Our results suggest that adult Mexican smokers buy single cigarettes with some regularity. Participants in every focus group purchased single cigarettes. Survey adjusted prevalence of purchased single cigarettes in the last month was 38% and the prevalence of buying single cigarettes at the last cigarette purchase was 10%. The only other published attempt to estimate prevalence of single cigarette use comes from a convenience sample of young US adults in disadvantaged areas, among whom 77% has purchased single cigarettes in the previous month.9
The lower prevalence of single cigarette use found in our sample is probably because of its population-based character. Nevertheless, our results are consistent with the notion that single cigarette use in Mexico is concentrated among younger smokers and smokers from lower income groups. In multivariate models, younger smokers more frequently purchased single cigarettes than older smokers, and there appeared to be a threshold effect for income, where the three highest income groups had a similarly decreased likelihood of having bought single cigarettes at the last cigarette purchase compared to the lowest income group. These findings support the notion that the availability of single cigarettes may help facilitate the early stages of nicotine addiction among young people and may keep disadvantaged groups smoking, even if it is at a lower intensity. Our data indicate that consumption of single cigarettes in Mexico is not limited to these populations, however.
The places where Mexican smokers buy single cigarettes are generally the same as those where they obtain cigarette packs, with approximately 80% of cigarette sales of either packs or single cigarettes take place in neighbourhood stores. Such stores often operate within the informal economy, which the World Bank estimates to account for 20% to 57% of all jobs in Mexico.23
The informal economy generally lies outside of the formal regulatory processes that aim to ensure implementation of commercial laws, including those that have made the sale of single cigarettes illegal.24
Location within the formal economy may decrease illegal single cigarette sales (no participant reported purchasing single cigarettes from supermarkets, for example); however, formal economic sector sales do not always follow the law, as has been found in previous research10
and was confirmed in our study’s finding that some smokers purchased their single cigarettes at convenience stores and gas stations. In countries like Mexico, the overall difficulty of effectively implementing a ban on single cigarette sales raises questions about prioritising this policy.
Given the difficulty of single cigarette bans, our results also provide heartening evidence of the possible harm reduction benefits of the availability of single cigarettes. Smokers in our focus groups indicated that the higher relative cost per cigarette and lower accessibility of single cigarettes compared to pack cigarettes makes the consumption of single cigarettes a viable strategy for limiting consumption and even helping to quit. Our survey and focus group data were consistent in finding that single cigarettes cost approximately double the unit price of a cigarette when bought in a pack of 20. Smokers are price sensitive across countries,25
and this sensitivity probably helps to explain why purchasing single cigarettes can inhibit consumption. The availability of cheaper cigarettes by the pack may nevertheless stifle attempts to use this method among those who are concerned about cost, as was recounted by one focus group participant.
Our survey results suggest that smokers who say that they use single cigarettes to control consumption are not only more likely to consume single cigarettes but they are also more likely to intend to quit than smokers who do not purchase single cigarettes to control consumption. Determining whether such quit intentions and accompanying use of single cigarettes translates into actual quit behaviour will require longitudinal analysis. Nevertheless, we expect that the relation between quit intention and quit behaviour will apply among Mexican smokers. If this holds true, then the greater price and extra effort necessary to find single cigarettes for sale may contribute to lower levels of consumption and, potentially provide smokers with a harm reduction strategy that has heretofore not been considered in debates on that issue.27
Indeed, young adults from a disadvantaged area in the US also indicated that they used single cigarettes as a harm reduction strategy.9
The harm reduction method may be particularly relevant to the case of Mexico, where even daily smokers smoke 6.7 cigarettes a day,28
which is a lower smoking intensity than in other countries.29
Our results also suggest that the potential public health impact of the availability of single cigarettes for harm reduction may be at least partly offset by the pro-smoking cues that their availability provides to smokers in general. Our index of the frequency of cravings to smoke upon seeing single cigarettes for sale was positively associated with single cigarette consumption, although the relation was weaker than for the frequency of smoking single cigarettes to reduce consumption. Those who experienced the most frequent cues to smoke from seeing single cigarettes for sale were less likely to intend to quit than those who did not experience such cues, whether because they reported not seeing single cigarettes for sale or, upon seeing them, they did not experience cravings. The population of smokers who react most strongly to the cues provided by single cigarettes may also be more receptive to other environmental cues to smoke, such as advertising, ash trays and cigarette package displays.30
If these other cues are not reduced or eliminated, then eliminating the cue of single cigarettes from their environment may have only a marginal effect on smokers’ consumption.
Research on cues to smoke has been conducted almost exclusively in laboratory settings and has only recently been studied in natural settings.30
To our knowledge, our effort to use surveys to capture exposure to cues and reactivity towards them is relatively novel. The associations we found between our measure and variables of interest provide evidence of construct validity. Although we used cognitive interviewing to confirm adequate comprehension of the measures we used, our measure may nevertheless suffer from biases associated with self-report, including potential under-reporting of a cue like this that could operate at a relatively unconscious level. Future research should further assess the reliability and validity of our measure, as well as other measurement approaches, in order to better understand how cueing works outside of laboratory settings.
What this paper adds
- Previous research on single cigarette vending and use has been focused on its potential to promote youth smoking. Single use among adults has received less attention, and some smokers have reported that they purchase more costly and relatively less accessible single cigarettes as a harm reduction strategy.
- The results from this study suggest that the availability of single cigarettes may provide adult smokers in Mexico with a viable strategy for cutting down and even quitting smoking. However, some smokers report that seeing single cigarettes cues smoking urges, thereby potentially undermining any beneficial effects associated with their availability.
There are also a number of other limitations to this study. The cross-sectional nature of the data precludes determination of causality for time varying characteristics. Longitudinal data analysis will be necessary to more adequately determine whether those who consume single cigarettes actually reduce consumption or quit at higher rates than those who do not. Relapse behaviour also should be examined to determine whether some ex-smokers may resume smoking because of the cues provided by the availability of single cigarettes in their environment. The results may not generalise to smokers in rural areas or other cities in Mexico. Furthermore, the moderate participation rate may also mean that the results do not generalise to all adult smokers in the cities where data were collected. Similar studies should be conducted in other countries, particularly where smokers have heavier smoking habits, as the relatively light smoking habit among Mexicans may limit these conclusions to Mexico.
In summary, this study provides evidence that the relatively widespread availability of single cigarettes and the practice of single cigarette consumption in Mexico may facilitate cutting down or even quitting, perhaps providing a harm reduction strategy that has heretofore not been considered. Nevertheless, our study also suggests that the availability of single cigarettes may promote smoking. Further studies should more squarely focus on this issue, as well as whether single cigarette availability promotes youth smoking. Younger smokers were more likely to more frequently purchase single cigarettes, providing some support for the idea of a gateway effect. Hence, single cigarette availability and use may facilitate heavier use.