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Preplanned Studies: Tobacco Use and Exposure Among Secondary School Students — China, 2019

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  • Summary

    What is already known about this topic?

    Using the framework of the global youth tobacco survey (GYTS), China CDC conducted the first round of a national tobacco survey among junior high school (JHS) students in 2014, indicating that 17.9% and 5.9% of respondents were experimental and current cigarette smokers, respectively.

    What is added by this report?

    China CDC implemented a second round of the survey in 2019 and included senior high school (SHS) and vocational senior high school (VSHS) students. Experimental and current cigarette use was much higher among VSHS (30.3%, 14.7%) and SHS (21.6%, 5.6%) students than in JHS students (12.9%, 3.9%). Minors being able to buy cigarettes without refusal, tobacco advertisements and promotions on movies, TV, and at retail outlets, parents smoking, and teacher smoking in school were also widely prevalent.

    What are the implications for public health practice?

    Despite positive changes from 2014 to 2019, the external factors compelling teenagers to smoke were extensive. The priority for tobacco control among secondary school students should be strengthening the implementation of existing laws and regulations and developing targeted policies and measures for VSHS.

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    [4] Xiao L, Feng GZ, Jiang Y, Zhang JR, Liu LX. Tobacco use rate and associated factors in middle school students in China. Chin J Epidemiol 2017;38(5):567 − 71. http://dx.doi.org/10.3760/cma.j.issn.0254-6450.2017.05.002 (In Chinese)CrossRef
    [5] Owens DK, Davidson KW, Krist AH, Barry MJ, Cabana M, Caughey AB, et al. Primary care interventions for prevention and cessation of tobacco use in children and adolescents: US preventive services task force recommendation statement. JAMA 2020;323(16):1590 − 98. http://dx.doi.org/10.1001/jama.2020.4679CrossRef
    [6] D’angelo D, Ahluwalia IB, Pun E, Yin S, Palipudi K, Mbulo L. Current cigarette smoking, access, and purchases from retail outlets among students aged 13-15 years-global youth tobacco survey, 45 countries, 2013 and 2014. MMWR Morb Mortal Wkly Rep 2016;65(34):898 − 901. http://dx.doi.org/10.15585/mmwr.mm6534a3CrossRef
    [7] Ministry of education and the Ministry of Health. Opinions on further strengthening school smoking control. 2010. http://www.gov.cn/gzdt/2010-07/13/content_1653147.htm.http://www.gov.cn/gzdt/2010-07/13/content_1653147.htm
    [8] Li XH, Galea G. Healthy China 2030: an opportunity for tobacco control. Lancet 2019;394(10204):1123 − 25. http://dx.doi.org/10.1016/S0140-6736(19)32048-3CrossRef
    [9] Administration National Radio and Television. Circular on strict control of smoking scenes in films and TV plays. 2011. (In Chinese). http://www.sapprft.gov.cn/sapprft/govpublic/10553/333004.shtml. (In Chinese). [2020-05-04].http://www.sapprft.gov.cn/sapprft/govpublic/10553/333004.shtml
    [10] Sinha DN, Palipudi KM, Oswal K, Gupta PC, Andes LJ, Asma S. Influence of tobacco industry advertisements and promotions on tobacco use in India: findings from the Global Adult Tobacco Survey 2009-2010. Indian J Cancer 2014;51(S1):S13 − 8. http://dx.doi.org/10.4103/0019-509X.147424. [2020-05-06]http://dx.doi.org/10.4103/0019-509X.147424
  • FIGURE 1.  Regional disparities in the proportion of experimental smoker and current smoker among secondary school students in China, 2019. (A) Proportion of experimental smoker (junior high school students); (B) Proportion of experimental smoker (senior high school students); (C) Proportion of experimental smoker (vocational senior high school students); (D) Proportion of current smoker (junior high school students); (E) Proportion of current smoker (senior high school students); (F) Proportion of current smoker (vocational senior high school students).

    TABLE 1.  Experimental and current cigarette use among secondary high school students in China, 2019.

    Characteristic
    (age in median)
    TotalUrbanRural
    Experimental smokersCurrent smokersExperimental smokersCurrent smokersExperimental smokersCurrent smokers
    N% (95% CI)*N% (95% CI)N% (95% CI)N% (95% CI)N% (95% CI)N% (95% CI)
    Both
    Overall (15 years old)282,42117.9(17.1−18.8)286,4555.9(5.5−6.4)150,42115.1(14.0−16.3)152,3025.0(4.2−5.8)132,00019.7(18.5−20.9)134,1536.5(5.9−7.2)
    Junior high school (14 years old)144,56612.9(12.0−13.9)146,4513.9(3.4−4.4) 76,1789.0(8.1−9.9) 77,0062.3(1.9−2.6) 68,38815.2(13.9−16.6) 69,4454.8(4.1−5.6)
    Senior high school (16 years old)104,34221.6(20.4−22.8)105,8685.6(5.1−6.1) 56,90817.7(16.4−19.0) 57,6794.1(3.5−4.7) 47,43423.9(22.3−25.6) 48,1896.4(5.7−7.1)
    Vocational senior high school (17 years old) 33,51330.3(27.7−32.9) 34,13614.7(12.7−16.6) 17,33529.6(25.1−34.2) 17,61714.5(10.8−18.1) 16,17830.9(28.1−33.6) 16,51914.8(12.9−16.7)
    Males
    Overall (15 years old)141,56826.0(24.8−27.3)143,9859.6(8.8−10.4) 75,58121.5(19.8−23.2) 76,7248.0(6.7−9.3) 65,98728.9(27.1−30.6) 67,26110.6(9.6−11.6)
    Junior high school (14 years old) 74,76617.9(16.6−19.2) 75,8975.8(5.0−6.5) 39,50112.1(10.9−13.4) 40,0063.2(2.7−3.8) 35,26521.2(19.3−23.1) 35,8917.2(6.1−8.4)
    Senior high school (16 years old) 49,30633.6(31.9−35.2) 50,23310.0(9.1−10.8) 27,15326.5(24.5−28.4) 27,6367.1(6.1−8.1) 22,15337.7(35.6−39.9) 22,59711.6(10.4−12.8)
    Vocational senior high school (17 years old) 17,49643.2(39.7−46.6) 17,85523.3(20.3−26.3) 8,92741.5(35.4−47.5) 9,08222.7(17.3−28.2) 8,56944.7(41.1−48.4) 8,77323.8(20.9−26.7)
    Females
    Overall (15 years old)140,8539.1(8.5−9.7)142,4701.9(1.7−2.1) 74,8408.1(7.5−8.7) 75,5781.6(1.4−1.9) 66,0139.7(8.8−10.6) 66,8922.1(1.8−2.4)
    Junior high school (14 years old) 69,8007.2(6.5−7.9) 70,5541.8(1.5−2.1) 36,6775.3(4.7−5.9) 37,0001.1(0.9−1.3) 33,1238.3(7.3−9.4) 33,5542.1(1.7−2.6)
    Senior high school (16 years old) 55,03610.2(9.4−11.0) 55,6351.4(1.1−1.6) 29,7559.3(8.4−10.1) 30,0431.2(1.0−1.4) 25,28110.7(9.5−12.0) 25,5921.4(1.1−1.8)
    Vocational senior high school (16 years old) 16,01714.0(12.3−15.7) 16,2813.7(2.9−4.4) 8,40814.6(12.1−17.2) 8,5354.0(2.8−5.2) 7,60913.4(11.2−15.6) 7,7463.4(2.5−4.2)
    *Abbreviation: CI=confidence intervals.
    Download: CSV

