Analysis of wedding appeals on cigarette packs in China

Culturally specific health-related features on cigarette packs sold in China

BACKGROUND

China is the country with the highest burden of tobacco-caused disease. We characterised the extent to which cigarette pack marketing features (eg, imagery, text, pack color) could potentially mislead consumers by suggesting products are healthy.

METHODS

We used two methods: group concept mapping and content analysis. First, we used a group concept mapping approach to generate and sort Chinese consumer responses to an open-ended prompt asking what marketing features suggest a product is 'healthy' or 'good for you'. Second, based on the concept mapping results, we developed a codebook of health-related features on cigarette packs that were relevant to the unique cultural context of product marketing in China. Two trained coders who were native Chinese speakers double-coded a sample of 1023 cigarette packs purchased in 2013 (wave 1) and 2017 (wave 2). We examined differences in the presence of features overall and over time.

RESULTS

Overall, 83.5% (n=854) of Chinese cigarette packs in our sample contained at least one 'healthy' or 'good for you' feature, and the presence of health-related features on packs remained constant between wave 1 (83.5%, n=354) and wave 2 (83.5%, n=500; p=1.00). Across both waves, the most common categories of culturally specific health features present related to recycling symbols, rare animal imagery, bright colours (eg, bright yellow) and botanical imagery (eg, bamboo, mint).

CONCLUSION

Health-related features on cigarette packs sold in China are common. Enhanced policies to address tobacco packaging, labelling and branding could support and facilitate a reduction in the high tobacco burden in China.

Tobacco control in China

Chinese men consume around 40% of the world's cigarettes, causing a substantial and growing burden of tobacco-attributed death and disease. In 2005, the Chinese Government ratified the WHO Framework Convention on Tobacco Control, and tobacco control measures have since increased nationwide. To assess tobacco control progress, obstacles, and opportunities, this Review describes the long-term evolution of cigarette consumption and the associated disease burden in mainland China, and the implementation of five important tobacco control strategies advocated by WHO. These strategies covered tobacco taxation; package warnings; advertising, promotion, and sponsorship bans; public smoking bans; and cessation services. Although only 2% of women in China now smoke, half of all adult men smoke cigarettes. By the 2010s, smoking accounted for about a fifth of all adult male deaths, and this proportion is rising, following a trajectory similar to that seen in the USA 40 years earlier. The self-regulating national tobacco monopoly and its influence on policy, the country's relatively low tobacco tax, and its weak package warnings and enforcement of other tobacco control strategies all highlight challenges in tobacco control. However, these challenges can also provide opportunities to discourage smoking initiation in young women and encourage cessation in men, assisting China's long march towards better health.

The problematic use of cultural symbols on Chinese cigarette packs

INTRODUCTION

China is the world's largest tobacco-consuming nation. With minimal packaging regulations, the Chinese tobacco industry can use many appeals to promote their products, including calling upon traditions and culture to make positive connections between consumers and harmful products. We analyzed the nature and extent of cultural appeals on Chinese cigarette packs.

METHODS

A total of 610 unique cigarette packs were collected in 2017 from five major Chinese cities (Beijing, Guangzhou, Shanghai, Kunming, and Chengdu) following a systematic protocol. Two trained independent coders knowledgeable about Chinese culture and language coded the packs in accordance with a specially developed codebook encompassing important Chinese cultural symbols. The prevalence of identified elements was determined and interpreted.

RESULTS

Overall, 60.7% (n=370) of the analyzed Chinese cigarette packs in our sample contained at least one culturally specific appeal. The most common cultural appeals included written arts (n=131; 21.5%), celebratory red as the primary pack color (n=119; 19.5%), visual arts (n=70; 11.4%), and special occasions (n=60; 9.9%). There was a diverse range of cultural appeals present on the packs.

CONCLUSIONS

Cultural appeals are common on Chinese tobacco packaging, with over 60% of all analyzed packs containing at least one culturally specific element. With China's packaging policies requiring health warning labels to occupy only 35% of the pack, the tobacco industry is allowed plenty of package space to incorporate cultural elements among other appeals. A plain and standardized packaging policy would eliminate the ability for Chinese tobacco companies to use cultural appeals on their cigarette packs.

Cigarette Gifting Among Nonsmokers in China: Findings From the International Tobacco Control China Survey

INTRODUCTION

Cigarette gifting is commonly practiced in China and has contributed to the social acceptability and high prevalence of cigarette smoking in the country. As a result, nonsmokers in China are particularly susceptible to smoking. While previous studies have examined cigarette gifting behaviors among smokers, little is known about cigarette gifting among nonsmokers.

AIMS AND METHODS

This study aimed to examine the percentage and correlates of giving and receiving cigarettes as gifts among adult nonsmokers in China. We analyzed nonsmokers (N = 1813) aged ≥18 years using data from the International Tobacco Control China Wave 5 Survey. Descriptive statistics summarized the characteristics of those who gave and received cigarettes as gifts. Multivariable logistic regression models were used to identify factors associated with the two behaviors.

RESULTS

Among nonsmokers, 9.9% reported giving cigarettes as gifts to family or friends in the last 6 months. A higher level of knowledge about smoking harms was associated with lower adjusted odds of gifting cigarettes. Nonsmokers aged 25-39 years, with middle income, positive attitude toward cigarette gifts, exposure to anti-smoking information, and exposure to smoking promotion, and those who reported receiving cigarettes as gifts from family or friends were more likely to give cigarettes as gifts. A total of 6.6% of nonsmokers reported receiving cigarettes as gifts in the last 6 months. High education, neutral or positive attitude toward cigarette gifts, exposure to anti-smoking information, exposure to smoking promotion, and having smoking friends were associated with receiving cigarettes as gifts.

