Introducción: El consumo de sustancias psicoactivas en la adolescencia y adultez temprana se ve sujeto a una naturaleza dinámica compleja. Objetivo: Evaluar los factores de riesgo para el consumo de SPA en jóvenes peruanos que participaron en la cohorte mayor de “Niños del Milenio” en dos periodos durante el 2009 al 2016. Materiales y métodos: Realizamos un estudio observacional, analítico, tipo cohorte basado en la revisión secundaria de la cohorte mayor de “Niños del Milenio” en Perú. Nuestra población incluyó aquellos registros con datos completos de la 1era a la 5ta ronda analizados en dos periodos de seguimiento. Se excluyeron aquellos registros que reportaron el consumo alguna SPA al inicio de cada periodo. Se obtuvo una potencia mayor al 80%. Realizamos un Modelo Lineal Generalizado familia Poisson con función de enlace log ajustado por clústeres que permitió calcular el riesgo relativo. El análisis se efectuó en Stata versión 14.0. Los valores p <0.05 fueron considerados estadísticamente significativos. Resultados: La incidencia de consumo de alguna SPA fue de 67.31% y 60.20% en el primer y segundo periodo, respectivamente. En el Periodo 1, ser hombre, tener amigos consumidores de alcohol o tabaco y pertenecer a una familia monoparental incrementó el riesgo de consumir alguna SPA. En el Periodo 2, ser hombre incrementó el riesgo de consumir alguna SPA mientras no encontrarse estudiando lo redujo. Conclusión: La incidencia de consumo de SPA fue 67.31% y 60.20% en cada periodo. Factores sociodemográficos y psicosociales incrementaron el riesgo de consumo. / Introduction: Psychoactive substance use onset in adolescence and youth is driven by a complex dynamic nature. Objective: We aim to evaluate risk factors related to PAS use in Peruvian youth enrolled in the older cohort of “Young Lives” Study in two periods through 2009 to 2016. Materials and Methods: We conducted a cohort type study based on secondary analysis of the older cohort of “Young Lives” Study in Peru. Our population included those subjects with complete data from all phases (1st to 5th). This data was analyzed in two follow-up periods. Those who declared the consumption of any PAS were excluded at baseline of each period. We obtained a power greater than 80%. We perform a Generalized Linear Model, Poisson family with log link adjusted by clusters from which we calculated crude and adjusted relative risk. The analysis was performed using Stata version 14.0. P-values <0.05 were considered statistically significant. Results: The incidence of PAS use was 67.31% and 60.20% in the first and second period, respectively. On Period 1, being male, having alcohol and tobacco consuming friends and belonging to a single-parent family increased the risk of consuming PAS. On Period 2, being male increased the risk of consuming any PAS and not being enrolled in school decreased it. Conclusion: PAS incidence was 67.31% and 60.20% in each period. Various sociodemographic and psychosocial factors increased the risk of consumption. / Tesis

This dissertation is an empirical investigation into the roles that different quantifiable and measurable perceptions play in defining individual behavior across a variety of decision-making contexts. In particular, the focus lies on smokers and the choices they make with regard to smoking and beyond. Chapter 1 analyzes a nationally representative sample of adults (23 years and older) in the United States, pertaining to the Annenberg Perception of Tobacco Risk Survey II (1999-2000). It is observed that three dimensions to smoking behavior viz., risk, temporality and addiction, interact to determine the smoking status of an individual. Although previous studies mostly looked into each of these dimensions in isolation, in this chapter, we empirically illustrate how perceptions on risk, time dimensions and addiction, jointly influence the smoking behavior of adults. Chapter 2 casts the smoker in the role of a parent and explores parental behavior towards the general health-risks facing their children. Using the dataset from a survey (2009), conducted in Orlando, Florida, on parents, having at least one child aged between 1 and 16 years, the chapter arrives at two findings relevant for policy: i) In each of the ‗smoker‘ and ‗non-smoker‘ parent categories, parents exhibit equal concern for themselves and their children, and ii) the level of concern shown by smoker-parents, towards health-risks faced by their children, is the same as that shown by their non-smoking counterparts. The analysis in this chapter also affirms the need to incorporate subjective risk assessment in willingness-to-pay (WTP) exercises to facilitate a deeper behavioral analysis of health risk valuation. Lastly, in Chapter 3, we focus on the issue of quantitative assessment of the perception of health risks from smoking. Particular interest lies in understanding how variants of a metric - namely, a survey question - have been employed in academic studies and industry-surveys, in order to measure smoking-related risk-perceptions. In the process of reviewing select tobacco-industry survey iv records, we analyze the implications of different features of this metric, (e.g., use of a ‗probe‘, the ‗Don‘t Know‘ option), and various interview modes (e.g. telephonic, face-to-face), for the estimates of perceived risk arrived at in these studies. The review makes clear that two aspects of health risks from smoking – the risk of contracting a smoking-related disease, as against the risk of prematurely dying from it conditional upon getting affected – have not been jointly explored so far. The dataset obtained from the Family Heart Disease and Prevention Survey (November 2010-March 2011), provides a unique opportunity to explore these two kinds of probabilities, particularly with regard to the risks of lung-cancer from smoking. Chapter 3 concludes by illustrating how individuals evaluate both these aspects of health-risks. While the probability of getting lung-cancer is found to be overestimated in conjunction with previous studies, the conditional probability of premature death is severely underestimated. Additionally, it is found that individuals‘ subjective assessments of either of these risk aspects predict smoking behavior in an identical manner. This calls into question the so-called ‗rationality‘ of smoking decisions with implications for policies designed for the control of tobacco consumption.

