriminate 47 between various intensity levels of drinking than the Sensation Seeking Scale. The first four dimensions of the social context of alcohol consumption (i.e., social facilitation, peer acceptance, emotional pain, and sex seeking) among college students were also identified as the social context of their cannabis use in a sample of young adults from a public university in the mid-Atlantic region (Beck et al., 2009). Furthermore, significantly higher scores of using cannabis for social facilitation and emotional pain were seen among those with cannabis use disorder, and students with higher depressive symptoms were also more likely to use cannabis for sex seeking or to relieve emotional pain. Similar dimensions of the social context of hookah tobacco use emerged in research conducted by Sharma, Beck, and Clark (2013) with a sample of college students. In this study, the researchers used qualitative interviews, expert review, and cognitive pilot testing to generate a pool of 50 potential scale items. The retained 19 scale items spanned the following three dimensions of hookah tobacco use: 1) social facilitation; 2) family and cultural influence; and, 3) hookah use as an alternative to cigarettes and drinking. The investigators also found social facilitation to be higher among frequent hookah tobacco users than infrequent users. The findings from these studies demonstrate the valuable utility of social context scales in identifying meaningful correlates of tobacco and alcohol use and potential targets for program development and intervention. Nonetheless, the social context framework is meant to be complementary to exploring intrapersonal motivators to a certain health behavior (Poland et al., 2006). Thus, in this dissertation research, the Health Belief Model guided the examination of intrapersonal factors for using loosies and reducing loosie use among urban, African American smokers. 48 2.6. Health Belief Model Scale Development and Validation The Health Belief Model (HBM) purports that modifications to health behaviors are driven by one’s perceptions of a health threat and the expected value in taking action to reduce the health threat (Champion & Skinner, 2008; Rosenstock, 1974). Since its inception, HBM has been widely used in research to promote positive health behaviors and to reduce negative health behaviors, though to a lesser degree (Champion, 1998; Champion & Monahan, 2008; Matthews, Sanchez-Johnsen, King, 2009). Seminal HBM research conducted by Champion (1984) measured the susceptibility, severity, benefits, barriers, and health motivation to conduct self- breast-examinations by women that resulted in the Champion Health Belief Model Scale. The Champion Health Belief Model Scale was later revised via focus group feedback to measure perceived susceptibility to breast cancer and perceived benefits and barriers to mammography utilization (Champion, 1998). In a sample of women age 50 and older recruited from a Health Maintenance Organization and a general medicine clinic, perceived benefits to mammography screening were higher and perceived barriers of screening were lower among those who had been screened than those who had not been screened. The Champion Health Belief Model Scale for mammography screening was further refined specifically for low-income African American women (Champion & Monahan, 2008). Changes such as modifying, adding, and/or deleting items, and including additional items to measure self-efficacy and fear toward screening were made. Results from this study shed light on the theoretical relationships of self- efficacy, perceived benefits, and fear such that women with higher scores for self- 49 efficacy and perceived benefits had decreased levels of fear toward mammography screening. In addition, increased fear and less perceived barriers were related to mammography screening adherence among low-income African American women. Relevant to the topical area of this dissertation, Matthews, Sanchez-Johnson, and King (2009) used the theoretical underpinnings of the Health Belief Model, Theory of Reasoned Action, and PRECEDE-PROCEED model to develop a culturally-targeted smoking cessation intervention for low to middle income African American smokers. Findings indicated biochemically-confirmed quit rates were higher among participants in the culturally-targeted arm of the study than those who received the standard smoking cessation treatment. As such, these applications of the Health Belief Model demonstrate its versatility in explaining intrapersonal factors for various health behaviors and its function in mobilizing health behavior change among African Americans. 2.7. Positionality in Qualitative Research Qualitative research is a process involving shared, dynamic dialogue between the researcher and participant, which is shaped by our respective identities and perceptions of one another (Bourke, 2014; England, 1994). This dissertation research focused on the experiences of urban, low-income, African American smokers who purchased and used loosies in Baltimore, MD and the District of Columbia. I am an Asian American, college-educated, cisgender female who was raised by a single mother in an urban, low-income household during my adolescent years. With research interests in tobacco-related health disparities, I first became interested in the risk factor of loosies when I served as a smoking cessation counselor for low- 50 income, primarily African American smokers. I personally related to the topic of loosies because my friends and I would purchase loosies as teenagers from our local corner store. This section focuses on the role that my positionality played while conducting semi-structured, in-depth interviews in June and July of 2018 with 25 African American loosie users who were kind enough to participate in this research. Undoubtedly, my sociodemographic characteristics influenced my interactions with participants. In reflection, I had both the insider and outsider perspective at different times throughout each interview process. In the next few paragraphs, I share examples that resonate with me. For some participants, I was an insider before they met me. One significant recruitment strategy used to engage participants was word-of-mouth (Resnicow, Baranowski, Ahluwalia, & Braithwaite, 1999). Although I did not ask participants to share information about the study with others in their social networks, participants graciously did. With this assurance from a trusted individual, I was also trusted and my role was then to maintain that trust. This trust translated to a safe environment to have an open, authentic discussion about the participants’ experiences with loosies – thus, an inside look. I also met with staff from local community organizations to introduce myself and the purpose of this research. When staff from a trusted community organization were the ones to spread information about the study, I was also automatically trusted by their program attendees. A clear depiction of being an outsider due to social class differences was exemplified in an interview I had with a young African American woman in 51 Baltimore, MD. I recall asking her to explain where in Baltimore City loosies were available, and where they were not. In her response, she explained that they are everywhere in impoverished neighborhoods, but where I lived, loosies were not sold. Her perceptions were true – they are not sold where I lived. The position of living in a geographical setting where loosies were not sold aided in the participant wanting to share more and to be more descriptive. This example describes the role that positionality can have in the discussion and perhaps how and what participants share with the researcher. As an Asian American, I had both an insider and outsider perspective. As a non-white individual, participants and I related in some aspects of race. However, I was sometimes an outsider because I am not African American. This racial difference is one in which I believe the building of strong rapport in the beginning of the research process is important. At the start of study visits, participants and I would spend time getting to know one another and then comprehensively going through the consent process and the purpose of this study. I strongly believe that this initial connection outside of an academic or clinical research setting allowed the research process to be successful and for the biases of positionality to be managed and used as a strength versus a weakness of the qualitative research. 2.8. Summary The Surgeon General’s report affirmed the negative health effects of cigarette smoking and tobacco use as the leading cause of preventable morbidity and mortality in the U.S. Nonetheless, African American smokers remain less likely to achieve abstinence despite initiating cigarette smoking at an older age, smoking fewer 52 cigarettes per day, having higher motivation to quit smoking, and having made more quit attempts than white American smokers – i.e., The Black/African American smoking paradox. The use of loosies is a notable risk factor for tobacco use in urban communities. Their sales persist due to their high acceptability and their role in the community’s informal economy. The practice of loosie use cultivates normative smoking beliefs and increases smoking propensity among urban, African American smokers - the priority population of this dissertation research. Thus, by developing and validating scales to understand the social context (i.e., why, when, where, from whom, and how) and the intrapersonal factors (Health Belief Model) surrounding loosie purchasing and use, this dissertation research contributes to tobacco control research and practice designed for urban, African Americans. This group of smokers face substantial barriers to living smokefree lives and are less influenced by non- targeted tobacco control policies and evidence-based cessation programs. 53 Chapter 3: Manuscript #1 3.1. Introduction The 2009 Family Smoking Prevention and Tobacco Control Act (Tobacco Control Act) granted the Food and Drug Administration (FDA) authority to regulate the manufacture, distribution, and marketing of tobacco products. To restrict tobacco marketing and cigarette sales to youth, the Tobacco Control Act prohibits the sale of cigarette packages with < 20 cigarettes, which includes the sale of single cigarettes (21 Code of Federal Regulations §§ 1140.14, 1140.16). Single cigarettes are unpackaged and sold individually, which impedes the enforcement of tobacco control policies and evades taxes on cigarette pack and carton sales (Smith et al., 2007; Stillman, Bone, Milam, Ma, & Hoke, 2014). Single cigarettes, (hereafter, loosies), are a unique phenomenon among racial and ethnic cigarette smokers, individuals with limited resources (not enough money to purchase a cigarette pack) (von Lampe, Kurti, & Johnson, 2018), and individuals with some college credits or less (Coady, Chan, Sacks, Mbamalu, & Kansagra, 2013; Guillory, Johns, Farley, & Ling, 2015; Latkin, Murray, Smith, Cohen, & Knowlton, 2013; Smith et al., 2007; Stillman et al., 2014). Despite the Tobacco Control Act regulations, loosies contribute to the disproportionate burden of tobacco use African Americans experience (Baker, Lee, Ranney, & Goldstein, 2016). They are nine times more likely to purchase a cigarette off the street than white Americans (Coady et al., 20013) and to have their last cigarette purchase be loosies (Guillory et al., 2015). 54 In Baltimore, MD and the District of Columbia (D.C.), the focus of the research reported here, pro-loosie norms and loosie availability are widespread among African Americans. During focus groups conducted with young adult African American cigarette smokers in Baltimore, loosie usage emerged as a convenient cigarette acquisition practice and a source of income for sellers (Smith et al., 2007). Research conducted by Stillman et al. (2014) found 74% of African American smokers agreed loosies should be available in their community. Approximately 65% reported seeing loosies being sold on the street every day; correspondingly, 29% were daily loosie purchasers and 85% had bought loosies at some time during the past month. Although there is a lack of empirical evidence specifically documenting the use of loosies in D.C., communication with a past chairperson of a D.C.-based tobacco free coalition confirms the issue of loosie use and sales by African Americans in D.C. (Debnam, 2018). Furthermore, Kirchner et al. (2015) found a higher rate of tobacco sales from retailers to minors in predominantly African American neighborhoods in the District of Columbia. These findings in Baltimore and D.C. shed light on the normative use of loosies and their contribution to overall pro-smoking beliefs among African Americans. Loosie purchasers are less likely to experience age restriction enforcement and exposure to the Surgeon General’s health warning label, “Caution: Cigarette Smoking May Be Hazardous to Your Health,” on cigarette packaging (See [USC04] 15 USC Ch. 36: Cigarette Labeling and Advertising) (Hall, Fleischer, Shigematsu, Arillo- Santillán, & Thrasher, 2015). There is a growing body of evidence that suggests the sale of loosies is an unintended consequence of increasing cigarette taxes aimed at 55 preventing smoking initiation and promoting cessation (Coady et al., 2013; Saenz-de- Miera et al., 2010). Data from the annual Community Health Survey found loosie purchasing increased by 12% following a $1.25 cigarette tax increase in 2008 (Coady et al., 2013). Though there is uncertainty whether using loosies supports cessation behavior (Thrasher et al., 2011), they are the preferred harm reduction strategy and aid to gradual cessation (Guillory et al., 2015; Smith et al., 2007; Thrasher et al., 2011). Among urban, African American young adult smokers in Baltimore, Smith and colleagues (2007) identified reasons why these smokers used loosies: help with “cutting back” on cigarette smoking (44%); and prevent further nicotine dependence (21%). Thrasher et al. (2011) observed smokers who most frequently purchased loosies were no more likely to attempt quitting smoking than those who did not purchase loosies. Consequently, using loosies may perpetuate cigarette smoking rather than promote cessation (Guillory et al., 2015; Sacks, Coady, Mbamalu, Johns, & Kansagra, 2012; Thrasher et al., 2011). The role of loosies along a smoking continuum, from initiation to quit attempts, underscores the need to explore both the contextual and individual factors that motivate their purchase and use. The social context framework is useful in explaining diverse sources of resistance against tobacco control among marginalized groups (Poland et al., 2006). Specifically, the social context describes the circumstances within which a phenomenon, such as the sale of loosies, takes place. That is, the why, where, when, from whom, and how African Americans purchase loosies (Poland et al., 2006). The social context of smoking cigarettes (Gittelsohn, 56 Roche, Alexander, & Tassler, 2001; Paul, 2010), hookah tobacco (Sharma, Beck, & Clark, 2013), cannabis (Beck et al., 2009) and its link to consuming alcohol (Beck et al., 2008; Beck & Summons, 1985; Sudhinaraset, Wigglesworth, & Takeuchi, 2016) have been studied. Despite the significance of social and environmental targets for intervention, the social context framework is a complement to understanding individual factors that influence a behavior and those factors needed for behavior change (Poland et al., 2006). Moreover, The Health Belief Model (HBM) posits that behavioral change involves an evaluation of the perceived health threat of using loosies (perceived susceptibility and severity) and expectations from reducing loosie use (perceived benefits and barriers) (Rosenstock, Strecher, & Becker, 1988). We revised HBM’s utility in health promotion, such as receiving vaccinations, to the discontinuation of a harmful behavior (using loosies). The purpose of this study was to extend previous qualitative research on loosie use by African Americans. We accomplished this aim by conducting qualitative interviews (Gill, Stewart, Treasure, & Chadwick, 2008) to gain an in-depth understanding of the social context and individual factors involved in the purchase and use of loosies among African American smokers. 3.2. Methods We conducted 25 semi-structured, in-depth interviews with a convenience sample of African American adult loosie users (ages 20-58 years) from Baltimore, MD and the District of Columbia (D.C.). We chose semi-structured qualitative interviews because this allowed us to utilize a set list of interview questions while simultaneously permitting unscripted dialogue and the use of follow-up questions 57 (Kendall, 2014). Eligibility included self-identifying as African American, ≥ 18 years, residing in either Baltimore or D.C., and having purchased and used loosies at least once in the past 30 days. Participants were recruited using purposive sampling techniques: 1) “word-of-mouth,” an oral and interpersonal communication style preference among African Americans that is an important recruitment strategy (Jones et al., 2009) (Jones, Steeves, & Williams, 2009; Okuyemi et al., 2007; Resnicow, Baranowski, Ahluwalia, & Braithwaite, 1999; Sankaré et al., 2015); and 2) flyers posted in local convenience stores, gas stations, take-out restaurants, The Washington Metropolitan Area Transit Authority stations (commonly referred to as Metro), community centers, and local branches of the public library in urban areas within the two cities (Jones et al., 2009). Interested individuals were directed to call the study team and eligibility was assessed over the telephone. Participation involved completing one study session. At the beginning of the session, eligibility was reassessed, and eligible participants were taken through the informed consent process, which allotted ample time for questions about the research and to make an informed decision about participation (Quinn et al., 2012). A paper- based survey was administered to measure demographic characteristics, smoking history, cigarette acquisition practices, and loosie use. Interviews were conducted by the first author and took place in a private area of public libraries and community centers. Interviews were digitally-recorded and guided by a theoretically-based interview guide focusing on understanding the participant’s social context of purchasing loosies (why, where, when, from whom, and how). Additionally, the interview guide included questions regarding perceived benefits (“What are the pros 58 to using loosies?”; “What would be the pros to not using loosies?”); susceptibility to persistent smoking from loosies (“How worried are you that loosies will support your continued smoking?”); severity of cigarette smoking (“How serious is using loosies?”; “How serious is using loosies to your health?”; “In general, how serious is smoking cigarettes to your health?”), benefits and barriers to reduce loosie use (“If you tried to stop using loosies, what would you miss about them?”); and self-efficacy needed to reduce loosie use (“What can you do to reduce your use of loosies? “How confident are you that you can do these strategies?”). Interviews lasted 60 to 90 minutes and were conducted in June and July of 2018. Participants were provided light refreshments and received $25 cash for their time and participation. This research was approved by The University of Maryland, College Park Institutional Review Board. Interviews were transcribed verbatim using a third party transcription service, Rev© (https://www.rev.com). The first and second authors developed a codebook using an iterative process that included both deductive and inductive methods - based on an a priori interview guide and emergent qualitative themes. The qualitative analysis was completed using the Framework Method (Ritchie et al., 2013), which has been utilized for semi-structured interviews (Ritchie et al., 2013) and qualitative studies on tobacco use (Struik & Baskerville, 2014; Vogt, Hall, & Marteau, 2007). The first and second authors coded each transcript using NVivo 12© (QSR International). All coding discrepancies were reconciled through discussion and interrater agreement (Campbell, Quincy, Osserman, & Pedersen, 2013). 59 3.3. Results Twenty-five African American loosie users (average age 37 years) participated. Participant characteristics are found in Table 3.1. and their cigarette acquisition practices are described in Table 3.2. The Social Context of Purchasing and Using Loosies We describe social context as the circumstances and settings surrounding the purchase and use of loosies: why, where, when, from whom, and how (Poland et al., 2006). Why explains personal reasons underlying loosie purchasing. Where denotes the types of geographical settings where loosies are available. When indicates the time of day loosies are purchased and psychological motives. From whom describes the types of loosie sellers. Within these dimensions are culturally appropriate mannerisms, etiquette, and preferences associated with how the selling and purchasing loosies occurs. Why Loosies Are Purchased Though individual loosie cost was perceived as expensive ($0.50 cents per loosie), their popularity stemmed from the low and immediate cost savings from buying them in comparison to a cigarette pack. For several participants, the cost of loosies made them a preferred option, especially if participants were light smokers – smoking 1 to 10 cigarettes per day (Okuyemi, Ebersole-Robinson, Nazir, & Ahluwalia, 2004; Schane, Ling, & Glantz, 2010). Yet, the majority bought loosies due to financial constraints, but would rather purchase a pack if it was economically feasible (Table 3.3., A1). Since Newports are the most widely sold loosie brand 60 (Wackowski et al., 2018), a few participants bought these as “fillers” until they could acquire their cigarette brand of choice, such as Maverick. Another central theme for loosie use was to control cigarette consumption by managing and keeping consumption low or gradually reducing the number of cigarettes smoked per day (Table 3.3., A2). One participant, a 40-year-old male from D.C., bought loosies near his workplace and used them as a strategy to quit smoking. As he explains, “When I’m trying to reduce my cigarette intake, I just leave my pack at home so I only get to buy loosies. And that’s not so convenient.” Other narratives revealed how loosies are used by daily and nondaily smokers: 1) to boost their high from other drugs – e.g., marijuana and liquor; 2) as an alternative to marijuana; and, 3) to fill the void of illicit drugs that are “worse off than cigarettes.” Where Loosies are Available and Accessible Loosies were perceived as being unique to “an urban community with more black people” because in the “suburbs you’re not [going] to find a loose one. You’re gonna have to buy a pack.” Subsequently, participants reported loosie availability in “downtown areas and mostly neighborhoods of poverty.” In the two cities, participants purchased loosies because they “...be sold all day everyday, no matter if you’re going north, east, south, or west. Somebody gonna be selling loose ones.” When Loosies Are Purchased When participants purchased loosies depended on their availability and personal smoking patterns. Participants in both cities remarked about the availability of loosies “in the morning, in the afternoon, [and] at night.” Yet, there appeared to be differences on availability based on where - residential neighborhoods or downtown 61 areas. In residential neighborhoods, loosies were easier to acquire from morning hours to early evening hours. Morning hours and afternoons were popular because “that’s when [loosie sellers] are trying to sell them” and individual sellers “might shift on to somewhere else [later in the day].” In comparison, participants who bought loosies in downtown areas acquired loosies during their lunch break, “towards the end of the day, or sometime in the evening.” Participants also bought loosies when socializing with sellers or when experiencing emotional triggers to smoke: feeling stressed, happy, bored, or while consuming alcohol. From Whom Loosies Are Purchased Loosie purchases occurred in retail stores and from individual sellers. Convenience stores, gas stations, liquor stores, take-out restaurants, and street vendors - ice cream trucks and hotdog stands - sell loosies. Because of the illegality associated with loosie sales, participants had their “go-to” retail stores where they could purchase loosies without fear of either party being legally reprimanded. Some participants stated stores would not sell loosies “unless they knew your face.” Some stores required aliases describing items they did not sell as a cue for loosie purchases, such as asking for candy (i.e, “blow pops” or “laffy taffy”). Consequently, participants were more likely to approach and purchase loosies from individuals than from unknown retail stores. Unless you were a regular customer, it was difficult to determine which stores sold loosies. Pulling open “heavy doors” to get in and out of the store, waiting in line with other customers, and worrying about hours of operation were stated as additional store purchasing hassles. 62 “…I would say it’s more accessible and easier for me to go buy from a buddy or a friend or someone I see …that sells singles throughout the year… [then] rather than going in the store where there’s a line. I have to wait for this person to clear up at the register ...or I might be in a hurry to go to work or I might be in a hurry to go to another destination: the movies, somewhere to eat.” (26 years, male, D.C. resident) Purchasing loosies from others emerged as normative behavior. Individuals sold loosies from their home or standing outside of neighborhood stores, gas stations, Metro stations, take-out restaurants, and courthouses. The sale of loosies is perceived as providing a service to the community via being an individual’s legitimate business. The majority of participants stated they preferred purchasing loosies from individuals rather than retail stores (Table 3.3., B1). The financial gain from selling loosies is limited and a common perception is, “...the person that’s standing on the corner is doing it because they need the money...” “I would rather buy cigarettes from him because he is my go-to guy and sometimes they’re selling single cigarettes to gain enough money to buy a pack, so they can sell more out [of] that pack. To probably catch a cab, catch an Uber or Metro or you just need something to eat...I’ll help him out because I know he’s not doing very well by selling singles, …he’s trying to… get something to eat...” (26 years, male, D.C. resident) Participants also had bargaining power and would receive deals from individual sellers. As one participant stated, “You could get just one for 50 cents, or if it’s just an individual, tell them… ‘Hey, I just have 5 cents with me.’ He’s gonna give you the cigarette. And you can’t do that in the store...” Overall, the seller might let buyers pay less than the going rate of $0.50 cents for one loosie (e.g., the buyer gets three loosies for $1.00) or is granted credit and pays later. 63 The sale of loosies by strangers who were not known “loosie sellers” emerged during the interviews. Participants would buy single cigarettes from strangers they saw smoking or holding a cigarette pack (Table 3.3., B2). “Have what you want instead of begging other people…it’s very rare that we would ask somebody for a cigarette. We used to. We don’t ask people for cigarettes no more. Because they 50 cents. First thing he’ll say is, “I’ll sell you one.” or he’ll say, “You got 50 cents. Go get you a single.” (58 years, male, D.C. resident) Participants shared mannerisms and etiquette associated with loosie transactions. Common practice involves sellers handing loosies to buyers before being paid. It is socially unacceptable for sellers to touch the cigarette they are selling. As a solution, sellers tap the cigarettes out from a hole in the bottom of a cigarette pack or, less desirably, let the buyer take out his/her/their own cigarette from the top of the pack (Table 3.3., B3). The Health Belief Model Framework for Purchasing and Using Loosies We define participant’s perceived benefits as the “pros” of using loosies and reducing loosie use. Perceived barriers are participant’s challenges to behavior change. Self-efficacy is a participant’s belief in his/her/their ability to perform self- identified strategies to reduce loosie use and to reduce loosie use overall. Perceived susceptibility and severity are participants’ belief about their risk of persistently smoking due to their loosie use and their attitudes about the risk of developing health issues from cigarette smoking. Perceived Benefits and Barriers Perceived benefits to buying loosies resembled underlying reasons for their use - accessibility; cheaper than a pack; managing cigarette consumption; bargaining 64 with sellers; using loosies as a cigarette “filler”; and to boost the effects of other drugs (Table 3.4., A1). When we explored the barriers to reducing loosie use, participants stated it would be difficult to relinquish the convenience of loosies - the ease of: smoking without having a pack, accessing loosies, and their low cost (Table 3.4., A2). The perceived benefits of curbing loosie included: 1) reducing the risk of buying contaminated and counterfeit cigarettes; 2) being exposed to pathogens through poor hygiene practices of loosie sellers; and, 3) lack of exposure to the Surgeon General’s health warning on cigarette packs (Table 3.4., A3). “…the benefits of having loosies is they’re always there…they’re easy to get to…they’re affordable and easy [to] access.” (26 years, female, Baltimore resident) “…sometimes you worry too about an open pack. You didn’t break it open, no seal to it so you don’t know how original the cigarette might be or maybe it’s some kind of fake cigarette you’re smoking. Maybe it’s been meddled with... You never can tell.” (40 years, female, D.C. resident) Self-efficacy and Identified Cognitive Behavioral Strategies During the interviews, participants were prompted to share thoughts on their ability to stop using loosies. Responses ranged from “practically zero” to “100%.” Participants mentioned evidence-based smoking cessation strategies they would employ to reduce their use of loosies. Strategies involved staying busy (exercising, listening to music, drinking water, eating snacks, chewing on gum or hard candy), avoiding triggers (managing stress, traveling a different route to avoid loosie sellers) and utilizing nicotine replacement therapy (nicotine patch, gum). Other strategies were stating they quit smoking to loosie sellers, having a cigarette pack in their possession at all times, and simply quitting smoking. 65 Perceived Severity and Susceptibility The seriousness of loosie use was synonymous with the severity of cigarette smoking (Table 3.4., B). Participants (n=12) expressed grave concern about the health consequences of cigarette smoking and termed loosies, “cancer sticks.” A few participants (n=3) explained they were not actively thinking about the health harms and addictiveness of cigarettes and it was “not that serious” because they were in control of their smoking. A predominant belief (n=17) was that having access to loosies did not put participants at risk for smoking more cigarettes per day nor did this behavior support continuation of smoking over time. In fact, most (n=16) believed using loosies kept their cigarette consumption low and they would smoke more if they had access to a pack. Nonetheless, some participants mentioned the risk of using loosies in aiding the continuation of smoking, “slips” during quit attempts, and smoking relapse (Table 3.4., C). “…I think if a person really wanted to they could stop, or slack up. So being around a person that sells cigarettes, it probably won’t bother much, especially if they have a strong mind or a strong will.” (31 years, male, Baltimore resident) “Just the same way some people bum cigarettes off each other, you know. You’re still gonna get cigarettes to smoke even if loosies aren’t out there on the streets. So I don’t think it has a direct effect on me quitting or starting all over again.” (40 years, female, D.C. resident) 3.4. Discussion To our knowledge, this is the first study to utilize semi-structured, in-depth interviews to understand loosie use among urban, African Americans. This research extends previous qualitative research by providing a comprehensive understanding of loosie use on individual smoking patterns. The practice of using loosies is established 66 as a preferred method to manage tobacco use (Smith et al., 2007). Our results indicate the emergence of two groups of loosie users: 1) individuals who use loosies as a harm reduction strategy; and, 2) those who purchase loosies due to financial circumstances and would prefer to buy cigarette packs if it were economically feasible. Our findings suggest access to loosies may maintain or increase smoking among those with limited financial means, who smoke a brand other than Newports – the typical brand of cigarettes sold as loosies (Wackowski et al., 2018) (i.e., using loosies as fillers), and who are not interested in purchasing cigarette packs (e.g., use cigarettes to complement other drugs, or are light or nondaily smokers). These findings also support past research on the high availability and use of loosies among African Americans and especially those who reside in economically disadvantaged urban communities (Latkin et al., 2013; Smith et al., 2007; Stillman et al., 2014; von Lampe et al., 2018). Most participants in this study reported multiple loosie purchasing opportunities throughout their day and did not need to travel more “than a block” from their work, home, or where they socialize to purchase loosies. Participant perceptions were that loosies were available “everywhere,” but within the confines of certain neighborhoods. Although illegal, the sale of loosies by retail stores and individuals were prevalent in Baltimore, MD and the District of Columbia. Supporting the need for stronger monitoring of tobacco retail stores nationwide, past research showed unexplained variation in FDA inspections and warning letters for selling loosies, which were unsubstantiated by correlates of loosie use such as state cigarette tax, youth smoking, and poverty (Baker et al., 2016). In the two cities of this research, 67 Baker et al. (2016) found there were few inspections between January and July of 2014. We found similar findings as Smith et al. (2007) and Stillman et al. (2014) reported more than a decade ago, which highlighted the ubiquity of loosies, their preferred acquisition mode, and a description of positive norms surrounding sellers. In our study, the selling and buying of loosies were deemed part of the informal economy, which provided a modest income to sellers and access to cigarettes for buyers with limited finances. Our participants preferred to support individuals versus retail stores as the former were selling loosies for income to meet essential needs. Participants also shared their dual role of selling and purchasing loosies, and the opportunity to buy <20 cigarettes and the lower cose of loosies from an individual seller was a “convenience.” This preference is reflective of the contextual factors of Baltimore and D.C. and differ from New York City’s South Bronx area where focus group data denote preference for buying single cigarettes from retail stores (von Lampe et al., 2018). Participants reported difficulty changing their use of loosies because of increased availability, accessibility, and low cost. These substantial barriers to changing cigarette acquisition practices and reducing overall cigarette smoking can be juxtaposed by the cognitive behavioral strategies stated by participants. Self-efficacy needed to utilize these strategies and reduce the use of loosies varied dramatically across participants depending on other factors such as interest in cessation. Those who purchased loosies as a harm reduction strategy and aid to gradual cessation were interested in modifying their use of loosies. 68 Future research should include designing culturally-relevant, smoking cessation campaigns that integrate a loosies-specific message. Research that examines perceived benefits to reducing loosie use at the community-level is warranted and could include techniques to prevent smoking initiation through access to loosies by minors. Some of our participants witnessed underage youth buying loosies from individual sellers. Participants who themselves sold loosies expressed not being comfortable selling cigarettes to anyone who “looked” <16 years of age. Their willingness to sell cigarettes to minors was based on the minor’s maturity level rather than his/her actual age. Limitations The study captures loosie use at one point in time among a convenience sample of African American smokers from two cities. Although these cities are in close geographical proximity to one another, there were fewer participants from D.C. This could be explained by recruitment strategies conducted early in the study. Although recruitment flyers were posted in local community-based organizations in both cities, verbal communication about the study spread quickly among visitors and their social networks at an organization focusing on unemployment and family instability in Baltimore. Future studies could use quota sampling techniques to ensure equal distribution of participants across geographic settings (Robinson, 2014). Conclusions Loosie sales are normative among urban, African Americans and occur due to personal motives, including situational circumstances, efforts to manage cigarette consumption, and to boost the effect of other drugs without purchasing a cigarette 69 pack. Combatting this threat to tobacco control involves policymaking designed specifically for prioritized groups and complementary strategies to prevent unintended consequences of existing policies. Policy enforcement and public health education are also needed to convey the potential harms of using loosies (persistent smoking) and to increase self-efficacy to reduce loosie use. 70 Table 3.1. Phase I: African American Loosie Users Demographics and Smoking History (n = 25) Gender n (%) Male 16 (64.0) Female 9 (36.0) Age (M, SD) (37.2, 13.3) Hispanic ethnicity n (%) 1 (4.0) Yes 24 (96.0) No Race n (%) Black/African American 23 (92.0) Black/African American and other race 2 (8.0) Place of residence (%) Baltimore, MD 20 (80.0) District of Columbia 5 (20.0) Marital status (%) Single 19 (76.0) Married or living with a partner 4 (16.0) Divorced or separated 2 (8.0) Education level (Highest completed) (%) Less than high school 6 (24.0) High school diploma 7 (28.0) GED or equivalent 6 (24.0) Some college or higher 6 (24.0) Employment (%) Full-time 3 (12.0) Part-time 6 (24.0) Unemployed 14 (56.0) Other 2 (8.0) Monthly household income (%) Less than $400 6 (24.0) Between $400 and $799 7 (28.0) Between $800 and $1,200 3 (12.0) More than or equal to $1200 8 (32.0) Smoking status (%) Daily 20 (80.0) Non-daily 5 (20.0) Number of cigarettes smoked daily (M, SD) Daily 10.9 (5.5) Non-daily 2.9 (1.5) Quit attempt in the last year (%) Yes 10 (40.0) No 15 (60.0) Intention to quit (%) Within next 6 months 10 (40.0) Longer than 6 months 7 (28.0) Not interested in quitting 8 (32.0) 71 Table 3.2. Phase I: Single Cigarette Acquisition Practices of African American Users (n = 25) Typical cigarette acquisition n (%) Pack 12 (48.0) Loosies 13 (52.0) Frequency of buying loosies (past 30 days)a Sometimes 7 (28.0) Often 5 (20.0) Very Often 13 (52.0) Frequency of seeing loosies being sold (past 30 days)a Often 5 (20.0) Very Often 20 (80.0) Frequency of cravings to smoke after seeing loosies being sold (past 30 days) 3 (12.0) Never 4 (16.0) Rarely 6 (24.0) Sometimes 7 (28.0) Often 5 (20.0) Very Often Frequency of buying loosies to reduce cigarette consumption Never 3 (12.0) Rarely 3 (12.0) Sometimes 8 (32.0) Often 5 (20.0) Very Often 6 (24.0) Number of loosies purchased at one time Two loosies 16 (64.0) More than two loosies 9 (36.0) Typical loosie type Menthol 24 (96.0) Non-menthol 1 (4.0) Cost per loosie 0.50 cents (100.0) aResponse categories not presented in the table indicate n=0. 72 Table 3.3. Phase I: The Social Context of Purchasing and Using Loosies A1. Purchasing loosies due to economic reasons (why) • “If you running short on money and you...smoke, it’s an easier way to keep your habit going.” (33 years, male, Baltimore resident) • “Sometimes when you’re not working...it’s hard to get the money to get a pack. And the way I smoke I would have to get a pack every day...I don’t have the money. I’d rather, if I can’t get the seven, eight dollar, but I can get 50 cents to a dollar.” (49 years, male, Baltimore resident) A2. Managing and reducing cigarette consumption (why) • “I don’t wanna whole pack because I feel that I shouldn’t be smoking. But one cigarette do leads to another one - now, I just get one [loosie].” (58 years, male, D.C. resident) • “I don’t have as many cigarettes sitting around so I don’t, I can’t just reach and keep smoking and develop a habit. So I rather buy the loose ones because they keep...I won’t...