Smoking among youths in China

Tobacco use and behaviour among South African adolescents and young adults: systematic review and meta-analysis

OBJECTIVE

Tobacco use, particularly the initiation of smoking during adolescence and young adulthood, represents a significant public health concern in South Africa. This study aims to conduct a comprehensive review of published literature about tobacco use and behaviour among adolescents and young adults and to determine an aggregated prevalence estimate of tobacco use within this demographic.

DESIGN

Systematic review and meta-analysis.

DATA SOURCES

PubMed/MEDLINE, EMBASE, Cochrane Library, Scopus and Google Scholar were searched from 1 January 2000 through 31 October 2023.

ELIGIBILITY CRITERIA

Studies were eligible for inclusion if they were cross-sectional studies conducted in South Africa and measured the prevalence and determinants of tobacco use among adolescents and young adults aged 12-24 years.

DATA EXTRACTION AND SYNTHESIS

Two reviewers independently extracted information for each article and saved it into an Excel spreadsheet. Risk of bias analysis was conducted using the Risk of Bias Assessment Tool for non-randomised studies. The methodology quality of each selected study was evaluated using the Joanna Briggs Institute checklist. The heterogeneity of prevalence estimates was assessed using I2 statistic (random-effects DerSimonian-Laid approach).

RESULTS

Out of 73 articles identified, 12 articles were included in the analysis. The pooled prevalence of current tobacco use among South African adolescents and young adults was estimated to be 22%. The pooled prevalence of tobacco use among school dropouts, university students and secondary school learners was 51%, 20% and 16%, respectively. Stratifying using gender, boys (26%) were two times more likely to use tobacco than girls (13%).

CONCLUSION

The elevated occurrence of tobacco usage among South African adolescents and young adults is a relevant public health concern. There is a need for more population-based prevalence studies at a national level to estimate the burden of tobacco use in South Africa.

PROSPERO REGISTRATION NUMBER

CRD42023428369.

Prevalence and Associated Factors of Cigarette Smoking among South African Adolescents and Young Adults: A Systematic Review and Meta-Analysis Protocol

Tobacco use, particularly the initiation of smoking during adolescence and young adulthood, represents a significant public health concern in South Africa. The influence of socio-cultural factors, marketing strategies of the tobacco industry, and accessibility of tobacco products have all been implicated in this context. This systematic review and meta-analysis protocol aims to scrutinise the body of literature on this issue, providing a comprehensive understanding of the patterns and determinants of tobacco use among South African adolescents and young adults, with an eye towards informing more effective policy interventions. The available literature for studies on tobacco use will be systematically searched and reviewed. Five international scholarly databases, namely PubMed, MEDLINE, EMBASE, Global Health, and Scopus, will be searched. Peer-reviewed studies will be included if they are conducted in South Africa or South African provinces and if they include the prevalence of tobacco use among adolescents and young adults aged between 12 and 24 years. The results of such an analysis can guide future policy designs, enabling them to be more targeted and thus more effective. The findings can also have implications for shaping global tobacco control strategies, given the transferability of successful interventions across different populations and cultural contexts. This protocol has been registered in the PROSPERO database (ID: CRD42023428369).

Current and former smokers among adolescents aged 12-17 years in Iran: a systematic review and meta-analysis

Background

Smoking, especially among adolescents, is considered a serious public health concern worldwide being associated with increased mortality. The present study was designed as the first systematic review and meta-analysis of the prevalence of current and former smoking behavior among adolescents in Iran.

Methods

Seven international scholarly databases, namely Scopus, Embase, Pubmed/Medline, ISI/Web of Science (WOS), the Cochrane Library, Psyc Info and Cinahl, were extensively searched from January 2000 to September 18, 2019. Google Scholar was also mined. Iranian databases were searched as well (namely, MagIran, Scientific Information Database (SID), and Barakatkns). The DerSimonian-Laird’s approach, via the Freeman-Tukey double arcsine method, was used to synthesize the prevalence estimates.

Results

The prevalence of current smokers among Iranian adolescents was estimated to be 9% (95% CI: 7 to 10). Stratifying based on gender, the prevalence was 12% among boys (95% CI: 10 to 14) and 6% among girls (95% CI: 5 to 8). The prevalence of former smokers among Iranian adolescents using the random-effect model was computed to be 24% (95% CI: 21 to 27).

Conclusion

The findings of this study showed that the prevalence of current and former smoking behavior among Iranian adolescents is a relevant public health concern. The country’s young population should be given more attention by health policy- and decision-makers and implementation of ad hoc prevention and control policies should be on their agenda.

Mental health and risk behaviors of children in rural China with different patterns of parental migration: a cross-sectional study

BACKGROUND

One in seven members of China's population are migrants. There are an estimated 41 million children left behind in rural areas who are living without one or both of their parents. The impact of two- and single-parent migration on child mental health and risk behaviors is unclear. The aim of this study was to compare the mental health and risk behaviors among children whose parents are either both migrating (B-LBC), have one parent migrating (O-LBC) or those whose parents do not migrate (N-LBC).

METHODS

This study was a cross-sectional survey using a self-administered questionnaire conducted in rural areas with high proportions of left behind children (LBC) in Anhui Province, southeast China. The tools used were the Strength and Difficulties Questionnaires, Youth Risk Behavior Survey and the Young's Internet Addiction Test for Chinese.

RESULTS

Full data were available for 699 B-LBC, 552 O-LBC and 741 N-LBC. After adjusting for gender, age, grade, number of siblings and self-rated socio-economic status, B-LBC were significantly more likely to have higher emotional symptoms scores (B(SE) = 0.36(0.11), p < 0.01), higher hyperactivity scores (B(SE) = 0.22(0.11), p < 0.01) and higher total difficulties scores (B(SE) = 0.79(0.29), p < 0.01) than N-LBC. B-LBC were also more likely to be an addicted internet user (OR(95%CI) = 1.91(1.33, 2.76), p < 0.01) compared to N-LBC. However, there were no identified differences between O-LBC and N-LBC or between O-LBC and B-LBC in any measures.

