Citation

Zheng, C., Feng, Z., Pearce, J. (2024). A longitudinal analysis of the impact of the local tobacco retail availability and neighbourhood deprivation on male smoking behaviours in Shanghai, China. Journal of Health and Place, 85, 103171. doi: 10.1016/j.healthplace.2023.103171.

Abstract

Some evidence from Western high-income countries suggests local tobacco retail availability and neighbourhood deprivation may influence smoking behaviours. However, this assertion has not been considered in China, where 44% of males continue to smoke. Data were analysed from Chinese males (n = 2054) who participated in Waves 3–5 (2009–2015) of the International Tobacco Control (ITC) China Survey by linking information on tobacco retail availability (estimated through population weighted Kernel Density of tobacco retailers in 2019) and neighbourhood deprivation (calculated as a composite score derived from the 2010 Chinese census) across Shanghai. Generalised Estimating Equation models were fitted to examine the impacts of local tobacco availability and neighbourhood deprivation on smoking behaviours (current smoking versus current non-smoking, quitting versus current smoking, longer durations of smoking abstinence versus current smoking) using the longitudinal data. Examining the impacts separately, participants living in neighbourhoods with greater availability and higher levels of deprivation were less likely to maintain longer durations of smoking abstinence in both unadjusted and adjusted models. Neighbourhood deprivation, but not availability, was found to be associated with higher odds of being a current smoker. Examining the impacts jointly, neighbourhood deprivation was still positively associated with current smoking and negatively associated with longer durations of smoking abstinence, but the negative association between availability and longer durations of smoking abstinence disappeared. The findings offer some evidence that greater tobacco retail availability and deprivation are obstacles on prolonged smoking cessation among males in Shanghai, China. Policymakers should consider small-area level place-based restrictions in China, such as reducing the availability of tobacco, as part of a comprehensive tobacco control strategy aimed at addressing the high prevalence of smoking.

Citation

Lyu, J., Sung, H.Y., Yao, T., Jiang, N., Quah, A.C.K., Meng, G., Jiang, Y., Fong, G.T., Max, W. (2023). Cigarette gifting among non-smokers in China: Findings from the International Tobacco Control China Survey. Nicotine & Tobacco Research, 25(5), 928-936. doi: 10.1093/ntr/ntac294.

Abstract

Introduction: 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.

Aims and Methods: 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.

Results: 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.

Conclusions: 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.

Implications: 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.

Citation

Hao, P., Xu, S.S., Sung, H.Y., Yao, T., Jiang, Y., Quah, A.C.K., Fong, G.T. (2022). Local brand smoking among adult smokers in China: Findings from the Wave 5 International Tobacco Control China Survey. China CDC Weekly, 4(21), 452-459.

Abstract

The objective of this study was to assess the percentage of local brand (LB) smoking among adult smokers in a diversity of cities in China and to identify factors associated with LB smoking including demographic characteristics and patterns of smoking such as cigarettes per day. This project analyzed data from the Wave 5 International Tobacco Control (ITC) China Survey that was conducted between November 2013 and July 2015. The ITC China Survey is a longitudinal cohort survey of smoking behavior and knowledge, beliefs, opinions, and attitudes about cigarette smoking and tobacco use among adults aged 18 and older in China. The Wave 5 Survey was conducted in 10 locations, including urban residents in 5 large cities (Beijing, Guangzhou, Kunming, Shanghai, and Shenyang) and residents in 5 rural areas (Changzhi, Huzhou, Tongren, Yichun, and Xining). The 10 locations were selected based on size, geographical representations, and levels of economic development.

Citation

Lyu, J., Sung, H.-Y., Yao, T., Quah, A.C.K., Jiang, Y., Fong, G.T., Max, W. (2022). Receiving and giving electronic cigarettes as gifts in China: Findings from the International Tobacco Control China Survey. Preventive Medicine Reports, 27, 101763. doi: 10.1016/j.pmedr.2022.101763

Abstract

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.

Citation

Liao, Y., Tang, J., Quah, A.C.K., Fong, G.T., McNeill, A. (2022). Attitudes towards smoking and COVID19, and changes of smoking behaviors before and after the outbreak of COVID-19: A nationwide cross-sectional survey study in China. Tobacco Induced Diseases, 20, 18.

Abstract

Introduction: China has more than 300 million current smokers. There is a controversy over smokers’ risk of COVID-19 infection. Smoking is a risk factor for COVID-19 disease progression, and the outbreak of COVID-19 may change people’s smoking behaviors. This study assessed people’s attitudes towards ‘smoking and COVID-19’ and changes of smoking behaviors before and after the outbreak of COVID-19.

Material and Methods: A cross-sectional web survey of 11009 adults in China was conducted between 7 May and 3 August 2020. Attitudes towards ‘smoking and COVID-19’ were compared among non-smokers (n=8837), ex-smokers (n=399) and current smokers (n=1773), and changes in smoking behaviors before and after the outbreak of COVID-19 were assessed among current smokers.