    TABLE 2.  Cigarette availability, advertisements and promotion, and smoking exposure among secondary high school students in China, 2019.

    RegionVariableTotalJunior high schoolSenior high schoolVocational senior high school
    N% (95% CI)N% (95% CI)N% (95% CI)N% (95% CI)
    TotalBoth
    Buying cigarettes as a minor without rejection*9,10883.3(82.0−84.6)3,12876.5(74.1−79.0)3,15287.6(86.0−89.2)2,82887.6(85.6−89.5)
    Buying cigarettes individually by stick11,0879.2(7.3−11.1)3,17616.2(12.1−20.3)4,2438.8(6.7−10.8)3,6683.7(2.5−4.9)
    Tobacco advertisements and promotions at retail outlets§69,55446.4(45.3−47.5)31,91748.9(47.5−50.2)26,41542.0(40.3−43.6)11,22246.7(44.8−48.7)
    Tobacco advertisements and promotions on the internet230,19223.4(22.8−23.9)111,30823.2(22.6−23.9)88,87221.4(20.6−22.1)30,01227.7(26.5−28.9)
    Tobacco advertisements and promotions on movies, TV, or videos**228,26271.7(71.0−72.3)116,41769.5(68.8−70.2)83,69972.9(71.9−73.9)28,14677.4(75.8−78.9)
    Free tobacco products provided by tobacco industry††287,8812.1(2.0−2.3)147,1062.0(1.8−2.2)106,3282.1(1.9−2.2)34,4472.8(2.4−3.1)
    Parents smoke§§288,12654.2(53.2−55.1)147,23552.8(51.6−53.9)106,40954.4(53.2−55.6)34,48259.2(57.6−60.8)
    Teacher smokes in school¶¶288,11846.9(45.3−48.5)147,22442.6(40.9−44.2)106,41154.0(51.8−56.3)34,48349.6(46.1−53.1)
    Males
    Buying cigarettes as a minor without rejection*7,65883.0(81.6−84.4)2,47275.4(72.8−78.0)2,71887.3(85.6−88.9)2,46887.3(85.1−89.5)
    Buying cigarettes individually by stick9,4629.0(7.2−10.9)2,51316.6(12.6−20.6)3,7189.1(6.9−11.2)3,2313.5(2.4−4.6)
    Tobacco advertisements and promotions at retail outlets§39,28945.2(44.1−46.4)17,83249.1(47.6−50.5)14,55438.8(37.2−40.4)6,90345.2(42.6−47.7)
    Tobacco advertisements and promotions on the internet115,89124.2(23.5−24.8)57,58824.0(23.3−24.8)42,46522.0(21.2−22.7)15,83828.2(26.4−30.0)
    Tobacco advertisements and promotions on movies, TV, or videos**115,69476.8(76.2−77.4)60,82574.1(73.3−74.9)40,19079.0(78.1−79.9)14,67983.0(81.5−84.4)
    Free tobacco products provided by tobacco industry††145,0642.7(2.5−2.9)76,3932.5(2.2−2.7)50,5702.7(2.4−2.9)18,1013.8(3.2−4.3)
    Parents smoke§§145,20653.9(53.0−54.9)76,47052.7(51.5−53.8)50,61053.8(52.4−55.1)18,12658.7(56.8−60.6)
    Teacher smokes in school¶¶145,19951.1(49.5−52.7)76,46145.9(44.1−47.6)50,61359.5(57.2−61.9)18,12555.7(51.9−59.5)
    Females
    Buying cigarettes as a minor without rejection*1,45085.2(82.3−88.1)65681.1(76.6−85.7)43489.6(85.1−94.1)36089.8(84.6−95.1)
    Buying cigarettes individually by stick1,62510.3(7.1−13.4)66314.6(9.1−20.1)5256.4(3.6−9.2)4376.0(1.9−10.2)
    Tobacco advertisements and promotions at retail outlets§30,26548.0(46.5−49.5)14,08548.6(46.8−50.4)11,86146.2(43.7−48.6)4,31949.7(46.5−52.8)
    Tobacco advertisements and promotions on the internet114,30122.5(21.9−23.1)53,72022.3(21.6−23.0)46,40720.8(19.8−21.7)14,17427.0(25.5−28.6)
    Tobacco advertisements and promotions on movies, TV, or videos**112,56865.9(65.1−66.7)55,59264.2(63.4−65.1)43,50966.9(65.6−68.2)13,46770.3(68.4−72.2)
    Free tobacco products provided by tobacco industry††142,8171.5(1.3−1.6)70,7131.5(1.3−1.6)55,7581.4(1.3−1.6)16,3461.5(1.2−1.8)
    Parents smoke§§142,92054.5(53.4−55.5)70,76552.9(51.6−54.2)55,79955.0(53.8−56.3)16,35659.9(57.9−61.9)
    Teacher smokes in school¶¶142,91942.2(40.6−43.9)70,76338.7(37.1−40.4)55,79848.7(46.4−51.0)16,35841.8(37.9−45.6)
    UrbanBoth
    Buying cigarettes as a minor without rejection*4,23484.1(82.2−86.0)1,20375.9(72.6−79.2)1,63987.1(84.6−89.5)1,39286.8(84.0−89.6)
    Buying cigarettes individually by stick5,1254.6(3.1−6.2)1,21410.7(7.4−13.9)2,1355.4(3.6−7.2)1,7762.0(0.7−3.3)
    Tobacco advertisements and promotions at retail outlets§34,75646.8(45.3−48.2)15,53449.4(47.8−51.0)13,52141.2(39.5−42.9)5,70148.0(44.9−51.2)
    Tobacco advertisements and promotions on the internet124,05422.7(22.0−23.4)59,35821.8(21.1−22.5)49,05320.3(19.5−21.2)15,64328.4(26.4−30.3)
    Tobacco advertisements and promotions on movies, TV, or videos**120,18569.5(68.5−70.4)60,16866.5(65.4−67.5)45,48970.3(69.3−71.4)14,52876.6(74.0−79.2)
    Free tobacco products provided by tobacco industry††152,8852.1(2.0−2.2)77,2281.9(1.8−2.1)57,8862.1(1.9−2.3)17,7712.7(2.1−3.3)
    Parents smoke§§153,02852.1(50.7−53.5)77,30449.8(48.2−51.4)57,92852.3(50.5−54.1)17,79658.8(56.7−60.9)
    Teacher smokes in school¶¶153,02537.7(35.4−40.0)77,29932.7(30.3−35.1)57,93145.4(42.1−48.7)17,79540.5(35.7−45.3)
    Males
    Buying cigarettes as a minor without rejection*3,45584.0(81.7−86.3)91374.8(70.8−78.9)1,36086.5(84.2−88.9)1,18286.8(83.4−90.1)
    Buying cigarettes individually by stick4,2524.6(3.0−6.2)91911.8(8.4−15.3)1,8115.6(3.6−7.5)1,5221.9(0.5−3.3)
    Tobacco advertisements and promotions at retail outlets§19,37646.0(44.2−47.9)8,59248.9(47.0−50.8)7,38838.5(36.3−40.8)3,39648.3(44.0−52.6)
    Tobacco advertisements and promotions on the internet62,29824.0(23.0−25.0)30,66922.6(21.7−23.5)23,53521.3(20.4−22.2)8,09430.5(27.4−33.6)
    Tobacco advertisements and promotions on movies, TV, or videos**61,05575.2(74.2−76.2)31,60871.4(70.3−72.6)22,00077.1(76.0−78.2)7,44782.8(80.5−85.2)
    Free tobacco products provided by tobacco industry††77,1552.7(2.5−2.9)40,1792.4(2.1−2.6)27,7752.9(2.5−3.3)9,2013.6(2.6−4.6)