CONCLUSIONS

Our findings found that living with one parent or both parents was associated with better mental health and fewer risk behaviors than was being separated from both parents. Future research is needed to consider the implications of these findings for policies and programs to protect LBC, especially for those with two migrating parents.

Psychological adjustment and behaviours in children of migrant workers in China

BACKGROUND

In China, there are around 274 million rural-urban migrants, an estimated 61 million children left behind in rural areas by parents, and 29 million children who accompany their parents to cities. The aim of this study was to compare the psychosocial adjustment and behaviours of left-behind children and migrant children.

METHODS

Full data were available for 761 left-behind children and 1,392 migrant children aged 11 to 17 in Zhejiang Province, eastern China. Participants completed a questionnaire focusing on migration status, risks behaviours, and psychological well-being, measured with the Strengths and Difficulties Questionnaire.

RESULTS

There were more left behind girls and more urban migrant boys (p < .001). The mean scores on the Strengths and Difficulties Questionnaire were all higher in left-behind children than migrant children: for emotional symptoms (3.82 vs. 3.03, p < .001), conduct problems (2.55 vs. 2.41, p = .048), hyperactivity (4.25 vs. 3.81, p < .001), and total difficulties (13.46 vs. 12.00, p = .020), whereas the prosocial score was lower (6.68 vs. 6.90, p < .001), all indicating lower levels of well-being in left-behind children. Overall, 11.4% of left-behind children and 8.8% of migrant children scored in the abnormal range for total difficulties. Left behind girls were particularly vulnerable to emotional problems. Left-behind children were more likely to admit to stealing and cheating on exams, but there were no differences in other risks behaviours, such as smoking and drinking.

CONCLUSIONS

Migration with parents, rather than separation from parents, was associated with better psychological well-being and fewer behavioural problems. Our findings have relevance for migrant parents in helping to inform decisions about where to raise their children as well as for policymakers in countries where migration is a major issue. When children are left behind, models of community support need to be considered, especially for those who are most vulnerable.

Prevalence and Determinants of Current Smoking and Intention to Smoke among Secondary School Students: A Cross-Sectional Survey among Han and Tujia Nationalities in China

Objectives: This study examined the patterns and determinants of current smoking and intention to smoke among secondary school students of Han and Tujia nationalities in China. Methods: A cross-sectional survey was conducted in three regions, namely, Chongqing, Liaocheng, and Tianjin, of China in 2015. A structured self-administered questionnaire was used for data collection. Results: Of the total subjects (n = 1805), 78.9% were ethnic Han and 21.1% were ethnic Tujia. Overall 9.4% (Han: 7.7%; Tujia: 15.5%) secondary school students were smokers and 37.28% smoked more than once per day. Of the non-smoker students (n = 1636), 17.4% have an intention to smoke. A total of 81.1% of students reportedly had never been taught throughout school about smoking or tobacco prevention. When compared to the students who were taught in the school about smoking or tobacco prevention (18.90%) students who were never taught were more likely to smoke (OR = 2.39; 95% CI = 1.14–5.01). As compared to Han nationality students who were from Tujia nationality were more likely to smoke (OR = 2.76; 95% CI = 1.88–4.04) and were more likely to have a higher frequency of smoking (95% CI (0.88, 0.88), p = 0.010). Non-smokers who were high school students (OR = 4.29; 95% CI = 2.12–8.66), whose academic performance were situated in the last 25% (OR = 2.23; 95% CI = 1.48–3.34) and lower than 50% (OR = 1.50; 95% CI = 1.02–2.20) were more likely to have an intention of smoking. Conclusions: About one in ten secondary school students was a smoker, one in three smokers smoked more than one time per day, and a quarter of non-smokers had an intention of smoking in China. Smoking rate was higher among students from Tujia than the Han nationality. This study provided some important information for future tobacco control programs among secondary school students in the ethnic minority autonomous region and minority settlements in a multi-ethnic country.

Trends in Cigarette Smoking Among Older Male Adults in China: An Urban-Rural Comparison

This study compared urban/rural trends in cigarette smoking rates among older male adults in China. Data were derived from the China Health and Nutrition Survey ( N = 5,147). Logistic models were computed to assess the occurrence of cigarette smoking between 1991 and 2011 across urban/rural administrative districts. Cigarette smoking rates remained consistent (about 50%) in rural villages over the last two decades but decreased by about 1.1 percentage points annually in urban neighborhoods. After adjusting for individual and community characteristics, divergent urban/rural trends in cigarette smoking rates did not vary statistically. Trends in cigarette smoking may be associated with unbalanced social and economic development in urban and rural China, and are an indicator of social determinants of health inequalities. Results suggest tobacco control policies and interventions should specifically focus on older adults vulnerable to economic inequality. Findings have implications for health and economic inequality among older adults in general.

Exploring the intergenerational persistence of health behaviour: an empirical study of smoking from China

Background

It is of significance to look into the intergenerational transmission of risk behaviour to explain the disparity of health. Our paper contributes to the literature by providing evidence in the context of China, focusing on smoking behaviour.

Methods

This paper studies the intergenerational transmission of smoking in the context of China using a nationally representative dataset – the China Health and Nutrition Survey (CHNS). The two-part model, the Tobit model, and the fixed effects model are utilized for the empirical analysis, respectively.

Results

We found a strong intergenerational persistence of health behaviour. That is, parents’ smoking behaviour is positively correlated with their children’s smoking initiation.

Conclusions

Our study provides evidence of the intergenerational persistence of health behaviour in the case of smoking, in the world’s most populous country. This has policy implications for the issue of intergenerational mobility and health education, as well as for tobacco control in China.

