Article Text
PDF
Abstract
Objectives Quantitative measurement of the prevalence of cigarette sharing and gifting in a town in rural China and evaluation of the impact of these practices on individual smoking habits and family expenditures.
Methods An interview-based cross-sectional study of 105 households in rural Hunan, China tabulated household cigarette gifting and expenditures. Individual smoking and cigarette sharing activities were also recorded among 198 household members aged >15 years who were resident for at least 6 months.
Results With regard to sharing cigarettes, 92% of men and 19% of women reported being offered a cigarette within the past week. Among previous and current smokers who had attempted to quit smoking, 90% reported that their friends had tried to dissuade them from quitting by tempting them with cigarettes. Concerning gifting cigarettes, 74% of households reported sending packaged cigarettes as gifts during the Chinese New Year Festival at an average expense of 2.8% of household annual income. Although households received an average of 12.4% of their annual cigarette consumption in the form of gifts during the Chinese New Year Festival, no association was found between the amount of cigarettes received by a household and the annual cigarette consumption for that household.
Conclusions Both gifting and sharing cigarettes are common in rural China. Gifting of cigarettes during the New Year Festival is a significant expenditure affecting both smoking and non-smoking households and may be an opportunity for additional mass media marketing. Among current and former smokers, sharing cigarettes in China is a major impediment to smoking cessation.
- Social marketing
- Denormalization
- Price
- Economics
- Low/Middle income country
Statistics from Altmetric.com
Introduction
Estimates of annual mortality attributable to smoking in China range from 673 0001 to over 1.2 million,2 however smoking is clearly among the largest preventable causes of premature death and disability in China. While recent tobacco control efforts have had limited success, tobacco consumption in China continues to increase.2 As outlined by Kohrman,3 in order to move from smoke-free in idea to smoke-free in practice there will need to be a mass mobilisation to diminish the normalisation of everyday activities involving cigarettes. The major social practices driving the consumption of cigarettes in China are sharing and gifting. Sharing cigarettes is defined as offering and accepting of single cigarettes for immediate consumption in a wide variety of social settings.4 This practice is often used as a social tool to convey masculinity,5 respect, economic status, as well as an array of traditional Chinese values including face, reciprocity or willingness to build connections.5 The importance of cigarette sharing is highlighted by the common practice of carrying two or more different brands of cigarettes at the same time. Men in China commonly carry multiple brands of cigarettes to be able to share cigarettes of varying prices according to the nature of their relationship with the recipient of the cigarettes. For example, a businessman may share expensive cigarettes with his clients and cheaper cigarettes with other less important acquaintances.5 There is a growing body of research across various academic disciplines that describes the high social value of sharing cigarettes in China. Cigarette sharing is a major cause of smoking initiation5–7 and significantly hinders smoking cessation.5 Particularly concerning is the peer pressure faced by individuals attempting to quit smoking. Smokers risk losing a shared activity and weakening of friendships when they stop smoking.4 Social pressure is typically exerted in the form of lighthearted but persistent offers of cigarettes to tempt the quitting individual to resume smoking.4 ,8 This probably contributes to the low rate of quitting among Chinese smokers.9
Recently there has been increased attention focused on the similar but distinct practice of giving packaged cigarettes as gifts. Gifting cigarettes is defined as the more formal practice of giving an entire pack or even a carton (1 carton=10 packs or 200 cigarettes) of cigarettes to commemorate an event.5 Gifts of cigarettes are regularly given throughout the year in China and can provide a substantial amount of cigarettes to smokers.10 Additionally, both domestic and international tobacco companies have aggressively promoted the practice of giving both larger and more expensive gifts of cigarettes during specific holidays. For example, Marlboro and other cigarette brands have been marketed in holiday-specific packaging in China to be used primarily as gifts.11 During the Chinese New Year Festival (CNY), China's most widely celebrated holiday, cigarettes have become the most common gift.12
Cigarettes have many attributes that make them ideal gifts. Even among non-smokers cigarettes are appreciated as gifts because of the ease with which they can be sold or exchanged at ‘gift recycling stores’.4 Ironically, a gift of expensive cigarettes can be intended and perceived as an expression of concern for the recipient's health.4 ,5 ,8