Results: Fewer current smokers (26.2%) agreed with the statement that ‘Current smokers are more likely than ex-smokers or non-smokers to contract COVID-19’ compared with non-smokers (53%) or ex-smokers (41.4%); fewer current smokers (55.9%) agreed with the statement ‘If contracted, current smokers are more likely than ex-smokers or non-smokers to risk disease progression’ compared with nonsmokers (75.5%) or ex-smokers (68.7%). There were no changes in cigarettes smoked per day (mean ± SD: 13.3 ± 9.55 vs 13.4 ± 9.69, p=0.414), percentage of daily smokers (70.8% vs 71.1%, p=0.882) and percentage of smokers with motivation to quit (intend to quit within the next 6 months, 9.4% vs 10.9%, p=0.148) before and after the outbreak of COVID-19.

Conclusions: The survey found that fewer current smokers agreed that smoking is a risk-factor for COVID-19 compared with non-smokers or ex-smokers. Among current smokers, there were no changes in their cigarette consumption and motivation to quit before and after the outbreak of COVID-19. More efforts are needed to educate smokers about the health risks of smoking, as well as efforts to promote their motivation to quit.

Citation

Fong, G.T., Yuan, J., Craig, L.V., Xu, S.S., Meng, G., Quah, A.C.K., Seo, H.G., Lee, S., Yoshimi, I., Katanoda, K., Tabuchi, T. (2021). Achieving the Goals of Healthy China 2030 Depends on Increasing Smoking Cessation in China: Comparative Findings from the ITC Project in China, Japan, and the Republic of Korea. China CDC Weekly, 3(22), 463-467. doi: 10.46234/ccdcw2021.120.

Abstract

Tobacco smoking is the number one preventable cause of disease and death in China, as it is globally. Indeed, the toll of smoking in China is much greater than its status as the world’s most populous country. There is a persistent and continuing need for China to implement the measures specified in the global tobacco control treaty, the World Health Organization (WHO) Framework Convention on Tobacco Control (FCTC), which China ratified in 2005. The theme for the 2021 WHO World No Tobacco Day focuses on the need to support smoking cessation. This article presents findings from the International Tobacco Control (ITC) Policy Evaluation Project cohort surveys in China, in comparison to ITC cohort surveys in two neighboring countries: Japan and the Republic of Korea. These findings demonstrate that smokers in China very much want to quit, but these intentions are not being translated into quit attempts, relative to smokers in Japan and the Republic of Korea. Additionally, about 80% of Chinese smokers want the Chinese government to do more to control smoking. These findings reaffirm the need for China to implement strong, evidence based measures to reduce smoking. The objective of Healthy China 2030 to reduce deaths from noncommunicable diseases by 30% can be achieved by reducing smoking prevalence from its current 26.6% to 20%, and this reduction can be achieved through strong implementation of FCTC measures.

Citation

Fong, G. T., & Jiang, Y. (2020). The Importance of Reducing Smoking in China: To Achieve Healthy China 2030 While Reducing the Severity of the COVID-19 Pandemic. China CDC Weekly, 2(22), 404-406.

No abstract available.

Citation

Sansone, G., Fong, G.T., Yan, M., Meng, G., Craig, L.V., Xu, S.S., Quah, A.C.K., Wu, C., Feng, G., Jiang, Y. (2019). 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). BMJ Open, 9, e031891.

Abstract

Objectives: To 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.

Design: Data are from Waves 3–5 (2009–2015) of the International Tobacco Control (ITC) China Survey, a cohort survey of smokers and non-smokers. Logistic regression analyses employing generalised estimating equations assessed changes in smoking prevalence and support for smoke-free laws over time; specific tests assessed whether partial smoking bans implemented in three cities between Waves 3 and 4 had greater impact.

Setting: Face-to-face surveys were conducted in seven cities (Beijing, Changsha, Guangzhou, Kunming, Shanghai, Shenyang and Yinchuan) and five rural areas (Changzhi, Huzhou, Tongren, Yichun and Xining).

Participants: In each survey location at each wave, a representative sample of approximately 800 smokers and 200 non-smokers (aged 18+) were selected using a multistage cluster sampling design.

Main outcome measures: Prevalence of smoking (whether respondents noticed smoking inside restaurants, bars and workplaces); smoking rules inside these venues; and support for complete smoking bans in these venues.

Results: Although smoking prevalence decreased and support increased over time, neither trend was greater in cities that implemented partial smoke-free laws. Smoking was higher in rural than urban workplaces (62% vs 44%, p<0.01), but was equally high in all restaurants and bars. There were generally no differences in secondhand smoke (SHS) exposure between smokers and non-smokers except in rural workplaces (74% vs 58%, p<0.05). Support for comprehensive bans was equally high across locations.

Conclusions: Partial laws have had no effect on reducing SHS in China. There is an urgent need for comprehensive smoke-free laws to protect the public from exposure to deadly tobacco smoke in both urban and rural areas. The high support among Chinese smokers for such a law demonstrates that public support is not a barrier for action.