    Parents smoke§§77,24452.0(50.5−53.5)40,22749.9(48.1−51.8)27,80151.4(49.6−53.3)9,21658.7(55.7−61.6)
    Teacher smokes in school¶¶77,24141.7(39.2−44.2)40,22435.6(33.1−38.2)27,80250.3(46.6−53.9)9,21547.3(41.4−53.2)
    Females
    Buying cigarettes as a minor without rejection*77984.7(81.2−88.2)29079.5(74.9−84.1)27989.7(82.6−96.8)21087.2(78.5−95.9)
    Buying cigarettes individually by stick8734.8(2.8−6.8)2956.9(3.3−10.5)3244.7(1.8−7.5)2542.9(0.1−5.7)
    Tobacco advertisements and promotions at retail outlets§15,38047.9(46.3−49.4)6,94250.1(48.3−51.8)6,13344.5(42.6−46.5)2,30547.4(43.8−51.1)
    Tobacco advertisements and promotions on the internet61,75621.3(20.4−22.1)28,68920.8(20.0−21.7)25,51819.4(18.3−20.5)7,54925.5(23.2−27.9)
    Tobacco advertisements and promotions on movies, TV, or videos**59,13062.9(61.9−64.0)28,56060.6(59.4−61.8)23,48963.6(62.3−64.9)7,08168.7(66.1−71.3)
    Free tobacco products provided by tobacco industry††75,7301.4(1.2−1.6)37,0491.4(1.2−1.6)30,1111.3(1.1−1.5)8,5701.5(1.0−2.0)
    Parents smoke§§75,78452.3(50.8−53.7)37,07749.7(48.2−51.2)30,12753.1(51.1−55.2)8,58058.9(56.4−61.5)
    Teacher smokes in school¶¶75,78433.2(30.9−35.4)37,07529.3(26.9−31.8)30,12940.7(37.5−43.9)8,58031.8(27.8−35.7)
    RuralBoth
    Buying cigarettes as a minor without rejection*4,87482.9(81.2−84.6)1,92576.7(73.7−79.7)1,51387.8(85.7−89.8)1,43688.3(85.6−90.9)
    Buying cigarettes individually by stick5,96211.5(8.9−14.1)1,96217.8(12.6−23.0)2,10810.1(7.4−12.7)1,8925.2(3.5−7.0)
    Tobacco advertisements and promotions at retail outlets§34,79846.2(44.6−47.7)16,38348.6(46.8−50.4)12,89442.3(40.1−44.6)5,52145.5(43.3−47.8)
    Tobacco advertisements and promotions on the internet106,13823.8(23.0−24.6)51,95024.1(23.1−25.0)39,81922.0(20.9−23.1)14,36927.0(25.7−28.4)
    Tobacco advertisements and promotions on movies, TV, or videos**108,07773.0(72.2−73.8)56,24971.2(70.3−72.1)38,21074.4(73.0−75.8)13,61878.1(76.3−79.9)
    Free tobacco products provided by tobacco industry††134,9962.1(2.0−2.3)69,8782.0(1.8−2.3)48,4422.0(1.8−2.3)16,6762.8(2.4−3.3)
    Parents smoke§§135,09855.4(54.2−56.7)69,93154.5(52.9−56.0)48,48155.6(54.1−57.2)16,68659.6(57.3−61.9)
    Teacher smokes in school¶¶135,09352.6(50.7−54.5)69,92548.2(46.1−50.2)48,48059.0(56.2−61.8)16,68857.9(53.9−61.9)
    Males
    Buying cigarettes as a minor without rejection*4,20382.5(80.7−84.2)1,55975.6(72.5−78.7)1,35887.6(85.4−89.7)1,28687.8(85.0−90.7)
    Buying cigarettes individually by stick5,21011.2(8.7−13.8)1,59417.9(12.9−22.8)1,90710.3(7.5−13.1)1,7094.9(3.4−6.4)
    Tobacco advertisements and promotions at retail outlets§19,91344.8(43.3−46.4)9,24049.1(47.3−51.0)7,16638.9(36.8−41.0)3,50742.3(39.8−44.7)
    Tobacco advertisements and promotions on the internet53,59324.3(23.4−25.2)26,91924.9(23.8−25.9)18,93022.4(21.3−23.4)7,74425.9(24.4−27.5)
    Tobacco advertisements and promotions on movies, TV, or videos**54,63977.8(77.0−78.6)29,21775.6(74.5−76.7)18,19080.1(78.9−81.2)7,23283.1(81.4−84.7)
    Free tobacco products provided by tobacco industry††67,9092.7(2.4−3.0)36,2142.5(2.2−2.9)22,7952.6(2.2−2.9)8,9003.9(3.2−4.6)
    Parents smoke§§67,96255.1(53.9−56.3)36,24354.3(52.8−55.7)22,80955.2(53.4−57.0)8,91058.7(56.2−61.2)
    Teacher smokes in school¶¶67,95856.9(55.1−58.7)36,23751.7(49.6−53.9)22,81164.9(62.1−67.7)8,91063.4(59.5−67.3)
    Females
    Buying cigarettes as a minor without rejection*67185.5(81.5−89.5)36681.8(75.8−87.7)15589.6(83.7−95.4)15092.2(86.7−97.6)
    Buying cigarettes individually by stick75213.3(8.5−18.1)36817.5(9.9−25.0)2017.5(3.3−11.6)1839.0(1.3−16.7)
    Tobacco advertisements and promotions at retail outlets§14,88548.1(45.9−50.2)7,14347.8(45.3−50.3)5,72847.0(43.4−50.5)2,01451.8(46.8−56.8)
    Tobacco advertisements and promotions on the internet52,54523.3(22.4−24.2)25,03123.2(22.1−24.2)20,88921.6(20.3−23.0)6,62528.4(26.4−30.4)
    Tobacco advertisements and promotions on movies, TV, or videos**53,43867.7(66.6−68.7)27,03266.2(65.1−67.3)20,02068.8(67.0−70.6)6,38671.8(69.0−74.5)
    Free tobacco products provided by tobacco industry††67,0871.5(1.4−1.6)33,6641.5(1.3−1.6)25,6471.5(1.3−1.8)7,7761.5(1.1−1.9)
    Parents smoke§§67,13655.8(54.4−57.3)33,68854.7(52.9−56.5)25,67256.1(54.5−57.7)7,77660.8(57.8−63.8)
    Teacher smokes in school¶¶67,13547.8(45.7−49.9)33,68844.1(42.0−46.2)25,66953.3(50.3−56.3)7,77850.9(45.7−56.1)
    * In the past 30 days before the date of investigation, current smokers had not experienced being refused due to age when buying cigarettes;
    In the past 30 days before the date of investigation, the current smokers had bought cigarettes individually by stick for themselves;
    § In the past 30 days before the date of investigation, students had seen tobacco advertisements and promotions at retail outlets;
    In the past 30 days before the date of investigation, the students had seen tobacco advertisements or video on the internet;
    ** In the past 30 days before the date of investigation, the students had seen smoking scenes on movies, TV, or videos;
    †† The students have been offered free tobacco products by the tobacco industry;
    §§ At least one of parents is smoker;
    ¶¶ The students had seen a teacher smoke in school during school hours.
    Abbreviation: CI=confidence intervals.
    Download: CSV