Similar to sharing cigarettes, gifting of cigarettes has been identified as a significant obstacle to quitting and a resource that enables some to start smoking.4 ,6 ,8 ,13 Because of this, in 2008 the Chinese Center for Disease Control (CCDC) and the World Lung Foundation (WLF) jointly implemented a mass media campaign to dissuade people from giving cigarettes during the CNY. While this campaign, named ‘Giving Cigarettes is Giving Harm’, was successful in lowering the percentage of people planning to give cigarettes as gifts during the CNY, it was limited to only urban areas.14 In rural China little has been done to reduce the use of cigarettes as gifts during the CNY. Rural communities may be particularly susceptible to the risks associated with gifting cigarettes for a few reasons. First, many rural residents have family members employed in industrialised regions of the country who have personal incomes far higher than their own. Large and expensive gifts of cigarettes are regularly given to rural smoking fathers by their children to demonstrate the wealth and success of the children. In the current economic situation the values of these gifts have grown to the point that they can be considered a form of remittance that can be a major (if not primary) source of cigarettes for some households.4 ,8 Second, this practice can also negatively impact rural residents who give these gifts since expenditures on cigarettes can represent a large portion of household income and can displace household spending on education, medical services and even food.15 ,16 The extent to which gifting and receiving cigarettes can increase smoking consumption and also detract from other quality of life expenditures is unknown and should be investigated for both health and social welfare purposes. Very few studies have provided quantitative assessments of sharing and gifting cigarettes in China, and even fewer among China's rural population. The aim of this study is to provide quantitative data on gifting and sharing cigarettes to further guide tobacco control efforts in rural China.
Methods
Data source and study sample
During January and February 2011 a cross-sectional survey was conducted among a convenience sample of 105 households in Songjiaqiao (SJQ), Hunan, China. SJQ, an agricultural village of roughly 2000 full-time residents, is about 60 km northeast of Changsha, the capital of Hunan Province. There is one primary school in SJQ while older children attend middle school and high school in a neighbouring village. Similar to other rural and agricultural townships in China, many of the working age residents travel to larger cities as migrant workers in search of job opportunities, leaving a disproportionate population of elderly and children. Almost all of the remaining adults in SJQ are engaged in some form of agricultural activity as either a primary or supplemental source of income. In addition to a few hardware and general stores, SJQ has five grocery stores, each of which regularly sells and trades cigarettes. Prices of cigarettes were identical in each of these stores. The cost of one carton of cigarettes was exactly 10 times the cost of a single pack. No tobacco control signage was observed in the village at the time of the study (see Hu et al4 for additional information on SJQ). At the time of the study the value of 1 Renminbi (RMB) was approximately US$0.15.
Data were collected using the Rural Cigarette Gifting Survey (RCGS). The RCGS is a culturally appropriate 85-item questionnaire that is completed by interviewers according to participants’ responses. Developed jointly by the authors in 2010, the RCGS was pilot tested in January 2011 before use and modified to ensure the validity of the questionnaire. The RCGS is a two-part survey consisting of one questionnaire for household data administered to the self-identified household head (HH) as well as accompanying individual questionnaires administered to every household resident over the age of 15 years who lived for ≥6 months in the household during the previous year. The age of 15 years was selected to be consistent with the WHO Global Adult Tobacco Survey (GATS).17 Similarly, current smokers were classified as smoking daily or less than daily to be consistent with the WHO GATS.17 The minimum of 6 months residency was designed to exclude family members who are migrant workers because they are likely to have very different demographics from full-time residents. The individual questionnaire was divided into four different sections: demographics, personal tobacco use, smoking initiation and cessation, and sharing cigarettes. Participants were asked about their personal cigarette sharing behaviour over the last 12 months, including whether they had offered cigarettes to smokers or non-smokers, carried multiple brands of cigarettes and for what reasons they shared cigarettes. Similarly, participants were asked about whether they had been offered individual cigarettes and what effect that had on their personal smoking behaviour. Gifts of cigarettes are typically given on a household by household basis and, as such, questions relating to gifting cigarettes focused on the behaviour of the household as a whole. The household portion of the RCGS was completed by interviewing HHs about the cigarette gifting practices of the entire household, including circumstances regarding gifting cigarettes, amount of cigarettes gifted, brand of cigarettes gifted and the recipients of such gifts. Similar data were gathered for cigarettes received as part of the CNY. The researchers gathered data on cigarettes received during the CNY and individual HH cigarette consumption with the hypothesis that there would be a positive correlation between the amount of cigarettes received during the CNY and HH personal annual cigarette consumption. Due to the length of the holiday, all activities reported 1 week before CNY and 1 week after CNY were scored as associated with CNY. Additionally, HH gave estimates for annual income and other household activities. Lastly, all smokers were asked about changes in their smoking behaviour during the CNY. Each house took between 30–80 min to complete according to family size.