Citation

Nargis, N., Yong, H.H., Driezen, P., Mbulo, L., Zhao, L., Fong, G.T., Thompson, M.E., Borland, R., Palipudi, K.M., Giovino, G.A., Thrasher, J.F., Siahpush, M. (2019). Socioeconomic patterns of smoking cessation behavior in low and middle-income countries: Emerging evidence from the Global Adult Tobacco Surveys and International Tobacco Control Surveys. PLOS One, 14(9), e0220223.

Abstract

Introduction: Tobacco smoking is often more prevalent among those with lower socio-economic status (SES) in high-income countries, which can be driven by the inequalities in initiation and cessation of smoking. Smoking is a leading contributor to socio-economic disparities in health. To date, the evidence for any socio-economic inequality in smoking cessation is lacking, especially in low- and middle-income countries (LMICs). This study examined the association between cessation behaviours and SES of smokers from eight LMICs.

Methods: Data among former and current adult smokers aged 18 and older came from contemporaneous Global Adult Tobacco Surveys (2008–2011) and the International Tobacco Control Surveys (2009–2013) conducted in eight LMICs (Bangladesh, Brazil, China, India, Mexico, Malaysia, Thailand and Uruguay). Adjusted odds ratios (AORs) of successful quitting in the past year by SES indicators (household income/wealth, education, employment status, and rural-urban residence) were estimated using multivariable logistic regression controlling for socio-demographics and average tobacco product prices. A random effects meta-analysis was used to combine the estimates of AORs pooled across countries and two concurrent surveys for each country.

Results: Estimated quit rates among smokers (both daily and occasional) varied widely across countries. Meta-analysis of pooled AORs across countries and data sources indicated that there was no clear evidence of an association between SES indicators and successful quitting. The only exception was employed smokers, who were less likely to quit than their non-employed counterparts, which included students, homemakers, retirees, and the unemployed (pooled AOR≈0.8, p<0.10).

Conclusion: Lack of clear evidence of the impact of lower SES on adult cessation behaviour in LMICs suggests that lower-SES smokers are not less successful in their attempts to quit than their higher-SES counterparts. Specifically, lack of employment, which is indicative of younger age and lower nicotine dependence for students, or lower personal disposable income and lower affordability for the unemployed and the retirees, may be associated with quitting. Raising taxes and prices of tobacco products that lowers affordability of tobacco products might be a key strategy for inducing cessation behaviour among current smokers and reducing overall tobacco consumption. Because low-SES smokers are more sensitive to price increases, tobacco taxation policy can induce disproportionately larger decreases in tobacco consumption among them and help reduce socio-economic disparities in smoking and consequent health outcomes.

Citation

Xu, S.S., Gravely, S., Meng, G., Elton-Marshall, T., O’Connor, R.J., Quah, A.C.K., Feng, G., Jiang, Y., Hu, G., Fong, G.T. (2019). Impact of China National Tobacco Company’s ‘premiumization’ strategy: Longitudinal findings from the ITC China Project (2006-2015). Tobacco Control, 28(Suppl 1), S68-S76.

Abstract

Background: In 2009, the China National Tobacco Company (CNTC) began their Premiumization Strategy, designed to encourage smokers to trade up to more expensive brands, mainly by promoting the concept that higher class cigarettes are better quality and less harmful. This study is the first evaluation of the strategy’s impact on: (1) prevalence of premium brand cigarettes (PBC), mid-priced brand cigarettes (MBC) and discount brand cigarettes (DBC) over 9 years, from 3 years pre-strategy (2006) to 6 years post-strategy (2015); and (2) changes in reasons for choosing PBCs, MBCs and DBCs.

Methods: A representative cohort of adult Chinese smokers (n=9047) in seven cities who participated in five waves of the International Tobacco Control (ITC) China Survey: pre-implementation (Wave 1 (2006; n=3452), Wave 2 (2007–2008; n=3586)); mid-implementation (Wave 3 (2009; n=4172)); and post-implementation (Wave 4 (2011–2012; n=4070), Wave 5 (2013–2015; n=2775)). Generalised estimating equations were conducted to examine changes in prevalence of PBCs, MBCs and DBCs, and reasons for brand choice from pre-implementation to post-implementation.

Results: From pre-implementation to post-implementation, there was an increase in prevalence of PBCs (5.4% to 23.2%, p<0.001) and MBCs (40.0% to 50.4%, p<0.001), and a decrease in DBCs (54.6% to 26.5%, p<0.001). There was an increase in smokers who chose their current brand because they believed it to be less harmful, both for MBC smokers (+13.0%, p=0.001) and PBC smokers (+9.0%, p=0.06). There was an increase for smokers in all brand classes for choosing their current brand because they were ‘higher in quality’ and because of affordable price, but the greatest increase was among PBC smokers (+18.6%, p<0.001 and +34.9%, p<0.001, respectively).

