Health Education Research Advance Access published online on February 16, 2008
Health Education Research, doi:10.1093/her/cyn002
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Psychosocial correlates of cigarette smoking among college students in China
1 Institute of Mental Health, Nanjing University, 22 Hankou Road, Nanjing 210093, China
2 Prevention Research Center, Carmen and Ann Adams Department of Pediatrics, Wayne State University School of Medicine, 4201 St Antoine Boulevard, Detroit, MI 4821, USA
3 Department of Social and Behavioral Health, School of Rural Public Health Texas A&M Health Science Center, College Station, TX 77843, USA
Correspondence to: * Correspondence to: X. Li. E-mail: xiaoming_li{at}wayne.edu
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Abstract |
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The objectives are to examine the smoking practice and intention among Chinese college students and to explore the association between cigarette smoking and individual and psychosocial factors. Cross-sectional data were collected from 1874 students from 19 college campuses in Jiangsu province, China. Both bivariate and multivariate analyses were performed to assess the associations of smoking practice and smoking intention with various individual and psychosocial factors. There was a significant gender difference in both smoking practice and smoking intention. Overall, 53% of the participants (70% male and 31% female) reported ever having smoked in their lifetime and 29% of the sample (49% male and 5% female) reported having smoked in the past 30 days. About one-fourth of the sample (44% male and 6% female) thought they were likely to smoke in the next 6 months. Male gender, low family socioeconomic status, perception of more peer smoking, more perceived benefits of smoking, higher level of pro-smoking attitude, higher level of perceived cost of non-smoking and more involvement in other health risk were positively associated with being a past or current smoker. Likewise, male gender, older age, more friends smoking, greater perceived benefits of smoking, higher pro-smoking attitudes and more health risk involvement were associated with the likelihood to smoke in the next 6 months. The data suggest a substantial smoking experimentation among college students in China, which presents both a challenge and an opportunity to prevent a large proportion of experimenters from progressing to regular smokers. The findings in the current study can be used to inform the development of effective smoking intervention prevention programs among college students in China.
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Introduction |
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China is the world's largest producer as well as consumer of tobacco, accounting for 37.5% of the global production and 38.8% of the global consumption [1]. The two national tobacco surveys conducted to date in China in 1984 and 1996 provided evidence of an increasing trend in smoking among the adult population [2–4]. Male smokers (who smoked at least one cigarette daily) increased from 56% in 1984 to 61% in 1996. The average number of cigarettes smoked daily has increased from 11 to 15 for men and from 9 to 10 for women from 1984 to 1996. The average age of smoking initiation was 3 years younger in 1996 compared with 1984. Smoking also continues to affect a large number of non-smokers in China. According to the 1996 survey, 91% of smokers smoked in public places and the overall rate of environmental tobacco smoke exposure was 72% [4]. Recent data from China suggested a continuously increasing trend of cigarette smoking among both men and women [5, 6]. A recent analysis of major causes of death in China revealed that cigarette smoking is the second preventable risk factor (next to hypertension) for death in China [7]. Both retrospective and prospective studies provide evidence that smoking accounts for
10–12% of mortality among men and 3.5% among women in China [7, 8]. Historically, advanced level of education was associated with lower smoking rates [9]. However, in recent years, smoking rate among those with higher education levels is also increasing. For example, a study in Shanghai, China, revealed that smoking rates among Chinese male physicians increased from 57% in 1984 to 66% in 1989 and the number of daily smokers among medical students increased from 9% in 1988 to 26% in 1992 [10]. These emerging epidemiological trends of cigarette smoking in China and its association with education underscore the importance of antismoking health promotion efforts among young adults including college students. As suggested by previous studies [11], a study of cigarette use among college students may provide unique data for a better understanding of the transition process from smoking initiation/experimentation in adolescence to nicotine addiction/dependence in adulthood. College years also present an ideal period for effective health promotion efforts preventing such a transition. Identification of individual characteristics and psychosocial factors associated with smoking among college students may lead to more effective health promotion efforts among adolescents and young adults [12].
Smoking has been a normative behavior among adult men in China for hundreds of years. The offering of cigarettes is a means for social and business interaction and a friendly gesture. In most areas of China, cigarettes are offered to and accepted by everyone (including women and children) during social revels such as a wedding ceremony. Smoking has been accepted as a catalyst of friendship and social activities, and provides a convenient mechanism to make new friends and develop personal and business relationships [6, 13]. In China, smoking is also considered a symbol of wealth and social status, and smoking American or Western brands cigarette is considered a sign of prestige and modernization [6, 14, 15]. Previous studies in the United States and Western nations documented a number of risk factors that were associated with cigarette smoking among adolescents and young adults (including college students). These factors include social normative beliefs, pro-smoking attitudes and perceptions, depression or stress, family and peer smoking, smoking resistance self-efficacy, involvement in other risk behaviors including experimentation and use of alcohol or illicit drugs, low socioeconomic status (SES), poor academic performance at school, low educational aspiration and poor perceived health status [16–23].