Citation:

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Tobacco Use and Exposure Among Secondary School Students — China, 2019

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Summary

What is already known about this topic?

Using the framework of the global youth tobacco survey (GYTS), China CDC conducted the first round of a national tobacco survey among junior high school (JHS) students in 2014, indicating that 17.9% and 5.9% of respondents were experimental and current cigarette smokers, respectively.

What is added by this report?

China CDC implemented a second round of the survey in 2019 and included senior high school (SHS) and vocational senior high school (VSHS) students. Experimental and current cigarette use was much higher among VSHS (30.3%, 14.7%) and SHS (21.6%, 5.6%) students than in JHS students (12.9%, 3.9%). Minors being able to buy cigarettes without refusal, tobacco advertisements and promotions on movies, TV, and at retail outlets, parents smoking, and teacher smoking in school were also widely prevalent.

What are the implications for public health practice?

Despite positive changes from 2014 to 2019, the external factors compelling teenagers to smoke were extensive. The priority for tobacco control among secondary school students should be strengthening the implementation of existing laws and regulations and developing targeted policies and measures for VSHS.

  • 1. Tobacco Control Office, Chinese Center for Disease Control and Prevention, Beijing, China
  • 2. Chinese Center for Disease Control and Prevention, Beijing, China
  • Corresponding authors:

    Lin Xiao, xiaolin@chinacdc.cn

    Xinhua Li, lixinhua@chinacdc.cn

    Online Date: May 29 2020
    doi: 10.46234/ccdcw2020.100
  • Using the framework of the global youth tobacco survey (GYTS), China CDC conducted the first round of tobacco survey among junior high school (JHS) students with a nationally and provincially representative sample in 2014 (2014 youth survey). A three-stage stratified cluster random sampling design was used in the survey. The selection of survey points (districts and counties) from each provincial-level administrative division (PLAD) of the mainland of China in the first stage and JHSs from each survey point in the second stage were implemented using a proportionate to population size sampling scheme (PPS), and students were randomly sampled in the third stage. The data was collected by students answering paper-based questionnaires, and 155,117 respondents were analyzed in total (total (1). To continuously provide evidence for policy-making and evaluation, China CDC implemented the second round of the epidemiological survey in 2019, in which the senior high school (SHS) and vocational senior high school (VSHS) students were included for the first time (2019 teenager survey). In this study, we report selected main findings of the 2019 teenager survey as relevant to cigarette smoking, availability, tobacco advertisements and promotion, and smoking exposure.

    A method of multistage stratified cluster random sampling was also applied in the 2019 teenager survey. First, 5 districts (for urban areas) and 5 counties (for rural areas) were selected in each PLAD of the mainland of China by PPS. Second, 3 JHSs, 2 SHSs, and 1 VSHS in each participating district/county were also selected using the PPS method. Both private and public schools were included in the original sampling frame and each school must have had more than 40 students otherwise it would be excluded. Third, one class in each grade of a selected school was randomly identified and all the students in the class were investigated. The sampling was carried out by the China CDC in coordination with local health and education authorities.

    Standardized paper-based questionnaires were distributed to students by trained investigators during school hours and centrally but independently completed by students with no teachers present. The quality controllers checked the completeness of all finished questionnaires. The provincial supervisors randomly selected 5% of respondents in each district or county and re-investigated using parts of the questionnaire to examine the accuracy. The subsequent data entry was completed by a professional company, and the entry quality (<5/10,000 error rate) was guaranteed by sampling checks. The data were further processed by accounting for missing data, outlier values, and logic mistakes for final utilization.

    Questions included primary information (school, grade, class and individual), cigarette use, addiction, cessation, e-cigarette, secondhand smoke exposure, tobacco availability, price, tobacco advertisements and promotion, smoking cognition and attitude, and tobacco control propaganda. Experimental smokers (ES) were those who had smoked cigarettes in the past including those who may have taken only one or two puffs. Current smokers (CS) were those who had smoked a cigarette at least one day in the past 30 days.

