The social norms concept provides a fresh basis for thinking about how public health policies and campaigns impact health behaviour. Social norms offer much promise to the field of public health, nonetheless, the potential role of norms in changing health behaviour have not been fully embraced. This thesis demonstrates that one of the mechanisms by which national level policies (e.g. tobacco control) can promote health behaviour change, such as an increase in quit intentions, is by making smoking less normative and an undesirable behaviour. This study is vital as it provides a broad conceptualization of tobacco denormalisation and shows how its reasoning is able to influence normative beliefs and smoking behaviour. A review of literature was carried out to establish the generic origins of denormalisation as well as demonstrate that this approach (i.e. social norms) has been widely adopted in schools and college settings to influence health behaviour. As a broader perspective of this thinking was imperative to address public health issues at a societal level, tobacco control was employed to investigate how individual polices influence behaviour and normative beliefs. The research methodology used was pluralistic in nature, given that the majority of past tobacco control policy studies employed either quantitative or qualitative methods. Thus adopting both methods a richer amount of data would be obtained in order to generate an improved understanding of how public policy affects norms and smoking behaviour. To empirically examine the relationship between public policy, social norms and smoking behaviour a broad conceptualization was developed to investigate the normative pathways between national level tobacco policy effects on youth and adults’ smoking behaviour. Quantitative results from the longitudinal study, the International Tobacco Control (ITC) Scotland/UK survey, indicate that a comprehensive smoke-free law that covers, without exception, an entire nation (i.e. Scotland) has increased adult smokers’ perceived social unacceptability of smoking, to some extent higher in Scotland than rest of the UK which, in turn, is associated with quit intentions at follow-up, in both countries. The examination of data from the UK Youth Tobacco Policy Study (YTPS) also demonstrated that the influence of tobacco marketing awareness on adolescents’ smoking intentions is mediated by perceived norms. Prior to the enactment of the UK Tobacco Advertising and Promotion Act (TAPA), higher levels of awareness of tobacco advertising and promotion were independently associated with higher levels of perceived sibling approval which, in turn, were positively related to smoking intentions. Independent paths from perceived smoking prevalence and benefits fully mediated the effects of advertising and promotion awareness on intentions, during and after the enactment of the TAPA. Results from the qualitative study generally supported the quantitative findings and provided new insights into how adolescents’ normative beliefs and smoking behaviour are influenced by tobacco control policies. The qualitative group discussion suggests that smoke-free legislation and anti-smoking ads influence perceptions of prevalence, acceptability and smoking behaviour. A number of theoretical implications were presented, including the belief that social norms campaigns and interventions must be focal and salient in individuals’ consciousness so as to effect the desired behaviour change. A theoretical framework of the various normative mechanisms should consequently be integrated into tobacco control policies and norm-based interventions to work in a synergistic manner to influence health-related behaviour. Practical implications of this conceptualization include the view that, instead of public health interventions focusing on conventional approaches (for example, scare tactics), an appropriate strategy would be to incorporate specific information that corrects normative misperceptions and ambiguities among referent populations at individual and societal levels, with consequential normative and health behaviour change. It is recommended that future research employing tobacco industry perceptions and possibly a descriptive norm as additional normative mediators, aside from unacceptability, would be of value to examine whether smoke-free legislation influences quitting partly via changing favourable tobacco industry perceptions, social acceptability of smoking and perceived prevalence of smoking. To sum up, the findings demonstrate that societal level policy measures such as smoke-free legislation and the TAPA are critical elements of a comprehensive tobacco control program that can significantly influence adult smokers’ quit intentions and reduce adolescents’ smoking intentions respectively, by signifying smoking to be less normative and to be socially unacceptable.