Pregnant and parenting young women rarely access community-based smoking cessation interventions. Targeted cessation interventions have been laden with challenges and have produced suboptimal outcomes. There is a paucity of qualitative research specific to young women that explores the context of their tobacco use, as well as their attitudes towards and experiences with smoking cessation supports in pregnancy and postpartum. To bridge this gap, an interpretive descriptive design was used to explore the personal and contextual factors influencing young women’s smoking behaviour during and after pregnancy. Factors were identified by analyzing influences at the multiple levels of McLeroy’s social ecological model of health promotion. Data were collected via in-depth, semi-structured interviews with young women aged 16-24 years (n=13) who smoked regularly preconception and were pregnant or parenting. Transcripts were analyzed using qualitative content analysis. Findings highlighted the complexity and chronicity of issues young women faced and emphasized the interplay of social determinants that influenced their smoking. Smoking was a crutch that helped them to relieve psychological distress stemming from exposure to adverse or traumatic experiences; and persistent stress in the context of socioeconomic hardship, neighborhood disadvantage and limited social support. Smoking also was influenced by young women’s understanding of the harms related to smoking during pregnancy and their reconceptualization of risk for smoking-related consequences postpartum. Young women described having limited discussions regarding smoking with maternity care providers and found their passive approach to cessation counselling unhelpful. They desired more comprehensive cessation support from providers. They expressed interest in a tailored group cessation program and offered suggestions for improving cessation supports for young women in pregnancy and postpartum. Study findings bridge gaps in the literature and identify appropriate next steps in addressing the issue of smoking in pregnancy and postpartum amongst young women by suggesting a multi-level approach to cessation. / Thesis / Master of Science (MSc)

