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Objective To document tobacco advertising practices of a popular, high-grade, domestic cigarette in China across a broad spectrum of channels. Methods Media monitoring and direct observations were conducted to assess tobacco advertisements for Zhonghua cigarettes in Shanghai, China, through the following channels: newspapers, TV, internet, outdoor advertisements and point-of-sale advertisements. Results Consistent with the national ban, no direct tobacco advertisements were found in newspapers or on TV. However, statements about counterfeit 'Zhonghua' cigarettes indirectly promoted Zhonghua tobacco through newspapers. Although no tobacco advertisements were found in Shanghai mainstream websites or in channels of national mainstream sites, a great amount of information was communicated about Zhonghua cigarettes via websites, using patriotic themes and associations with Chinese culture. Large outdoor tobacco advertisements of 'Loving my China' were found in downtown Shanghai. Zhonghua tobacco advertisements were present in almost all of the points-of-sale observed (95%). Conclusions Zhonghua cigarettes are promoted directly and indirectly through a variety of channels. This study suggests there is an urgent need to establish comprehensive bans that prohibit all types of tobacco advertisements in China. [ABSTRACT FROM AUTHOR]

Objective The purpose of this study was to determine to what extent Chinese media coverage of tobacco issues in 17 Chinese cities comprises messaging known to motivate healthy behaviour. Methods This study involved a content analysis of 4821 articles that contained at least one full paragraph focused on tobacco issues from newspapers published in cities that participated in the Tobacco-Free City—Gates Tobacco Control Project in China between 1 January 2008 and 30 June 2011. Results The number of tobacco-focused articles increased over the study period. The number of articles varied considerably among different newspapers and cities. Education, prevention and cessation programs (35%) were the most frequent theme. There was also considerable variation in the volume of coverage each month. News articles were the most frequent article type (70%). The majority of the articles (72%) were positive for tobacco control. There were significant differences between party newspapers and local newspapers in prominence, article type, slant and fear appeal. One quarter (n=729) of the articles mentioned the severity of tobacco use, while only 10% of the articles referred to susceptibility to the threat. Conclusions The coverage of events was predominantly positive toward tobacco control. However, media reports could better support tobacco control efforts if they did a better job at provoking an emotional response to the harms of tobacco use and promoting a sense among smokers that they can succeed in quitting smoking. [ABSTRACT FROM AUTHOR]

Objective To identify the international philanthropies that have invested in tobacco control in China, describe their role and strategies in changing the social norms of tobacco use, and define the outcomes achieved. Methods Information on the international philanthropic donor China projects, including activities and outcomes, was gathered from multiple sources including organisational websites, key informant interviews and emails with project officers, and published research papers and reports. Results Philanthropic donations to China's tobacco control efforts began in 1986. The donors provided funds to national, city, provincial government organisations, non-government organisations, universities, and healthcare organisations throughout China to establish a tobacco control workforce and effective programmes to reduce the burden of tobacco use. Conclusions International engagement has been an important dimension of tobacco control in China. Recognising the large burden of illness and capitalising on proven effective control measures, philanthropic organisations understandably seized the opportunity to achieve major health gains. Much of the international philanthropic investment has been directed at public information, policy change and building the Chinese research knowledge base. Documenting research and evaluation findings will continue to be important to ensure that promising practices and lessons learned are identified and shared with the China tobacco control practitioners. The ultimate question is whether foreign philanthropy is making a difference in tobacco control and changing social norms in China? The answer is plainly and simply that we do not know; the evidence is not yet available. [ABSTRACT FROM AUTHOR]

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. [ABSTRACT FROM AUTHOR]