INTRODUCTION: The rate of smoking is significantly higher among people living with HIV (PLWH) in comparison to the general population (CDC, 2017b; Humfleet et al., 2009). Tobacco use among PLWH heightens the risk for HIV-related symptoms and is a pertinent public health issue. Smokers living with HIV are also more likely to develop non-AIDS-related illness in comparison to non-smokers living with HIV. Smoking cessation interventions are desperately needed to cater towards PLWH. This warrants the need for patient-provider interactions in healthcare facilities regarding smoking cessation. AIM: To document rates of smoking and visitations to healthcare facilities among persons living with and without HIV in higher vs. lower-risk areas and to examine associations among healthcare visitations, stressors, and smoking in these sub-samples (i.e., PLWH in higher-risk areas, PLWH in lower-risk areas, people without HIV in higher-risk areas, people without HIV in lower-risk areas). METHODS: Secondary analyses were conducted using data from a network-based, HIV endemic study that was conducted in Metro Atlanta (Rothenberg, Dai, Adams & Heath, 2017). The study included 927 participants from 10 Atlanta zip codes (5 lower-risk and 5 higher-risk based on reported HIV cases). Participants provided information on their smoking status and healthcare visitations, as well as whether they had experienced several stressors (e.g., violence, homelessness, being threatened with a weapon, lack of transportation). Descriptive analyses and frequency distributions were conducted and presented on key variables. Logistic regression analyses were conducted to examine associations between key variables and smoking. RESULTS: Overall, the rate of smoking was quite high in this study. Seventy-four percent of the sample smoked, which is almost five times the smoking rate among the general adult U.S. population (CDC, 2016a). The smoking rate was strikingly high among PLWH in the higher-risk areas (95%). In unadjusted analyses, participants who were older, male, homeless, and do not drive their own car were more likely to smoke. In the adjusted analyses age, gender, and lack of transportation remained significant predictors of smoking. Visitations to healthcare facilities were not significantly associated with smoking or other variables in this study. DISCUSSION: Smoking appears quite common among PLWH, especially those living in higher-risk areas. This study provided important information on the extent to which persons living with and without HIV in higher and lower-risk areas of Atlanta are receiving healthcare services, as well as how demographic factors and stress relate to smoking in these sub-samples. Future research is needed to develop and disseminate effective smoking cessation programs among smokers living with HIV.

Parental reports are often used in studies of asthma and allergic diseases in children. A change in respondent from parent to index subject usually occurs during adolescence. Little is known about the effects this change in method might have on the outcomes of a longitudinal study. Smoking is a major cause of respiratory symptoms among adults and environmental tobacco smoke (ETS) is a risk factor for asthma among children. Less is known about these associations among teenagers. In order to improve prevention of smoking, it is important to identify populations at risk of becoming smokers.       The aim of this thesis were to 1) evaluate the methodological change from parental to self-completion of a questionnaire about asthma and allergic diseases, and 2) to study determinants for, and respiratory health effects of ETS and personal smoking in teenagers. In 1996, a longitudinal study of asthma and allergic diseases among schoolchildren started within the Obstructive Lung Disease in Northern Sweden (OLIN) studies. All children in first and second grades (aged 7-8 years) in three municipalities, Luleå, Kiruna and Piteå (n=3,525) were invited and 97% participated by parental completion of a questionnaire. The cohort has been followed with annual questionnaires until age 16-17 years and with high participation rates (>91%). From age 12-13 years, the teenagers were the respondents and questions about their tobacco use were included. In addition to the questionnaire completed by the teenagers at age 13-14 years, a questionnaire was also distributed to a random sample of 10% of the parents and 294 participated (84%).   The parents and the teenagers reported a similar prevalence of asthma, respiratory symptoms, rhinitis, eczema and environmental factors. Two statistically significant differences were found: the teenagers reported a higher prevalence of wheezing during or after exercise (14% vs 8%, p<0.05), and having a dog in the home in the last 12 months (42% vs 29%, p<0.001). Answer agreement between parents and teenagers on questions about asthma was almost perfect with kappa values of 0.8-0.9. Corresponding kappa values for questions about respiratory symptoms and rhinitis were 0.3-0.6 and for eczema 0.5-0.6. Agreement about environmental factors varied from 0.2-0.9. Kappa values for parental smoking were 0.8-0.9. The risk factor pattern for allergic diseases was similar regardless of respondent, ie parent or teenager. The prevalence of smoking increased from 3% at 12-13 years to 6% at 14-15 years. Smoking was more common among girls, while the use of snus was more common among boys. Significant risk factors related to smoking among teenagers were smoking family members, female sex and living in an apartment. Having physician-diagnosed asthma did not prevent the teenagers from becoming smokers. Factors related to using snus were a smoking mother and male sex.  Daily smokers aged 16-17 years (9%) reported a significantly higher prevalence of wheezing and physician-diagnosed asthma compared to non-smokers. There was a significant dose-response association with higher prevalence of wheeze among those who smoked ≥11 cigarettes per day compared to those who smoked ≤10 per day. In multivariate analyses, maternal environmental tobacco smoke exposure was a significant risk factor for ever wheeze and physician-diagnosed asthma at age 16-17 years, while daily smoking was a risk factor for current wheeze. In conclusion, the methodological change of questionnaire respondent from parent to index subject did not substantially alter the findings of this longitudinal study. There were significant sex differences in the tobacco use: smoking was more common among girls and snus was more common among boys. The most important factor related to tobacco use was presence of family members who smoke. Both maternal ETS exposure and personal smoking was associated with asthma and wheeze in adolescence. ETS was associated with lifetime symptoms but daily smoking was more strongly associated with current symptoms.

