Research paper Tob Control: first published as 10.1136/tc.2009.031336 on 10 August 2009. Downloaded from Risk factors associated with smoking behaviour in recreational venues: findings from the International Tobacco Control (ITC) China Survey X Li,1,4 Q Li,2,3 L Dong,4 B Sun,4 J Chen,4 Y Jiang,3 Y Yang,3 B Zhou,1 G T Fong2 1 Department of Epidemiology, ABSTRACT China will become smokers, 50 million of whom School of Public Health, China Objective: To explore the determinants of smoking will die from smoking-attributable diseases.9 Medical University, Shenyang, China; 2 Department of behaviour in recreational venues and to provide scientific According to the Report on Tobacco Control in Psychology, University of bases for establishing smoke-free measures applying to China for 2007, 540 million non-smokers are Waterloo, Waterloo, Ontario, these locations. suffering from secondhand smoke, including 180 3 Canada; National Center for Methods: The International Tobacco Control (ITC) China million children aged below 15.10 Chronic and Non-communicable Survey—a face-to-face cross-sectional survey of repre- Disease Control and Prevention, Recreational venues (for example, restaurants, Chinese Center for Disease sentative adult smokers from six cities (Shenyang, Beijing, coffee shops and karaoke lounges) that allow Control and Prevention, Beijing, Shanghai, Guangzhou, Changsha and Yinchuan) was smoking expose people to contexts in which 4 China; Shenyang Center for conducted between April and August 2006. A total of smoking may be viewed as the norm. This may Disease Control and Prevention, 4815 smokers were selected using multistage sampling encourage their progression to more regular smok- Shenyang, China methods, and final analyses were conducted on 2875 ing.11 12 Further, the tobacco industry is actively Correspondence to: smokers who reported patronising recreational venues at promoting tobacco in recreational settings which Baosen Zhou, Department of least once in the last six months. Multivariate logistic may contribute to smoking uptake and relapse Epidemiology, School of Public 13–15 Health, China Medical University, regression models were used to identify factors influen- back to smoking for those trying to quit. No 92 Beier Road, Heping District, cing the smoking behaviour within recreational settings. Recreational venues tend to be frequented by the Shenyang, Liaoning Province, PR Outcome measure: Whether a smoker reported smok- trend-setters in society: the elite, in China. If China. 110001; bszhou@ ing in recreational venues during the last 6 months. smoking goes on in these recreational venues, then mail.cmu.edu.cn Results: 84% of subjects reported smoking in people get the idea that smoking is acceptable and Received 5 May 2009 recreational venues. 32.0% of patrons reported partial that smoking in these public places is just the way Accepted 28 July 2009 or complete bans on smoking in these locations. things are. Thus, smoke-free laws in recreational Published Online First The following factors were significant predicators settings would be a powerful way to ‘‘de-normal- 10 August 2009 of smoking in recreational venues: absence ise’’ smoking in China. http://tobaccocontrol.bmj.com/ of bans on smoking, support for non-bans, being China’s high prevalence of smoking and tremen- aged 18–24 years, positive smoking-related attitudes, dous burden from tobacco-induced diseases make low number of health effects reported and not tobacco prevention an essential health priority.616 living in Beijing. However, China currently has no smoke-free law Conclusions: The findings point to the importance of at the national level, let alone one aimed at the informing Chinese smokers about the active smoking and population within recreational venues, which are passive smoking harmfulness in both building support for all common venues for smoking and passive smoke-free laws and in reducing smokers’ desire to smoking exposure. Most current prevention pro- smoke within recreational venues. They also point to the grammes are based on the social influence importance of good enforcement of smoke-free laws approach, which targets the proximal psychosocial when implemented. Such strategies could also serve to variables believed to promote individuals to on September 29, 2021 by guest. Protected copyright. de-normalise smoking in China, a key strategy for smoke.17–19 Although such programmes are some- reducing smoking in general. what effective, the smoking-related risk factors utilised are based mainly on Western studies.20 21 Whether these factors have the same influence on Developing countries (with low and middle Chinese smoking behaviour, especially in recrea- incomes) are facing a rapidly growing epidemic of tional venues, has not