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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)Total Urban Rural Experimental smokers Current smokers Experimental smokers Current smokers Experimental smokers Current smokers N % (95% CI)* N % (95% CI) N % (95% CI) N % (95% CI) N % (95% CI) N % (95% CI) Both Overall (15 years old) 282,421 17.9(17.1−18.8) 286,455 5.9(5.5−6.4) 150,421 15.1(14.0−16.3) 152,302 5.0(4.2−5.8) 132,000 19.7(18.5−20.9) 134,153 6.5(5.9−7.2) Junior high school (14 years old) 144,566 12.9(12.0−13.9) 146,451 3.9(3.4−4.4) 76,178 9.0(8.1−9.9) 77,006 2.3(1.9−2.6) 68,388 15.2(13.9−16.6) 69,445 4.8(4.1−5.6) Senior high school (16 years old) 104,342 21.6(20.4−22.8) 105,868 5.6(5.1−6.1) 56,908 17.7(16.4−19.0) 57,679 4.1(3.5−4.7) 47,434 23.9(22.3−25.6) 48,189 6.4(5.7−7.1) Vocational senior high school (17 years old) 33,513 30.3(27.7−32.9) 34,136 14.7(12.7−16.6) 17,335 29.6(25.1−34.2) 17,617 14.5(10.8−18.1) 16,178 30.9(28.1−33.6) 16,519 14.8(12.9−16.7) Males Overall (15 years old) 141,568 26.0(24.8−27.3) 143,985 9.6(8.8−10.4) 75,581 21.5(19.8−23.2) 76,724 8.0(6.7−9.3) 65,987 28.9(27.1−30.6) 67,261 10.6(9.6−11.6) Junior high school (14 years old) 74,766 17.9(16.6−19.2) 75,897 5.8(5.0−6.5) 39,501 12.1(10.9−13.4) 40,006 3.2(2.7−3.8) 35,265 21.2(19.3−23.1) 35,891 7.2(6.1−8.4) Senior high school (16 years old) 49,306 33.6(31.9−35.2) 50,233 10.0(9.1−10.8) 27,153 26.5(24.5−28.4) 27,636 7.1(6.1−8.1) 22,153 37.7(35.6−39.9) 22,597 11.6(10.4−12.8) Vocational senior high school (17 years old) 17,496 43.2(39.7−46.6) 17,855 23.3(20.3−26.3) 8,927 41.5(35.4−47.5) 9,082 22.7(17.3−28.2) 8,569 44.7(41.1−48.4) 8,773 23.8(20.9−26.7) Females Overall (15 years old) 140,853 9.1(8.5−9.7) 142,470 1.9(1.7−2.1) 74,840 8.1(7.5−8.7) 75,578 1.6(1.4−1.9) 66,013 9.7(8.8−10.6) 66,892 2.1(1.8−2.4) Junior high school (14 years old) 69,800 7.2(6.5−7.9) 70,554 1.8(1.5−2.1) 36,677 5.3(4.7−5.9) 37,000 1.1(0.9−1.3) 33,123 8.3(7.3−9.4) 33,554 2.1(1.7−2.6) Senior high school (16 years old) 55,036 10.2(9.4−11.0) 55,635 1.4(1.1−1.6) 29,755 9.3(8.4−10.1) 30,043 1.2(1.0−1.4) 25,281 10.7(9.5−12.0) 25,592 1.4(1.1−1.8) Vocational senior high school (16 years old) 16,017 14.0(12.3−15.7) 16,281 3.7(2.9−4.4) 8,408 14.6(12.1−17.2) 8,535 4.0(2.8−5.2) 7,609 13.4(11.2−15.6) 7,746 3.4(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)
Region Variable Total Junior high school Senior high school Vocational senior high school N % (95% CI) N % (95% CI) N % (95% CI) N % (95% CI) Total Both Buying cigarettes as a minor without rejection* 9,108 83.3(82.0−84.6) 3,128 76.5(74.1−79.0) 3,152 87.6(86.0−89.2) 2,828 87.6(85.6−89.5) Buying cigarettes individually by stick† 11,087 9.2(7.3−11.1) 3,176 16.2(12.1−20.3) 4,243 8.8(6.7−10.8) 3,668 3.7(2.5−4.9) Tobacco advertisements and promotions at retail outlets§ 69,554 46.4(45.3−47.5) 31,917 48.9(47.5−50.2) 26,415 42.0(40.3−43.6) 11,222 46.7(44.8−48.7) Tobacco advertisements and promotions on the internet¶ 230,192 23.4(22.8−23.9) 111,308 23.2(22.6−23.9) 88,872 21.4(20.6−22.1) 30,012 27.7(26.5−28.9) Tobacco advertisements and promotions