University of South Carolina Scholar Commons Theses and Dissertations 2015 Changing Cigarette Consumption Patterns and their Relationship to Tobacco Control Policies in a Population of Low-Intensity Smokers Santosha Kamala Swayampakala University of South Carolina Follow this and additional works at: https://scholarcommons.sc.edu/etd Part of the Nutritional Epidemiology Commons Recommended Citation Swayampakala, S. K.(2015). Changing Cigarette Consumption Patterns and their Relationship to Tobacco Control Policies in a Population of Low-Intensity Smokers. (Doctoral dissertation). Retrieved from https://scholarcommons.sc.edu/etd/3631 This Open Access Dissertation is brought to you by Scholar Commons. It has been accepted for inclusion in Theses and Dissertations by an authorized administrator of Scholar Commons. For more information, please contact [email protected]. Changing Cigarette Consumption Patterns and their Relationship to Tobacco Control Policies in a Population of Low-Intensity Smokers by Santosha Kamala Swayampakala Bachelor of Homoeopathic Medicine and Surgery NTR University of Health Sciences, 2004 Master of Science in Public Health University of South Carolina, 2007 ________________________________________ Submitted in Partial Fulfillment of the Requirements For the Degree of Doctor of Philosophy in Epidemiology The Norman J. Arnold School of Public Health University of South Carolina 2015 Accepted by: Nancy L. Fleischer, Major Professor Co-Chairman, Examining Committee James F. Thrasher, Co-Chairman James W. Hardin, Committee Member Jihong Liu, Committee Member Geoffrey T. Fong, Committee Member Lacy Ford, Senior Vice Provost and Dean of Graduate Studies DEDICATION I would like to dedicate this accomplishment to my husband and my best friend, Srinivasa Pavan Dasika. I would not have achieved this milestone without your love, support, patience and encouragement. I also want to dedicate this dissertation to my daughter, Akshara Dasika, for being my sunshine and for the countless sacrifices you made while I pursued this degree. ii ACKNOWLEDGEMENTS I am greatly indebted to a number of people instrumental in my successful completion of this dissertation. First off, I would like to thank my dissertation co-chairs, Drs. Nancy Fleischer and James Thrasher, and committee members, Drs. James Hardin, Jihong Liu and Geoff Fong for your immeasurable support during this process and for challenging me to increase my critical thinking skills. Special thanks to my wonderful advisor, Dr. Fleischer, for being there with me every step of the way during this dissertation and for the generous amount of time spent in mentoring me. I really admire your knowledge, dedication to the field, and positive attitude. Dr. Thrasher, my life-time mentor, to you I express my sincere gratitude for being my inspiration to work in the field of tobacco control. You constantly gave me opportunities that I could only dream of in order to broaden my horizons. To the faculty and staff in the Department of Epidemiology and Biostatistics, especially Dr. Natalie Colabianchi, and the Division of Tobacco Prevention and Control at SCDHEC, thank you all for the continued support. Finally, I express my deepest gratitude to my parents, my closest friend and sister, Dr. Shelly-Ann Bowen, and all my family and friends for the love and support over the years and for being my biggest cheerleaders. iii ABSTRACT Tobacco use is the single most preventable cause of premature death and disability in the world. Every year six million people will die from tobacco-related diseases. To curb the growing tobacco epidemic, World Health Organization (WHO) adopted its first-ever global public health treaty, Framework Convention on Tobacco Control (FCTC) that obligates ratifying countries to implement a range of tobacco control policies. Most of the evidence for the effectiveness of the WHO’s FCTC recommended tobacco control policies comes from high-income countries (HICs). This evidence suggests that as smoking prevalence declines in response to tobacco control policies and programs, the proportion of smokers who smoke less than daily increases and the number of cigarettes smoked by daily smokers decrease. There have been far fewer studies from low- and middle-income countries (LMICs) evaluating tobacco control policies, particularly from LMICs where non-daily smoking and light intensity smoking patterns have been dominant since before the implementation of FCTC-recommended tobacco control policies. This dissertation uses data from the 2008 – 2012 Mexico administration of the International Tobacco Control Policy Evaluation (ITC) project and the 2012 – 2014 Mexico administration of the Warning Wearout project 1) to examine the changes in cigarette consumption patterns of non-daily, daily-light (<=5 cigarettes iv per day (CPD)) and daily-heavy smokers (>5 CPD) during the rapid implementation of tobacco control policies and identifying factors that are associated with changes in cigarette consumption (paper-I),2) to evaluate the impact of lack of secondhand smoke exposure at workplaces and hospitality industry venues on cessation behaviors and whether this association differs across smoking intensity groups(paper-II), and 3) to identify the correlates of responses to health warning labels (HWLs) (paper-III). In paper- I, we found that across the three smoking intensity groups, non-daily smokers were more likely to achieve abstinence at the follow-up, about a quarter of non-daily smokers continued to smoke at the same levels across follow-up periods, and reducing smoking intensity can be a stepping stone towards cessation for daily-heavy smokers. Perceived addiction was consistently important factor associated with changes in smoking consumption for all the three smoking intensity groups. For non-daily smokers only, anti-smoking social norms promoted smoking cessation. Paper-II findings suggest that lack of secondhand smoke exposure in workplaces and hospitality industry venues was unassociated with quit behaviors across the three smoking intensity groups. The smoke-free workplace and hospitality industry policies were limited in reach since only about a third of the study sample was exposed to these policies. In paper-III, we found that after a few years of implementing pictorial HWLs in Mexico, attention to HWLs declined over the study period while cessation-related responses to HWLs continued to increase over time. Also, HWLs in Mexico appear to be equally effective across socio- economic groups (SES) and for, some measures, slightly more effective among low SES groups than high SES groups. Taken together, results from this dissertation highlight the v need to design and study interventions that specifically target non-daily smokers who, despite not smoking every day, find it hard to quit. Also, it is recommended that the Mexican government should take additional actions to increase compliance to smoke- free policies and expand the policies to places where Mexicans continue to be exposed to SHS. Finally, LMICs that have limited resources should consider pictorial HWLs as a priority and rotate the content frequently to prevent wearout of HWLs. vi TABLE OF CONTENTS DEDICATION ................................................................................................................................... ii ACKNOWLEDGEMENTS ............................................................................................................... iii ABSTRACT ...................................................................................................................................... iv LIST OF TABLES .............................................................................................................................. x LIST OF FIGURES .......................................................................................................................... xii CHAPTER 1: INTRODUCTION ...................................................................................................... 1 1.1 STATEMENT OF THE PROBLEM ......................................................................... 1 1.2 STUDY AIMS AND HYPOTHESES ........................................................................ 3 1.3 SIGNIFICANCE OF RESEARCH ............................................................................. 6 CHAPTER 2: BACKGROUND ........................................................................................................ 9 2.1 PAPER-I: CHANGES IN CIGARETTE CONSUMPTION PATTERNS ................... 9 2.2 PAPER II: IMPACT OF SMOKE-FREE POLICIES ON CIGARETTE CONSUMPTION PATTERNS ..................................................................................... 19 vii 2.3 PAPER III: ASSESSING THE CORRELATES OF TRAJECOTIES OF ADULT’S HWL RESPONSES ............................................................................... 35 CHAPTER 3: FACTORS ASSOCIATED WITH CHANGING CIGARETTE CONSUMPTION PATTERNS AMONG LOW-INTENSITY SMOKERS: RESULTS FROM ITC-MEXICO SURVEY .................................................................................. 51 3.1 INTRODUCTION: ................................................................................................. 51 3.2 METHODS: .......................................................................................................... 55 3.3 RESULTS: ............................................................................................................. 61 3.4 DISCUSSION: ......................................................................................................