    Weighting strategies based on a complex sampling design were applied to parameter estimation (2). Point values and 95% confidence intervals (CI) for each parameter were calculated and reported in this study. The difference of values with no overlap in CI is identified to be statistically significant between subgroups. All analyses were done with SAS (version 9.4; SAS Institute, Inc. Cary, NC, USA).

    A total of 288,192 students participated in the survey, including 147,270 JHS students, 106,432 SHS students, and 34,490 VSHS students. The overall response rate was 94.8%.

    ES prevalence rate among secondary school students was 17.9%, with 12.9%, 21.6%, and 30.3% for JHS, SHS, and VSHS students, respectively, and higher rates in male students (17.9%, 33.6%, and 43.2%) than in female students (7.2%, 10.2%, and 14.0%), respectively. The overall CS prevalence rate was 5.9% and the highest was observed among VSHS students (14.7%), and then SHS (5.6%) and JHS (3.9%) students with higher rates in male students (23.3%, 10.0%, and 5.8%) than in female students (3.7%, 1.4%, and 1.8%). For both ES and CS, the prevalence rates were higher in rural areas than in urban areas for JHS and SHS mainly among male students; VSHS showed no statistical differences. Significant regional disparities were present between schools for both ES and CS. High ES and CS were mainly from PLADs of the Southwest (Tibet, Yunnan, and Guizhou), as well as Hunan and Qinghai for JHS and SHS. Comparatively, the ES and CS prevalence rates were higher in the Southwest (Yunnan and Guizhou) and the North (Heilongjiang, Inner Mongolia) for VSHS. (Table 1, Figure 1)

    Characteristic
    (age in median)
    TotalUrbanRural
    Experimental smokersCurrent smokersExperimental smokersCurrent smokersExperimental smokersCurrent smokers
    N% (95% CI)*N% (95% CI)N% (95% CI)N% (95% CI)N% (95% CI)N% (95% CI)
    Both
    Overall (15 years old)282,42117.9(17.1−18.8)286,4555.9(5.5−6.4)150,42115.1(14.0−16.3)152,3025.0(4.2−5.8)132,00019.7(18.5−20.9)134,1536.5(5.9−7.2)
    Junior high school (14 years old)144,56612.9(12.0−13.9)146,4513.9(3.4−4.4) 76,1789.0(8.1−9.9) 77,0062.3(1.9−2.6) 68,38815.2(13.9−16.6) 69,4454.8(4.1−5.6)
    Senior high school (16 years old)104,34221.6(20.4−22.8)105,8685.6(5.1−6.1) 56,90817.7(16.4−19.0) 57,6794.1(3.5−4.7) 47,43423.9(22.3−25.6) 48,1896.4(5.7−7.1)
    Vocational senior high school (17 years old) 33,51330.3(27.7−32.9) 34,13614.7(12.7−16.6) 17,33529.6(25.1−34.2) 17,61714.5(10.8−18.1) 16,17830.9(28.1−33.6) 16,51914.8(12.9−16.7)
    Males
    Overall (15 years old)141,56826.0(24.8−27.3)143,9859.6(8.8−10.4) 75,58121.5(19.8−23.2) 76,7248.0(6.7−9.3) 65,98728.9(27.1−30.6) 67,26110.6(9.6−11.6)
    Junior high school (14 years old) 74,76617.9(16.6−19.2) 75,8975.8(5.0−6.5) 39,50112.1(10.9−13.4) 40,0063.2(2.7−3.8) 35,26521.2(19.3−23.1) 35,8917.2(6.1−8.4)
    Senior high school (16 years old) 49,30633.6(31.9−35.2) 50,23310.0(9.1−10.8) 27,15326.5(24.5−28.4) 27,6367.1(6.1−8.1) 22,15337.7(35.6−39.9) 22,59711.6(10.4−12.8)
    Vocational senior high school (17 years old) 17,49643.2(39.7−46.6) 17,85523.3(20.3−26.3) 8,92741.5(35.4−47.5) 9,08222.7(17.3−28.2) 8,56944.7(41.1−48.4) 8,77323.8(20.9−26.7)
    Females
    Overall (15 years old)140,8539.1(8.5−9.7)142,4701.9(1.7−2.1) 74,8408.1(7.5−8.7) 75,5781.6(1.4−1.9) 66,0139.7(8.8−10.6) 66,8922.1(1.8−2.4)
    Junior high school (14 years old) 69,8007.2(6.5−7.9) 70,5541.8(1.5−2.1) 36,6775.3(4.7−5.9) 37,0001.1(0.9−1.3) 33,1238.3(7.3−9.4) 33,5542.1(1.7−2.6)
    Senior high school (16 years old) 55,03610.2(9.4−11.0) 55,6351.4(1.1−1.6) 29,7559.3(8.4−10.1) 30,0431.2(1.0−1.4) 25,28110.7(9.5−12.0) 25,5921.4(1.1−1.8)
    Vocational senior high school (16 years old) 16,01714.0(12.3−15.7) 16,2813.7(2.9−4.4) 8,40814.6(12.1−17.2) 8,5354.0(2.8−5.2) 7,60913.4(11.2−15.6) 7,7463.4(2.5−4.2)
    *Abbreviation: CI=confidence intervals.

    Table 1.  Experimental and current cigarette use among secondary high school students in China, 2019.

    Figure 1.  Regional disparities in the proportion of experimental smoker and current smoker among secondary school students in China, 2019. (A) Proportion of experimental smoker (junior high school students); (B) Proportion of experimental smoker (senior high school students); (C) Proportion of experimental smoker (vocational senior high school students); (D) Proportion of current smoker (junior high school students); (E) Proportion of current smoker (senior high school students); (F) Proportion of current smoker (vocational senior high school students).