Background China is the home to the world's largest cigarette maker, China National Tobacco Company (CNTC), yet little is known publicly about the design and emissions of Chinese cigarettes. CNTC is currently in the process of consolidating its brands and has ambitions to export its cigarettes. Machine-measured tar yields of many of its cigarette brands have also been reduced, similar to what occurred in Western countries from the 1970s through the 1990s with so-called ‘low-tar’ cigarettes introduced to address consumer concerns about health risks from smoking. Method The current study examines the design and physical characteristics, labelled smoke emissions and tobacco metals content of leading brands of Chinese cigarettes from seven cities purchased in 2005–6 and in 2007. Results Findings suggest that similar to most countries, tar levels of Chinese cigarettes are predicted primarily by tobacco weight and filter ventilation. Ventilation explained approximately 50% of variation observed in tar and 60% variation in carbon monoxide yields. We found little significant change in key design features of cigarettes purchased in both rounds. We observed significant levels of various metals, averaging 0.82 μg/g arsenic (range 0.3–3.3), 3.21 μg/g cadmium (range 2.0–5.4) and 2.65 μg/g lead (range 1.2–6.5) in a subsample of 13 brands in 2005–6, substantially higher than contemporary Canadian products. Conclusion Results suggest that cigarettes in China increasingly resemble those sold in Western countries, but with tobacco containing higher levels of heavy metals. As CNTC looks to export its product around the world, independent surveillance of tobacco product characteristics, including tobacco blend characteristics, will become increasingly important. [ABSTRACT FROM PUBLISHER]

Objective The goal of this study was to summarise the websites of electronic cigarette (e-cigarette) manufacturers in China and describe how they market their products. Methods From March to April 2013, we used two search keywords 'electronic cigarette' (Dian ZiXiang Yan in Chinese) and 'manufacturer' (Sheng Chan Chang Jia in Chinese) to search e-cigarette manufacturers in China on Alibaba, an internet-based e-commerce business that covers business-to-business online marketplaces, retail and payment platforms, shopping search engine and data-centric cloud computing services. A total of 18 websites of 12 e-cigarette manufacturers in China were analysed by using a coding guide which includes 14 marketing claims. Results Health-related benefits were claimed most frequently (89%), followed by the claims of no secondhand smoke (SHS) exposure (78%), and utility for smoking cessation (67%). A wide variety of flavours, celebrity endorsements and e-cigarettes specifically for women were presented. None of the websites had any age restriction on access, references to government regulation or lawsuits. Instruction on how to use e-cigarettes was on 17% of the websites. Conclusions Better regulation of e-cigarette marketing messages on manufacturers' websites is needed in China. The frequent claims of health benefits, smoking cessation, strategies appealing to youth and women are concerning, especially targeting women. Regulators should prohibit marketing claims of health benefits, no SHS exposure and value for smoking cessation in China until health-related, quality and safety issues have been adequately addressed. To avoid e-cigarette use for initiation to nicotine addiction, messages targeting youth and women should be prohibited. [ABSTRACT FROM AUTHOR]

Background Differences in carcinogen exposure from different cigarette products could contribute to differences in smoking-associated cancer incidence among Chinese compared with US smokers. Methods Urine concentrations of metabolites of nicotine, the tobacco-specific nitrosamine (TSNA) 4-(methylnitrosamino)-1-(3-pyridyl)-1-butanol (NNAL), and polycyclic aromatic hydrocarbon metabolites (PAHs) were compared in 238 Chinese and 203 US daily smokers. Results Comparing Chinese versus US smokers, daily nicotine intake and nicotine intake per cigarette smoked were found to be similar. When normalised for cigarettes per day, urine NNAL excretion was fourfold higher in US smokers, while the excretion of urine metabolites of the PAHs fluorene, phenanthrene and pyrene metabolites was 50% to fourfold higher in Chinese smokers (all, p<0.0001). Similar results were seen when NNAL and PAHs excretion was normalised for daily nicotine intake. Conclusions Patterns of carcinogen exposure differ, with lower exposure to TSNA and higher exposure to PAHs in Chinese compared with US smokers. These results most likely reflect country differences in cigarette tobacco blends and manufacturing processes, as well as different environmental exposures. Trial registration number NCT00264342. [ABSTRACT FROM AUTHOR]

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. [ABSTRACT FROM AUTHOR]

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. [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]