[I would be] less likely to get addicted, become addicted. It’s cheaper and I don’t wanna become a chainsmoker.” (24 years, female, Baltimore resident) • “I can have the money to buy a pack of cigarettes. I figure why waste my money if I’m trying to quit, versus I can go buy...I’d say six cigarettes and they’ll probably last me all day because I’m stretching it out” (40 years, female, D.C. resident) • “...when I know I’m smoking too much, I’m trying to cut back, or trying to actually get off of the cigarettes, it’s like, ‘Alright, let me just buy four loosies...and try to manage with these four for the rest of the day.’ Opposed to having a whole pack and smoking 10 of them, or having a whole pack and smoking unnecessarily. (31 years, male, Baltimore resident) B1. Buyer preference for individual sellers (From whom) • “...I can go to the store and buy ‘em for the same price, get the same thing [for] what I paid for, or I can go right here to this person...they selling obviously because they need the money. The store, y’all gonna make money regardless...” (26 years, male, Baltimore resident) • “...sometimes you see like the older people...trying to sell their cigarettes...to make a couple of bucks...maybe to catch up and so to feed their kids...yeah, so that’s another thing too...you never know what you doing... how you helping somebody.” (26 years, female, Baltimore resident) • “But even in the store, they trying to sell loose ones. I don’t buy ‘em from the store. I’d rather give it to the small man. So rather than give it to the man that own the store, he got money anyway...I’d rather give it to the man outside trying to make a couple dollars.” (55 years, male, Baltimore resident) B2. Purchasing loosies from strangers seen smoking (From whom) • “...don’t pull out a pack of cigarettes in a very populated area...people are on it...I’d say if you work around a bunch of smokers don’t pull out a pack of cigarettes. People will typically ask you to buy a loose one.” (24 years, male, Baltimore resident) • “I bought a pack of cigarettes today, and as soon as I bought ‘em, somebody bought four of them.” (31 years, male, Baltimore resident) • “If you see anybody sitting with a pack of cigarettes, they’ll sell you a cigarette.” (58 years, male, Baltimore resident) B3. Mannerisms and etiquette in loosie transaction (How) • “If they [loosie sellers] don’t give you the cigarettes first, that means that they keeping your money so they have to...let you get a cigarette out the box [first].” (37 years, female, D.C. resident) • “They’ll [loosie sellers] open it from the bottom...by doing that, what you take is on the side of the concrete you scrape it until it creates a little hole, and then out of that little hole they just tap it out, and you’ll be able to pull out the cigarette for yourself...I think that’s the best way to do it. Because that way the person’s hand don’t come into contact with the cigarette...let’s say that they open it from the lid...they grabbing the cigarette out, and I’m about to purchase that. I might tell them, “Oh, I don’t want...” and I feel like this is a common thing...they normally do, and I look on the inside...Let’s say it’s only like five cigarettes left. So that mean in them other 15 cigarettes you sold you probably touched all these cigarettes.” (28 years, male, Baltimore resident) 73 Table 3.4. Phase I: The Health Belief Model Framework for Purchasing and Using Loosies A1. Perceived benefits to loosie use • “A benefit to have loose ones around is...you don’t have to walk that far to get...some cigarettes. Maybe some people might wanna save their money, they don’t like paying none of it and you just want that one when like they at work, you know, and they can’t really smoke cigarettes, they just want one real quick.” (25 years, female, Baltimore resident) A2. Perceived barriers to reducing loosie use • “You can always get ‘em from anywhere. You - sometimes you might not even have to leave off your block or off your porch, or whatever. Versus buying a pack of cigarettes, which you gotta go to a store. And they gotta be open.” (26 years, male, Baltimore resident) A3. Perceived benefits of reducing loosie use • “I be concerned to see...if they put anything in the cigarettes that you don’t know about, or they tamper with the cigarettes...so I be pretty concerned and cautious about it.” (37 years, female, D.C. resident) • “Sometimes I worry a little bit about health and hygiene...if it’s a pack of cigarettes you open it by yourself, you know it’s safe, it’s hygienic, someone hasn’t meddle with it. But if you’re buying it from someone, some individual on the street, you know don’t where his hands has been to...it keeps [getting] handled back and forth...” (40 years, female, D.C. resident) • “Because you don’t know where their hands been at...I don’t want everybody or anybody touching cause he’s selling them loose ones so everybody gonna touch it. So you don’t want everybody touching your cigarette and then it goes right in your mouth.” (37 years, female, D.C. resident) • “You don’t...get a chance to read the warning label to know how that stuff is killing me...not knowing how dangerous that these cigarettes are, really, to our health.” (49 years, male, Baltimore resident) • “And I wonder, I always was curious to find out like, “Is that really a Newport?” Because it says Newport because if you know cigarettes are marked on the filter as to what they are and it’s like, “Is that really a Newport or is that something you made?” (55 years, female, D.C. resident) B. Perceived severity of loosie use and cigarette smoking • “...when you think of quitting, and loosies, and packs of cigarettes, you have to put like the pack and the loosies [together], ‘cause it’s all the same product.” (55 years, female, D.C. resident) • “It’s [Loosies] just as serious as a pack to your health...100%...to my health I think it is very serious because I probably don’t smoke as much with loose ones as I would with a pack but smoking is smoking.” (24 years, male, Baltimore resident) • “It’s real serious...because whether you’re smoking loosies or the whole pack, it’s still a cigarette...it’s still dangerous to your health... now [you] have the box [pack] to read the warning label, but that loosie came out of that same box with the warning label on it...” (49 years, male, Baltimore resident) • “One step at a time...it’s no big difference. Cigarettes is bad, period. But, you cut down on ‘em, you win.” (25 years, female, Baltimore resident) C. Perceived susceptibility of loosie use in persistent smoking • “I know I’m not the only one that goes through this, but every time I try and quit smoking, I go through some type of dramatic event to where I need [a] cigarette. And I’m not gonna buy a pack...pretty sure no one else gonna buy a pack. They just promise themselves they’re gonna quit. They’re just gonna think to yourself...just one more cigarette...it’s just one...it’s just two, but eventually...you back up [smoking more cigarettes]. We’re not gonna have a big quit and leave if loose ones are around at all.” (24 years, male, Baltimore resident) • “I stop smoking for a period, until a loosie come up. I mean, a single cigarette come up. Got singles, and I want one, so I get one.” (58 years, male, D.C. resident) • “I’m very worried about it because me buying loosies, let’s me know that I’m not even trying to quit...I’m saying, ‘Man, I’m buying loosies, at least I am buying a pack. At least I’m cutting back.’ But it’s just the opposite.” (55 years, male, Baltimore resident) 74 Chapter 4: Manuscript #2 4.1. Introduction Despite closing the racial gap in cigarette smoking prevalence between white Americans and African Americans (approximately 17%, respectively) (U.S. HHS, 2014), widening tobacco-related health disparities remain and African Americans disproportionately experience greater physical consequences a result of its use (Trinidad, Pérez-Stable, White, Emery, & Messer, 2011). Though African Americans smoke fewer cigarettes per day, have more desire to quit smoking, and make more quit attempts than white Americans, white Americans are more likely to quit and maintain smokefree lives (CDC, 2012). For urban, African Americans, the challenge to prevent smoking initiation and achieve prolonged cessation is even greater. Smoking prevalence among urban, African Americans is substantially higher (34- 43%) (Andrews et al., 2014; Helms, King, & Ashley, 2017; D. Lee, Turner, Burns, & Lee, 2007) than what is seen in the broader U.S. population (15.5%) (National Center for Chronic Disease Prevention and Health Promotion, 2014). This high smoking prevalence is due in part to pervasive tobacco advertising and the ubiquity of cigarettes (Lee, Henriksen, Rose, Moreland-Russell, & Ribisl, 2015), the normalization of smoking (Andrews et al., 2014), and chronically stressful lives and environments (Budescu, Taylor, & McGill, 2011; Lee, Henriksen, Rose, Moreland- Russell, & Ribisl, 2015; Levinson, 2017; Shuaib et al., 2011). In order to eliminate tobacco-related health disparities among urban, African Americans, there must be a prioritization of risk factors unique to this population of 75 smokers. One significant risk factor that has received limited attention is the use of single cigarettes, which are commonly referred to as “loosies,” “singles,” “jacks,” or “loose ones” (hereafter, loosies) (Coady, Chan, Sacks, Mbamalu, & Kansagra, 2013; Guillory, Johns, Farley, & Ling, 2015; Hall, Fleischer, Shigematsu, Arillo-Santillán, & Thrasher, 2015; Latkin, Murray, Smith, Cohen, & Knowlton, 2013; Smith et al., 2007; Stillman, Bone, Milam, Ma, & Hoke, 2014). Loosies are untaxed, unpackaged loose cigarettes, which are illegally sold by retail stores and individual sellers (Latkin et al., 2013; Smith et al., 2007; Stillman et al., 2014; von Lampe, Kurti, & Johnson, 2018). Despite the ban on loosies, they are an integral part of the smoking culture among urban, African Americans [for detailed information on the ban, see the 2009 Family Smoking Prevention and Tobacco Control Act (21 Code of Federal Regulations §§ 1140.14, 1140.16)] (Smith et al., 2007; Stillman et al., 2014; von Lampe et al., 2018). Guillory et al. (2015) noted that African Americans are nine times more likely to purchase loosies than their white counterparts. Additionally, there are reasons why urban, African Americans purchase and use single cigarettes: 1) their cost and accessibility make them convenient; and 2) perceptions that purchasing them keeps cigarette consumption low in comparison to buying cigarette packs (Smith et al., 2007; Stillman et al., 2014). Yet, empirical data do not support the use of loosies as a preferred harm reduction strategy. In fact, those who purchase loosies at least several times a week were more likely to have higher overall tobacco use (Stillman et al., 2014) and were no more likely to quit smoking (Thrasher, Villalobos, Barnoya, Sansores, & O’Connor, 2011). For urban, African Americans, these trends are compounded by the absence of culturally relevant smoking cessation 76 interventions designed specifically for this prioritized group and their feeling of no personal connection with standard smoking cessation protocols (e.g., setting a “quit day”) that are commonly used by the general population (Baker, Palmer, & Lee, 2016). Counterstrategies to loosie use are stymied without a valid instrument tool to identify promising potential targets for intervention. Thus, we developed two complementary, theoretically-based scales to measure: 1) the social context of purchasing and using loosies (i.e., why, where, when, from whom, and how); and 2) intrapersonal beliefs and attitudes toward reducing loosie use via the Health Belief Model (perceived benefits, perceived barriers, perceived severity, perceived susceptibility, and self-efficacy) (Poland et al., 2006; Rosenstock, Strecher, & Becker, 1988). In this paper, we report three distinct study phases, in which we: 1) rigorously developed a pool of potential scale items, 2) collected empirical cross-sectional data from urban, African American loosie users, and 3) refined the scales and assessed their reliability and validity. 4.2. Methods Phase 1: Item Generation Item development involved the steps of qualitative interviews, expert review, and iterative cognitive pilot testing (Table 4.1.) as also conducted by Krause (2002) and Holt et al. (2009). First, we conducted semi-structured, in-depth interviews with 25 African American loosie users in June and July of 2018. Eligibility criteria included being 18 years of age and older, self-identifying as African American, residing in either Baltimore, MD or the District of Columbia (D.C.), and having purchased and 77 used loosies at least once in the past 30 days. Participants were recruited through various channels including, word-of-mouth (Resnicow, Baranowski, Ahluwalia, & Braithwaite, 1999), and flyers posted in several urban communities of Baltimore and D.C.. All study visits were held in private areas within local community centers and public libraries. Participants were compensated $25 in cash for their time and participation. The qualitative data were analyzed using the Framework Method to gain a comprehensive understanding of the social context and intrapersonal factors related to loosie use (Ritchie, Lewis, Lewis, Nicholls, & Ormston, 2013). We then developed the initial set of 53 items based on emergent interview themes and a review of the existing literature (Smith et al., 2007; Stillman et al., 2014; Thrasher et al., 2009; Thrasher et al., 2011; von Lampe et al., 2018). Items based on the social context of using loosies were guided by existing social context scales that measure alcohol (Beck & Summons, 1985), hookah (Sharma, Beck, & Clark, 2013), and cannabis use (Beck et al., 2009). We distributed this pool of items for review to a convenience sample of three leading national experts in tobacco control and health psychology (Berg, 2014). The expert reviewers were asked to rate each item (1 = very poor to 5 = very good) on its face and content validity, clarity, conciseness, grammar, reading level, and redundancy to other items (Worthington & Whittaker, 2006). Upon initial review, the items received an average expert rating of 3 (i.e., acceptable) or higher. We incorporated the reviewers’ suggestions and added three items based on their recommendations: one item on perceived severity of smoking within the situational context of one’s life (“Considering everything else you have going on in your life, how serious is cigarette smoking?”) and two items related 78 to emotional triggers for loosie purchasing (i.e., “when I am happy,” “when I drink alcohol”). Using the SMOG Readability Formula (McLaughlin, 1969), we determined the 56 items were worded at a 5th grade reading level. Two of the three experts reviewed the updated pool of 56 items and no additional revisions were made prior to pilot testing. Pilot Testing Participant recruitment, eligibility, and study procedures for pilot testing were the same as those employed for the qualitative interviews. We re-contacted the initial set of interview participants to determine their eligibility and interest in participation and also recruited new participants through posting flyers as previously described in our item development phase. Pilot testing visits were held in October and November of 2018 and participants were compensated $15 in cash for their time and participation. To determine if the items were understandable and appropriate, we used the “think aloud” cognitive interview method and used probes to garner more information when necessary (Collins, 2003). During the first round of pilot testing with 15 African American loosie users, participants made recommendations on the wording of the items, and one item was removed due to redundancy with the geographic location of sellers (“Please indicate how often you buy loosies in the following situations...In my neighborhood”). We made revisions based on the feedback and then completed a second iteration of pilot testing with nine participants until saturation on the garnered feedback was reached. The final pool included 55 items. Of which, 29 items described the social context of using loosies and 26 items 79 underpinned the theoretical constructs of the Health Belief Model, as adapted specifically for reducing loosie use (Rosenstock et al., 1988). Phase 2: Psychometric Testing with urban, African American loosie users A convenience sample of 122 African American loosie users was recruited in December of 2018 from five District of Columbia Housing Authority (DCHA) public housing sites. Inclusion criteria for psychometric testing were the same as the qualitative interviews and pilot testing criteria. The recruitment strategies were also the same – word-of-mouth and flyer postings at key locations such as the community room and bulletin boards within each DCHA site. A DCHA community navigator worked with each site’s resident council to reserve a 3-hour time block on the community room’s activities calendar for study procedures to be conducted. The research team assessed eligibility of interested residents and completed the informed consent process with those who were eligible and interested in participating (Quinn et al., 2012). Following these study procedures, participants completed the self- administered, paper-and-pencil survey. Light refreshments were served and each participant received $15 in cash for their time and participation. The Institutional Review Board at University of Maryland College Park approved all phases of this study. Materials The survey took approximately 30 minutes to complete and consisted of four sections: 1) demographic information, 2) smoking history and loosie usage, 3) the pool of potential scale items, and 4) convergent and discriminant validity measures. Demographic information included age, ethnicity, race, marital status, monthly 80 household income, highest level of education completed, and employment status (Section 1). Section 2 measured smoking history variables: age of initiation, current cigarette smoking patterns, nicotine dependence, and cigarette acquisition practices (e.g., typical cigarette purchasing by a carton, pack, or as loosies). The frequency of loosie use was collected by a measure from previous research, “How often have you bought loosies in the past 30 days?”(Thrasher et al., 2009). Response options were rarely (1), sometimes (2), often (3), and very often (4). Due to the relatively small numbers for “rarely” (n=8; 6.6%), we collapsed the first two response categories and created a frequency of use measure with sometimes (1), often (2), and very often (3). We also collected data on the frequency of seeing loosies being sold, feeling cravings to smoke upon seeing loosies being sold, and buying loosies specifically to reduce the amount of cigarettes smoked (Thrasher et al., 2009). The generated pool of items constructed to measure the social context of using loosies (29 items) and Health Belief Model constructs adapted for reducing this specific behavior (26 items) were incorporated within Section 3. Based on the items, response categories followed a 5- point Likert scale for either frequency (1 = never to 5 = very often) or agreement (1 = strongly disagree to 5 = strongly agree). The final section of the survey, Section 4, included valid measures of the Attitudes towards Smoking Scale (ATS-18) (Etter, Humair, Bergman, & Perneger, 2000) and the Marlowe-Crowne Social Desirability Scale to assess convergent and discriminant validity, respectively (Crowne & Marlowe, 1960). ATS-18 measures attitudes toward smoking using a 5-point Likert scale of agreement (1 = strongly disagree to 5 = strongly agree) and consists of three dimensions: adverse effects of smoking, psychoactive benefits of smoking, and 81 pleasure of smoking. We reverse scored items on the latter two factors of ATS-18 to compute total scale scores; higher scores indicated greater negative attitudes toward smoking. The13-item short form of the Marlowe-Crowne Social Desirability Scale measures the extent to which a person responds in a socially desirable way (Ballard, 1992). The total scale score ranges from 0 to 13, with higher scores indicating a higher tendency to respond in a socially desirable way. Scores were computed by reverse scoring responses for eight of the 13 items. 4.3. Results Participant Characteristics Study participants were non-Hispanic, African Americans (average age of 55.7 years) and were predominantly women, had ≤ a high school education, were unemployed, and had never been married as shown in Table 4.2. Participants’ cigarette acquisition practices are displayed in Table 4.3. Phase 3: Scale Refinement and Determination of Reliability and Validity Exploratory Factor Analysis We conducted an exploratory factor analysis (EFA) to explore the validity of these newly developed items (Henson & Roberts, 2006). For EFA and subsequent analyses, we divided the generated pool of 55 items by the 1) Social Context and 2) Health Belief Model to examine the underlying latent variables, which are unique to each of these theoretical frameworks. The Kaiser-Meyer-Olkin test resulted in values of 0.79 and 0.81 respectively, which are above 0.60 (Kaiser, 1970) and indicate the sufficiency of the data for factorability (Tabachnick & Fidell, 2000; Worthington & Whittaker, 2006). We also conducted the Shapiro-Wilks test and all items were 82 determined to have non-normal distributions (p<.001) (Ghasemi & Zahediasl, 2012). Given the theoretical underpinnings of the items and recommendations for non- normally distributed data, we employed the factor extraction method of principal axis factoring with oblique rotation to optimize parsimonious models and permit correlation between factors (Costello & Osborne, 2005; Worthington & Whittaker, 2006). For factor retention, we assessed whether eigenvalues were greater than 1 and used the scree test method to graphically examine the eigenvalues and the natural bend in these data (Cattell, 1966; Costello & Osborne, 2005). As exemplified in the validation of a past social context scale (Sharma, Beck, & Clark, 2013) and meeting best practice guidelines (Worthington & Whittaker, 2006), items were retained if they were above 0.40 and had no cross-loadings above 0.40. Two-item factors were examined for their contribution to the total explained variance and the strength of the association (r = >0.70) between the two items were assessed (Costello & Osborne, 2005; Worthington & Whittaker, 2006) There was ≤9% of missing data and multiple imputation techniques were utilized for exploratory factor analyses (Newman, 2014). EFA for The Social Context of Loosies Scale (SCL-11) The initial model extracted eight factors with eigenvalues greater than 1 and accounted for 69.2% of the variance. In the final model, four factors had eigenvalues greater than 1 and were above the “leveling off” of eigenvalues in the scree plot. The final four-factor solution consisted of 11 items as presented in Table 4.4. and explained 78.0% of the variance. Triggers include emotional arousals that influence loosie purchasing and use. Retail Stores identifies types of retail stores where loosies are frequently purchased. Harm Reduction involves cessation behavior – i.e., buying 83 loosies due to motivations to keep cigarette consumption low, to cut back, or to quit smoking. The fourth and final factor, Individual Sellers, highlights the frequency with which users purchase loosies from individuals in two typical settings (i.e., in front of an establishment or in a crowded area) or from strangers. The Triggers and Individual Sellers subscales moderately correlated (r = 0.40). Other subscales had low correlations (r = 0.02 – 0.18) to one another. Subscale scores were computed by summing item responses. To reach the least number of latent variables with the most shared variance, we first eliminated items that did not load at or above 0.40 on any of the factors (Henson & Roberts, 2006). These eliminated items measured: 1) the frequency of purchasing loosies because they are cheaper than a pack, wanting to smoke but not having enough money to purchase a pack, from people one knows well, when having an urge to smoke or drinking alcohol, to socialize with a loosie seller, or in the evening; and 2) agreement with “It bothers me when sellers touch the cigarette that I am buying,” “Stores won’t sell you loosies unless they know you,” and “It is important to use code words such as ‘Laffy Taffy’ or ‘Blow Pop’ (two types of candy) when buying loosies from stores.” Two items, one assessing the frequency of buying loosies “in the afternoon” (coefficient = 0.69 and 0.63) and the other measuring agreement with, “I can ask to buy cigarettes from strangers I see smoking,” (coefficient = 0.63 and 0.48) had cross-loadings and were subsequently deleted. Further, four items were removed to strengthen the internal consistency of the subscales: 1) Loosie use “in the morning” was removed from Triggers (coefficient = 84 0.40); 2) Loosie purchasing “late at night” (coefficient = 0.48) and “they (loosies) are easy to get” (coefficient = 0.48) were eliminated from Individual Sellers; and, 3) “inside a take-out restaurant” (coefficient = 0.57) was removed from Retail Stores. Additionally, a two-item factor, “I prefer to buy loosies than to ‘bum’ cigarettes for free” and “I prefer to buy loosies from a person than from a store (such as a convenience store),” was deleted due to a moderate correlation (r = 0.41, p<.0001) that was significantly under the recommended r = 0.70 cutoff value (Tavakol & Dennick, 2011). EFA for The Health Belief Model for Loosies Scale (HBML-20) The initial solution resulted in seven dimensions with eigenvalues greater than 1 and explained 66.5% of the total variance. The following items were eliminated from the factor analysis because they did not load at or above 0.40 on any of the emerging factors: “If I was trying to quit smoking, I might have temptations to buy a loosie,” “I can stop buying loosies soon,” and “I can stop carrying change and/or dollar bills in my pocket to avoid buying loosies.” Although “Buying loosies makes me feel like I am smoking less than I really am” and “I am in control of how much I smoke when I buy loosies” loaded as the seventh factor, the two-item factor was eliminated due to a low eigenvalue = 1.1 below the bend in the scree plot. In addition, the conceptual decision was made to remove “I can use nicotine replacement therapy such as patch or gum to avoid buying loosies,” from Self-efficacy toward Cognitive Strategies (coefficient = 0.50) because this item describes a behavioral strategy conceptually different from the other items, had a lower correlation to the other retained items, and was not a primary theme from our qualitative interviews. 85 The final 20-item HBML-20 Scale accounted for 71.1% of the total variance and includes six factors as presented in Table 4.5. Perceived Benefits in this study describes the expected benefits, or avoidance of harms, from no longer using loosies. Perceived Barriers is defined as one’s perceived challenges to reducing their loosie use. Perceived Severity measures one’s belief about the seriousness of cigarette smoking. Perceived Susceptibility involves the perceived risk of loosies in promoting persistent smoking patterns. Lastly, Self-efficacy towards Cognitive Strategies and Behavioral Strategies identifies potential strategies to reduce loosie use and measures one’s confidence in performing these specific strategies. Self-efficacy toward Cognitive Strategies and Behavioral Strategies subscales correlated to one another (r = 0.45) and also correlated to Perceived Benefits (r = 0.46 and r = 0.50, respectively). Higher scores on the Health Belief Model for Loosie Use Scale indicate an overall greater likelihood to reduce loosie use and higher scores on the subscales denote stronger endorsement of the HBM construct. Reliability The internal consistency of SCL-11 was α = 0.73. The Cronbach’s alpha for each subscale was: 0.88 for Triggers (3 items), 0.92 for Retail Stores (3 items), 0.72 for Harm Reduction (2 items), and 0.71 for Individual Sellers (3 items). Similarly, the internal consistency of HBML-20 was 0.87 and the subscales had excellent internal consistency: Perceived Benefits (4 items) was 0.78, Perceived Barriers (4 items) was 0.83, Perceived Severity (2 items) was 0.85, Perceived Susceptibility (3 items) was 0.71, Self-Efficacy for Cognitive Strategies was 0.85 (4 items), and Self-Efficacy for Behavioral Strategies (3 items) was 0.81. 86 Convergent Validity We employed bivariate correlation analyses between the scores for each scale and their subscales with ATS-18 to examine convergent validity (Boateng, Neilands, Frongillo, Melgar-Quiñonez, & Young, 2018; Etter et al., 2000). The SCL-11 dimensions of Triggers (r = -0.18, p = .05), Harm Reduction (r = 0.28, p<.01), and Individual Sellers (r = -0.24, p = .01) correlated with the valid measure of attitudes toward smoking. However, the overall SCL-11 (r = -0.14, p = 0.14) and Retail Stores subscale (r = -0.02, p = 0.82) did not significantly correlate with ATS-18. The HBML-20 (r = 0.34, p<.001) and its subscales, Perceived Benefits (r = .24, p<.05), Perceived Severity (r = 0.43, p<.001), Self-efficacy toward Cognitive Strategies (r = 0.45, p<.001), and Self-efficacy toward Behavioral Strategies (r = .24, p = .01) had statistically significant correlations with ATS-18. Perceived Barriers (r = 0.82, p = 0.40) and Perceived Susceptibility (r = -.12, p = .20) did not. Discriminant Validity To establish discriminant validity and whether the self-report data were free of social desirability bias, we examined the association between the scores for the 13- item Marlowe-Crowne Social Desirability Scale (Ballard, 1992) and SCL-11, HBML- 20, and their subscales. The non-significant results indicated social desirability bias did not influence the overall two scales (SCL-11 r = -0.18, p>.05; HBML-20 r = 0.01, p>.05). Factors from both scales were not associated with social desirability bias except for the social context of purchasing loosies from Retail Stores (r = -.26, p<.01) and Perceived Susceptibility of persistent smoking due to loosie use (r = -0.31, p = .001). 87 Group Differentiation Group differentiation in subscale scores were then examined across frequency of loosie use, gender, and cigarette smoking status using one-way analysis of variance. Group Differentiation for Social Context of Loosies Scale (SCL-11) Triggers differed significantly across the frequency of using loosies (F = 15.33, p<.0001) and cigarette smoking status (F = 9.06, p<.01). Bonferonni post-hoc comparisons indicate those who purchase loosies very often (M = 11.43, SD = 3.40, 95% CI 10.37, 12.49) had significantly higher scores for Triggers than those who purchased loosies often (M = 8.88, SD = 3.27, 95% CI 7.72, 10.04) and sometimes (M = 7.66, SD = 3.08, 95% CI 6.75, 8.57). Daily smokers (M = 10.11, SD = 3.75, 95% CI 9.22, 11.00) also had higher scores for Triggers than non-daily smokers (M = 7.29, SD = 2.28, 95% CI 7.29, 9.05). Using loosies to reduce harm (i.e., Harm Reduction) (F = 4.80, p<.05) was greater among non-daily smokers (M = 7.50, SD = 2.06, 95% CI 6.63, 7.94) in comparison to those who smoke cigarettes daily (M = 6.63, SD = 2.38, 95% CI 6.06, 7.19). Purchasing loosies from Individual Sellers differed based on frequency of loosie use (F = 3.49, p<.05). Specifically, individuals who purchased loosies very often (M = 10.82 SD = 3.40, 95% CI 9.76, 11.88) had higher mean scores for Individual Sellers than those who bought loosies sometimes (M = 9.11 SD = 2.86, 95% CI 8.27, 9.95). Group Differentiation for Health Belief Model for Loosies Scale (HBML-20) For Perceived Barriers (F = 4.71, p = .01), Bonferroni post hoc tests revealed individuals who sometimes purchased loosies (M = 13.69, SD = 4.50, 95% CI 12.37, 88 15.02) had lower perceived barriers to reducing their purchasing of loosies in comparison to those who bought loosies very often (M = 16.12, SD = 3.60, 95% CI 15.0, 17.24). Self-efficacy for Cognitive Strategies (F = 3.85, p = .05) was higher among non-daily (M = 13.93, SD = 4.25, 95% CI 12.71, 15.15) than daily (M = 12.32, SD = 4.52, 95% CI 11.25, 13.39) smokers. Other group differences were not statistically significant. 4.4. Discussion Loosies are an established risk factor for tobacco use, perpetuates normative smoking beliefs, increases smoking behavior, and contributes to tobacco-related health disparities that urban, African Americans experience (Guillory et al., 2015; Latkin et al., 2013; Smith et al., 2007; Stillman et al., 2014; von Lampe et al., 2018; Wackowski et al., 2018). Still, there is limited current research on the correlates of loosie use among this priority population. To our knowledge, this is the first study to develop valid measures on the use of single cigarettes for utilization with urban, African Americans. We also document the use of loosies in the District of Columbia where there is a paucity of empirical research on the subject (Baker, Lee, Ranney, & Goldstein, 2016; Debnam, 2018). We developed two scales, The Social Context of Loosies Scale (SCL-11) and The Health Belief Model for Loosies Scale (HBML-20), using a meticulous approach that involved qualitative interviews, expert review, and cognitive pilot testing. The scales indicated strong internal consistency, convergent validity, and discriminant validity. Further, the scales are promising for use when identifying targets for intervention. SCL-11 has potential utility in establishing why, when, and from whom 89 individuals are purchasing loosies and provides intervention strategies at the point of sale for single cigarettes. Complementary to SCL-11, HBML-20 identifies intrapersonal beliefs and attitudes associated with reducing loosie use. The two scales can be leveraged together for a comprehensive approach for preventing and reducing loosie use. Or, these scales can be used separately based on the focus of the intervention. Within this sample of loosie users, frequent users and daily smokers had higher scores of emotional triggers to buy loosies; while non-daily smokers had higher mean scores for purchasing loosies as a harm reduction strategy. These findings suggest daily smokers may be purchasing loosies due to limited funds and/or to maintain their smoking; whereas non-daily smokers may be buying them as a means to cut back on the number of cigarettes they smoke per day. In support of these trends, non-daily smokers had greater self-efficacy to use cognitive strategies to reduce their loosie use than daily smokers. Those who sometimes purchased loosies also had less perceived barriers to change their behavior than those who used loosies very often. Among cigarette smokers who resided in the District of Columbia Housing Authority’s public housing neighborhoods, loosie acquisition practices included buying from individual sellers more often than from retail stores. Nonetheless, counterstrategies are direly needed in both public health education and enforcement of the Tobacco Control Act by the FDA to quell loosie usage. Loosie use is embraced by the priority population reported here as a helpful method to manage cigarette consumption, and the lack of loosie-specific health education resources leave users 90 uninformed about the potential risks of loosies in perpetuating long-term smoking patterns. Baker et al (2016) found the number of tobacco retailer inspections by the FDA to vary substantially across states, which did not align with the geographical trends of the sale of single cigarettes as identified in previous research (Guillory et al., 2015; Smith et al., 2007; Stillman et al., 2014; von Lampe et al., 2018). Loosie use, as an unintended consequence of increasing cigarette tax policies aimed to prevent and reduce cigarette smoking, also emerged in this study and have been demonstrated in previous research (Coady, Chan, Sacks, Mbamalu, & Kansagra, 2013; Saenz de Miera et al., 2010). On October 1, 2018, the total tax levy for cigarettes increased from $2.94 to $4.94 dollars (MyTax.DC.gov, 2018). In June of 2018, prior to the tax increase, participants from D.C. reported the going rate of loosies to be $0.50 cents per loosie. Notably, from October to December of 2018, the cost of loosies increased to $0.75 cents each, and participants paid anywhere from $0.50 to $1.00 for one cigarette. This emergent finding describes the dynamic role of loosie use within tobacco control policies and requires more attention. The study’s limitations should be considered within the interpretation of these results and used to guide future studies. Inherent to scale development and validation research, the reported findings have limited generalizability beyond urban, African American smokers who reside in the public housing neighborhoods in the District of Columbia. Future direction includes administering the scales to larger, diverse samples of loosie users. Moreover, given the uniqueness of the loosie phenomenon within certain subgroups, the scales could be administered to identify potential targets for intervention that are specific to certain demographic characteristics (racial and 91 ethnic minorities) and/or geographic settings. Using loosies as a preferred harm reduction method is also underscored in multiple studies, appears intrinsic for some loosie users, and warrants further investigation (Smith et al., 2007; Stillman et al., 2014; von Lampe et al., 2018). Thus, we decided to retain Harm Reduction as a 2- item factor in SCL-11 despite the items having a lower correlation (r = 0.58, p<.0001) than recommended (r = 0.70) (Worthington & Whittaker, 2006). In summary, the use of single cigarettes among urban, African Americans is a substantial risk factor for smoking propensity. SCL-11 and HBML-20 are valid scales that can be used to identify potential social, environmental, and intrapersonal targets for preventing and reducing loosie use. 92 Table 4.1. Instrument Development and Testing Procedure Step Description 1 Semi-structured in-depth interviews with 25 African American loosie users 2 Initial item development 3 Item review for face and construct validity by 3 experts 4 Item revisions based on expert review 5 Cognitive pilot testing among 15 African American loosie users 6 Item revisions based on cognitive pilot testing 7 Second wave of cognitive pilot testing among 9 African American loosie users 8 Final item revisions based on second wave of cognitive pilot testing 9 Psychometric testing of the Loosie Scale among 122 African American loosie users 93 Table 4.2. Phase III: African American Loosie Users Demographics and Smoking History (n=122) Loosie Use Frequency Total Very sample Sometimes Often often (n = 122) (n = 47) (n = 33) (n = 42) Gender n (%) Male 47 (38.5) 18 (38.2) 10 (30.3) 19 (45.2) Female 74 (60.7) 29 (61.7) 22 (66.7) 23 (54.8) Trans woman 1 (0.8) 0 1 (3.0) 0 Age (M, SD) 55.7, 11.7 56.7, 12.1 57.0, 10.9 54.1, 11.9 Hispanic ethnicity n (%) No 114 (93.4) 45 (95.7) 29 (87.9) 40 (95.2) Yes 5 (4.1) 2 (4.3) 2 (6.1) 1 (2.4) Race n (%) Black/African American 119 (97.5) 46 (97.9) 32 (97.0) 41 (97.6) Black/African American and other race 3 (2.5) 1 (2.1) 1 (3.0) 1 (2.4) Marital status n (%) Single 65 (53.3) 27 (57.4) 20 (60.6) 18 (42.9) Married or living with partner 26 (21.3) 9 (19.1) 6 (18.2) 11 (26.2) Divorced, separated, or widowed 29 (23.8) 11 (23.4) 5 (15.2) 13 (31.0) Education level n (%) Less than high school 56 (45.9) 26 (55.3) 15 (45.5) 15 (35.7) High school diploma 34 (27.9) 8 (17.0) 12 (36.4) 14 (33.3) GED or equivalent 16 (13.1) 7 (14.9) 4 (12.1) 5 (11.9) Some college or higher 16 (13.1) 6 (12.8) 2 (6.1) 8 (19.0) Employment n (%) Full-time 6 (4.9) 3 (6.4) 1 (3.0) 2 (4.8) Part-time 9 (7.4) 5 (10.6) 1 (3.0) 3 (7.1) Unemployed 93 (76.2) 33 (70.2) 26 (78.8) 34 (81.0) Other 9 (7.3) 2 (4.3) 5 (15.0) 3 (7.2) Monthly household income n (%) Less than $400 34 (27.9) 11 (23.4) 10 (30.3) 13 (31.0) Between $400 and $799 40 (32.8) 12 (25.5) 13 (39.4) 15 (35.7) Between $800 and $1,200 18 (14.8) 9 (19.1) 5 (12.0) 4 (9.5) More than or equal to $1200 11 (9.0) 4 (8.5) 3 (9.1) 4 (9.5) Don’t know or refused 18 (14.8) 11 (24.4) 2 (6.0) 5 (11.9) Cigarette smoking status n (%) Daily 71 (58.2) 19 (40.4) 19 (57.6) 33 (78.6) Non-daily 49 (40.2) 27 (57.4) 14 (42.4) 8 (19.0) Number of cigarette smoked daily (M, SD) Daily 14.1 (8.3) 11.9 (5.6) 14.6 (8.0) 14.8 (9.4) Non-daily 6.9 (7.0) 6.6 (5.5) 7.8 (9.5) 6.1 (6.3) Quit attempt in the last year n (%) No 59 (48.2) 26 (55.3) 19 (57.6) 27 (64.3) Yes 60 (49.2) 20 (42.6) 12 (36.4) 15 (35.7) Intention to quit n (%) Within next 6 months 37 (30.4) 14 (29.8) 13 (39.4) 10 (23.8) Longer than 6 months 37 (30.4) 12 (25.5) 12 (36.4) 13 (31.0) Not interested in quitting 44 (36.1) 18 (38.3) 7 (21.2) 19 (45.2) 94 Table 4.3. Phase III: Single Cigarette Acquisition Practices of African American Users (n = 122) Typical cigarette acquisition n (%) Carton 3 (2.5) Pack 72 (59.0) Loosies 41 (33.6) Frequency of buying loosies (past 30 days) Sometimes 47 (38.6) Often 33 (27.0) Very Often 42 (34.4) Frequency of seeing loosies being sold (past 30 days) Rarely 9 (7.4) Sometimes 27 (22.1) Often 29 (23.8) Very Often 55 (45.1) Frequency of cravings to smoke after seeing loosies being sold (past 30 days) Never 9 (7.4) Rarely 19(15.6) Sometimes 27 (22.1) Often 38 (31.1) Very Often 27 (22.1) Frequency of buying loosies to reduce cigarette consumption Never 11 (9.0) Rarely 17 (13.9) Sometimes 27 (22.1) Often 37 (30.3) Very Often 27 (22.1) Number of loosies purchased at one time (M, SD) 4.8 (2.9) Typical loosie type Menthol 117 (95.9) Non-menthol 3 (2.5) Cost per loosie 0.50 cents 62 (50.8) 0.75 cents 38 (31.1) 1.00 dollar 13 (10.7) Totals may not equal n=122 (100%) due to missing data. 95 Table 4.4. Retained Factors for the Social Context of Loosies Scale Factor loadings Social Context Items M (SD) 1 2 3 4 Please indicate how often you purchase loosies in the following situations. Triggers When I’m stressed. 