Citation

Huang, J., Zheng, R., Chaloupka, F., Fong, G.T., Li, Q., Jiang, Y. (2015). Differential responsiveness to cigarette price by education and income among adult urban Chinese smokers. Tobacco Control, 24(Suppl 3), iii76-iii82.

Abstract

Background: Few 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 on socioeconomic status in China.

Objective: To estimate the conditional cigarette consumption price elasticity among adult urban smokers in China and to examine the differential responses to cigarette price increases among groups with different income and/or educational levels.

Methods: Multivariate analyses employing the general estimating equations method were conducted using the first three waves of the International Tobacco Control (ITC) China Survey. Analyses based on subsample by education and income were conducted.

Findings: Conditional cigarette demand price elasticity ranges from −0.12 to −0.14. No differential responses to cigarette price increase were found across education levels. The price elasticity estimates do not differ between high-income smokers and medium-income smokers. Cigarette consumption among low-income smokers did not decrease after a price increase, at least among those who continued to smoke.

Conclusions: Relative to other low-income and middle-income countries, cigarette consumption among Chinese adult smokers is not very sensitive to changes in cigarette prices. The total impact of cigarette price increase would be larger if its impact on smoking initiation and cessation, as well as the pricereducing behaviours such as brand switching and trading down, were taken into account.

Citation

Elton-Marshall, T., Xu, S.S., Meng, G., Quah, A.C.K., Sansone, G.C., Feng, G., Jiang, Y., Driezen, P., Maizurah, O., Awang, R., Fong, G.T. (2015). The lower effectiveness of text-only health warnings in China compared to pictorial warnings in Malaysia: Findings from the ITC Project. Tobacco Control, 24(Suppl 4), iv6-iv13.

Abstract

Background: In 2009, China changed its health warnings on cigarette packs from side-only text warnings to two text-only warnings on 30% of the bottom of the front and back of the pack. Also in 2009, Malaysia changed from similar text warnings to pictorial health warnings consistent with Framework Convention on Tobacco Control (FCTC) Article 11 Guidelines.

Objective: To measure the impact of the change in health warnings in China and to compare the text-only health warnings to the impact of the pictorial warnings introduced in Malaysia.

Methods: We measured changes in key indicators of warning effectiveness among a longitudinal cohort sample of smokers from Waves 1 to 3 (2006–2009) of the International Tobacco Control (ITC) China Survey and from Waves 3 to 4 (2008–2009) of the ITC Malaysia Survey. Each cohort consisted of representative samples of adult (≥18 years) smokers from six cities in China (n=6575) and from a national sample in Malaysia (n=2883). Generalised Estimating Equations (GEE) were used to examine the impact of the health warnings on subsequent changes in salience of warnings, cognitive and behavioural outcomes.

Findings: Compared to Malaysia, the weak text-only warning labels in China led to a significant change in only two of six key indicators of health warning effectiveness: forgoing cigarettes and reading the warning labels. The change to pictorial warnings in Malaysia led to significant and substantial increases in five of six indicators (noticing, reading, forgoing, avoiding, thinking about quitting).

Conclusions: The delay in implementing pictorial warnings in China constitutes a lost opportunity for increasing knowledge and awareness of the harms of cigarettes, and for motivating smokers to quit

Citation

O’Connor, R.J., Schneller, L., Caruso, R., Stephens, W.E., Li, Q., Jiang, Y., Fong, G.T. (2015). Toxic metal and nicotine content of cigarettes sold in China, 2009 and 2012. Tobacco Control, 24(Suppl 4), iv55-iv59.

Abstract

Background: Metals of primary health concern can accumulate in the tobacco plant and contribute to smokers’ exposures to carcinogens, a significant cause of the millions of smoking-related deaths in China each year. These exposures are due to the smoker's addiction to nicotine.

Objective: This study sought to explore toxic heavy metal and nicotine concentrations in the tobacco of Chinese cigarette brands purchased in 2009 and 2012, as well as its regional variation.

Methods: Cigarette packs for this study were purchased from seven Chinese cities in 2009 and 2012, and 91 pairs of cigarettes were matched based on UPC for comparison. Ten cigarette sticks were randomly selected from each pack and tested using polarised energy dispersive X-ray fluorescence (XRF) for arsenic (As), cadmium (Cd), chromium (Cr), nickel (Ni) and lead (Pb) concentrations. Nicotine analysis was conducted following Coresta's Recommended Method N°62. Data analysis was conducted using SPSS, encompassing descriptive statistics, correlations and generalised estimating equations to observe changes in brand varieties overtime.

Findings: On average, from 2009 to 2012, As, Cd, Cr and Pb concentrations have decreased in Chinese tobacco. Of the seven cities where the cigarette brands were purchased, only four cities showed significant differences of the selected metals from 2009 to 2012. However, there was no significant change in the tobacco nicotine content from 2009 to 2012.

