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This paper describes the methods of sampling design and data collection of Wave 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. [ABSTRACT FROM AUTHOR]

Objective To compare predictive values of small-for-gestational-age (SGA) by different measures for secondhand smoke (SHS) exposure during pregnancy and to develop and validate a prediction model for SGA using SHS exposure along with sociodemographic and pregnancy factors. Methods We compared the predictability of different measures of SHS exposure during pregnancy for SGA among 545 Chinese pregnant women, and then used the optimal SHS measure along with other clinically available factors to develop and validate a prediction model for SGA. We fit logistic regression models to predict SGA by single measures of SHS exposure (self-report, serum cotinine and CYP2A6*4) and different combinations (self-report +cotinine, cotinine+CYP2A6*4, self-report+CYP2A6*4 and self-report+cotinine+CYP2A6*4). Results We found that self-reported SHS exposure alone predicted SGA (area under the receiver operating characteristic curve or area under the receiver operating curve (AUROC), 0.578) better than the other two single measures (cotinine, 0.547; CYP2A6*4, 0.529) or as accurately as combined SHS measures (0.545-0.584). The final prediction model that contained self-reported SHS exposure, prepregnancy body mass index, gestational weight gain velocity during the second and third trimesters, gestational diabetes, gestational hypertension and the third-trimester biparietal diameter Z-score could predict SGA fairly accurately (AUROC, 0.698). Conclusions Self-reported SHS exposure at peribirth performs better in predicting SGA than a single measure of serum cotinine at the same time, although repeated biochemical cotinine assessments throughout pregnancy may be optimal. Our simple prediction model is fairly accurate and can be potentially used in routine prenatal care. [ABSTRACT FROM AUTHOR]

Objective The goal of this study was to assess the healthcare costs attributable to secondhand smoke (SHS) exposure among non-smoking adults (age =19) in rural China. Methods We analysed data from the 2011 National Rural Household Survey which was conducted among adults in five provinces and one municipality in China (N=12 397). Respondents reported their smoking status, health conditions and healthcare expenditures. Relative risks were obtained from published sources. Healthcare costs included annual outpatient and inpatient hospitalisation expenditures for five SHS-related diseases: asthma, breast cancer ( female only), heart disease, lung cancer and tuberculosis. SHS-attributable healthcare costs were estimated using a prevalence-based annual cost approach. Findings The total healthcare costs of SHS exposure in rural China amounted to $1.2 billion in 2011, including $559 million for outpatient visits and $612.4 million for inpatient hospitalisations. The healthcare costs for women and men were $877.1 million and $294.3 million, respectively. Heart disease was the most costly condition for both women ($701.7 million) and men ($180.6 million). The total healthcare costs of SHS exposure in rural China accounted to 0.3% of China's national healthcare expenditures in 2011. Over one-fifth of the total healthcare costs of SHS exposure in rural China were paid by health insurance. The out-of-pocket expenditures per person accounted for almost half (47%) of their daily income. Conclusions The adverse health effects of SHS exposure result in a large economic burden in China. Tobacco control policies that reduce SHS exposure could have an impact on reducing healthcare costs in China. [ABSTRACT FROM AUTHOR]

Objectives Quantitative measurement of the prevalence of cigarette sharing and gifting in a town in rural China and evaluation of the impact of these practices on individual smoking habits and family expenditures. Methods An interview-based cross-sectional study of 105 households in rural Hunan, China tabulated household cigarette gifting and expenditures. Individual smoking and cigarette sharing activities were also recorded among 198 household members aged >15 years who were resident for at least 6 months. Results With regard to sharing cigarettes, 92% of men and 19% of women reported being offered a cigarette within the past week. Among previous and current smokers who had attempted to quit smoking, 90% reported that their friends had tried to dissuade them from quitting by tempting them with cigarettes. Concerning gifting cigarettes, 74% of households reported sending packaged cigarettes as gifts during the Chinese New Year Festival at an average expense of 2.8% of household annual income. Although households received an average of 12.4% of their annual cigarette consumption in the form of gifts during the Chinese New Year Festival, no association was found between the amount of cigarettes received by a household and the annual cigarette consumption for that household. Conclusions Both gifting and sharing cigarettes are common in rural China. Gifting of cigarettes during the New Year Festival is a significant expenditure affecting both smoking and non-smoking households and may be an opportunity for additional mass media marketing. Among current and former smokers, sharing cigarettes in China is a major impediment to smoking cessation. [ABSTRACT FROM AUTHOR]