3.3 (1.3) 0.70 When I’m bored. 2.9 (1.4) 0.98 When I’m happy. 3.0 (1.3) 0.82 Cronbach’s α=0.88; males=0.86; females=0.89; daily smokers=0.89; non-daily smokers=0.83 Retail Stores Inside a convenient store. 1.8 (1.0) 0.80 Inside a gas station. 1.8 (1.1) 0.94 Inside a liquor store. 1.7 (1.1) 0.96 Cronbach’s α=0.92; males=0.89; females=0.94; daily smokers=0.95; non-daily smokers=0.86 Harm Reduction I want to control the number of cigarettes I smoke. 3.4 (1.2) 0.71 I want to quit smoking entirely. 3.5 (1.5) 0.82 Cronbach’s α=0.72; males=0.66; females=0.75; daily smokers=0.71; non-daily smokers= 0.72 Individual Sellers From a ‘loosie’ seller standing outside an establishment (such as stores, restaurants, or court houses). 3.4 (1.3) 0.64 From a ‘loosie’ seller on the street in a crowded area (such as where people hang out or a downtown area). 3.5 (1.3) 1.0 From a stranger I see smoking cigarettes. 2.9 (1.4) 0.41 Cronbach’s α=0.71; males=0.83; females=0.85; daily smokers=0.73; non-daily smokers=0.80 96 Table 4.5. Retained Factors for the Health Belief Model for Loosies Scale Health Belief Model Items Factor loadings M (SD) 1 2 3 4 5 6 Perceived Benefits If I tried to stop buying loosies, my chances of… Being exposed to germs would go down. 3.0 (1.3) 0.51 Buying a laced cigarette, such as a ‘dipper’ would go down. 2.9 (1.4) 0.51 Quitting smoking would go up. 3.0 (1.3) 0.74 Staying an ex-smoker would go up. 3.2 (1.3) 0.81 Cronbach’s α=0.78; males=0.74; females=0.80; daily smokers=0.80; non-daily smokers=0.72 Perceived Barriers If I tried to stop buying loosies, it would be hard for me to give up... That loosies are easy to get. 3.9 (1.2) 0.61 That loosies are cheaper than a pack. 3.8 (1.3) 0.82 The convenience of buying loosies (such as waiting in line). 3.6 (1.3) 0.71 Being able to smoke without buying a pack. 3.8 (1.2) 0.65 Cronbach’s α=0.83; males=0.77; females=0.84; daily smokers=0.84; non-daily smokers=0.79 Perceived Severity In general, how harmful is cigarette smoking? 3.9 (1.2) 0.98 Considering everything else you have going on in your life, how harmful is 3.9 (1.2) 0.74 your cigarette smoking? Cronbach’s α=0.85; males=0.77; females=0.90; daily smokers=0.87; non-daily smokers=0.82 Perceived Susceptibility Seeing loosies being sold makes me want to smoke. 2.7 (1.5) 0.57 Having loosies available to me makes it easier for me to smoke. 3.2 (1.5) 0.93 Having loosies available to me makes it hard for me to quit smoking. 3.0 (1.4) 0.48 Cronbach’s α=0.71; males=0.61; females=0.85; daily smokers=0.73; non-daily smokers=0.78 Self-efficacy toward Cognitive Strategies Do something else to calm my nerves. 3.2 (1.4) 0.61 Keep myself busy (such as listen to music or read a book). 3.3(1.3) 0.51 Use my willpower. 3.2 (1.3) 0.74 Quit smoking altogether. 3.3 (1.3) 0.87 Cronbach’s α=0.85; males=0.84; females=0.87; daily smokers=0.86; non-daily smokers=0.83 Self-efficacy toward Behavioral Strategies Avoid buying loosies when I see a loosies seller. 3.1 (1.3) 0.65 Avoid buying or bumming cigarettes from other smokers. 3.1 (1.4) 0.63 Avoid places where I usually buy loosies. 3.1 (1.3) 0.84 Cronbach’s α=0.81; males=0.74; females=0.86; daily smokers=0.80; non-daily smokers=0.83 97 Chapter 5: Conclusions 5.1. Overview and Summary The practice of single cigarette use encourages normative smoking beliefs and promotes continual smoking patterns among urban, African American smokers. Though past research studies have documented the complex issue of loosies, limited research is available to inform public health action regarding loosie use and regulatory enforcement of the Tobacco Control Act. The goals of this dissertation were to expand the literature by providing an updated depiction of loosie use by urban, African American smokers and to identify potential targets for developing future interventions. Specifically, the aims of this dissertation were to: 1) examine the social context, beliefs, and attitudes of loosie use, and 2) develop two valid scales guided by the social context of loosie use and the Health Belief Model. Through a mixed-method, three-phase approach, the findings highlight the need to address the circumstantial and well-intentioned use of single cigarettes among urban, African Americans. Phase I of the study consisted of 25 semi-structured, in-depth interviews with urban, African American loosie users from Baltimore, MD and the District of Columbia (D.C.). The interview transcripts were analyzed using the Framework Method (Ritchie and Lewis, 2003) that allowed for the retention of each participant’s unique experience with loosies while also permitting the evaluation of themes across participants. The results from this phase identified loosie use as being a convoluted issue with two emerging groups of loosie users: 1) individuals who purchased loosies 98 as an easy way to access cigarettes; and, 2) those who bought them for use as a harm reduction strategy. Perceived benefits of loosie use were based on loosies’ convenience and low immediate cost, which also were significant barriers to reducing loosie purchasing behavior. Still, potential perceived gains from reducing loosie use was hinged upon the avoidance of other health harms (i.e., purchasing a “fake” cigarette or one that had been meddled with or being exposed to the seller’s poor hygiene habits). Some participants affirmed loosies’ role in maintaining their smoking patterns and failed quit attempts (perceived susceptibility). Participants had either no confidence at all to reduce their loosie use or were very confident to stop (self-efficacy). Participant-identified strategies to reduce loosie use were cognitive, behavioral, and pharmacotherapy ones. These strategies are similar to those mentioned in the smoking cessation research conducted by Patnode and colleagues (2015). The qualitative findings from this phase were subsequently used to guide the next phase of this dissertation research. In Phase II, a generated pool of 53 items was developed from the in-depth interview themes and a review of the existing literature. Three expert reviewers then provided feedback and suggested the inclusion of three items to strengthen the content validity of when participants used loosies and the perceived severity of cigarette smoking. Next, pilot testing using the “think aloud” cognitive interview method was conducted in two rounds (Collins, 2003). Fifteen African American loosie users provided wording recommendations to improve the interpretation of the items. Revisions were made based on this feedback, and a second iteration of pilot testing was conducted with nine participants. The final pool consisted of 29 items 99 based on the social context of using loosies and 26 items based on the theoretical constructs of the Health Belief Model. In the final phase of this research, Phase III, psychometric data from the 55 items were collected from 122 African American loosie users who resided in five D.C. public housing neighborhoods. With these data, rigorous exploratory factor analysis and reliability and validity testing were conducted that lead to the development and validation of two scales: The Social Context of Loosies Scale (SCL- 11) and the Health Belief Model for Loosies Scale (HBML-20). In summary, the use of loosies by urban, African Americans from Baltimore, MD and the District of Columbia is a substantial risk factor for smoking propensity. Loosie sales persist due to their high acceptability and their role in the community’s informal economy. Both the SCL-11 and HBML-20 are valid scales, which can be used to identify potential social, environmental, and intrapersonal targets for addressing loosie use. This could ultimately lead to the development and enforcement of tobacco control policies and the advancement of evidence-based cessation programs that are designed for urban, African American cigarette smokers. 5.2. Implications This dissertation research increases our understanding of single cigarette use by urban, African Americans and contributes to the literature in two novel ways. To begin with, this is the first qualitative study to utilize semi-structured, in-depth interviews (Phase I) to examine individualized patterns of loosie use among members of the priority population. Secondly, the research of Phases II and III culminates with the development and validation of the first two measures designed by, and for, urban, 100 African American loosie users - The Social Context of Loosies Scale (SCL-11) and the Health Belief Model for Loosies Scale (HBML-20). The results of this research shed light on the complexity of loosie use. That is, the use of loosies as a harm reduction strategy. Despite a common belief by the participants that loosies kept cigarette consumption lower than cigarette acquisition from packs, some participants expressed how the availability of loosies made it difficult for them to quit smoking due to the perception that it was “just one more cigarette.” The perceived barriers to reducing loosie use (i.e., being able to smoke without having a pack, convenience, and low cost of loosies) are substantial challenges to modify and overcome, and may greatly hinder the value and expectations of participant-identified benefits to reducing their purchasing and use of loosies. The Need for Multilevel Interventions Tobacco-related health disparities are pervasive among urban, African Americans – in part due to the complex interactions between behavioral, social, economic, and environmental factors as evidenced by this dissertation research. Multilevel interventions whose levels are defined by the social ecological model and include larger environment (“upstream” factors) and more individual factors (“downstream” factors) (McLeroy, Bibeau, Steckler, & Glanz, 1988) are necessary (Agurs-Collins et al., 2019) to address loosies. The findings reported here are a starting point for such efforts. For example, by focusing on the individual level, people who purchase loosies due to limited financial means may benefit from social and environmental strategies aimed at reducing the availability and accessibility of 101 loosies. The experiences and beliefs of the participants who use loosies as a harm reduction strategy underscore the need for integrating a loosies-specific component into existing evidence-based smoking cessation programs. Interventions that target the broader community, social, and environmental contexts and that also affect individual behavior or risk (Agurs-Collins et al., 2019) can produce greater reductions in tobacco-related disparities. The Social Context of Loosies Scale (SCL-11) and Health Belief Model for Loosies Scale (HBML-20) can be used to identify meaningful targets for: 1) social and environmental, and 2) individual intervention, respectively. Research to assess the effectiveness of these multilevel interventions that can measure the complex interplay between the levels is urgently needed. 5.3. Strengths and Limitations A primary strength of this study was its use of a mixed-method, exploratory sequential design and primary data collection with urban, African American loosie users. Qualitative interviews, expert review, and pilot testing were conducted to rigorously develop two scales. Within the sample of loosie users, there was group heterogeneity for other sociodemographics, such as educational attainment, employment status, cigarette smoking patterns, loosie use frequency, and motivation to quit smoking. The development of all study materials and products (e.g., interview guide, qualitative data analysis, scale development, and exploratory factor analysis) were guided by the theoretical frameworks of the social context and the Health Belief Model to account for both interpersonal and intrapersonal factors associated with the purchasing and use of single cigarettes. 102 Even so, the interpretation of this dissertation’s findings should be considered within the context of its limitations, which are mostly due to the convenience samples used in this research. Although Phase I of this study (qualitative interviews) is the first research study to establish the use of single cigarettes among urban, African American loosie users in the District of Columbia (D.C.), the sample of 25 loosie users in this phase consisted of five participants that were from the District of Columbia while 20 were Baltimore residents. Still, the themes that emerged were consistent across the participants from both cities and assured the decision to present the 25 participants as one sample. Furthermore, the participants from Phase I (qualitative interviews) and Phase II (pilot testing) were African American loosie users from various urban sections of Baltimore and D.C., rather than being primarily D.C. public housing residents as recruited to participate in Phase III (psychometric testing). Conducting Phase III in D.C. public housing neighborhoods significantly increased the feasibility of recruiting 100-130 participants and administering paper-and-pencil surveys in-person. Nonetheless, recruitment strategies for Phases I and II did include the posting of study flyers on public housing sites and by word-of-mouth among D.C. public housing residents. Although data were not specifically collected on whether a participant resided in public housing, some participants in Phase I and Phase II verbally shared that they were public housing residents in either Baltimore or D.C. Further, D.C. public housing participants in Phases I and II resided in one of the five public housing sites where Phase III study procedures were conducted. These participants were not permitted to participate in Phase III. This study also sought to explore the stability of 103 the scales over time. However, due to a small sample size for test-retest reliability, this component of reliability testing could not be adequately assessed. Subsequently, the external validity of this dissertation research is limited to individuals who share the same sociodemographic characteristics. Inherent to scale validation, the reliability and validity of SCL-11 and HBML-20, and subsequent findings, are unique to urban, African American loosie users who reside in D.C. public housing neighborhoods. 5.4. Future Directions This research provided a comprehensive, individual-level understanding of loosie use by urban, African Americans in Baltimore, MD and the District of Columbia. Undoubtedly, single cigarette use must be a prioritized topic in addressing tobacco-related health disparities. Given the good psychometric properties of the scales for this population, future research is needed to explore their utility in addressing single cigarette use. As the availability and accessibility of loosies may differ between geographic regions, and even between two communities in close proximity to one another, SCL-11 may be administered to one homogenous sample to determine the most optimal intervention targets for individuals within a specific community. Research is also needed to test the potential impact of targeting intrapersonal factors as described in HBML-20. In particular, future studies may increase self-efficacy for cognitive and behavioral strategies and uncover whether targeting perceived benefits to reducing loosie use will shift the balance between perceived benefits and barriers. Future research should also consider the broader contextual levels and factors (e.g., behavioral, environmental, policy, organizational, 104 interpersonal) that influence the use of loosies among urban, African American smokers. Overall, this dissertation highlights the impact and importance of increased cigarette taxation on the sale of single cigarettes, which should be explored in prospective longitudinal studies. For example, in June and July of 2018, both the Baltimore and D.C. participants reported the cost of loosies as $0.50 cents per loosie. Three months later on October 1, 2018 (MyTax.DC.gov, 2018), the combined cigarette tax rate increased to $4.94 in the District of Columbia. Thus, by the time pilot testing and psychometric data were collected, the D.C. participants reported paying $0.50 cents, $0.75 cents, or $1.00 per loosie. To further strengthen the findings reported here, the scale development and validation of SCL-11 and HBML-20 may be replicated in a larger, more diverse sample of urban, African American loosie users. Confirmatory factor analysis could be conducted with a different, larger sample to verify the factor structures of the two developed scales. 105 Appendices 106 Appendix A: Methods A.1. Study Design This dissertation research utilized a mixed-method, sequential exploratory design (Creswell, Gutmann, & Hanson, 2003) to develop and validate two theoretically-based scales the: 11-item Social Context of Loosies Scale (SCL-11) and 20-item Health Belief Model for Loosies Scale (HBML-20). The SCL-11 measured the social context of purchasing and using loosies while the HBML-20, captured Health Belief Model constructs for single cigarette use. The study was conducted in three phases and culminated with the development of two publishable manuscripts. Semi-structured, in-depth interviews were conducted with 25 urban, African American loosie users (Phase I). The interview guide, which included open-ended questions with probes, was theoretically guided by the social context of purchasing and using loosies, HBM constructs (i.e., perceived susceptibility, perceived severity, perceived benefits, perceived barriers, and self-efficacy), and existing literature related to the sale and use of single cigarettes (Guillory, Johns, Farley, & Ling, 2015; Stillman, Bone, Milam, Ma, & Hoke, 2014; Sacks, Coady, Mbamalu, Johns, & Kansagra, 2012; Thrasher, Villalobos, Barnoya, Sansores, & O’Connor, 2011). (Appendix C.4.). The qualitative themes that emerged from this phase were then used to inform the subsequent study phases (Phase II and Phase III). In these later phases, a pool of potential items was developed, reviewed by three experts, pilot tested (n=24), and administered to 122 urban, African American loosie users. Following psychometric data collection, exploratory factor analyses were employed to explore 107 the underlying latent variables of each of the two scales. The scales’ reliability and validity were also examined. Table A.1. explicates the study phases and the procedures conducted within each phase. Table A.1. Outline of Study Phases and Procedures Phase I: Phase II: Phase III: Qualitative Scale Development and Survey Administration Interviews Pilot Testing and Scale Validation Semi-structured, Create survey items; Survey administration; Description in-depth interviews; Expert review; Pilot Quantitative analysis; Qualitative data testing round 1 & 2 Psychometric analysis; analysis Test-retest* reliability Expert review (n=3); Survey administration Sample Size Interviews (n=25) Pilot Testing Round 1 (n=122); Test-retest (n= 15) and 2 (n=9) (n=11) Informed Consent In-person, written consent Recruitment Flyer postings; Oral and interpersonal communication Public libraries, community-based Community-centers Setting organizations located within or near the within five District of community in which the participant resides Columbia Housing Authority (DCHA) Sites Incentive $25 cash $15 cash $15 cash A.2. Study Setting Phase I: The semi-structured, in-depth interviews were conducted in quiet, private rooms in community-based locations (i.e., public libraries and a community-based organization located within or near the community in which the research participant resided). The two specific settings were reserved rooms: 1) in Enoch Pratt Free Library or DC Public Library branches in Baltimore, MD or the District of Columbia, respectively; and 2) the Center for Urban Families in the Penn-North section of Baltimore, MD. Phase II: The setting for pilot testing the survey was the same as in Phase I. 108 Phase III: Survey administration was conducted in the community rooms of five District of Columbia Housing Authority (DCHA) public housing sites. A.3. Priority Population The priority population for this dissertation research was urban, African Americans who purchased and used loosies. Individuals were eligible to participate in the study if they were: 1) ≥18 years of age; 2) self-identified as African American; 3) resided in either Baltimore, MD or the District of Columbia and, 4) purchased and used loosies at least once in the past month (Appendix B). Previous studies have documented the use of loosies by the priority population in Baltimore, MD (Latkin, Murray, Clegg-Smith, Cohen, & Knowlton, 2013; Smith et al., 2007; Stillman, Bone, Milam, Ma, Hoke, 2014), and although loosie use is known to be pervasive in D.C. (Debnam, 2018), it has not yet been reported in published literature. By focusing on these two urban cities, this dissertation was able to update past qualitative research conducted in Baltimore and document the use of loosies among urban, African American smokers in D.C. A.4. Sampling Procedures Several strategies were used to recruit a convenience sample (Jager, Putnick, & Bornstein, 2017) of urban, African American adult loosie users in Baltimore, MD and the District of Columbia for Phases I and II of this dissertation research. Participants were recruited via: 1) study flyer postings; and, 2) oral and interpersonal communication (e.g., “word-of-mouth”). Study flyers were posted in local convenience stores, gas stations, take-out restaurants, the Washington Metropolitan Area Transit Authority stations (commonly referred to as Metro stations), community 109 centers, local branches of the public library in urban areas within the two cities, and in communal areas of DCHA public housing sites (Jones et al., 2009). Oral and interpersonal communication (e.g., “word-of-mouth”) is a communication style preference among African Americans (Resnicow, Baranowski, Ahluwalia, & Braithwaite, 1999) and was used as an effective recruitment strategy in this research. As part of my research training with the dissertation committee chair, I have developed ongoing relationships with two community stakeholders in the District of Columbia who assisted with study recruitment. Mr. Charles Debnam, BA, MCHES, CTTS, CAC is the Deputy Chief Executive Officer of the Community Wellness Alliance, a community-based organization that focuses on developing health and wellness programs in the Washington, DC metropolitan area. Mr. Debnam is also a Certified Tobacco Treatment Specialist (CTTS) and a past chair of the DC Tobacco Free Coalition. The coalition is composed of faith- and community-based organizations that aim to educate the community about the health effects of tobacco and second-hand smoke. For Phase I, Mr. Debnam assisted with the posting of study flyers in public housing communities. Individuals who participated in this phase of the research were also re-contacted to determine their interest and eligibility to pilot test the developed items (Phase II). Participants from either Phase I and/or Phase II were ineligible to participate in Phase III (survey administration for psychometric testing). For Phase III, Mr. Ron Friday, a Community Navigator from DCHA’s Office of Resident Services, posted study flyers in communal areas of the five DCHA public housing sites where study procedures were held. Mr. Friday also verbally 110 communicated about the study with the residents and assisted with the scheduling and coordinating with the DCHA sites and residents for survey administration. A.5. Study Procedures Primary data collection for this dissertation research was conducted from June of 2018 to January of 2019 (Table A.2.). Table A.2. Timeline of Primary Data Collection June Dec. 2018 July Aug. Sept. Oct. Nov. 2018 Phase I: Qualitative Interviews and Analyses X X X Phase II: Scale Development and Pilot X X X Testing Phase III: Survey Administration and Scale X Validation Informed Consent Process and Participant Incentives For Phases I and II of the study, the investigator assessed whether an individual met the study’s eligibility criteria via a brief telephone screener (Appendices C.3. & D.4.). In-person eligibility was conducted for those who participated in Phase III. (Appendix E.3.). Individuals who were eligible and interested to participate were taken through the informed consent process and were allotted ample time to ask questions about the research and make an informed decision about their participation (Quinn et al., 2012). They were then asked to provide written consent prior to conducting any study procedures. Cash incentives were used in this research. In a recently published community-based smoking cessation intervention, a community advisory board recommended using cash incentives versus gift cards to increase engagement and 111 retention among low socioeconomic status, African American participants in Baltimore, MD (Estreet et al., 2017). Phase I received $25 in cash and Phase II and Phase III received $15 in cash. Participants who completed the survey for a second time (i.e., test-retest reliability testing) received an additional $15 in cash. In all study phases, participants received the incentive at the completion of data collection. Phase I: Semi-structured, In-depth Interviews Previous focus group research revealed group-level norms, attitudes, perceived benefits, and the acceptability of loosies among urban, African Americans in Baltimore, MD (Smith et al., 2007; Stillman et al., 2007). This dissertation research aimed to extend previous findings by gaining an in-depth understanding of the social context and cognitive processes involved with loosie use through semi-structured interviews. The use of semi-structured, in-depth interviews – i.e., interviews in which participants are asked to respond to pre-set, open-ended questions – were an appropriate extension to focus group data by examining detailed, individualized experiences with a phenomenon such as the use of loosies (Gill, Stewart, Treasure, & Chadwick, 2008). Prior to each interview, the participant completed a brief questionnaire that included items about their sociodemographic characteristics, smoking history, nicotine dependence, cigarette acquisition practices, use of loosies, quitting behavior, and exposure to cigarette warning labels (Appendix C.3.). These semi-structured, in- depth interviews were conducted using the interview guide (Appendix C.4.). The questions were theoretically guided by the social context and HBM. Specifically, the inductive, qualitative exploration focused on: 1) why, when, where, from whom, and 112 how loosies were purchased and used, and 2) the perceived susceptibility, severity, benefits, and barriers of using loosies. Exit questions asked for participant’s opinions regarding recruitment for Phase III of the study. Interviews were conducted by the investigator and each lasted between 60 to 90 minutes. See Figure A.1. for a description of the Phase I recruitment efforts. Figure A.1. Phase I Participant Flowchart The interviews were digitally recorded and transcribed verbatim using Rev.com®, an online transcription service. The qualitative data were organized and coded into major themes using the Framework Method as outlined by Gale, Heath, Cameron, Rashid, and Redwood (2013) in NVivo 11®, a software package that supports qualitative and mixed-methods research. The Framework Method is an appropriate thematic analysis approach often used in qualitative studies focusing on tobacco use (Stuik & Baskerville, 2014; Vogt, Hall, & Marteau, 2007) and for semi- structured, in-depth interviews; where it is important to compare and contrast data by 113 themes across many cases, while also retaining the individual’s perspective (Gale, Heath, Cameron, Rashid, & Redwood, 2013; Ritchie & Lewis, 2003). Two coders (the investigator of this dissertation research and a doctoral student) created a codebook and completed qualitative analysis using an iterative process (DeCuir- Gunby et al., 2011; Macqueen & McLellan, 1998). (Appendix C.5.). Phase II: Survey Development and Pilot Testing The development of survey items was guided by the major themes identified in Phase I and past research investigating the use of single cigarettes (Guillory, Johns, Farley, & Ling, 2015; Sacks, Coady, Mbamalu, Johns, & Kansagra, 2012; Stillman, Bone, Milam, Ma, & Hoke, 2014 Thrasher, Villalobos, Barnoya, Sansores, & O’Connor, 2011). The purpose of the developed scales was to understand the social context of using loosies and related HBM constructs for reducing loosie use. Expert Review The generated scale items were reviewed by a convenient sample of three experts (Berg, 2014). Expert 1 is a Professor at a top-ranked public research university, Chair of the Department of Social and Behavioral Sciences in the university’s College of Public Health, and Director of a public health research-based laboratory. Expert 1’s expertise is in tobacco control and smoking cessation research as well as health psychology as it relates to health behavior and psychometric assessment. Expert 2 is a Professor at the same academic institution as Expert 1 and is the Director of another public health research-based lab. Expert 2 is a clinical psychologist with a research focus on health psychology and behavioral interventions for substance dependence, which includes tobacco control and smoking cessation 114 research. Expert 3 is an Assistant Professor within a College of Public Health at a public research university and serves as the manager of the research and evaluation division of the Arizona state quitline. Expert 3’s expertise is in developing evidence- based interventions to facilitate health promotion among low-income, underserved cigarette smokers. Experts 1 and 2 are co-investigators on several NIH-funded research studies to improve smoking cessation outcomes among primarily urban, low- income, African Americans. To assess the items’ content and face validity, these experts provided their feedback on the items’ language, clarity, and quality (Worthington & Whittaker, 2006). Specifically, the expert reviewers were asked to rate each item (1 = very poor to 5 = very good) on its face and content validity, clarity, conciseness, grammar, reading level, and redundancy to other items (Worthington & Whittaker, 2006) and to provide any additional suggestions (Appendix D.1.). Pilot testing Subsequently, the survey was pilot tested with a total of 24 urban, African American loosie users in two rounds as outlined in Figure A.2. Prior to providing feedback for the developed items, participants were administered a brief questionnaire as in Phase I (Appendix D.4.). Pilot testing involved the Think-aloud method (Collins, 2003) to assure that participants were “able to understand the questions being asked, that questions were understood in the same way by all respondents, and that respondents were willing and able to answer such questions” (Collins, 2003, p. 229). A cognitive testing guide was developed (with probes) and was used during the pilot testing process (Appendix D.5.). The first round of pilot 115 testing was with 15 African American loosie users. Revisions were made based on their feedback and a second round of pilot testing was conducted until saturation on the garnered feedback was reached. Nine participants participated in this second round. Participant characteristics from Phase II are presented in Tables A.3. and A.4. The doctoral candidate took notes and the pilot testing sessions were also digitally recorded. Each session lasted about 30 to 45 minutes. Figure A.2. Phase II Participant Flowchart Phase III: Survey Administration To coordinate study procedures, The DCHA community navigator, Mr. Ron Friday, worked with each of the five site’s resident council to reserve a 3-hour time block on their community room’s “activities” calendar. The investigator administered 116 the eligibility screener to determine eligibility of each interested resident. The informed consent process was completed by eligible and interested DCHA residents. Following these study procedures, participants completed the self-administered, paper-and-pencil survey which took approximately 30 minutes to complete. Additional assistance (e.g., reading of questions by the investigator due to due to a resident having eyesight challenges) was provided on an as needed basis. In addition to the pool of developed items, these survey questions were included: demographics, smoking history, nicotine dependence, cigarette acquisition practices, use of loosies, quitting behavior and two scales (i.e., Marlowe-Crowne Social Desirability Scale 13-item short form, Attitudes toward Smoking) to examine convergent and discriminant validity (Appendix E.3.). In order to examine test-retest reliability, participants from one DCHA site were asked if they would be interested in completing the survey for the second time 10 days post their first survey completion (Table A.5.) (Park, Kang, Jang, Lee, & Chang, 2017). Test-retest reliability was conducted at one site because of scheduling conflicts with the DCHA December holiday parties being held in the community rooms. Figure A.3. depicts participant flow through Phase III of this dissertation research. 117 Figure A.3. Phase III Participant Flowchart Sample Size The sample size for Phase I was dependent on the saturation of qualitative themes (Francis et al., 2009). A comprehensive review of theory-based, semi- structured interviews demonstrated that the minimum number of participants needed to reach thematic saturation is 13 (Francis et al., 2009). The current study used a conservative approach with the sample size of 25 theory-based, semi-structured, in- depth interviews and saturation of themes was reached in this sample. Similar qualitative studies with urban, African Americans have had similar sample sizes of n=28 (see Baker, Palmer, & Lee, 2016 and Smith et al., 2007). To strengthen the feasibility of the study, the sample size of Phase III was 122 urban, African American loosie users from a convenience sample recruited from the five DCHA public housing sites. However, the sample size was guided by the recommended number of 118 participants needed to conduct a factor analysis (Schwab, 1980; Worthington & Whittaker, 2006). Guidelines from Worthington and Whittaker (2006) propose that smaller sample sizes (n=100) may be adequate if all communalities are .60 or greater or with at least 4:1 items per factor and factor loadings greater than 0.60” (Worthington & Whittaker, 2006, p. 817). The sample size in Phase III was slightly above n=100 (i.e., n=122) and guidelines by Worthington and Whittaker were adapted to incorporate other scale development considerations such as the number of retained items and the internal consistency of each retained factor. Exploratory factor analysis was conducted separately for the two theoretical underpinnings of the pool of items. For the purpose of examining relationships between variables in one-way analysis of variance frameworks, n=90, was deemed an adequate sample size in a power analysis using G*Power 3.1 © (effect size = 0.3; power = 0.80, and alpha = 0.05). It is also estimated that about 30 to 50 participants were needed to assess the developed scale’s test-retest reliability within the recommended 7 to 13 days between time 1 and time 2 (Park, Kang, Jang, Lee, & Chang, 2017). Due to scheduling conflicts with the DCHA December holiday parties, the necessary sample size for test-retest reliability testing was not achieved. A.6. Measures The measures included asking questions about a participant’s sociodemographic characteristics, smoking history, nicotine dependence, cigarette acquisition practices, frequency of loosie use, and quitting behavior (Appendices C.3., D.4., and E.3.). In Phase I, the survey also asked about participants’ exposure to 119 health warning labels, but these questions were later removed because they were often misinterpreted by participants. The survey was administered prior to the semi- structured, in-depth interviews (Phase I) and pilot testing of the developed scales (Phase II). Participants in Phase III were asked these items in addition to the final version of the theoretically-based scales, which measured the social context and HBM constructs for loosie use (Appendix E.3.). Measures examining sociodemographic characteristics, smoking history, nicotine dependence, cigarette acquisition practices, frequency of loosie use, quitting behavior, and exposure to cigarette warning labels were adapted from the National Adult Tobacco Survey (NATS) and the Population Assessment of Tobacco and Health (PATH) Study and were assessed at each study phase (Table A.7.) NATS is a stratified, national telephone-based survey of non-institutionalized adults that examines the prevalence of tobacco use and factors promoting or impeding its use (CDC, 2018). Items used in this dissertation research were from the NATS 2013-2014 questionnaire (CDC, 2016). The PATH Study is an ongoing longitudinal cohort study to inform FDA’s regulatory activities under the Tobacco Control Act. Items on tobacco use behavior, attitudes and beliefs, and tobacco-related outcomes are collected from a national sample of smokers and non-smokers (PATH, 2017). PATH- adapted items were from the second wave of administration (2014 - 2015) (PATH, 2017). Survey items regarding gender (Bauer, Braimoh, Scheim, & Dharma, 2017), income, and the use of loosies (Stillman, Bone, Milam, Ma & Hoke, 2014; Thrasher et al., 2009) were adapted from other sources to increase inclusivity and the appropriateness of the questions for this priority population and topic. 120 Table A.7. Outline of Measures by Study Phase Phase I: Phase II: Phase III: Test- Qualitative Scale Survey retest: Interviews Development Administration Reliability and Pilot and Scale Testing Testing Validation Measures Sociodemographic Characteristics X X X Smoking History X X X Nicotine Dependence X X X Cigarette Acquisition Practices X X X X Loosie Use Frequency X X X X Quitting Behavior X X X Health Warning Label Exposure X Social Context for Loosies Items X* X X Health Belief Model for Loosies Items X* X X Marlowe-Crowne Social Desirability Scale X X Attitudes toward Smoking Scale (ATS-18) X X *Note. These items were asked as the pilot testing content. Sociodemographic Characteristics Questions regarding age, gender, ethnicity, race, marital status, education level, monthly household income, and employment status were asked of each participant as a way of describing the study sample. Age was treated as a continuous variable. Participants were provided response options for the other sociodemographic variables, which were then treated as categorical variables in data analysis (CDC, 2016; PATH, 2017). The response categories for marital status, education level, and employment status were collapsed as presented in manuscripts #1 and #2. 