Conclusions: Tobacco in Chinese cigarettes purchased in seven geographically disbursed cities contains consistently high levels of metals, including carcinogens like Cd. One source may be the improper use of fertilisers. These numbers should be monitored more carefully and regulated by health officials.

Citation

Huang, J., Zheng, R., Chaloupka, F., Fong, G.T., Li, Q., Jiang, Y. (2014). Chinese smokers' cigarette purchase behaviours, cigarette prices and consumption: Findings from the ITC China Survey. Tobacco Control, 23(Suppl 1), i67-i72.

Abstract

Background: While 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 purchasing behaviours and their impact on cigarette price and consumption in China, the world's largest cigarette consumer.

Objective: The aim of the present study was to examine the extent and determinants of cost/price-related purchase behaviours, and estimate the impact of these behaviours on cigarette prices paid by Chinese smokers. It also assesses the socioeconomic differences in compensatory purchase behaviours, and examines how they influence the relationship between purchase behaviours, cigarette prices and cigarette consumption.

Methods: Multivariate analyses using the general estimating equations method were conducted using data from the International Tobacco Control China Survey (the ITC China Survey), a longitudinal survey of adult smokers in seven cities in China: Beijing, Changsha, Guangzhou, Kunming, Shanghai, Shenyang and Yinchuan. In each city, about 800 smokers were surveyed in each wave. The first three waves-wave 1 (conducted between March to December 2006), wave 2 (November 2007 to March 2008) and wave 3 (May to October 2009 and February to March 2010)-of the ITC China Survey data were used in this analysis. Various aspects of smokers' self-reported price/cost-related cigarette purchasing behaviours were analysed.

Results: Nearly three-quarters (72%) of smokers surveyed indicated that a major reason they chose their most-used cigarette brand was its low cost/price. Almost half (50.6%) of smokers reported buying in cartons in their most recent cigarette purchase. Smokers with lower income and/or low levels of education were more likely to choose a brand because of its low cost/price. However, those with higher income and/or high levels of education were more likely to buy cartons. Gender and age were also related to type of purchase behaviours. Those behaviours led to reductions in purchase prices. The price savings ranged from ¥0.54 to ¥1.01 per pack of cigarettes, depending on the behaviour examined, representing a price reduction of 8% to 15%.

Conclusions: A significant portion of Chinese urban adult smokers engaged in cost/price-reducing purchase behaviours. Such behaviours reduce cigarette purchase prices and are associated with increased cigarette consumption. Smokers of different socioeconomic status engaged in different purchase behaviours to mitigate the impact of higher cigarette prices. Reducing tobacco use through raising tobacco taxes/prices in China needs to take into account these cost/price-reducing behaviours.

Citation

Shang, C., Chaloupka, F., Zahra, N., Fong, G.T. (2014). The distribution of cigarette prices under different tax structures: Findings from the International Tobacco Control Policy Evaluation (ITC) Project. Tobacco Control, 23(Suppl 1), i23-i29.

Abstract

Background: The distribution of cigarette prices has rarely been studied and compared under different tax structures. Descriptive evidence on price distributions by countries can shed light on opportunities for tax avoidance and brand switching under different tobacco tax structures, which could impact the effectiveness of increased taxation in reducing smoking.

Objective: This paper aims to describe the distribution of cigarette prices by countries and to compare these distributions based on the tobacco tax structure in these countries.

Methods: We employed data for 16 countries taken from the International Tobacco Control Policy Evaluation Project to construct survey-derived cigarette prices for each country. Self-reported prices were weighted by cigarette consumption and described using a comprehensive set of statistics. We then compared these statistics for cigarette prices under different tax structures. In particular, countries of similar income levels and countries that impose similar total excise taxes using different tax structures were paired and compared in mean and variance using a two-sample comparison test.

Findings: Our investigation illustrates that, compared with specific uniform taxation, other tax structures, such as ad valorem uniform taxation, mixed (a tax system using ad valorem and specific taxes) uniform taxation, and tiered tax structures of specific, ad valorem and mixed taxation tend to have price distributions with greater variability. Countries that rely heavily on ad valorem and tiered taxes also tend to have greater price variability around the median. Among mixed taxation systems, countries that rely more heavily on the ad valorem component tend to have greater price variability than countries that rely more heavily on the specific component. In countries with tiered tax systems, cigarette prices are skewed more towards lower prices than are prices under uniform tax systems. The analyses presented here demonstrate that more opportunities exist for tax avoidance and brand switching when the tax structure departs from a uniform specific tax.

Citation

White, J.S., Li, J., Hu, T.W., Fong, G.T., Jiang, Y. (2014). The effect of cigarette prices on brand-switching in China: A longitudinal analysis of data from the ITC China Survey. Tobacco Control, 23(Suppl 1), i54-i60.