Along with a local guide, interviewers travelled from door to door to the homes of participants and introduced themselves as students of Xiangya School of Public Health conducting a survey on the health of residents in SJQ. Informed consent was obtained orally. Interviewers would then ask who was the HH and begin by administering the household section of the RCGS followed by the individual section for every participant who met the inclusion criteria. Interviewers positioned themselves so that participants could easily see how the interviewers were recording their responses in order to maintain the integrity of the response. Interviews were primarily conducted in Mandarin Chinese except occasionally when the local Changsha dialect was needed for elderly residents. After completing the survey for each household, a small gift of an apron was given as a sign of gratitude.
The results were tabulated using Epidata V.3.1 and analysed using both SPSS V.15.0 and Prism V.5.0d. All p values presented are two-tailed.
Results
Individual demographics and smoking behaviour
Complete datasets were obtained from 100 adult men and 98 adult women representing 105 households. A demographic profile is presented in table 1. Seventy-four (74%) of the men and seven (7%) of the women reported being current smokers. These rates of smoking are slightly higher but are overall consistent with other studies of China's adult rural populations.18 Daily cigarette consumption by male smokers was significantly higher than by female smokers (25.6 vs 9.3 cigarettes/day, p=0.0012).
Individual demographic data for survey participants
Carrying multiple brands, a practice used to enable sharing of cigarettes of varying price for different occasions, was reported by 37% (30/81) of smokers. The price per pack of the cigarette brand most commonly smoked by each participant ranged from 2.1 to 8 RMB with a mean (SD) of 3.74 (2.09) RMB.
Effects of sharing cigarettes and the CNY on cessation and increased consumption
Sharing cigarettes within the past week was common among male smokers in the study set (figure 1). 95% of male smokers (70/74) offered cigarettes to known smokers while only 38% of male smokers (28/74) offered cigarettes to persons of unknown smoking status. Male non-smokers and all women offered cigarettes at lower rates.
Sharing cigarettes stratified by gender and smoking status. Percentages of respondents who reported offering cigarettes to known and possible smokers within the past week. Error bars depict standard error of the mean.
Ninety-two per cent of men (92/100) and 19% of women (19/98) reported being offered a cigarette within the past week. Over 62% of current smokers (50/81) had tried to quit at least once in their life. Of the 50 people who had tried to stop smoking, 40 (80%) said their friends had ever tempted them with cigarettes to deter their quitting efforts and 30 (60%) said that this behaviour had seriously impacted their attempts to quit smoking. Thirty-six of the 81 current smokers (44%) reported that they consumed more cigarettes during the 2-week CNY period. The most frequently cited reason for smoking more was having additional guests with whom to smoke (53%, 19/36), followed by having more leisure time (39%, 14/36) and having more cigarettes (8%, 3/36). Of all smokers who had tried to quit smoking, 38% (19/50) said the cigarettes they received during the CNY had negatively influenced their efforts to quit.