been identified to date. An tobacco use; rates in these regions began increasing examination of the behaviour, beliefs and char- in the early 1970s, and currently, 82% of the acteristics of smokers who frequently patronise world’s 1.1 billion smokers are in developing recreational venues may help in designing an countries, with over 50% in Asia alone.1–3 One appropriate and effective smoking prevention such country, the world’s largest producer, con- programme applying to these venues. sumer and victim of tobacco, is China.4 Currently, To bridge this data gap, the present study China is home to 350 million smokers (30% of the focused on smoking among adults within recrea- world’s smokers) and loses approximately one tional settings. To the best of our knowledge, this million people per year directly or indirectly is the first reported study to identify potential because of tobacco-related deaths.5–7 If the smoking risk factors for smoking behaviour within recrea- situation cannot be controlled effectively, it is tional settings in China. In this study, we estimated that about two million smoking-related attempted to provide information on the deter- deaths will occur among Chinese men by the year minants of smoking behaviour in recreational 2025,8 and 200 million children currently living in venues, and to develop a practical and effective _ i30 Tobacco Control 2010;19(Suppl 2):i30 i39. doi:10.1136/tc.2009.031336 Research paper Tob Control: first published as 10.1136/tc.2009.031336 on 10 August 2009. Downloaded from smoking intervention strategy for recreational venues by we directly asked on average, how many cigarettes, including examining the behaviour, beliefs and opinions of smokers factory made and ‘‘hand-rolled’’ cigarettes, they smoke per day. who patronised these venues. Weekly smokers were asked for the average cigarettes they smoked per week. METHODS This section provides an outline of the methods used in the ITC Reported smoking in entertainment venues China Survey. A more detailed description can be found in the Smokers were asked a series of questions on whether they had paper by Wu et al.22 gone to each of several entertainment venues in the past 6 months, and for each venue, whether they had smoked. The Sampling design entertainment venues were restaurants, coffee shops and This study was the baseline survey for the International karaoke lounges. Tobacco Control (ITC) China Survey, a cohort survey of adult smokers and non-smokers, designed to evaluate tobacco control Knowledge of health effects policies. Survey waves are being conducted every year over a Knowledge of the harmful effects of smoking was assessed by five-year period. asking the respondents if they believed that cigarette smoking The ITC China Survey used a stratified multistage cluster can cause coronary heart disease (CHD), stroke, impotence, sampling design in which six cities were first selected based on premature ageing, emphysema, stained teeth in smokers, lung geographical representations and levels of economic develop- cancer in smokers, lung cancer in non-smokers and addiction to ment. These six cities were Shenyang, Beijing, Shanghai, tobacco. Guangzhou, Changsha and Yinchuan. Within each city, 10 street districts (Jie Dao) were randomly selected, with prob- Extent of smoking restrictions ability of selection proportional to the population size of the Jie Reported smoking restrictions for the recreational venues were Dao. Within each of these Jie Dao, two residential blocks (Ju assessed by asking: ‘‘Which of the following best describes the Wei Hui) were selected, again with probability of selection rules about smoking in indoor entertainment places such as proportional to the population size of the Ju Wei Hui, from restaurants, coffee shops, and karaoke lounges that you go most which a city-identified list of family households was used to often?’’ Response options include: (1) smoking is not allowed in sample 300 dwelling units (households) from every Ju Wei Hui any indoor areas; (2) smoking is allowed only in some indoor using a simple random sampling method without replacement. areas; and (3) no rules or restrictions. Information on age, gender and smoking status for all adults living in these 300 households was collected. The enumerated 300 households were then randomly ordered, and individuals 18 Support for smoking restrictions years or older who had smoked at least 100 cigarettes in their Support for smoking restrictions for these venues were http://tobaccocontrol.bmj.com/ lifetime were then approached following the randomised order established by asking: ‘‘For the restaurants or bars venues, until 40 adult smokers were surveyed. To increase the sample please tell me if you think smoking should be allowed in all size