Prevalence and determinants of cigarette smoking among adolescents in secondary schools in Port Harcourt, Southern Nigeria

BACKGROUND

Cigarette smoking remains a major preventable public health problem associated with premature deaths worldwide. Adolescence is a unique developmental stage between childhood and adulthood. Smoking is a lifestyle habit acquired during adolescence and into adulthood, with its associated morbidity and mortality. It is therefore important to determine the factors associated with cigarette smoking in these adolescents in order to institute preventive measures and health policies to protect these adolescents early.

OBJECTIVE

This study aims to determine the prevalence of smoking, factors associated with smoking, and knowledge of the harmful effects of smoking in these adolescents.

METHODS

A cross-sectional study of 1120 adolescents aged 10-19 years selected from 10 secondary schools in Port Harcourt was conducted using a multistage sampling technique. The Global Youth Tobacco Survey (GYTS) core questionnaire was used to collect data from the subjects. A smoker was defined as one who had ever smoked a cigarette or who had one or two puffs, while a current smoker was defined as one who had taken a puff or smoked cigarettes in the last 30 days preceding the day of the questionnaire's completion.

RESULTS

Eighty subjects (7.1%) were smokers. This was significantly (p=<0.001) higher in males (9.7%) than in females (4%). Thirty seven (3.3%) subjects were current smokers. The mean age at which smoking was initiated was 12.47±3.0 years. Twenty six (32.5%) of the smokers reported that they were initiated into cigarette smoking by their friends, 36 (45%) just wanted to experiment, 7 (8.8%) were influenced by media advertisements while 5 (6.3%) were due to parental exposure. Parental history of smoking and poor knowledge of cancer of the lungs as a harmful effect of smoking, was significantly (p=<0.05) associated with cigarette smoking.

CONCLUSION

The prevalence of smoking in adolescents in Port Harcourt is high and is associated with parental smoking and poor knowledge of cancer of the lungs as a harmful effect. We recommend that adolescent health education with an emphasis on the harmful effects of smoking be included in the curriculum of all secondary schools.

Smoking related attitudes, motives, and behaviors of male secondary school students in an urban setting of China

Background

Most smokers have their first experience of cigarette use when they are teenagers (i.e. at schools). Aiming tobacco control initiatives at secondary school students offers preventive measures to eliminate or reduce tobacco use initiation by students. This study assessed smoking-related attitudes, motives and behavior as well as other factors associated with smoking among male secondary school students in an urban setting in China.

Methods

A cross-sectional survey was conducted in urban areas of Chongqing using a structured questionnaire administered to 1297 male secondary school students. Logistic regression analysis was employed to investigate the factors that affect smoking.

Results

Of the participants (n = 1297), 27.7% were secondary and 72.3% were middle school students. Overall, 30.5% of the participants were smokers. The majority of the students procured their first cigarette from friends. The motivations of middle school students to smoke their first cigarette were curiosity (70.5%) and imitation (13.1%). The motivations of high school students for smoking their first cigarette were to satisfy their curiosity (51.8%), relief of stress and social pressures (17.1%), and imitation of smoker friends (15.9%). Respondents from poor family financial conditions were more likely to smoke than those from rich family financial conditions [odds ratio (OR) 1.59, 95% confidence intervals (CI) 1.00, 2.52]. Respondents whose fathers were smokers were more likely to smoke than those whose fathers were non-smokers (OR 1.65, 95% CI 1.25, 2.17). Respondents who had one or two smoker friends (OR 2.98, 95% CI 1.93, 4.60) and three or more smoker friends (OR 5.92, 95% CI 4.35, 8.05) were more likely to smoke than those who did not have any. Respondents who were neutral (OR 0.43, 95% CI 0.20, 0.91) and disagreed about the item “friends smoking” (OR 0.18, 95% CI 0.08, 0.39) were less likely to smoke than those who agreed with the item.

Conclusions

This study indicates that male students who have negative attitudes toward smoking, who do not have a father or friends who smoke, and are from affluent backgrounds exhibit low tendency to start smoking at a young age. This study provides some implications for tobacco control policies among male secondary school students in urban settings.

Tobacco Use by Middle and High School Chinese Adolescents and their Friends

Understanding the similarity of the tobacco use of youth and their friends and unraveling the extent to which this similarity results from selection or socialization is central to peer influence models of tobacco use. The similarity between the tobacco use of Chinese adolescents and their friends were explored in middle (880, 13.3 years, 399 girls) and high school (849, 16.6 years, 454 girls) cohorts assessed yearly at three times. Boys were more similar to their friends in tobacco use than were girls. Growth curve models revealed escalation of use during middle school and stable use during high school for boys, whereas models for girls could not be computed. Evidence of selection effects emerged from cross-lagged panel analyses revealing pathways from boys' tobacco use to subsequent changes in their friends' use; assessment of selection and influence processes could not be assessed for girls. The results from this study suggest that peer influence processes may differ for Chinese boys and girls and that further quantitative and qualitative research is necessary to understand these processes.

Parental migration and smoking behavior of left-behind children: evidence from a survey in rural Anhui, China

Background

Parental migration is most an important factor affecting children’s behaviors. Few studies have addressed the association between parental migration and children’s smoking behavior in China. This study aims to estimate the current smoking prevalence among children, evaluate the association of parental migration and the smoking behavior of children and identify factors associated with smoking behavior among left-behind children (LBC).

Methods

A cross-sectional study was conducted in 6 cities in Anhui province during July and August, 2012. All participants were interviewed face-to-face using a standardized questionnaire. Only children 10 to 14 years old that live in rural villages for at least 6 months during the previous year were included in the study.

Results

A total of 1343 children met the sampling criteria and participated in the study. Of these, 56 % are LBC and 44 % live with both parents. The average rate of smoking is 3.4 %. The rate of smoking is statistically higher for LBC with both parents out (rate = 6.1 %; OR = 5.59, P < 0.001) than for children living with both parents (1.4 %). Similarly, the rate of LBC with father home only (rate = 5.0 %; OR = 5.60, P = 0.005) is also statistically higher than for children living with both parents when controlling other variables. Factors affecting the smoking behavior of LBC, include gender (i.e., boys), (perceived) school performance and primary caregiver.

