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Therese Hesketh, MRCPCH, Mfphm, MPH, Qu Jian Ding, MD and Andrew Tomkins, FRCP

Therese Hesketh and Andrew Tomkins are with the Centre for International Child Health, Institute of Child Health, University College London, London, England. Qu Jian Ding is with the Institute for Population Studies, Zhejiang Medical University, Hangzhou, People's Republic of China.

Correspondence: Requests for reprints should be sent to Therese Hesketh, MRCPCH, MFPHM, MPH, ICH-China Reproductive Health Project, 51A Narada Gardens, Wen Yi Rd, Hangzhou 310012, People's Republic of China (e-mail:hesketh{at}mail.hz.zj.cn).

	ABSTRACT

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Objectives. To inform a prevention strategy, this study determined the prevalence of and attitudes toward smoking among Chinese secondary school students.

Methods. Self-completion questionnaires were administered to 13- to 18-year-olds attending school in Zhejiang Province, eastern China.

Results. Of the 6674 respondents, 15.9% (25.7% of the boys, 5.4% of the girls) were ever smokers. Only 0.3% were regular smokers. Of the ever smokers, 41.9% had smoked before 10 years of age and 7.9% before 5 years of age. Parental smoking was the strongest predictor of smoking.

Conclusions. The very low prevalence of regular smoking found in this age group suggests that prevention programs in school may be beneficial. Parents should be encouraged to adopt more responsible attitudes toward smoking in the home.

	INTRODUCTION

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The prevention of smoking in young Chinese has been described as the single greatest opportunity for preventing noncommunicable disease in the world today.¹ In China, 320 million people are smokers, equal to the number in all developed countries combined. Two thirds of the men become daily smokers before reaching 25 years of age,² and few quit smoking³; thus, preventing young people from starting smoking is a key public health objective.⁴ Currently, only limited data about smoking behavior and attitudes in young Chinese are available to inform education programs. The aim of this study was to acquire such information for a school-based prevention program. The study was carried out, in December 1998, in 3 distinct areas of Zhejiang Province: Hangzhou (urban), Xiaoshan (rich rural), and Chunan (poor rural).

	METHODS

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The study design was a cross-sectional survey in which self-completion questionnaires were used. The questionnaire contained validated questions recommended for use in young people.⁵ Some changes were made to account for cultural differences. Local authorities limited the number of schools permitted to participate, so the aim of sampling was to include a range of schools that, as a whole, would be representative of the entire province. To achieve this goal, we used the academic score—the percentage of final-year students entering university—as the means of selection. Three secondary schools in each area were invited to participate, covering an age range of predominantly 13 to 18 years and an academic score range of 18% to 75%. All pupils attending on a particular day completed the questionnaire anonymously under examination conditions. No schools or individual students refused to participate.

	RESULTS

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There were 6674 questionnaires completed; 52% were completed by boys. The age range was 12 to 19 years (mean = 15.1 years, SD = 1.6 years).

Smoking Prevalence
Overall, 15.9% of the sample (25.7% of the boys and 5.4% of the girls) had smoked at some time, with significantly more respondents in the 2 rural areas reporting ever smoking: 11.5% in Hangzhou, 18.2% in Xiaoshan, and 19.0% in Chunan (P = .0001) (Table 1). However, only 0.3%, 20 in total, and no girls, classed themselves as regular smokers (defined as at least 1 cigarette per week).

Smoking Associations
Odds ratios (ORs; based on Pearson c²) for relations between ever smoking and selected characteristics were examined. The strongest associations were with maternal smoking (OR = 3.9; 95% confidence interval [CI] = 2.2, 4.9); paternal smoking (OR = 3.5; 95% CI = 2.9, 4.1); having friends who smoke (OR = 3.4; 95% CI = 2.7, 4.0); low level of father's education (illiterate or primary only) (OR = 2.9; 95% CI = 2.4, 3.5), and a poor self-reported academic record (OR = 2.1; 95% CI = 1.9, 2.4).

Attitudes Toward Smoking
Most students gave "informed" answers, irrespective of their smoking status, across all 3 areas. Overall, fewer than 10% thought that young smokers had a tough or glamorous image. Significantly more of the ever smokers thought that smoking improved mood and increased confidence or popularity, but the percentages throughout were low: between 5% and 19%. Thirty percent of the ever smokers said that smoking calmed the nerves, compared with 14% of the never smokers. Almost equal numbers of smokers (86%) and nonsmokers (82%) said that smoking harmed health. Only 6.5% believed that smoking helped weight loss, a factor thought to contribute to the high smoking prevalence among girls in the West.⁶ Boys, irrespective of smoking status, were more likely to give "uninformed" answers.

	DISCUSSION

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This study highlighted 3 areas that have important policy implications: (1) low rates of regular smoking, (2) enlightened attitudes toward smoking, and (3) the importance of parental influences on smoking behavior in young people.