Abstract

Background: Recent 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 low response. One possible explanation is that smokers buffer themselves from rising cigarette prices by switching to cheaper cigarette brands.

Objective: This study examines how cigarette prices influence consumers’ choices of cigarette brands in China.

Methods: This study uses panel data from the first three waves of the International Tobacco Control China Survey, drawn from six large cities in China and collected between 2006 and 2009. The study sample includes 3477 smokers who are present in at least two waves (8552 person-years). Cigarette brands are sorted by price into four tiers, using excise tax categories to determine the cut-off for each tier. The analysis relies on a conditional logit model to identify the relationship between price and brand choice.

Findings: Overall, 38% of smokers switched price tiers from one wave to the next. A ¥1 change in the price of cigarettes alters the tier choice of 4–7% of smokers. Restricting the sample to those who chose each given tier at baseline, a ¥1 increase in price in a given tier would decrease the share choosing that tier by 4% for Tier 1 and 1–2% for Tiers 2 and 3.

Conclusions: China's large price spread across cigarette brands appears to alter the brand selection of some consumers, especially smokers of cheaper brands. Tobacco pricing and tax policy can influence consumers’ incentives to switch brands. In particular, whereas ad valorem taxes in a tiered pricing system like China's encourage trading down, specific excise taxes discourage the practice.

Citation

Li, L., Borland, R., Yong, H.H., Fong, G.T., Jiang, Y., Li, Q., Hammond, D., Quah, A.C.K. (2014). Reported exposures to anti-smoking messages and their impact on Chinese smokers' subsequent quit attempts. International Journal of Behavioural Medicine, 21(4), 667-676.

Abstract

Background: It is important to monitor whether anti-smoking messages (if any) are noticed by the public in China and whether they have any impact on smokers' quitting behaviours over time

Purpose: This study aimed to examine Chinese smokers' exposure to anti-smoking messages in a range of channels and to determine if exposure was associated with subsequent quit attempts.

Method: A prospective cohort design was employed. Participants were 6,509 adult smokers who completed at least one of the first three waves (2006-2009) of the International Tobacco Control (ITC) China Survey sampled from six Chinese cities. The main measures were reported exposure to antismoking messages in a range of channels and smokers' subsequent quit attempts. Generalized Estimating Equations (GEE) modelling was used to combine respondents from all three waves while accounting for inherent within-person correlation.

Results: The overall exposure levels to anti-smoking messages were low and varied between cities and from one channel to another. Television was the medium with the greatest overall exposure (over 50 % in almost all the cities across all the waves). After controlling for a range of covariates, higher level of combined exposure were positively related to higher subsequent quit attempts (adjusted odds ratio = 1.03, 95 % CI 1.02 ~ 1.05, p < .001); among the individual channels, exposures in newspapers and on posters were significant in their own right.

Conclusion: The findings suggest that anti-smoking warning messages have the potential to stimulate Chinese smokers to make quit attempts, but they also indicate that the levels and strength of warning messages in China need to be increased. China should consider adopting proven international practices, including mandating pictorial health warnings on cigarette packages, adopting prominent point-of-sale warnings, and carrying out strong and ongoing mass media campaigns.

Citation

Gravely, S., Fong, G.T., Cummings, K.M., Yan, M., Quah, A.C.K., Borland, R., Yong, H.H., Hitchman, S.C., McNeill, A., Hammond, D., Thrasher, J.F., Willemsen, M.C., Seo, H.G., Jiang, Y., Cavalcante, T.M., Perez, C., Omar, M., Hummel, K. (2015). Awareness, trial, and current use of electronic cigarettes in 10 countries: findings from the ITC Project. International Journal of Environmental Research and Public Health, 12(5), 4631-4637.

Abstract

Background: In recent years, electronic cigarettes (e-cigarettes) have generated considerable interest and debate on the implications for tobacco control and public health. Although the rapid growth of e-cigarettes is global, at present, little is known about awareness and use. This paper presents self-reported awareness, trial and current use of e-cigarettes in 10 countries surveyed between 2009 and 2013; for six of these countries, we present the first data on e-cigarettes from probability samples of adult smokers.

Methods: A cross-sectional analysis of probability samples of adult (≥ 18 years) current and former smokers participating in the International Tobacco Control (ITC) surveys from 10 countries. Surveys were administered either via phone, face-to-face interviews, or the web. Survey questions included sociodemographic and smoking-related variables, and questions about e-cigarette awareness, trial and current use.