Conclusions

Parental migration is associated with a significant increase in smoking behavior among children. Intervention studies that target LBC would help to develop strategies to reduce smoking among rural children. Gender-specific strategies and anti-smoking education also appears to be needed to reduce tobacco use among rural LBC.

Smoking among Secondary School Students in Negeri Sembilan, Malaysia

This study was done to determine the prevalence of smoking and factors influencing cigarette smoking among secondary school students in Negeri Sembilan, Malaysia. This is a cross-sectional school survey conducted on 4500 adolescent students based on a structured questionnaire. Data was collected using the supervised self administered questionnaire the Youth Risk Behaviour Surveillance in the Malaysian National Language Bahasa Malaysia. The prevalence of smoking among the students was 14.0%. About a third of the students (37.8%) started smoking at 13 to 14 years of age. The prevalence of smoking among the male students was higher (26.6%) compared to the female students (3.1 %). Adolescent smoking was associated with (1) sociodemographic factors (age, ethnicity, rural/urban status); (2) environmental factors (parental smoking, staying with parents); (3) behavioural factors (playing truant and risk-taking behaviours such as physical fighting, drug use, alcohol use, sexual activity, lack of seatbelt use, riding with a drunk driver); (4) lifestyle behaviours (being on diet and lack of exercise); (5) personal factors (feeling sad and suicidal behaviours). In conclusion, smoking is a major problem among Malaysian adolescents. Certain groups of adolescents tend to be at higher risk of smoking. This problem should be curbed early by targeting these groups of high risk adolescents. Asia Pac J Public Health 2005; 17(2): 130-136.

Prevalence and associated factors of smoking in middle and high school students: a school-based cross-sectional study in Zhejiang Province, China

OBJECTIVES

To determine the prevalence and associated factors of smoking in a Chinese adolescent population.

SETTING

A multistage, stratified cluster sampling technique was used in the present cross-sectional study conducted in Zhejiang Province of China. Based on socioeconomic status, school levels and geographical positions, 253 middle school classes, 122 academic school classes and 115 vocational high school classes located in 12 urban areas and 18 rural areas were chosen.

PARTICIPANTS

A total of 9617 middle school students, 5495 academic high school students and 4430 vocational high school students were recruited in this survey.

PRIMARY AND SECONDARY OUTCOME MEASURES

Ever, current smoking status and associated factors were collected via a self-administered questionnaire. Logistic regression models were used to examine the associations between current smoking and the associated factors. ORs with their 95% CIs were reported.

RESULTS

Overall, the prevalence of ever-smokers and current smokers was 33.83% and 7.93%, respectively. Focused on current smokers, significantly higher risks of adolescent smoking were observed in an older age group, boys, rural areas and vocational high school. Other significant factors were parents smoking, secondhand smoke exposure, parental divorce or separation, living with family, school performance and belief that smoking is harmful.

CONCLUSIONS

The prevalence of smoking was relatively high among Chinese adolescents in Zhejiang Province. Factors related to personal characteristics, family and school were associated with adolescent smoking.

Alcohol consumption is higher among left-behind Chinese children whose parents leave rural areas to work

AIM

Over the past few decades, a large number of rural residents have migrated to cities in China and left their children behind. This study estimated how many 10- to 14-year-old children in rural Anhui drank alcohol and examined the association between parental migration and children's alcohol use.

METHODS

A cross-sectional study was conducted in six cities in Anhui between July and August 2012. All participants had lived in the study villages for at least six months during the previous year and were interviewed face-to-face using a standardised questionnaire.

RESULTS

More than half (57%) of the 1367 subjects were left-behind children, 43% lived with both parents and 9.6% currently drank alcohol. When we controlled for other variables, the rate of alcohol use was statistically higher among left-behind children if both parents had migrated (14.0%) than among children living with both parents (7.8%) (p = 0.002). Boys, children with siblings and those with a poorer academic performance were more likely to drink.

CONCLUSION

Children in rural China were more likely to drink if both their parents had migrated in search of work. School-based interventions could help to reduce alcohol use among rural left-behind children, especially boys.

Smoking behaviors and intentions among adolescents in rural China: the application of the Theory of Planned Behavior and the role of social influence

INTRODUCTION

This study investigated the associations between the variables of the theory of planned behavior (TPB), influence of significant others, and smoking intentions and behaviors among adolescents living in rural southern China.

METHODS

A cross-sectional study was conducted among 2609 students in two junior high schools in rural Shantou, Guangdong province, using a self-administered questionnaire. Logistic regression models were fitted to estimate univariate and adjusted odds ratios and corresponding 95% confidence intervals.

RESULTS

Multivariate analyses showed that having favorable attitudes towards smoking on psychological and social aspects, perceived behavioral control, and having most friends who were current smokers were significantly associated with smoking intentions in the next six months and in the next five years. Having most family members who were current smokers was also significantly related to smoking intention in the next five years. Having favorable attitudes towards smoking on psychological aspect and negative attitudes on physical aspect, perceived support from friends on smoking, and having most friends and senior relatives being current smokers were significantly associated with increased likelihood of ever smoking. Perceived behavioral control and having most friends being current smokers were also significantly associated with regular smoking and smoking in the past 30days.

CONCLUSIONS

Our results suggest that the key constructs of the TPB model and friends' smoking behaviors play important roles in accounting for smoking intentions and behaviors among a sample of rural Chinese adolescents.

A Meta-Analysis of Cigarette Smoking Prevalence among Adolescents in China: 1981-2010

BACKGROUND

Systematic data regarding adolescent smoking are needed at the national level to support evidence-based tobacco control in China. The goal of this study was to estimate smoking prevalence among Chinese adolescents using published data.