Low Rates of Regular Smoking
We were initially skeptical about the low rates of regular smoking observed in our study. Other published studies^7–10 have shown somewhat higher rates of smoking, but comparison is hampered mainly by lack of consistency in the questions asked and failure to distinguish experimentation and regular smoking. However, feedback sessions with teachers and students following analysis of the findings gave us the impression that the rates of regular smoking are indeed very low.

The message is clear: smoking rates among male youths are low, but, historically, males begin smoking early in their adult life. Consequently, strategies need to be developed to reduce initiation of smoking as males enter adulthood. These strategies may include school-based prevention programs or strategies targeted specifically at the 18- to 24-year age group. The low rates of success of school-based programs in Western countries have been partly blamed on the fact that patterns of regular smoking, and probably nicotine addiction, are already established, even in early secondary school.¹¹ That this is clearly not the case in our study population implies that there may be greater potential for school-based programs in China.

Enlightened Attitudes
Most of these students were aware of the dangers and disadvantages of smoking. Therefore, school-based programs need to provide young people with the ability to resist the pressures to start smoking. In Western settings, intensive programs of this type have been most successful, at least in delaying initiation of smoking.^{12, 13}

Parental Influences
Parental smoking was strongly associated with smoking in these schoolchildren. Some parents actually give cigarettes to their young children. In China, anecdotal evidence suggests that cigarettes are used to pacify young children.¹⁴ The volunteering of this information by 84 respondents was surprising, because many cannot have clear memories of their early years. The extent of this practice may therefore be underestimated. Such evidence, however, indicates potential for improved health education in the mass media, and within antenatal and child health clinics, to inform current and future parents about the dangers of introducing children to health-damaging practices.

	Acknowledgments

 
The research was funded through a grant from the United Kingdom Department for International Development. The views expressed in the article, however, are those of the authors.

We wish to thank the education and health officials, head teachers, class teachers, and school nurses who were actively and enthusiastically involved in this research.

T. Hesketh planned and supervised the study, analyzed the data, and wrote the paper. Q. J. Ding helped with preparation of the questionnaire, was responsible for all logistics, and administered the questionnaire in the classrooms. A. Tomkins was involved in the planning of the study and contributed to the writing of the paper.

	Footnotes

 
Peer Reviewed

Accepted for publication December 15, 2000.

	References

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1. Mackay J. Smoking in China: the limits of space. Tob Control.1997;6:77–79.[Medline]

2. Yang GH, Fan LX, Tan J, et al. Smoking in China: findings of the 1996 National Prevalence Survey. JAMA.1999;282:1247–1253.[Abstract/Free Full Text]

3. Liu BQ, Peto R, Chen MZ, et al. Emerging tobacco hazards in China, 1: retrospective proportional mortality study of one million deaths. BMJ.1998;317:1411–1422.[Abstract/Free Full Text]

4. WHO Fact Sheet: Smoking in China: A Time Bomb for the 21st Century. Geneva, Switzerland: World Health Organization; August 1997.

5. Gillies P. Accuracy in the measurement of the prevalence of smoking in young people. Health Educ J.1985;44:36–38.

6. Pirie PL, Murray DM, Luepker RV. Gender differences in cigarette smoking and quitting in a cohort of young adults. Am J Public Health.1991;81:324–327.[Abstract/Free Full Text]

7. Zhu BP, Liu M, Shelton D, Liu S, Giovino GA. Cigarette smoking and risk factors for smoking among elementary school students in Beijing. Am J Public Health.1996;86:368–375.[Abstract/Free Full Text]

8. Li X, Fang X, Stanton B. Cigarette smoking among Chinese adolescents and its association with demographic characteristics, social activities and problem behaviours. Subst Use Misuse.1996;31:545–563.[Medline]

9. Mei J. An investigation on the smoking situation among middle school students in Japan and Jiangxi, China [in Chinese]. Chung Hua Liu Hsing Ping Hsueh Tsa Chih. 1993;14(2):87–91.

10. Sun WY, Ling T. Smoking behavior among adolescents in Shanghai. Am J Health Promot.1997;11:331–336.[Medline]

11. Preventing the Uptake of Smoking in Young People. York, England: NHS Centre for Reviews and Dissemination, University of York; October 1999. Effective Health Care Bulletin.

12. Reid DJ, McNeill AD, Glynn TJ. Reducing the prevalence of smoking in youth in Western countries: an international review. Tob Control.1995;4:266–267.

13. Bruvold WH. A meta-analysis of adolescent smoking prevention programs. Am J Public Health.1993;83:872–880.[Abstract/Free Full Text]

14. Mackay J. Smoking among Chinese youth: a cure for crying? Tob Control.1993;2:7–12.

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