Results: There was considerable cross-country variation by year of data collection and for awareness of e-cigarettes (Netherlands (2013: 88%), Republic of Korea (2010: 79%), United States (2010: 73%), Australia (2013: 66%), Malaysia (2011: 62%), United Kingdom (2010: 54%), Canada (2010: 40%), Brazil (2013: 35%), Mexico (2012: 34%), and China (2009: 31%)), in self-reports of ever having tried e-cigarettes (Australia, (20%), Malaysia (19%), Netherlands (18%), United States (15%), Republic of Korea (11%), United Kingdom (10%), Mexico (4%), Canada (4%), Brazil (3%), and China (2%)), and in current use (Malaysia (14%), Republic of Korea (7%), Australia (7%), United States (6%), United Kingdom (4%), Netherlands (3%), Canada (1%), and China (0.05%)).

Conclusions: The cross-country variability in awareness, trial, and current use of e-cigarettes is likely due to a confluence of country-specific market factors, tobacco control policies and regulations (e.g., the legal status of e-cigarettes and nicotine), and the survey timing along the trajectory of e-cigarette awareness and trial/use in each country. These ITC results constitute an important snapshot of an early stage of what appears to be a rapid progression of global e-cigarette use.

Citation

Yao, T., Huang, J., Sung, H.Y., Ong, M., Mao, Z., Jiang, Y., Fong, G.T., Max, W. (2014). Who purchases cigarettes from cheaper sources in China? Findings from the ITC China Survey. Tobacco Control, 23(Suppl 1), i97-i101.

Abstract

Objective: The 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 this study was to identify factors associated with purchasing cigarettes from cheaper sources among adult smokers in China.

Methods: Data were analysed from Waves 1 to 3 of the International Tobacco Control China Survey conducted in 2006–2009 among adult smokers in six cities in China (N=7980). One survey question asked, “In the last 6 months, have you purchased cheaper cigarettes than you can get from local stores for economic reasons?” We examined whether sociodemographic factors and smoking intensity were associated with purchasing cigarettes from cheaper sources using the general estimating equations model. Sociodemographic factors considered were gender, age, marital status, monthly household income, education, employment status and city of residence.

Results: 15.6% of smokers reported purchasing cigarettes from cheaper sources. After controlling for other covariates, the associations of the behaviour of purchasing cigarettes from cheaper sources with age (adjusted OR (AOR)=1.49, 95% CI 1.17 to 3.92 for age 18–24 compared with age 55+) and with income (AOR=2.93, 95% CI 2.27 to 3.79 for low income compared with high income) were statistically significant, but there was no statistically significant relationship with smoking intensity.

Conclusions: Our findings indicate that young and low-income smokers are more likely than older and high-income smokers to purchase cigarettes from cheaper sources in China. Tobacco control policies that reduce the availability of cigarettes from cheaper sources could have an impact on reducing cigarette consumption among young and low-income smokers in China.

Citation

Sansone, G., Fong, G.T., Hall, P.A., Guignard, R., Beck, F., Mons, U., Pötschke-Langer, M., Yong, H.H., Thompson, M.E., Omar, M., Jiang, Y. (2013). Time perspective as a predictor of smoking status: Findings from the International Tobacco Control (ITC) Surveys in Scotland, France, Germany, China, and Malaysia. BioMed Central Public Health, 13(1), 346.

Abstract

Background: Prior studies have demonstrated that time perspective—the propensity to consider shortversus long-term consequences of one’s actions—is a potentially important predictor of health-related behaviors, including smoking. However, most prior studies have been conducted within single highincome countries. The aim of this study was to examine whether time perspective was associated with the likelihood of being a smoker or non-smoker across five countries that vary in smoking behavior and strength of tobacco control policies.

Methods: The data were from the International Tobacco Control (ITC) Surveys in five countries with large probability samples of both smokers (N=10,341) and non-smokers (N=4,955): Scotland, France, Germany, China, and Malaysia. The surveys were conducted between 2005 and 2008. Survey respondents indicated their smoking status (smoker vs. non-smoker) and time perspective (future oriented vs. not future-oriented) and provided demographic information.

Results: Across all five countries, non-smokers were significantly more likely to be future-oriented (66%) than were smokers (57%), χ2 (1, N = 15,244) = 120.64, p < .001. This bivariate relationship between time perspective and smoking status held in a multivariate analysis. After controlling for country, age, sex, income, education, and ethnicity (language in France), those who were future-oriented had 36% greater odds of being a non-smoker than a smoker (95% CI: 1.22 to 1.51, p<.001).

Conclusion: These findings establish time perspective as an important predictor of smoking status across multiple countries and suggest the potential value of incorporating material to enhance future orientation in smoking cessation interventions.

Citation

Yong, H., Siahpush, M., Borland, R., Li, L., O’Connor, R.J., Yang, J., Fong, G.T., Jiang, Y. (2013). Urban Chinese smokers from lower socioeconomic backgrounds face more barriers to quitting: Results from the International Tobacco Control China Survey. Nicotine & Tobacco Research, 15(6), 1044-1051.

Abstract

Introduction: 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.

Methods: 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.

Results: 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).

Conclusions: 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.