Conclusions: Our findings demonstrate that the rising trend in Chinese smokers’ choice of ‘less harmful’, ‘higher quality’ and ‘affordable’ cigarettes, particularly PBCs, is likely due to CNTC’s aggressive marketing strategies. Strong tobacco control policies that prohibit CNTC’s marketing activities are critical in order to dispel erroneous beliefs that sustain continued smoking in China, where the global tobacco epidemic is exerting its greatest toll.

Citation

Ngo, A., Fong, G.T., Craig, L., Shang, C. (2019). Analysis of gender differences in the impact of taxation and taxation structure on cigarette consumption in 17 ITC countries. International Journal of Environmental Research and Public Health, 16(7), e1275.

Abstract

Although increasing taxes has been established as the most effective tobacco control policy, it is not clear whether these policies reduce cigarette consumption equally among women and men. In this study, we examine whether the association between taxation/taxation structure and cigarette consumption differs by gender. The data is from the International Tobacco Control Policy Evaluation (ITC) Projects in 17 countries. Cigarette consumption was measured by gender for each ITC country. Generalized estimating equations (GEE) were employed to investigate gender differences in the association between cigarette consumption and tax structures, while controlling for time-variant demographic characteristics such as unemployment rates, proportions of adults, and percent of female population. Tiered tax structures are associated with higher cigarette consumption among both males and females. Female smokers are more responsive to an average tax increase than male smokers. Among males, higher ad valorem share in excise taxes is associated with lower cigarette consumption, but it is not the case for females. Females may not be as responsive to the prices raised by ad valorem taxes, despite being responsive to average taxes, suggesting that smokers by gender may face different prices.

Citation

Gravely, S., Driezen, P., Ouimet, J., Quah, A.C.K., Cummings, K.M., Thompson, M.E., Boudreau, C., Hammond, D., McNeill, A., Borland, R., Thrasher, J.F., Edwards, R., Omar, M., Hitchman, S., Yong, H-H., Barrientos-Gutierrez, T., Willemsen, M.C., Bianco, E., Boado, M., Goma, F., Seo, H.G., Nargis, N., Jiang, Y., Perez, C., & Fong, G.T. (2019). Prevalence of awareness, ever-use, and current use of nicotine vaping products (NVPs) among adult current smokers and ex-smokers in 14 countries with differing regulations on sales and marketing of NVPs: Cross-sectional findings from the ITC Project. Addiction, 114(6), 1060-1073.

Abstract

Aims: This paper presents updated prevalence estimates of awareness, ever‐use, and current use of nicotine vaping products (NVPs) from 14 International Tobacco Control Policy Evaluation Project (ITC Project) countries that have varying regulations governing NVP sales and marketing.

Design, setting, participants and measurements: A cross‐sectional analysis of adult (≥18 years) current smokers and ex‐smokers from 14 countries participating in the ITC Project. Data from the most recent survey questionnaire for each country were included, which spanned the period 2013 to 2017. Countries were categorized into four groups based on regulations governing NVP sales and marketing (allowable or not), and level of enforcement (strict or weak where NVPs are not permitted to be sold): (1) most restrictive policies (MRPs): not legal to be sold or marketed with strict enforcement: Australia, Brazil, Uruguay; (2) restrictive policies (RPs): not approved for sale or marketing with weak enforcement: Canada, Malaysia, Mexico, New Zealand (NZ); (3) less restrictive policies (LRPs): legal to be sold and marketed with regulations: England, Netherlands, Republic of Korea, United States (US); (4) no regulatory policies (NRPs): Bangladesh, China, Zambia. Countries were also grouped by World Bank Income Classifications. Country‐specific weighted logistic regression models estimated adjusted NVP prevalence estimates for: awareness, ever/current use, and frequency of use (daily vs. non‐daily).

Findings: NVP awareness and use were lowest in NRP countries. Generally, ever‐ and current use of NVPs were lower in MRP countries [ever‐use: 7.1% to 48.9%; current use: 0.3% to 3.5%] relative to LRP countries [ever‐use: 38.9% to 66.6%; current use: 5.5% to 17.2%] and RP countries [ever‐use: 10.0% to 62.4%; current use: 1.4% to 15.5%]. NVP use was highest among high income countries, followed by upper‐middle income countries, and then by lower‐middle income countries.

Conclusions: With a few exceptions, awareness and use of nicotine vaping products (NVPs) varies by the strength of national regulations governing NVP sales/marketing, and by country income. In countries with no regulatory policies, use rates were very low, suggesting that there was little availability, marketing and/or interest in NVPs in these countries where smoking populations are predominantly poorer. The higher awareness and use of NVPs in high income countries with moderately (e.g., Canada, NZ) and less (e.g., England, US) restrictive policies, is likely due to the greater availability and affordability of NVPs.

