D.Phil. / The aim of this study was to explore the psychosocial factors which impact on smoking behaviour and to consider the impact of these factors on the formulation of national policy, as well as business and management practices around the marketing and promotion of tobacco products. An analytic induction approach was followed in analysing the data of multiple cases. Interviews and observations were used to gather in-depth information on nine participants (smokers, ex-smokers, social smokers and non-smokers). The data was subjected to analytic induction in order to build a typology of smoking behaviour. This theoretical tool was compared to current knowledge and culminated in a model of psychosocial factors that influence smoking behaviour, which was tested against a further four cases. No negative cases were found. The outcome of this study suggests that promoters of tobacco products should follow a more focused approach towards dark marketing. It also highlights that government and other anti-smoking agencies are not always effective in reducing smoking and counteracting covert marketing practices. The study also illustrated that analytic induction can be applied successfully in consumer behaviour studies. Finally, it contributed to local knowledge of qualitative research, as analytic induction has not been applied fully in a local study before.

Masters Research: Faculty of Health Sciences / Background Smoking is undoubtedly a major risk factor for morbidity, disability and premature death. Its use results in grave health and economic losses not only to the individual but also to the population and the world at large. Many surveys have been done in South Africa to estimate the prevalence of smoking. It is therefore imperative and expedient to have an overall impression of the prevalence rates over time. And also it is important to assess how subgroups affect the prevalence and trends in the national population. This will be of help in determining which subgroups have achieved reduction in smoking prevalence and which have not; evaluating the tobacco control policies in the country; and in designing specific interventions. This research was undertaken to determine the trends and patterns of smoking in the South African adult population Objectives The objectives for this study were: Regarding the South African adult population during 1995 – 1998, to: 1. Compute the prevalence of smoking and assess the trends of smoking prevalence. 2. Assess the patterns and trends of smoking prevalence in subgroups by sex, age, marital status, race, locality (urban or rural), education and province. 3. Identify factors in the population that may account for patterns and trends in smoking prevalence over time 4. Make recommendations regarding the public health implications of the findings 5 Methods This was an analytical study involving secondary analysis of existing datasets from four South African representative national surveys. From 11 surveys, which measured smoking in the South African population, four surveys were selected using some inclusion and exclusion criteria. The population of interest was the South Africa adult population (18 – 49), so variables of interest (outcome variable was current smokers) for this group were extracted. Prevalence (frequency) rates estimation of smoking in the national population and in subgroups were then estimated. Unadjusted odds ratios and adjusted odds ratios were computed by bi-variate cross tabulation and multivariate logistic regression respectively. Time-trend analyses (Maentel Haenszel chi-squared test) were computed by logistic regression for trend in proportions Results From 1995 to 1997 about 1/3 of the adult South African population were smokers, but that dropped significantly to about ¼ in 1998. For the period however, there was no significant trend. The prevalence of smoking varied with, and was largely depended on population subgroup; while it was as high as 63.9% among Coloured males, 62.3% among Coloured females, 53.7 % among all males, 52.7% among rural males, it was as low as 11.4% among all females, 6.8% among rural females, 10.83% among Indian females and 5.06% among Black females. The only significant trends was an increasing smoking prevalence among Blacks, Coloured men, people with tertiary education, Free State and Gauteng provinces, age group 35 – 44; urban men and a decreasing smoking prevalence in all women, urban women and black women, age group 18 – 24 and the Eastern Cape, Kwazulu-Natal, Northen Cape and Mpumalanga provinces. Sex, race, age, and education were the major risk factors for smoking in the

Chong Kin Ngai. / Summary in Chinese. / Thesis (MBA) - Chinese University of Hong Kong. / Bibliography: l. 118-119.