METHODS

Published studies were located electronically from the commonly used databases in Chinese and English, complemented by manual searching. Forty-five studies were selected of the 9771 retrieved from the databases. These studies targeted adolescents aged 12-17 or middle/high school students, were conducted during the 1981-2010, and had adequate data for meta-analysis. The 45 selected studies covered 52 sites in different parts of China. Smoking rates were estimated using the sample-weighted and random effect method.

RESULTS

The estimated prevalence rate of lifetime smoking (ever smoked) varied within a narrow range (39.04%-46.03%) for males and progressively increased from 2.47% in 1981-1985 to 19.72% in 2001-2005 for females. The prevalence rate of current (30-day) smoking for males declined from 26.62% in 1981-1985 to 10.86% in 1996-2000 before increasing again. The prevalence of current smoking for females increased from 0.29% in 1981-1985 to 3.26% in 2006-2010.

CONCLUSIONS

The high levels of male smoking and the rapid increase in female smoking indicate growing burdens from tobacco-related diseases, underscoring the urgent need to strengthen adolescent tobacco control in China.

A Protection Motivation Theory-Based Scale for Tobacco Research among Chinese Youth

Rates of tobacco use among adolescents in China and other lower and middle-income countries remain high despite notable prevention and intervention programs. One reason for this may be the lack of theory-based research in tobacco use prevention in these countries. In the current study, a culturally appropriate 21-item measurement scale for cigarette smoking was developed based on the core constructs of Protection Motivation Theory (PMT). The scale was assessed among a sample of 553 Chinese vocational high school students. Results from correlational and measurement modeling analysis indicated adequate measurement reliability for the proposed PMT scale structure. The two PMT Pathways and the seven PMT constructs were significantly correlated with adolescent intention to smoke and actual smoking behavior. This study is the first to evaluate a PMT scale for cigarette smoking among Chinese adolescents. The scale provides a potential tool for assessing social cognitive processes underlying tobacco use. This is essential for understanding smoking behavior among Chinese youth and to support more effective tobacco use prevention efforts. Additional studies are needed to assess its utility for use with Chinese youth in other settings.

The role of cognitive attributions for smoking in subsequent smoking progression and regression among adolescents in China

Previous studies have documented that cognitive attributions are correlated with adolescent smoking. The present study further explored whether cognitive attributions for smoking influenced adolescents' future smoking behaviors, especially transitions to more advanced stages of smoking. Participants were 12,382 middle and high school students (48.5% males and 51.5% females) in seven large cities in China. They completed two waves of surveys one year apart. Cognitive attributions for smoking and three smoking behavior outcomes (lifetime smoking, past 30-day smoking, and daily smoking) were assessed. Changes in smoking, including progression from lower stages to higher stages and regression from higher stages to lower stages, over a one-year period, were defined longitudinally. Polychotomous logistic regression was used to examine associations between cognitive attributions for smoking and changes in smoking status over one year, adjusting for demographic characteristics and other plausible confounders. Seven out of eight cognitive attributions for smoking were associated with subsequent smoking behaviors (p<0.05). Curiosity, autonomy, social image, social belonging, and coping influenced earlier stages of smoking, whereas mental enhancement and engagement influenced later stages of smoking. Curiosity, autonomy, social image, and mental enhancement preceded smoking progression; social belonging prevented smoking regression; and coping and engagement both preceded smoking progression and prevented smoking regression. This study demonstrates that different cognitive attributions influence smoking at different stages in different ways. These findings could inform smoking prevention and cessation programs targeting Chinese adolescents.

Development and psychometric properties of the health-risk behavior inventory for Chinese adolescents

BACKGROUND

There is a growing body of research investigating adolescent risk behaviors in China, however, a comprehensive measure that evaluates the full spectrum of relevant risk behaviors is lacking. In order to address this important gap, the current study sought to develop and validate a comprehensive tool: the Health-Risk Behavior Inventory for Chinese Adolescents (HBICA).

METHODS

Adolescents, ages 14-19  years (n = 6,633), were recruited from high schools across 10 cities in mainland China. In addition, a clinical sample, which included 326 adolescents meeting DSM-IV criteria for Conduct Disorder, was used to evaluate predictive validity of the HBICA. Psychometric properties including internal consistency (Cronbach's alpha), test-retest reliability, convergent validity, and predictive validity were analyzed.

RESULTS

Based upon item analysis and exploratory factor analysis, we retained 33 items, and 5 factors explained 51.75% of the total variance: Suicide and Self-Injurious Behaviors (SS), Aggression and Violence (AV), Rule Breaking (RB), Substance Use (SU), and Unprotected Sex (US). Cronbach's alphas were good, from 0.77 (RB) to 0.86 (US) for boys, and from 0.74 (SD) to 0.83(SS) for girls. The 8  weeks test-retest reliabilities were moderate, ranged from 0.66 (AV) to 0.76 (SD). External validities was strong, with Barratt Impulsiveness Scale-11 was 0.35 (p < 0.01), and with aggressive behavior and rule-breaking behavior subscales of the Youth Self Report were 0.54 (p < 0.01) and 0.68 (p < 0.01), respectively. Predictive validity analysis also provided enough discriminantity, which can distinguish high risky individual effectively (cohen' d = 0.79-2.96).

CONCLUSIONS

These results provide initial support for the reliability and validity of the Health-Risk Behavior Inventory for Chinese Adolescents (HBICA) as a comprehensive and developmentally appropriate assessment instrument for risk behaviors in Chinese adolescents.

A qualitative exploration of youth in the "new" China: perspectives on tobacco use from adolescents in southwest China

School-based prevention programs are not common in China and the attempts to modify successful Western prevention programs have largely shown little effect. Distinct cultural and social systems differences could explain why modified programs have been unsuccessful. Smoking behavior is examined from the perspective of Chinese adolescents as part of the development of a large intervention trial. A total of 16 focus groups with 128 participants were conducted in Chengdu in Sichuan province of China. Impressions of adolescent smokers were mixed, most seeing the behavior as common among boys. Smokers were seen as being overwhelmed and stressed. Girls' smoking was mostly seen as universally "bad" and reflecting poorly on a girl's character. However, a small portion of focus group participants suggested that female smoking was fashionable and trendy. With social norms changing rapidly in the "new" China, understanding what the new generation of Chinese youth thinks about smoking is critical in determining how to address and tailor prevention efforts.

