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In 2008, the United Kingdom became one of the first countries in Europe to implement graphic anti-smoking warnings. However, at present there has been very little research to reveal insights into how UK smokers may perceive the warnings and what impact they might exert on smokers' intention to quit smoking. This thesis evaluated the effectiveness of graphic anti-smoking warnings from a social psychological perspective. A qualitative study (Study 1) was conducted to tap the phenomenology of smoking, to gain insight into how smokers may experience the warnings and to establish whether smokers believed that graphic warnings would motivate them to quit smoking. The existing literature in this area has ·identified several factors which may predict intention to quit following exposure to graphic warnings. This thesis tested whether the use of fear, either on its own or in interaction with other factors, encourages smokers to form intentions to quit smoking. Four studies (with an experimental 2- factorial design) were conducted to detennine the main and interaction effects of fear and information processing, fear and hypocnsy-induced dissonance and fear and self-efficacy on intentions to quit smoking. The studies consistently revealed no significant main or interaction effects of fear on intention. The only main effect that was observed was due to hypocrisy-induced dissonance. That is, following the implementation of the hypocrisy paradigm (Aronson, Fried and Stone, 1991), findings suggested that smokers who were made to feel highly hypocritical of their smoking behaviour were motivated to fonn greater intentions to quit smoking than those smokers in the low hypocrisy condition. Having considered a diverse range of psychological factors and their potential impact on intentions to quit smoking at the intra-personal level. the latter part of the thesis examined the impact of graphic warnings at the intergroup level. Specifically, three studies were conducted to test the potential effects of the graphic warnings in the context of the intergroup relationship between smokers and non-smokers. Two studies identified that graphic warnings led to the fonnation of negative non-smoker attitudes (e.g. blame) towards smokers. Furthennore, these attitudes were greatest amongst non-smokers with a strong just-world belie{ (Lerner, 1980). A final study questioned whether awareness of negative non-smoker attitudes would motivate smokers to form intentions to quit. Findings revealed that smokers asked to read a summary of negative non-smoker attitudes towards smoking who also agreed with its content, were encouraged to form the greatest intentions to quit smoking across all of the studies conducted for this thesis. Implications of these findings, study limitations and directions for future research are discussed.

Background: Smoking and tobacco use is the biggest cause of premature death worldwide. Smoking cessation services report a four-fold increase in successfully supporting clients to quit and are reported to increase a smoker's chances of stopping smoking four-fold. Yet, there remains a knowledge gap of the comparative success and cost effectiveness of smoking cessation providers and the socio-demographics of their clients. Aim: To compare differences in clients, effectiveness and costs by smoking cessation service delivered in dental, GP, pharmacy and NHS Stop Smoking Services in Bradford & Airedale. Methods: Retrospective smoking cessation data were accessed (July 2011 - December 2011) from four smoking cessation services (dental, GP, pharmacy and NHS SSS) in Bradford & Airedale. The analysis compared the socio-demographic features of clients, spatial distribution of smoking cessation services by setting and the clients who use them and the cost and effectiveness by service. Results: Of those using the services across the smoking cessation services, 3% used dental, 11% pharmacy, 31% NHS SSS and 55% GP. Dental and NHS SSS had the largest proportion of clients who had 'quit' (Chi square p=O.01). Clients attending dental services travelled further than other clients (ANOVA: p=O.01). Dental services had the highest mean cost per quitter: £167.84. Pharmacy services were cost effective when compared against usual care (NHS SSS), whereas dental services were more effective and more costly and GP services were less effective and less costly compared to usual care (NHS SSS). Conclusions: This novel research shows variations in smoking cessation service by setting when considering client socio-demographic features, spatial distribution of clients and service distribution and the cost and effectiveness by setting in Bradford & Airedale. These research findings provide the foundations by which to further explore the role of dental services as a smoking cessation service provider.