Thesis (M.D.)—Boston University

The research literature suggests that clinicians fail to adequately use health education interventions that have been demonstrated to be effective. This thesis examines the use of smoking cessation education (SCE) by clinicians who care for pregnant women. It investigates the clinician, organisational and dissemination variables which impact on the provision of smoking cessation education in antenatal clinics. Individual behaviour change theory, organisational theory and diffusion theory are used to guide the design and analysis of the research. A series of cross-sectional studies are used to investigate the provision of SCE and the outcomes of dissemination of a tested SCE program. Data are collected from multiple sources and both qualitative and quantitative research methods are used. Studies 1 and 2 indicated there was a performance gap between the reported SCE practice of clinicians who provide care for pregnant women and the recommended guidelines for SCE practice. The primary modifiable barriers to the provision of SCE by clinicians were: low clinician self-efficacy with regard to SCE; inadequate smoking assessment; lack of hospital SCE policy; and inadequate training. To overcome these barriers a SCE program was disseminated to 23 hospital antenatal clinics in NSW. Prior to dissemination, the organisational context of the clinics was explored using qualitative methods to determine the potential barriers to dissemination and to recommend strategies to overcome these barriers (Study 3). The remaining Studies (4-6) describe the outcomes of program dissemination using two methods of dissemination (intensive and simple). Clinics were randomly allocated to the two dissemination methods. Studies 4 and 5 describe program adoption by clinic managers three months after the initial dissemination. Study 6 investigates the implementation and maintenance of the program by clinicians 18 months after dissemination. The final study also examines the effect of two methods of dissemination on the provision of SCE in antenatal clinics. Most managers adopted or partially adopted the new SCE program. The fidelity of program adoption was better when intensive dissemination methods were used and when managers had more positive perceptions of the program. Dissemination method did not affect the number of SCE interventions offered by clinics, but clinicians in the intensive dissemination group were more likely to use more intensive and effective forms of SCE intervention. Nevertheless, the program was poorly implemented and SCE was not systematically provided in clinics after dissemination. The organisational, individual and dissemination barriers to health education are described.

Introduction: The association between smoking and depression has been well established, but the nature of the relationship has not been determined. A synthesis of longitudinal studies examining the onset of smoking and depression among adolescents demonstrated consistent evidence of both smoking predicting depression and depression predicting smoking in multiple populations; however, more work is needed to develop and test the mechanisms associated with the onset of the co-occurrence of smoking and depression. This thesis examines the role of a broad range of potential confounders on the relationship between smoking and depression, and investigates a potential mechanism of effect. Method: Analyses were conducted using the Nicotine Dependence in Teens (NDIT) cohort which included 1293 students initially aged 12-13 years recruited from all grade seven classes in a convenience sample of ten secondary schools in Montreal, Canada surveyed twenty times over five years. Multiple regressions were performed to examine the temporal relationship of potential confounders on the relationship between smoking and depression and to empirically observe variables that could be intermediate on pathways between smoking and depression. A growth curve model was developed to test the effect of perceived self medication on changes in depression scores over time. Results: A concept map of the smoking and depression relationship in the NDIT cohort was developed according to the results of proportional hazard and fixed effect regressions in which friend smoking, stress, and anxiety-associated variables were identified as intermediate variables. Perceived self-medication was associated with decelerated rates of change of depressive symptoms over times, suggesting that smoking may increase mean levels of stress and depressive symptoms, but may offer the perception of control. Conclusion: In concert, this thesis suggests a model in which stress and the perceived control of psychobiological function using cigarettes lead to the development of increased depressive symptoms and increased cigarette use.