Household cigarette gifting behaviour and the economic burden of cigarettes
Of the 105 households interviewed, 77 (73%) reported sending cigarettes as a gift and 84 (80%) reported receiving gifted cigarettes. All reported gifts consisted of 10-pack cartons. Sending cigarettes as a gift was pervasive among both households where the HH smoked and households where the HH was a non-smoker (75%, 49/65, vs 73%, 29/40). Among families giving cigarettes during the CNY, the average total number of cartons gifted was 6.35 (range 1–24). The average amount spent on cigarettes as gifts during the holiday was 633 RMB (range 50–2550), accounting for 2.8% (range 0.1–26%) of yearly family income. Households where the HH was a current smoker spent more money and a higher percentage of their annual income on gifts of cigarettes than households with a non-smoking HH (table 2). Annual household income averaged 33 000 RMB and was positively correlated with both number of cartons sent (p=0.0067, Pearson R=0.30; figure 2) and the total value of gifts sent (p=0.0002, Pearson R=0.41). While the majority of gifted cigarettes sent were to family members (80%), the brands of cigarettes given to non-family work-related recipients were significantly higher in price (80 vs 243 RMB/carton, p<0.0001). The size and value of the gift received was not significantly associated with increased tobacco consumption by the HH. The weighted average of the price per pack of cigarettes received by smoking HHs during the CNY was 8 RMB/pack. Households in which the HH smoked reported receiving an average of 4.6 cartons during the CNY, which represents an average of 13.4% (range 0.0–54.8%) of total household annual cigarette consumption for households in which a smoker was present (cigarettes received during CNY/annual cigarette consumption of all household members).
Household cigarette gifting behaviour during the Chinese New Year
Correlation between family income and quantity of gifted cigarette cartons. Log10 values of annual household income in Renminbi (RMB) and number of cartons of cigarettes gifted during the Chinese New Year (CNY) are plotted. Line of best fit is plotted (slope = 0.2567 ± 0.09205, Pearson R=0.30).
Discussion
Limitations of study
The small sample size and the limited geographical distribution of the participants make it hard to generalise these results for the rest of China. Additionall,y this subject has not been extensively studied and there are few published data with which to compare these results. It is particularly difficult to estimate accurately the total financial expenditure on tobacco products, both for gifting and personal consumption. As shown by this study, gifting of cigarettes during the CNY is widespread and costly. To some extent, these costs may be offset by received cigarettes that can be smoked, sold or traded, further complicating estimation of the fraction of household budgets dedicated to tobacco products. Further studies should specifically inquire about how different demographics use the cigarettes they receive during the CNY and, specifically, what non-smokers do with their cigarettes. One possible method would be to sample participants from people selling cigarettes to gift recycling stores. Another important aspect that should be investigated is the extent to which gifted cigarettes are from family members working in distant urban economies or from local acquaintances.
Sharing cigarettes
This study provides a quantitative picture of the culture of gifting and sharing cigarettes in rural China. Smoking in rural China continues to be extremely high among men and merits prompt attention by public health advocates, practitioners and authorities. It is clear that cigarettes are a valuable tool for social communication. This can be seen in the large proportion of respondents that carry two packs of cigarettes in order to be able to offer the appropriate cigarette for diverse situations. The fact that so many non-smokers reported offering cigarettes exemplifies the extent to which cigarette sharing has become an integral part of daily life in rural China. Social pressures demand that even a non-smoker should allow his guests to smoke and even provide them with cigarettes. Additionally, the large percentage of male smokers who offer cigarettes to people without knowledge of their smoking status indicates the daily pressures that non-smokers face. Mass media campaigns are needed to rightly stigmatise this behaviour in both rural and urban locations. Given the deep resistance presented by Chinese tobacco companies to other elements of the WHO Framework Convention on Tobacco Control (FCTC) such as increased taxes and the addition of graphic warning labels, mass media campaigns may be an effective strategy to diminish smoking that is supported by the culture of cigarette sharing. Furthermore, if these mass media campaigns also included education detailing the harms of prolonged tobacco use, it would help deter people from offering cigarettes to their friends trying to quit smoking.4 ,8
Gifting cigarettes and the CNY
Previous research suggests that, among low-income Chinese farmers, the cost of cigarettes limits consumption.19 We hypothesised that there would be a positive correlation between the number of cartons or the total monetary value of the cigarettes received during the CNY and the total amount of cigarettes smoked by HHs. The data collected in this study indicate that gifts received during CNY provide low-income households an average of 12.4% of their annual cigarette consumption unless a substantial amount of cigarettes received are sold or given away. This may significantly reduce financial barriers to smoking among lower income households. Furthermore, smoking HHs received cigarettes that were on average more than twice as expensive as their normal brand of cigarettes. Retail gift exchange is well-established in Chinese society and presents a venue for the conversion of expensive gifted cigarettes to lower priced cigarettes. Depending on the conversion of expensive to cheaper cigarettes, the CNY could provide more than 25% of annual cigarette consumption. However, contrary to our hypothesis, neither the quantity nor the value of the cigarettes received during the CNY was significantly associated with the number of cigarettes consumed by the smoking HHs. If all households received cigarettes regardless of whether the HH was a light or heavy smoker, no correlation would be seen between received cigarettes and number of cigarettes consumed by HHs. This could be particularly concerning given that gifts of cigarettes probably have a bigger impact on light smokers than on heavy smokers.10
Without effective interventions, gifting and sharing cigarettes are likely to continue to be common practices in rural China. The data in the present study show that wealthier families sent both larger and more expensive gifts of cigarettes during the CNY, possibly indicating that, as rural China continues to prosper, a significant portion of this new wealth is likely to be spent on gifts of cigarettes.