121 Tobacco and Single Cigarette Use Measures Smoking History Smoking history was operationalized with items that measured the age at smoking initiation, smoking status (“Have you smoked at least 100 cigarettes in your entire lifetime?), smoker identity (“Do you consider yourself a smoker?”), and if participants were ever a daily cigarette smoker. Current smoking patterns were assessed by determining if participants smoked every day or some days, and the average number of cigarettes smoked on a typical day that they smoked (CDC, 2016; PATH 2017). Nicotine Dependence Nicotine dependence was assessed using questions adapted from the Fagerstrom Test for Nicotine Dependence Scale (Heatherton, Kozlowski, Frecker, & Fagerstrom, 1991), NATS (2013-2014), and PATH (wave 2 during 2014-2015). One item was used to measure each of the following: 1) the duration of time to one’s first cigarette after waking up; and 2) restlessness and irritability after having not smoked for a while. The other four items assess dependence through 1) whether or not one wakes up in the middle of the night to smoke, 2) the presence of strong cravings, 3) “needing” a tobacco product, and 4) difficulty thinking about other things besides smoking during the past 30 days. The latter four items had a dichotomous (yes/no) response format. Cigarette Acquisition Practices Cigarette acquisition practices identified how an individual typically purchased cigarettes. The 12 items asked about participants’ purchasing of cigarettes 122 by the carton, pack or as singles, their preferences (brand and menthol versus non- menthol), and buying of loosies. Items that measured loosie use included the cost that participants paid per loosie, the cigarette brand they bought as a loosie, the number of loosies they purchased at one time, and where or from whom they purchased loosies (CDC, 2016; PATH 2017; Thrasher et al., 2009). Additional questions about loosie use consisted of the frequency in the past month in which participants: 1) saw loosies being sold, 2) felt cravings to smoke upon seeing loosies being sold, and 3) purchased loosies to reduce the amount of cigarettes they smoked. Loosie Use Frequency Thrasher et al. (2009) operationalized self-reported frequency of loosie use in the past 30 days as “never,” “once in a while,” “often,” or “very often.” In this dissertation, the response options were revised to “rarely,” “sometimes,” “often,” and “very often” with a 4-point Likert response scale. The response option, “never,” was not included because the use of loosies, at least once in the past 30 days, was an eligibility criterion for this study. Quitting Behavior Three questions were asked to examine quitting behavior (CDC, 2016; PATH, 2017). One item was used to assess whether the participant made at least one quit attempt in the last year (“During the past 12 months, have you stopped smoking for 24 hours or more because you were trying to quit?”). A second item determined whether an individual contemplated quitting smoking for good (“Are you thinking about quitting cigarettes for good?” yes/no). Individuals who responded “yes” to contemplating quitting smoking were then asked about how soon they were likely to 123 quit smoking and selected one of the following responses: within the next 30 days, within the next 6 months, within the year, longer than a year, or don’t know. Exposure to Health Warning Labels Exposure to health warning labels captured how often one had seen a health warning on cigarette pack(s) in the past 30 days and had thought about the health risks of smoking. Response options ranged from “rarely,” “sometimes,” “often,” and “very often” (CDC, 2016). Social Context for Loosies Scale (SCL-11) Following the completion of Phase II, 29 items measured the social context of purchasing and using loosies: 1) why (5 items), 2) when (10 items), 3) where and from whom (8 items), and 4) how (6 items). The final Social Context of Loosies Scale (SCL-11) consisted of 11 items with the following subscales: 1) Triggers (3 items), 2) Retail Stores (3 items), 3) Harm Reduction (2 items), and 4) Individual Sellers (3 items). Triggers include the cognitive and emotional arousals that influence loosie purchasing and use. Retail Stores identifies types of retail stores where loosies are frequently purchased. Harm Reduction involves using loosies due to motivations to keep cigarette consumption low, to cut back, or to quit smoking. Lastly, Individual Sellers highlights the frequency with which users purchased loosies from individual sellers who are standing in front of an establishment or in a crowded area or from a stranger. SCL-11 subscale scores and total scale score were computed by summing item responses. Each item followed a 5-point likert response scale for either frequency (1 = never to 5 = very often) or agreement (1 = strongly disagree to 5 = 124 strongly agree), and total scale scores may have a minimum value of 11 to a maximum value of 55. Health Belief Model for Loosies Scale (HBML-20) Twenty-six items were administered for psychometric testing and included perceived benefits to reducing loosies (4 items), perceived barriers to reducing loosie use (4 items), perceived susceptibility to the risks of loosies on persistent smoking patterns (6 items), perceived severity of cigarette smoking (2 items), self-efficacy to reduce loosie use (1 item), and self-efficacy to use cognitive behavioral strategies (9 items). The final scale included 20 items with the following six subscales: 1) Perceived benefits (4 items) to reducing loosie use 2) Perceived barriers (4 items), 3) Perceived severity (2 items), 4) Perceived susceptibility (3 items), 5) Self-efficacy toward Cognitive Strategies (4 items), 6) Self-efficacy toward Behavioral Strategies (3 items). Each item followed a 5-point likert response scale for agreement (1 = strongly disagree to 5 = strongly agree) and subscale scores were computed by summing item responses. The total score for HBML-20 was calculated by reverse coding the four items on Perceived barriers. Total scale scores ranged from 20 to 100. Marlowe-Crowne Social Desirability Scale The Marlowe-Crowne Social Desirability Scale’s 13-item short form was used and served as a viable substitute for the 33-item long form (Reynolds, 1982). The scale measures an individual’s tendency to respond in a socially desirable manner using a True/False response format. The Marlowe-Crowne Social Desirability Scale has been used to measure social desirability among African American participants (Jemmott, Jemmott, & Fong, 1998; Taylor, Kamaruck, & Shiffman, 2004). Among 125 Phase III participants, the internal consistency of the Marlowe-Crowne Social Desirability 13-item short form was a = 0.74. The total scale score for the 13-item short form ranged from 0 to 13 with higher scores indicating a higher tendency to respond in a socially desirable way. Scores were computed by reverse scoring responses for eight of the 13 items (i.e., items #1, 2, 3, 4, 6, 8, 11, and 12). Attitudes toward Smoking Scale (ATS-18) ATS-18 measures attitudes toward smoking and consists of three subscales: 1) adverse effects of smoking, 2) psychoactive benefits of smoking, and 3) pleasure of smoking (Etter et al., 2012). Responses ranged from 1 = strongly disagree to 5 = strongly agree and the total score was calculated by reverse coding items of the last two factors (i.e., psychoactive benefits of smoking and pleasure of smoking). Total scale scores ranged from 18 to 90, with higher scores endorsing negative attitudes toward smoking. The internal consistency of ATS-18 with data from the 122 urban, African American loosie users from Phase III was a = 0.78. A.7. Analytical Plan In this section, the statistical methods used to examine the validity and reliability of the two developed scales are presented. Prior to employing specific statistical methods, the data were reviewed to assure that the assumptions of each test or method had been met. Specifically, the analytical plan was designed to answer the research questions proposed for the quantitative portion of this dissertation: 1. To what degree do the developed scales measure their intended theoretical frameworks (construct validity)? 126 1a. How well does the Social Context of Loosies Scale (SCL-11) measure the social context (i.e., why, when, where, from whom, and how) of purchasing and using loosies? 1b. How well does the Health Belief Model for Loosies Scale (HBML-20) measure HBM constructs for reducing loosie use? 2. How reliable are the developed scales (reliability)? 2a. What is the general agreement between items within the subscale (internal consistency reliability)? 2b. How stable is the scale over time (test-retest reliability)? 3. To what extent does SCL-11 and HBML-20 demonstrate convergent validity? 4. To what extent does SCL-11 and HBML-20 demonstrate discriminant validity? 5. How well do the measured constructs in SCL-11 and HBML-20 behave as expected in relation to known group trends for loosie use (construct validity testing via group differentiation)? Psychometric Analysis Construct Validity Factor analysis is a technique used to assess the theoretical underpinnings of a given dataset and the extent to which these operationalizations represent the true constructs they intend to measure (Henson & Roberts, 2006). As such, factor analysis, instead of principal component analysis, was selected as the factor extraction method to examine the construct validity of the two scales. Researchers have argued the limitations of principal component analysis as a true factor analysis method (Costello 127 & Osborne, 2005; Henson & Roberts, 2006; Worthington & Whittaker, 2006), and thus factor analysis was applied here. Exploratory Factor Analysis Exploratory factor analysis (EFA) is useful in understanding the construct validity of a newly developed scale and the covariance between its variables (Costello & Osborne, 2005; Henson & Roberts, 2006; Worthington & Whittaker, 2006). This was the first theoretical application of the social context and Health Belief Model for the use of loosies within an urban, African American sample. EFA forms the understanding of how the items group together into meaningful subscales, which in turn distinguishes specific theoretical constructs within the theoretically-based, multidimensional scale. The EFA was conducted for the developed scales and followed standardized guidelines for best practices established by Worthington and Whittaker (2006) and Costello and Osborne (2005). For EFA and subsequent analyses, the generated pool of 55 items were separated into: 1) Social Context (Figure A.4.) and 2) Health Belief Model (Figure A.5.) to examine the underlying latent variables that are unique to each of these theoretical frameworks. Figure A.4. Exploratory Factor Analysis Model for the Social Context of Loosies Scale 128 Figure A.5. Exploratory Factor Analysis Model for the Health Belief Model for Loosies Scale Sampling Adequacy The Kaiser-Meyer-Olkin (KMO) test was employed to assure the adequacy of sampling and the factorability of the correlation matrix. In the initial models, the KMO test resulted in values of 0.78 for SCL-11 and 0.81 for HBML-20, which is above the recommended 0.60 and indicated the sufficiency of the sample and data to employ factor analysis (Kaiser, 1970). Number of Factors and Items Retained Factor retention involved whether eigenvalues were greater than 1.0 and the scree test method (Cartell, 1966). The scree test method involved the graphical examination of eigenvalues and the natural bend or break point in the data where the curve flattens out (Costello & Osborne, 2005). The number of factors above the break was used in determining how many factors to retain. Factors with fewer than three items were eliminated unless there was a high correlation (>0.70) between the two 129 items. Items with factor loadings above 0.40 (Boateng et al., 2018) and had no or few item cross-loadings (items that load at .40 or higher on two or more factors) were retained for each factor. Rotation Methods An oblique rotation method was used with the default settings for the delta (0) and kappa (4) values (Costello & Osborne, 2005). The oblique rotation method was recommended to be more accurate than the orthogonal rotation method and permitted correlation between factors (Costello & Osborne, 2005; Henson & Roberts, 2006; Worthington & Whittaker, 2006). Although the theoretical constructs operationalized within the scale are distinct from one another, they are all theoretical constructs of one health behavior theory – i.e., social context and HBM, together form composite constructs (perceived threat and perceived expectations), and it is intuitively understood that there exists an underlying connection between them. Reliability Internal Consistency The inter-relatedness of the items within each subscale were assessed using Cronbach’s Alpha (Cronbach, 1951). An alpha level between .70 and .95 was deemed appropriate for each subscale (Tavakol & Dennick, 2011). Items with a low Cronbach’s alpha of < .70 with other items were removed to increase the consistency within the subscales. Test-retest Reliability The stability of the subscales over time was examined using Pearson correlation to observe the strength of the linear relationship between the subscales at 130 Time 1 and Time 2, which was 10 days apart (Portney & Watkins, 2000). The interpretation of the observed Pearson correlation coefficients were based on recommended guidelines (Mukaka, 2012). The guidelines deem r values between 0.00 to 0.30 to be negligible, 0.30 to 0.50 to be low, 0.50 to 0.70 to be moderate, 0.70 to 0.90 to be high, and 0.91 to 1.00 to be very high. Validity Testing Convergent and Discriminant Validity Testing Pearson’s correlation was conducted to assess the relation between SCL-11 and HBML-20 subscales to ATS-18 and the Marlowe-Crowne Social Desirability Scale. Specifically, the composite scores of each subscale (i.e., perceived susceptibility, perceived severity, perceived benefits, perceived barriers) were correlated with the composite score for: ATS-18 and the Marlowe-Crowne Social Desirability Scale (Reynolds, 1982). Pearson correlation coefficients were evaluated based on the correlation coefficient cut-off values as reported above by Mukaka (2012). Correlation coefficients had to be ≤ 0.25 for subscales to be identified as free of social desirability bias. Group Differentiation Group differentiation in subscale scores for SCL-11 and HBML-20 were examined across frequency of loosie use, gender, and cigarette smoking status using one-way analysis of variance. Significant results were reported as a part of manuscript #2. 131 Missing Data The study’s methods and protocol aimed to prevent any missing data during data collection. The likelihood of missing data was minimized by collecting all data in-person; thus, providing the opportunity for the investigator to administer the survey and double-check for the completeness and accuracy of the data before the interview was over. The patterns of missing data were evaluated to determine if the mechanism was missing at random (MAR), missing completely at random (MCAR), or missing not at random (MNAR). Little’s MCAR test (Little, 1988) was not statistically significant (p>0.05) and revealed that the missing data were missing completely at random. Missing data was determined to be ≤13% for all variables in the data. For variables included in the exploratory factor analysis and subsequent analyses, the percentage of missing data was ≤9% per variable. Missing data for variables used in exploratory factor analysis and subsequent analyses were handled via multiple imputation of five complete datasets in SPSS and statistics were obtained by averaging results across all imputed datasets (Dong & Peng, 2013; Newman, 2014; Schafer, 1999). 132 Appendix B: IRB Application and Approval Letters B.1. Initial IRB Application University of Maryland College Park Institutional Review Board IRB Initial Application - Part 1 Last edited by: Lilianna Phan Full Last edited on: April 23, 2018 Expedited [click for checklist] Exempt [1209494-1] Understanding the Knowledge, Attitudes, and Beliefs about Single Cigarettes: The Impact of“Loosies” Usage among a High-risk Population Answer all questions on this form completely, include attachments and obtain signatures of Co- Investigators and your department IRB Liaison prior to final submission on IRBNet. I. Principal Investigator Name: Lilianna Phan, M.S., MPH Status: Graduate Student Department: SPHL- Public Health Phone: 786-384-4320 Email: lphan1@umd.edu Address: 909 S. Linwood Ave. Baltimore, MD 21224 II. Faculty Advisor N/A Note: A faculty advisor is required if the PI is a student resident or fellow and the Faculty Advisor MUST sign this package through IRBNet.Name: James Butler Department: SPHL- Public Health Phone: 301-405-0757 Email: jbutler9@umd.edu Address: 4200 Valley Drive, Room 1234Y, College Park, MD 20742 III. Co-Investigators N/A Note: All co-investigators MUST sign this package through IRBNet. Name: Department: Phone: Email: Address: IV. Funding Information N/A Note: A copy of the awarded grant application (minus budgetary information) must be provided. - 1 - Generated on IRBNet 133 Status Funding Type Sponsor Name ORAA # COI Pending Federal Government University of Maryland No Tobacco Center of RegulatoryScience Funding Title: V. Project Information Lay Summary: The sale of single cigarettes, also called loosies, is the selling of an illegal, untaxed, loose cigarette, which remains prominent among African Americans in urban communities despite its ban in The Family Protection and Control Act of 2009. Loosies are viewed positively amongAfrican Americans as a harm reduction strategy, though evidence suggests the opposite; they actually promote smoking initiation, the continuation of smoking, support nondaily smokingpatterns and increase opportunities for slips and relapse. This current study aims to capture the attitudes and beliefs surrounding loosies and the knowledge of potential harms of using loosies among African American users in urban areas. The findings from this current study will informlatter phases of the study, which is a scale development and validation measuring the use of loosies. Requested Review Path: Full Expedited Exempt Projected Completion Date: 05/31/2019 Research Category: Faculty or Staff Research Graduate Student Research Student/Faculty Collaboration Undergraduate Student Research Other: Academic Committee Review: Yes - Masters committee Yes - Dissertation committee No additional academic review required Participant Incentives: Cash Check Raffle/ Lottery: - 2 - Generated on IRBNet 134 Economically disadvantaged persons Educationally disadvantaged persons Elderly/aged persons Hospital patients or outpatients Illiterate persons Individuals with physical disabilities Minority group(s) Minors/children [inclusion of anyone under 18 requires a Parental Consent Form] Non-English speakers Pregnant women Prisoners Students (non-minors) UMCP employees Other special characteristics and special populations: Informed Consent Process: Informed consent will be obtained from subjects and documented with a signed, written consent form Informed consent will be obtained from subjects, but no signed consent form will be used. This includes oral consent and implied consent (e.g., completing a survey). [please see the Requesting a Waiver of Informed Consent Guidance] Fully informed consent will not be obtained from all subjects. This includes deception, withholding information, etc. [please see the Requesting a Waiver of Informed Consent Guidance] Will health information be collected?(See the HIPAA section of the IRB website for more information and additional resources.) No Yes, data are de-identified or constitute a limited data set. Yes, subject's authorization will be obtained or a waiver or alteration of authorization will be requested. [complete IRB Form HIPAA] VIII.Research Procedures Research Procedures: Records review - retrospective Records review - prospective Education research Behavioral experiments Behavioral observation - 4 - Generated on IRBNet 135 • The research will not be initiated and subjects cannot be recruited until final written approval is granted. The following signatures are required for new project submissions: • Principal Investigator • Research Advisor(s)• IRB Liaison (click here for list) INSTRUCTIONS TO RESEARCHERS [top] Now that you have completed this document, check your work, attach all appropriate documents,electronically sign and submit your work. Based on your responses, the following additional documentation must be included with this package before submission. Upload additional documentationin the Designer. Documents available in the IRBNet Forms and Templates Library: • Consent Form (template and Completion Guide in Library) Additional required documentation:No additional documents are required for this project. If you have any questions, please refer to the guidelines in the IRBNet Forms and Templates Library or contact irb@umd.edu. - 6 - Generated on IRBNet 136 INITIAL APPLICATION PART 2 a. Abstract: The 2009 Family Smoking Prevention and Tobacco Control Act granted the Food and Drug Administration (FDA) authority to regulate the manufacture, distribution, and marketing of tobacco products. The provisions banned the sale of single cigarettes, otherwise known as “loosies”, as a means to restrict tobacco marketing and sales to youth. Despite the Tobacco Control Act prohibition to protect public health, the sale of single cigarettes remains prominent among urban, African American, and young adult cigarette smokers. In addition to promoting smoking initiation among youth, loosies enable the continuation of smoking, support intermittent smoking patterns, and increase opportunities for slips and relapse. The sale of single cigarettes also impedes the reach of existing tobacco control policies by reducing exposure to warning labels on packages and behavior change related to increased cigarette taxes. Past research, though limited, identify the high availability of loosies and the positive attitudes towards the use of loosies among high-risk populations. More work must be done to further understand how users perceive loosies and their knowledge about the potential harms of loosies. The proposed study aims to use a qualitative approach to explore users’ existing attitudes and beliefs surrounding loosies (Aim 1) and their knowledge of the harms of using loosies (Aim 2). Data will be collected through in-person, theoretically guided, in-depth interviews with 25 loosies users. The qualitative findings will inform the latter phases of a larger study for a scale development and validation. An amendment(s) to include the pilot testing and developed survey will be submitted to IRB once these materials have been developed. We will not implement latter phases of the study until we have received IRB approval. The information included in this initial application is for the first phase of the study, which are semi-structured, in-depth interviews. b. Subject Selection: • Recruitment: Participant recruitment will follow purposive sampling methods, which will include snowball sampling. Several strategies will be used to recruit the study sample. With the permission of local businesses and organizations, flyers will be posted in bodegas or neighborhood grocery stores, recreational centers, and other public health-related program offices in areas where the use of loosies has been identified 137 from stakeholders (e.g., community members, local store employees, etc.) of urban neighborhoods within the District of Columbia and Baltimore City, Maryland. Social media outlets (such as Facebook and Instagram) have been deemed an effective strategy for recruiting African Americans in research participation and will also be used in this study (Admon, Haefner, Kolenic, Chang, Davis, Moniz, 2016). Participants from public housing neighborhoods in the District of Columbia (D.C.) area may potentially be recruited from the assistance of the District of Columbia Housing Authority (DCHA) and the Community Wellness Alliance, a community-based organization that focuses in developing health and wellness programs in the Washington, DC metropolitan area. In public housing neighborhoods, flyers will be posted on bulletin boards in communal spaces and residents may learn about the study from other residents. • Eligibility Criteria: Individuals will be eligible to participate in the semi-structured in-depth interviews if they a) are 18 years old and older, b) self-identify as African American c) reside in the District of Columbia (D.C.) or Baltimore City, Maryland, d) and have purchased loosies at least once in the past 30 days. • Rationale: The use of loosies has been documented among African Americans residing in urban areas in past research conducted in Baltimore City, Maryland (Smith et al., 2007; Latkin, Murray, Clegg- Smith, Cohen, & Knowlton, 2013; Stillman, Bone, Milam, Ma, Hoke, 2014). The use of loosies has also emerged during focus groups about the social context of smoking among African Americans in an ongoing research project conducted by our research team in public housing neighborhoods in the D.C. area. • Enrollment Numbers: We aim to enroll 25 participants to complete in- person, semi-structured, in-depth interviews. c. Rationale for Enrollment Numbers: A comprehensive review of theory-based, semi-structured interviews demonstrated that the minimum number of participants needed to reach thematic saturation is 13 participants (Francis, Johnston, Robertson, Glidewell, Entwistle, Eccles, & Grimshaw, 2009). The current study utilizes a conservative approach, and 25 theory-based, semi-structured, in-depth interviews are proposed to be conducted. The first two participants will serve as pilot participants to test the appropriateness of the questions in the interviewer’s guide and to assess the amount of time needed to complete the interview. If less than 25 participants will be enrolled in the study, we will contact and inform the IRB immediately. N=25 is the maximum number of interviews that will be conducted, and we do not anticipate the need to increase this enrollment number. If more than 25 138 interviews will be needed to reach thematic saturation, we will contact the IRB and request approval to increase the enrollment number. d. Procedures: The initial eligibility screening will be completed by telephone. The semi-structured, in-depth interviews will be conducted in reserved, quiet, private areas (such as a room in a public library - DC Public Library and Enoch Pratt Free Library branch, church, recreation center, or organization) located within or near the community in which the research participant resides in the District of Columbia and Baltimore City, Maryland. Participants will be offered water and a light snack (such as fruit or cookies) during the in-depth interview and will be compensated $25 dollars for their time. For participants who become ineligible (from the time of the initial telephone eligibility screening to the in-person interview) will be compensated $25 for their time. Participants will complete a questionnaire about their sociodemographic characteristics, cigarette smoking history and patterns, nicotine dependence, cigarette purchasing behaviors, and use of loosies prior to the semi- structured, in-depth interview. The semi-structured, in-depth interviews will be conducted using an interviewer’s guide, which focuses on understanding the individual’s perceived susceptibility, severity, benefits, and barriers of using loosies and assesses one’s existing knowledge of the potential harms of loosies. The “exit” questions will ask about participants’ opinions on how to recruit for the latter phases (scale development and validation) of the larger study. Interviews will be conducted by the investigator and will take about 45- 60 minutes to complete. The questionnaire and interviewer’s guide have been submitted as supporting documents. The questions from the interviewer’s guide will be pilot tested with the first two participants that participate in the study. e. Risks: There may be some potential risks from participating in this research study. Participants may feel psychological discomfort about the topics covered in the interview, which include their purchasing and use of loosies and cigarette smoking behaviors. f. Benefits: There are no direct benefits to participating in this research study. However, there are some potential overall benefits to be gained from this research. The data collected during the qualitative interviews will inform the development and validation of a scale measuring the use of loosies. We hope that the findings of this research will increase the 139 field’s understanding and documentation of the “loosies” phenomena, aid in the determination of individual-level targets for intervention approaches addressing the use of loosies, and provide a validated measurement tool for interventions targeting the use of loosies in the future. g. Confidentiality: We will take precautions and do our best to protect participants’ personal information. Participants will be given the option to choose an alias for the audio-recorded interview and their name will not be included on the questionnaire or other collected data. An identification key will be used to link participants’ personal information with their collected data. The key will be kept separate from the data. Only the investigator will have access to the identification key and the audio- recordings of the interviews. The key and all data will be kept in a secure location such as a locked cabinet in a limited access or locked office. All electronic files will be password-protected and stored on the university’s secure server as well an encrypted hard drive. The research records will be kept for a period of seven years after the completion of data collection. After which time, the research records will be destroyed in compliance with the methods of destroying the data that have been set by the university. h. Consent Process: If an individual is interested and eligible to participate in the study, the investigator will obtain the participant’s consent to participate in the study prior to the start of data collection. The consent process will be conducted in a reserved, quiet, private area. Participants will be provided with opportunities to ask questions prior to providing their consent for study participation. Participants will be asked to provide their permission to audio record the session prior to beginning the interview. All participants will be asked if they would like to participate in future research. Study participation is not contingent on the audio- recording of the interview and whether or not the participant would like to participate in future research. All participants will be asked to sign two copies of the IRB-approved consent form and will receive one copy of the written informed consent for their records. The investigator will keep the other copy in a secure and locked area. i. Conflict of Interest: No conflict of interest. 140 j. HIPAA Compliance: Not Applicable. k. Research Outside of the United States: This research will not be conducted outside of the United States. l. Research Involving Prisoners: Not Applicable. m. SUPPORTING DOCUMENTS Your Initial Application must include a completed Initial Application Part 1 (On-Line Document), the information required in items 1-11 above, and all relevant supporting documents including: consent forms, letters sent to recruit participants, questionnaires completed by participants, and any other material that will be presented, viewed or read to human subject participants. The consent forms in your approved IRBNet PACKAGE must be used. When creating or editing your consent form, please provide the most recent IRBNet package number at the bottom, right corner of the consent form. This ensures you are using the most “up-to-date” version of the form. To find your IRBNet package number, go to the MY PROJECTS tab and click on the title of your project. In the PROJECT OVERVIEW page, your IRBNet package number will be listed at the top, next to your project title. 141 B.2. IRB Initial Application and Amendment Approval Letters 1204 Marie Mount Hall College Park, MD 20742-5125 TEL 301.405.4212 FAX 301.314.1475 irb@umd.edu www.umresearch.umd.edu/IRB INSTITUTIONAL REVIEW BOARD DATE: May 21, 2018 TO: Lilianna Phan, M.S., MPH FROM: University of Maryland College Park (UMCP) IRB PROJECT TITLE: [1209494-1] Understanding the Knowledge, Attitudes, and Beliefs about Single Cigarettes: The Impact of “Loosies” Usage among a High-risk Population REFERENCE #: SUBMISSION TYPE: New Project ACTION: APPROVED APPROVAL DATE: May 21, 2018 EXPIRATION DATE: May 20, 2019 REVIEW TYPE: Expedited Review REVIEW CATEGORY: Expedited review category # 7 Thank you for your submission of New Project materials for this project. The University of Maryland College Park (UMCP) IRB has APPROVED your submission. This approval is based on an appropriate risk/benefit ratio and a project design wherein the risks have been minimized. All research must be conducted in accordance with this approved submission. Prior to submission to the IRB Office, this project received scientific review from the departmental IRB Liaison. This submission has received Expedited Review based on the applicable federal regulations. This project has been determined to be a Minimal Risk project. Based on the risks, this project requires continuing review by this committee on an annual basis. Please use the appropriate forms for this procedure. Your documentation for continuing review must be received with sufficient time for review and continued approval before the expiration date of May 20, 2019. Please remember that informed consent is a process beginning with a description of the project and insurance of participant understanding followed by a signed consent form. Informed consent must continue throughout the project via a dialogue between the researcher and research participant. Unless a consent waiver or alteration has been approved, Federal regulations require that each participant receives a copy of the consent document. Please note that any revision to previously approved materials must be approved by this committee prior to initiation. Please use the appropriate revision forms for this procedure. All UNANTICIPATED PROBLEMS involving risks to subjects or others (UPIRSOs) and SERIOUS and UNEXPECTED adverse events must be reported promptly to this office. Please use the appropriate reporting forms for this procedure. All FDA and sponsor reporting requirements should also be followed. All NON-COMPLIANCE issues or COMPLAINTS regarding this project must be reported promptly to this office. - 1 - Generated on IRBNet 142 1204 Marie Mount Hall College Park, MD 20742-5125 TEL 301.405.4212 FAX 301.314.1475 irb@umd.edu www.umresearch.umd.edu/IRB INSTITUTIONAL REVIEW BOARD DATE: June 1, 2018 TO: Lilianna Phan, M.S., MPH FROM: University of Maryland College Park (UMCP) IRB PROJECT TITLE: [1209494-2] Understanding the Knowledge, Attitudes, and Beliefs about Single Cigarettes: The Impact of “Loosies” Usage among a High-risk Population REFERENCE #: SUBMISSION TYPE: Amendment/Modification ACTION: APPROVED APPROVAL DATE: June 1, 2018 EXPIRATION DATE: May 20, 2019 REVIEW TYPE: Expedited Review REVIEW CATEGORY: Expedited review category # 7 Thank you for your submission of Amendment/Modification materials for this project. The University of Maryland College Park (UMCP) IRB has APPROVED your submission. This approval is based on an appropriate risk/benefit ratio and a project design wherein the risks have been minimized. All research must be conducted in accordance with this approved submission. Prior to submission to the IRB Office, this project received scientific review from the departmental IRB Liaison. This submission has received Expedited Review based on the applicable federal regulations. This project has been determined to be a Minimal Risk project. Based on the risks, this project requires continuing review by this committee on an annual basis. Please use the appropriate forms for this procedure. Your documentation for continuing review must be received with sufficient time for review and continued approval before the expiration date of May 20, 2019. Please remember that informed consent is a process beginning with a description of the project and insurance of participant understanding followed by a signed consent form. Informed consent must continue throughout the project via a dialogue between the researcher and research participant. Unless a consent waiver or alteration has been approved, Federal regulations require that each participant receives a copy of the consent document. Please note that any revision to previously approved materials must be approved by this committee prior to initiation. Please use the appropriate revision forms for this procedure. All UNANTICIPATED PROBLEMS involving risks to subjects or others (UPIRSOs) and SERIOUS and UNEXPECTED adverse events must be reported promptly to this office. Please use the appropriate reporting forms for this procedure. All FDA and sponsor reporting requirements should also be followed. All NON-COMPLIANCE issues or COMPLAINTS regarding this project must be reported promptly to this office. - 1 - Generated on IRBNet 143 1204 Marie Mount Hall College Park, MD 20742-5125 TEL 301.405.4212 FAX 301.314.1475 irb@umd.edu www.umresearch.umd.edu/IRB INSTITUTIONAL REVIEW BOARD DATE: June 26, 2018 TO: Lilianna Phan, M.S., MPH FROM: University of Maryland College Park (UMCP) IRB PROJECT TITLE: [1209494-3] Understanding the Knowledge, Attitudes, and Beliefs about Single Cigarettes: The Impact of “Loosies” Usage among a High-risk Population REFERENCE #: SUBMISSION TYPE: Amendment/Modification ACTION: APPROVED APPROVAL DATE: June 26, 2018 EXPIRATION DATE: May 20, 2019 REVIEW TYPE: Expedited Review REVIEW CATEGORY: Expedited review category # 7 Thank you for your submission of Amendment/Modification materials for this project. The University of Maryland College Park (UMCP) IRB has APPROVED your submission. This approval is based on an appropriate risk/benefit ratio and a project design wherein the risks have been minimized. All research must be conducted in accordance with this approved submission. Prior to submission to the IRB Office, this project received scientific review from the departmental IRB Liaison. This submission has received Expedited Review based on the applicable federal regulations. This project has been determined to be a Minimal Risk project. Based on the risks, this project requires continuing review by this committee on an annual basis. Please use the appropriate forms for this procedure. Your documentation for continuing review must be received with sufficient time for review and continued approval before the expiration date of May 20, 2019. Please remember that informed consent is a process beginning with a description of the project and insurance of participant understanding followed by a signed consent form. Informed consent must continue throughout the project via a dialogue between the researcher and research participant. Unless a consent waiver or alteration has been approved, Federal regulations require that each participant receives a copy of the consent document. Please note that any revision to previously approved materials must be approved by this committee prior to initiation. Please use the appropriate revision forms for this procedure. All UNANTICIPATED PROBLEMS involving risks to subjects or others (UPIRSOs) and SERIOUS and UNEXPECTED adverse events must be reported promptly to this office. Please use the appropriate reporting forms for this procedure. All FDA and sponsor reporting requirements should also be followed. All NON-COMPLIANCE issues or COMPLAINTS regarding this project must be reported promptly to this office. - 1 - Generated on IRBNet 144 1204 Marie Mount Hall College Park, MD 20742-5125 TEL 301.405.4212 FAX 301.314.1475 irb@umd.edu www.umresearch.umd.edu/IRB INSTITUTIONAL REVIEW BOARD DATE: October 19, 2018 TO: Lilianna Phan, M.S., MPH FROM: University of Maryland College Park (UMCP) IRB PROJECT TITLE: [1209494-4] Understanding the Knowledge, Attitudes, and Beliefs about Single Cigarettes: The Impact of “Loosies” Usage among a High-risk Population REFERENCE #: SUBMISSION TYPE: Amendment/Modification ACTION: APPROVED APPROVAL DATE: October 19, 2018 EXPIRATION DATE: May 20, 2019 REVIEW TYPE: Expedited Review REVIEW CATEGORY: Expedited review category # 7 Thank you for your submission of Amendment/Modification materials for this project. The University of Maryland College Park (UMCP) IRB has APPROVED your submission. This approval is based on an appropriate risk/benefit ratio and a project design wherein the risks have been minimized. All research must be conducted in accordance with this approved submission. Prior to submission to the IRB Office, this project received scientific review from the departmental IRB Liaison. This submission has received Expedited Review based on the applicable federal regulations. This project has been determined to be a Minimal Risk project. Based on the risks, this project requires continuing review by this committee on an annual basis. Please use the appropriate forms for this procedure. Your documentation for continuing review must be received with sufficient time for review and continued approval before the expiration date of May 20, 2019. Please remember that informed consent is a process beginning with a description of the project and insurance of participant understanding followed by a signed consent form. Informed consent must continue throughout the project via a dialogue between the researcher and research participant. Unless a consent waiver or alteration has been