This study revisits the effect of duration by residence in relation to smoking during pregnancy. It contributes to the literature by incorporating a health inequity perspective, and discusses whether immigrants tend to converge with Swedish women’s smoking. The study is based on Swedish Medical Birth Register and includes 1 1864 52 pregnancies between 1991 and 2012. Logistic regression was performed to attain crude and adjusted Odds Ratios and 95 % confidence intervals. Immigrants’ are divided by categorizing countries of origin depending on levels of Human Development (IHDI). Overall immigrant women show low levels of smoking during pregnancy when they arrive to Sweden, by duration of residence levels of smoking increase and converge with smoking patterns of Swedish women. I found that there are differences in smoking patterns depending on IHDI of the country. Immigrant women of higher categories of IHDI show higher levels of smoking although the increase of smoking is higher among immigrant women from categories of lower IHDI. However, immigrant women’s smoking during pregnancy is affected by duration of residence, and the increased smoking is associated with health inequalities related to their country of origins IHDI, and by socioeconomic inequalities in Sweden.

This study analyzes the depiction of drug usage, cigarette smoking and alcohol consumption in movies in terms of character stereotyping and typecasting. Because movies are focused on making money they are being used as marketing tools by alcohol and cigarette conglomerates (Grube, 2004). The study also explores youth perception of such content and tries to determine the behavioral implications or influence of such content on young children. The goal of this research is to analyze the social cognitive influence of movies on the youth and the effects of censorship in movies today. The research compares this effect in the two largest movie markets - the American market (Hollywood) and the Indian market (Bollywood) and the effect of these depictions on the youth to see whether this issue warrants a global understanding and awareness. The aim of this study is to understand the nature of the movie markets and the depiction of such content in movies. It analyses the issue solely from the perspective of a youth audience to better understand how the youth today perceive movies and to see if depiction of cigarette smoking, alcohol consumption and drug usage has a positive or negative effect on the youth audience. A part of the analysis of the study is to also better understand censorship techniques employed for both movie markets to see if they are effective or need to be improved upon. Finally the study asks the question of social responsibility and whether movies and movie stars have a responsibility to maintain higher censorship standards or they are merely depiction art through the medium and should not be held accountable for their depictions on screen.

(DSM-IV-TR/) nor in withdrawal scales. However, a related term, "impatience" is listed in some nicotine withdrawal scales. (Hughes J. R., Measurements of the Effects of Abstinence from Tobacco: A Qualitative Review, 2007). Although impatience is not a synonym of impulsivity, both share the synonym "impetuous". Therefore, impatience can be considered a measure of impulsivity. Although some reviews of the effect of smoking cessation on impatience have occurred, we know of no quantitative review of prospective studies of whether smoking cessation increases impatience. Purpose: To evaluate the effect of smoking cessation on impatience as measured by the Minnesota Nicotine Withdrawal Scale-Revised (MNWS). Methods: A literature search of MEDLINE (PubMED), EMBASE, and PsychInfo was conducted. Articles containing relevant keywords were reviewed by two evaluators independently. To be considered for inclusion in the meta-analysis, studies had to be prospective studies, had to have pre-cessation impatience measurements, to include at least overnight abstinence, had to have smoking abstinence biochemically verified, and had to include effect size as an outcome measure. Results: All pooled analyses were based on random-effects models. Seven trials met the selection criteria. The total number of subjects was 426. There was a significant level of heterogeneity among studies (X2(6), pI2= 89%). The summary mean effect for impatience after tobacco cessation was an increase of .44 on a 0-3 scale (95% confidence interval [CI], 0.21-0.67) and a p-value Conclusion: The meta-analysis shows that impulsivity increases post smoking cessation. These findings imply that smoking cessation may have an effect on decision making. Additionally higher rates of impulsivity have been associated with smoking relapse. (Doran, Spring, McChargue, Peradia, & Richmond, 2004). In order to better assist in the development of individual treatments, a better understanding is needed of how increased impulsivity influences cognitive behavior and relapse rates. These findings support the inclusion of impulsivity as a criterion for nicotine withdrawal.