on movies, TV, or videos** 228,262 71.7(71.0−72.3) 116,417 69.5(68.8−70.2) 83,699 72.9(71.9−73.9) 28,146 77.4(75.8−78.9) Free tobacco products provided by tobacco industry†† 287,881 2.1(2.0−2.3) 147,106 2.0(1.8−2.2) 106,328 2.1(1.9−2.2) 34,447 2.8(2.4−3.1) Parents smoke§§ 288,126 54.2(53.2−55.1) 147,235 52.8(51.6−53.9) 106,409 54.4(53.2−55.6) 34,482 59.2(57.6−60.8) Teacher smokes in school¶¶ 288,118 46.9(45.3−48.5) 147,224 42.6(40.9−44.2) 106,411 54.0(51.8−56.3) 34,483 49.6(46.1−53.1) Males Buying cigarettes as a minor without rejection* 7,658 83.0(81.6−84.4) 2,472 75.4(72.8−78.0) 2,718 87.3(85.6−88.9) 2,468 87.3(85.1−89.5) Buying cigarettes individually by stick† 9,462 9.0(7.2−10.9) 2,513 16.6(12.6−20.6) 3,718 9.1(6.9−11.2) 3,231 3.5(2.4−4.6) Tobacco advertisements and promotions at retail outlets§ 39,289 45.2(44.1−46.4) 17,832 49.1(47.6−50.5) 14,554 38.8(37.2−40.4) 6,903 45.2(42.6−47.7) Tobacco advertisements and promotions on the internet¶ 115,891 24.2(23.5−24.8) 57,588 24.0(23.3−24.8) 42,465 22.0(21.2−22.7) 15,838 28.2(26.4−30.0) Tobacco advertisements and promotions on movies, TV, or videos** 115,694 76.8(76.2−77.4) 60,825 74.1(73.3−74.9) 40,190 79.0(78.1−79.9) 14,679 83.0(81.5−84.4) Free tobacco products provided by tobacco industry†† 145,064 2.7(2.5−2.9) 76,393 2.5(2.2−2.7) 50,570 2.7(2.4−2.9) 18,101 3.8(3.2−4.3) Parents smoke§§ 145,206 53.9(53.0−54.9) 76,470 52.7(51.5−53.8) 50,610 53.8(52.4−55.1) 18,126 58.7(56.8−60.6) Teacher smokes in school¶¶ 145,199 51.1(49.5−52.7) 76,461 45.9(44.1−47.6) 50,613 59.5(57.2−61.9) 18,125 55.7(51.9−59.5) Females Buying cigarettes as a minor without rejection* 1,450 85.2(82.3−88.1) 656 81.1(76.6−85.7) 434 89.6(85.1−94.1) 360 89.8(84.6−95.1) Buying cigarettes individually by stick† 1,625 10.3(7.1−13.4) 663 14.6(9.1−20.1) 525 6.4(3.6−9.2) 437 6.0(1.9−10.2) Tobacco advertisements and promotions at retail outlets§ 30,265 48.0(46.5−49.5) 14,085 48.6(46.8−50.4) 11,861 46.2(43.7−48.6) 4,319 49.7(46.5−52.8) Tobacco advertisements and promotions on the internet¶ 114,301 22.5(21.9−23.1) 53,720 22.3(21.6−23.0) 46,407 20.8(19.8−21.7) 14,174 27.0(25.5−28.6) Tobacco advertisements and promotions on movies, TV, or videos** 112,568 65.9(65.1−66.7) 55,592 64.2(63.4−65.1) 43,509 66.9(65.6−68.2) 13,467 70.3(68.4−72.2) Free tobacco products provided by tobacco industry†† 142,817 1.5(1.3−1.6) 70,713 1.5(1.3−1.6) 55,758 1.4(1.3−1.6) 16,346 1.5(1.2−1.8) Parents smoke§§ 142,920 54.5(53.4−55.5) 70,765 52.9(51.6−54.2) 55,799 55.0(53.8−56.3) 16,356 59.9(57.9−61.9) Teacher smokes in school¶¶ 142,919 42.2(40.6−43.9) 70,763 38.7(37.1−40.4) 55,798 48.7(46.4−51.0) 16,358 41.8(37.9−45.6) Urban Both Buying cigarettes as a minor without rejection* 4,234 84.1(82.2−86.0) 1,203 75.9(72.6−79.2) 1,639 87.1(84.6−89.5) 1,392 86.8(84.0−89.6) Buying cigarettes individually by stick† 5,125 4.6(3.1−6.2) 1,214 10.7(7.4−13.9) 2,135 5.4(3.6−7.2) 1,776 2.0(0.7−3.3) Tobacco advertisements and promotions at retail outlets§ 34,756 46.8(45.3−48.2) 15,534 49.4(47.8−51.0) 13,521 41.2(39.5−42.9) 5,701 48.0(44.9−51.2) Tobacco advertisements and