Smoking is strongly linked to disadvantage (Jarvis & Wardle, 1999). Psychological approaches to studying the 'poor smoker' have tended to neglect potentially important 'macro-social' factors. This thesis takes a social psychological approach, focused on social identity (Campbell, 1997). It aims to consider the construction of identities and meaning-systems amongst different socio-economic status groups in England. Two studies were undertaken, representing a mixed methodological approach. In the first study, smokers and non-smokers from higher and lower socio-economic groups were given a conceptual map task to capture their spontaneous associations with the topic. This was followed by an in-depth interview. A thematic analysis showed that smokers were identified as 'unhealthy, stressed out and addicted'. They were also identified with 'Other' already stigmatised groups such as the old, the young and working-class groups. Non-smokers emphasised a moral discourse surrounding smoking to draw boundaries between themselves and 'bad' smokers. Higher SES smokers tended to distance themselves from the negative dimensions of smoking identities, whereas lower SES tended to internalise them. The second study was a Q-methodological one, comprising a sample of smokers from different SES groups. A six-factor model of 'smoking identities' was generated. Three identities oriented around a biomedical model of smoking as an addictive health risk. The other three reflected alternative or paradoxical constructions of smoking based on pleasure, freedom and the rights of smokers. It is concluded that taking into account smoking identities and the conceptual understandings underlying them offers the opportunity to locate health promotion where the audience is thinking (Joffe, 2002). This is particularly important when targeting lower SES smokers.

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Background The national alcohol and drug strategies signalled a shift in national policy on how treatment for alcohol and drug addiction should be conceptualised and ultimately operationalised within Scotland. The research to inform local practice however has primarily been conducted in America or drawn from the mental health recovery field in the United Kingdom. Aims The aim of this study was therefore to develop a coherent theory of recovery from alcohol and drug addiction in order to inform policy and practice and guide the local implementation of recovery orientated systems of care. Methods The study methodology was guided by constructivist grounded theory and was thus based on the lived experience of thirty-seven individuals in recovery from addiction and twenty one people who had experience of addiction within their family. All participants were recruited via theoretical sampling from within community based recovery groups, mutual aid fellowships (Alcoholics Anonymous, Narcotics Anonymous, Al-Anon), staff working within treatment settings and the wider community. Findings The core category of recovery was identified as “Healing the Wounded Self” in the recognition that recovery from addiction was essentially a journey of personal and spiritual growth. This study demonstrates the relevance of our early years in the formation of our earliest memories of self-hood and how these can shape our life trajectory.

Objectives The central objective of this study was to investigate the relationship between shame and substance use. The Experiences of Shame Scale CESS) was used to differentiate between different sources of shame, namely character, behaviour and body shame. Drug-related shame was examined as a possible additional source of shame. The study also aimed to investigate potential constructs underlying the association between shame and substance use. Aggression was considered alongside the self-related concepts of self-ambivalence and self-esteem as potential mediators. Finally, the relationship between shame and distress disclosure was examined. Method 100 participants were recruited for the study; 50 poly-drug users were recruited from drug and alcohol services for the substance use (SU) group and 50 non-substance using participants were recruited online via mental health charities for the comparison group. The study used a cross-sectional design to investigate differences between the groups. Standardised self-report questionnaire measures were used. Results Findings indicate that the SU group participants scored higher on all ESS subscales. After adjusting for demographic differences between the groups, only differences on Character shame remained significant. Aggression was found to be a significant mediator of the relationship between Character shame and substance use. Findings also suggest that the highest level of shame experienced by SU participants is related to substance use. Moreover, self-ambivalence, self-esteem and willingness to disclose distress were associated with shame, regardless of substance use.

