Tobacco advertising, environmental smoking bans, and smoking in Chinese urban areas

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Abstract

Objectives

To evaluate whether cigarette smoking in Chinese urban areas was respectively associated with exposure to tobacco advertising and smoking bans in households, workplaces, and public places.

Methods

Participants were 4735 urban residents aged 15 years and older, who were identified through multi-stage quota-sampling conducted in six Chinese cities. Data were collected on individual sociodemographics and smoking status, and regional tobacco control measures. The sample was characterized in terms of smoking prevalence, and multilevel logistic models were employed to analyze the association between smoking and tobacco advertising and environmental smoking restrictions, respectively.

Results

Smoking prevalence was 30%. Multilevel logistic regression analysis showed that smoking was positively associated with exposure to tobacco advertising, and negatively associated with workplace and household smoking bans.

Conclusions

The association of smoking with both tobacco advertising and environmental smoking bans further justifies implementation of comprehensive smoking interventions and tobacco control programs in China.

Introduction

Exposure to tobacco smoke causes serious disease and premature death. Globally, the tobacco-smoking epidemic is responsible for approximately 5.4 million deaths each year, including more than 600,000 non-smokers (World Health Organization, 2008). The annual death toll is projected to exceed 8 million by 2030. More than 80% of these deaths will occur in less developed nations, and the epidemic will strike hardest in those countries with rapidly growing economies (World Health Organization, 2008). China leads the world in tobacco consumption and approximately one million persons Chinese die each year from tobacco-related causes (The People's Republic of China Ministry of Health, 2007). This death toll is projected to reach two million annually by 2025 and three million by 2050. A projected 100 million Chinese will die from smoking-related causes over the next 50 years if the current high prevalence of smoking persists (Doll et al., 2004, Peto et al., 1996).

Exposure to tobacco smoke in public places is common in China, and occurs in most restaurants and 70% of schools and hospitals, government buildings, and train stations (Stillman et al., 2007). Restrictions on smoking in public places were associated with a higher probability of delaying smoking uptake and lowering smoking prevalence (US Department of Health and Human Services, 2006, Wakefield et al., 2000). Smoke-free laws may reduce smoking prevalence substantially (New York State Department of Health, 2011). In a report in 2000, the US Surgeon-General stated that smoke-free policies are the most effective way to reduce exposure to tobacco smoke (Wakefield et al., 2000). Many studies have shown that smoke-free workplace policies substantially reduce worker exposure to tobacco smoke (Fichtenberg and Glantz, 2002, Skeer et al., 2005), and encourage smokers to quit or reduce their smoking (Eriksen and Cerak, 2008, Moher et al., 2005). Studies have also demonstrated that restricting smoking in the home is effective in reducing exposure to passive tobacco smoke, and such restriction could help reduce experimental smoking among children and adolescents, and more generally encourage smoking cessation (Kegler and Malcoe, 2002, Li et al., 2009). We found that almost all of the studies on the association between smoking restrictions and smoking came from the more economically developed countries, such as the United States, various European countries, Australia, Canada, and Japan (US Department of Health and Human Services, 2006, Wakefield et al., 2000, Fichtenberg and Glantz, 2002, Skeer et al., 2005, Moher et al., 2005, Mackay et al., 2010). There have been no studies reporting on this relationship in China. This emerges as a very important gap to close in order to develop appropriate tobacco control strategies.

To counter the global spread of tobacco use, the World Health Organization (WHO) established the Framework Convention on Tobacco Control (FCTC) in 1999. This framework was fully endorsed by member states on May 21, 2003. The Chinese National People's Congress ratified the FCTC on August 27, 2005 (Yang et al., 2005). The FCTC provides clear guidance through Article 8 (Protection from Exposure to Tobacco Smoke). Article 8 outlines specific measures and approaches for reducing population-wide tobacco smoke exposure. More than 739 million people worldwide are protected by comprehensive, national smoke-free laws, an increase of more than 385 million since 2008 (World Health Organization, 2011). Implementation of FCTC recommended activities has been progressing slowly in China. Nevertheless, by ratifying the FCTC, China has agreed that all workplaces and public places should be smoke-free by 2011. Moreover, efforts have recently been made to expand the number of smoke-free places. China does not have a comprehensive smoke-free law. However, several national laws and policies regulate smoking in public places. The central government is revising the Regulations on the Sanitary Administration of Public Places to strengthen controls on secondhand smoke (Li et al., 2010). In recent years, Ministry of Health and Ministry of Education regulations have required smoke-free schools and hospitals. At present, nearly half of the Chinese midsize and large cities have implemented smoke-free policies or regulations pertaining to public places. In many cases, however, extant policies or regulations are weak due to limited enforcement (Li et al., 2010). On the other hand, Chinese organizations are now creating smoke-free environments, and nationwide campaigns are being waged to ban smoking on university campuses and in hospitals (Yang et al., 2009b, Lin and Fraser, 2011).