approved, Federal regulations require that each participant receives a copy of the consent document. Please note that any revision to previously approved materials must be approved by this committee prior to initiation. Please use the appropriate revision forms for this procedure. All UNANTICIPATED PROBLEMS involving risks to subjects or others (UPIRSOs) and SERIOUS and UNEXPECTED adverse events must be reported promptly to this office. Please use the appropriate reporting forms for this procedure. All FDA and sponsor reporting requirements should also be followed. All NON-COMPLIANCE issues or COMPLAINTS regarding this project must be reported promptly to this office. - 1 - Generated on IRBNet 145 1204 Marie Mount Hall College Park, MD 20742-5125 TEL 301.405.4212 FAX 301.314.1475 irb@umd.edu www.umresearch.umd.edu/IRB INSTITUTIONAL REVIEW BOARD DATE: November 5, 2018 TO: Lilianna Phan, M.S., MPH FROM: University of Maryland College Park (UMCP) IRB PROJECT TITLE: [1209494-5] Understanding the Knowledge, Attitudes, and Beliefs about Single Cigarettes: The Impact of “Loosies” Usage among a High-risk Population REFERENCE #: SUBMISSION TYPE: Amendment/Modification ACTION: APPROVED APPROVAL DATE: November 5, 2018 EXPIRATION DATE: May 20, 2019 REVIEW TYPE: Expedited Review REVIEW CATEGORY: Expedited review category # 7 Thank you for your submission of Amendment/Modification materials for this project. The University of Maryland College Park (UMCP) IRB has APPROVED your submission. This approval is based on an appropriate risk/benefit ratio and a project design wherein the risks have been minimized. All research must be conducted in accordance with this approved submission. Prior to submission to the IRB Office, this project received scientific review from the departmental IRB Liaison. This submission has received Expedited Review based on the applicable federal regulations. This project has been determined to be a Minimal Risk project. Based on the risks, this project requires continuing review by this committee on an annual basis. Please use the appropriate forms for this procedure. Your documentation for continuing review must be received with sufficient time for review and continued approval before the expiration date of May 20, 2019. Please remember that informed consent is a process beginning with a description of the project and insurance of participant understanding followed by a signed consent form. Informed consent must continue throughout the project via a dialogue between the researcher and research participant. Unless a consent waiver or alteration has been approved, Federal regulations require that each participant receives a copy of the consent document. Please note that any revision to previously approved materials must be approved by this committee prior to initiation. Please use the appropriate revision forms for this procedure. All UNANTICIPATED PROBLEMS involving risks to subjects or others (UPIRSOs) and SERIOUS and UNEXPECTED adverse events must be reported promptly to this office. Please use the appropriate reporting forms for this procedure. All FDA and sponsor reporting requirements should also be followed. All NON-COMPLIANCE issues or COMPLAINTS regarding this project must be reported promptly to this office. - 1 - Generated on IRBNet 146 1204 Marie Mount Hall College Park, MD 20742-5125 TEL 301.405.4212 FAX 301.314.1475 irb@umd.edu www.umresearch.umd.edu/IRB INSTITUTIONAL REVIEW BOARD DATE: November 28, 2018 TO: Lilianna Phan, M.S., MPH FROM: University of Maryland College Park (UMCP) IRB PROJECT TITLE: [1209494-6] Understanding the Knowledge, Attitudes, and Beliefs about Single Cigarettes: The Impact of “Loosies” Usage among a High-risk Population REFERENCE #: SUBMISSION TYPE: Amendment/Modification ACTION: APPROVED APPROVAL DATE: November 28, 2018 EXPIRATION DATE: May 20, 2019 REVIEW TYPE: Expedited Review REVIEW CATEGORY: Expedited review category # 7 Thank you for your submission of Amendment/Modification materials for this project. The University of Maryland College Park (UMCP) IRB has APPROVED your submission. This approval is based on an appropriate risk/benefit ratio and a project design wherein the risks have been minimized. All research must be conducted in accordance with this approved submission. Prior to submission to the IRB Office, this project received scientific review from the departmental IRB Liaison. This submission has received Expedited Review based on the applicable federal regulations. This project has been determined to be a Minimal Risk project. Based on the risks, this project requires continuing review by this committee on an annual basis. Please use the appropriate forms for this procedure. Your documentation for continuing review must be received with sufficient time for review and continued approval before the expiration date of May 20, 2019. Please remember that informed consent is a process beginning with a description of the project and insurance of participant understanding followed by a signed consent form. Informed consent must continue throughout the project via a dialogue between the researcher and research participant. Unless a consent waiver or alteration has been approved, Federal regulations require that each participant receives a copy of the consent document. Please note that any revision to previously approved materials must be approved by this committee prior to initiation. Please use the appropriate revision forms for this procedure. All UNANTICIPATED PROBLEMS involving risks to subjects or others (UPIRSOs) and SERIOUS and UNEXPECTED adverse events must be reported promptly to this office. Please use the appropriate reporting forms for this procedure. All FDA and sponsor reporting requirements should also be followed. All NON-COMPLIANCE issues or COMPLAINTS regarding this project must be reported promptly to this office. - 1 - Generated on IRBNet 147 1204 Marie Mount Hall College Park, MD 20742-5125 TEL 301.405.4212 FAX 301.314.1475 irb@umd.edu www.umresearch.umd.edu/IRB INSTITUTIONAL REVIEW BOARD DATE: December 8, 2018 TO: Lilianna Phan, M.S., MPH FROM: University of Maryland College Park (UMCP) IRB PROJECT TITLE: [1209494-7] Understanding the Knowledge, Attitudes, and Beliefs about Single Cigarettes: The Impact of “Loosies” Usage among a High-risk Population REFERENCE #: SUBMISSION TYPE: Amendment/Modification ACTION: APPROVED APPROVAL DATE: December 8, 2018 EXPIRATION DATE: May 20, 2019 REVIEW TYPE: Expedited Review REVIEW CATEGORY: Expedited review category # 7 Thank you for your submission of Amendment/Modification materials for this project. The University of Maryland College Park (UMCP) IRB has APPROVED your submission. This approval is based on an appropriate risk/benefit ratio and a project design wherein the risks have been minimized. All research must be conducted in accordance with this approved submission. Prior to submission to the IRB Office, this project received scientific review from the departmental IRB Liaison. This submission has received Expedited Review based on the applicable federal regulations. This project has been determined to be a Minimal Risk project. Based on the risks, this project requires continuing review by this committee on an annual basis. Please use the appropriate forms for this procedure. Your documentation for continuing review must be received with sufficient time for review and continued approval before the expiration date of May 20, 2019. Please remember that informed consent is a process beginning with a description of the project and insurance of participant understanding followed by a signed consent form. Informed consent must continue throughout the project via a dialogue between the researcher and research participant. Unless a consent waiver or alteration has been approved, Federal regulations require that each participant receives a copy of the consent document. Please note that any revision to previously approved materials must be approved by this committee prior to initiation. Please use the appropriate revision forms for this procedure. All UNANTICIPATED PROBLEMS involving risks to subjects or others (UPIRSOs) and SERIOUS and UNEXPECTED adverse events must be reported promptly to this office. Please use the appropriate reporting forms for this procedure. All FDA and sponsor reporting requirements should also be followed. All NON-COMPLIANCE issues or COMPLAINTS regarding this project must be reported promptly to this office. - 1 - Generated on IRBNet 148 Appendix C: Phase I Materials C.1. Phase I: Recruitment Flyer for Qualitative Interviews Do you buy single cigarettes? (also known as “loosies”) Would you like to take part in a research study to discuss your experience with loosies? If so, The University of Maryland invites YOU to participate! Participants must be: • African American • 18 years of age or older • A resident of D.C. or Baltimore City • Have bought loosies at least once in the past 30 days • Willing to commit 2 hours of your time for an in- person interview For your participation in this research study… You will receive a $25 gift card for your time. For more information and to schedule an interview Call: Lil Phan at (443) 885-0722 Brought to you by: The University of Maryland School of Public Health IRB # 1209494-1 149 Research Study About Loosies Call: (443) 885-0722 Research Study About Loosies Call: (443) 885-0722 Research Study About Loosies Call: (443) 885-0722 Research Study About Loosies Call: (443) 885-0722 Research Study About Loosies Call: (443) 885-0722 Research Study About Loosies Call: (443) 885-0722 Research Study About Loosies Call: (443) 885-0722 Research Study About Loosies Call: (443) 885-0722 Research Study About Loosies Call: (443) 885-0722 Research Study About Loosies Call: (443) 885-0722 C.2. Phase I: Informed Consent Form Institutional Review Board 1204 Marie Mount Hall ● 7814 Regents Drive ● College Park, MD 20742 ● 301-405-4212 ● irb@umd.edu CONSENT TO PARTICIPATE Project Title Understanding the Knowledge, Attitudes, and Beliefs about Single Cigarettes: The Impact of “Loosies” Usage among a High-risk Population Purpose of the Study This research is being done by Lilianna Phan, M.S., MPH at the University of Maryland, College Park. You are invited to join this research study because 1) you are African American 2) at least 18 years old 3) live in the District of Columbia or Baltimore City, Maryland 4) and have used loosies at least once in the past 30 days. The purpose of this research study is to understand the opinions and knowledge about cigarettes that are sold individually, which are also called “loosies.” Procedures Participating in this study involves a one-on-one interview where we will have a conversation. The study visit will take about 2 hours to complete. The interview will be recorded with the use of an audio recorder. You will also be asked to complete a short survey about your personal information (such as your age), smoking, how you buy cigarettes, and your use of loosies. Potential Risks and There are no more than minimal risk associated with this study. Discomforts Sometimes, answering questions about your smoking may be uncomfortable. You can choose not to answer a question or you may stop the interview at any time. Just tell the interviewer you want to stop. Potential Benefits You may not receive a direct benefit from participating. We hope that what we find out in this study will help us learn more about the opinions towards loosies. Confidentiality Only the researchers will have access to the data. Any potential loss of confidentiality will be minimized by storing data in a secure location such as: locked office and password protected computer. If we write a report or article about this research project, your identity will be protected to the maximum extent possible. Your information may be shared with representatives of the University of Maryland, College Park or governmental authorities if you or someone else is in danger or if we are required to do so by law. Compensation You will receive $25. You will be responsible for any taxes assessed on the compensation. 150 Right to Withdraw You do not have to be in this research study. You can request to and Questions end the audio recording of the interview at any time. You can agree to be in this study now and change your mind later. If you decide not to be in this study or if you stop participating at any time, you will not be penalized or lose any benefits to which you otherwise qualify. If you decide to stop taking part in the study, if you have questions, concerns, or complaints, or if you need to report an injury related to the research, please contact the investigator: Lilianna Phan, M.S., MPH University of Maryland College Park Department of Behavioral and Community Health 2377 SPH Building #255 College Park, Maryland 20742 LPhan1@umd.edu 443-885-0722 Participant Rights If you have questions about your rights as a research participant or wish to report a research-related injury, please contact: University of Maryland College Park Institutional Review Board Office 1204 Marie Mount Hall College Park, Maryland, 20742 E-mail: irb@umd.edu Telephone: 301-405-0678 This research has been reviewed according to the University of Maryland, College Park IRB procedures for research involving human subjects. Statement of Consent We would like to keep your name and contact information after the For Future Research end of this study so that we can contact you for future research Studies studies. We will store your information in a secure database. To ensure confidentiality, your contact information will be kept in a locked file cabinet and on separate computer files that are password protected at the University of Maryland, School of Public Health, and will be accessible only to Lilianna Phan who will have the password to access the information. Please read each sentence below and think about your choice. Please circle either Yes or No, and then sign your name below. 1. My name and contact information may be kept for future research studies. Yes No 2. My name and contact information may be shared with other researchers who focus on tobacco-related research for future research studies. Yes No If you do not want your name and contact information kept for future research studies, please check here: 151 ____I do not want my name and contact information to be kept in a database for future research studies. Statement of Consent Your signature indicates that you are at least 18 years of age; you have read this consent form or have had it read to you; your questions have been answered to your satisfaction and you voluntarily agree to participate in this research study. You will receive a copy of this signed consent form. If you agree to participate, please sign your name below. Signature and Date NAME OF PARTICIPANT [Please Print] SIGNATURE OF PARTICIPANT DATE 152 C.3. Phase I: Eligibility and Screening Survey Unders tanding the Knowledge, Attitudes, and Beliefs about Single Cigarettes: The Im pact of “Loosies” Usage among a High-risk Population Eligibility and Screening Survey – Interviews [__][__]/[__]__] Date Assessment Completed (MM/DD/YY) /[__][__] Study ID Number: [__][__][__] Eligibility The following questions will help us understand if you are eligible to participate in the study. __________ 1. How did you learn about this research study? 2. How old are you? (INELIGIBLE if age less than 18) Age.........................................................................................number in years [__][__] [__] 3. Do you live here in ________(the District of Columbia or Baltimore City)? No (INELIGIBLE – STOP INTERVIEW) ................................ 0 Yes .................................................................................................. 1 4. I’m going to read a list of racial categories. Which one or more of the following do you [__] consider yourself to be? (INELIGIBLE if race is not African American - STOP INTERVIEW) Black or African American.............................................................0 White .............................................................................................. 1 Asian ............................................................................................... 2 Native American or Other Pacific Islander .................................... 3 American Indian or Alaska Native..................................................4 Other race ....................................................................................... 5 If other, specify_________________________________________ 5. How often have you bought a single cigarette for your use during the past month? [__][__] (INELIGIBLE if never - STOP INTERVIEW) Enter number of loosies .................................................................. Number If eligible: You are eligible to participate in this study. Now, I will share more details about the study with you so that you may ask any questions you might have and can decide whether or not you would like to participate. (Begin the informed consent process.) If ineligible: You are ineligible to participate in this study. Thank you very much for speaking with me and for your time. 153 Socio-Demographics The following questions will help us understand more about individuals who use loosies. 6. What is your current gender identity? [__] Male.................................................................................................0 Female ............................................................................................ 1 Trans male/Trans man .................................................................... 2 Trans female/Trans woman ............................................................ 3 Gender queer/Gender non-conforming...........................................4 Different identity ............................................................................ 5 If different, specify___________________________________ 7. Are you Hispanic, or of Spanish origin? No ................................................................................................... 0 [__] Yes .................................................................................................. 1 8. The next question is about your marital status. Are you now... [__] Married ........................................................................................... 1 Living with a partner ...................................................................... 2 Divorced ......................................................................................... 3 Widowed ........................................................................................ 4 Separated ........................................................................................ 5 Single, that is, never married and not living with a partner ........... 6 Refused ........................................................................................... 9 [__][__][__] 9. What is the highest level of school you have completed? 5th grade or less ............................................................................... 1 6th grade .......................................................................................... 2 7th grade .......................................................................................... 3 8th grade .......................................................................................... 4 9th grade .......................................................................................... 5 10th grade ........................................................................................ 6 11th grade ........................................................................................ 7 12th grade, no diploma .................................................................... 8 GED or equivalent .......................................................................... 9 High school diploma.......................................................................10 Some college, no degree..................................................................11 Certificate, diploma, or associate degree.........................................12 Bachelor’s degree.............................................................................13 Master’s degree................................................................................14 Professional degree (MD, DDS, DVM, LLB, JD)...........................15 Doctoral degree (PhD, EDD)...........................................................16 Refused.............................................................................................999 154 [__] 10. Now I would like to ask about the combined income of everybody who lives with you. Combined income includes income from all sources for all persons in this household, including income from jobs, Social Security, retirement income, public assistance, and all other sources. Less than $400 a month ........................................................ 1 Between $400 and $799 a month ......................................... 2 Between $800 and $1,200 a month ...................................... 3 More than or equal to $1,200 a month ................................. 4 Don’t know ........................................................................... 8 Refused ................................................................................. 9 11. Which of the following describes your current working situation? Working full-time ................................................................. 1 [__] Working part-time ................................................................ 2 Not working/Disabled or unable to work ............................. 3 Not working/Looking for work ............................................ 4 Not working/Not looking for work ....................................... 5 Keeping house or raising children full-time ................................... 6 Student ............................................................................................ 7 Retired ............................................................................................ 8 Refused ........................................................................................... 9 Smoking History 12. Have you smoked at least 100 cigarettes in your entire life? [__] No ................................................................................................... 0 Yes .................................................................................................. 1 Don’t know ..................................................................................... 2 Refused ........................................................................................... 3 [__] 13. Do you consider yourself a smoker? No ................................................................................................... 0 Yes .................................................................................................. 1 [__][__] 14. How old were you when you first started smoking fairly regularly? Enter age. ........................................................................................................ Numbe r 15. Have you ever smoked cigarettes daily? [__] No .................................................................................................. 0 [__] Yes ................................................................................................ 1 16. Do you now smoke cigarettes... Everyday ......................................................................................... 0 Some days ...................................................................................... 1 Not at all ......................................................................................... 2 Refused ........................................................................................... 3 If “everyday,” go to 16; If “some days,” skip to 17. 17. On average, about how many cigarettes do you now smoke each day? [__][__] 155 (A pack usually has 20 cigarettes in it). Less than 1 cigarette ....................................................................... 666 Enter number of cigarettes ........................................................................................................ Numbe r 18. On average, about how many cigarettes do you smoke on days that you smoked? [__][__] (A pack usually has 20 cigarettes in it). Less than 1 cigarette ....................................................................... 666 Enter number of cigarettes ........................................................................................................ Numbe r Nicotine Dependence [__] 19. How soon after you first wake up do you smoke your first cigarette? Within 5 minutes ............................................................................ 1 6 – 30 minutes ................................................................................ 2 31 – 60 minutes .............................................................................. 3 After 60 minutes ............................................................................. 4 Don’t know ..................................................................................... 8 Refused ........................................................................................... 9 20. Do you sometimes wake up at night in order to have a cigarette or other tobacco [__] product? No ................................................................................................... 0 Yes .................................................................................................. 1 Don’t know ..................................................................................... 8 Refused ........................................................................................... 9 21. During the past 30 days, have you had a strong craving to use tobacco products [__] of any kind? No ................................................................................................... 0 Yes .................................................................................................. 1 Don’t know ..................................................................................... 8 Refused ........................................................................................... 9 22. During the past 30 days, did you ever feel like you really needed to use a [__] tobacco product? No ................................................................................................... 0 Yes .................................................................................................. 1 Don’t know ..................................................................................... 8 Refused ........................................................................................... 9 23. During the past 30 days, was there a time when you wanted to use a tobacco [__] product so much that you found it difficult to think of anything else? No ................................................................................................... 0 Yes .................................................................................................. 1 Don’t know ..................................................................................... 8 156 Refused ........................................................................................... 9 24. How true is this statement for you? After not using tobacco for a while, I feel [__] restless and irritable. Would you say... Not at all true .................................................................................. 0 Sometimes true ............................................................................... 1 Often true ........................................................................................ 2 ........................................................................................................ Always true .................................................................................... 3 Don’t know ..................................................................................... 8 Refused ........................................................................................... 9 Cigarette Purchasing Behavior 25. What cigarette brand do you usually buy? [_______] Brand .............................................................................................. Text [__] 26. Are the cigarettes you typically buy non-menthol or menthol? Non-menthol ................................................................................... 0 Menthol .......................................................................................... 1 [__] 27. Do you usually buy cigarettes by the carton, pack or as loosies? Carton ............................................................................................. 1 Pack ................................................................................................ 2 Loosies ........................................................................................... 3 ........................................................................................................ 28. Where do you typically see loosies being sold? [__] Convenience store .......................................................................... 1 Gas station ...................................................................................... 2 Supermarket ................................................................................... 3 ........................................................................................................ Liquor store .................................................................................... 4 Drug store ....................................................................................... 5 Tobacco discount store ................................................................... 6 ........................................................................................................ Another discount store such as Walmart or Costco ....................... 7 [__] Another person ............................................................................... 8 Other ............................................................................................... 9 If other, specify__________________________________ 29. How often have you noticed loosies being sold in the past 30 days? Never .............................................................................................. 0 Rarely ............................................................................................. 1 Sometimes ...................................................................................... 2 Often ............................................................................................... 3 Very often ....................................................................................... 4 30. How often did you feel cravings to smoke upon seeing singles being sold? [__] Never .............................................................................................. 0 Rarely ............................................................................................. 1 Sometimes ...................................................................................... 2 Often ............................................................................................... 3 Very Often ...................................................................................... 4 157 31. How often have you bought loosies in the past month? [__] Rarely ............................................................................................. 1 Sometimes ...................................................................................... 2 Often ............................................................................................... 3 [_______] Very Often ...................................................................................... 4 32. What cigarette brand do you typically buy when purchasing [__].[__][__] loosies? Brand ................................................................................ Text 33. How much do you usually pay for a loosie? Enter cost per loosie [__][__] ........................................................................................................ Numbe r 34. How many loosies do you usually buy at one time? Enter number of loosies................................................................. [__][__] Number 35. How often do you buy loosies to reduce the amount that you smoke? [__] Never .............................................................................................. 0 Rarely ............................................................................................. 1 Sometimes ...................................................................................... 2 Often ............................................................................................... 3 Very Often ...................................................................................... 4 36. The last time you bought single cigarettes for yourself, did you buy them at or [__] from... Convenience store .......................................................................... 1 Gas station ...................................................................................... 2 Supermarket ................................................................................... 3 ........................................................................................................ Liquor store .................................................................................... 4 Drug store ....................................................................................... 5 Tobacco discount store ................................................................... 6 ........................................................................................................ Another discount store such as Walmart or Costco ....................... 7 Another person ............................................................................... 8 Other ............................................................................................... 9 If other, specify__________________________________ Quitting Behavior 37. During the past 12 months, have you stopped smoking for 24 hours or more [__] because you were trying to quit? No ................................................................................................... 0 Yes .................................................................................................. 1 Don’t know ..................................................................................... 2 Refused ........................................................................................... 3 38. Are you thinking of quitting cigarettes for good? [__] No ................................................................................................... 0 Yes .................................................................................................. 1 Don’t know ..................................................................................... 8 158 Refused ........................................................................................... 9 If “yes,” go to 37; If “no,” skip to 38. 39. How soon are you likely to quit smoking? Would you say... [__] Within the next 30 days .................................................................. 1 Within the next 6 months ............................................................... 2 Within the year ............................................................................... 3 Longer than a year .......................................................................... 4 Don’t know ..................................................................................... 8 Refused ........................................................................................... 9 Cigarette Warning Labels 40. How often, if at all, have you seen a health warning on cigarette packs [__] in the past 30 days? Would you say... Rarely ............................................................................................. 1 Sometimes ...................................................................................... 2 Often ............................................................................................... 3 Very Often ...................................................................................... 4 41. How often, if at all, have you thought about the health risks of smoking [__] cigarettes in the past 30 days? Would you say... Rarely ............................................................................................. 1 Sometimes ...................................................................................... 2 Often ............................................................................................... 3 Very Often ...................................................................................... 4 C.4. Phase I: Qualitative Interview Guide 1234 School of Public Health Bldg College Park, Maryland 20742-2611 301.405.2463 TEL 301.314.9167 FAX SCHOOL OF PUBLIC HEALTH Department of Behavioral and Community Health Understanding the Knowledge, Attitudes, and Beliefs about Single Cigarettes: The Impact of “Loosies” Usage among High-risk Populations Interview Guide ___________________________________________________________________________ Study Aims 1. To explore users’ existing attitudes and beliefs about loosies. 2. To assess their knowledge of the potential harms of using loosies. Introduction Thank you for taking the time to speak with me about your use of loosies. As you may know, I am a doctoral candidate at the University of Maryland College Park, School of Public Health. As a part of my dissertation research, I am conducting interviews with individuals like you. You are being asked to participate in this interview because you are African American, 18 years old or older, reside in the District of Columbia or Baltimore City, MD, and have used loosies at least once in the past month. I want to understand African American loosies users’ 159 attitudes, beliefs, and experiences with loosies. Your opinions and ideas are very important to me and will be used to make a scale to measure the use of loosies and recommendations for future smoking cessation programs serving African American smokers. Before we start, I would like to mention that the interview will last about two hours. Also, I will be recording our discussion to ensure that I capture your thoughts and feelings exactly the way that you have stated them, rather than relying on my memory of what was said during our discussion. When our discussion notes are typed up, known as transcripts, I will not include your name or any identifying information. If at any time you feel uncomfortable with a topic of discussion being recorded, please let me know. Ground Rules (1) I will ask you a number of questions that I will need your honest thoughts and ideas. I want to have a conversation where you feel comfortable sharing your thoughts. (2) There are no wrong answers to any of the questions I will pose to you today. (3) More importantly, the information you share during our discussion is confidential, meaning I cannot discuss this conversation with other people. In other words, what is said here stays here. (5) Finally, please speak loudly and clearly so that I are able to hear what you are saying on the recording. Do you have any questions? Ok, let’s get started. If it is ok with you, I’d like to start the recording now. Would that be ok? [start the audio recording] Great. A. Social Context of Using Loosies A.1. Why 1. People use loosies for many different reasons. Tell me why you use loosies. PROBE: To save money PROBE: To cut down on smoking PROBE: To help with quitting A.2. What 2. What makes you buy loosies? PROBE: Cost, convenience, craving a cigarette A.3. When 3. When do you usually buy loosies? PROBE: Morning, afternoon, evening PROBE: When needing a cigarette PROBE: After work, school PROBE: Seeing someone with a cigarette PROBE: When having an urge to smoke. 4. When are loosies typically available in the neighborhood? PROBE: time of day; Day of the week 160 A.4. Where 5. Where do you buy loosies? PROBE: Neighborhood store; What type of store(s)? PROBE: From a neighbor PROBE: On the street A.5. Who 6. Who typically sells loosies? PROBE: Cashier at the store, family member, friend, neighbor. 7. Who typically buys loosies? PROBE: Family members, friends, neighbors. PROBE: Do you have craving when you see loosies being sold? A.6. Social Norms 8. What do others think of loosies? PROBE: Family members, friends, neighbors 9. How does their opinions on loosies influence your behavior? B. Perceived Susceptibility 10. How worried are you that loosies will make you continue to smoke? PROBE: Keep you smoking a few cigarettes or PROBE: keep you from quitting smoking 11. If you quit smoking, how worried are you that loosies could cause you to start smoking again? 