International Tobacco Control China Research Articles

Cigarette Gifting Among Nonsmokers in China: Findings From the International Tobacco Control China Survey.

Cigarette gifting is commonly practiced in China and has contributed to the social acceptability and high prevalence of cigarette smoking in the country. As a result, nonsmokers in China are particularly susceptible to smoking. While previous studies have examined cigarette gifting behaviors among smokers, little is known about cigarette gifting among nonsmokers. This study aimed to examine the percentage and correlates of giving and receiving cigarettes as gifts among adult nonsmokers in China. We analyzed nonsmokers (N = 1813) aged ≥18 years using data from the International Tobacco Control China Wave 5 Survey. Descriptive statistics summarized the characteristics of those who gave and received cigarettes as gifts. Multivariable logistic regression models were used to identify factors associated with the two behaviors. Among nonsmokers, 9.9% reported giving cigarettes as gifts to family or friends in the last 6 months. A higher level of knowledge about smoking harms was associated with lower adjusted odds of gifting cigarettes. Nonsmokers aged 25-39 years, with middle income, positive attitude toward cigarette gifts, exposure to anti-smoking information, and exposure to smoking promotion, and those who reported receiving cigarettes as gifts from family or friends were more likely to give cigarettes as gifts. A total of 6.6% of nonsmokers reported receiving cigarettes as gifts in the last 6 months. High education, neutral or positive attitude toward cigarette gifts, exposure to anti-smoking information, exposure to smoking promotion, and having smoking friends were associated with receiving cigarettes as gifts. It is concerning that Chinese cultural norms that support cigarette gifting have extended to giving nonsmokers cigarettes as gifts. Effective anti-smoking messages are needed. Changing the norms around cigarette gifting and increasing knowledge about smoking harms should help reduce cigarette gifting among nonsmokers. Easy access to cigarettes received as gifts, along with the wide acceptance of smoking in China, places Chinese nonsmokers in a risky position. More educational campaigns targeting nonsmokers to proactively prevent them from smoking are called for. The ineffectiveness of existing anti-smoking information highlights the need for more effective anti-smoking messages. That attitude toward cigarette gifts is the strongest predictor of giving cigarettes as gifts suggests the need for interventions to reverse the positive attitude about cigarette gifting to decrease the popularity of this activity.

Receiving and giving electronic cigarettes as gifts in China: Findings from International Tobacco Control China Survey

Cigarette gifting is pervasive in China. As the Chinese are increasingly aware of harm from smoking cigarettes, e-cigarettes, often promoted as less harmful alternatives to cigarettes, may be viewed as appropriate gifts. This study is the first using population-based survey data to examine receiving and giving e-cigarettes as gifts in China. We analyzed 9,274 adults from Wave 5 of the International Tobacco Control China Survey, which was completed in July 2015. We found that the prevalence of receiving e-cigarettes as gifts was 1.3% among all respondents and 5.3% among urban smokers; the prevalence of giving e-cigarettes as gifts was 0.5% among all respondents and 1.2% among urban smokers. These prevalence estimates were very low among nonsmokers and rural respondents. Further analysis on urban smokers (N = 3,312) found that those aged 40–54 and 55+, those with high education levels, heavy smokers, and those who perceived e-cigarettes as equally/more harmful than cigarettes were more likely to receive e-cigarette gifts; and those who ever used e-cigarettes were significantly more likely to both receive and give e-cigarette gifts. Urban smokers with positive attitude about cigarette gifting were also more likely to give e-cigarette gifts to others, but those aged 55+ were less likely to gift e-cigarettes. Findings of this study indicate that the Chinese may perceive e-cigarettes as appropriate gifts for smokers, especially heavy smokers. Precautions should be taken to prevent e-cigarettes from becoming a gift choice for nonsmokers. Health campaigns designed to combat the social acceptance of cigarette gifting may also help reduce e-cigarette gifting.

Local Brand Smoking Among Adult Smokers: Findings from the Wave 5 International Tobacco Control China Survey - China, 2015.

What is already known about this topic?Branding of cigarettes may play a role in shaping the smoking behaviors of Chinese smokers, and local brand (LB) cigarettes may reflect this influence because of greater tax and non-tax incentives compared to non-LB. Some of these brands are regional flagships that market to smokers using local landmarks or icons.What is added by this report?LB brands were significantly more likely to be the usual brand of smokers residing in provincial-level administrative divisions (PLADs) that produced their own LB cigarettes [adjusted odds ratio (AOR): 30.95; 95% confidence interval (CI): 26.36–36.49] compared to those residing in PLADs that had non-local ventures with non-LB cigarettes. Further, smokers residing in urban areas were found to be less likely to smoke LB cigarettes (AOR: 0.79; 95% CI: 0.67–0.93) compared to those in rural areas.What are the implications for public health practice?These findings suggest that LB smoking may be a result of industry-driven incentives to boost LB sales, fueled by such as supply-side strategies to boost LB sales or targeted cultural/social marketing that appeals to certain demographic groups. Although addressing these incentives to support LBs would be challenging given the nature of China’s tobacco industry, doing so would have potential to reduce cigarette smoking and ultimately the health burden of smoking in China.