promotions on the internet¶ 124,054 22.7(22.0−23.4) 59,358 21.8(21.1−22.5) 49,053 20.3(19.5−21.2) 15,643 28.4(26.4−30.3) Tobacco advertisements and promotions on movies, TV, or videos** 120,185 69.5(68.5−70.4) 60,168 66.5(65.4−67.5) 45,489 70.3(69.3−71.4) 14,528 76.6(74.0−79.2) Free tobacco products provided by tobacco industry†† 152,885 2.1(2.0−2.2) 77,228 1.9(1.8−2.1) 57,886 2.1(1.9−2.3) 17,771 2.7(2.1−3.3) Parents smoke§§ 153,028 52.1(50.7−53.5) 77,304 49.8(48.2−51.4) 57,928 52.3(50.5−54.1) 17,796 58.8(56.7−60.9) Teacher smokes in school¶¶ 153,025 37.7(35.4−40.0) 77,299 32.7(30.3−35.1) 57,931 45.4(42.1−48.7) 17,795 40.5(35.7−45.3) Males Buying cigarettes as a minor without rejection* 3,455 84.0(81.7−86.3) 913 74.8(70.8−78.9) 1,360 86.5(84.2−88.9) 1,182 86.8(83.4−90.1) Buying cigarettes individually by stick† 4,252 4.6(3.0−6.2) 919 11.8(8.4−15.3) 1,811 5.6(3.6−7.5) 1,522 1.9(0.5−3.3) Tobacco advertisements and promotions at retail outlets§ 19,376 46.0(44.2−47.9) 8,592 48.9(47.0−50.8) 7,388 38.5(36.3−40.8) 3,396 48.3(44.0−52.6) Tobacco advertisements and promotions on the internet¶ 62,298 24.0(23.0−25.0) 30,669 22.6(21.7−23.5) 23,535 21.3(20.4−22.2) 8,094 30.5(27.4−33.6) Tobacco advertisements and promotions on movies, TV, or videos** 61,055 75.2(74.2−76.2) 31,608 71.4(70.3−72.6) 22,000 77.1(76.0−78.2) 7,447 82.8(80.5−85.2) Free tobacco products provided by tobacco industry†† 77,155 2.7(2.5−2.9) 40,179 2.4(2.1−2.6) 27,775 2.9(2.5−3.3) 9,201 3.6(2.6−4.6) Parents smoke§§ 77,244 52.0(50.5−53.5) 40,227 49.9(48.1−51.8) 27,801 51.4(49.6−53.3) 9,216 58.7(55.7−61.6) Teacher smokes in school¶¶ 77,241 41.7(39.2−44.2) 40,224 35.6(33.1−38.2) 27,802 50.3(46.6−53.9) 9,215 47.3(41.4−53.2) Females Buying cigarettes as a minor without rejection* 779 84.7(81.2−88.2) 290 79.5(74.9−84.1) 279 89.7(82.6−96.8) 210 87.2(78.5−95.9) Buying cigarettes individually by stick† 873 4.8(2.8−6.8) 295 6.9(3.3−10.5) 324 4.7(1.8−7.5) 254 2.9(0.1−5.7) Tobacco advertisements and promotions at retail outlets§ 15,380 47.9(46.3−49.4) 6,942 50.1(48.3−51.8) 6,133 44.5(42.6−46.5) 2,305 47.4(43.8−51.1) Tobacco advertisements and promotions on the internet¶ 61,756 21.3(20.4−22.1) 28,689 20.8(20.0−21.7) 25,518 19.4(18.3−20.5) 7,549 25.5(23.2−27.9) Tobacco advertisements and promotions on movies, TV, or videos** 59,130 62.9(61.9−64.0) 28,560 60.6(59.4−61.8) 23,489 63.6(62.3−64.9) 7,081 68.7(66.1−71.3) Free tobacco products provided by tobacco industry†† 75,730 1.4(1.2−1.6) 37,049 1.4(1.2−1.6) 30,111 1.3(1.1−1.5) 8,570 1.5(1.0−2.0) Parents smoke§§ 75,784 52.3(50.8−53.7) 37,077 49.7(48.2−51.2) 30,127 53.1(51.1−55.2) 8,580 58.9(56.4−61.5) Teacher smokes in school¶¶ 75,784 33.2(30.9−35.4) 37,075 29.3(26.9−31.8) 30,129 40.7(37.5−43.9) 8,580 31.8(27.8−35.7) Rural Both Buying cigarettes as a minor without rejection* 4,874 82.9(81.2−84.6) 1,925 76.7(73.7−79.7) 1,513 87.8(85.7−89.8) 1,436 88.3(85.6−90.9) Buying cigarettes individually by stick† 5,962 11.5(8.9−14.1) 1,962 17.8(12.6−23.0) 2,108 10.1(7.4−12.7) 1,892 5.2(3.5−7.0) Tobacco advertisements and promotions at retail outlets§ 