Objectives To investigate the effect of secondhand smoke exposure from a partner on the risk of having a newborn baby with neural tube defects (NTDs) in Chinese non-smoking women. Methods Data were derived from an on-going population-based case-control study of external malformations in northern China. The case group included 580 infants or fetuses with NTDs identified between November 2002 and December 2007. Controls were 795 newborn infants without major external malformations. Data were collected by trained health workers through face-to-face interviews within 1 week after delivery. Results A total of 81.4% of partners of case women and 71.8% of partners of control women smoked during the women's peri-conceptional period. The adjusted OR for NTDs associated with partner smoking was 1.6 (95% CI 1.2 to 2.1). Compared with non-smoking women with non-smoking partners, fetal NTD risk among women with smoking partners was 1.7 (1.3 to 2.4) and 1.1 (0.7 to 1.7) for women exposed and not exposed to partner smoking, respectively. Among women who were exposed to partner smoking, the risk of NTDs was 1.4 (0.9 to 2.0), 1.8 (1.2 to 2.6), 1.9 (1.2 to 3.0) and 2.7 (1.6 to 4.7) for partner smoking of <1, 1-9, 10-19 and ≥20/day, respectively (p for trend <0.001). Conclusion Peri-conceptional exposure to partner smoking may increase the risk of NTDs in the offspring of Chinese non-smoking women. [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]

Objective To determine the prevalence of tobacco advertisements and warning messages at points of sale as well as to examine the density of tobacco retail outlets in neighbourhoods and around schools in Hangzhou, China. Method Tobacco retail outlets (n=1639) in all food and tobacco specialty stores were observed objectively by trained students. Tobacco advertisements and warning messages were assessed with an audit, and stores’ addresses were recorded with Global Positioning System coordinates. The distances (1) between all pairs of tobacco retail outlets (2) between each tobacco retail outlet and 15 middle schools were calculated to assess the density of tobacco retail outlets in neighbourhoods and around schools. Results Among the 1639 tobacco retail outlets, <1% had ‘no sales to minors’ signs, 1.5% had tobacco warning messages, 28% had signs indicating tobacco sale and 12.4% had tobacco advertisements. For 48.7% of tobacco retail outlets, the nearest distances to other tobacco retail outlets were <50 m. For 80% of schools, there was at least one tobacco retail outlets within a 100 m radius. Conclusion Tobacco advertisement in retail outlets is prevalent and the density of tobacco retail outlets is high in Hangzhou, China. Signs indicating ‘no sales to minors’ and tobacco warning signs are almost non-existent. These findings point to an urgent need for the enforcement of regulations on display of ‘no sales to minors’ and a new density standard for tobacco retail outlets based on protecting the public’s health. [ABSTRACT FROM AUTHOR]

Objective To understand how British American Tobacco (BAT) and Philip Morris (PM) researched the role and popularity of cigarette gifting in forming relationships among Chinese customs and how they exploited the practice to promote their brands State Express 555 and Marlboro. Methods Searches and analysis of industry documents from the Legacy Tobacco Documents Library complemented by searches on LexisNexis Academic news, online search engines and information from the tobacco industry trade press. Results From 1980-1999, BAT and PM employed Chinese market research firms to gather consumer information about perceptions of foreign cigarettes and the companies discovered that cigarettes, especially prestigious ones, were gifted and smoked purposely for building relationships and social status in China. BAT and PM promoted their brands as gifts by enhancing cigarette cartons and promoting culturally themed packages, particularly during the gifting festivals of Chinese New Year and Mid-Autumn Festival to tie their brands in to festival values such as warmth, friendship and celebration. They used similar marketing in Chinese communities outside China. Conclusions BAT and PM tied their brands to Chinese cigarette gifting customs by appealing to social and cultural values of respect and personal honour. Decoupling cigarettes from their social significance in China and removing their appeal would probably reduce cigarette gifting and promote a decline in smoking. Tobacco control efforts in countermarketing, large graphic warnings and plain packaging to make cigarette packages less attractive as gifts could contribute to denormalising cigarette gifting. [ABSTRACT FROM AUTHOR]