Limiting the practice of gifting cigarettes during the CNY should be sought for the reduction in tobacco consumption and also for the secondary benefit of saving family income for other quality of life expenses. Owing to the pervasiveness of gifting cigarettes, tobacco consumption is shielded from household financial pressures, especially given the importance of maintaining ‘face’ in Chinese society. It is very likely that gifts of cigarettes would take precedence over other household expenditures and may possibly be an impediment to using taxation to lower tobacco consumption.5
Future tobacco control strategies may benefit from emphasising the fact that expensive cigarettes are not inherently safer than their less expensive counterparts, thus decreasing the attractiveness of cigarettes as gifts. With further education, this instinct to respect the health of the recipient might divert gifting expenditures from cigarettes to other well-branded expensive luxury items. If cigarettes could be replaced with other expensive items such as medicine, electronics or even food items, it would be more beneficial for the overall well-being of families than gifts of cigarettes.20 The difference in the price of cigarettes given to work and non-work relationships is indicative of the social and economic value of cigarette gifting, a foreboding sign for tobacco control measures aimed at limiting this practice.
One of the most direct methods of educating tobacco consumers is the use of mandated text and graphic warnings on all cigarette packaging, a recommendation strongly supported by the FCTC. Graphic warning labels have been shown to effectively increase awareness of the dangers of smoking and to reduce overall consumption in other countries including the USA, UK, Australia and Canada,21 and there is little reason to think that similar success could not be achieved in China. It has been clearly demonstrated that Chinese adults would be less likely to give cigarettes as gifts if China adopted graphic warning labels.22
Conclusion
The present study highlights the connections between the common practices of sharing and gifting cigarettes and the smoking behaviour of rural Chinese residents. While more research is needed to demonstrate a causal relationship between gifting and sharing cigarettes and decreased smoking cessation and increased daily consumption, the results of this study strongly suggest that these social practices are significant contributors to tobacco consumption. The implementation of tobacco control efforts in the context of the CNY poses both a challenge and an opportunity. The World Lung Foundation campaign to limit the amount of cigarettes that are given as a gift14 should be seen as a good first step, but similar efforts must be extended to rural China to denormalise behaviours associated with cigarettes.
What this paper adds
-
Gifting and sharing cigarettes, both pervasive in China, are increasingly recognised for the importance they hold for tobacco control efforts. These practices have not previously been examined quantitatively in rural China.
-
Sharing cigarettes among men is pervasive, even among non-smokers, and may have serious implications for impairing tobacco cessation efforts in China.
-
This paper shows the significant financial investment in gifting cigarettes and illustrates the impact it can have on low-income families.
-
This study also points out the role of tobacco gifting as a form of remittance that may effectively subsidise rural tobacco consumption.
References
Footnotes
-
Contributors All authors made substantial contributions to study design and manuscript preparation. ZCR and MH preformed data collection and analysis.
-
Funding Funding was provided by the Fulbright Program, US State Department to ZCR and a China Medical Board Distinguished Professor Award to SYX.
-
Competing interests None.
-
Ethics approval Ethics approval was obtained from the Central South University School of Public Health Institutional Review Board.
-
Provenance and peer review Not commissioned; externally peer reviewed.
-
Data sharing statement Original data is available upon request.