    Overall, among students who had experienced the following scenarios in the 30 days before the date of investigation, 76.5% of CS from JHS reported that they had not been rejected for attempting to buy cigarettes as minors under the age of 18 years, which was lower than those from SHS (87.6%) and VSHS (87.6%). The proportion of CS buying cigarettes by stick was 16.2%, 8.8%, and 3.7% for JHS, SHS, and VSHS, respectively, and was much higher in rural than in urban areas. Approximately 2.8 % of VSHS students reported they had even been offered free tobacco products by the tobacco industry, which was higher than in JHS and SHS students (2.0%) and higher in male students than in female students. Approximately 48.9% and 46.7% of respondents from JHS and VSHS, respectively, reported they had seen advertisements and promotions at retail outlets, which was higher than those from SHS (42.0%). Nearly a quarter of respondents had seen tobacco advertisements and promotions on the internet with the highest being VSHS students (27.7%), and the differences between genders and between urban-rural areas only appeared in JHS students. The proportions of respondents having seen smoking scenes on movies, TV, or videos were 69.5%, 72.9%, and 77.4% among students from JHS, SHS, and VSHS, respectively (Table 2). In addition, over half of the students reported that at least one of their parents is a smoker, and this was higher in rural areas than in urban areas for JHS and SHS. About half of SHS and VSHS students and 42.6% of JHS students had seen a teacher smoke in school. The proportions were higher in male students than in female students, and higher in rural areas than in urban areas. (Table 2)