This vast cost of drug addiction, to both individuals and society, continues to fuel research investigating its aetiology and treatment (Gordon et al., 2006). Definitions of addiction often feature a loss of control on reward seeking behaviour, specifically deficits in inhibitory control (impulsive action) and the preference for immediate over delayed rewards (impulsive choice). Indeed, impulsivity is thought to be influential in the onset, progression and propensity to relapse into drug addiction. This thesis utilised a range of methodologies in order to elucidate the role of impulsive behaviour in the progressive pathophysiological process of addiction. Animal models of impulsivity were used to elucidate causality between drug use (specifically, acute nicotine administration) and changes in impulsive behaviour (both impulsive choice and impulsive action). Furthermore, dopaminergic neural mechanisms implicated as mediatory in drug related impulsive choice and action were assessed via dopamine 01 and 02 receptor antagonism. Acute drug administration produced a dose-related increase in both constructs, and findings suggest the independent roles of dopamine 01 and 02 receptors in mediating these behaviours. In the second part of this thesis the wider environmental and sociological context of drug use and impulsive behaviour within a UK prison population were investigated. This population is characterised by elevated impulsivity, and the prominence of their impulsive behaviour and drug use are immensely costly to both themselves and society. Multiple dimensions of behavioural and self- reported impulsivity were assessed in both drug users and non-users, along with their criminal behaviour and psychological functioning. Even within a highly impulsive population, drug users exhibited elevated impulsivity (compared to non users). In recruiting both drug users seeking and not-seeking treatment, the methodology also permitted investigation whether impulsivity could distinguish these groups, as well as the bi-directional relationship between impulsivity in treatment progression. In the third section of this thesis, treatment completers were interviewed on their experience of impulsivity, their past, present and future drug use, and their views on drug treatment. An Interpretative Phenomenological Analysis of the interviews was conducted. Implications are discussed in terms of current research, theory and implications. The findings implicate impulsivity as influential throughout stages of drug addiction and highlight the value of diverse viewpoints in approaching the heterogeneous construct.

Aim of the research Smoke-free policies have only recently been introduced in the Balkans. These countries are characterized by high smoking prevalence and research evidence has suggested problems at the level of compliance with smoking bans. The aim of the present research was to provide an understanding of non-compliance with smoke-free policies in one of these countries, Albania. Methods The theoretical frameworks guiding the investigation included the reactance and normative approaches (used across all studies) and the general theory of deterrence (Study 4 only). Hence, four studies were conducted, investigating constructs informed by the reactance approach (age, gender, and attitudes), the normative approach (descriptive and injunctive norms), and empirical research in the area (smoking status, type of ban, health risk beliefs). Study 4 additionally assessed legal, moral, and social deterrents to non-compliance and non-smokers' self-efficacy to be assertive. Participants included 140 teachers (Study 1), 203 healthcare workers (Study 2), 295 adults (Study 3), and 944 university students (Study 4). The measures used were self-report questionnaires. Results showed that Albanian smokers had an overall positive attitude towards the ban and good awareness of the health consequences of passive smoking. Nonetheless, they were not very well informed as regards smoke- free policies and reported strong social norms favouring non-compliance. As regards the general predictors of non-compliance, they included reactance variables (gender and attitude), normative variables (descriptive norms), and smoking-specific variables (smoking status). Study 4 showed that this predictive model additionally contributed to the explanation of non-compliance, beyond the general model of compliance with the law (the deterrence model). Furthermore, findings from Study 4 also found weak legal, moral, and social deterrents to non-compliance as reported by both smokers and non-smokers. Moreover, non-smokers reporting weak deterrents to non-compliance behaviour (of smokers) also reported lower self-efficacy to be assertive. Discussion Findings suggested that non-compliance with smoke-free policies in Albania might be explicable in terms of the pro-smoking normative influences, attitudinal variables, and individual characteristic (gender, smoking status). Furthermore, smokers do not seem to expect much in terms of either legal, moral, or social consequences to noncompliance behaviour. Finally, the low self- efficacy and weak descriptive norms of assertiveness among non-smokers represent additional factors related to higher non-compliance rates among smokers. These findings suggest the need for practical enforcement of tobacco control policies in Albania as well as further efforts towards promoting non-smokers assertiveness behaviour. Importance of research Despite the several limitations, the present research represents the first systematic attempt to provide feedback on the implementation of the smoking ban in public places in Albania. As such, it has important practical implications for policy makers and suggests several directions for future research.