Cognitive attributions for smoking among adolescents in China

To design more effective health communication messages for smoking cessation and prevention, it is important to understand people's own perceptions of the factors that influence their decisions to smoke. Studies have examined cognitive attributions for smoking in Western countries but not in the Chinese cultural context. In a study of 14,434 Chinese adolescents, exploratory factor analysis grouped 17 cognitive attributions into 8 factors: curiosity, coping, social image, social belonging, engagement, autonomy, mental enhancement, and weight control. The factors were ranked based on the participants' self-reports of importance and by the strength of their associations with smoking behavior. Among all smokers, curiosity was the most frequently-ranked attribution factor at the early stages of smoking but not for daily smoking. Coping was highly-ranked across smoking stages. Social image and social belonging were more highly-ranked at earlier stages, whereas engagement and mental enhancement were ranked more highly at later stages of smoking. More attributions were associated with smoking among males than among females. This information could be useful for the development of evidence-based anti-smoking programs in China.

Patterns of smoking and its association with psychosocial work conditions among blue-collar and service employees of hospitality venues in Shenyang, PR China

Background

To characterize the smoking patterns of hospitality employees in blue-collar and service occupations, and to examine its relations with psychosocial work conditions.

Methods

The Shenyang Hospitality Industry Employees Survey-a face-to-face cross-sectional study of representative hospitality industry employees-was conducted between March and July 2008. A total of 4,213 workers were selected using stratified random cluster sampling designs, and final analyses were performed on 2,508 blue-collar and service subjects. Multilevel-logistic regression models were used to estimate the contribution of psychosocial work conditions to smoking status.

Results

Blue-collar and service employees smoked at a rate 1.4 times that of the general population (49.4% vs. 35.8%), more particularly for females (12.9% vs. 3.08%). Strain jobs had significantly higher odds ratio of daily smoking (OR 2.09, 95%CI: 1.28-3.41) compared to the relaxed category. The passive jobs (OR 2.01, 95%CI 1.27 to 3.17), highest job demands (OR 1.72, 95%CI: 1.13-2.61), and lowest job control (OR 2.56, 95%CI: 1.57-4.16) were also associated with a significantly higher daily smoking ratio. The negative relationship between job stability and smoking behavior was slightly stronger among daily than occasional smokers. However, neither job strain nor any of its components was found to be significantly associated with occasional smoking.

Conclusions

Smoking in hospitality blue-collar and service employees is certainly a major occupational health problem in Shenyang. This evidence also suggests an association between psychosocial-work conditions and smoking status, and implies that more intervention studies where changes in work environment are carried out in combination with health promotion interventions should be performed.

Risk factors for smoking among school adolescents in Greece

OBJECTIVE

We conducted this study among school adolescents to identify factors, which influence schoolchildren to smoke.

METHODS

We carried out a cross-sectional study in a sample of 924 students of all classes (ages 12-18 years old) in 15 public high schools in a semi-urban area in Crete, Greece, using a questionnaire. The questionnaire comprised of 46 questions covering children's lifestyle habits regarding daily activities and leisure time, frequency of risk-taking behaviour, knowledge about the hazards and long-term consequences of smoking.

RESULTS

23.9% of participants were experimental smokers and 18.6% were current smokers. 11.4% of the total population was daily smokers. There was a significant increase in the prevalence of experimental and current smokers with school grades, while peaks in last grades were observed. Boys started smoking earlier than girls, mean (standard error) age 13.4 (2.3) years vs. 14.1 (2.3) years, P = 0.01. Stepwise logistic regression analysis showed a positive relationship between current smoking and having brother or sister smoking [odds ratio (95% confidence interval) 2.7 (1.7-4.4) and 1.8 (1.1-3.3) respectively], having more than three friends who were smokers [2.6 (2-3.4)] and last school grade [1.4 (1.2-1.7)]. Students appeared to be informed about long-term smoking hazards and had negative views on children who smoke especially in the lower grades.

CONCLUSIONS

Prevention programmes should be imposed early in elementary schools while cessation policies should target at all grades, in particular at critical grades depending on population-specific characteristics.

A diathesis-stress model of engagement in risky behaviors in Chinese adolescents

The current study examined whether the association between the occurrence of negative events and increased engagement in risky behavior is moderated by maladaptive and/or adaptive coping strategies. At time 1, 411 adolescents (ages 14-19) from Yue Yang, Hunan, completed self-report measures assessing coping strategies, engagement in risky behaviors, and the occurrence of negative events. Once a month for the subsequent 6 months, adolescents completed measures assessing engagement in risky behaviors and the occurrence of negative events. In line with our hypotheses, results of hierarchical linear modeling analyses indicated that adolescents possessing high levels of maladaptive coping strategies reported greater engagement in risky behaviors following the occurrence of negative events than adolescents possessing low levels. In contrast to our hypotheses, the association between the occurrence of negative events and increased engagement in risky behavior was not moderated by adaptive coping strategies.

Smoking, cessation and expenditure in low income Chinese: cross sectional survey

Background

This study was carried-out to explore smoking behaviour and smoking expenditure among low income workers in Eastern China to inform tobacco control policy.

Methods

A self-completion questionnaire was administered to 1958 urban workers, 1909 rural workers and 3248 migrant workers in Zhejiang Province, Eastern China in 2004.