Introduction: The association between smoking and depression has been well established, but the nature of the relationship has not been determined. A synthesis of longitudinal studies examining the onset of smoking and depression among adolescents demonstrated consistent evidence of both smoking predicting depression and depression predicting smoking in multiple populations; however, more work is needed to develop and test the mechanisms associated with the onset of the co-occurrence of smoking and depression. This thesis examines the role of a broad range of potential confounders on the relationship between smoking and depression, and investigates a potential mechanism of effect. Method: Analyses were conducted using the Nicotine Dependence in Teens (NDIT) cohort which included 1293 students initially aged 12-13 years recruited from all grade seven classes in a convenience sample of ten secondary schools in Montreal, Canada surveyed twenty times over five years. Multiple regressions were performed to examine the temporal relationship of potential confounders on the relationship between smoking and depression and to empirically observe variables that could be intermediate on pathways between smoking and depression. A growth curve model was developed to test the effect of perceived self medication on changes in depression scores over time. Results: A concept map of the smoking and depression relationship in the NDIT cohort was developed according to the results of proportional hazard and fixed effect regressions in which friend smoking, stress, and anxiety-associated variables were identified as intermediate variables. Perceived self-medication was associated with decelerated rates of change of depressive symptoms over times, suggesting that smoking may increase mean levels of stress and depressive symptoms, but may offer the perception of control. Conclusion: In concert, this thesis suggests a model in which stress and the perceived control of psychobiological function using cigarettes lead to the development of increased depressive symptoms and increased cigarette use.

The dangerous health effects of smoking during pregnancy and during the postpartum period are well-established, yet a significant proportion of pregnant women continue to smoke despite being aware of the health risks and wanting to quit. While many risks factors for continued smoking or relapse have been identified, these factors are largely demographic and difficult to change. The purpose of the present study was to identify and measure the psychological factors that predict smoking cessation intentions and behaviours among pregnant women, during pregnancy and the postpartum period, who are either currently smoking or have recently quit. Pregnant smokers (N= 56) were asked to complete a series of questionnaires designed to access their reasoning at the three levels outlined by the Reasons Model and their feelings of autonomy and competence, and partner support in quitting smoking as indicated by Self-Determination Theory. Participants were also asked to complete a number of other questionnaires and a short, semi-structured interview to assess other factors potentially related to smoking behaviour. Participants were then re-contacted twice after their baby was born, at approximately two months and four months postpartum. At both times, participants were asked to again complete the questionnaire package and a short semi-structured interview. It was hypothesized that Reasons Model and Self-Determination Theory would predict both current and future intentions to quit smoking, and smoking behaviour, respectively. It was also hypothesized that those with direct experience with quitting smoking or reducing their smoking behaviour during pregnancy and postpartum (multigravida) would be more accurate in predicting their intentions to quit smoking and smoking behaviour than would those who were pregnant for the first time (primagravida). The results indicated some support for the ability of the two models to predict intentions to quit and smoking behaviour, though was limited by the small sample size. Further, level of direct experience emerged as a significant factor in participants’ ability to predict their intentions and behaviour regarding smoking. The current study suggests that both the Reasons Model and Self-Determination Theory are important tools for assessing and developing interventions for helping women to make positive changes in their smoking behaviour during pregnancy and postpartum.

The dangerous health effects of smoking during pregnancy and during the postpartum period are well-established, yet a significant proportion of pregnant women continue to smoke despite being aware of the health risks and wanting to quit. While many risks factors for continued smoking or relapse have been identified, these factors are largely demographic and difficult to change. The purpose of the present study was to identify and measure the psychological factors that predict smoking cessation intentions and behaviours among pregnant women, during pregnancy and the postpartum period, who are either currently smoking or have recently quit. Pregnant smokers (N= 56) were asked to complete a series of questionnaires designed to access their reasoning at the three levels outlined by the Reasons Model and their feelings of autonomy and competence, and partner support in quitting smoking as indicated by Self-Determination Theory. Participants were also asked to complete a number of other questionnaires and a short, semi-structured interview to assess other factors potentially related to smoking behaviour. Participants were then re-contacted twice after their baby was born, at approximately two months and four months postpartum. At both times, participants were asked to again complete the questionnaire package and a short semi-structured interview. It was hypothesized that Reasons Model and Self-Determination Theory would predict both current and future intentions to quit smoking, and smoking behaviour, respectively. It was also hypothesized that those with direct experience with quitting smoking or reducing their smoking behaviour during pregnancy and postpartum (multigravida) would be more accurate in predicting their intentions to quit smoking and smoking behaviour than would those who were pregnant for the first time (primagravida). The results indicated some support for the ability of the two models to predict intentions to quit and smoking behaviour, though was limited by the small sample size. Further, level of direct experience emerged as a significant factor in participants’ ability to predict their intentions and behaviour regarding smoking. The current study suggests that both the Reasons Model and Self-Determination Theory are important tools for assessing and developing interventions for helping women to make positive changes in their smoking behaviour during pregnancy and postpartum.