12. Some people are concerned about the health consequences of smoking such as developing lung cancer and heart disease. How concerned are you about developing one of these diseases related to smoking? PROBE: What makes you concerned? Not concerned? PROBE: Do you feel that you are at risk for other health conditions? Which ones? C. Perceived Severity 13. How serious is using loosies is to your health? 14. How concerned are you that using loosies could increase your smoking? PROBE: Do you think loosies impact your smoking? 15. In general, how serious is smoking cigarettes to your health? D. Perceived Benefits 16. What are the pros to using loosies? PROBE: low cost; less harm to the body 161 17. What are the pros to not using loosies? PROBE: Better health; less smoke in the house E. Perceived Barriers 18. What are the cons to using loosies? 19. What are the cons to not using loosies? Probe: If you stopped using loosies, what would you miss about them? F. Knowledge 20. What are some ways that loosies can negatively impact your smoking? 21. What can you do to reduce your use of loosies? G. Self-efficacy 22. How confident are you that you can do these strategies (i.e., strategies mentioned in Question 20)? H. Exit Questions We are nearing the end of the interview, and I’m asking for your opinion on recruiting individuals like yourself to answer an online survey. 23. Tell me about how easy or difficult it would be for someone to access an online survey. Probe: What device would you use to complete the survey? Would you prefer completing the survey by phone or online? 24. What are some ways I could reach people to have them complete an online survey? PROBE: Flyers, social media, through their friends. 25. How much time would you be willing to spend on a survey? 26. How much should people be compensated for completing the survey? 27. Before we wrap up, is there anything else you would like to add that I didn’t ask? G. Closing Thank you very much for your time, and sharing your thoughts about loosies. The information you provided will help us understand how to better serve individuals just like yourself. 162 C.5. Phase I: Qualitative Data Analysis Codebook Social Context of Loosie Use Construct Code Description Example(s) Why Accessibility Buying loosies because they are • All over the city. I mean, highly available in one’s built wherever you go, east, environment. west, somebody's selling loose ones. • That's because it's right there, and ... or sometimes, say for instance I'm on, I'm going to the bus stop, and I'm like, "Damn, I forgot to get cigarettes or get a cigarette," and the person at the bus stop is selling them, okay, that saves me the trip from going back across the street, or waiting until I'm getting where I'm going to get them. Why 24/7 Buying loosies because they are • Available pretty much Availability highly available at all times (24 the same amount hours of the day/ 7 days of the regardless of whatever week). time or day. • 24/7 • You can find them all the time. • But Penn North, they has them all day every day. Why Cost Buying loosies because of their • 50 cent is more low monetary cost. convenient. • And it's cheap, I say. • Um, I use loosies because it's a, it's a, a cheaper way, and to, you know, getting your nicotine intake daily. Why Buying loosies 1. Buying loosies due to being • It's like, if you running due to financially limited 2. One would short on money and you economic purchase a pack if it were know you smoke, it's a reasons financially feasible. easier way to keep your habit going. • I'd keep buying until I'm able to just get a pack 163 and I can have the money for a pack. Why Urge to smoke Buying loosie(s) due to • When I'm craving one, desire/craving to smoke. and, um, I'd say when I just see someone selling loose ones, I might just, you know buy a 50 cent or a dollar. Why Manage Buying loosie(s) to maintain a • Then, I don't wanna cigarette certain number of cigarettes whole pack because I consumption smoked per day/prevent increase feel that I shouldn't be in smoking intensity. smoking. • Yeah, see, no, I don't really smoke cigarettes heavy, so I just buy loosies. Why Reduce Buying loosie(s) to reduce the • And also, you know, I'm cigarette number of cigarettes smoked per telling myself that I consumption day over time. really should be quitting so I try to, you know, psychologically put in my mind that, you know, if I'm buying loose ones then I'm not really, you know, buying a whole pack and, you know, killing myself slowly. • And that's another reason, yup. See, really, I'd prefer to stop smoking- smoking. Why Ancillary harm A person leaves their cigarette • Or when I'm trying to reduction pack at home so that their only reduce my cigarette strategy option to acquire cigarettes is to intake, so I just leave my buy loosie(s) which has monetary pack at home. So I only costs and interrupts their day. get to buy loosies. And that's not so convenient but kind of like reduces how much cigarettes I take. Why As a filler Buying loosie(s) until one’s own • I don't have what I cigarette brand of choice or pack normally smoke and I can be purchased. want a cigarette. Why As a booster Buying loosie(s) to enhance the • I use it to, uh, for, for a effects of another drug (e.g., stress reliever and, uh, to marijuana). boost my high when I'm smokin' marijuana. 164 • Um, it just, it just boosts the liquor. • And uh, to go with my drugs when I was using. Why As an Buying loosies when one does not • But once you stop alternative to have access to other drugs (e.g., smoking the marijuana, other drug marijuana) it's like you just gotta smoke something, so the next best thing be that cancer stick. Where Loosies an Loosies are distinct to urban • Um, now you, you urban settings. know, you've got the phenomenon hood, this is the hood, right here. And you might go like, you might go down Pratt street. Pratt in Monroe, right? Where most of the white people at. It depends on what nationality you live with. You understand what I'm saying? So if you live right here in the hood, you can walk from this store to that store, somebody is selling loose ones. You can walk across the street on that corner, and that corner. Somebody ... wherever the most traffic at in the hood, and they selling drugs, that's where the most cigarettes gon be sold. • Basically a lotta, a lotta, uh, places of poverty I could find them, but county areas, suburbs, you're not finding a loose one. When Morning Loosies are typically available • So basically I would get and bought in the morning. them in the morning because like I said, I may not have time to get them. • Mm-hmm (affirmative), yeah, it's easier in the morning and the 165 afternoon, rather than at night. When Afternoon Loosies are typically available • I would say a little bit and bought in the afternoon. after 12 noon. It's easier to find it. He might shift on to somewhere else right. When Evening Loosies are typically available • It's like 8 pm, or and bought in the early whatever, I'll stop by a evening/evening. corner store, or anybody I see outside selling loose ones. From Neighborhood Purchasing loosies or seeing • Um, I gotta store on whom stores loosies sold within neighborhood both ends of my street stores (e.g., convenience stores, that sell loose ones. gas stations, and liquor stores). • Convenience stores, and mostly gas stations. Like if the convenience store's closed, the gas stations. From Strangers/ The act of an individual asking • Yeah, people are on it. whom anyone seen and/or others asking to buy single Uh, I'd say if you work smoking or cigarettes from seeing them around a bunch of with a cigarette smoking or having a pack of smokers don't pull out a pack cigarettes in their hand. pack of cigarettes. People will, uh, typically ask you to buy a loose one. I mean, but if I need the money, I will accept the 50 cent or a dollar. • Like I bought a pack of cigarettes today, and as soon as I bought 'em, somebody bought, uh, four of them. From Individuals/ Purchasing loosies or seeing • You probably see a lot whom People loosies sold from individuals of them, there's, there's standing outside of neighborhood one that are part of the stores, metro stations, or on the metro station, they're in street, etc. there right. • Um, this, this, this lady down there, livin' down my way, yeah. Everybody go to her for the loose ones. From Purchasing Purchasing loosies from family, • I mean, usually it's whom within social friends, or co-workers. friends. Or relatives or networks something like that. 166 How Loosies The manners associated with • Usually they'd be etiquette selling and buying loosies (e.g., howling "loose ones, how sellers should hand loosies to loose ones, loose ones," the buyer). but if you see nobody else and you're walking down, you can say, um, can I buy one of the cigarettes from you. • Oh no, I mean, in the midst of me watching, let's say that they open it from the lid. And they grabbing the cigarette out, and I'm about to purchase that. I might tell them, "Oh, oh, oh, I don't ..." You know, "Don't touch the cigarette." How Social The social appropriateness of • like I said, cigarettes are appropriateness buying loosies from someone vs. expensive... and I don't of purchasing asking to bum a cigarette. wanna say, you know, loosies "Can I get one?" So people don't really ... they don't really people drive people to give you one. You gotta say, "Can I buy it?" People will, uh, typically ask you to buy a loose one. • We used to. We don't ask people for cigarettes no more. How Loosies and Narrative about the social context • When you think of a Convenience of buying loosies from store selling loose ones, Stores convenience stores. you wanna think of, uh, specific store that you know sells loose ones. Because, you know it's illegal, so a lot of, a lot of stores won't do it unless they know your face. So, you have to, I say, you have to really know where to go in terms of stores. How Buyer Buyer prefers to purchase loosies • But yeah, it do, because preferences from individual sellers versus it's like I can go to the inside of neighborhood stores. store and buy 'em for the same price, get the 167 same thing what I paid for, or I can go right here to this person I know they selling obviously because they need the money. The store, y'all gonna make money regardless, so I'mma go here. Health Belief Model for Loosie Use Construct Code Description Example Perceived Increased Perceived risk that • So I think, unless it's really Susceptibility smoking due to loosie use will you know I really feel that loosies increase the urge or strong craving to number of smoke, that's when you cigarettes smoked know, that's when I feel it per day. can, it has made me smoke more. Perceived Maintenance of Perceived risk that • I'm very, I'm very worried. Susceptibility smoking due to loosie use will Seriously. Cause I know that loosies contribute to it ain't getting no better, at persistent smoking least in my mind telling patterns over time. myself if I buy loose ones, it's gonna help me more, but which it is, but it gon continue to keep me smoking for real. Perceived Smoking Perceived risk that • Very worried. It happens Susceptibility relapse due to loosie use will lead every time. With loosies in loosies to a “slip” or particular, and I know I'm relapse. not the only one that goes through this, but every time I try and quit smoking, uh, I go through some type of dramatic event to where I need cigarette. And I'm not gonna buy a pack. Perceived Severity Seriousness of Perceived • I think it's very serious. It's using loosies seriousness of just as serious as a pack to and smoking health harms your health. It is just as, just associated with as serious. 100%. cigarette smoking. Perceived Benefits of Accessibility Perceived positive • And I know I always have loosie use outcomes of loosie access to loosies, especially use from to its in a place like DC. high availability in Whenever I see a group of the built people get up on the street environment. there's always someone selling loosies by the corner, 168 yeah, so it's really accessible then. And it's everywhere, every street corner. • Uh, one, they're convenient because you don't have to search or go far for it. Perceived Benefits of Cost Perceived positive • So I think loosie's are like, loosie use outcomes of loosie that's the only benefit I can use from to its low see is it's economical. monetary cost. • The only benefit is based off what I have in my pocket. I can have the cigarette without having to wait to go buy a pack. Perceived Benefits of Bargain power Perceived positive • You could get just one for 50 loosie use outcomes of loosie cents, or if it's just an use from being individual tell them like hey, able to negotiate I just five cents with me. the cost of a • You know, 25 cent, 35 cent, cigarette. and expect somebody just to give them a loose one 'cause that's what they want. Perceived Benefits of Manage Perceived positive • and that'll kind of like help loosie use consumption outcomes of loosie me somewhat in the long run use from being because I wouldn't be able to manage smoking 11 a day. cigarette consumption. Perceived Benefits of As a booster Perceived positive • Uh, my benefits is, it's loosie use outcomes of loosie boosts my high when I use from being smoke marijuana. able to enhance the effects of another drug (e.g., marijuana). Perceived Benefits of Health hygiene Perceived positive • And you know, if it's a pack reducing loosie use outcomes from of cigarettes you open it by reducing loosie use yourself, you know it's safe, by decreasing it's hygenic, someone hasn't one’s exposure to meddled with it. But if sellers’ poor you're buying it from hygiene practices. someone, some individual on the streets, you don't know where his hands has been to. And yeah, you know, it keeps handling back and forth, you don't know that for real. Perceived Benefits of Contamination Perceived positive • Yeah. I be concerned to see reducing loosie use outcomes from if, um, if they put anything 169 reducing loosie use in the cigarettes that you by decreasing the don't know about, or they risk of buying a tamper with the cigarettes, so contaminated I be pretty concerned and cigarette (e.g., cautious about it. cigarette content mixed with other ingredients such as drugs). Perceived Benefits of Counterfeit Perceived positive • And I wonder, I always was reducing loosie use cigarettes outcomes from curious to find out like, "Is reducing loosie use that really a Newport?" by decreasing the Because it says Newport risks of purchasing because if you know a different cigarettes are marked on the cigarette brand filter as to what they are and than advertised. it's like, "Is that really a Newport or is that something you made?" Perceived Benefits of Surgeon Perceived positive • …get a chance to read the reducing loosie use General health outcomes from warning label to know how warning labels reducing loosie use that this stuff is killing me. by being able to • You probably, you know, see and read the now have the box to read health warning the- the warning label, but label on cigarette that loosie came out of that packs. same box with the warning label on it, so. Self-efficacy to reduce Self-efficacy to One’s confidence • I'm so unconfident. loosie use reduce loosie in their ability to • Oh, I'm very confident. use reduce their purchasing and use of loosies. Self-efficacy to use Self-efficacy to One’s confidence • You mean taking my pack strategies to reduce use strategies in their ability to with me? I can do that. And loosie use use strategies to telling people that I am reduce their quitting smoking for a while, purchase and use I can do that. of loosies. • I'd say like a two. Because if I say if I took, say if I say, "Look, alright I'ma take four cigarettes out this pack." And it'll last me for eight hours. And it don't, then I'm turning round buying loosies. Identified Strategies to Willpower Willpower (e.g., • Well I mean if I have put my reduce loosie use self-control, mind to quitting, then I'm not perseverance) to going to let that, uh, bother reduce loosie use. me. 'Cause I've already put 170 my mind to quit. I'm doing good, and cigarettes is a common thing that you're not going to go without seeing. • I may have the craving- craving, but it's within my willpower, you know, to stop. Like, I, uh, just like with the other thing, um, I've managed that well. Identified Strategies to Quit smoking Quit smoking • Um, you could quit. reduce loosie use altogether to • Yeah, I just try to stop reduce loosie use. smoking all the way around. Identified Strategies to Social Interpersonal • Maybe I just lie to them I've reduce loosie use strategies strategies to reduce quit smoking for a while and loosie use. I hope I can keep it up. Identified Strategies to Behavioral BCT (e.g., • Avoid areas that are selling reduce loosie use cognitive avoiding key loosies and kind of like go therapy (BCT) places, leaving around- cash at home) to • Um... by not carrying change reduce loosie use. on me. Identified Strategies to Nicotine NRT (i.e., patch, • Um, I would probably some reduce loosie use replacement gum, or lozenge) nicotine products, like therapy to reduce loosie nicotine patches or gum. use. 171 Appendix D: Phase II Materials D.1. Expert Review Rating Form Expert Reviewer: Please rate each item on the quality of its clarity, conciseness, grammar, the appropriateness of its reading level (8th grade), face validity, and redundancy with other items. For each set of items under a theoretical construct domain, please rate the set of items on its content validity. Please respond 1 - 5; 1 being very poor, 2 poor, 3 acceptable, 4 good, 5 very good. The following questions are about single cigarettes, which are also called loosies, loose ones, or singles. Please answer the following questions. There are no right or wrong answers. Social Context of Loosie Use Drafted Survey Items Why How often do you buy single cigarettes because... Response scale: 1 to 5 - never, rarely, sometimes, often, very often 1. It is easily accessible. 2. It is cheap. 3. I have a craving to smoke but don’t have enough money to buy a pack. 4. I want to manage the number of cigarettes I smoke. (i.e., to prevent smoking more cigarettes). 5. I want to cut back the number of cigarettes I smoke. 6. I want to quit smoking entirely. How Please indicate how much you agree or disagree with the statement. Response scale: 1 to 5 - strongly disagree, disagree, undecided, agree, strongly agree 1. It bothers me when sellers touch the cigarette that I am buying. 2. It is more socially acceptable to buy a single cigarette than to ‘bum’ a cigarette for free. 3. I can ask to buy a cigarette from a stranger if I see them smoking or they have a pack. 4. I would rather buy single cigarettes from an individual than a store (i.e., gas station, convenience store). 172 Theoretical Construct Clarity Conciseness Grammar Reading Level Face Validity Redundancy Content Validity 5. It is important to use code words (e.g., ‘Laffy Taffy,’ ‘Blow Pop’) when buying single cigarettes from stores. 6. Stores won’t let you buy single cigarettes unless they know you. Where How often do you buy single cigarettes from... Response scale: 1 to 5 - never, rarely, sometimes, often, very often 1. Inside a convenience store. 2. Inside a gas station. 3. Inside a liquor store. 4. Inside a take-out restaurant. 5. From a person standing outside an establishment. 6. From a person on the street in a crowded area. 7. In my neighborhood. 8. In a busy downtown area. From How often do you buy single cigarettes from... Whom Response scale: 1 to 5 - never, rarely, sometimes, often, very often 1. From a stranger I see smoking cigarettes. 2. From a designated ‘loosie’ seller. 3. From a person I know well (e.g., family member, friend, neighbor, co-worker). When How often do you buy single cigarettes... Response scale: 1 to 5 - never, rarely, sometimes, often, very often 1. In the morning. 2. In the afternoon. 3. In the evening. 4. Late at night. 5. When I’m craving a cigarette. 6. When I’m stressed. 7. When I’m bored. 8. To be social (i.e., talking/hanging out with loosie seller) 173 Health Belief Model for Loosie Use Drafted Survey Items Perceived 1. How serious do you believe Severity cigarette smoking is to your health? Response scale: 1 to 5 - not at all serious, a little serious, moderately serious, serious, very serious Perceived Please indicate how much you agree or disagree with the statement. Susceptibility Response scale: 1 to 5 - strongly disagree, disagree, undecided, agree, strongly agree 1. Buying single cigarettes maintains my smoking behavior. 2. Buying single cigarettes makes me feel like I am smoking less than I really am. 3. I am in control of how much I smoke when I buy single cigarettes. 4. Seeing single cigarettes being sold makes me want to smoke. 5. If I quit smoking, I would be worried about single cigarettes. 6. Having single cigarettes available to me makes it difficult for me to quit smoking. Perceived Please indicate how much you agree or disagree with the statement. Benefits Response scale: 1 to 5 - strongly disagree, disagree, undecided, agree, strongly agree If I stopped buying single cigarettes, my chance of... 1. Being exposed to disease causing bacteria would decrease. 2. Buying a laced or contaminated cigarette would decrease. 3. Being able to quit smoking would increase. 4. Being able to stay quit for good would increase. Perceived Please indicate how much you agree or disagree with the statement. Barriers Response scale: 1 to 5 - strongly disagree, disagree, undecided, agree, strongly agree I would find it difficult to give up the... 1. Convenience of buying single cigarettes (e.g., not waiting in line). 2. Low cost of single cigarettes. 174 Theoretical Construct Clarity Conciseness Grammar Reading Level Face Validity Redundancy Content Validity 3. Easy accessibility of single cigarettes. Self-Efficacy Please indicate how likely the statement is for you. Response scale: 1 to 5 - extremely unlikely, unlikely, neutral, likely, extremely likely How likely is it that I can... 1. Tell sellers that I don’t want to buy single cigarettes when they ask me. 2. Refrain from asking other smokers if I can buy single cigarettes from them. 3. Avoid the store or area where I typically buy single cigarettes. 4. Stop carrying change and/or dollar bills in my pocket. 5. Do something else to calm my nerves instead of using single cigarettes. 6. Keep myself busy (e.g., listen to music, read a book) instead of using single cigarettes. 7. Use nicotine replacement therapy (e.g., patch or gum) instead of using single cigarettes. 8. Use my will power to stop buying single cigarettes. 9. Stop buying single cigarettes soon. 10. Easily quit smoking. 11. Easily quit smoking for good. 175 D.2. Phase II: Recruitment Flyer for Pilot Testing Do you buy single cigarettes for your use? (also known as “loosies”) Would you like to take part in a research study to discuss your experience with loosies? If so, The University of Maryland invites YOU to participate! Participants must be: • African American • 18 years of age or older • A resident of D.C. or Baltimore City • Have bought loosies at least once in the past 30 days for your own use • Willing to commit an hour of your time for an in-person interview For your participation in this research study… You will receive a $15 gift card for your time. For more information and to schedule an interview Call: Lil Phan at (443) 885-0722 Brought to you by: The University of Maryland School of Public Health IRB # 1209494-4 176 Research Study About Loosies Call: (443) 885-0722 Research Study About Loosies Call: (443) 885-0722 Research Study About Loosies Call: (443) 885-0722 Research Study About Loosies Call: (443) 885-0722 Research Study About Loosies Call: (443) 885-0722 Research Study About Loosies Call: (443) 885-0722 Research Study About Loosies Call: (443) 885-0722 Research Study About Loosies Call: (443) 885-0722 Research Study About Loosies Call: (443) 885-0722 Research Study About Loosies Call: (443) 885-0722 D.3. Phase II: Informed Consent Form Institutional Review Board 1204 Marie Mount Hall ● 7814 Regents Drive ● College Park, MD 20742 ● 301-405-4212 ● irb@umd.edu CONSENT TO PARTICIPATE Project Title Understanding the Knowledge, Attitudes, and Beliefs about Single Cigarettes: The Impact of “Loosies” Usage among a High-risk Population Purpose of the Study This research is being done by Lilianna Phan, M.S., MPH at the University of Maryland, College Park. You are invited to join this research study because 1) you are African American 2) at least 18 years old 3) live in the District of Columbia or Baltimore City, Maryland 4) and have used loosies at least once in the past 30 days. The purpose of this research study is to learn more about people’s experiences with cigarettes that are sold individually, which are also called “loosies.” Procedures Participating in this study involves completing a survey that asks about your personal information (such as your age), smoking, how you buy cigarettes, and your use and opinions related to loosies. Potential Risks and There are no more than minimal risk associated with this study. Discomforts Sometimes, answering questions about your smoking may be uncomfortable. You can choose not to answer a question or you may stop the survey at any time. Potential Benefits You may not receive a direct benefit from participating. We hope that what we find out in this study will help us learn more about the opinions towards loosies. Confidentiality Only the researchers will have access to the data. Any potential loss of confidentiality will be minimized by storing data in a secure location such as: locked office and password protected computer. If we write a report or article about this research project, your identity will be protected to the maximum extent possible. Your information may be shared with representatives of the University of Maryland, College Park or governmental authorities if you or someone else is in danger or if we are required to do so by law. Compensation You will receive $15. You will be responsible for any taxes assessed on the compensation. Right to Withdraw You do not have to be in this research study. You can request to and Questions end the survey at any time. You can agree to be in this study now and change your mind later. If you decide not to be in this study or if you stop participating at any time, you will not be penalized or lose any benefits to which you otherwise qualify. 177 If you decide to stop taking part in the study, if you have questions, concerns, or complaints, or if you need to report an injury related to the research, please contact the investigator: Lilianna Phan, M.S., MPH University of Maryland College Park Department of Behavioral and Community Health 2377 SPH Building #255 College Park, Maryland 20742 LPhan1@umd.edu 443-885-0722 Participant Rights If you have questions about your rights as a research participant or wish to report a research-related injury, please contact: University of Maryland College Park Institutional Review Board Office 1204 Marie Mount Hall College Park, Maryland, 20742 E-mail: irb@umd.edu Telephone: 301-405-0678 This research has been reviewed according to the University of Maryland, College Park IRB procedures for research involving human subjects. Statement of Consent We would like to keep your name and contact information after the For Future Research end of this study so that we can contact you for future research Studies studies. We will store your information in a secure database. To ensure confidentiality, your contact information will be kept in a locked file cabinet and on separate computer files that are password protected at the University of Maryland, School of Public Health, and will be accessible only to Lilianna Phan who will have the password to access the information. Please read each sentence below and think about your choice. Please circle either Yes or No, and then sign your name below. 1. My name and contact information may be kept for future research studies. Yes No 2. My name and contact information may be shared with other researchers who focus on tobacco-related research for future research studies. Yes No If you do not want your name and contact information kept for future research studies, please check here: ____I do not want my name and contact information to be kept in a database for future research studies. Statement of Consent Your signature indicates that you are at least 18 years of age; you have read this consent form or have had it read to you; your questions have been answered to your satisfaction and you 178 voluntarily agree to participate in this research study. You will receive a copy of this signed consent form. If you agree to participate, please sign your name below. Signature and Date NAME OF PARTICIPANT [Please Print] SIGNATURE OF PARTICIPANT DATE 179 D.4. Phase II: Eligibility and Screening Survey Understanding the Knowledge, Atti tudes, and Beliefs about Single Cig arettes: The Impact of “Loosies” Usage among a High-risk Population Eligibility and Screening Survey – Pilot Testing [__][__]/[__][__]/[__][__] Date Assessment Completed (MM/DD/YY) Study ID Number: [__][__][__] Eligibility The following questions will help us understand if you are eligible to participate in the study. _______ 1. How did you learn about this research study? _ 2. How old are you? (INELIGIBLE if age less than 18) [__][__] Age...................................................................................number in years [__] 3. Do you live here in ________(the District of Columbia or Baltimore City)? No (INELIGIBLE – STOP INTERVIEW) ................................ 0 Yes ................................................................................................. 1 4. I’m going to read a list of racial categories. Which one or more of the following do [__] you consider yourself to be? (INELIGIBLE if race is not African American - STOP INTERVIEW) Black or African American.............................................................0 White .............................................................................................. 1 Asian .............................................................................................. 2 Native American or Other Pacific Islander .................................... 3 American Indian or Alaska Native..................................................4 Other race ....................................................................................... 5 If other, specify_________________________________________ 5. How many times have you bought a single cigarette for your use during [__][__] the past month? (INELIGIBLE if never - STOP INTERVIEW) Enter number of times......................................................Number Enter number of loosies purchased in the past month......Number If eligible: You are eligible to participate in this study. Now, I will share more details about the study with you so that you may ask any questions you might have and can decide whether or not you would like to participate. (Begin the informed consent process.) If ineligible: You are ineligible to participate in this study. Thank you very much for speaking with me and for your time. 180 Socio-Demographics The following questions will help us understand more about individuals who use loosies. 6. What is your current gender identity? [__] Male.................................................................................................0 Female.............................................................................................1 Trans male/Trans man.....................................................................2 Trans female/Trans woman.............................................................3 Gender queer/Gender non-conforming...........................................4 Different identity.... ........................................................................5 If different, specify___________________________________ 7. Are you Hispanic, or of Spanish origin? [__] No ........................................................................................................ 0 Yes ........................................................................................................ 1 8. The next question is about your marital status. Are you now... [__] Married ........................................................................................................ 1 Living with a partner ........................................................................................................ 2 Divorced ........................................................................................................ 3 Widowed ........................................................................................................ 4 Separated ........................................................................................................ 5 Single, that is, never married and not living with a partner ........................................................................................................ 6 Refused ........................................................................................................ 9 181 [__][__][__] 9. What is the highest level of school you have completed? 5th grade or less..........................................................................1 6th grade.....................................................................................2 7th grade.....................................................................................3 8th grade.....................................................................................4 9th grade.....................................................................................5 10th grade...................................................................................6 11th grade...................................................................................7 12th grade, no diploma...............................................................8 GED or equivalent.....................................................................9 High school diploma.................................................................10 Some college, no degree...........................................................11 Certificate, diploma, or associate degree..................................12 Bachelor’s degree......................................................................13 Master’s degree.........................................................................14 Professional degree (MD, DDS, DVM, LLB, JD)....................15 Doctoral degree (PhD, EDD)....................................................16 Refused.................................................................................... 999 182 [__] 10. Now I would like to ask about the combined income of everybody who lives with you. Combined income includes income from all sources for all persons in this household, including income from jobs, Social Security, retirement income, public assistance, and all other sources. Less than $400 a month ....................................................................................................... 1 Between $400 and $799 a month ....................................................................................................... 2 [__] Between $800 and $1,200 a month ....................................................................................................... 3 More than or equal to $1,200 a month ....................................................................................................... 4 Don’t know ....................................................................................................... 8 Refused ....................................................................................................... 9 11. Which of the following describes your current working situation? Working full-time ....................................................................................................... 1 Working part-time ....................................................................................................... 2 Not working/Disabled or unable to work ....................................................................................................... 3 Not working/Looking for work ....................................................................................................... 4 Not working/Not looking for work ....................................................................................................... 5 Keeping house or raising children full-time ....................................................................................................... 6 Student ....................................................................................................... 7 Retired ....................................................................................................... 8 183 Refused ....................................................................................................... 9 Smoking History 12. Have you smoked at least 100 cigarettes in your entire life? [__] No .................................................................................................. 0 Yes ................................................................................................. 1 Don’t know .................................................................................... 2 Refused .......................................................................................... 3 [__] 13. Do you consider yourself a smoker? No .................................................................................................. 0 Yes ................................................................................................. 1 [__][__] 14. How old were you when you first started smoking fairly regularly? Enter age. .......................................................................Number 15. Have you ever smoked cigarettes daily? [__] No ................................................................................................. 0 [__] Yes ................................................................................................ 1 16. Do you now smoke cigarettes... Everyday ........................................................................................ 0 Some days ...................................................................................... 1 Not at all ........................................................................................ 2 Refused .......................................................................................... 3 If “everyday,” go to 16; If “some days,” skip to 17. 17. On average, about how many cigarettes do you now smoke each day? [__][__] (A pack usually has 20 cigarettes in it). Less than 1 cigarette......................................................................666 Enter number of cigarettes.....................................................Number 18. On average, about how many cigarettes do you smoke on days that you [__][__] smoked? (A pack usually has 20 cigarettes in it). Less than 1 cigarette.....................................................................666 Enter number of cigarettes.....................................................Number Nicotine Dependence [__] 18. 19. How soon after you first wake up do you smoke your first cigarette? Within 5 minutes ............................................................................ 1 6 – 30 minutes ................................................................................ 2 31 – 60 minutes .............................................................................. 3 After 60 minutes ............................................................................ 4 Don’t know .................................................................................... 8 Refused .......................................................................................... 9 20. Do you sometimes wake up at night in order to have a cigarette or other [__] tobacco product? No .................................................................................................. 0 Yes ................................................................................................. 1 Don’t know .................................................................................... 8 184 Refused .......................................................................................... 9 20. During the past 30 days, have you had a strong craving to use tobacco [__] products of any kind? No .................................................................................................. 0 Yes ................................................................................................. 