Background In England there is a comprehensive framework of tobacco control policies to reduce smoking-related harm. Policy evaluation helps to ascertain how policies may be improved so that they have the greatest impact; ineffective policies can be dropped or improved, while effective policies can be kept and improved further in order to optimise their impact. The evaluation of tobacco control policy requires high quality and timely data on smoking and smoking cessation behaviour. Time series analysis (TSA) is a robust way of evaluating policy, as it takes existing trends into account, but requires frequently collected data in large samples over long time periods. The aims of this thesis were to investigate the suitability of a range of existing data sources for evaluating the impact of tobacco control policies in England on quitting behaviour, validate potentially suitable measures, and use validated measures to evaluate the impact of recent tobacco control initiatives in England using TSA. Methods A range of data sources which provide information on smoking cessation behaviour were analysed to determine their adequacy for evaluating tobacco control policies, and previously unvalidated measures were validated. Different approaches to TSA – interrupted time series analysis and multiple time series analysis - were employed to evaluate the impact of the introduction of a new smoking cessation medication, varenicline, the broadening of the indications for nicotine replacement therapy (NRT) to include people with cardiovascular disease and adolescents, and the effect of anti-tobacco mass media campaigns on quitting behaviour. Results Two key indicators of quitting behaviour are quit attempts and smoking prevalence; however, there are currently no frequently collected data from large enough samples covering a long time period on these measures. Survey data are generally not suitable for policy evaluation because they are infrequently carried out and often have small sample sizes, making it difficult to detect small and transient changes in behaviour. In contrast, routine sources of data such as electronic medical records data are often frequently collected in large samples over long time periods. A validation study showed that primary care data from The Health Improvement Network are an accurate source of data on prescribing of smoking cessation medication. Time series analyses of these data showed that both the introduction of varenicline, and the broadening of the indications for NRT, did not increase rates of prescribing for smoking cessation medication. Another study found that tobacco control mass media campaigns appear to be more effective at triggering quitting behaviour than pharmaceutical company NRT campaigns. Conclusions Although there are significant gaps in the existing data available, there are some high quality time series data which can be used to evaluate the impact of tobacco control policies in England. There is a need for regular collection of data on key indicators of quitting behaviour, and the use of time series analysis in policy evaluation can play a vital role in strengthening the evidence for the effectiveness of policies, both in tobacco control, and in other areas of public health. The time series studies in this thesis suggest that recent changes to the availability of pharmacological smoking cessation aids have not had a significant impact on public health, and that recent cuts in tobacco control advertising are likely to have reduced quitting behaviour. .

Background: The common argument used against the implementation of tobacco control policies is that revenue from tobacco duty is considerably higher than the health care costs smoking imposes on society. This point is true as revenue in the United Kingdom (UK) totalled £9.1 billion while recent costs estimates for the treatment of smoking-attributable disease totalled £5.2 billion to the UK National Health Service. However, this argument becomes unclear when indirect costs such as productivity loss or cost of absenteeism are incorporated. In the UK, there were 29.2 million employed adults in 2011 of which 20% were current smokers. This equates to approximately 5.84 million employed adult smokers. There are currently no studies which have quantified the economic impact of smoking-attributable indirect costs to both employers and the wider society in the UK. These costs are suspected to impose a large economic burden to society but the best practice methodology for estimating indirect costs and the magnitude of these costs are still unknown. Therefore, the aims of this thesis were to quantify the economic impact of smoking-attributable indirect costs due to productivity loss from premature mortality and absenteeism of workforce and to evaluate workplace interventions which could potentially decrease the burden of smoking in the workforce in the UK. Methods: A number of methods were used along with a range of data sources which provided the information to quantify the economic impact of smoking in the workforce. Cost-of-illness methodology based on the human capital method was utilised to quantify the monetary burden of smoking in the workforce due to premature mortality in the UK. Systematic review and meta-analysis was used to examine the epidemiological association between smoking and absenteeism while also providing the necessary parameters to estimate costs of absence in the UK. Finally, decision analysis and Markov simulation modelling was used to conduct both cost-benefit analysis and cost-effectiveness analysis from the employer's perspective for evaluating workplace smoking cessation interventions of brief advice, individual counselling and nicotine replacement therapy with individual counselling. Results: Cost-of-smoking modelling estimated that smoking was responsible for 96,105 deaths (58% male) in adults aged 35 years and over (17% of all deaths) in the UK annually, resulting in 1.2 million years of total life lost and 357,831 years of productive life lost valued at £4.93 billion in 2010. From the systematic review of 29 longitudinal studies, current smokers had a 33% increase in risk of absenteeism and were absent for an average of 2.74 more days per year compared with non-smokers. Compared with never smokers, ex-smokers had a 14% increase in risk of absenteeism; however, no increase in duration of absence could be detected. Indirect comparison meta-analysis showed that current smokers also had a 19% increase in risk of absenteeism compared with ex-smokers. Consequently, smoking was estimated to cost UK employers £1.46 billion in 2011 from absenteeism in the workplace. Workplace interventions for smoking cessation provide a possible method for reducing the burden of smoking in the workforce. Cost-benefit analysis of workplace interventions resulted in brief advice being the optimal decision strategy for women while brief advice and individual counselling both were optimal decision strategies for men in terms of minimising total costs and maximising return on investment for the employer. If the employer valued maximising quitting instead, cost-effectiveness analysis showed that nicotine replacement therapy with individual counselling would be the optimal strategy given a maximised budget constraint. Conclusion: This thesis has provided the first indirect cost-of-smoking study quantifying the productivity loss due to premature mortality and absenteeism in UK; the first systematic review and meta-analysis which has explored the association between smoking and absence from work; and the first cost-benefit and cost-effectiveness analyses of workplace interventions for smoking cessation in the UK. The implications of this research have particular relevance for UK policy makers and employers to justify stronger tobacco control policy which promotes smoking cessation. However, these findings are not unique to the UK. The thesis has provided the framework and methodology for studies that can strengthen the evidence-base around the economics of smoking in other countries as well.