Citation

Shang, C., Myung Lee, H., Chaloupka, F., Fong, G.T., Thompson, M.E., O’Connor, R.J. (2019). Association between tax structure and cigarette consumption: findings from the International Tobacco Control Policy Evaluation (ITC) Project. Tobacco Control, 28(Suppl 1), S31-S36.

Abstract

Background: Recent studies show that greater price variability and more opportunities for tax avoidance are associated with tax structures that depart from a specific uniform one. These findings indicate that tax structures other than a specific uniform one may lead to more cigarette consumption.

Objective: This paper aims to examine how cigarette tax structure is associated with cigarette consumption.

Methods: We used survey data taken from the International Tobacco Control Policy Evaluation Project in 17 countries to conduct the analysis. Self-reported cigarette consumption was aggregated to average measures for each surveyed country and wave. The effect of tax structures on cigarette consumption was estimated using generalised estimating equations after adjusting for sociodemographic characteristics, average taxes and year fixed effects.

Findings: Our study provides important empirical evidence of a relationship between tax structure and cigarette consumption. We find that a change from a specific to an ad valorem structure is associated with a 6%–11% higher cigarette consumption. In addition, a change from uniform to tiered structure is associated with a 34%–65% higher cigarette consumption. The results are consistent with existing evidence and suggest that a uniform and specific tax structure is the most effective tax structure for reducing tobacco consumption.

Citation

Nargis, N., Zheng, R., Xu, S.S., Fong, G.T., Feng, G., Jiang, Y., Wang, Y., Hu, X. (2019). Cigarette affordability in China, 2006-2015: Findings from the ITC China Survey. International Journal of Environmental Research and Public Health, 16(7), 1205.

Abstract

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.

Citation

Xu, S.S., Gravely, S., Meng, G., Elton-Marshall, T., O’Connor, R.J., Quah, A.C.K., Feng, G., Jiang, Y., Hu, G., Fong, G.T. (2019). Impact of China National Tobacco Company’s ‘premiumization’ strategy: Longitudinal findings from the ITC China Project (2006-2015). Tobacco Control, 28(Suppl 1), S68-S76.

Abstract

Background: In 2009, the China National Tobacco Company (CNTC) began their Premiumization Strategy, designed to encourage smokers to trade up to more expensive brands, mainly by promoting the concept that higher class cigarettes are better quality and less harmful. This study is the first evaluation of the strategy’s impact on: (1) prevalence of premium brand cigarettes (PBC), mid-priced brand cigarettes (MBC) and discount brand cigarettes (DBC) over 9 years, from 3 years pre-strategy (2006) to 6 years post-strategy (2015); and (2) changes in reasons for choosing PBCs, MBCs and DBCs.

Methods: A representative cohort of adult Chinese smokers (n=9047) in seven cities who participated in five waves of the International Tobacco Control (ITC) China Survey: pre-implementation (Wave 1 (2006; n=3452), Wave 2 (2007–2008; n=3586)); mid-implementation (Wave 3 (2009; n=4172)); and post-implementation (Wave 4 (2011–2012; n=4070), Wave 5 (2013–2015; n=2775)). Generalised estimating equations were conducted to examine changes in prevalence of PBCs, MBCs and DBCs, and reasons for brand choice from pre-implementation to post-implementation.

Results: From pre-implementation to post-implementation, there was an increase in prevalence of PBCs (5.4% to 23.2%, p<0.001) and MBCs (40.0% to 50.4%, p<0.001), and a decrease in DBCs (54.6% to 26.5%, p<0.001). There was an increase in smokers who chose their current brand because they believed it to be less harmful, both for MBC smokers (+13.0%, p=0.001) and PBC smokers (+9.0%, p=0.06). There was an increase for smokers in all brand classes for choosing their current brand because they were ‘higher in quality’ and because of affordable price, but the greatest increase was among PBC smokers (+18.6%, p<0.001 and +34.9%, p<0.001, respectively).

Conclusions: Our findings demonstrate that the rising trend in Chinese smokers’ choice of ‘less harmful’, ‘higher quality’ and ‘affordable’ cigarettes, particularly PBCs, is likely due to CNTC’s aggressive marketing strategies. Strong tobacco control policies that prohibit CNTC’s marketing activities are critical in order to dispel erroneous beliefs that sustain continued smoking in China, where the global tobacco epidemic is exerting its greatest toll.

Citation

Im, P.K., McNeill, A., Thompson, M.E., Fong, G.T., Xu, S.S., Quah, A.C.K., Jiang, Y., Shahab, L. (2015). Individual and interpersonal triggers to quit smoking in China: A cross-sectional analysis. Tobacco Control, 24(Suppl 4), iv40-iv47.

Abstract

Aims: To determine the most prominent individual and interpersonal triggers to quit smoking in China and their associations with sociodemographic characteristics.