    RegionVariableTotalJunior high schoolSenior high schoolVocational senior high school
    N% (95% CI)N% (95% CI)N% (95% CI)N% (95% CI)
    TotalBoth
    Buying cigarettes as a minor without rejection*9,10883.3(82.0−84.6)3,12876.5(74.1−79.0)3,15287.6(86.0−89.2)2,82887.6(85.6−89.5)
    Buying cigarettes individually by stick11,0879.2(7.3−11.1)3,17616.2(12.1−20.3)4,2438.8(6.7−10.8)3,6683.7(2.5−4.9)
    Tobacco advertisements and promotions at retail outlets§69,55446.4(45.3−47.5)31,91748.9(47.5−50.2)26,41542.0(40.3−43.6)11,22246.7(44.8−48.7)
    Tobacco advertisements and promotions on the internet230,19223.4(22.8−23.9)111,30823.2(22.6−23.9)88,87221.4(20.6−22.1)30,01227.7(26.5−28.9)
    Tobacco advertisements and promotions on movies, TV, or videos**228,26271.7(71.0−72.3)116,41769.5(68.8−70.2)83,69972.9(71.9−73.9)28,14677.4(75.8−78.9)
    Free tobacco products provided by tobacco industry††287,8812.1(2.0−2.3)147,1062.0(1.8−2.2)106,3282.1(1.9−2.2)34,4472.8(2.4−3.1)
    Parents smoke§§288,12654.2(53.2−55.1)147,23552.8(51.6−53.9)106,40954.4(53.2−55.6)34,48259.2(57.6−60.8)
    Teacher smokes in school¶¶288,11846.9(45.3−48.5)147,22442.6(40.9−44.2)106,41154.0(51.8−56.3)34,48349.6(46.1−53.1)
    Males
    Buying cigarettes as a minor without rejection*7,65883.0(81.6−84.4)2,47275.4(72.8−78.0)2,71887.3(85.6−88.9)2,46887.3(85.1−89.5)
    Buying cigarettes individually by stick9,4629.0(7.2−10.9)2,51316.6(12.6−20.6)3,7189.1(6.9−11.2)3,2313.5(2.4−4.6)
    Tobacco advertisements and promotions at retail outlets§39,28945.2(44.1−46.4)17,83249.1(47.6−50.5)14,55438.8(37.2−40.4)6,90345.2(42.6−47.7)
    Tobacco advertisements and promotions on the internet115,89124.2(23.5−24.8)57,58824.0(23.3−24.8)42,46522.0(21.2−22.7)15,83828.2(26.4−30.0)
    Tobacco advertisements and promotions on movies, TV, or videos**115,69476.8(76.2−77.4)60,82574.1(73.3−74.9)40,19079.0(78.1−79.9)14,67983.0(81.5−84.4)
    Free tobacco products provided by tobacco industry††145,0642.7(2.5−2.9)76,3932.5(2.2−2.7)50,5702.7(2.4−2.9)18,1013.8(3.2−4.3)
    Parents smoke§§145,20653.9(53.0−54.9)76,47052.7(51.5−53.8)50,61053.8(52.4−55.1)18,12658.7(56.8−60.6)
    Teacher smokes in school¶¶145,19951.1(49.5−52.7)76,46145.9(44.1−47.6)50,61359.5(57.2−61.9)18,12555.7(51.9−59.5)
    Females
    Buying cigarettes as a minor without rejection*1,45085.2(82.3−88.1)65681.1(76.6−85.7)43489.6(85.1−94.1)36089.8(84.6−95.1)
    Buying cigarettes individually by stick1,62510.3(7.1−13.4)66314.6(9.1−20.1)5256.4(3.6−9.2)4376.0(1.9−10.2)
    Tobacco advertisements and promotions at retail outlets§30,26548.0(46.5−49.5)14,08548.6(46.8−50.4)11,86146.2(43.7−48.6)4,31949.7(46.5−52.8)
    Tobacco advertisements and promotions on the internet114,30122.5(21.9−23.1)53,72022.3(21.6−23.0)46,40720.8(19.8−21.7)14,17427.0(25.5−28.6)
    Tobacco advertisements and promotions on movies, TV, or videos**112,56865.9(65.1−66.7)55,59264.2(63.4−65.1)43,50966.9(65.6−68.2)13,46770.3(68.4−72.2)
    Free tobacco products provided by tobacco industry††142,8171.5(1.3−1.6)70,7131.5(1.3−1.6)55,7581.4(1.3−1.6)16,3461.5(1.2−1.8)
    Parents smoke§§142,92054.5(53.4−55.5)70,76552.9(51.6−54.2)55,79955.0(53.8−56.3)16,35659.9(57.9−61.9)
    Teacher smokes in school¶¶142,91942.2(40.6−43.9)70,76338.7(37.1−40.4)55,79848.7(46.4−51.0)16,35841.8(37.9−45.6)
    UrbanBoth
    Buying cigarettes as a minor without rejection*4,23484.1(82.2−86.0)1,20375.9(72.6−79.2)1,63987.1(84.6−89.5)1,39286.8(84.0−89.6)
    Buying cigarettes individually by stick5,1254.6(3.1−6.2)1,21410.7(7.4−13.9)2,1355.4(3.6−7.2)1,7762.0(0.7−3.3)
    Tobacco advertisements and promotions at retail outlets§34,75646.8(45.3−48.2)15,53449.4(47.8−51.0)13,52141.2(39.5−42.9)5,70148.0(44.9−51.2)
    Tobacco advertisements and promotions on the internet124,05422.7(22.0−23.4)59,35821.8(21.1−22.5)49,05320.3(19.5−21.2)15,64328.4(26.4−30.3)
    Tobacco advertisements and promotions on movies, TV, or videos**120,18569.5(68.5−70.4)60,16866.5(65.4−67.5)45,48970.3(69.3−71.4)14,52876.6(74.0−79.2)
    Free tobacco products provided by tobacco industry††152,8852.1(2.0−2.2)77,2281.9(1.8−2.1)57,8862.1(1.9−2.3)17,7712.7(2.1−3.3)
    Parents smoke§§153,02852.1(50.7−53.5)77,30449.8(48.2−51.4)57,92852.3(50.5−54.1)17,79658.8(56.7−60.9)
    Teacher smokes in school¶¶153,02537.7(35.4−40.0)77,29932.7(30.3−35.1)57,93145.4(42.1−48.7)17,79540.5(35.7−45.3)
    Males
    Buying cigarettes as a minor without rejection*3,45584.0(81.7−86.3)91374.8(70.8−78.9)1,36086.5(84.2−88.9)1,18286.8(83.4−90.1)
    Buying cigarettes individually by stick4,2524.6(3.0−6.2)91911.8(8.4−15.3)1,8115.6(3.6−7.5)1,5221.9(0.5−3.3)
    Tobacco advertisements and promotions at retail outlets§19,37646.0(44.2−47.9)8,59248.9(47.0−50.8)7,38838.5(36.3−40.8)3,39648.3(44.0−52.6)
    Tobacco advertisements and promotions on the internet62,29824.0(23.0−25.0)30,66922.6(21.7−23.5)23,53521.3(20.4−22.2)8,09430.5(27.4−33.6)
    Tobacco advertisements and promotions on movies, TV, or videos**61,05575.2(74.2−76.2)31,60871.4(70.3−72.6)22,00077.1(76.0−78.2)7,44782.8(80.5−85.2)
    Free tobacco products provided by tobacco industry††77,1552.7(2.5−2.9)40,1792.4(2.1−2.6)27,7752.9(2.5−3.3)9,2013.6(2.6−4.6)
    Parents smoke§§77,24452.0(50.5−53.5)40,22749.9(48.1−51.8)27,80151.4(49.6−53.3)9,21658.7(55.7−61.6)
    Teacher smokes in school¶¶77,24141.7(39.2−44.2)40,22435.6(33.1−38.2)27,80250.3(46.6−53.9)9,21547.3(41.4−53.2)
    Females
    Buying cigarettes as a minor without rejection*77984.7(81.2−88.2)29079.5(74.9−84.1)27989.7(82.6−96.8)21087.2(78.5−95.9)
    Buying cigarettes individually by stick8734.8(2.8−6.8)2956.9(3.3−10.5)3244.7(1.8−7.5)2542.9(0.1−5.7)
    Tobacco advertisements and promotions at retail outlets§15,38047.9(46.3−49.4)6,94250.1(48.3−51.8)6,13344.5(42.6−46.5)2,30547.4(43.8−51.1)
    Tobacco advertisements and promotions on the internet61,75621.3(20.4−22.1)28,68920.8(20.0−21.7)25,51819.4(18.3−20.5)7,54925.5(23.2−27.9)
    Tobacco advertisements and promotions on movies, TV, or videos**59,13062.9(61.9−64.0)28,56060.6(59.4−61.8)23,48963.6(62.3−64.9)7,08168.7(66.1−71.3)
    Free tobacco products provided by tobacco industry††75,7301.4(1.2−1.6)37,0491.4(1.2−1.6)30,1111.3(1.1−1.5)8,5701.5(1.0−2.0)
    Parents smoke§§75,78452.3(50.8−53.7)37,07749.7(48.2−51.2)30,12753.1(51.1−55.2)8,58058.9(56.4−61.5)
    Teacher smokes in school¶¶75,78433.2(30.9−35.4)37,07529.3(26.9−31.8)30,12940.7(37.5−43.9)8,58031.8(27.8−35.7)
    RuralBoth
    Buying cigarettes as a minor without rejection*4,87482.9(81.2−84.6)1,92576.7(73.7−79.7)1,51387.8(85.7−89.8)1,43688.3(85.6−90.9)
    Buying cigarettes individually by stick5,96211.5(8.9−14.1)1,96217.8(12.6−23.0)2,10810.1(7.4−12.7)1,8925.2(3.5−7.0)
    Tobacco advertisements and promotions at retail outlets§34,79846.2(44.6−47.7)16,38348.6(46.8−50.4)12,89442.3(40.1−44.6)5,52145.5(43.3−47.8)
    Tobacco advertisements and promotions on the internet106,13823.8(23.0−24.6)51,95024.1(23.1−25.0)39,81922.0(20.9−23.1)14,36927.0(25.7−28.4)
    Tobacco advertisements and promotions on movies, TV, or videos**108,07773.0(72.2−73.8)56,24971.2(70.3−72.1)38,21074.4(73.0−75.8)13,61878.1(76.3−79.9)
    Free tobacco products provided by tobacco industry††134,9962.1(2.0−2.3)69,8782.0(1.8−2.3)48,4422.0(1.8−2.3)16,6762.8(2.4−3.3)
    Parents smoke§§135,09855.4(54.2−56.7)69,93154.5(52.9−56.0)48,48155.6(54.1−57.2)16,68659.6(57.3−61.9)
    Teacher smokes in school¶¶135,09352.6(50.7−54.5)69,92548.2(46.1−50.2)48,48059.0(56.2−61.8)16,68857.9(53.9−61.9)
    Males
    Buying cigarettes as a minor without rejection*4,20382.5(80.7−84.2)1,55975.6(72.5−78.7)1,35887.6(85.4−89.7)1,28687.8(85.0−90.7)
    Buying cigarettes individually by stick5,21011.2(8.7−13.8)1,59417.9(12.9−22.8)1,90710.3(7.5−13.1)1,7094.9(3.4−6.4)
    Tobacco advertisements and promotions at retail outlets§19,91344.8(43.3−46.4)9,24049.1(47.3−51.0)7,16638.9(36.8−41.0)3,50742.3(39.8−44.7)
    Tobacco advertisements and promotions on the internet53,59324.3(23.4−25.2)26,91924.9(23.8−25.9)18,93022.4(21.3−23.4)7,74425.9(24.4−27.5)
    Tobacco advertisements and promotions on movies, TV, or videos**54,63977.8(77.0−78.6)29,21775.6(74.5−76.7)18,19080.1(78.9−81.2)7,23283.1(81.4−84.7)
    Free tobacco products provided by tobacco industry††67,9092.7(2.4−3.0)36,2142.5(2.2−2.9)22,7952.6(2.2−2.9)8,9003.9(3.2−4.6)
    Parents smoke§§67,96255.1(53.9−56.3)36,24354.3(52.8−55.7)22,80955.2(53.4−57.0)8,91058.7(56.2−61.2)
    Teacher smokes in school¶¶67,95856.9(55.1−58.7)36,23751.7(49.6−53.9)22,81164.9(62.1−67.7)8,91063.4(59.5−67.3)
    Females
    Buying cigarettes as a minor without rejection*67185.5(81.5−89.5)36681.8(75.8−87.7)15589.6(83.7−95.4)15092.2(86.7−97.6)
    Buying cigarettes individually by stick75213.3(8.5−18.1)36817.5(9.9−25.0)2017.5(3.3−11.6)1839.0(1.3−16.7)
    Tobacco advertisements and promotions at retail outlets§14,88548.1(45.9−50.2)7,14347.8(45.3−50.3)5,72847.0(43.4−50.5)2,01451.8(46.8−56.8)
    Tobacco advertisements and promotions on the internet52,54523.3(22.4−24.2)25,03123.2(22.1−24.2)20,88921.6(20.3−23.0)6,62528.4(26.4−30.4)
    Tobacco advertisements and promotions on movies, TV, or videos**53,43867.7(66.6−68.7)27,03266.2(65.1−67.3)20,02068.8(67.0−70.6)6,38671.8(69.0−74.5)
    Free tobacco products provided by tobacco industry††67,0871.5(1.4−1.6)33,6641.5(1.3−1.6)25,6471.5(1.3−1.8)7,7761.5(1.1−1.9)
    Parents smoke§§67,13655.8(54.4−57.3)33,68854.7(52.9−56.5)25,67256.1(54.5−57.7)7,77660.8(57.8−63.8)
    Teacher smokes in school¶¶67,13547.8(45.7−49.9)33,68844.1(42.0−46.2)25,66953.3(50.3−56.3)7,77850.9(45.7−56.1)
    * In the past 30 days before the date of investigation, current smokers had not experienced being refused due to age when buying cigarettes;
    In the past 30 days before the date of investigation, the current smokers had bought cigarettes individually by stick for themselves;
    § In the past 30 days before the date of investigation, students had seen tobacco advertisements and promotions at retail outlets;
    In the past 30 days before the date of investigation, the students had seen tobacco advertisements or video on the internet;
    ** In the past 30 days before the date of investigation, the students had seen smoking scenes on movies, TV, or videos;
    †† The students have been offered free tobacco products by the tobacco industry;
    §§ At least one of parents is smoker;
    ¶¶ The students had seen a teacher smoke in school during school hours.
    Abbreviation: CI=confidence intervals.