Results

Overall 54% of the men and 1.8% of all women were current smokers (at least 1 cigarette per day). Smoking was least common in migrant men (51%), compared with 58% of urban workers and 64% rural inhabitants (P < 0.0001). Forty-nine percent of rural males smoke more than 10 cigarettes/day, and 22% over 20/day. The prevalence of smoking increased with age. Overall 9% of the males had successfully quit smoking. Reasons for quitting were to prevent future illness (58%), current illness (31%), family pressures (20%) and financial considerations (20%). Thirteen percent of current smokers had ever tried to quit (cessation for at least one week) while 22% intended to quit, with migrants most likely to intend to quit. Almost all (96%) were aware that smoking was harmful to health, though only 25% were aware of the dangers of passive smoking. A mean of 11% of personal monthly income is spent on smoking rising to a mean of 15.4% in rural smokers. This expenditure was found to have major opportunity costs, including in terms of healthcare access.

Conclusion

The prevalence of smoking and successful quitting suggest that smoking prevalence in low income groups in Eastern China may have peaked. Tobacco control should focus on support for quitters, on workplace/public place smoking restrictions and should develop specific programmes in rural areas. Health education messages should emphasise the opportunity costs of smoking and the dangers of passive smoking.

Tobacco use among youth and adults in Mainland China: the China Seven Cities Study

OBJECTIVE

The China Seven Cities Study (CSCS) monitors geographic and temporal trends in tobacco use among adolescents and adults in seven cities throughout Mainland China: Harbin, Shenyang, Wuhan, Chengdu, Kunming, Hangzhou, and Qingdao. This article presents the methodology and prevalence data from the baseline survey of the CSCS, conducted in 2002.

METHODS

Stratified random samples of middle schools, high schools, and colleges were selected within each city. Students and their parents completed self-report surveys of their tobacco use. Data were obtained from 6138 middle school students, 5848 academic high school students, 2448 vocational high school students, 2556 college students, and 25 697 parents.

RESULTS

Smoking prevalence varied across age groups, school types, genders, and cities. Past-month smoking prevalence was 9% among middle school students, 8% among academic high school students, 26% among vocational high school students, 21% among college students, and 40% among parents. Smoking prevalence was higher among males than among females, with larger gender disparities among adults than among youth. Smoking also varied across cities, with higher smoking prevalence in southwestern cities and lower prevalence in coastal cities. Intraclass correlations of students within schools are presented to inform statistical power estimates for further research in China.

CONCLUSIONS

These results provide a baseline for future longitudinal studies of smoking in these cities and identify demographic groups at risk for tobacco-related disease. Effective smoking prevention programmes for youth and smoking cessation programmes for adults are needed in China, especially in the lower-income southwestern cities and in vocational high schools throughout the country.

Influences affecting adolescent smoking behavior in China

This study examined multiple influences on the use of tobacco by adolescents in China. Using the theory of triadic influences as a guide, we selected interpersonal, attitudinal/cultural, and intrapersonal constructs from baseline data to predict adolescent smoking 1 year later. We used prospective data from middle and high school students (N = 11,583) and their parents from the China Seven Cities Study, a longitudinal study that is evaluating the effects of changing economic and social factors on health behaviors including tobacco use. A multilevel regression analysis provided some support that each of the influences in the theory of triadic influences affects adolescent smoking in China. After adjusting for important confounders including age, gender, socioeconomic status, and smoking behaviors (lifetime and past 30-day) at baseline, we found significant risk factors within each of the three categories, including interpersonal influences (parental monitoring, good friend smoking, and peer smoking), attitudinal/cultural influences (school academic ranking, initial liking of smoking, and the meaning of smoking), and intrapersonal influences (susceptibility to smoking, and low self-confidence to quit smoking). Results suggest that the etiology of smoking among adolescents in China might be similar to that observed in western countries and that some of the techniques used successfully in prevention programs in those countries might be useful guides when developing prevention programs in China.

A randomized intervention of smoking for adolescents in urban Wuhan, China

BACKGROUND

Tobacco use is a significant public health problem in China. Culturally specific smoking prevention programs are needed for Chinese adolescents. This study evaluated a school-based smoking prevention curriculum with a social normative approach developed in the United States for adolescents in urban Wuhan, China.

METHODS

As a randomized trial, the intervention was implemented in 1998 with 7th grade students in seven schools with seven matched control schools. Multilevel logistic regression models were used to compare ever and recent (past-month) smoking behaviors for the control and program conditions.

RESULTS

At the 1-year follow-up, smoking had increased more rapidly in the control schools than in the program schools. The odds of baseline nonsmokers initiating smoking did not differ between the program and control groups (OR=1.08 with 95% CI=0.71, 1.64). The program prevented progression to recent smoking among boys who were baseline ever smokers. Among boys who were recent smokers at baseline, the prevention program significantly reduced risk of remaining recent smokers at follow-up (OR=0.45 with 95% CI=0.23, 0.88).

CONCLUSIONS

This social normative smoking prevention curriculum did not demonstrate a significant primary prevention effect but showed potential for secondary prevention. Culturally specific smoking prevention programs are needed for Chinese adolescents.

Attitudes to smoking cessation and triggers to relapse among Chinese male smokers

Background

Smoking is related to many diseases, and the relapse to smoking after cessation in China is noticeable. We examined the attitudes of Chinese male smokers regarding smoking cessation and reasons for relapse.

Methods

We interviewed 201 male smokers in Hangzhou City, Zhejiang province, China who had tried to quit smoking at least once in order to identify reasons for quitting and situations triggering relapse.

Results

The most significant reported reasons for quitting included personal health (77.1%), the cost of cigarettes (53.7%), and family pressures to quit (29.9%). The most common factors triggering relapse were social situations (34.3%), feeling negative or down (13.4%) and times of being alone (8.4%).

Conclusion

Health and family concerns, personal factors, the influence of others and a lack of cessation resources were cited as salient factors concerning smoking cessation among male smokers in this study. Effective smoking control efforts in China will require attention to these influences if China is to curb its current smoking epidemic.

Role of parents and peers in influencing the smoking status of high school students in Taiwan

OBJECTIVES

To assess parental influence on smoking behaviour by high school students in an Asian culture and to compare the relative importance of parental and peer influence.