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This thesis uses the ASSIST intervention (a school-based, peer-led smoking intervention) to explore issues relating to the successful diffusion of a health promotion message through informal contacts. Social network data and process evaluation data gathered during the evaluation of the intervention are used to examine whether opinion leaders (peer supporters) identified through a 'whole-community' approach to peer nomination were appropriate to disseminate a smoke-free message to their peers and whether this social diffusion approach is acceptable to young people. More specifically, the aims are to i) investigate whether the peer supporters were appropriate in terms of their position in social space, ii) ascertain whether their peers perceived them as suitable to adopt the role, and iii) examine issues relating the acceptability of the ASSIST approach. The peer nomination process identified peer supporters who were largely appropriate to undertake the peer supporter role. They were significantly more influential in terms of their social position than other students in their year. They were also contained in a range of social groups and the majority of students knew at least one peer supporter. Peer supporters were representative of the rest of the year group but were more likely to be smokers than other students. Respondents considered the majority suitable to carry out the role although more positive appraisals were received from peer supporters. The ASSIST approach was in general viewed positively by the students involved. Respondents reported being happier talking with their peers than adults about smoking. Peer supporters had conversations about smoking. However, these conversations tended to be with non-smoking friends and peer supporters. The majority of respondents were positive about peer supporters talking to other Year 8 students about smoking although more encouraging appraisals were received from peer supporters and non-smokers. The findings will provide valuable learning which may be utilised to maximise the effectiveness of future applications of this novel approach both in the field of smoking prevention and elsewhere.

I conducted a review to show that smoking cessation in TB patients can have positive TB outcomes. Behavioural interventions (BI) for smoking cessation are known to be effective and cost effective but there are important variations in quit rates that are hard to explain. My aim was to develop and validate a fidelity index for BIs in smoking cessation, and use it to explore the extent to which variations in smoking quit outcomes reflect the degree to which providers implement the various components and the quality of delivery of a smoking cessation programme in TB treatment settings. I developed and tested a theoretically mapped fidelity index comprising two sub-indices: ‘Adherence’ for measuring compliance (37 items) and ‘Quality’ for measuring provider competence (8 items). Items were rated as fully, partially, or not, implemented against a behaviourally anchored response scale. Fidelity was measured in a prospective study of 18 providers in TB clinics in Pakistan (154 patients) whose sessions were audio-recorded and then coded. These providers had participated in delivering the same BIs as part of the ASSIST trial four years earlier. Reliability was assessed in three ways. There was good inter-coder reliability using Kripendorff’s alpha, Principal Components Analysis showed the items of the index were coherent in measuring fidelity and Generalisability theory showed that the index reliably differentiated between providers by capturing the variation in their BI delivery practice. Provider Adherence and Quality of provision were positively correlated. I tested the assumption that relative provider practice was consistent between the ASSIST trial in 2010 and the fidelity study in 2014. Using Kendall’s W coefficient of concordance on data from a self-recorded checklist used in both studies, I found moderate to strong concordance. I then used binomial regression analysis to estimate the relationship between fidelity and ASSIST trial provider-level quit rates. This showed that the provider-level quit rate was positively associated with Quality of interaction (odds ratio: 2.15; 95% CI, 1.43 to 3.24) but negatively associated with Adherence to BI content (odds ratio: 0.55; 95% CI, 0.40 to 0.77). A negative interaction was found between Adherence and Quality and quit rates. This research makes several contributions to the field. We have a better understanding of the impact of smoking on TB. I developed and validated a new, theoretically-informed, fidelity index which can be used to quantify and score delivery of BI ingredients in a standardised way and used to better understand how BIs influence outcomes. I report that the quality of delivery of BIs maybe as important as content in influencing smoking cessation.