Delay discounting is considered by many to be a risk factor for substance use disorders and other health-related behavior problems. While these health-related behavior problems are often treated with incentive-based interventions, little is known about whether delay discounting (DD) moderates response to that treatment approach. The present study examined how response to incentive-based smoking-cessation treatment varied as a function of baseline DD scores among pregnant women participating in randomized controlled clinical trials examining the efficacy of financial incentives. Women were assigned to a condition wherein they earned vouchers exchangeable for retail items contingent on abstinence from recent smoking or to a control condition wherein they received vouchers of comparable value but independent of smoking status. Individual differences in DD of hypothetical monetary rewards were measured at the study intake and follow-up assessments. We examined whether individual differences in baseline scores on that instrument predict antepartum and postpartum smoking status using logistic regression, and if sustaining abstinence caused changes in DD scores from intake to 24-weeks postpartum. We did not see any significant main effects of DD or interactions of DD with treatment on antepartum or postpartum smoking status. Treatment condition, baseline smoking rate (cigs/day), a history of quit attempts pre-pregnancy, and educational attainment were all associated with increased odds of abstaining from smoking at the late-pregnancy antepartum assessment, and treatment condition was the only significant predictor of abstaining from smoking at 24-weeks postpartum, three months after the treatment formally ended. We saw no discernible evidence that sustained abstinence from smoking was associated with post-treatment decreases in DD. Overall, we saw no evidence that being a steeper discounter is associated with a lack of success in quitting smoking in either treatment condition. Being assigned to the incentives condition was the only predictor of antepartum and postpartum abstinence. The observed associations of a lower baseline smoking rate, higher educational attainment, and a history of having attempted to quit smoking previously with increased odds of success in achieving antepartum smoking abstinence is consistent with results from previous reports on predictors of response to this treatment underscoring the reliability of these relationships.

Caffeine and nicotine are the two most commonly consumed licit psychoactive drugs in the world. In addition, they are frequently co-administered with over 86% of cigarette smokers reporting caffeine use versus 77% of non-smokers. Research suggests the combination of nicotine and caffeine produces effects that are more rewarding or pleasurable than either drug alone, and this potential reward enhancement may influence patterns of tobacco use initiation and maintenance. Waterpipe tobacco smoking is an alternative tobacco use method that is increasing in prevalence in the U.S. and offers a novel opportunity for nicotine and caffeine co-administration via a caffeinated tobacco product (Tangiers F-Line). Based on previous work, this caffeinated tobacco product was hypothesized to enhance reward-related and cardiovascular effects in waterpipe users relative to tobacco-only waterpipe preparations. Thirty-two waterpipe tobacco smokers who regularly drank caffeinated beverages participated in a four condition, Latin-square ordered, within-subjects study. In each condition, there was a 45-minute double-blind product administration period that differed by the content of waterpipe product smoked: caffeine and nicotine (Tangiers F-Line), nicotine and no caffeine (Tangiers), reduced (low) nicotine and caffeine (low nicotine Tangiers F-Line), or neither nicotine nor caffeine (Soex). Outcome measures included blood plasma caffeine and nicotine, cardiovascular response, expired air carbon monoxide (CO), puff topography, and subjective ratings. Plasma analyses revealed no detectable levels of caffeine from either caffeinated product, but significant nicotine exposure from all nicotine-containing products. Few differences between conditions were observed for subjective measures. Larger puff volumes were observed for products that contained low or no nicotine, resulting in higher CO concentrations for these conditions. While findings do not address whether caffeine can be delivered via volatilization, they suggest that measurable caffeine exposure was not observed for the products examined and under the conditions explored here. Importantly, study results support continued investigation of the effects of waterpipe tobacco smoking using a placebo-controlled design as well as demonstrate that tobacco dependence and toxicity capabilities are still concerns for these and other waterpipe products.