CONCLUSIONS

It is concerning that Chinese cultural norms that support cigarette gifting have extended to giving nonsmokers cigarettes as gifts. Effective anti-smoking messages are needed. Changing the norms around cigarette gifting and increasing knowledge about smoking harms should help reduce cigarette gifting among nonsmokers.

IMPLICATIONS

Easy access to cigarettes received as gifts, along with the wide acceptance of smoking in China, places Chinese nonsmokers in a risky position. More educational campaigns targeting nonsmokers to proactively prevent them from smoking are called for. The ineffectiveness of existing anti-smoking information highlights the need for more effective anti-smoking messages. That attitude toward cigarette gifts is the strongest predictor of giving cigarettes as gifts suggests the need for interventions to reverse the positive attitude about cigarette gifting to decrease the popularity of this activity.

Perceived effectiveness of four different cigarette health warning label themes among a sample of urban smokers and non-smokers in China

OBJECTIVE

This study, conducted in China, evaluated the effectiveness of four different themes of health warning labels (HWLs) that used both text and pictures: (1) self-harm from using cigarettes, (2) harming family or children with secondhand smoke, (3) reinforcing compliance with existing smoke-free policies and (4) anticigarette gift giving practices.

METHODS

A cross-sectional randomised experimental survey was conducted among 3247 adult (aged 18+ years) participants in Beijing, Shanghai and Shenzhen in 2017, using quotas for age group, gender and smoking status. Participants were randomly assigned to one of the four HWL themes. Each participant viewed eight HWLs and rated how effective these themed-labels were in terms of credibility, raising awareness of health harms of smoking on family and children, improving compliance with public smoking bans, stopping the practice of gifting cigarettes, thinking about quitting and preventing smoking using a 10-point scale, with 10 being most effective. Analysis of variance and independent t-tests were used to analyse these data.

FINDINGS

All four HWL themes performed well for each outcome with average ratings >6.5. Harming family or children with secondhand smoke was the theme that received the highest ratings for each outcome, with credibility (8.0, 95% CI 7.86 to 8.09) and prevention of smoking (8.8, 95% CI 8.63 to 8.91) outcomes being significantly higher (p<0.05). Overall, analysis of ratings by gender, income and education did not impact outcomes.

CONCLUSION

All four HWL themes tested could be effective in China; the theme of secondhand smoke harming family or children may be a particularly credible/effective theme.

Are E-Cigarette and Tea Cigarette Gifting Behaviors Associated with Tobacco Use and Failed Quit Attempts in China?

This study aims to investigate e-cigarette and tea cigarette gifting in China and their influencing factors, as well as to explore whether they were associated with tobacco use and cessation. Using a multistage sampling design, 1512 household heads from Guangdong and Shaanxi provinces were recruited for the study and filled out an online questionnaire about smoking status, social participation, e-cigarette, and tea cigarette gifting. Results showed that more than 30% and nearly 3% of participants had been gifted tea cigarettes and e-cigarettes, respectively. Marital status, province of residence, smoking status, and social participation were associated with gifting behaviors. Logistic regressions showed that receiving e-cigarettes (OR = 3.43, p < 0.05) and tea cigarettes (OR = 1.70, p < 0.01) were related to tobacco use. Smokers who have received e-cigarettes (OR = 9.85, p < 0.01) and tea cigarettes (OR = 1.92, p < 0.05) were also less likely to quit smoking.

Cigarette sharing and gifting in China: Patterns, associated factors, and behavioral outcomes

INTRODUCTION

The purpose of this study was to investigate the patterns and factors associated with cigarette sharing and gifting, and to explore whether smoking can be predicted by these social practices.

METHODS

A cross-sectional survey using a multi-stage sampling design was conducted online from 30 April to 30 July 2020 in China. A sample of 982 household heads from Guangdong Province and 530 household heads from Shaanxi province were involved in the data analysis. Demographic characteristics, social participation, beliefs and behaviors related to cigarette sharing and gifting were assessed. Chi-squared analysis and multiple logistic regression analysis were used to explore the key factors associated with cigarette sharing and gifting, and to identify their relationship with smoking.

RESULTS

The shared and gift cigarettes were both mainly offered to friends, and receiving gift cigarettes mostly occurred during the holidays. Gender and province were associated with cigarette sharing, and marital status and social participation were associated with cigarette gifting. Cigarette gifting beliefs and smoking status were prominent predictors for both sharing and gifting cigarettes. Cigarette gifting beliefs were significantly higher among smokers than non-smokers, and people with high cigarette gifting beliefs were 1.68 (adjusted odds ratio, AOR=19.17; 95% CI: 13.31-27.61) times more likely to be a smoker. Offering shared cigarettes has been found to significantly predict tobacco use (AOR=19.17; 95% CI: 13.31-27.61), while people who received shared and gift cigarettes were 1.50 (95% CI: 1.08-2.09) and 2.58 (95% CI: 1.66-4.00) times more likely to be a current smoker than those who did not receive cigarettes, respectively.

CONCLUSIONS

Cigarette sharing and gifting were especially pervasive among male smokers and married people in Shaanxi Province. Offering shared cigarettes and receiving shared/gift cigarettes might facilitate cigarette use. This study provides evidence-based data to support the design and implementation of tobacco control programs for the denormalization of gifting and sharing cigarettes.