Secondhand smoke exposure and support for smoke-free policies in cities and rural areas of China from 2009 to 2015: a population-based cohort study (the ITC China Survey)

ObjectivesTo examine trends in smoking prevalence in key venues (workplaces, restaurants, bars) and in public support for comprehensive smoke-free laws, with comparisons between cities and rural areas in China.DesignData are...

Cigarette Affordability in China, 2006⁻2015: Findings from International Tobacco Control China Surveys.

China is world’s largest market of machine-made cigarettes. In 2015, more than 315 million or around 26.9% of the adult population in China were smokers—50.6% among men and 2.2% among women. Growing affordability of cigarettes led to increased cigarette consumption in China to the detriment of public health. This study investigated whether the level and growth in cigarette affordability in China was equally shared by smokers from all demographic and socio-economic statuses (SES) and across all price tiers of cigarette brands. The data came from the urban smoker sample (≥18 years) of the International Tobacco Control China Surveys conducted in five waves over 2006–2015. Cigarette affordability was measured by Relative Income Price—percentage of per capita household income needed to purchase 100 cigarette packs of the last purchased brand. Overall and group-specific trends in affordability by age, gender, SES (e.g., income, education, and employment status), and price tiers were analyzed using generalized estimating equations method. Cigarette affordability was higher among older, female, and higher-SES smokers, and for cheaper brands. It increased overall and across all groups over time. The increase was significantly larger among younger and lower-SES smokers, a trend that poses an added challenge to tobacco control and health equity. To reduce cigarette affordability and consumption among these vulnerable groups, a uniform specific excise system should be introduced in place of the existing tiered ad valorem excise. The specific excise should be periodically adjusted to inflation and per capita income growth observed among younger and lower-SES people, who can potentially experience faster income growth than the national average. The excise tax policy can also be complimented with minimum price regulations and restrictions on price promotions.

Perceived acceptability of female smoking in China.

Female smoking prevalence in China is very low but may rise with increased tobacco marketing towards women and changing norms. However, little is known about current perceptions of women smoking in China. This study sought to examine smokers' and non-smokers' perceived acceptability of female smoking and how it changed over time in China. Data come from Waves 1 to 3 (2006-2009) of the International Tobacco Control China Survey, a face-to-face cohort survey of approximately 800 adult smokers and 200 non-smokers in each of seven cities in mainland China. At Wave 3 (2009), about 38% of smokers and 9% of non-smokers agreed that female smoking is acceptable with women being almost twice as likely to do so as men (67% vs 36% and 11% vs 6%, respectively). In addition to women, smokers who were younger and had more positive perceptions of smoking in general were more likely to say that female smoking is acceptable. This perception significantly increased from Wave 1 (2006) to Wave 3 (2009), as did the perception that smoking is a sign of sophistication, but other general perceptions of smoking did not significantly change between 2006 and 2009. Norms against female smoking appear to remain strong in China, but female smoking may be becoming more acceptable. It is important to monitor these perceptions to prevent a rise in female smoking prevalence along with an increase in tobacco-related death and disease among women in China.

Differential responsiveness to cigarette price by education and income among adult urban Chinese smokers: findings from the ITC China Survey

BackgroundFew studies have examined the impact of tobacco tax and price policies in China. In addition, very little is known about the differential responses to tax and price increases based...

The heterogeneous effects of cigarette prices on brand choice in China: implications for tobacco control policy

BackgroundChina has long kept its tobacco taxes below international standards. The Chinese government has cited two rationales against raising tobacco tax, namely, the unfair burden it places on low-income smokers...

Smoking-related thoughts and microbehaviours, and their predictive power for quitting

BackgroundNegative attitudes to smoking are well-established predictors of intentions to quit and quit behaviours, but less attention has been given to whether quitting is influenced by smoking-related thoughts and microbehaviours...

Who purchases cigarettes from cheaper sources in China? Findings from the ITC China Survey

ObjectiveThe availability of cigarettes from cheaper sources constitutes a major challenge to public health throughout the world, including China, because it may counteract price-based tobacco control policies. The goal of...

Chinese smokers’ cigarette purchase behaviours, cigarette prices and consumption: findings from the ITC China Survey

BackgroundWhile cigarette purchasing behaviour has been shown to be linked with certain tobacco use outcomes such as quit intentions and quit attempts, there have been very few studies examining cigarette...