Understanding the factors that influence regular tobacco use often involves detailed assessment of individuals' smoking behavior (i.e., puff topography), including measuring puff number, volume, duration, and inter-puff interval (IPI) via mouthpiece-based, computerized devices. For example, puff topography measurement has been used to study smoking cessation medications, as well as to demonstrate brand-induced changes in smoking behavior. However, some research suggests that the use of a mouthpiece to evaluate puff topography may alter natural smoking behavior. Thus, this study was designed to compare topography measurement using mouthpiece-based methods (i.e., desktop and portable computerized devices) to methods that do not use a mouthpiece (i.e., direct observation via video recordings).Thirty smokers of "full-flavor" or "light" cigarettes (≥15 cigarettes/day) participated in six Latin-square ordered, 2.5-hour experimental sessions. Sessions were separated by at least 48 hours, and were preceded by at least 8 hours of objectively-verified tobacco abstinence (i.e., CO level ≤10 ppm). Conditions differed by type of cigarettes smoked (own brand, Merit® Ultra-light) and by type of topography measurement method used (desktop, portable, video observation). All three measurement methods were sensitive to manipulations of cigarette brand (i.e., increased puff duration and volume for own brand relative to ultra-light; P 0.68). All methods were also reliable, as demonstrated by high correlations across cigarette bouts within each condition (most r's > 0.78). In contrast, participants perceived the use of either mouthpiece-based device to alter aspects of their smoking behavior (e.g., increased difficulty, reduced enjoyment, altered cigarette taste; P < .05) relative to direct observation alone. Although direct observational methods may be optimal for measuring certain smoking characteristics, the many logistical challenges posed by this method likely limit its usefulness in a laboratory setting. Taken together, these results suggest that mouthpiece-based devices offer a convenient and useful tool for researchers examining smoking topography.

Cigarette smoking and other forms of tobacco use are responsible for over 440,000 deaths per year in the U.S. Health consequences associated with cigarette smoking include cardiovascular disease, respiratory disease, and cancer. Despite awareness of the health risks, approximately 21% of the U.S. adult population smokes. Efforts to-date to reduce smoking-related disease and illness have focused on prevention and intervention strategies that encourage cessation. Adolescence is a critical period for both intervention and prevention. Because more than three-fourths (80%) of adult smokers reported starting to smoke prior to the age of 18, prevention and brief intervention is likely to be most effective during this early period of time. In addition, earlier age of onset for smoking is associated with greater subsequent dependence severity, more substantive health sequelae, and less successful outcomes following subsequent quit attempts. Several studies have explored potential demographic and psychosocial variables that may help predict the likelihood adolescents may initiate smoking. Interestingly, many of these studies have focused predominately on Caucasian populations. Thus, is it unclear whether such findings hold true with population subgroups such as African American youth. In research to-date, AA and Caucasian groups differ in rates of smoking initiation, subsequent levels of nicotine dependence, and tobacco cessation efforts. Additionally, as adults, AA bear a disproportionate weight of smoking-related adverse health effects. Previous studies posit that certain variables (demographics, social/peer influences) may differentially influence smoking in AA adolescents. Clearly, more research is needed comparing predictors of AA adolescent smoking to those published with predominantly Caucasian adolescent samples. The present study (N=150) employed a computer-directed assessment to examine smoking in an urban sample of AA adolescents recruited through their primary care provider. The assessment included demographic and psychosocial variables previously found to predict the likelihood of an adolescent trying a cigarette in Caucasian adolescent samples (e.g., peer smoking, adult smoking in the home, self-esteem, and self-efficacy). Findings indicated that AA adolescent smokers (ever smokers) were more likely to have friends who have tried smoking, were more likely to have adult smokers in the home, and scored lower in self-efficacy skills germane to avoiding situations where smoking was present, as compared to nonsmokers. Additionally, computerized assessment for tobacco use was found to be useful in clinic settings. Study findings can aid in the development of specialized prevention and cessation campaigns for minority populations.