Methods: Data come from Waves 1-3 (2006-2009) of the International Tobacco Control (ITC) China Survey, analysed cross-sectionally as person-waves (N=14 358). Measures included sociodemographic and smoking characteristics. Those who quit between waves (4.3%) were asked about triggers that 'very much' led them to stop smoking, and continuing smokers about triggers that 'very much' made them think about quitting. Triggers covered individual (personal health concerns, cigarette price, smoking restrictions, advertisements, warning labels) and interpersonal factors (family/societal disapproval of smoking, setting an example to children, concerns about secondhand smoke).

Results: Over a third of respondents (34.9%) endorsed at least one trigger strongly; quitters were more likely than smokers to mention any trigger. While similar proportions of smokers endorsed individual (24.4%) and interpersonal triggers (24.0%), quitters endorsed more individual (61.1%) than interpersonal (48.3%) triggers. However, the most common triggers (personal health concerns; setting an example to children) were the same, endorsed by two-thirds of quitters and a quarter of smokers, as were the least common triggers (warning labels; cigarette price), endorsed by 1 in 10 quitters and 1 in 20 smokers. Lower dependence among smokers and greater education among all respondents were associated with endorsing any trigger.

Conclusions: Individual rather than interpersonal triggers appear more important for quitters. Major opportunities to motivate quit attempts are missed in China, particularly with regard to taxation and risk communication. Interventions need to focus on more dependent and less-educated smokers.

Citation

Li, J., White, J.S., Hu, T.W., Fong, G.T., Jiang, Y. (2015). The heterogeneous effects of cigarette prices on brand choice in China: Implications for tobacco control policy. Tobacco Control, 24(Suppl 3), iii25-iii32.

Abstract

Background: China 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 and the ability of consumers to switch to cheaper brands.

Objective: This study examines how different socioeconomic subgroups of Chinese smokers switch brands in response to cigarette price changes.

Methods: We model smokers' choice of cigarette tier as a function of tier-specific prices. We examine heterogeneous responses to prices by estimating mixed logit models for different income and education subgroups that allow for random variation in smokers' preferences. We use data from three waves of the longitudinal International Tobacco Control China Survey, collected in six large Chinese cities between 2006 and 2009.

Findings: Low-income and less educated smokers are considerably more likely to switch tiers (including both up-trading and down-trading) than are their high-socioeconomic status (SES) counterparts. For those in the second-to-lowest tier, a ¥1 ($0.16, or roughly 25%) rise in prices increases the likelihood of switching tiers by 5.6% points for low-income smokers and 7.2% points for less educated smokers, compared to 1.6% and 3.0% points for the corresponding high-SES groups. Low-income and less educated groups are also more likely to trade down compared to their high-SES counterparts.

Conclusions: Only a small percentage of low-income and less educated Chinese smokers switched to cheaper brands in response to price increases. Hence, the concern of the Chinese government that a cigarette tax increase will lead to large-scale brand switching is not supported by this study.

Citation

Li, L., Borland, R., Fong, G.T., Jiang, Y., Yang, Y., Wang, L., Partos, T.R., Thrasher, J.F. (2015). Smoking-related thoughts and microbehaviours, and their predictive power for quitting: Findings from the International Tobacco Control (ITC) China Survey. Tobacco Control, 24(4), 354-361.

Abstract

Background: Negative 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 that reflect a concern about smoking.

Objectives: This paper aimed to describe the occurrence of smoking-related thoughts and microbehaviours among Chinese smokers, and to examine their predictive power for making quit attempts and sustained abstinence.

Methods: The data came from the first three waves of the International Tobacco Control China Survey. Four measures of recent thoughts about smoking and two microbehaviour measures (collectively referred to as microindicators) were examined.

Results: Most smokers (around three-quarters) reported thinking about harms of smoking to themselves or to others at least occasionally, and an increasing minority reported the two microbehaviours of prematurely butting out cigarettes and forgoing them. All microindicators were positively related to subsequent quit attempts in individual predictor analyses, but only serious thoughts about quitting and butting out cigarettes had independent relationships. Overall, there was no clear relationship between these microindicators and sustained abstinence.

Conclusions: There was a moderately high level of occurrence of recent smoking-related thoughts and microbehaviours among the Chinese adult smokers in the six cities studied. Like in the West, microindicators of concern about smoking were positively associated with subsequent quit attempts, but unlike in the West, they were largely unrelated to sustained abstinence.

Citation

Yao, T., Huang, J., Sung, H.Y., Ong, M., Mao, Z., Jiang, Y., Fong, G.T., Max, W. (2015). Determinants of smoking-induced deprivation in China. Tobacco Control, 24(Suppl 4), iv35-iv39.

Abstract

Objective: Spending on cigarettes may deprive households of other items like food. The goal of this study was to examine the prevalence of and factors associated with this smoking-induced deprivation among adult smokers in China.

Methods: The data came from waves 1-3 of the International Tobacco Control (ITC) China Survey, conducted from 2006 to 2009 among urban adults aged 18 years or older in China. We focus on the samples of current smokers from six cities (N=7981). Smoking-induced deprivation was measured with the survey question, “In the last six months, have you spent money on cigarettes that you knew would be better spent on household essentials like food?” We examined whether sociodemographic factors, smoking intensity and price paid per pack of cigarettes were associated with smoking-induced deprivation using generalised estimating equations modelling.