Background Large-scale international events such as World Expos and Olympic Games have the potential to strengthen smoke-free norms globally. The Shanghai 2010 World Expo was one of the first large-scale events to implement and evaluate the adoption of strict tobacco control policies. Objective To evaluate implementation of tobacco control policies at the 2010 World Expo in Shanghai, China. Methods This mixed methods evaluation was conducted from July to October 2010. Observations were conducted in all 155 pavilions and outdoor queuing areas, all 45 souvenir shops, a random sample of restaurants (51 of 119) and selected outdoor non-smoking areas in all sections of the Expo. In addition, intercept surveys were completed with 3022 visitors over a 4-month period. Results All pavilions and souvenir shops were smoke-free. Restaurants were smoke-free, with only 0.1% of customers observed smoking. Smoking was more common in outdoor non-smoking areas, but still relatively rare overall with only 4.5% of visitors observed smoking. Tobacco products were not sold or marketed in any public settings except for three pavilions that had special exemptions from the policy. Overall, 80.3% of visitors were aware of the smoke-free policy at the World Expo, 92.5% of visitors supported the policy and 97.1% of visitors were satisfied with the smoke-free environment. Conclusions Tobacco control policies at the World Expo sites were generally well-enforced and accepted although compliance was not 100%, particularly in outdoor non-smoking areas. [ABSTRACT FROM AUTHOR]

Objective To investigate smoking prevalence and cessation services provided by male physicians in hospitals in three Chinese cities. Methods Data were collected from a survey of male physicians employed at 33 hospitals in Changsha, Qingdao and Wuxi City (n=720). Exploratory factor analysis was performed to identify latent variables, and confirmatory structural equation modelling analysis was performed to test the relationships between predictor variables and smoking in male physicians, and their provision of cessation services. Results Of the sampled male physicians, 25.7% were current smokers, and 54.0% provided cessation services by counselling (18.8%), distributing self-help materials (17.1%), and providing traditional remedies or medication (18.2%). Factors that predicted smoking included peer smoking (OR 1.14 95% CI 1.03 to 1.26) and uncommon knowledge (OR 0.94 95% CI 0.89 to 0.99), a variable measuring awareness of the association of smoking with stroke, heart attack, premature ageing and impotence in male adults as well as the role of passive smoking in heart attack. Factors that predicted whether physicians provided smoking cessation services included peer smoking (OR 0.82 95% CI 0.76 to 0.89), physicians' own smoking (OR 0.87 95% CI 0.81 to 0.93), training in cessation (OR 1.36 95% CI 1.27 to 1.45) and access to smoking cessation resources (OR 1.69 95% CI 1.58 to 1.82). Conclusions The smoke-free policy is not strictly implemented at healthcare facilities, and smoking remains a public health problem among male physicians. A holistic approach, including a stricter implementation of the smoke-free policy, comprehensive education on the hazards of smoking, training in standard smoking-cessation techniques and provision of cessation resources, is needed to curb the smoking epidemic among male physicians and to promote smoking cessation services in China. [ABSTRACT FROM AUTHOR]

Objective To develop an approach for rapid assessment of tobacco control interventions in China. We examined the correlation between components of the Strength of Tobacco Control (SOTC) index and a proposed rapid evaluation indicator, the Policy Performance Indicator (PPI), which is based on protection of non-smokers from secondhand smoke (SHS). The PPI was used to assess the implementation of policies related to SHS at the provincial/municipal level in China. Methods Stratified random sampling was used to select five types of organisational and household respondents in two municipalities and five provinces in China (Shanghai and Tianjin, Heilongjiang, Henan, Guangdong, Zhejiang and Jiangxi, respectively). Data collection methods included key informant interviews, observation and intercept surveys (organisations), and a modified Global Adult Tobacco Survey (GATS) questionnaire (households). SOTC scores (SHS policy, capacity and efforts), PPI (no smoking in designated smoke-free places) and mid-term to long-term impact (knowledge, attitude and reduced exposure to SHS) were measured, and correlations among them were calculated. Results The PPI varied across the seven locations. Shanghai led in the component indicators (at 56.5% for indoor workplaces and 49.1% for indoor public places, respectively), followed by Guangdong, Tianjin and Zhejiang (at 30-35% for these two indicators), and finally, Henan and Jiangxi (at 20-25%). Smoke-free policies were more effectively implemented at indoor workplaces than indoor public places. The PPI correlated well with certain components of the SOTC but not with the long-term indicators. Conclusions The PPI is useful for evaluating implementation of smoke-free policies. As tobacco control programmes are implemented, the PPI offers an indicator to track success and change strategies, without collecting data for a full SOTC index. [ABSTRACT FROM AUTHOR]