    Table 2.  Cigarette availability, advertisements and promotion, and smoking exposure among secondary high school students in China, 2019.

  • The health hazards due to starting to smoke at an early stage of life is higher than starting later in life (3). Most adult smokers smoked their first cigarette before 18 years of age, which makes it hard to quit once they get addicted and thereby leads to an increase in lifetime smoking (4-5). Developing continued monitoring of tobacco use and strengthening tobacco control in children and adolescents would be greatly beneficial to reducing the number of smokers.

    Compared with the 2014 youth survey, the prevalence rates of ES and CS among JHS students in 2019 decreased by 27.9% (17.9% vs. 12.9%) and 33.9% (5.9% vs. 3.9%), respectively. Globally, the prevalence rate of CS among JHS students in China is lower than in 45 GYTS countries (6.8% in median), and close to Mongolia (3.9%) and Bahamas (3.8%) (6).

    The reported rate of having seen smoking scenes on movies, TV, or videos has decreased by 14.1% (80.9% vs. 69.5%) from 2014 to 2019. Other indicators related to cigarette availability and advertisements on the internet have declined but no statistical significance was observed besides the reported rate of having seen marketing activities at retail outlets having increased by 17.8% (41.5% vs. 48.9%).

    These declines may be partially explained by the great tobacco control efforts in China to protect children and adolescents in recent years using measures such as strengthening health education, banning tobacco advertisements, and prohibiting tobacco use inside secondary and primary schools (7-9). The improvement of social civilization and environmental hygiene may also possibly contribute to the reduction of tobacco use. In addition, the popularity of e-cigarettes might potentially make some cigarette smokers smoke e-cigarettes instead, which will be further analyzed in future research.

    Despite positive changes in the past five years, the external factors compelling teenagers to smoke were extensive. First, although laws exist to prohibit selling tobacco product to minors in China, 76.5%, 87.6%, and 87.6% of CS from JHS, SHS, and VSHS, respectively, reported that they had not been rejected for being under 18 years old when buying cigarettes, indicating that relevant laws have not been well implemented. Second, the presence of buying cigarettes individually and getting free tobacco products from the tobacco industry indicated tobacco companies prefer to use a variety of strategies for promoting its products. Third, plenty of research revealed that tobacco advertisements and promotions are causally associated with the initiation and progression of tobacco use among children and adolescents (10). However, 48.9%, 42.0%, and 46.7% of respondents from JHS, SHS, and VSHS, respectively, reported they had seen tobacco advertisements and promotions at retail outlets, and nearly a quarter of respondents had seen them on the internet, which indicates that tobacco retail outlets and the internet should be the focus of regulations. Finally, our study showed that smoking scenes in movies, TV, or videos are widely prevalent.

    Parents and teachers play an important role in the development of smoking habits for children and adolescents (4). Unfortunately, despite a slight decline, approximately half of the students in this study reported that at least one parent smokes and that teachers smoked in school. According to the “Opinions on further strengthening school smoking control” jointly launched by the Ministry of Education and the Ministry of Health in 2010, teachers are not allowed to smoke in school, especially in front of students. (7) The present study reflects a big gap in actual implementation.

    In this study, we investigated SHS and VSHS students for the first time. The proportion of ES and CS among SHS and VSHS students is 1.9 and 2.21 folds of JHS, and it is 2.35 and 3.77 folds of JHS for VSHS. This disparity is more prominent in male students and urban areas. These results suggest that targeted measures of tobacco control are urgently needed in senior high schools, especially to protect VSHS students.

    A potential limitation is the self-reported design based on a paper-based questionnaire, which may probably cause mistakes in the process of data collection or potentially due to underreporting. However, the large sample size can make up for this disadvantage and this design can well maintain comparability with previous and other studies. Standardized and electronic survey systems, platform-based data management, and environmental nicotine detection should be considered for future surveys. In addition, the classification of urban-rural areas is roughly based on the naming of an area as “district (Qu)” and “county (Xian)” and is consistent with most studies in China.

    In conclusion, there is a large decline in the ES and CS prevalence rates among JHS students from 2014–2019 in China. However, the tobacco control situation remains challenging with big regional disparities in the proportion of ES and CS, relatively easy access to cigarettes, high exposure to advertisements and promotions from tobacco industry, and inefficient policy implementation. Cigarette smoking in SHS, especially VSHS, is widely prevalent, suggesting the urgent need for targeted tobacco control measures.

    Acknowledgements: We thank all the colleagues from local institutions in the data collection.

    Conflict of interests: The authors declare no competing interests.

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