Findings: 7.3% of smokers reported smoking-induced deprivation due to purchasing cigarettes. Lowincome and middle-income smokers were more likely to have smoking-induced deprivation compared with high-income smokers (adjusted OR (AOR)=2.06, 95% CI 1.32 to 2.31; AOR=1.44, 95% CI 1.10 to 1.69); smokers living in Shenyang (AOR=1.68, 95% CI 1.25 to 2.24) and Yinchuan (AOR=2.50, 95% CI 1.89 to 3.32) were more likely to have smoking-induced deprivation compared with smokers living in Beijing. Retired smokers were less likely to have smoking-induced deprivation compared with employed smokers (AOR=0.67, 95% CI 0.52 to 0.87). There was no statistically significant relationship between smoking intensity, price paid per pack of cigarettes and smoking-induced deprivation.

Conclusions: Our findings indicate that certain groups of smokers in China acknowledge spending money on cigarettes that could be better spent on household essentials. Tobacco control policies that reduce smoking in China may improve household living standards by reducing smoking-induced deprivation.

Citation

Huang, L.L., Thrasher, J.F., Jiang, Y., Li, Q., Fong, G.T., Chang, Y., Walsemann, K.M., Friedman, D. (2015). Impact of the ‘Giving Cigarettes is Giving Harm’ campaign on knowledge and attitudes of Chinese smokers. Tobacco Control, 24(Suppl 4), iv28-iv34.

Abstract

Objective: To date there is limited published evidence on the efficacy of tobacco control mass media campaigns in China. This study aimed to evaluate the impact of a mass media campaign 'Giving Cigarettes is Giving Harm' (GCGH) on Chinese smokers' knowledge of smoking-related harms and attitudes towards cigarette gifts.

Methods: Population-based, representative data were analysed from a longitudinal cohort of 3709 adult smokers who participated in the International Tobacco Control (ITC) China Survey conducted in six Chinese cities before and after the campaign. Logistic regression models were estimated to examine associations between campaign exposure and attitudes towards cigarette gifts measured postcampaign. Poisson regression models were estimated to assess the effects of campaign exposure on postcampaign knowledge, adjusting for precampaign knowledge.

Findings: Fourteen percent (n=335) of participants recalled the campaign within the cities where the GCGH campaign was implemented. Participants in the intervention cities who recalled the campaign were more likely to disagree that cigarettes are good gifts (71% vs 58%, p<0.01) and had greater levels of campaign-targeted knowledge than those who did not recall the campaign (mean=1.97 vs 1.62, p<0.01). Disagreeing that cigarettes are good gifts was higher in intervention cities than in control cities. Changes in campaign-targeted knowledge were similar in both cities, perhaps due to a secular trend, low campaign recall or contamination issues.

Conclusions: These findings suggest that the GCGH campaign increased knowledge of smoking harms, which could promote downstream cessation. This study provides evidence to support future campaign development to effectively fight the tobacco epidemic in China.

Citation

Elton-Marshall, T., Fong, G.T., Yong, H.H., Borland, R., Xu, S.S., Quah, A.C.K., Feng, G., Jiang, Y. (2015). Smokers’ sensory beliefs mediate the relation between smoking a ‘light/low tar’ cigarette and perceptions of harm. Tobacco Control, 24(Suppl 4), iv21-iv27.

Abstract

Background: The sensory belief that ‘light/low tar’ cigarettes are smoother can also influence the belief that ‘light/low tar’ cigarettes are less harmful. However, the ‘light’ concept is one of several factors influencing beliefs. No studies have examined the impact of the sensory belief about one's own brand of cigarettes on perceptions of harm.

Objective: The current study examines whether a smoker's sensory belief that their brand is smoother is associated with the belief that their brand is less harmful and whether sensory beliefs mediate the relation between smoking a ‘light/low tar’ cigarette and relative perceptions of harm among smokers in China.

Methods: Data are from 5209 smokers who were recruited using a stratified multistage sampling design and participated in wave 3 of the International Tobacco Control (ITC) China Survey, a face-to-face survey of adult smokers and non-smokers in seven cities.

Results: Smokers who agreed that their brand of cigarettes was smoother were significantly more likely to say that their brand of cigarettes was less harmful (p<0.001, OR=6.86, 95% CI 5.64 to 8.33). Mediational analyses using the bootstrapping procedure indicated that both the direct effect of ‘light/low tar’ cigarette smokers on the belief that their cigarettes are less harmful (b=0.24, bootstrapped bias corrected 95% CI 0.13 to 0.34, p<0.001) and the indirect effect via their belief that their cigarettes are smoother were significant (b=0.32, bootstrapped bias-corrected 95% CI 0.28 to 0.37, p<0.001), suggesting that the mediation was partial.

