Increasing cigarette taxes is an effective strategy for reducing tobacco use but there may be negative consequences especially in disadvantaged minority communities. According to a study conducted by researchers at Columbia University Mailman School of Public Health, a dramatic rise in illegal street sales of untaxed cigarettes was reported among minority low-income persons immediately after the price increase that reinforced smoking and undermined cessation efforts.

This is the first study to examine how living in a disadvantaged minority neighborhood shapes the impact of smoking policies on individual tobacco use. Participants in 14 focus groups in Central Harlem, New York told researchers that a large cigarette tax increase in New York City led to "a pervasive illegal cigarette market in a low-income minority community." In an area where smoking rates were already likely to be higher than in the general population, even those motivated to quit were lured by bootleggers selling low-price cigarettes.

"Although interest in quitting was high among the smokers interviewed, bootleggers created an environment in which discounted cigarettes were easier to access than cessation services," said Donna Shelley, MD, MPH, assistant professor of clinical Sociomedical Sciences at the Mailman School of Public Health and the study's principal investigator. "Popular brands could be bought on the streets for as little as $5 per pack, and the phenomenon of the $5 man -- the commonly used term for a highly visible network of bootleggers who appeared after the tax increase -- emerged as a new source of low-cost cigarettes."

According to the study, most smokers admitted buying cigarettes from the $5 man throughout the community on street corners, in busy shopping areas, outside subway entrances, and in apartment buildings. Other accessible sources of reduced-price cigarettes, respondents noted, included "loosies" -- single, out-of-package cigarettes sold illegally at local grocery stores or bodegas. Buying cigarettes out of state was another price-minimizing strategy.

While smokers described additional strategies to avoid price increases such as cutting down and switching to discount brands, purchasing from the $5 man was the principal behavioral response to the tax increase reported by respondents. Although almost all smokers described a history of quit attempts, they noted that opportunities for reduced-price cigarettes were so prevalent that most smokers needed only to alter purchasing patterns rather than smoking patterns.

For smokers living in Harlem, smoking was an important strategy to cope with individual level stressors such as low incomes and unemployment. "We do not dispute that cigarette taxes are an effective method for reducing tobacco use," remarked Dr. Shelley. "Yet, our findings support the argument that programs and policies to alter health risk behaviors are limited without addressing the structural inequalities and other pressing social factors that help sustain nicotine addiction, shape individual attitudes and behaviors, and inform community norms."

In New York City, the tax increase was accompanied by programs specifically recommended to reduce socioeconomic disparities in smoking prevalence. Population-based cessation services included free nicotine patches, free counseling, and pharmacotherapy at several smoking cessation clinics located in low-income communities. Further, New York State offers a Medicaid pharmacotherapy benefit that preceded the tax increase. Yet, according to the study, only a handful of those interviewed were aware of these resources.

"Our findings suggest that further research is needed to investigate interventions that address individual and structural barriers to utilizing cessation resources among disadvantaged populations where smoking rates are highest, and tobacco tax evasion must be addressed in a more comprehensive manner to assist low-income communities in reducing the burden of smuggling activity," noted Dr. Shelley.

The study, which was funded by the Centers for Disease Control and Prevention and the American Legacy Foundation, will be in the August 2007 print issue of the American Journal of Public Health, published by the American Public Health Association, and is online at http://www.ajph.org ("The $5 Man: The Underground Economic Response to a Large Cigarette Tax Increase in New York City.")