METHODS

A 5% nationally representative sample, including 44 976 high school students in 10th to 12th grade (aged 15-18 years) in Taiwan, were surveyed in 1995. Each completed a long self administered questionnaire. Parental influence was measured by examining both parental behaviour (smoking status) and attitudes (perceived "tender loving care" (TLC) by adolescents). Changes in smoking status were used to determine peer influence, defined as the increase in the likelihood of smoking from grade 10 to 12 in a steady state environment. Odds ratios (ORs) were calculated for parental and peer influence, using logistic regression.

RESULTS

Adolescents of smoking parents with low TLC had the highest smoking rates and those of non-smoking parents with high TLC had the lowest. The difference was more than twofold in boys and more than fourfold in girls. When either parental smoking status or TLC alone was considered, parental influence was similar to peer influence in boys, but larger than peer influence in girls. However, when smoking status and TLC were considered jointly, it became larger than peer influence for both groups (OR 2.8 v 1.8 for boys and OR 3.9 v 1.3 for girls).

CONCLUSION

When parental influence is taken as parental behaviour and attitude together, it plays a more important role than peer influence in smoking among high school students in Taiwan. This study, characterising such relationships among Asian populations for the first time, implies that future prevention programmes should direct more efforts toward the parental smoking and parent-child relationships, and not aim exclusively at adolescents in schools.

Family characteristics and smoking among urban and rural adolescents living in China

BACKGROUND

Adolescent smoking is a public health concern in China. Although the family is an important social influence in China, few associations among family characteristics and adolescent smoking have been examined using Chinese samples.

METHODS

Survey data on psychosocial variables and smoking were collected from a sample of 3629 7th grade adolescents (46% female; 54% male; mean age 12.7 years) in Wuhan, China. For adolescents, past 30-day smoking, family relationships, parents' negative sanctioning of smoking, parents' agreement with smoking, and parents' smoking behaviors are assessed. To account for the clustered data structure, hierarchical logistic regression analyses controlling for demographics (urbanization, age) examined the independent and multivariate effects of family characteristics for each gender.

RESULTS

Girls are less likely than boys to report smoking and are more likely to report positive family relationships, and having parents with negative attitudes toward them smoking. Positive family relationships and age were strongly associated with smoking for both genders. No significant differences exist by gender.

CONCLUSION

These findings suggest that the quality of family relationships are important for adolescent female and male smoking in China.

Smoking and drinking patterns among residents of Li ethnic minority villages in Hainan, China

BACKGROUND

In China, approximately 67% of male adults are smokers and 64% of them are drinkers. Tobacco and alcohol use are more prevalent among many of China's 55 ethnic minority populations, but specific data are lacking for them, including the Li population.

METHODS

Cross-sectional data from 379 residents sampled from 12 Li villages in Hainan Province were used for this analysis. Data were collected in 2003 using a questionnaire adopted from the U.S. National Household Survey on Drug Abuse. Both lifetime and current use of tobacco and alcohol products, including prevalence, frequency and amount of use, as well as age patterns of onset of use were assessed.

FINDINGS

Eighty-five percent of the sample were Li minority and 43% were female with a mean age of 34.7 years (SD = 14.5). While fewer female subjects of the sample reported smoking (1.9% of lifetime smoking) and drinking (21.0% lifetime drinking), 84.1% of the male sample were lifetime smokers and 92.5% were lifetime drinkers; 78.1% were 30-day smokers and 88.4% were 30-day drinkers; and 58.6% were daily smokers and 15.8% were daily drinkers. In addition, 79.1% male villagers were binge drinkers, and 21.4% were intoxicated in the past month. The risk of onset of smoking and drinking increased after 10 years of age, peaked at 18-19 years (hazard = 16.0% for smoking and 19.5% for drinking), then declined until leveling off at 25 years of age. Eighty-five to 97% of the males simultaneously used alcohol and tobacco.

CONCLUSIONS

The prevalence rates of tobacco and alcohol use in Li male villagers are higher than those of the national average and other ethnic minorities in China. Indepth studies are needed to obtain more detailed information regarding issues such as detailed types of tobacco and alcohol products, causes of use, as well as willingness to participate in tobacco and alcohol control interventions in order to develop and deliver substantial intervention programs.

Patterns of cigarette smoking among students from 19 colleges and universities in Jiangsu Province, China: a latent class analysis

Entrance into college may be associated with elevated risk of progression in cigarette use among Chinese students. The purpose of this study was to examine patterns and dynamics of cigarette smoking by age and grade among college students in China. Cross-sectional data from 1845 students (44% females) in 19 colleges and universities in Jiangsu Province were derived from the Chinese Youth Health Risk Behavior Survey in 2001. Data were analyzed using latent class analysis (LCA). Overall 11 mutually exclusive types (latent classes) of cigarette users were derived and their proportions estimated from four variables: lifetime smoking, past 30-day smoking, attempting to quit in the past, and intention to smoke in the future. Two types (resistant never-smokers, self-stopped resistant nonsmokers) were observed across age groups and grades for both males and females while other smoking types varied with gender, age and grade. Advanced cigarette smoking types appeared in older age groups and higher grades. The cross-sectional age and grade trend suggests substantial progression in cigarette smoking among Chinese college students, underscoring the need for prevention among these students. Results also suggest that LCA may be an effective methodology for analyzing behavioral types and their dynamics with a limited number of variables.

Harmful health effects of cigarette smoking

This is a comprehensive review on the harmful health effects of cigarette smoking. Tobacco smoking is a reprehensible habit that has spread all over the world as an epidemic. It reduces the life expectancy among smokers. It increases overall medical costs and contributes to the loss of productivity during the life span. Smoking has been shown to be linked with various neurological, cardiovascular, and pulmonary diseases. Cigarette smoke not only affects the smokers but also contributes to the health problems of the non-smokers. Exposure to environmental tobacco smoke contributes to health problems in children and is a significant risk factor for asthma. Cigarette smoke contains several carcinogens that alter biochemical defense systems leading to lung cancer.