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Rökning är ett utbrett samhällsproblem världen över och sjukdomar relaterade till rökning leder till mer än åtta miljoner dödsfall årligen. Effektiva rökavvänjningsmetoder spelar därför en viktig roll i samhället då de besparar samhället sjukvårdskostnader och främjar folkhälsan. I detta arbete genomförs en hälsoekonomisk utvärdering av ett SMS-baserat stöd för rökavvänjning. Syftet med arbetet är att fylla en kunskapslucka vad det gäller kostnadseffektivitet av digitala rökavvänjningsinsatser och samtidigt ge ett underlag tillbeslutsfattare som ansvarar för att prioritera folkhälsofrämjande insatser. Den hälsoekonomiska utvärderingen använder sig av kostnadseffektivitetsanalys som metod och baseras på en klinisk studie, där långsiktiga kostnader och hälsoeffekter skattas med hjälpav en beslutsanalytisk modell primärt baserad på en Markovmodell. De tre vanligaste följdsjukdomarna av rökning; KOL (kronisk obstruktiv lungsjukdom), lungcancer och hjärt- och kärlsjukdom modelleras mot bakgrund av hur många som slutar röka med hjälp av SMS-stödet. Data från olika källor används i modellen och i de fall data saknas görs antaganden baserade på tidigare studier för att kunna skatta kostnader och hälsoeffekter. Arbetet påvisar att en implementering av ett SMS-baserat stöd skulle generera ökade hälsoeffekter till lägre kostnader i jämförelse med att inte implementera ett sådant stöd. Resultatet från grundscenariot visar att interventionen skulle leda till kostnadsbesparingar på 63 539 kr per individ som tar del av interventionen och 0,30 vunna år i perfekt hälsa, sett över ett livstidsperspektiv. Resultaten bör tolkas med viss försiktighet då de är förknippade med osäkerheter, men kan användas som en del av det underlag beslutsfattare behöver för att fattabeslut om hur hälso- och sjukvårdens resurser ska prioriteras. Trots osäkerheterna i underlagetförefaller ett SMS-baserat stöd för rökavvänjning ha positiva hälsoeffekter och samtidigt spara resurser och därmed framstår metoden som en potentiellt viktig insats i framtida folkhälsoarbete. / Smoking is a globally widespread societal problem and diseases related to smoking account for more than eight million deaths annually. Effective smoking cessation methods therefore play an important role in society as they save society´s healthcare resources and promote public health. In this work, a health economic evaluation of an SMS-based smoking cessation is performed. The purpose of the work is to fill a knowledge gap in terms of cost-effectiveness of digital smoking cessation initiatives and at the same time provide a basis for decision-makers who are responsible for prioritizing public health promotion initiatives. The health economic evaluation uses cost-effectiveness analysis as a method and is based on a clinical study, where long-term costs and health effects are estimated using a decision-analytical model with a Markov structure. The three most common sequelae of smoking; COPD (chronic obstructive pulmonary disease), lung cancer and cardiovascular disease are modeled based on how many people stop smoking with the help of the SMS support. Data from different sources are used in the model and required assumptions based on previous studies are used to be able to estimate costs and health effects. The work shows that the implementation of an SMS-based support would generate increased health effects at lower costs in comparison with not implementing such support. The results from the basic scenario show that the intervention would lead to cost savings of SEK 63,539 per individual who takes part in the intervention and a gain in 0.30 years in full health, seen over a lifetime perspective. The results should be interpreted with some caution as they are associated with uncertainties but can be used as part of the basis on which decision-makers need to make decisions about how health care resources should be prioritized. Despite these uncertainties the SMS-based support for smoking cessation appears to save resources and lead to positive health effects and the method should be considered a potentially important addition in future public health policy.

Yes / Payment incentives are known to influence healthcare but little is known about the impact of paying directly for achieved outcomes. In England, novel purchasing (commissioning) of National Health Service (NHS) stop smoking services, which paid providers for quits achieved whilst encouraging new market entrants, was implemented in eight localities (primary care trusts (PCTs)) in April 2010. This study examines the impact of the novel commissioning on these services. Accredited providers were paid standard tariffs for each smoker who was supported to quit for four and 12 weeks. A cluster-controlled study design was used with the eight intervention PCTs (representing 2,138,947 adult population) matched with a control group of all other (n=64) PCTs with similar demographics which did not implement the novel commissioning arrangements. The primary outcome measure was changes in quits at four weeks between April 2009 and March 2013. A secondary outcome measure was the number of new market entrants within the group of the largest two providers at PCT-level. The number of four-week quits per 1,000 adult population increased per year on average by 9.6% in the intervention PCTs compared to a decrease of 1.1% in the control PCTs (incident rate ratio 1108, p<0001, 95% CI 1059 to 1160). Eighty-five providers held 'any qualified provider' contracts for stop smoking services across the eight intervention PCTs in 2011/12, and 84% of the four-week quits were accounted for by the largest two providers at PCT-level. Three of these 10 providers were new market entrants. To the extent that the intervention incentivized providers to overstate quits in order to increase income, caution is appropriate when considering the findings. Novel commissioning to incentivize achievement of specific clinical outcomes and attract new service providers can increase the effectiveness and supply of NHS stop smoking services.