Objectives The present work sought to evaluate different worksite smoking control policies and their associations with employees' smoking behaviours and attitudes among Chinese male workers. Methods This was a cross-sectional survey with a self-administered standardised questionnaire, conducted among seven production workplaces of one multinational company in Shanghai in 2008. In total, 1043 male workers were involved. Current smoking prevalence, daily cigarette consumption, quitting intention and their potential association with workplace smoking control policies (smoke free or restricted smoking) were measured. Results Current smoking prevalence in workplaces where smoke-free policies had been imposed for 3 years was 55.5%, about 18% lower than in workplaces that only restricted smoking. Smokers in smoke-free workplaces also smoked 3.4 cigarettes less per day, made more quit attempts, were more confident of successfully quitting and more willing to accept a company sponsored cessation programme. Those patterns declined or were not found among the workplaces where smoking control policies had been imposed for 10 years. Smoker quitting intentions were not associated with workplace smoking policies regardless of the duration of the policies imposed. Conclusions A smoke-free workplace policy was found to have a significant association with lower smoking prevalence and daily cigarette consumption, but not with employee quitting intentions. Restrictive smoking policies had no impact on employee smoking behaviours. The impact of workplace smoking control policies may vary over time. [ABSTRACT FROM AUTHOR]

Objective To describe workplace exposure to secondhand smoke (SHS) among different working populations in Shanghai; to identify any association between respiratory symptoms and SHS exposure in these workplaces. Design Cross-sectional survey with a standardised questionnaire. Setting 150 worksites (including restaurants, shopping malls, hotels, hospitals, schools, kindergartens). Subjects 3530 workers. Outcome measures Prevalence of workers with workplace exposure to SHS; average time of exposure to SHS per day; proportion of workers reporting any respiratory and sensory symptoms. Results 13.3% of employees were covered by complete smoke-free policies. Restaurant employees had the highest level of exposure to SHS (67% exposed with 2.95±3.10 h of exposure on average per day) while kindergarten employees had the lowest level (0.5% exposed with 0.01±0.01 h of exposure per day). Compared with employees from kindergartens, nonsmoking workers from restaurants and shopping malls reported a higher proportion of respiratory and sensory symptoms and were more likely to suffer from all eight respiratory and sensory symptoms (OR 1.8-8.9). The length of exposure to SHS each day was positively associated with all eight symptoms except runny nose. Conclusions Workplace exposure to SHS is extensive in Shanghai and the implementation of the current municipal regulation does not provide adequate worker protection. There is an urgent need to establish 100% smoke-free legislation covering all workplaces and public places in Shanghai. [ABSTRACT FROM AUTHOR]

Objectives To evaluate student tobacco control advocacy behavioural capacity using longitudinal trace data. Methods A tobacco control advocacy curriculum was developed and implemented at schools of public health (SPH) or departments of public health in seven universities in China. Participants comprised undergraduate students studying the public health curriculum in these 13 Universities. A standardised assessment tool was used to evaluate their tobacco control advocacy behavioural capacity. Repeated measures analysis of variance, paired t tests and paired Χ2 tests were used to determine differences between dependent variables across time. Multivariate analysis of variance (MANOVA) and multivariate logistic regression were used to assess treatment effects between intervention and control sites. Results Respective totals of 426 students in the intervention group and 338 in the control group were available for the evaluation. Approximately 90% of respondents were aged 21 years or older and 56% were women. Findings show that the capacity building program significantly improved public health student advocacy behavioural capacity, including advocacy attitude, interest, motivation and anti-secondhand smoke behaviours. The curriculum did not impact student smoking behaviour. Conclusions This study provides sufficient evidence to support the implementation of tobacco control advocacy training at Chinese schools of public health. [ABSTRACT FROM AUTHOR]