Citation

Sansone, N., Fong, G.T., Lee, W.B., Laux, F., Sirirassamee, B., Seo, H.G., Omar, M., Jiang, Y. (2013). Comparing the experience of regret and its predictors among smokers in four Asian countries: Findings from the ITC Surveys in Thailand, South Korea, Malaysia, and China. Nicotine & Tobacco Research, 15(10), 1663-1672.

Abstract

Introduction: Nearly all smokers in high-income Western countries report that they regret smoking (Fong, G. T., Hammond, D., Laux, F. L., Zanna, M. P., Cummings, M. K., Borland, R., & Ross, H. [2004]. The near-universal experience of regret among smokers in four countries: Findings from the International Tobacco Control Policy Evaluation Survey. Nicotine and Tobacco Research, 6, S341–S351. doi:10.1080/14622200412331320743), but no research to date has examined the prevalence of regret among smokers in non-Western, low- and middle-income countries.

Methods: Data were from the International Tobacco Control (ITC) Surveys of smokers in 4 Asian countries (China, Malaysia, South Korea, and Thailand); N = 9,738. Regret was measured with the statement: “If you had to do it over again, you would not have started smoking.”

Results: Prevalence of regret in 3 countries (South Korea = 87%, Malaysia = 77%, and China = 74%) was lower than that found by Fong et al. in the United States, Australia, Canada, and the United Kingdom (89%–90%); but was higher in Thailand (93%). These significant country differences in regret corresponded with differences in tobacco control and norms regarding smoking. The predictors of regret in the Asian countries were very similar to those in the 4 Western countries: Regret was more likely to be experienced by smokers who smoked fewer cigarettes per day, perceived greater benefits of quitting and higher financial costs of smoking, had more prior quit attempts, worried that smoking would damage their health, and felt that their loved ones and society disapproved of smoking. Regret was also positively associated with intentions to quit (r = 0.23, p < .001).

Conclusions: Across the Asian countries and high-income Western countries, the prevalence of regret varies, but the factors predicting regret are quite consistent. Regret may be an important indicator of tobacco control and is related to factors associated with future quitting.

Citation

Borland, R., Li, L., Driezen, P., Wilson, N., Hammond, D., Thompson, M.E., Fong, G.T., Mons, U., Willemsen, M.C., McNeill, A., Thrasher, J.F., Cummings, K.M. (2012). Cessation assistance reported by smokers in 15 countries participating in the International Tobacco Control (ITC) Policy Evaluation Survey. Addiction, 107(1), 197-205.

Abstract

Aims: To describe some of the variability across the world in levels of quit smoking attempts and use of various forms of cessation support.

Design: Use of the International Tobacco Control Policy Evaluation Project surveys of smokers, using the 2007 survey wave (or later, where necessary).

Settings: Australia, Canada, China, France, Germany, Ireland, Malaysia, Mexico, the Netherlands, New Zealand, South Korea, Thailand, United Kingdom, Uruguay and United States.

Participants: Samples of smokers from 15 countries.

Measurements: Self-report on use of cessation aids and on visits to health professionals and provision of cessation advice during the visits.

Findings: Prevalence of quit attempts in the last year varied from less than 20% to more than 50% across countries. Similarly, smokers varied greatly in reporting visiting health professionals in the last year (<20% to over 70%), and among those who did, provision of advice to quit also varied greatly. There was also marked variability in the levels and types of help reported. Use of medication was generally more common than use of behavioural support, except where medications are not readily available.

Conclusions: There is wide variation across countries in rates of attempts to stop smoking and use of assistance with higher overall use of medication than behavioural support. There is also wide variation in the provision of brief advice to stop by health professionals.

Citation

Li, Q., Fong, G.T., Zhang, J.Y., Wang, C., Mao, Z., Hu, T.W., Jiang, Y. (2012). Effects of the cigarette excise tax adjustment on cigarette retail prices and intention to quit smoking in China in 2009 (Language: Chinese). Chinese Journal of Epidemiology, 33(8), 870-871.

Abstract

There is no abstract available for this publication.

Citation

Huang, L.L., Thrasher, J.F., Jiang, Y., Li, Q., Fong, G.T., Quah, A.C.K. (2012). Incidence and correlates of receiving cigarettes as gifts and selecting preferred brand because it was gifted: Findings from the ITC China Survey. BioMed Central Public Health, 12, 996-1004.

Abstract

Background: Giving 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.

Methods: Data 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.

Results: The 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.

Conclusions: The 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 de-normalize the practice of giving cigarettes as gifts in order to decrease the social acceptability of smoking.

Citation

Yang, J., Hammond, D., Driezen, P., O’Connor, R.J., Li, Q., Yong, H.H., Fong, G.T., Jiang, Y. (2011). The use of cessation assistance among smokers from China: Findings from the ITC China Survey. BioMed Central Public Health, 11, 75.