The effect of cigarette prices on brand-switching in China: a longitudinal analysis of data from the ITC China Survey

BackgroundRecent studies have found that Chinese smokers are relatively unresponsive to cigarette prices. As the Chinese government contemplates higher tobacco taxes, it is important to understand the reasons for this...

Incidence and correlates of receiving cigarettes as gifts and selecting preferred brand because it was gifted: Findings from the ITC China Survey

BackgroundGiving cigarettes as gifts is a common practice in China, but there have been few systematic studies of this practice. The present study was designed to estimate the incidence of receiving cigarettes as gifts, correlates of this practice, and its impact on brand selection in a representative sample of urban adult smokers in China.MethodsData were analyzed from Wave 2 of the International Tobacco Control (ITC) China Survey, where 4843 adult urban smokers were interviewed in six major Chinese cities between October 2007 and January 2008. The incidence of most recent cigarette acquisition due to gifting and the prevalence of preferred brand selection due to having received it as a gift were estimated. Bivariate and adjusted logistic regression models were estimated to identify factors associated with these two outcomes.ResultsThe incidence of receiving cigarettes as a gift at most recent cigarette acquisition was 3.5%. Smokers who received these gifted cigarettes were more likely to be female, older, have higher educational attainment, live in Beijing, and smoke fewer cigarettes per day. The prevalence of choosing one’s preferred brand due to having received it as a gift was 7.0%, and this was more likely among smokers who lived in Beijing and Guangzhou, had lower educational attainment, smoked less frequently, and had smoked their preferred brand for less than one year.ConclusionsThe 3.5% incidence of one’s most recent cigarette acquisition due to gifting is consistent with prevalence estimates based on longer reference periods and translates into the average smoker receiving a gift of cigarettes approximately five times a year. Gifting also appears to have a significant influence on brand preference. Tobacco control interventions in China may need to denormalize the practice of giving cigarettes as gifts in order to decrease the social acceptability of smoking.

Urban Chinese Smokers From Lower Socioeconomic Backgrounds Face More Barriers to Quitting: Results From the International Tobacco Control-China Survey

Research findings on social disparities in barriers to quitting faced by smokers from mainly Western English-language countries may or may not generalize to smokers in China. This paper sought to determine whether nicotine dependence, quitting self-efficacy, quitting interest differ by socio-economic status (SES), and whether they mediate the relationship between SES and quitting behavior of urban Chinese smokers. Data come from 7,309 adult smokers who participated in the first 3 waves of the International Tobacco Control-China survey conducted in 7 cities across China. The association of socio-economic indicators with nicotine dependence, quitting self-efficacy, quitting interest, and behavior was evaluated using generalized estimating equations models along with a formal test of mediational effects. The SES index indicated that those from lower SES were significantly more addicted (p < .001), less confident (p < .001), and less interested in quitting (p < .05). This finding was replicated by education and employment status, but it was not clearly related to income. Mediational analyses revealed that the effects of SES on making quit attempts and quit success among those who tried were indirect. For quit attempts, self-efficacy, interest to quit, and heaviness of smoking index (HSI) were all significant mediators of the SES effect (p < .001), but for maintenance, only HSI was a significant mediator (p < .001). Urban Chinese smokers from lower socio- economic backgrounds experience greater levels of psychological and behavioral barriers to quitting than their counterparts from higher socio-economic backgrounds and as such, they need more help to quit and do so successfully.

Beliefs about the relative harm of “light” and “low tar” cigarettes: findings from the International Tobacco Control (ITC) China Survey

BackgroundMany smokers in Western countries perceive “light” or “low tar” cigarettes as less harmful and less addictive than “regular” or “full flavoured” cigarettes. However, there is little research on whether...

Health knowledge and perception of risks among Chinese smokers and non-smokers: findings from the Wave 1 ITC China Survey

BackgroundAwareness of health risks of smoking is strongly associated with smoking behaviour. However, there are no population-based studies of smoking-related health knowledge in China.ObjectiveThe aim of current study was to...

Individual-level factors associated with intentions to quit smoking among adult smokers in six cities of China: findings from the ITC China Survey

BackgroundOver 350 million smokers live in China, and this represents nearly one-third of the smoking population of the world. Smoking cessation is critically needed to help reduce the harms and...

Regional differences in awareness of tobacco advertising and promotion in China: findings from the ITC China Survey

ObjectiveTo examine whether levels of, and factors related to, awareness of tobacco advertising and promotion differ across six cities in China.MethodsData from wave 1 of the International Tobacco Control (ITC)...

Support for smoke-free policies among smokers and non-smokers in six cities in China: ITC China Survey

ObjectiveTo examine levels of support for comprehensive smoke-free policies in six large Chinese cities.MethodsData from Wave 1 of the International Tobacco Control (ITC) China Survey (April–August 2006) were analysed. The...