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THE PATTERN, CORRELATES, AND PREDICTORS OF CIGARETTE SMOKING IN ADOLESCENCE Jennifer Anne Fidler A thesis submitted for the degree of Doctor of Philosophy UNIVERSITY COLLEGE LONDON 1 UMI Number: U591757 All rights reserved INFORMATION TO ALL USERS The quality of this reproduction is dependent upon the quality of the copy submitted. In the unlikely event that the author did not send a complete manuscript and there are missing pages, these will be noted. Also, if material had to be removed, a note will indicate the deletion. Dissertation Publishing UMI U591757 Published by ProQuest LLC 2013. Copyright in the Dissertation held by the Author. Microform Edition © ProQuest LLC. All rights reserved. This work is protected against unauthorized copying under Title 17, United States Code. ProQuest LLC 789 East Eisenhower Parkway P.O. Box 1346 Ann Arbor, Ml 48106-1346 DECLARATION I, Jennifer Anne Fidler, confirm that the work presented in this thesis is my own. Where information has been derived from other sources, or contributions have been made by other researchers, I confirm that this has been indicated in the thesis. 2 Acknowledgements ACKNOWLEDGEMENTS First and foremost I would like to extend my very grateful thanks to my supervisors, Robert West and Jane Wardle: to Robert, for his kind, supportive, guidance and for believing in a PhD student he inherited - it has been a privilege to be supervised by him; and to Jane, who gave me the opportunity to work on such an interesting project and whose dedication to research has inspired me to pursue a career in academia. I would also like to thank all my friends and colleagues at the Health Behaviour Unit for their support. Special thanks go to Pippa, Lion, and Emily, who have joined me on this journey. Also to the many people who had the misfortune to share a room with me over the years. A number of colleagues, past and present, have provided me with unfailing guidance and support on all matters statistical and methodological, from whom I have learned so much and am truly grateful; Naomi Henning Brodersen, Ellen van Jaarsveld, Jane Bradbury and David Boniface. I also thank Dr Michael Ussher for valuable thoughts and suggestions on my upgrade document, and anonymous reviewers for helpful comments on various manuscripts. The HABITS project was a large undertaking and my thanks go to everyone involved in its conception, design and creation, to Cancer Research UK and the Department of Health for funding the project, to all the researchers who collected data, and to the 5863 students who took part, without whom there would be no PhD! Finally, to my husband Stephen, who has been wonderful - thank you! 3 Abstract ABSTRACT The health effects of smoking are well known and, despite efforts to reduce smoking in adolescence, prevalence of smoking during the teenage years in the UK has remained stable over recent years. This thesis examines smoking uptake during adolescence and identifies the social, psychological and physical factors associated with this process using data from the longitudinal Health And Behaviour In Teenagers study (HABITS). Between 1999 and 2003 over 5000 students from South London were assessed annually from age 11 to age 16. Self-report questionnaires identified smoking status as well as a range of demographic, social and psychological variables. Objective height, waist and weight data were taken and saliva samples provided for cotinine assay. First, analyses examining smoking prevalence and the sociodemographic factors associated with smoking behaviour were conducted. Gender and ethnicity differences were observed, although the association between smoking and deprivation was less clear. The development of smoking behaviour among an understudied group, ‘one time triers’ of cigarettes, was tracked, revealing that even brief experimentation with cigarettes leads to a lasting vulnerability for later smoking. Second, social factors associated with smoking were examined and the association between smoking by friends, parents and step-parents and adolescent smoking documented. An independent relationship between early dating and later smoking was also revealed. Third, psychological factors associated with adolescent smoking were identified, and the lack of a prospective relationship between attitudes towards smoking and smoking behaviour was confirmed. Fourth, significantly smaller increases over time in BMI and waist, but not height, were observed among smokers compared with non-smokers. Finally, a population level model of the vulnerability and trigger factors associated with smoking, based on an individual level theory of motivation, was constructed. The findings presented extend current literature on adolescent smoking and have implications for effective prevention strategies. 4 Table of contents TABLE OF CONTENTS ABSTRACT............................................................................................................................................... 4 TABLE OF CONTENTS.......................................................................................................................... 5 LIST OF TABLES..................................................................................................................................... 8 LIST OF FIGURES................................................................................................................................. 11 LIST OF APPENDICES......................................................................................................................... 12 CHAPTER 1: INTRODUCTION........................................................................................................13 1.1 Smoking and h e a l t h .............................................................................................................................13 1.2 Smoking P revalence .............................................................................................................................14 1.2.1 Adults....................................................................................................................................................... 14 1.2.2 Adolescents .............................................................................................................................................15 1.2.3 Age o f uptake ........................................................................................................................................17 1.2.4 Gender differences ...............................................................................................................................17 1.3 Smoking and a d d ic t io n ........................................................................................................................19 1.4 T he D evelopment o f smoking in adolescence ............................................................................20 1.5 Smoking prevention ...............................................................................................................................21 1.6 Con clusion .............................................................................................................................................. 22 CHAPTER 2: FACTORS ASSOCIATED WITH ADOLESCENT SMOKING............................23 2.1 Sociodemographic factors .................................................................................................................23 2.1.1 Gender................................................................................................................................................... 23 2.1.2 Ethnicity .................................................................................................................................................