Abstract

Background: Stop smoking medications significantly increase the likelihood of smoking cessation. However, there are no population-based studies of stop-smoking medication use in China, the largest tobacco market in the world. This study examined stop-smoking medication use and its association with quitting behavior among a population based sample of Chinese smokers.

Methods: Face-to-face interviews were conducted with 4,627 smokers from six cities in the ITC China cohort survey. Longitudinal analyses were conducted using Wave 1 (April to August, 2006) and Wave 2 (November 2007 to January 2008).

Results: Approximately 26% of smokers had attempted to quit between Waves 1 and 2, and 6% were abstinent at 18-month follow-up. Only 5.8% of those attempting to quit reported NRT use and NRT was associated with lower odds of abstinence at Wave 2 (OR = 0.11; 95%CI = 0.03-0.46). Visiting a doctor/health professional was associated with greater attempts to quit smoking (OR = 1.60 and 2.78; 95%CI = 1.22-2.10 and 2.21-3.49 respectively) and being abstinent (OR = 1.77 and 1.85; 95%CI = 1.18- 2.66 and 1.13-3.04 respectively) at 18-month follow-up relative to the smokers who did not visit doctor/health professional.

Conclusions: The use of formal help for smoking cessation is low in China. There is an urgent need to explore the use and effectiveness of stop-smoking medications in China and in other non-Western markets.

Citation

Seidenberg, A.B., Rees, V.W., Alpert, H.R., O’Connor, R.J., Connolly, G.N. (2011). Ignition strength of 25 international cigarette brands. Tobacco Control, 20(1), 77-80.

Abstract

Background: Cigarette-ignited fires are a leading cause of fire death and injury throughout the world and remain a global public health and safety problem. To reduce this harm, a small number of countries now require cigarettes to have reduced ignition propensity (RIP). It is not known if cigarette manufacturers are voluntarily introducing RIP cigarettes in other countries to help save lives.

Methods: Using the ASTM E2187-04 test method, per cent full length burn (%FLB) was measured for three popular brands from each of seven countries that did not have RIP legislation at the time of purchase. Results were compared with %FLB measurements from four popular US brands purchased in a jurisdiction (Vermont) with an RIP law. SRM 1082 reference cigarette was also tested to assure laboratory quality control.

Results: All cigarette brands purchased in countries not requiring fire safety standards for cigarettes exceeded 75% FLB. In contrast, none of the cigarette brands from the USA exceeded 10% FLB. The SRM 1082 reference cigarette demonstrated 5% FLB.

Conclusion: Cigarette ignition propensity can be greatly reduced through legislation that requires cigarette fire safety standards. RIP cigarettes have the potential to significantly decrease the number of fire deaths, injuries and destruction of property caused by cigarette-ignited fires. Appropriate standards should be applied in cigarette markets globally.

Citation

Li, L., Feng, G., Jiang, Y., Yong, H.H., Borland, R., Fong, G.T. (2011). Prospective predictors of quitting behaviours among adult smokers in six cities in China: Findings from the International Tobacco Control (ITC) China Survey. Addiction, 106(7), 1335-1345.

Abstract

Aims: To examine predictors of quitting behaviours among adult smokers in China, in light of existing knowledge from previous research in four western countries and two southeast Asian countries.

Design: Face-to-face interviews were carried out with smokers in 2006 using the International Tobacco Control (ITC) China Survey, with follow-up about 16 months later. A stratified multi-stage cluster sampling design was employed.

Setting: Beijing and five other cities in China.

Participants: A total of 4732 smokers were first surveyed in 2006. Of these, 3863 were re-contacted in 2007, with a retention rate of 81.6%.

Measurements: Baseline measures of socio-demographics, dependence and interest in quitting were used prospectively to predict both making quit attempts and staying quit among those who attempted.

Findings: Overall, 25.3% Chinese smokers reported having made at least one quit attempt between waves 1 and 2; of these, 21.7% were still stopped at wave 2. Independent predictors of making quit attempts included having higher quitting self-efficacy, previous quit attempts, more immediate intentions to quit, longer time to first cigarette upon waking, negative opinion of smoking and having smoking restrictions at home. Independent predictors of staying quit were being older, having longer previous abstinence from smoking and having more immediate quitting intentions.

Conclusions: Predictors of Chinese smokers' quitting behaviours are somewhat different to those found in previous research from other countries. Nicotine dependence and self-efficacy seem to be more important for attempts than for staying quit in China, and quitting intentions are related to both attempts and staying quit.

Citation

Jiang, Y., Elton-Marshall, T., Fong, G.T., Li, Q. (2010). Quitting smoking in China: Findings from the ITC China Survey. Tobacco Control, 19(Suppl 2), i12-i17.

Abstract

Background: Few studies have examined interest in quitting smoking and factors associated with quitting in mainland China.