Objective To determine the coverage of smoking restriction policies in indoor workplaces in China and to assess the relationships between these restrictive policies and secondhand smoke (SHS) exposure and smoking behaviours. Methods A cross-sectional household survey was conducted in six counties in Sichuan, Jiangxi and Henan provinces in 2004. Using a standardised questionnaire, information on demographic characteristics, knowledge, attitudes and behaviours related to smoking and SHS exposure was collected through face-to-face interviews by trained local investigators among 12 036 respondents. Of respondents, 2698 individuals worked mainly indoors and were included in data analysis. Results Only 28.5% of respondents reported that indoor workplaces had a smoke-free policy. Even when respondents reported smoke-free policies, 41.1% smokers reported that they were non-compliant with policies and smoked at work. In addition, 32.0% of nonsmokers reported being exposed to SHS at work despite smoke-free policies. Non-smokers who reported no smoking restriction policies were 3.7 times more likely to be exposed to SHS than those working in smoke-free workplaces (adjusted OR 3.7, 95% CI 1.3 to 10.1). On average, respondents complying with smoke-free policies smoked 3.8 fewer cigarettes than those reporting no policies in their workplaces at a marginally non-significant level (p=0.06) (adjusted mean difference --3.8, 95% CI --8.0 to 0.5). Conclusions In China, few workplaces have implemented policies to restrict smoking, and, even in workplaces that have policies, workers report exposure to SHS while at their places of employment. Many workers report a lack of compliance with smoke-free policies. China needs better implementation of SHS policies to promote compliance. Working to improve implementation of smoke-free policies would promote cessation since Chinese smokers who were compliant with these efforts reported smoking fewer cigarettes per day. [ABSTRACT FROM AUTHOR]

Objective To explain China's cigarette pricing mechanism and the role of the Chinese State Tobacco Monopoly Administration (STMA) on cigarette pricing and taxation. Methods Published government tobacco tax documentation and statistics published by the Chinese STMA are used to analyse the interrelations among industry profits, taxes and retail price of cigarettes in China. Results The 2009 excise tax increase on cigarettes in China has not translated into higher retail prices because the Chinese STMA used its policy authority to ensure that retail cigarette prices did not change. The government tax increase is being collected at both the producer and wholesale levels. As a result, the 2009 excise tax increase in China has resulted in higher tax revenue for the government and lower profits for the tobacco industry, with no increase in the retail price of cigarettes for consumers. Conclusions Numerous studies have found that taxation is one of the most effective policy instruments for tobacco control. However, these findings come from countries that have market economies where market forces determine prices and influence how cigarette taxes are passed to the consumers in retail prices. China's tobacco industry is not a market economy; therefore, non-market forces and the current Chinese tobacco monopoly system determine cigarette prices. The result is that tax increases do not necessarily get passed on to the retail price. [ABSTRACT FROM AUTHOR]

The China Tobacco Museum in Shanghai is the largest in China, consisting of seven pavilions of tobacco-related exhibits. A focus group and previous survey data revealed that the museum conveys messages that make tobacco use appealing. Of the pavilions, three were found to contain blatant misinformation about tobacco and tobacco consumption. We argue that the China Tobacco Museum is a platform for tobacco promotion, a form of tobacco advertising, promotion and sponsorship, and thus contravenes the FCTC. [ABSTRACT FROM AUTHOR]

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. [ABSTRACT FROM AUTHOR]

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. [ABSTRACT FROM AUTHOR]

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. [ABSTRACT FROM AUTHOR]

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. [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]

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 post-campaign. Poisson regression models were estimated to assess the effects of campaign exposure on post-campaign knowledge, adjusting for pre-campaign 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. [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]

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. [ABSTRACT FROM AUTHOR]

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. [ABSTRACT FROM AUTHOR]