The FCTC requires that each party to the Convention “undertake a comprehensive ban, and restrict tobacco advertising, promotion, and sponsorship on radio, television, print media, and also, as appropriate, other media such as the Internet” (World Health Organization, 2003). Several studies have documented that complete bans on tobacco advertising and promotion can protect youth from initiating smoking and adults from continuing to smoke (Biener and Siegel, 2006, Blecher, 2008, Chapman, 1996, Li et al., 2009, Martínez-Donate et al., 2005, Nelson, 2003).

China has been tightening up bans on tobacco advertising. The Standing Committee of the National People's Congress approved the Law of the People's Republic of China on Tobacco Monopoly in June 1991. According to this Law “advertising for tobacco products shall be banned on radio and television stations, or in newspapers or periodicals”. However, there is no comprehensive legislation that specifically bans tobacco advertising and promotion. Tobacco advertising remains widespread (Li et al., 2009). Noteworthy, the comprehensive legislation that has banned tobacco advertising covers all forms of tobacco advertising and sponsorship. The comprehensive legislation for smoke-free air covers 100% of indoor areas in all workplaces and public places. Such legislation has proven effective in many countries (World Health Organization, 2008, Fong et al., 2006, Edwards et al., 2008, Mackay et al., 2010, Braverman and Aarø, 2004, Saffer and Chaloupka, 2000).

This study will explore the association between smoking in Chinese urban areas and exposure to tobacco advertising and environmental restrictions on smoking. Results will inform future tobacco control policies and interventions in China.

Section snippets

Study design

This study used a cross-sectional multistage sampling design. In Stage 1, six Chinese cities were selected based on geographic location and economic development status. The six study cities and their respective population size and economic focus were Hangzhou (6.7 million, light industry and tourism), Nanjing (6.2 million, education and light industry), Guangzhou (7.7 million, light industry and commerce), Taiyuan (3.5 million, manufacturing), Yinchuan (1.6 million, agriculture and light

Results

Among the 4735 respondents, current smoking prevalence was 30%, daily smoking prevalence was 23%, and occasional smoking prevalence was 7%. Sample characteristics resembled those from national surveys, except for a higher male-to-female ratio (Department of Comprehensive Statistics of National Bureau of Statistics, 2008). Current smoking prevalence was associated with age, gender, education, marital status, occupation, smoking restrictions in households, workplaces, and advertising exposure,

Discussion

This study is the first in China to investigate the association between tobacco control measures implemented in major urban areas and smoking status. We focus our discussion on the information generated by the multilevel analyses. The ‘null’ model has the only constant term, a city-level random effect. This term accounts for variation in smoking prevalence across the six study cities. The ‘null’ model shows the proportion of variation explained by attributes of living in different cities.

Conclusion

The association of current smoking with both tobacco advertising and environmental smoking bans, which emerged from this exploratory research, holds very important public health implications for China. Our findings should be most informative for policymakers, and encourage them to develop and implement effective tobacco control policies and interventions. Given the enormity of the Chinese smoking-related healthcare burden, reductions in smoking will inevitably increase both population life

Role of funding source

This study was partly funded by WHO (WP/2002/IC/TFI/2.2/001/03.02.AW.03), and the National Social Science Foundation of China (01BSH030).

Contributors

TY conceived the study design, conceptualized the ideas, and supervised the data management and analyses. XX and YG conducted the data collection. ML drafted the manuscript. IR provided technical support for the data analysis, and in revising the manuscript. All authors reviewed previous drafts and approved the final version.

Conflict of interest

No conflict declared.

Acknowledgements

We thank local teams from the “Building advocacy capacity for tobacco control among the public health workforce in China (supported by The International Union Against Tuberculosis and Lung Disease)” project for organizing the data collection. We would like to thank Yan Lin and Trish Fraser from the International Union Against Tuberculosis and Lung Disease for her advice and editing of this article.

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