Objective: To characterise interest in quitting, quitting behaviour, the use of cessation methods and reasons for thinking about quitting among adult urban smokers in six cities in China.

Methods: Data is from Wave 1 of the ITC China Survey, a face-to-face household survey of 4732 adult smokers randomly selected from six cities in China in 2006. Households were sampled using a stratified multistage design.

Findings: The majority of smokers had no plan to quit smoking (75.6%). Over half (52.7%) of respondents had ever tried to quit smoking. Few respondents thought that they could successfully quit smoking (26.5%). Smokers were aware of stop-smoking medications (73.5%) but few had used these medications (5.6%). Only 48.2% had received advice from a physician to quit smoking. The number one reason for thinking about quitting smoking in the last 6 months was concern for personal health (55.0%). Most smokers also believed that the government should do more to control smoking (75.2%).

Conclusion: These findings demonstrate the need to: (1) increase awareness of the dangers of smoking; (2) provide cessation support for smokers; (3) have physicians encourage smokers to quit; (4) deformalize tobacco use so that smokers feel pressured to quit; (5) implement smoke-free laws to encourage quitting; (6) develop stronger warning labels about the specific dangers of smoking and provide resources for obtaining further cessation assistance; and (7) increase taxes and raise the price of cigarettes.

Citation

Feng, G., Jiang, Y., Li, Q., Yong, H.H., Elton-Marshall, T., Yang, J., Li, L., Sansone, N., Fong, G.T. (2010). Individual-level factors associated with intentions to quit smoking among adult smokers in six cities of China: Findings from the ITC China Survey. Tobacco Control, 19(Suppl 2), i6-i11.

Abstract

Background: Over 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 burden caused by smoking-related diseases. It is therefore important to identify the determinants of quitting and of quit intentions among smokers in China. Such knowledge would have potential to guide future tobacco control policies and programs that could increase quit rates in China.

Objective: To identify the correlates of intentions to quit smoking among a representative sample of adult smokers in six cities in China.

Methods: Data from wave 1 (2006) of the International Tobacco Control (ITC) Policy Evaluation Project China Survey, a face-to-face survey of adult Chinese smokers in six cities: Beijing, Shenyang, Shanghai, Changsha, Guangzhou and Yinchuan, was analysed. Households were sampled using a stratified multistage design. About 800 smokers were surveyed in each selected city (total n¼4815).

Results: Past quit attempts, duration of past attempts, Heaviness of Smoking Index (HSI), outcome expectancy of quitting, worry about future health and overall opinion of smoking were found to be independently associated with intentions to quit smoking, but demographic characteristics were not.

Conclusions: The determinants of quit intentions among smokers in China are fairly similar to those found among smokers in Western countries, despite the fact that interest in quitting is considerably lower among Chinese smokers. Identifying the determinants of quit intentions provides possibilities for shaping effective policies and programs for increasing quitting among smokers in China.

Citation

Elton-Marshall, T., Fong, G.T., Zanna, M.P., Jiang, Y., Hammond, D., O’Connor, R.J., Yong, H.H., Li, L., King, B., Li, Q., Borland, R., Cummings, K.M., Driezen, P. (2010). Beliefs about the relative harm of "light" and "low tar" cigarettes: Findings from the International Tobacco Control (ITC) China Survey. Tobacco Control, 19(Suppl 2), i54-i62.

Abstract

Background: Many 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 similar perceptions exist among smokers in low and middle incomes, including China.

Objective: To characterise beliefs about ‘‘light’’ and ‘‘low tar’’ cigarettes among adult urban smokers in China.

Methods: We analysed data from Wave 1 of the ITC China Survey, a face-to-face household survey of 4732 adult Chinese smokers randomly selected from six cities in China in 2006. Households were sampled using a stratified multistage design.

Findings: Half (50.0%) of smokers in our sample reported having ever tried a cigarette described as ‘‘light,’’ ‘‘mild’’ or ‘‘low tar’’. The majority of smokers in our sample (71%) believed that ‘‘light’’ and/or ‘‘low tar’’ cigarettes are less harmful compared to ‘‘full flavoured’’ cigarettes. By far the strongest predictor of the belief that ‘‘light’’ and/or ‘‘low tar’’ cigarettes are less harmful was the belief that ‘‘light’’ and/or ‘‘low tar’’ cigarettes feel smoother on the respiratory system (p,0.001, OR=53.87, 95% CI 41.28 to 70.31).

Conclusion: Misperceptions about ‘‘light’’ and/or ‘‘low tar’’ cigarettes were strongly related to the belief that these cigarettes are smoother on the respiratory system. Future tobacco control policies should go beyond eliminating labelling and marketing that promotes ‘‘light’’ and ‘‘low tar’’ cigarettes by regulation of product characteristics (for example, additives, filter vents) that reinforce perceptions that ‘‘light’’ and ‘‘low tar’’ cigarettes are smoother on the respiratory system and therefore less harmful.