Background: Tobacco use by physicians represents a significant barrier in promoting smoking cessation through physician interventions. To assess the need for and nature of smoking cessation services among physicians in China, a detailed literature review was conducted. Methods: A literature review of studies published, in Chinese or in English, between 1987 and 2010, was carried out. The Medline, PubMed and Wanfang Data (a Chinese literature search database) electronic databases were searched for published studies. Results: It was found that the overall current smoking prevalence among Chinese physicians ranged from 14% to 64% (men: 26% to 61%; women: 0% to 19%). There were significant gender differences in the smoking prevalence across studies with men smoking more than women. Though inconsistent, there were variations in smoking rates by professional posts and medical specialty. The quit smoking rates ranged from 5% to 14% across studies, with a higher rate among female physicians. Asking about smoking status or advising patients to quit smoking was not common practice among the physicians. Conclusions: The results of this review suggest that while smoking habits of Chinese physicians vary among studies and across physicians in different specialties; prevalence rates tend to be higher than in physicians in the developed countries. Quitting rates were low among Chinese physicians, and the delivery of advice on quitting smoking was not common across the studies. Strategies to improve Chinese physicians’ engagement in smoking cessation should address multiple factors including tobacco use and quitting practices among the physicians, their training needs and awareness of their professional responsibility with a healthcare system change approach. [ABSTRACT FROM AUTHOR]

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 n=4815). 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. [ABSTRACT FROM PUBLISHER]

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]

Objective To explore the determinants of smoking behaviour in recreational venues and to provide scientific bases for establishing smoke-free measures applying to these locations. Methods The International Tobacco Control (ITC) China Survey—a face-to-face cross-sectional survey of representative adult smokers from six cities (Shenyang, Beijing, Shanghai, Guangzhou, Changsha and Yinchuan) was conducted between April and August 2006. A total of 4815 smokers were selected using multistage sampling methods, and final analyses were conducted on 2875 smokers who reported patronising recreational venues at least once in the last six months. Multivariate logistic regression models were used to identify factors influencing the smoking behaviour within recreational settings. Outcome measure Whether a smoker reported smoking in recreational venues during the last 6 months. Results 84% subjects reported smoking in recreational venues. Analyses showed that smoke-free laws had been exempted, 32.0% of the patrons reporting bans on smoking in these locations. The following factors were significant predictors of smoking in recreational venues: absence of bans on smoking, support for non-bans, being aged 18–24 years, positive smoking-related attitudes, low number of health effects reported and not living in Beijing. Conclusions The findings point to the importance of informing Chinese smokers about the active smoking and passive smoking harmfulness in both building support for smoke-free laws and in reducing smokers’ desire to smoke within recreational venues. They also point to the importance of good enforcement of smoke-free laws when implemented. Such strategies could also serve to de-normalise smoking in China, a key strategy for reducing smoking in general. [ABSTRACT FROM PUBLISHER]

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) denormalise 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. [ABSTRACT FROM PUBLISHER]

Objective The existence of less expensive cigarettes in China may undermine public health. The aim of the current study is to examine the use of less expensive cigarettes in six cities in China. Methods Data was from the baseline wave of the International Tobacco Control (ITC) China Survey of 4815 adult urban smokers in 6 cities, conducted between April and August 2006. The percentage of smokers who reported buying less expensive cigarettes (the lowest pricing tertile within each city) at last purchase was computed. Complex sample multivariate logistic regression models were used to identify factors associated with use of less expensive cigarettes. The association between the use of less expensive cigarettes and intention to quit smoking was also examined. Results Smokers who reported buying less expensive cigarettes at last purchase tended to be older, heavier smokers, to have lower education and income, and to think more about the money spent on smoking in the last month. Smokers who bought less expensive cigarettes at the last purchase and who were less knowledgeable about the health harm of smoking were less likely to intend to quit smoking. Conclusions Measures need to be taken to minimise the price differential among cigarette brands and to increase smokers' health knowledge, which may in turn increase their intentions to quit. [ABSTRACT FROM PUBLISHER]

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 smoke-free policies in place). Face-to-face interviews were conducted with 4815 smokers and 1270 non-smokers. 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. [ABSTRACT FROM PUBLISHER]

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. [ABSTRACT FROM PUBLISHER]

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. [ABSTRACT FROM PUBLISHER]