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High relapse rates among smokers attempting to quit have been linked with failure to cope with cigarette cravings and withdrawal symptoms. Smoking cravings and withdrawal behavior is known to be influenced by stress and exposure to smoking cues. Exercise appears to reduce cigarette cravings and withdrawal symptoms. However no study has investigated the effects of exercise on cue-elicited cravings and withdrawal symptoms, or on ad libitum smoking behavior. Aim: Four experimental studies were designed to examine the effects of exercise on smoking behavior. Initial studies focused on the effects of a single session of brisk walk on cigarette cravings and withdrawal symptom. Further research examined the effects of the walk on withdrawal symptoms and cravings and response to smoking cues and time spent on ad libitum smoking. Methods: All studies examined the effects of a short bout of brisk walking (15- 20 minutes) versus a passive control condition. For the purposes of the experiments, participants were temporarily smoking abstinent or non-abstinent. Multiple and single item measures of cravings and withdrawal, as well as different experimental designs were used in order to enhance the reliability of the findings. In Studies 2,3, and 4 after the exercise (or the control) participants were exposed to smoking cues. In these studies after the laboratory session, ad libitum smoking was determined from the subject's cell phone text message. Results: Cigarette cravings, withdrawal symptoms and negative affect decreased rapidly during exercise and remained reduced for 20-50 minutes after exercise. This pattern was robust across the four studies, across different abstinent periods, across single and multiple measures of cravings and withdrawal symptoms, across experimental designs and across samples. Furthermore, it was shown that exercise attenuated increases in cue elicited cravings and withdrawal symptoms. Results also indicated a two- to threefold longer time to the next cigarette following exercise. Exercise produced these effects by mimicking the relaxing effects of smoking. Conclusions: Short bouts of brisk walk are recommended as an aid to managing cigarette cravings and withdrawal symptoms.

UK resident Bangladeshi men pose a public health challenge because of their preference for traditional tobacco use along side cigarette smoking. Studies investigating UK black and minority ethnic tobacco use have not had a primary focus on this issue. Furthermore, the extent and nature of dual tobacco use by Bangladeshi men had not been reliably established due to a reliance on self-report and a definitional confusion about paan with and without tobacco. This study aims to establish the prevalence of dual tobacco use by UK resident Bangladeshi men using a random survey design. It also plans to establish baseline information for dual tobacco use against the key determinants of a health inequality model. Psychosocial, health and nicotine related parameters of dual tobacco users are compared with cigarette only smokers and paan tobacco chewers. Risk factors for dual tobacco use have been explored through multivariate analysis. Three hundred and twenty-five men of Bangladeshi origin were randomly selected using the Tower Hamlets Electoral Register and interviewed at home using a pre piloted questionnaire incorporating items used in other relevant UK studies. Expired carbon monoxide readings were recorded using a Bedfont CO monitor. Dual tobacco was used by 22% of the sample, while 36% smoked cigarette only, 70/0 chewed paan tobacco only, and 350/0 did not use any form of tobacco. When dual tobacco users were compared with the cigarette smokers in bivariate analysis, there were significant differences in terms of self reported social class, age, education, employment, and heath status. A multivariate analysis controlling for age, education status, social class, self reported health and social capital scores showed tha1 only wife's tobacco use predicted dual tobacco use (OR=6.3). The findings from this study confirm the diversity and social nature of dual tobacco use by UK Bangladeshi men. These observations need to be considered and integrated into the development and implementation of tobacco cessation interventions for UK Bangladeshi adults in public health programs.