There is longstanding causal relationship between cigarette smoking and lung cancer. Smoke-free policies and anti-smoking campaigns have been linked to the decline in smoking acceptance and contribute to the unintended consequence of stigmatizing smokers. Lung cancer is viewed as a self-inflicted disease and patients’ feel judged in a manner different from other cancers affecting social interactions between family, friends, and healthcare professionals. Lung cancer stigma contributes to depression, anxiety, poor self-esteem, guilt, shame, blame, threatens a person’s social identity, and limits social support that deeply affects patients and their support persons. This dissertation contains a review of the literature related to smoking and stigma, an evaluation of the psychometric properties of an investigator-developed instrument, “Lung Cancer Stigma Scale” (LuCaSS) and the main findings from a cross-sectional observational study of 104 lung cancer patients assessing factors associated with lung cancer stigma. The Model of Stigma Induced Identity Threat provides the framework to examine stigma and the relationship between social constraints, self-esteem, and smoking and to test whether social support mediates the relationship between stigma, and depression/anxiety. The LuCaSS was a reliable and valid instrument measuring lung cancer stigma (alpha = 0.89). The principle components analysis determined three subscales measuring internalized stigma: social rejections/judgment, blame/guilt, and shame. Social constraints, self-esteem, smoking each significantly contributed to the prediction of stigma controlling for SES. Lung cancer patients with greater social constraints and lower self-esteem and who were smokers scored higher on stigma. Social support was a mediator for the relationship between stigma and depression but not for anxiety. The findings are consistent with Stigma Induced Identity Threat Model. A stigmatized identity can lead to stress-related health outcomes such as depression. A lung cancer diagnosis has numerous negative psychosocial effects on patients. Integrating stigma tools (i.e. LuCaSS) in practice settings may assist with determining potential stigma related distress among lung cancer patients. Emphasizing the need for social support and implementing more advocacy efforts may also help minimize the effects of stigma and depression. Future studies are necessary to further examine the role of social support in minimizing stigma and psychosocial distress.

Thesis (PhD)- Stellenbosch University, 1987. / AFRIKAANSE OPSOMMING: 'n Groep ligte rokers en 'n groep strawwe rokers is met mekaar vergelyk ten opsigte van die effek van nikotien-inname op kortikale geaktieerdheid in 'n spanningsituasie en in 'n ontspanningsituasie, beide sander deprivasie van nikotien en nadat hulle daarvan gedepriveer is. Die groepe is ook met hulle onderskeie kontrolegroepe ( geen nikotien-inname tydens die eksperimentele sessie) ten opsigte van kortikale geaktiveerdheid vergelyk. Voorts is daar bepaal of daar 'n verband tussen ekstraversie, neurotisisme, kartikale geaktiveerdheid en getal sigarette gerook by die verskillende groepe rokers bestaan het. Resultate het daarop gedui dat ligte rokers deur 'n lae mate van kortikale geaktiveerdheid en strawwe rokers deur 'n hoe mate van kortikale geaktiveerdheid gekenmerk word en dat ligte rokers waarskynlik vir die stimulerende effek van nikotien rook. Geen beduidende stimulering was by die strawwe rokers te bespeur nie. Daar is 'n beduidende positiewe verband tussen getal sigarette per dag gerook en ekstraversie by die strawwe rokers wat minder as dertig sigarette per dag gerook het gevind.

The median prevalence of smoking among women of childbearing age in the United States is 22.4%. Of women who identify themselves as smokers in the three months prior to conception, 55% quit during pregnancy; however, 40% of those who quit relapse and return to smoking within six months after delivery. Smoking has been identified as an important means of stress management among smokers in general, and though limited to the perinatal period, pregnancy-specific stress adds to a woman’s typical day-to-day stress burden. Little data exists as to the effect of SHS exposure on smoking status during pregnancy and the impact of SHS exposure on the maternal perception of stress is unknown. Due to limited evidence, a critical need exists to examine the relationships of perceived maternal stress, SHS exposure, and perinatal smoking status in order to better understand perinatal smoking behaviors. The purposes of this dissertation were to: 1) evaluate the literature examining the relationship between the variables of maternal stress, SHS exposure, and perinatal smoking status; 2) determine the reliability and validity of the Everyday Stressors Index (ESI) use in pregnant women; and 3) to investigate the impacts of maternal perception of everyday stress, and SHS exposure on perinatal smoking status. Evidence obtained from the critical review of the literature supported an association between psychosocial stress and smoking during pregnancy or postpartum. Little information regarding the role of SHS exposure on perinatal smoking status was discovered. Psychometric testing of the ESI demonstrated strong internal consistency reliability, and factor analysis yielded three factors capturing three important domains of everyday stress. SHS exposure emerged as the most significant predictor of smoking status. Persistent smokers/relapsers had the highest ESI scores, followed by quitters, and then nonsmokers. While ESI means decreased in all smoking status groups from the first to the third trimester, the magnitude of decrease was not predictive. A significant interaction effect of SHS exposure in the home and decrease in ESI score occurred in the quit group only with quitters 1.14 times more likely to experience a decrease in ESI score compared to smokers/relapsers.