1 Don’t know .................................................................................... 8 Refused .......................................................................................... 9 21. During the past 30 days, did you ever feel like you really needed to use a [__] tobacco product? No .................................................................................................. 0 Yes ................................................................................................. 1 Don’t know .................................................................................... 8 Refused .......................................................................................... 9 22. During the past 30 days, was there a time when you wanted to use a [__] tobacco product so much that you found it difficult to think of anything else? No .................................................................................................. 0 Yes ................................................................................................. 1 Don’t know .................................................................................... 8 Refused .......................................................................................... 9 23. How true is this statement for you? After not using tobacco for a while, I [__] feel restless and irritable. Would you say... Not at all true ................................................................................. 0 Sometimes true .............................................................................. 1 Often true ....................................................................................... 2 Always true .................................................................................... 3 Don’t know .................................................................................... 8 Refused .......................................................................................... 9 Cigarette Purchasing Behavior 24. Do you usually buy cigarettes by the carton, pack or as loosies? [__] Carton ............................................................................................ 1 Pack ................................................................................................ 2 Loosies ........................................................................................... 3 25. How often have you bought loosies in the past month? [__] Rarely ............................................................................................. 1 Sometimes ...................................................................................... 2 Often .............................................................................................. 3 Very Often ..................................................................................... 4 26. How many loosies do you usually buy at one time? Enter number of loosies................................................. Number [__][__] 185 27. How often do you buy loosies to reduce the amount that you smoke? [__] Never .............................................................................................. 0 Rarely ............................................................................................. 1 Sometimes ...................................................................................... 2 Often .............................................................................................. 3 Very Often ..................................................................................... 4 28. What cigarette brand do you typically buy when purchasing loosies? [_____] Brand............................................................................Text 29. How much do you usually pay for a loosie? Enter cost per loosie.....................................................Number [__] Quitting Behavior 30. During the past 12 months, have you stopped smoking for 24 hours or more [__] because you were trying to quit? No .................................................................................................. 0 Yes ................................................................................................. 1 Don’t know .................................................................................... 2 Refused .......................................................................................... 3 31. Are you thinking of quitting cigarettes for good? [__] No .................................................................................................. 0 Yes ................................................................................................. 1 Don’t know .................................................................................... 8 Refused .......................................................................................... 9 If “yes,” go to 32. 32. How soon are you likely to quit smoking? Would you say... [__] Within the next 30 days ................................................................. 1 Within the next 6 months ............................................................... 2 Within the year .............................................................................. 3 Longer than a year ......................................................................... 4 Don’t know .................................................................................... 8 Refused .......................................................................................... 9 186 D.5. Phase II: Pilot Testing Interview Guide 1234 School of Public Health Bldg. College Park, Maryland 20742-2611 301.405.2463 TEL 301.314.9167 FAX SCHOOL OF PUBLIC HEALTH Department of Behavioral and Community Health Understanding the Knowledge, Attitudes, and Beliefs about Single Cigarettes: The Impact of “Loosies” Usage among High-risk Populations Pretesting Interview Guide ___________________________________________________________________________ A. Introduction Thank you for taking the time to speak with me about your use of loosies. As you may know, I am a doctoral candidate at the University of Maryland College Park, School of Public Health. As a part of my dissertation research, I am conducting interviews with individuals like you to get your feedback on a survey that I am developing. You are being asked to participate in this interview because you are African American, 18 years old or older, reside in the District of Columbia or Baltimore City, MD, and have used loosies at least once in the past month. I want to get feedback on the survey from your viewpoint, and your opinions and ideas about the survey are very important to me. Information that you provide during this interview will be used to improve the survey and to make recommendations for future smoking cessation programs serving African American smokers. Before we start, I would like to mention that the interview will last about one and a half hours. I will record our discussion to ensure that I capture your thoughts and feelings exactly the way that you have stated them, rather than relying on my memory of what was said. I will not include your name or any identifying information with the recording. If at any time you feel uncomfortable with a topic of discussion being recorded, please let me know. B. Ground Rules I would like to go over a few ground rules. First, I will need your honest thoughts and ideas. I want to have a conversation where you feel comfortable sharing your thoughts. Second, there are no wrong answers the questions that you will respond to during today’s conversation. Third, and more importantly, the information you share during our discussion is confidential, meaning I cannot discuss this conversation with other people. In other words, what is said here stays here. Finally, please speak loudly and clearly so that I am able to hear what you are saying on the recording. C. Instructions Here is the survey that we will review together. [hand participant the scale] To get a better sense of if the survey is performing the way it was intended, I will ask that you read the questions and think aloud while you answer the questions. 187 Do you have any questions? Ok, let’s get started. I’m going to start the recording now.[start the audio recording] D. Probes (when applicable) General: • How did you go about answering that question? • Tell me what you are thinking • I noticed you hesitated before you answered – what were you thinking about? • How easy did you find this question to answer? • How difficult did you find this question to answer? • Tell me why do you say that Comprehension: • What does the question mean to you? • How would you rephrase the question? • What did you understand by X (e.g., question, phrase, term)? Retrieval: • How did you remember that? • Did you have a particular time period in mind? • How did you determine your answer(s)? Confidence/Judgment: • How well do you remember this? • How sure of your answer are you? Response: • How did you feel about answering this question? • Were you able to find your first answer to the question from the response options shown? E. Closing Thank you very much for completing these questions and for sharing your thoughts. Do you have any questions so far? [Answer participant’s questions] Great. I have a few more questions to ask you before we wrap up today’s visit. [Begin rest of survey] 188 D.6. Phase II: Pool of Scale Items for Pilot Testing The following questions are about single cigarettes, which are also called loosies, loose ones, or singles. Please answer the following questions. There are no right or wrong answers. Please indicate how often you buy loosies for the following reasons. Never Rarely Sometimes Often Very Often 1. They are easy to get. 2. They are cheap. 3. I want to smoke but don’t have enough money to buy a pack. 4. I want to control the number of cigarettes I smoke. (i.e., to not smoke too much). 5. I want to cut back the number of cigarettes I smoke. 6. I want to quit smoking entirely. Please indicate how often you buy loosies in the following situations. Never Rarely Sometimes Often Very Often 7. In my neighborhood. 8. Inside a convenience store. 9. Inside a gas station. 10. Inside a liquor store. 11. Inside a take-out restaurant. 12. From a ‘loosie’ seller standing outside an establishment (e.g., stores, restaurants, court houses). 13. From a ‘loosie’ seller on the street in a crowded area (e.g., where people hang out, downtown area). 14. From a stranger I see smoking cigarettes. 15. From a person I know well (e.g., family member, friend, neighbor, co- worker). 16. In the morning. 17. In the afternoon. 18. In the evening. 19. Late at night. 20. When I’m craving a cigarette. 21. When I’m stressed. 22. When I’m bored. 23. When I’m happy. 24. When I drink alcohol. 25. To be social (i.e., talking/hanging out with loosie seller). 189 Please indicate how much you agree or disagree with the statement. Strongly Disagree Undecided Agree Strongly Disagree Agree 26. It is more socially acceptable to buy a loosie than to ‘bum’ a cigarette for free. 27. I would rather buy loosies from a person than from a store (i.e., gas station, convenience store). 28. When I see strangers smoking, I can ask to buy a cigarette from them. 29. It bothers me when sellers touch the cigarette that I am buying. 30. Stores won’t sell you loosies unless they know you. 31. It is important to use code words (e.g., ‘Laffy Taffy,’ ‘Blow Pop’) when buying loosies from stores. 32. Buying loosies makes me feel like I am smoking less than I really am. 33. Buying loosies helps me maintain my smoking behavior. 34. I am in control of how much I smoke when I buy loosies. 35. Seeing loosies being sold makes me want to smoke. 36. Having loosies available to me makes it difficult for me to quit smoking. 37. If I quit smoking, I would be worried about buying loosies. 38. I can stop buying loosies soon. If I stopped buying loosies, it will be hard for me to give up... 39. That loosies are easy to get (i.e., available everywhere and at anytime). 40. The convenience of buying loosies (e.g., not waiting in line). 41. The low cost of loosies. 42. Being able to manage withdrawal symptoms (e.g., cravings, irritability, difficulty concentrating). 43. Being able to smoke without having a pack. The following questions ask about how you are feeling right now. Please indicate how much you agree or disagree that you can do the following things to avoid buying loosies. Strongly Disagree Undecided Agree Strongly Disagree Agree 44. Refuse to buy loosies when a seller offers one to me. 45. Not ask other smokers if I can buy loosies from them. 190 46. Avoid places where I typically buy loosies. 47. Stop carrying change and/or dollar bills in my pocket. 48. Do something else to calm my nerves. 49. Keep myself busy (e.g., listen to music, read a book). 50. Use nicotine replacement therapy (e.g., patch or gum). 51. Use my will power. 52. Quit smoking altogether. If I stopped buying loosies, my chances of... 53. Being exposed to infection would decrease. 54. Buying a laced or contaminated cigarette would decrease. 55. Being able to quit smoking would increase. 56. Being able to stay an ex-smoker for good would increase. Please indicate your response for the following questions. Not at all Slightly Somewhat Very Extremely Harmful Harmful Harmful Harmful Harmful 57. How harmful do you believe cigarette smoking is to your health? 58. Considering everything else that you have going on, how harmful is cigarette smoking in your life? 191 Appendix E: Phase III Materials E.1. Phase III: Recruitment Flyer for Survey Administration Do you buy single cigarettes for your use? (also known as “loosies” or “singles”) Would you like to take part in a research study to complete a survey about loosies? If so, The University of Maryland invites YOU to participate! Participants must be: • African American • 18 years of age or older • A resident of D.C. or Baltimore City • Have bought loosies in the past 30 days for your own use • Willing to commit about 30 minutes Date: Time: Location: For your participation in this research study… You will receive a $15 gift card for your time. For more information call: Lil Phan at (443) 885-0722 Brought to you by: The University of Maryland School of Public Health IRB # 1209494-6 192 E.2. Phase III: Informed Consent Form Institutional Review Board 1204 Marie Mount Hall ● 7814 Regents Drive ● College Park, MD 20742 ● 301-405-4212 ● irb@umd.edu CONSENT TO PARTICIPATE Project Title Understanding the Knowledge, Attitudes, and Beliefs about Single Cigarettes: The Impact of “Loosies” Usage among a High-risk Population Purpose of the Study This research is being done by Lilianna Phan, M.S., MPH at the University of Maryland, College Park. You are invited to join this research study because 1) you are African American 2) at least 18 years old 3) live in the District of Columbia or Baltimore City, Maryland 4) and have used loosies at least once in the past 30 days. The purpose of this research study is to learn more about people’s experiences with cigarettes that are sold individually, which are also called “loosies.” Procedures Participating in this study involves completing a survey that asks about your personal information (such as your age), smoking, how you buy cigarettes, and your use and opinions related to loosies. Potential Risks and There are no more than minimal risk associated with this study. Discomforts Sometimes, answering questions about your smoking may be uncomfortable. You can choose not to answer a question or you may stop the survey at any time. Potential Benefits You may not receive a direct benefit from participating. We hope that what we find out in this study will help us learn more about the opinions towards loosies. Confidentiality Only the researchers will have access to the data. Any potential loss of confidentiality will be minimized by storing data in a secure location such as: locked office and password protected computer. If we write a report or article about this research project, your identity will be protected to the maximum extent possible. Your information may be shared with representatives of the University of Maryland, College Park or governmental authorities if you or someone else is in danger or if we are required to do so by law. Compensation You will receive $15. You will be responsible for any taxes assessed on the compensation. Right to Withdraw You do not have to be in this research study. You can request to and Questions end the survey at any time. You can agree to be in this study now and change your mind later. If you decide not to be in this study or if 193 you stop participating at any time, you will not be penalized or lose any benefits to which you otherwise qualify. If you decide to stop taking part in the study, if you have questions, concerns, or complaints, or if you need to report an injury related to the research, please contact the investigator: Lilianna Phan, M.S., MPH University of Maryland College Park Department of Behavioral and Community Health 2377 SPH Building #255 College Park, Maryland 20742 LPhan1@umd.edu 443-885-0722 Participant Rights If you have questions about your rights as a research participant or wish to report a research-related injury, please contact: University of Maryland College Park Institutional Review Board Office 1204 Marie Mount Hall College Park, Maryland, 20742 E-mail: irb@umd.edu Telephone: 301-405-0678 This research has been reviewed according to the University of Maryland, College Park IRB procedures for research involving human subjects. Statement of Consent We would like to keep your name and contact information after the For Future Research end of this study so that we can contact you for future research Studies studies. We will store your information in a secure database. To ensure confidentiality, your contact information will be kept in a locked file cabinet and on separate computer files that are password protected at the University of Maryland, School of Public Health, and will be accessible only to Lilianna Phan who will have the password to access the information. Please read each sentence below and think about your choice. Please circle either Yes or No, and then sign your name below. 1. My name and contact information may be kept for future research studies. Yes No 2. My name and contact information may be shared with other researchers who focus on tobacco-related research for future research studies. Yes No If you do not want your name and contact information kept for future research studies, please check here: ____I do not want my name and contact information to be kept in a database for future research studies. Statement of Consent Your signature indicates that you are at least 18 years of age; you have read this consent form or have had it read to you; your 194 questions have been answered to your satisfaction and you voluntarily agree to participate in this research study. You will receive a copy of this signed consent form. If you agree to participate, please sign your name below. Signature and Date NAME OF PARTICIPANT [Please Print] SIGNATURE OF PARTICIPANT DATE 195 E.3. Eligibility Screening and Survey Loosies Survey Study ID:__ __ __ __ Date Assessment Completed (MM/DD/YY) __ __ / __ __ / __ __ Site ________________________ Study ID Number __ __ __ __ Eligibility: Thank you for your interest. The following questions will help us understand if you are eligible to participate. 1. How did you learn about this research study? ________________________________ 2. How old are you? (INELIGIBLE if less than 18) ____________________ 3. Do you live here in ___________________________________________(the District of Columbia or Baltimore City)? (INELIGIBLE if not a DC or Bmore Resident) ☐ No ☐ Yes 4. I’m going to read a list of racial categories. Which one or more of the following do you consider yourself to be? (INELIGIBLE if race is not African American - STOP INTERVIEW). ☐ Black or African American ☐ White ☐ Asian ☐ Native American or Other Pacific Islander ☐ American Indian or Alaska Native ☐ Other race If other, specify_________________________________________ 5. During the past 30 days, On how many days have you bought single cigarettes (i.e., “loosies,” “singles,” “jacks,” “loose ones”) for your use? (INELIGIBLE if “0” - Response must be between “1” and “30”) _______ days 6. On the days that you bought loosies, how many times a day do you usually buy loosies? _______ times 7. How many loosies do you usually buy at one time? _______ loosies at one time If eligible: You are eligible to participate in this study. Now, I will share more details about the study with you so that you may ask any questions you might have and can decide whether or not you would like to participate. (Begin the informed consent process.) If ineligible: You are ineligible to participate in this study. Thank you very much for speaking with me and for your time. 196 The following questions will help us understand more about you. Please fill in the circle for the answer that pertains to you. There are no right or wrong answers. We are interested in your honest opinions. 1. Are you Hispanic or of Spanish origin? ¢ No ¢ Yes 2. What is your current gender identity? ¢ Male ¢ Female ¢ Trans male/Trans man ¢ Trans female/Trans woman ¢ Gender queer/Gender non-conforming ¢ Different identity - Please specify___________________________________ 3. The next question is about your marital status. Are you now... ¢ Married ¢ Living with a partner ¢ Divorced ¢ Widowed ¢ Separated ¢ Single, that is, never married and not living with a partner. ¢ Refused 4. What is the highest level of school that you have completed? ¢ 5th grade or less ¢ 12th grade, High school diploma ¢ 6th grade ¢ GED or equivalent ¢ 7th grade ¢ Some college, no degree ¢ 8th grade ¢ College certificate, diploma, associate degree ¢ 9th grade ¢ Bachelor’s degree ¢ 10th grade ¢ Master’s degree ¢ 11th grade ¢ Professional degree (MD, DDS, DVM, LLB, JD) ¢ 12th grade, no diploma ¢ Doctoral degree (PhD, EDD) 5. Including yourself, how many people live with you? ________ people in my household 197 6. Now I would like to ask about the combined income of everybody who lives with you. Combined income includes income from all sources for all persons in this household, including income from jobs, Social Security, retirement income, public assistance, and all other sources. ¢ Less than $400 a month ¢ Between $400 and $799 a month ¢ Between $800 and $1,200 a month ¢ Between $1,201 and $1,600 a month ¢ Between $1,601 and $2,000 a month ¢ Between $1,201 and $1,600 a month ¢ More than or equal to $2,000 a month ¢ Don’t know ¢ Refused 7. Which of the following describes your current working situation? ¢ Working full-time ¢ Working part-time ¢ Not working.... (if “not working” please also select a response below) ☐ Disabled or unable to work ☐ Looking for work ☐ Looking for work ¢ Keeping house or raising children full-time ¢ Student ¢ Retired ¢ Refused The following questions ask about your experiences with cigarette smoking. 8. Have you smoked at least 100 cigarettes in your entire life? ¢ No ¢ Yes 9. Do you consider yourself a smoker? ¢ No ¢ Yes 10. How old were you when you first started smoking fairly regularly? ____________________ years old 11. Have you ever smoked cigarettes daily? ¢ No ¢ Yes 198 12. Do you now smoke cigarettes... ¢ Everyday ¢ Some days 13. On average, about how many cigarettes do you smoke on days that you smoked? ____________________ cigarettes 14. How soon after you first wake up do you smoke your first cigarette? ¢ Within 5 minutes ¢ 6 - 30 minutes ¢ 31 - 60 minutes ¢ After 60 minutes 15. Do you sometimes wake up at night in order to have a cigarette or other tobacco product? ¢ No ¢ Yes 16. During the past 30 days, have you had a strong craving to use a cigarette or other tobacco product? ¢ No ¢ Yes 17. During the past 30 days, did you ever feel like you really needed to use a cigarette or other tobacco product? ¢ No ¢ Yes 18. During the past 30 days, was there a time when you wanted to use a cigarette or other tobacco product so much that you found it difficult to think of anything else? ¢ No ¢ Yes 19. How true is this statement for you? “After not using tobacco for awhile, I feel restless and irritable.” ¢ Not at all true ¢ Sometimes true ¢ Often true ¢ Always true The following questions ask about your experiences with buying cigarettes. 20. What cigarette brand do you usually buy when you can have your choice? _________________________ (name of cigarette brand) 21. Are the cigarettes you usually buy non-menthol or menthol? ¢ Non-Menthol ¢ Menthol 22. Do you usually buy cigarettes by the carton, pack or as loosies? ¢ Carton ¢ Pack ¢ Loosies 23. What cigarette brand do you usually buy when you buy loosies? _________________________ (name of loosie brand) 199 24. How much do you usually pay for a loosie? __. __ __ (cost per loosie) 25. How often have you bought loosies in the past 30 days? ¢ Rarely ¢ Sometimes ¢ Often ¢ Very Often 26. How often have you noticed loosies being sold in the past 30 days? ¢ Rarely ¢ Sometimes ¢ Often ¢ Very Often 27. How often did you feel cravings to smoke upon seeing loosies being sold in the past 30 days? ¢ Never ¢ Rarely ¢ Sometimes ¢ Often ¢ Very Often 28. How often do you buy loosies specifically to reduce the amount that you smoke? ¢ Never ¢ Rarely ¢ Sometimes ¢ Often ¢ Very Often 29. The last time you bought loosies for yourself, did you buy them at or from... ¢ Convenience store Gas station ¢ ¢ Liquor store ¢ Another person ¢ Other - Please specify_________________________________________ 200 The following questions are specifically about single cigarettes, which are also called loosies, loose ones, singles, or jacks. Please check the appropriate box to indicate your answer. DIRECTIONS: Please indicate how often you buy LOOSIES for the following reasons. Never Rarely Sometimes Often Very Often 1. They are easy to get. 2. They are cheaper than a pack. 3. I don’t have enough money to buy a pack. 4. I want to control the number of cigarettes I smoke. 5. I want to quit smoking entirely. DIRECTIONS: Please indicate how often you buy LOOSIES in the following situations. Never Rarely Sometimes Often Very Often 6. Inside a convenience store. 7. Inside a gas station. 8. Inside a liquor store. 9. Inside a take-out restaurant. 10. From a ‘loosie’ seller standing outside an establishment (such as stores, restaurants, or court houses). 11. From a ‘loosie’ seller on the street in a crowded area (such as where people hang out or a downtown area). 12. From a stranger I see smoking cigarettes. 13. From a person I know well (such as family member, friend, neighbor, co-worker). 14. In the morning. 15. In the afternoon. 16. In the evening. 17. Late at night. 18. When I have an urge to smoke. 19. When I’m stressed. 20. When I’m bored. 21. When I’m happy. 22. When I drink alcohol. ☐ N/A - I don’t drink alcohol 23. To socialize with a ‘loosie’ seller. DIRECTIONS: Please indicate how much you agree or disagree with the statement. 201 Strongly Disagree Undecided Agree Strongly Disagree Agree 24. I prefer to buy loosies than to ‘bum’ cigarettes for free. 25. I prefer to buy loosies from a person than from a store (such as a convenience store). 26. I can ask to buy cigarettes from strangers I see smoking. 27. It bothers me when sellers touch the cigarette that I am buying. 28. Stores won’t sell you loosies unless they know you. 29. It is important to use code words (such as ‘Laffy Taffy,’ ‘Blow Pop’) when buying loosies from stores. 30. Buying loosies makes me feel like I am smoking less than I really am. 31. I am in control of how much I smoke when I buy loosies. 32. Seeing loosies being sold makes me want to smoke. 33. Having loosies available to me makes it easier for me to smoke. 34. Having loosies available to me makes it hard for me to quit smoking. 35. If I was trying to quit smoking, I might have temptations to buy a loosie. 36. I can stop buying loosies soon. DIRECTIONS: If I tried to stop buying loosies right now, it would be hard for me to give up... Strongly Disagree Undecided Agree Strongly Disagree Agree 37. That loosies are easy to get. 38. That loosies are cheaper than a pack. 39. The convenience of buying loosies (such as not waiting in line). 40. Being able to smoke without buying a pack. 202 DIRECTIONS: The following questions ask about how you are feeling right now at this very moment. Please indicate how much you agree or disagree that you can do the following things to AVOID BUYING LOOSIES when you want to smoke. Strongly Disagree Undecided Agree Strongly Disagree Agree 41. Avoid buying loosies when I see a loosie seller. 42. Avoid buying or bumming cigarettes from other smokers. 43. Avoid places where I usually buy loosies. 44. Stop carrying change and/or dollar bills in my pocket. 45. Do something else to calm my nerves. 46. Keep myself busy (such as listen to music or read a book). 47. Use nicotine replacement therapy (such as patch or gum). 48. Use my will power. 49. Quit smoking altogether. DIRECTIONS: If I stopped buying loosies, my chances of... Strongly Disagree Undecided Agree Strongly Disagree Agree 50. Being exposed to infection would go down. 51. Buying a contaminated or laced cigarette (such as a ‘dipper’) would go down. 52. Quitting smoking would go up. 53. Staying an ex-smoker would go up. 203 DIRECTIONS: Please indicate your response for the following questions. Not at Slightly Somewhat Very Extremely all Harmful Harmful Harmful Harmful Harmful 54. In general, how harmful is cigarette smoking? 55. Considering everything else you have going on in your life, how harmful is cigarette smoking? The following are some statements about smoking. Please indicate how much you agree or disagree with the statement. Strongly Disagree Undecided Agree Strongly Disagree Agree 1. Smoking is extremely dangerous to my health. 2. Smoking is ruining my health. 3. My cigarette smoke leaves an unpleasant smell. 4. Smoking gives me very bad breath. 5. I spend too much money on cigarettes 6. My cigarette smoke bothers other people a great deal. 7. My second-hand smoke is dangerous to those around me. 8. Smoking is bad for my skin. 9. It bothers me to be dependent on cigarettes. 10. I would have more energy if I did not smoke. 11. A cigarette calms me down when I am stressed. 12. Smoking calms me down when I am upset. 13. A cigarette helps me deal with difficult situations. 14. After a cigarette, I am able to concentrate better. 15. I like the motions of smoking. 16. It feels so good to smoke. 17. I love smoking. 18. I like to hold a cigarette between my fingers. 204 Below are a number of statements about personal attitudes and traits. Please read each item and decide whether the statement is true or false for you. True False 1. It is sometimes hard for me to go on with my work if I am not encouraged. 2. I sometimes feel resentful when I don’t get my own way. 3. On a few occasions, I have given up doing something because I thought too little of my ability. 4. There have been times when I felt like rebelling against people in authority even though I knew they were right. True False 5. No matter who I’m talking to, I’m always a good listener. 6. There have been occasions when I took advantage of someone. 7. I’m always willing to admit it when I make a mistake. 8. I sometimes try to get even, rather than forgive and forget. 9. I am always courteous, even to people who are disagreeable. 10. I have never been irked when people expressed ideas very different from my own. 11. There have been times when I was quite jealous of the good fortune of others. 12. I am sometimes irritated by people who ask favors of me. 13. I have never deliberately said something that hurt someone’s feelings. The following questions ask about your experiences related to quitting smoking. 1. During the past 12 months, have you stopped smoking for 24 hours or smoke because you were trying to quit? ¢ No ¢ Yes 2. How soon are you likely to quit smoking? ¢ Not thinking about quitting smoking right now ¢ Within the next 30 days ¢ Within the next 6 months ¢ Within the year ¢ Longer than a year Thank you very much for your time and participation! 205 E.4. Test-retest Reliability Testing: Eligibility Screening and Survey Loosies Survey - TRT Study ID:__ __ __ __ Date Assessment Completed (MM/DD/YY) __ __ / __ __ / __ __ Site ________________________ Study ID Number __ __ __ __ The following questions will help us understand more about you. Please fill in the blank or circle for the answer that pertains to you. There are no right or wrong answers. We are interested in your honest opinions. 1. Do you now smoke cigarettes... ¢ Everyday ¢ Some days 2. On average, about how many cigarettes do you smoke on days that you smoked? ____________________ cigarettes The following questions ask about your experiences with buying cigarettes. 3. What cigarette brand do you usually buy when you can have your choice? _________________________ (name of cigarette brand) 4. Are the cigarettes you usually buy non-menthol or menthol? ¢ Non-Menthol ¢ Menthol 5. Do you usually buy cigarettes by the carton, pack or as loosies? ¢ Carton ¢ Pack ¢ Loosies 6. What cigarette brand do you usually buy when you buy loosies? _________________________ (name of loosie brand) 7. How much do you usually pay for a loosie? __. __ __ (cost per loosie) 8. How often have you bought loosies in the past 30 days? ¢ Rarely ¢ Sometimes ¢ Often ¢ Very Often 206 The following questions are specifically about single cigarettes, which are also called loosies, loose ones, singles, or jacks. Please check the appropriate box to indicate your answer. DIRECTIONS: Please indicate how often you buy LOOSIES for the following reasons. Never Rarely Sometimes Often Very Often 1. They are easy to get. 2. They are cheaper than a pack. 3. I don’t have enough money to buy a pack. 4. I want to control the number of cigarettes I smoke. 5. I want to quit smoking entirely. DIRECTIONS: Please indicate how often you buy LOOSIES in the following situations. Never Rarely Sometimes Often Very Often 6. Inside a convenience store. 7. Inside a gas station. 8. Inside a liquor store. 9. Inside a take-out restaurant. 10. From a ‘loosie’ seller standing outside an establishment (such as stores, restaurants, or court houses). 11. From a ‘loosie’ seller on the street in a crowded area (such as where people hang out or a downtown area). 12. From a stranger I see smoking cigarettes. 13. From a person I know well (such as family member, friend, neighbor, co-worker). 14. In the morning. 15. In the afternoon. 16. In the evening. 17. Late at night. 18. When I have an urge to smoke. 19. When I’m stressed. 20. When I’m bored. 21. When I’m happy. 22. When I drink alcohol. ☐ N/A - I don’t drink alcohol 23. To socialize with a ‘loosie’ seller. 207 DIRECTIONS: Please indicate how much you agree or disagree with the statement. Strongly Disagree Undecided Agree Strongly Disagree Agree 24. I prefer to buy loosies than to ‘bum’ cigarettes for free. 25. I prefer to buy loosies from a person than from a store (such as a convenience store). 26. I can ask to buy cigarettes from strangers I see smoking. 27. It bothers me when sellers touch the cigarette that I am buying. 28. Stores won’t sell you loosies unless they know you. 29. It is important to use code words (such as ‘Laffy Taffy,’ ‘Blow Pop’) when buying loosies from stores. 30. Buying loosies makes me feel like I am smoking less than I really am. 31. I am in control of how much I smoke when I buy loosies. 32. Seeing loosies being sold makes me want to smoke. 33. Having loosies available to me makes it easier for me to smoke. 34. Having loosies available to me makes it hard for me to quit smoking. 35. If I was trying to quit smoking, I might have temptations to buy a loosie. 36. I can stop buying loosies soon. DIRECTIONS: If I tried to stop buying loosies right now, it would be hard for me to give up... Strongly Disagree Undecided Agree Strongly Disagree Agree 37. That loosies are easy to get. 38. That loosies are cheaper than a pack. 39. The convenience of buying loosies (such as not waiting in line). 208 40. Being able to smoke without buying a pack. DIRECTIONS: The following questions ask about how you are feeling right now at this very moment. Please indicate how much you agree or disagree that you can do the following things to AVOID BUYING LOOSIES when you want to smoke. Strongly Disagree Undecided Agree Strongly Disagree Agree 41. Avoid buying loosies when I see a loosie seller. 42. Avoid buying or bumming cigarettes from other smokers. 43. Avoid places where I usually buy loosies. 44. Stop carrying change and/or dollar bills in my pocket. 45. Do something else to calm my nerves. 46. Keep myself busy (such as listen to music or read a book). 47. Use nicotine replacement therapy (such as patch or gum). 48. Use my will power. 49. Quit smoking altogether. DIRECTIONS: If I stopped buying loosies, my chances of... Strongly Disagree Undecided Agree Strongly Disagree Agree 50. Being exposed to infection would go down. 51. Buying a contaminated or laced cigarette (such as a ‘dipper’) would go down. 52. Quitting smoking would go up. 53. Staying an ex-smoker would go up. DIRECTIONS: Please indicate your response for the following questions. Not at Slightly Somewhat Very Extremely all Harmful Harmful Harmful Harmful Harmful 54. In general, how harmful is cigarette smoking? 209 55. Considering everything else you have going on in your life, how harmful is cigarette smoking? The following are some statements about smoking. Please indicate how much you agree or disagree with the statement. Strongly Disagree Undecided Agree Strongly Disagree Agree 1. Smoking is extremely dangerous to my health. 2. Smoking is ruining my health. 3. My cigarette smoke leaves an unpleasant smell. 4. Smoking gives me very bad breath. 5. I spend too much money on cigarettes 6. My cigarette smoke bothers other people a great deal. 7. My second-hand smoke is dangerous to those around me. 8. Smoking is bad for my skin. 9. It bothers me to be dependent on cigarettes. 10. I would have more energy if I did not smoke. 11. A cigarette calms me down when I am stressed. 12. Smoking calms me down when I am upset. 13. A cigarette helps me deal with difficult situations. 14. After a cigarette, I am able to concentrate better. 15. I like the motions of smoking. 16. It feels so good to smoke. 17. I love smoking. 18. I like to hold a cigarette between my fingers. 210 Below are a number of statements about personal attitudes and traits. Please read each item and decide whether the statement is true or false for you. True False 1. It is sometimes hard for me to go on with my work if I am not encouraged. 2. I sometimes feel resentful when I don’t get my own way. 3. On a few occasions, I have given up doing something because I thought too little of my ability. 4. There have been times when I felt like rebelling against people in authority even though I knew they were right. True False 5. No matter who I’m talking to, I’m always a good listener. 6. There have been occasions when I took advantage of someone. 7. I’m always willing to admit it when I make a mistake. 8. I sometimes try to get even, rather than forgive and forget. 9. I am always courteous, even to people who are disagreeable. 10. I have never been irked when people expressed ideas very different from my own. 11. There have been times when I was quite jealous of the good fortune of others. 12. I am sometimes irritated by people who ask favors of me. 13. I have never deliberately said something that hurt someone’s feelings. Thank you very much for your time and participation! 211 Appendix F: Additional Tables and Figures Table A.3. Phase II: African American Loosie Users Demographics and Smoking History (n = 24) Gender n (%) Male 13 (54.2) Female 11 (45.8) Age (M, SD) (49.0, 12.7) Hispanic ethnicity n (%) 1 (4.2) Yes 23 (95.8) No Race n (%) Black/African American 23 (95.8) Black/African American and other race 1 (4.2) Place of residence n (%) Baltimore, MD 7 (29.2) District of Columbia 17 (70.8) Marital status n (%) Single 16 (66.7) Married or living with a partner 5 (20.8) Divorced or separated 3 (12.5) Education level (Highest completed) n (%) Less than high school 5 (20.8) High school diploma 7 (29.2) GED or equivalent 5 (20.8) Some college or higher 7 (29.2) Employment n (%) Full-time 1 (4.2) Part-time 6 (25.0) Unemployed 16 (66.7) Retired 1 (4.2) Monthly household income n (%) Less than $400 8 (33.3) Between $400 and $799 6 (25.0) Between $800 and $1,200 4 (16.7) More than or equal to $1200 5 (20.8) Smoking status n (%) Daily 15 (62.5) Non-daily 9 (37.5) Number of cigarettes smoked daily (M, SD) Daily 9.9 (4.9) Non-daily 2.5 (2.0) Quit attempt in the last year n (%) Yes 8 (33.3) No 16 (66.7) Intention to quit n (%) Within next 6 months 13 (54.2) Longer than 6 months 6 (25.0) Not interested in quitting 5 (20.8) 212 Table A.4. Phase II: Single Cigarette Acquisition Practices of African American Users (n=24) Typical cigarette acquisition n (%) Pack 6 (25.0) Loosies 18 (75.0) Frequency of buying loosies (past 30 days) Rarely 2 (8.3) Sometimes 4 (16.7) Often 8 (33.3) Very Often 10 (41.7) Frequency of buying loosies to reduce cigarette consumption Never 1 (12.0) Rarely 5 (12.0) Sometimes 5 (32.0) Often 4 (20.0) Very Often 9 (24.0) Number of loosies purchased at one time One loosie 4 (16.7) Two loosies 12 (50.0) Three loosies 1 (4.2) Four loosies 6 (25.0) Six loosies 1 (4.2) Cost per loosie $0.50 cents 10 (41.7) $0.75 cents 10 (41.7) $1.00 2 (8.3) 213 Table A.5. Phase III: Test Retest Reliability for the Social Context of Loosies Scale (n=11) Time 1 Time 2 Social Context Items M (SD) M (SD) k p Please indicate how often you purchase loosies in the following situations. Triggers When I’m stressed. 