Background: Smoking contributes to health inequalities and there is a need to focus interventions on the disadvantaged. Abrupt quitting is widely advocated, but assisted ‘reduction’ may be an option for those not ready to quit. Physical activity acutely reduces cigarette cravings and withdrawal symptoms, and may increase long-term cessation and reduce weight gain. This thesis reports on the multi-method evaluation of an intervention delivered by Health Trainers (HTs) and a pilot randomised controlled trial of the Exercise Assisted Reduction then Stop (EARS) intervention for disadvantaged smokers who are not ready to quit, but do wish to reduce, without nicotine replacement therapy. This programme of research aimed to evaluate four aspects of the EARS trial: 1) Recruitment, 2) Study attrition, 3) Main quantitative outcomes, and 4) Intervention fidelity. Methods: 1) Recruitment: Smokers were recruited through mailed invitations from three primary care practices (62 participants) and one National Health Stop Smoking Service (SSS) database (31 participants). Six other participants were recruited via a variety of other community-based approaches. Data were collected through questionnaires, field notes, work sampling, and databases. Chi-squared and t-tests were used to compare baseline characteristics of participants. 2) Study Attrition: Disadvantaged smokers who wanted to reduce but not quit were randomised (N=99), of whom 61 (62%) completed follow-up assessments at 16 weeks. Univariable logistic regression was conducted to determine the effects of intervention arm, method of recruitment, and participant characteristics (socio-demographic factors, and lifestyle, behavioural and attitudinal characteristics) on attrition, followed by multivariable logistic regression on those factors found to be related to attrition. 3) Main quantitative outcomes: Data at 16 weeks were collected for various smoking and physical activity outcomes. Primary analyses consisted of an intention to treat analysis based on complete case data. Secondary analyses explored the impact of handling missing data, examining different methods including last baseline observation carried forward, last observation carried forward, and multiple imputation. 4) Intervention fidelity: Three researchers scored a total of 90 audio recorded consultations for 30 different participants split between three HTs delivering the intervention. Delivery was scored using a 0-6 likert scale for 12 different processes identified as being fundamental to the intervention. Results: 1) Recruitment: Depending on the intensity and time invested in following up those who did not initially respond to a letter, we randomised between 5.1–11.1% of those invited through primary care and SSS, with associated researcher time to recruit one participant varying from 18 –157 minutes. Recruitment rates were similar for invitations sent from primary care and SSS. Despite substantial time and effort, only six participants of our total of 99 were recruited through a wide variety of other community-based approaches, with an associated researcher time of 469 minutes to recruit one participant. Targets for recruiting a disadvantaged population were met, with 91% of the sample in social classes C2–E, and 41% reporting moderate to severe depression or anxiety. However, we under-recruited single parent smokers. Chi squared tests revealed that those recruited from the SSS database were more likely to respond to an initial letter, had used cessation aids before and had attempted to quit in the past year. Overall, initial responders were more likely to be physically active than those who were recruited via follow-up telephone calls. No other demographic or behaviour characteristics were associated with recruitment approach or intensity of effort. Qualitative feedback indicated that participants had been attracted by the prospect of being assigned to an intervention that focused on smoking reduction rather than abrupt quitting. 2) Attrition: Participants with low confidence to quit, and who were undertaking less than 150 minutes of moderate and vigorous physical activity per week at baseline were less likely to complete the 16-week follow-up assessment. Exploratory analysis revealed that those who were lost to follow-up early in the trial (i.e., by 4 weeks), compared with those completing the study, were younger, had smoked for fewer years and had lower confidence to quit in the next 6 months. Participants who recorded a higher expired air carbon monoxide reading at baseline were more likely to drop out late in the study, as were those recruited via follow-up telephone calls. Multivariable analyses showed that only completing less than 150 minutes of physical activity retained any confidence in predicting attrition in the presence of other variables. 3) Main quantitative outcomes: Compared with controls, intervention smokers made more quit attempts (36 v 10%; Odds Ratio 5.05, (95% CI: 1.10; 23.15)), and a greater proportion achieved ≥ 50% reduction in cigarettes smoked (63 v 32%; 4.21 (1.32; 13.39). Post-quit abstinence measured by exhaled carbon monoxide at 4 week follow-up showed promising differences between groups (23% v 6%; 4.91 (0.80; 30.24). No benefit of intervention on physical activity was found. Secondary analyses suggested that the standard missing data assumption of ‘missing’ being equivalent to ‘smoking’ may be conservative resulting in a reduced intervention effect. 4) Fidelity: All three HTs demonstrated high levels of skill in delivering a client-centred motivational interviewing based intervention. Processes relating to physical activity were not delivered as well as those relating to smoking behaviour. Processes related to social support were poorly delivered. There was little variation between individual HT scores and the scores of the researchers completing the scoring. Conclusions: 1) Recruitment: Mailed invitations, and follow-up, from health professionals was an effective method of recruiting disadvantaged smokers into a trial of an exercise intervention to aid smoking reduction. Recruitment via community outreach approaches was largely ineffective. 2) Study attrition: The findings indicate that those who take more effort to be recruited, are younger, are heavier smokers, have less confidence to quit, and are less physically active require more effort to be retained once recruited . 3) Main quantitative outcomes: A smoking reduction intervention for economically disadvantaged smokers which involved personal support to increase physical activity appears to be more effective than usual care in achieving reduction and may promote cessation. The effect does not appear to be influenced by an increase in physical activity. 4) Intervention fidelity was deemed to be successful overall. Key areas for improvement have been identified, including recommendations for future training as well as methodological implementation.