34,798 46.2(44.6−47.7) 16,383 48.6(46.8−50.4) 12,894 42.3(40.1−44.6) 5,521 45.5(43.3−47.8) Tobacco advertisements and promotions on the internet¶ 106,138 23.8(23.0−24.6) 51,950 24.1(23.1−25.0) 39,819 22.0(20.9−23.1) 14,369 27.0(25.7−28.4) Tobacco advertisements and promotions on movies, TV, or videos** 108,077 73.0(72.2−73.8) 56,249 71.2(70.3−72.1) 38,210 74.4(73.0−75.8) 13,618 78.1(76.3−79.9) Free tobacco products provided by tobacco industry†† 134,996 2.1(2.0−2.3) 69,878 2.0(1.8−2.3) 48,442 2.0(1.8−2.3) 16,676 2.8(2.4−3.3) Parents smoke§§ 135,098 55.4(54.2−56.7) 69,931 54.5(52.9−56.0) 48,481 55.6(54.1−57.2) 16,686 59.6(57.3−61.9) Teacher smokes in school¶¶ 135,093 52.6(50.7−54.5) 69,925 48.2(46.1−50.2) 48,480 59.0(56.2−61.8) 16,688 57.9(53.9−61.9) Males Buying cigarettes as a minor without rejection* 4,203 82.5(80.7−84.2) 1,559 75.6(72.5−78.7) 1,358 87.6(85.4−89.7) 1,286 87.8(85.0−90.7) Buying cigarettes individually by stick† 5,210 11.2(8.7−13.8) 1,594 17.9(12.9−22.8) 1,907 10.3(7.5−13.1) 1,709 4.9(3.4−6.4) Tobacco advertisements and promotions at retail outlets§ 19,913 44.8(43.3−46.4) 9,240 49.1(47.3−51.0) 7,166 38.9(36.8−41.0) 3,507 42.3(39.8−44.7) Tobacco advertisements and promotions on the internet¶ 53,593 24.3(23.4−25.2) 26,919 24.9(23.8−25.9) 18,930 22.4(21.3−23.4) 7,744 25.9(24.4−27.5) Tobacco advertisements and promotions on movies, TV, or videos** 54,639 77.8(77.0−78.6) 29,217 75.6(74.5−76.7) 18,190 80.1(78.9−81.2) 7,232 83.1(81.4−84.7) Free tobacco products provided by tobacco industry†† 67,909 2.7(2.4−3.0) 36,214 2.5(2.2−2.9) 22,795 2.6(2.2−2.9) 8,900 3.9(3.2−4.6) Parents smoke§§ 67,962 55.1(53.9−56.3) 36,243 54.3(52.8−55.7) 22,809 55.2(53.4−57.0) 8,910 58.7(56.2−61.2) Teacher smokes in school¶¶ 67,958 56.9(55.1−58.7) 36,237 51.7(49.6−53.9) 22,811 64.9(62.1−67.7) 8,910 63.4(59.5−67.3) Females Buying cigarettes as a minor without rejection* 671 85.5(81.5−89.5) 366 81.8(75.8−87.7) 155 89.6(83.7−95.4) 150 92.2(86.7−97.6) Buying cigarettes individually by stick† 752 13.3(8.5−18.1) 368 17.5(9.9−25.0) 201 7.5(3.3−11.6) 183 9.0(1.3−16.7) Tobacco advertisements and promotions at retail outlets§ 14,885 48.1(45.9−50.2) 7,143 47.8(45.3−50.3) 5,728 47.0(43.4−50.5) 2,014 51.8(46.8−56.8) Tobacco advertisements and promotions on the internet¶ 52,545 23.3(22.4−24.2) 25,031 23.2(22.1−24.2) 20,889 21.6(20.3−23.0) 6,625 28.4(26.4−30.4) Tobacco advertisements and promotions on movies, TV, or videos** 53,438 67.7(66.6−68.7) 27,032 66.2(65.1−67.3) 20,020 68.8(67.0−70.6) 6,386 71.8(69.0−74.5) Free tobacco products provided by tobacco industry†† 67,087 1.5(1.4−1.6) 33,664 1.5(1.3−1.6) 25,647 1.5(1.3−1.8) 7,776 1.5(1.1−1.9) Parents smoke§§ 67,136 55.8(54.4−57.3) 33,688 54.7(52.9−56.5) 25,672 56.1(54.5−57.7) 7,776 60.8(57.8−63.8) Teacher smokes in school¶¶ 67,135 47.8(45.7−49.9) 33,688 44.1(42.0−46.2) 25,669 53.3(50.3−56.3) 7,778 50.9(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.
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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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