Smoking-related stigma: A public health tool or a damaging force?

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