Date of Award


Document Type

Open Access Dissertation


Epidemiology and Biostatistics

First Advisor

Nancy L. Fleischer

Second Advisor

James F. Thrasher


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 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 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.


© 2015, Santosha Kamala Swayampakala