Date of Award


Document Type

Open Access Dissertation


Health Services and Policy Management


Norman J. Arnold School of Public Health

First Advisor

Nancy L. Fleischer


Cigarette smoking is the leading cause of preventable death in the world. In an effort to address the tobacco epidemic, the World Health Organization’s Framework Convention on Tobacco Control (FCTC) has formulated a number of policies that are thought to reduce cigarette consumption by making smoking socially unacceptable. It is possible that tobacco control policies that aim to make smoking socially unacceptable may also result in the stigmatization of smokers. Social factors such as social norms and socioeconomic status may also influence the development of smoking-related stigma. While some researchers suggest that smoking-related stigma may be an important public health tool to reduce smoking consumption and increase smoking cessation; there are no studies that have evaluated the relationship between smoking behavior and cessation and smoking-related stigma, using panel data. This dissertation used data from a population-based, longitudinal survey (2008-2012) of adult smokers in Mexico and Uruguay to evaluate three aims. First, we evaluated how social norms (i.e., close social network, friend number and societal norms) and socioeconomic status (SES) are associated with smoking-related stigma (i.e., feeling uncomfortable, perception of a negative stereotype of smokers and perception that smokers are marginalized). Second, we examined the relationship between exposure to tobacco control policy (i.e., perceived exposure to health warning labels and exposure to second hand smoking (SHS) in restaurants/cafes, enclosed workplaces and bars) and smoking-related stigma. For the first and second aim, we also investigated the role of nicotine dependence as an effect modifier on these associations. Finally, in the third aim, we evaluated the association between smoking-related stigma and smoking behavior and smoking cessation. Results from the first aim suggest that strong anti-smoking injunctive norms (i.e., close social network and societal norms) were associated with higher levels of all indicators of perceived stigma in Mexico and Uruguay. Furthermore, we found that nicotine dependence modified the association between friend norms and stigma in Mexico and societal norms and stigma in Uruguay. In this study, we found that while Mexican smokers with lower education and lower income were less likely to be stigmatized (perceiving a negative stereotype), Uruguayan smokers with lower education and lower income were more likely to be stigmatized (perceiving a negative stereotype). Nicotine dependence was found to be an important effect modifier between SES and stigma in Uruguay. In the second aim, we found that perceived attention to HWLs on cigarette packages was positively associated with all aspects of smoking-related stigma in both Mexico and Uruguay. This study also suggests that while Mexican smokers exposed to SHS in enclosed working areas were more likely to feel stigmatized (feeling uncomfortable), Uruguayan smokers exposed to SHS in enclosed working areas were less likely to feel stigmatize (perceiving a negative stereotype) when compared to smokers not exposed to SHS. Finally, we found that Smoking-related stigma was associated with a higher likelihood of making a quit attempt, in both Mexico and Uruguay and quitting among Mexican participants. Smoking-related stigma (negative stereotype) was also associated with less relapse among Mexican respondents. Results from this dissertation suggest that factors that drive the social unacceptability of tobacco (i.e.; social norms and exposure to tobacco control policy) may also produce stigmatization among smokers. Future studies need to consider smoking-related stigma when developing the next generation of tobacco control policies and programs that promote smoking cessation as, smoking-related stigma may be an important factor influencing smoking cessation.

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