“Light” and “low tar” cigarettes have been designed by the tobacco industry to allay smokers’ concerns about the health risks of smoking. Few studies have examined which factors lead smokers to believe that “light” cigarettes are less harmful. In particular few studies have addressed whether the belief that “light” cigarettes are smoother predicts the belief that “light” cigarettes are less harmful. There is some evidence that this relation should exist especially given that the belief that “light” cigarettes are smoother has been used to market these cigarettes and there is a natural association between smoother and less harmful. I conducted 7 studies to examine various aspects of the relation between the sensory belief that “light,” “low tar” or your own brand of cigarettes is smoother and the belief that “light,” “low tar” or your own brand of cigarettes is less harmful. Study 1 used Wave 1 to Wave longitudinal data from the International Tobacco Control Four Country Survey (ITC-4) to demonstrate that smokers in Canada, the United States, the United Kingdom, and Australia who believe that “light” cigarettes are smoother at Wave 1 are significantly more likely to believe that “light” cigarettes are less harmful at Wave 2 (p=0.002, OR=1.59 95% CI 1.19-2.12). Study 2 used Wave 1 cross-sectional data from the International Tobacco Control China Survey (ITC China) to demonstrate that smokers in China who believe that “light” and/or “low tar” cigarettes are smoother are significantly more likely to believe that “light” and/or “low tar” cigarettes are less harmful (p<0.001, OR=62.86 95% CI 47.65-82.91). Study 3 used Wave 1-Wave 2 longitudinal data from the ITC China Survey to demonstrate that smokers in China who believe that “light” and/or “low tar” cigarettes are smoother at Wave 1 are significantly more likely to believe that “light” and/or “low tar” cigarettes are less harmful at Wave 2 (p=0.02 OR=1.63 95% CI 1.10-2.43). Study 4 used Wave 3 cross-sectional data from the North American Student Smoking Survey (NASSS) to demonstrate that adolescent smokers in North America who believe that “light” cigarettes are smoother believe that “light” cigarettes are healthier (p<0.001 OR=3.96 95% CI 2.92-5.36), and in a separate model, that the belief that “light” cigarettes are less harsh also predicts the belief that “light” cigarettes are healthier (p<0.001, OR=5.45 95% CI 4.34-6.84). Study 5 used Wave 3 to Wave 4 longitudinal data from the North American Student Smoking Survey (NASSS) to demonstrate that adolescent smokers in North America who believe that “light” cigarettes are less harsh at Wave 3 predicts the belief that “light” cigarettes are healthier at Wave 4 (p=0.02, OR=1.72 95% CI 1.08-2.72). Studies 6 and 7 examined how the personalized belief that your own brand of cigarettes is smoother related to the belief that your own brand of cigarettes is less harmful. Study 6 used cross-sectional data from Wave 6 of the ITC Four Country Survey in Canada only. Study 6 demonstrated that smokers who believed that their own brand of cigarettes is smoother were significantly more likely to say that their brand of cigarettes is less harmful (p=0.004, OR=2.23 95% CI 1.29-3.86). Study 7 used cross-sectional data from Wave 2 of the ITC China Survey to demonstrate that smokers who believed that their own brand of cigarettes is smoother believed that their brand of cigarettes is less harmful (p<0.001, OR=5.10 95% CI 3.69-7.03). The findings from this dissertation demonstrate the importance of implementing tobacco control policies that address cigarette design and marketing that provide the impression that a cigarette is smoother and therefore less harmful.