Conclusions: These results demonstrate the importance of implementing tobacco control policies that address the impact that cigarette design and marketing can have in capitalising on the smoker's natural associations between smoother sensations and lowered perceptions of harm.

Citation

Wu, C., Thompson, M.E., Fong, G.T., Jiang, Y., Yang, Y., Feng, G., Quah, A.C.K. (2015). Methods of the International Tobacco Control (ITC) China Survey: Waves 1, 2, and 3. Tobacco Control, 24(Suppl 4), iv1-iv5.

Abstract

This paper describes the methods of sampling design and data collection of waves 1, 2 and 3 of the International Tobacco Control (ITC) China Survey, with major focus on longitudinal features of the study. Key measures of quality of the survey data, such as retention rates and final sample sizes, are presented. Sample replenishment procedures are outlined, including the addition of a new city, Kunming, at wave 3. Methods for constructing the longitudinal and cross-sectional survey weights are briefly described.

Citation

Schneller, L., Zwierzchowski, B., Caruso, R., Li, Q., Jiang, Y., Fong, G.T., O’Connor, R.J. (2015). Changes in tar yields and cigarette design in samples of Chinese cigarettes, 2009-2012. Tobacco Control, 24(Suppl 4), iv60-iv63.

Abstract

Background: China is home to the greatest number of smokers as well as the greatest number of smoking-related deaths. An active and growing market of cigarettes marketed as ‘light’ or ‘low tar’ may keep health-concerned smokers from quitting, wrongly believing that such brands are less harmful.

Objective: This study sought to observe changes in cigarette design characteristics and reported tar, nicotine and carbon monoxide (TNCO) levels in a sample of cigarette brands obtained in seven Chinese cities from 2009 to 2012.

Methods: Cigarettes were purchased and shipped to Roswell Park Cancer Institute, where 91 pairs of packs were selected for physical cigarette design characteristic testing and recording of TNCO values. Data analysis was conducted using SPSS, and was initially characterised using descriptive statistics, correlations and generalised estimating equations to observe changes in brand varieties over time.

Findings: Reported TNCO values on packs saw mean tar, nicotine and CO levels decrease from 2009 to 2012 by 7.9%, 4.5% and 6.0%, respectively. Ventilation was the only cigarette design feature that significantly changed over time (p<0.001), with an increase of 31.7%. Significant predictors of tar and CO yield overall were ventilation and per-cigarette tobacco weight, while for nicotine tobacco moisture was also an independent predictor of yield.

Conclusions: The use of ventilation to decrease TNCO emissions is misleading smokers to believe that they are smoking a ‘light/low’ tar cigarette that is healthier, and is potentially forestalling the quitting behaviours that would begin to reduce the health burden of tobacco in China, and so should be prohibited.

Citation

Sansone, N., Yong, H.H., Li, L., Jiang, Y., Fong, G.T. (2015). Perceived acceptability of female smoking in China: Findings from Waves 1 to 3 of the ITC China Survey. Tobacco Control, 24(Suppl 4), iv48-iv54.

Abstract

Background: 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.

Objective: This study sought to examine smokers’ and non-smokers’ perceived acceptability of female smoking and how it changed over time in China.

Methods: 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.

Results: 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.

Conclusions: 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.

Citation

Fong, G.T., Sansone, G., Yan, M., Craig, L., Quah, A.C.K, Jiang, Y. (2015). Evaluation of smoke-free policies in seven cities in China: Longitudinal findings from the ITC China Project (2007-2012). Tobacco Control, 24(Suppl 4), iv14-iv20.

Abstract

Background: China is the world's largest consumer of tobacco, with hundreds of millions of people exposed daily to secondhand smoke (SHS). Comprehensive smoke-free policies are the only effective way to protect the population from the harms of SHS. China does not have a comprehensive national smoke-free law but some local-level regulations have been implemented.

Objective: To evaluate local level smoke-free regulations across 7 cities in China by measuring the prevalence of smoking in public places (workplaces, restaurants and bars), and support for smoke-free policies over time.

Methods: Data were from waves 2 to 4 of the International Tobacco Control (ITC) China Survey (2007- 2012), a face-to-face cohort survey of approximately 800 smokers in each of 7 cities in mainland China. Multivariate logistic regression models estimated with generalised estimating equations were used to test the changes in variables over time.

Results: As of 2012, over three-quarters of respondents were exposed to smoking in bars; more than two-thirds were exposed to smoking in restaurants and more than half were exposed to smoking in indoor workplaces. Small decreases in the prevalence of smoking were found overall from waves 2 to 4 for indoor workplaces, restaurants and bars, although the decline was minimal for bars. Support for complete smoking bans increased over time for each venue, although it was lowest for bars.

Conclusions: Existing partial smoking bans across China have had minimal impact on reducing smoking in public places. A strongly enforced, comprehensive national smoke-free law is urgently needed in order to achieve greater public health gains