Citation

Li, Q., Hyland, A., O’Connor, R.J., Zhao, G., Du, L., Li, X., Fong, G.T. (2010). Support for smoke-free policies among smokers and non-smokers in six cities in China: ITC China Survey. Tobacco Control, 19(Suppl 2), i40-i46.

Abstract

Objective: To examine levels of support for comprehensive smoke-free policies in six large Chinese cities.

Methods: Data from Wave 1 of the International Tobacco Control (ITC) China Survey (April–August 2006) were
analysed. The ITC China Survey employed a multistage sampling design in Beijing, Shenyang, Shanghai, Changsha, Guangzhou and Yinchuan (none of which has comprehensive smokefree policies in place). Face-to-face interviews were conducted with 4815 smokers and 1270 nonsmokers.Multivariate logistic regression models were used to identify factors associated with support for comprehensive smoke-free policies.

Results: About one in two Chinese urban smokers and four in five non-smokers believed that secondhand smoke (SHS) causes lung cancer. The majority of respondents supported comprehensive smoke-free policies in hospitals, schools and public transport vehicles while support for smoke-free workplaces, restaurants and bars was lower. Levels of support were generally comparable between smokers and non-smokers. Support for comprehensive smoke-free policies was positively associated with knowledge about the harm of SHS.
Respondents who worked in a smoke-free worksite or who frequented smoke-free indoor entertainment places were more likely to support comprehensive smoking restriction in bars and restaurants.

Conclusion: Considerable support for smoke-free policies exists in these six large cities in China. Greater public education about the dangers of SHS may further increase support. Experiencing the benefits of smoke-free indoor entertainment places and/or workplaces increases support for these policies and suggests that some initial smoke-free policy implementation may hasten the diffusion of these public health policies.

Citation

Li, X., Dong, L., Sun, B., Liang, H., Chen, J., Zhang, L., Jiang, Y., Lv, Y. (2010). The willingness of smoking cessation and its determinants. Chinese Journal of Preventive Medicine, 11(7), 663-667.

Abstract

Objective: To explore the determinants of willingness to quit smoking among regular smokers, and to provide a scientific basis for establishing smoking cessation strategies for adult smokers.

Methods: The study was conducted between April to August 2006. A stratified multistage cluster sampling design was used to select residents from 10 streets in Shenyang. Households were then randomly selected from the communities of the selected streets. The average of 40 adult smokers were selected from each of 20 communities. The information of age, gender and smoking status was collected from 801 participants.

Results: The rate of voluntary cessation of smoking was 30.7%(29.8% in male and 46.7%in female). The government employees had the highest proportion of voluntary cessation of smoking (47.5%), followed by retired population (36.7%) and technical professionals (21.4%). The associated factors of smoking cessation include objection from relatives, public opinion, the advocacy efforts and measures of tobacco control.

Conclusion: The proportion of voluntary smoking cessation was low in Shenyang. Additional advocacy efforts and control measures should be taken to encourage the cessation of smoking.

Citation

Xu, J., Liang, B., Li, X., Xie, F., Yao, H., Li, Q., Jiang, Y., Yang, Y., Feng, G., Jiao, S., Li, X., Zhu, G. (2010). Health consciousness and its influential factors among low tar cigarette smokers in six cities of China (Language: Chinese). Chinese Journal of Public Health, 25(10).

Abstract

Publication written in Chinese. Please visit link to view article.

Citation

Yang, J., Hammond, D., Driezen, P., Fong, G.T., Jiang, Y. (2010). Health knowledge and perception of risks among Chinese smokers and non-smokers: Findings from ITC China Survey. Tobacco Control, 19(Suppl 2), i18-i23.

Abstract

Background: Awareness 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.

Objective: The aim of current study was to use a population-based sample from the International Tobacco Control China Wave 1 survey to examine variations between current, former and never smokers' health knowledge about smoking and the impact of health knowledge awareness on smokers' intention to quit.

Methods: A face-to-face interview was conducted with 5986 adult smokers and non-smokers from six cities in China. Respondents were asked whether they believed smoking causes heart disease, stroke, impotence, lung cancer, emphysema, stained teeth, premature ageing in smokers and lung cancer in non-smokers. Current smokers were also asked additional questions on how smoking affects their current and future health as well as whether they had plans to quit smoking and if they believe they would have health benefit from quitting.

Findings: The overall awareness of health risks of smoking in China was low compared to developed countries. Current smokers in China were less likely than non-smokers and former smokers to acknowledge the consequences of smoking. Current smokers who were more aware of the health consequences of smoking were more likely to intend to quit smoking.

Conclusion: These findings highlight the need to increase awareness about the health effects of smoking in China, particularly among current smokers to increase quitting.