3.3 (1.3) 3.6 (0.9) 0.30 0.66 When I’m bored. 2.9 (1.4) 3.5 (1.1) 0.30 0.07 When I’m happy. 3.0 (1.3) 3.6 (1.3) 0.30 0.02 Retail Stores Inside a convenient store. 1.8 (1.0) 2.7 (1.4) 0.19 0.25 Inside a gas station. 1.8 (1.1) 2.2 (1.3) 0.55 <.01 Inside a liquor store. 1.7 (1.1) 2.1 (1.2) 0.25 0.15 Harm Reduction I want to control the number of cigarettes I smoke. 3.4 (1.2) 3.3 (0.9) 0.01 0.94 I want to quit smoking entirely. 3.5 (1.5) 3.3 (1.3) 0.85 <.001 Individual Sellers From a ‘loosie’ seller standing outside an establishment (such as stores, restaurants, or court houses). 3.4 (1.3) 2.4 (1.2) 0.32 0.01 From a ‘loosie’ seller on the street in a crowded area (such as where people hang out or a downtown area). 3.5 (1.3) 2.9 (1.0) 0.31 0.07 From a stranger I see smoking cigarettes. 2.9 (1.4) 2.2 (1.3) 0.06 0.66 214 Table A.6. Phase III: Test Retest Reliability for the Health Belief Model for Loosies Scale (n=11) Health Belief Model Items Time 1 Time 2 M (SD) M (SD) k p Perceived Benefits If I tried to stop buying loosies, my chances of… Being exposed to germs would go down. 3.0 (1.3) 3.1 (1.4) 0.30 0.02 Buying a laced cigarette, such as a ‘dipper’ would go down. 2.9 (1.4) 3.3 (1.3) 0.06 0.68 Quitting smoking would go up. 3.0 (1.3) 3.7 (1.0) 0.06 0.71 Staying an ex-smoker would go up. 3.2 (1.3) 3.2 (1.3) 0.18 0.27 Perceived Barriers If I tried to stop buying loosies, it would be hard for me to give up... That loosies are easy to get. 3.9 (1.2) 4.0 (0.8) 0.08 0.66 That loosies are cheaper than a pack. 3.8 (1.3) 4.1 (0.5) 0.11 0.57 The convenience of buying loosies (such as waiting in line). 3.6 (1.3) 3.8 (0.6) 0.15 0.39 Being able to smoke without buying a pack. 3.8 (1.2) 3.9 (1.0) 0.09 0.60 Perceived Severity In general, how harmful is cigarette smoking? 3.9 (1.2) 4.2 (0.6) 0.10 0.51 Considering everything else you have going on in your life, how harmful is 3.9 (1.2) 4.1 (0.9) 0.63 0.74 your cigarette smoking? Perceived Susceptibility Seeing loosies being sold makes me want to smoke. 2.7 (1.5) 3.8 (0.6) 0.22 0.15 Having loosies available to me makes it easier for me to smoke. 3.2 (1.5) 3.8 (0.8) 0.21 0.12 Having loosies available to me makes it hard for me to quit smoking. 3.0 (1.4) 3.6 (1.2) 0.33 0.12 Self-efficacy toward Cognitive Strategies Do something else to calm my nerves. 3.2 (1.4) 3.7 (1.2) 0.12 0.42 Keep myself busy (such as listen to music or read a book). 3.3(1.3) 3.9 (0.8) 0.11 0.48 Use my willpower. 3.2 (1.3) 3.5 (1.2) 0.14 0.32 Quit smoking altogether. 3.3 (1.3) 3.3 (1.1) 0.06 0.66 Self-efficacy toward Behavioral Strategies Avoid buying loosies when I see a loosies seller. 3.1 (1.3) 3.3 (1.1) 0.15 0.40 Avoid buying or bumming cigarettes from other smokers. 3.1 (1.4) 3.4 (1.0) 0.25 0.13 Avoid places where I usually buy loosies. 3.1 (1.3) 3.0 (1.2) 0.01 0.90 215 Bibliography Admon, L., Haefner, J.K., Kolenic, G.E., Chang, T., Davis, M.M., & Moniz, M.H. (2016). Recruiting pregnant patients for survey research: A head to head comparison of social media-based versus clinic-based approaches. J Med Internet Res., 18(12), e326-339. Agurs-Collins, T., Persky, S., Paskett, E. D., Barkin, S. L., Meissner, H. I., Nansel, T. R., Arteaga, S. S., Zhang, X., Das, R., … Farhat, T. (2019). Designing and Assessing Multilevel Interventions to Improve Minority Health and Reduce Health Disparities. American Journal of Public Health, 109(S1), S86-S93. Alexander, L.A., Trinidad, D.R., Sakuma, K.K., Pokhrel, P., Herzog, T.A., Clanton, E.T., ... & Fagan, P. (2016). Why We Must Continue to Investigate Menthol’s Role in the African American Smoking Paradox, Nicotine & Tobacco Research, 18(1), S91- S101, https://doi.org/10.1093/ntr/ntv209 Andrews, J. O., Mueller, M., Newman, S. D., Magwood, G., Ahluwalia, J. S., White, K., & Tingen, M. S. (2014). The Association of Individual and Neighborhood Social Cohesion, Stressors, and Crime on Smoking Status Among African- American Women in Southeastern US Subsidized Housing Neighborhoods. Journal of Urban Health : Bulletin of the New York Academy of Medicine, 91(6), 1158–1174. https://doi.org/10.1007/s11524-014-9911-6 Arnett, J. J., & Brody, G. H. (2008). A fraught passage: The identity challenges of African American emerging adults. Human Development, 51(5-6), 291-293. 216 Ashley, D.L., Backinger, C.L., van Bemmel, D.M., & Neveleff, D.J (2014). Tobacco Regulatory Science: Research to Inform Regulatory Action at the Food and Drug Administration’s Center for Tobacco Products, Nicotine & Tobacco Research, 16(8), 1045–1049. Azjen, I. (1991). The Theory of Planned Behavior. Organizational Behavior and Human Decision Processes, 50(2), 179-211. Balbach, E.D., Gaslor, R.J., & Barbeau (2003). R.J. Reynolds’ Targeting of African Americans: 1988-2000. American Journal of Public Health, 93(5), 822-827. Ballard, R. (1992). Short Forms of the Marlowe-Crowne Social Desirability Scale. Psychological Reports, 71(3), 1155–1160. https://doi.org/10.2466/pr0.1992.71.3f.1155 Baker, C.J., Palmer, S.D., Lee, C.V. (2016). Smoking cessation intervention preferences among urban African Americans: A mixed methods approach. Western Journal of Nursing Research, 38(6): 704-720. Baker, H.M., Lee, J. G. L., Ranney, L. M., & Goldstein, A. O. (2016). Single Cigarette Sales: State Differences in FDA Advertising and Labeling Violations, 2014, United States. Nicotine & Tobacco Research, 18(2), 221– 226. http://doi.org/10.1093/ntr/ntv053 Bauer, G. R., Braimoh, J., Scheim, A. I., & Dharma, C. (2017). Transgender-inclusive measures of sex/gender for population surveys: Mixed-methods evaluation and recommendations. PLoS ONE, 12(5), e0178043. 217 Beck, K. H., Arria, A. M., Caldeira, K. M., Vincent, K. B., O’Grady, K. E., & Wish, E. D. (2008). Social Context of Drinking and Alcohol Problems Among College Students. American Journal of Health Behavior, 32(4), 420–430. https://doi.org/10.5555/ajhb.2008.32.4.420 Beck, K. H., Caldeira, K. M., Vincent, K. B., O’Grady, K. E., Wish, E. D., & Arria, A. M. (2009). The Social Context of Cannabis Use: Relationship to Cannabis Use Disorders and Depressive Symptoms among College Students. Addictive Behaviors, 34(9), 764–768. https://doi.org/10.1016/j.addbeh.2009.05.001 Beck, K. H., & Summons, T. G. (1985). A comparison of the social context for alcohol consumption of college students and convicted DWI offenders. Journal of Alcohol and Drug Education, 30(2), 31–39. Beck, K.H., Thombs, D.L., Mahoney, C.A., & Fingar, K.M. (1995). Social context and sensation seeking: Gender differences in college student drinking motivations. The International Journal of the Addictions, 30(9), 1101-1115. Beck, K.H., Thombs, D.L., & Summons, T.G. (1991). A factor analytic study of social context of drinking in a high school population. Psychology of Addictive Behaviors 5(2), 66.77. Beck, K.H., Thombs, D.L., & Summons, T.G. (1993). The social context of drinking scales: Construct validation and relationship to indicants of abuse in an adolescent population. Addictive Behavior, 18, 159-169. Beck, K.H. & Treiman, K.A. (1996). The relationship of social context of drinking, perceived social norms, and parental influence to various drinking patterns of adolescents. Addictive Behaviors, 21(5), 633-644. 218 Berg, C. J. (2014). Reasons for Nondaily Smoking among Young Adults: Scale Development and Validation. Journal of Smoking Cessation, 9(1), 17–25. http://doi.org/10.1017/jsc.2013.8 Boateng, G. O., Neilands, T. B., Frongillo, E. A., Melgar-Quiñonez, H. R., & Young, S. L. (2018). Best Practices for Developing and Validating Scales for Health, Social, and Behavioral Research: A Primer. Frontiers in Public Health, 6. https://doi.org/10.3389/fpubh.2018.00149 Bourke, B. (2014). Positionality: Reflecting on the Research Process. The Qualitative Report, 19(33), 1-9. Brown-Johnson, C. G., England, L. J., Glantz, S. A., & Ling, P. M. (2014). Tobacco Industry Marketing to Low Socio-economic Status Women in the US. Tobacco Control, 23, e139–e146. Bryne, B.M. (2001). Structural equation modeling with AMOS: Basic concepts, applications, and programming. Mahwah, NJ: Lawrence Erlbaum. Budescu, M., Taylor, R. D., & McGill, R. K. (2011). Stress and African American women’s smoking/drinking to cope: Moderating effects of kin social support. Journal of Black Psychology, 37(4), 452-484. Campbell, J. L., Quincy, C., Osserman, J., & Pedersen, O. K. (2013). Coding In-depth Semistructured Interviews: Problems of Unitization and Intercoder Reliability and Agreement. Sociological Methods & Research, 42(3), 294–320. https://doi.org/10.1177/0049124113500475 Campaign for Tobacco Free Kids. (2018). The Toll of Tobacco on the United States. Retrieved from: https://www.tobaccofreekids.org/problem/toll-us 219 Caraballo, R. S., & Asman, K. (2011). Epidemiology of menthol cigarette use in the United States. Tobacco Induced Diseases, 9(1), S1. http://doi.org/10.1186/1617-9625-9-S1-S1 Carvajal, R., Clissold, D., & Shapiro, J. (2009). The Family Smoking Prevention and Tobacco Control Act: An Overview. Food & Drug L.J., 717. Cattell, R.B. (1966). The Scree Test For The Number Of Factors. Multivariate Behavioral Research, 1(2), 245-276, DOI: 10.1207/s15327906mbr0102_10 Centers for Disease Control and Prevention [CDC]. (2017a). African Americans and Tobacco Use. Retrieved from: https://www.cdc.gov/tobacco/disparities/african-americans/index.htm Centers for Disease Control and Prevention [CDC]. (2016). Current Cigarette Smoking Among Adults—United States, 2005–2015. Morbidity and Mortality Weekly Report, 65(44):1205–11. Centers for Disease Control and Prevention [CDC]. (2009). Cigarette smoking among adults and trends in smoking cessation – United States, 2008. Morbidity and Mortality Weekly Report, 58, 1227-1232. Centers for Disease Control and Prevention [CDC]. (2017b). Cigarette Smoking and Tobacco Use Among People of Low Socioeconomic Status. Retrieved from: https://www.cdc.gov/tobacco/disparities/low-ses/index.htm Centers for Disease Control and Prevention [CDC]. (2011). Quitting Smoking Among Adults --- United States, 2001—2010. Morbidity and Mortality Weekly Report, 60(44);1513-1519. 220 Champion, V.L. (1998). Revised susceptibility, benefits, and barriers scale for mammography screening. Research in Nursing & Health, 22, 341-348. Champion, V.L. & Monahan, P.O. (2008). Measuring mammography and breast cancer beliefs in African American women. Journal of Health Psychology, 13(6), 827-837. https://doi.org/10.1177/1359105308093867 Champion, V.L., & Skinner, C.S. (2008). The Health Belief Model. In Glanz, K., Rimer, B.K., Viswanath, K., Eds. (4th ed). Health Behavior and Health Education: Theory, Research, and Practice. San Francisco: Jossey-Bass. pp. 45-65. Chen, G., Gully, S.M., & Eden, D. (2001). Validation of a New General Self-Efficacy Scale. Organizational Research Methods, 4(1), 62-83. Chen, P., & Jacobson, K. C. (2012). Developmental trajectories of substance use from early adolescence to young adulthood: Gender and racial/ethnic differences. Journal of adolescent health, 50(2), 154-163. Clark, P.I., Gautam, S., & Gerson, L.W. (1996). Effect of menthol cigarettes on biochemical markers of smoke exposure among black and white smokers. Chest. 110(5):1194–1198. Coady, M. H., Chan, C. A., Sacks, R., Mbamalu, I. G., & Kansagra, S. M. (2013). The Impact of Cigarette Excise Tax Increases on Purchasing Behaviors Among New York City Smokers. American Journal of Public Health, 103(6), e54–e60. Cochrane Review, The. (2018). Tobacco Addiction Resources: Key review summaries. Retrieved from: http://tobacco.cochrane.org/resources 221 Collins, D. (2001). Pretesting survey instruments: An overview of cognitive methods. Quality of Life Research, 12, 229-238. Costello, A. B., & Osborne, J. W. (2005). Best Practices in Exploratory Factor Analysis: Four Recommendations for Getting the Most From Your Analysis. Exploratory Factor Analysis, 10(7), 9. Creswell, V. L., Gutmann, M., & Hanson, W. E. (2003). An Expanded Typology for Classifying Mixed Methods Research Into Designs. Handbook of Mixed Methods in Social and Behavioral Research (Tashakkori & Teddlie, 2003). Crowne, D. P., & Marlowe, D. (1960). A new scale of social desirability independent of psychopathology. Journal of Consulting Psychology, 24(4), 349–354. https://doi.org/10.1037/h0047358 Das, S.K. (2003). Harmful health effects of cigarette smoking. Molecular and Cellular Biochemistry, 253(2), 159-165. Debnam, C. (April 25, 2018). Personal phone communication. DeCuir-Gunby, J.T., Marshall, P.L., & McCulloch, A.W. (2011). Developing and using a codebook for the analysis of interview data: An example from a professional development research project. Field Methods, 23(2), 136-155. District of Columbia Tax Rates Changes Take Effect Monday, October 1 | otr. (n.d.). Retrieved February 9, 2019, from https://otr.cfo.dc.gov/release/district- columbia-tax-rates-changes-take-effect-monday-october-1 District Sentinel Radio. (2017, February). Selling Loosies for Snitches [Audio podcast]. Retrieved from: https://soundcloud.com/the-district- sentinel/episode-22217-selling-loosies-for-snitches 222 Dong, Y., & Peng, C.Y. J. (2013). Principled missing data methods for researchers. SpringerPlus, 2, 222. http://doi.org/10.1186/2193-1801-2-222 Estreet, A., Apata, J., Kamangar, F., Schultzman, C., Buccheri, J., O’Keefe, A.,...& Sheikhattari, P. (2017). Improving participants’ retention in a smoking cessation intervention using a community-based participatory research approach. Int J Prev Med, 8(106). Etter, J. F., Humair, J. P., Bergman, M. M., & Perneger, T. V. (2000). Development and validation of the Attitudes Towards Smoking Scale (ATS-18). Addiction (Abingdon, England), 95(4), 613–625. Fagan, P., King, G., Lawrence, D., Petrucci, S.A., Robinson, R.G., Banks, D...& Grana, R. (2004). Eliminating Tobacco-Related Health Disparities: Directions for Future Research. Am J Public Health, 94, 211–217. Fakunle, D.O., Milam, A.J., Furr-Holden, C.D., Butler, J., Thorpe, R.J., LaVeist, T.A. (2016). The inequitable distribution of tobacco outlet density: The role of income in two Black mid-atlantic geopolitical area. Public Health, 136, 35-40. Francis, J.J., Johnston, M. Robertson, C., Glidewell, L., Entwistle, V., Eccles, M.P., & Grimshaw, J.M. (2009). What is an adequate sample size? Operationalising data saturation for theory-based interview studies, Psychology & Health, 25(10), 1229-1245. Freedman, K. S., Nelson, N. M., & Feldman, L. L. (2012). Smoking initiation among young adults in the United States and Canada, 1998-2010: a systematic review. Preventing chronic disease, 9. 223 Gale, N.K., Heath, G., Cameron, E., Rashid, S., Redwood, S. (2013). Using the framework method for the analysis of qualitative data in multi-disciplinary health research. BMC Medical Research Methodology, 13: 117. Gardiner, P.S. (2004). The African Americanization of menthol cigarette use in the United States, Nicotine & Tobacco Research, 6(1), S55–S65. Geronimus, A. T., Neidert, L. J., & Bound, J. (1993). Age patterns of smoking in US black and white women of childbearing age. American Journal of Public Health, 83(9), 1258-1264. Ghasemi, A., & Zahediasl, S. (2012). Normality Tests for Statistical Analysis: A Guide for Non-Statisticians. International Journal of Endocrinology and Metabolism, 10(2), 486–489. https://doi.org/10.5812/ijem.3505 Gill, P., Stewart, K., Treasure, E., & Chadwick, B. (2008). Methods of data collection in qualitative research: interviews and focus groups. British Dental Journal, 204(6), 291–295. https://doi.org/10.1038/bdj.2008.192 Gittlesohn, J., Roche, K.M., Alexander, C.S., Tassler, Patsy. (2001). The social context of smoking among African-American and white adolescents in Baltimore City. Ethn Health, 6(3-4):211-25. Glanz, K. & Bishop, D.B. (2010). The role of behavioral science theory in development and implementation of public health interventions. Annu Rev Public Health, 31, 399-418. Glanz, K., Rimer, B.K., Viswanath, K. (2015). Health Behavior: Theory, Research, and Practice. San Francisco, CA. Jossey-Bass. 224 Gong, Y., Palmer, S., Gallacher, J., Marsden, T., Fone, D. (2016). A Systematic Review of the Relationship between Objective Measurements of the Urban Environment and Psychological Distress. Environment International, 96, 48- 57. https://doi.org/10.1016/j.envint.2016.08.019 Guillory, J., Johns, M., Farley, S. M., & Ling, P. M. (2015). Loose Cigarette Purchasing and Nondaily Smoking Among Young Adult Bar Patrons in New York City. American Journal of Public Health, 105(8), e140–e147. http://doi.org/10.2105/AJPH.2014.302518 Hall, M.G., Fleischer, N.L., Reynales-Shigematsu, L.M., Arillo-Santillan, E., & Thrasher, J.F. (2015). Increasing availability and consumption of single cigarettes: Trends and implications for smoking cessation from the ITC Mexico survey. Tobacco Control, 24, iii64-iii70. Hatchett, B. F., Holmes, K., Duran, D. A., & Davis, C. (2000). African Americans and Research Participation. Journal of Black Studies, 30(5), 664-675. Heatherton TF, Kozlowski LT, Frecker RC, Fagerstrom KO (1991). The Fagerstrom Test for Nicotine Dependence: a revision of the Fagerstrom Tolerance Questionnaire. Br J Addict, 86:1119-27. Helms, V. E., King, B. A., & Ashley, P. J. (2017). Cigarette smoking and adverse health outcomes among adults receiving federal housing assistance. Preventive Medicine, 99, 171–177. https://doi.org/10.1016/j.ypmed.2017.02.001 225 Henson, R. K., & Roberts, J. K. (2006). Use of Exploratory Factor Analysis in Published Research: Common Errors and Some Comment on Improved Practice. Educational and Psychological Measurement, 66(3), 393–416. https://doi.org/10.1177/0013164405282485 Hiscock, R., Bauld, L., Amos, A., Fidler, J.A., & Munafò, M. (2012). Socioeconomic status and smoking: a review. Ann N Y Acad Sci., 1248:107-23. Hochbaum, G. M. (1958). Public Participation in Medical Screening Programs: a socio-psychological study. US Department of Health, Education, and Welfare, Public Health Service, Bureau of State Services, Division of Special Health Services, Tuberculosis Program. Hochbaum, G., Rosenstock, I., & Kegels, S. (1952). Health belief model. United States Public Health Service, W432W8784. Holt, C. L., Clark, E. M., Roth, D., Crowther, M., Kohler, C., Fouad, M., Southward, P. L. (2009). Development and Validation of Instruments to Assess Potential Religion-Health Mechanisms in an African American Population. The Journal of Black Psychology, 35(2), 271–288. https://doi.org/10.1177/0095798409333593 Hood E. (2005). Dwelling disparities: how poor housing leads to poor health. Environmental health perspectives, 113(5), A310-7. Husten, C. G. (2009). How should we define light or intermittent smoking? Does it matter? Nicotine & Tobacco Research, 11(2), 111–121. http://doi.org/10.1093/ntr/ntp010 226 Husten, C.G. & Deyton, L.R. (2013). Understanding the Tobacco Control Act: efforts by the U.S. Food and Drug Administration to make tobacco-related morbidity and mortality part of the USA's past, not its future. Lancet, 381(9877), 1570- 80. Inoue-Choi, M., Liao, L. M., Reyes-Guzman, C., Hartge, P., Caporaso, N., & Freedman, N. D. (2017). Association of Long-term, Low-Intensity Smoking With All-Cause and Cause-Specific Mortality in the National Institutes of Health–AARP Diet and Health Study. JAMA Internal Medicine, 177(1), 87– 95. Jager, J., Putnick, D. L., & Bornstein, M. H. (2017). More than Just Convenient: The Scientific Merits of Homogeneous Convenience Samples. Monographs of the Society for Research in Child Development, 82(2), 13–30. http://doi.org/10.1111/mono.12296 Jha, P., Ramasundarahettige, C., Landsman, V., Rostron, B., Thun, M., Anderson, R.N...Peto, R. (2013). 21st-Century Hazards of Smoking and Benefits of Cessation in the United States. N Engl J Med, 368, 341-350. Jeffries, S. K., Choi, W., Butler, J., Harris, K. J., & Ahluwalia, J. S. (2005). Strategies for recruiting African-American residents of public housing developments into a randomized controlled trial. Ethnicity and Disease, 15(4), 773. Jemmott III, J., Jemmott, L., & Fong, G. (1998). Abstinence and safer sex HIV risk Reduction interventions for African American adolescents: A randomized controlled trial. Jama: The Journal of the American Medical Association, 279(19), 1529. 227 Jones, R. A., Steeves, R., & Williams, I. (2009). Strategies for Recruiting African American Men into Prostate Cancer Screening Studies. Nursing Research, 58(6), 452–456. https://doi.org/10.1097/NNR.0b013e3181b4bade Kaiser, H.F. (1970). A second generation Little Jiffy. Psychometrika, 35, 401-415. Kandel, D.B. (1995). Ethnic differences in drug use. In G.J. Botvin, S. Schinke, & M.A. Orlandi (Eds.), Drug abuse prevention with multiethnic youth. (pp. 81– 105). Thousand Oaks: Sage. Kandel, D., Schaffran, C., Hu, M. C., & Thomas, Y. (2011). Age-related differences in cigarette smoking among whites and African-Americans: evidence for the crossover hypothesis. Drug & Alcohol Dependence, 118(2), 280-287. Kang, H. (2013). The prevention and handling of the missing data. Korean Journal of Anesthesiology, 64(5), 402–406. http://doi.org/10.4097/kjae.2013.64.5.402 Keller, P. A., Feltracco, A., Bailey, L. A., Li, Z., Niederdeppe, J., Baker, T. B., & Fiore, M. C. (2010). Changes in Tobacco Quitlines in the United States, 2005- 2006. Preventing Chronic Disease, 7(2), A36. Kendall, L. (2014). The Conduct of Qualitative Interviews: Research Questions, Methodological Issues, and Researching Online. https://doi.org/10.4324/9781410618894-13 Keyes, K. M., Vo, T., Wall, M. M., Caetano, R., Suglia, S. F., Martins, S. S., ... & Hasin, D. (2015). Racial/ethnic differences in use of alcohol, tobacco, and marijuana: is there a cross-over from adolescence to adulthood?. Social Science & Medicine, 124, 132-141. 228 Kim, E. (2014). Gov. Cuomo on Eric Garner: 'If people don’t trust the justice system, you have a problem'. Retrieved from: http://www.today.com/news/new-york-gov-cuomo-eric-garner-if-people-dont- trust-1D80339939 Kirchner, T.R., Villanti, A.C., Cantrell, J., Anesetti-Rothermel, A., Ganz, O., Conway, K.P….& Abrams, D.B. (2015). Tobacco retail outlet advertising practices and proximity to schools, parks and public housing affect Synar underage sales violations in Washington, DC. Tobacco Control, 24, e52-e58. Krause, N. (2002). A Comprehensive Strategy for Developing Closed-Ended Survey Items for Use in Studies of Older Adults. The Journals of Gerontology: Series B, 57(5), S263–S274. https://doi.org/10.1093/geronb/57.5.S263 Kulak, J.A., Cornelius, M.E., Fong, G.T. Giovino, G.A. (2016). Differences in Quit Attempts and Cigarette Smoking Abstinence Between Whites and African Americans in the United States: Literature Review and Results From the International Tobacco Control US Survey. Nicotine & Tobacco Research, 18(1), S79–S87. Lacey, L.P., Manfredi, C., Balch, G., Warnecke, R.B., Allen, K., & Edwards, C. (1993). Social support in smoking cessation among black women in Chicago public housing. Public Health Reports, 108(3), 387-394. Lambert, S.F., Brown, T.L., Phillips, C.M., & Ialongo, N.S. (2004). The relationship between perceptions of neighborhood characteristics and substance use among urban African American adolescents. American Journal of Community Psychology, 34(4), 205-218. 229 Lampe, K., Kurti, M., Johnson, J., & Rengifo, A. (2016). “I Wouldn’t Take My Chances on the Street”: Navigating Illegal Cigarette Purchases in the South Bronx. Journal of Research in Crime and Delinquency, 53(5), 654-680. Latkin, C., Murray, L., Smith, K. M. C., Cohen, J., & Knowlton, A. R. (2013). The prevalence and correlates of single cigarette selling among urban disadvantaged drug users in Baltimore, Maryland. Drug and Alcohol Dependence, 132(3), 466–470. http://doi.org/10.1016/j.drugalcdep.2013.03.007 Little, R.J.A. (1988). A Test of Missing Completely at Random for Multivariate Data with Missing Values. Journal of the American Statistical Association, 83:404, 1198-1202, DOI: 10.1080/01621459.1988.10478722 Liu, X., Li, R., Lanza, S. T., Vasilenko, S., & Piper, M. (2013). Understanding the Role of Cessation Fatigue in the Smoking Cessation Process. Drug and Alcohol Dependence, 133(2), 548–555. http://doi.org/10.1016/j.drugalcdep.2013.07.025 Lee, J. G. L., Henriksen, L., Rose, S. W., Moreland-Russell, S., & Ribisl, K. M. (2015). A Systematic Review of Neighborhood Disparities in Point-of-Sale Tobacco Marketing. American Journal of Public Health, 105(9), e8–e18. http://doi.org/10.2105/AJPH.2015.302777 Lee, D., Turner, N., Burns, J., & Lee, T. (2007). Tobacco use and low-income African Americans: policy implications. Addict Behav., 32(2):332-41. 230 Levinson, A. H. (2017). Where the U.S. tobacco epidemic still rages: Most remaining smokers have lower socioeconomic status. Journal of Health Care for the Poor and Underserved, 28(1), 100–107. Marshall, L.L., Zhang, L., Malarcher, A.M., Mann, N.H., King, B.A., & Alexander, R.L. (2017). Race/Ethnic Variations in Quitline Use Among US Adult Tobacco Users in 45 States, 2011–2013, Nicotine & Tobacco Research, 72(12), 1473–1481, https://doi.org/10.1093/ntr/ntw281 Maryland Resource Center for Quitting. Health Belief Model. Retrieved from: https://mdquit.org/health-behavior-models/health-belief-model Matthews, A.K., Sanchez-Johnson, L., King, A. (2009). Development of a culturally targeted smoking cessation intervention for African American smokers. J Community Health, 34: 480-492. https://doi.org/10.1007/s10900-009-9181-5 McLeroy, K. R., Bibeau, D., Steckler, A., & Glanz, K. (1988). An ecological perspective on health promotion programs. Health education quarterly, 15(4), 351-377. Meehan, S. (2016). Crime Roundup: Man Shot After Argument in Northeast Capitol Hill Saturday Night. Retrieved from: https://www.hillnow.com/2016/05/16/crime- roundup-man-shot-after- argument-in-northeast-capitol-hill-saturday-night/ Mennis, J. & Mason, M. (2016). Tobacco outlet density and attitudes towards smoking among urban adolescent smokers. Substance Abuse, 37(4):521-525. Moon-Howard, J. (2003). African American women and smoking: starting later. American Journal of Public Health, 93(3), 418-420. 231 Mukaka, M. (2012). A guide to appropriate use of Correlation coefficient in medical research. Malawi Medical Journal : The Journal of Medical Association of Malawi, 24(3), 69–71. National Center for Chronic Disease Prevention and Health Promotion. (2014). The Health Consequences of Smoking—50 Years of Progress: A Report of the Surgeon General. Atlanta (GA): Centers for Disease Control and Prevention (US). Retrieved from http://www.ncbi.nlm.nih.gov/books/NBK179276/ Newman, D. (2014). Missing Data. Organizational Research Methods, 17(4), 372- 411. http://doi.org/10.1177/1094428114548590 Noar, S.M. & Zimmerman, R.S. (2005). Health behavior theory and cumulative knowledge regarding health behaviors: are we moving in the right direction? Health Educ Res., 20(3), 275-90. Norman, P., Conner, M., & Bell, R. (1999). The theory of planned behavior and smoking cessation. Health Psychology, 18(1), 89-94. Office of Disease Prevention and Health Promotion. (2016). Tobacco Use. In Healthy People 2020. Retrieved from: https://www.healthypeople.gov/2020/topics- objectives/topic/tobacco-use Okuyemi, K. S., Cox, L. S., Nollen, N. L., Snow, T. M., Kaur, H., Choi, W., … Ahluwalia, J. S. (2007). Baseline characteristics and recruitment strategies in a randomized clinical trial of African-American light smokers. American Journal of Health Promotion: AJHP, 21(3), 183–191. https://doi.org/10.4278/0890-1171-21.3.183 232 Okuyemi, K. S., Ebersole-Robinson, M., Nazir, N., & Ahluwalia, J. S. (2004). African-American menthol and nonmenthol smokers: differences in smoking and cessation experiences. Journal of the National Medical Association, 96(9), 1208–1211. Pampel, F. C. (2008). Racial convergence in cigarette use from adolescence to the mid-thirties. Journal of Health and Social Behavior, 49(4), 484. Park, M.S., Kang, K.J., Jang, S.J., Lee, J.Y., & Chang, S.J. (2017). Evaluating test- retest reliability in patient-record outcome measures for older people: A systematic review. International Journal of Nursing Studies, 79, 58-69. Perneger, T.V., Courvoisier, D.S., Hudelson, P.M., & Gayet-Ageron, A. (2015). Sample size for pre-tests of questionnaires. Qual Life Res. 24(1), 147-51. Poland, B., Frohlich, K., Haines, R. J., Mykhalovskiy, E., Rock, M., & Sparks, R. (2006). The social context of smoking: the next frontier in tobacco control? Tobacco Control, 15(1), 59–63. https://doi.org/10.1136/tc.2004.009886 Portney LG, Watkins MP (2000) Foundations of clinical research: Applications to practice. Upper Saddle River, NJ: Prentice Hall. Quinn, S. C., Garza, M. A., Butler, J., Fryer, C. S., Casper, E. T., Thomas, S. B., … Kim, K. H. (2012). Improving Informed Consent with Minority Participants: Results from Researcher and Community Surveys. Journal of Empirical Research on Human Research Ethics : JERHRE, 7(5), 44–55. https://doi.org/10.1525/jer.2012.7.5.44 233 Rabius, V., Wiatrek, D., & McAlister, A. L. (2012). African American Participation and Success in Telephone Counseling for Smoking Cessation. Nicotine & Tobacco Research, 14(2), 240–242. http://doi.org/10.1093/ntr/ntr129 Resnicow, K., Baranowski, T., Ahluwalia, J. S., & Braithwaite, R. L. (1999). Cultural sensitivity in public health: defined and demystified. Ethnicity & Disease, 9(1), 10–21. Resnicow, K., Soler, R., Braithwaite, R. L., Ahluwalia, J. S., & Butler, J. (2000). Cultural sensitivity in substance use prevention. Journal of Community Psychology, 28(3), 271-290. Ritchie, J., Lewis, J., Lewis, P. of S. P. J., Nicholls, C. M., & Ormston, R. (2013). Qualitative Research Practice: A Guide for Social Science Students and Researchers. SAGE. Robinson, O. C. (2014). Sampling in Interview-Based Qualitative Research: A Theoretical and Practical Guide. Qualitative Research in Psychology, 11(1), 25–41. https://doi.org/10.1080/14780887.2013.801543 Romano, P. S., Bloom, J., & Syme, S. L. (1991). Smoking, social support, and hassles in an urban African-American community. American Journal of Public Health, 81(11), 1415–1422. Rosenstock, I.M. (1974). Historical origins of the Health Belief Model. Health Education & Behavior, 2(4), 328. Rosenstock, I.M., Stretcher, V.J., & Becker, M.H. (1988). Social learning theory and the Health Belief Model. Health Educ Q, 15(2)175-83. 234 Rosenstock, I. M., Stretcher, V. S., & Becker, M. H. (1994). Developing effective behavior change interventions. University of Illinois: Fishbein M, 3. Sacks, R., Coady, M.H., Mbamalu, I.G., Johns, M., & Kansagra, S.M. (2012). Exploring the next frontier for tobacco control: Nondaily smoking among New York City adults. Journal of Environmental and Public Health, doi: 10.1155/2012/145861 Saenz de Miera, B., Thrasher, J.F., Chaloupka, F.J., Watters, H., Hernandez-Avila, M., & Fong, G.T. (2010). Self-reported price, consumption and brand switching of cigarettes in a cohort of Mexican smokers before and after a cigarette tax increase. Tobacco Control, 19(6): 481–487. Sankaré, I. C., Bross, R., Brown, A. F., del Pino, H. E., Jones, L. F., Morris, D. M., … Kahn, K. L. (2015). Strategies to Build Trust and Recruit African American and Latino Community Residents for Health Research: A Cohort Study. Clinical and Translational Science, 8(5), 412–420. https://doi.org/10.1111/cts.12273 Schafer, J.L. (1999). Multiple imputation: a primer. Stat Methods in Med., 8(1):3–15. Schane, R. E., Ling, P. M., & Glantz, S. A. (2010). Health Effects of Light and Intermittent Smoking: A Review. Circulation, 121(13), 1518–1522. http://doi.org/10.1161/CIRCULATIONAHA.109.904235 Schleyer, T. K. L., & Forrest, J. L. (2000). Methods for the Design and Administration of Web-based Surveys. Journal of the American Medical Informatics Association: JAMIA, 7(4), 416–425. 235 Schwab, D.P. (1980). Construct validity in organizational behavior. In B.M. Staw & L.L. Cummings (eds.) Research in Organizational Behavior, 2, 3-43. Greenwich, CT: JAI Press. Schneider, J.E., Reid, R.J., Peterson, N.A., Lowe, J.B, & Hughey, J. (2005).Tobacco outlet density and demographic at the tract level analysis in Iowa: Implications for environmentally based prevention initiatives. Prev Sci, 6(4), 319-25. Sharma, E., Beck, K. H., & Clark, P. I. (2013). Social Context of Smoking Hookah Among College Students: Scale Development and Validation. Journal of American College Health, 61(4), 204–211. Shuaib, F., Foushee, H. R., Ehiri, J., Bagchi, S., Baumann, A., & Kohler, C. (2011). Smoking, sociodemographic determinants, and stress in the Alabama Black Belt. The Journal of Rural Health: Official Journal of the American Rural Health Association and the National Rural Health Care Association, 27(1), 50–59. https://doi.org/10.1111/j.1748-0361.2010.00317.x Sherer, M., Maddux, J.E., Mercandante, B., Prentice-Dunn, S., Jacobs, B., & Rogers, R.W. (1982). The Self-Efficacy Scale: Construction and Validation. Psychological Reports, 51(2), 663-671. Smith, K., C., Stillman, F., Bone, L., Yancey, N., Price, E., Belin, P., & Kromm, E.E. (2007). Buying and selling “loosies” in Baltimore: The informal exchange of cigarettes in the community context. Journal of Urban Health: Bulletin of the New York Academy of Medicine, 4(84), 494-507. 236 Stahre, M., Okuyemi, K.S., Joseph, A.M., & Fu, S.S. (2010). Racial/ethnic differences in menthol cigarette smoking, population quit ratios and utilization of evidence-based tobacco cessation treatments. Addiction, 105 (1), 75-83. Stillman, F.A., Bone, L. R., Milam, A.J., Ma, J., Hoke, K. (2014). Out of view but in plain sight: The illegal sale of single cigarettes. Journal of Urban Health: Bulletin of the New York Academy of Medicine, 2(91), 355-365. Stillman, F. A., Bone, L., Avila-Tang, E., Smith, K., Yancey, N., Street, C., et al. (2007). Barriers to smoking cessation in inner-city African American young adults. American Journal of Public Health, 97,1405-1408. http://dx.doi.org/10.2105/AJPH.2006,101659 Strasser, A.A., Ashare, R.L., Kaufman, M, et al. (2013). The effect of menthol on cigarette smoking behaviors, biomarkers and subjective responses. Cancer Epidemiol Biomarkers Prev., 22(3):382–389. Struik, L. L., & Baskerville, N. B. (2014). The Role of Facebook in Crush the Crave, a Mobile- and Social Media-Based Smoking Cessation Intervention: Qualitative Framework Analysis of Posts. Journal of Medical Internet Research, 16(7), e170. http://doi.org/10.2196/jmir.3189 Sudhinaraset, M., Wigglesworth, C., & Takeuchi, D. T. (2016). Social and Cultural Contexts of Alcohol Use. Alcohol Research : Current Reviews, 38(1), 35–45. Tabachnick, B.G., & Fidell, L.S. (2001). Using multivariate Statistics. Boston: Allyn and Bacon. 237 Taylor, T., Kamarck, T., & Shiffman, S. (2004). Validation of the detroit area study discrimination scale in a community sample of older african american adults: The Pittsburgh healthy heart project. International Journal of Behavioral Medicine, 11(2), 88-94. doi:10.1207/s15327558ijbm1102_4 Tavakol, M., & Dennick, R. (2011). Making sense of Cronbach’s alpha. International Journal of Medical Education, 2, 53–55. http://doi.org/10.5116/ijme.4dfb.8dfd Thomas, S.B. & Quin, S.C. (2008). Poverty and Elimination of Urban Health Disparities: Challenge and Opportunity. Ann N Y Acad Sci, 1136: 111-25. http://doi:10.1196/annals.1425.018 Thombs, D.L. & Beck, K.H. (1994). The social context of four adolescent drinking patterns. Health Education Research: Theory & Practice, 9(1), 13-22. Thrasher, J.F., Villalobos, V., Barnoya, J., Sansores, R., & O’Connor, R. (2011). Consumption of single cigarettes and quitting behavior: A longitudinal analysis of Mexican smokers. BMC Public Health, 134, 11. Thrasher, J.F., Villalobos, V., Dorantes-Alonso, A., Arillo-Santillan, E., Cummings, K. M., Cummings, O’Connor, R., & Fong, G.T. (2009). Does the availability of single cigarettes promote or inhibit cigarette consumption? Perceptions, prevalence and correlates of single cigarette use among adult Mexican smokers. Tobacco Control, 18, 431-437. Thun, M.J., Carter, B.D., Feskanich, D., Freedman, N., Lopez, A.D....Gapsture, S.M. (2013). Prentice, R., 50-Year Trends in Smoking-Related Mortality in the United States. N Engl J Med, 368, 351-364. 238 Trinidad, D., R., Gilpin, E.A., ee, L., & Pierce, J. (2004). Do the majority of Asian- American and African-American smokers start as adults? American Journal of Preventive Medicine, 26(2), 156-158. Trinidad, D. R., Pérez-Stable, E. J., Emery, S. L., White, M. M., Grana, R. A., & Messer, K. S. (2009). Intermittent and light daily smoking across racial/ethnic groups in the United States. Nicotine & Tobacco Research, 11(2), 203–210. http://doi.org/10.1093/ntr/ntn018 U.S. Census Bureau. (2016). A Comparison of Rural and Urban America: Household Income and Poverty. Retrieved from: https://www.census.gov/newsroom/blogs/random- samplings/2016/12/a_comparison_of_rura.html U.S. Census Bureau. (2017). Geography: Urban and Rural. Retrieved from: https://www.census.gov/geo/reference/urban-rural.html U.S. Department of Health and Human Services. The Health Consequences of Smoking: 50 Years of Progress. A Report of the Surgeon General. Atlanta, GA: U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, National Center for Chronic Disease Prevention and Health Promotion, Office on Smoking and Health, 2014. U.S. Department of Health and Human Services. (2018). Healthy People 2020. Retrieved from https://www.healthypeople.gov. U.S. Department of Health and Human Services. (2017). Smokefree.gov. Retrieved from: https://smokefree.gov 239 U.S. Food and Drug Administration. (2018). Family Smoking Prevention and Tobacco Control Act - An Overview. Retrieved from: https://www.fda.gov/TobaccoProducts/GuidanceComplianceRegulatoryInfor mation/ucm246129.htm#youth U.S. Preventive Services Task Force (USPSTF). (2016). Tobacco Smoking Cessation In Adults, Including Pregnant Women: Behavioral and Pharmacotherapy Interventions. Retrieved from: https://www.uspreventiveservicestaskforce.org/Page/Document/UpdateSumm aryFinal/tobacco-use-in-adults-and-pregnant-women-counseling-and- interventions Vaz, S., Falkmer, T., Passmore, A. E., Parsons, R., & Andreou, P. (2013). The Case for Using the Repeatability Coefficient When Calculating Test–Retest Reliability. PLoS ONE, 8(9), e73990. http://doi.org/10.1371/journal.pone.0073990 Vogt, F., Hall, S., & Marteau, T.M. (2007). Understanding why smokers do not want to use nicotine dependence medications to stop smoking: Qualitative and quantitative studies. Nicotine & Tobacco Research, 10(8), 1405-1413. von Lampe, K., Kurti, M., & Johnson, J. (2018). “I’m gonna get me a loosie” Understanding single cigarette purchases by adult smokers in a disadvantaged section of New York City. Preventive Medicine Reports, 12, 182–185. https://doi.org/10.1016/j.pmedr.2018.09.016 240 Wackowski, O. A., Evans, K. R., Harrell, M. B., Loukas, A., Lewis, M. J., Delnevo, C. D., & Perry, C. L. (2018). In Their Own Words: Young Adults’ Menthol Cigarette Initiation, Perceptions, Experiences and Regulation Perspectives. Nicotine & Tobacco Research: Official Journal of the Society for Research on Nicotine and Tobacco, 20(9), 1076–1084. https://doi.org/10.1093/ntr/ntx048 Warren, J.R. & Catona, D. (2013). Urban, low-income, African American light smokers: Perceptions of cessation counseling. Journal of the Poor and Underserved, 24(3), 1306-1316. Watson, C., Richter, P., de Castro, B. R., Sosnoff, C., Potts, J., Clark, P., … Watson, C. (2017). Smoking Behavior and Exposure: Results of a Menthol Cigarette Crossover Study. American Journal of Health Behavior, 41(3), 309–319. http://doi.org/10.5993/AJHB.41.3.10 Watson, B., Robinson, D. H. ., Harker, L., & Arriola, K. R. J. (2016). The Inclusion of African-American Study Participants in Web-Based Research Studies: Viewpoint. Journal of Medical Internet Research, 18(6), e168. http://doi.org/10.2196/jmir.5486 Wesley, T. (2012a). Corner Store Loosies EP. Retrieved from: https://tefwesley.bandcamp.com/album/corner-store-loosies-ep Wesley, T. (2012b). Corner Store Loosies. [video file] Retrieved from: https://www.youtube.com/watch?v=-aEsbHpTAr0 Worthington, R.L. & Whittaker, T.A. (2006). Scale Development Research: A Content Analysis and Recommendations for Best Practices, The Counseling Psychologist, 34(6), 806-838. 241