Copies of author's previously published articles inserted. / Bibliography: leaves 174-192. / xiii, 222 leaves : ill. ; 30 cm. / Title page, contents and abstract only. The complete thesis in print form is available from the University Library. / Thesis (Ph.D.)--University of Adelaide, Dept. of Psychology, 1994

Background: Current smoking-cessation medicines can assist smokers to quit, but have limited efficacy. Supplementing them with a replacement for the sensory and behavioural aspects of smoking, which are hypothesised to act as secondary reinforcers, could in theory help to alleviate urges to smoke and withdrawal, and may assist smoking cessation. Methods: Three studies were conducted to examine sensorimotor replacement (SMR) effects. The first two employed a cross-over design to assess the effects of two SMR products, nicotine-free electronic cigarettes (ECs) and de-nicotinised cigarettes (DNCs), on short-term withdrawal, urges to smoke, and user acceptability. Study 1 (N= 35), compared EC to a stress ball (SB) to control for behavioural distraction and Study 2 (N=41) tested whether SMR effects were ‘dose dependent’ by comparing DNCs with ECs. The final study was part of a randomised controlled trial (N= 200) of DNCs in combination with standard treatment. It examined whether SMR effects on abstinence are moderated by scores on a ‘behavioural’ dependence measure (GN-SBQ). Results: The EC was preferred over the SB, and alleviated urge to smoke more than SB, but the effect was modest and short-lived. The DNC and EC had similar effects acutely, but DNC suppressed urges to smoke and withdrawal to a somewhat greater extent over a day of abstinence. DNCs combined with standard smoking-cessation treatment improved short-term abstinence regardless of GN-SBQ scores. Conclusion: SMR effects on urge and withdrawal alleviation were modest and a ‘dose response’ effect was not clearly established. An attempt to identify smokers for whom SMR may be of particular benefit was not successful. SMR however, was perceived as helpful and appealing, and results from the trial suggest that adding SMR may enhance existing treatments. It was proposed that rather than directly alleviating urges/withdrawal, SMR may operate as a coping tool in ‘high-risk’ situations, by providing an alternative to smoking.

Lung cancer is one of the most important causes of 'avoidable deaths' globally and is responsible for approximately 900,000 deaths per year. However, lung cancer rates tend to be higher for males than for females and the disease also varies geographically, as rates are far higher in developed countries compared to developing countries. Scotland has the highest rate of lung cancer of any country where lung cancer data is available. However, explaining the spatial distribution of this disease is difficult because lung cancer has a number of known causes that operate at a range of different spatial scales. This is further complicated by the lag time between the period of exposure to a risk factor and the date of diagnosis. This thesis examines the causes of lung cancer across Scotland, using lung cancer registrations for the period 1988 to 1991. Exploratory methods are presented for examining the geographical distribution of the disease in small areas using methods of age-standardisation and cluster detection to identify areas with unusual rates. Estimates of the key risk factors potentially associated with lung cancer are calculated for the same small areas. These include estimates of smoking behaviour, air pollution levels in 1971 and 1991, radon gas potential, coal mining activity, quarrying activity and area deprivation. The risk factors are incorporated into a set of regression models to examine which factors are significant in explaining lung cancer incidence. Finally, the residual values derived from the optimum model of lung cancer incidence in Scotland are examined to identify areas where lung cancer incidence is particularly high and low. This study revealed that there were marked geographical differences in lung cancer rates, with higher rates in the large urban areas, especially Glasgow, and also the more deprived areas of Scotland. Smoking was consistently significant in explaining lung cancer incidence for all cohorts, types of lung cancer and urban-rural areas. The estimated air pollution levels in 1971 were also found to be significant, but the 1991 estimates were not. Exposure to radon was only significant in explaining lung cancer in the younger age groups. However, the coal mining and quarrying variables did not independently influence the incidence of the disease. Area deprivation and measure of urbanness both had a significant effect on lung cancer incidence in Scotland that was independent of the key risk factors. The analysis of the residual values showed that, having controlled for the key risk factors, lung cancer incidence is higher than expected in rural rather than urban areas.

Some metals and metalloids make significant contributions to the harmful effects of tobacco consumption although understanding the mechanisms involved in toxicity is hampered by the lack of information on their chemical and valence species, both in tobacco and in smoke. This research addresses the speciation of the metals and metalloids most frequently implicated, particularly those elements that exist in nature in multiple valence states, namely arsenic (As) and chromium (Cr), there being considerable differences in toxicity with oxidation state. A strategy was devised to overcome some of the problems that have thwarted earlier attempts at speciation. Firstly tobacco plants were cultivated under controlled conditions in compost burdened with high levels of metals and metalloids resulting in leaf with up to 250 µg g⁻¹ As, although Cr uptake was less successful. Secondly valence speciation even at the exceptionally low concentrations of As and Cr in smoke from unburdened tobacco was achieved with XANES analysis using the exceptionally bright Diamond synchrotron source. This revealed that combustion of tobacco has a marked effect on valence speciation with As(III), the reduced form of As, dominating (and persisting) in condensate of tobacco smoke while ash is dominated by the oxidised form, As(V). Chromium also appears to be present in smoke mainly as reduced Cr(III) species. HPLC-ICPMS analysis of arsenic indicates the dominance of inorganic over organic species (~4:1). Other metals were investigated in less detail. These findings establish that arsenic is present in smoke in its most toxic form and represents a significant risk to health. Conversely smokers appear to be exposed to the less harmful species of chromium. These results support a recent WHO report that includes As but not Cr in a list of four metals and metalloids recommended for regulation in crops and commercial products in the interests of public health.