Objectives To examine contextual and individual demographical predictors of smoking and exposure to second-hand smoke (SHS) in a tobacco-cultivating rural area of southwest China. Methods A cross-sectional survey of 4070 consenting individuals aged 18 years or more was conducted in 2010. Information on demographical characteristics, tobacco smoking status and SHS exposure were obtained by a standard questionnaire. Multilevel logistic regression was used to model the variation in prevalence of smoking and SHS exposure. Results In the study population, the prevalence rates of smoking and exposure to SHS were 63.5% and 74.7% for men, and 0.6% and 71.2% for women, respectively. Men were more likely to use tobacco than women: OR 8.27, 95% CI (4.83 to 10.97). Age was inversely associated with the probability of tobacco use (OR 0.98, 95% CI 0.97 to 0.99), and exposure to SHS (OR 0.97, 95% CI 0.96 to 0.99). Individual educational level was inversely associated with smoking, but showed no association with exposure to SHS. Adults who did not grow tobacco were less likely to consume tobacco (OR 0.75, 95% CI 0.57 to 0.99) and to be exposed to SHS (OR 0.76, 95% CI 0.58 to 0.99). Living in a high-income community was associated with a low rate of current smoking (OR 0.66, 95% CI 0.57 to 0.77) and SHS exposure (OR 0.58, 95% CI 0.52 to 0.65). Conclusions Future interventions to reduce smoking and exposure to SHS in China should focus more on tobacco farmers, less-educated individuals and on poor rural communities. [ABSTRACT FROM AUTHOR]

This paper describes the design features, data collection methods and analytical strategies of the ITC China Survey, a prospective cohort study of 800 adult smokers and 200 adult non-smokers in each of six cities in China . In addition to features and methods which are common to ITC surveys in other countries, the ITC China Survey possesses unique features in frame construction, a large first phase data enumeration and sampling selection; and it uses special techniques and measures in training, field work organisation and quality control. It also faces technical challenges in sample selection and weight calculation when some selected upper level clusters need to be replaced by new ones owing to massive relocation exercises within the cities. [ABSTRACT FROM PUBLISHER]

Background Low-tar cigarette smoking is gaining popularity in China. The China National Tobacco Corporation (CNTC) promotes low-tar cigarettes as safer than regular cigarettes. Methods A total of 543 male smokers smoking cigarettes with different tar yields (15 mg, regular cigarettes, 10e13 mg low-tar cigarettes and <10 mg low-tar cigarettes) were recruited in Shanghai, China, who then completed a questionnaire on smoking behaviour and provided a urine sample for analysis of the nicotine metabolites cotinine and trans-39-hydroxycotinine. A total of 177 urine samples were selected at random for the analysis of the carcinogens polycyclic aromatic hydrocarbon metabolites (PAHs) (1-hydroxypyrene, naphthols, hydroxyfluorenes and hydroxyphenanthrenes) and the tobacco specific nitrosamine 4-(methylnitrosamino)-1-(3-pyridyl)-butanone (NNK) metabolites, 4-(methylnitrosamino)-1-(3-pyridyl)-butanol (NNAL) and NNAL-glucuronide. Values were normalised by creatinine to correct for possible distortions introduced by dilution or concentration of the urine. Results Smokers of low-tar cigarettes smoked fewer cigarettes per day (p¼0.001) compared to smokers of regular cigarettes. Despite this lower reported consumption, levels of cotinine, trans-39-hydroxycotinine and PAHs in urine of people smoking low-tar cigarettes were not correlated with nominal tar delivery of the cigarettes they smoked. Urine concentrations of NNAL were higher in smokers of lower tar than higher tar cigarettes. Conclusions Chinese low-tar cigarettes do not deliver lower doses of nicotine and carcinogens than regular cigarettes, therefore it is unlikely that there would be any reduction in harm. CNTC's promotion of low-tar cigarettes as 'less harmful' is a violation of the World Health Organization Framework Convention on Tobacco Control, which China ratified in 2005. [ABSTRACT FROM AUTHOR]

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. Low-income 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. [ABSTRACT FROM AUTHOR]

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 price-reducing behaviours such as brand switching and trading down, were taken into account. [ABSTRACT FROM AUTHOR]

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. [ABSTRACT FROM AUTHOR]

Objective To assess the perceived effectiveness of cigarette health warnings in China, compared with picture and text-only warnings from other countries. Method 1169 individuals (adult smokers, adult nonsmokers and youth) from four Chinese cities (Beijing, Shanghai, Kunming and Yinchuan) viewed 10 health warnings on cigarette packages, which included (a) the current Chinese text warnings covering 30% of the front/back of the pack (introduced October 2008); (b) the former Chinese text warning located on the side of the pack; (c) four picture warnings covering 50% of the front/back of the pack from Canada (lung cancer), Singapore (mouth disease), Hong Kong (gangrene) and European Union (clogged arteries); and (d) the same four warnings without the picture. Participants rated and ranked the 10 warnings on dimensions including how effective each would be in motivating smokers to quit and in convincing youth not to start smoking. Results Both Chinese warnings were consistently rated as least effective, with the new Chinese warning rated only slightly higher than the old warning. The picture warnings were consistently ranked or rated as most effective, with the text-only versions in the middle. Results were consistent across subject group, city and sex. Conclusions (1) Picture warnings are rated as much more effective than the same warnings without pictures. (2) The revised health warnings in China, introduced in October 2008, are only marginally more effective than the previous warning and far less effective than even text warnings from other countries. These results, coupled with population-based evaluation studies, suggest that pictorial warnings would significantly increase the impact of health warnings in China. [ABSTRACT FROM PUBLISHER]