However, limited data are available regarding psychosocial correlates of cigarette smoking among college students in China. A study among medical students in Wuhan, China, found that having a family member who smoked was significantly associated with smoking [24]. The same study also suggested that stress, curiosity and loneliness were associated with smoking initiation [24]. A study among Chinese college students in Hong Kong suggested that positive attitudes toward substance use were significantly associated with cigarette smoking [25]. A study among college students from three Chinese cities (Beijing, Wenzhou and Hangzhou) revealed that perceived benefits of smoking were associated with cigarette smoking [26]. However, most of the factors examined in the current literature are potentially highly correlated with each other and no study has simultaneously examined theses factors among college students in China. Therefore, the current study was designed to examine smoking practice and intention among Chinese college students and to explore the association between cigarette smoking and a number of individual and psychosocial factors, including subjective norms of family and peer smoking, personal attitudes and perception toward smoking, depressive symptoms, social relation and engagement in other health risk behaviors.
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Methods |
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Study site and participants
The data were collected in 2001–02 from 19 colleges in Jiangsu province in Eastern China. Jiangsu, with a population of 71 million, is among the wealthier and more educated administrative regions (i.e. provinces, autonomous regions and municipalities) in China. The participating colleges include 9 colleges from Nanjing, the capital city of Jiangsu province, and 10 from other Jiangsu cities outside Nanjing. The procedures for school selection and recruitment have been described in detail elsewhere [11]. The participating schools were selected by the local educational researchers to be representative of the local schools in terms of type, number of students enrolled, admission criteria (e.g. cutoff score on the national college entrance examination).
Survey procedure
Permission was obtained from the local college administrators and written informed consents were obtained from students. All participating students completed a self-administered questionnaire during regular class time. The school personnel (including those who provided assistance with the recruitment) were asked to leave the classrooms during the survey. The responses were anonymous and participants were assured of the confidentiality of their responses. A total of 1900 students (100 students in each of the participating colleges) were approached and 1874 (56% male and 44% female) agreed to participate and completed the questionnaire, which yielded a participation rate of 98.63%. The study protocol was approved by the local Institutional Review Boards in both the United States and China.
Measures
Cigarette smoking practice and intention
Six items were employed to measure cigarette smoking practice: ‘ever smoked’, ‘smoked in the past 30 days’, ‘age at which the first whole cigarette was smoked’, frequency (i.e. number of days smoked) and quantity (i.e. number of cigarettes smoked daily) of smoking in the past 30 days, and ‘ever tried to quit’. These items were adapted from similar items in the US Centers for Disease Control and Prevention 2000 Youth Risk Behavior Survey (2001) [27]. For the purpose of data analysis in the current study, a three-category variable (never smoked, past smoked and currently smoked) was created by combining the responses to the items of ever smoked and smoked in the past 30 days. Youth who ever smoked but had not smoked in the past 30 days were classified as ‘past smokers’ and those who reported smoking in the past 30 days were considered as ‘current smokers’. In addition, all students were asked about their intention to smoke in the next six months on a three-point scale (very likely, likely and unlikely). For the purpose of data analysis, the ‘very likely’ and ‘likely’ responses were combined into a single category (i.e. likely) in the current study.
Family SES
Six items in the survey were used to measure various aspects of family SES (e.g. level of family income, place of family residence, parental education and parental occupation). An overall family SES indicator was created by summing the dichotomous responses to the six items as to whether their father and mother (or their legal guardians) had college level of education, whether their father and mother (or their legal guardians) had a professional job, whether they had an above-average monthly family income and whether their family resided in an urban area. The composite index ranged from 6 to 12 with a higher score indicating a higher family SES.
Depression
Depressive symptoms were measured using the Center of Epidemiological Studies Depression Scale (CES-D) [28]. The existing Chinese version of the CES-D [29] was examined and modified by the investigators to ensure the accuracy of the translation. The Cronbach alpha was 0.88 for the current study sample. The scale scores ranged from 0 to 60, with higher scores indicating higher frequency of depressive symptoms.
Social alienation
Participants' feelings and perception of social relations with others in school were measured using the Alienation scale developed by Jessor and Jessor [30]. The Alienation scale consists of 15 items assessing perceived uncertainty in daily life and isolation from others. The scale was translated into Chinese by the authors in the current study. Independent back translation was performed to ensure the accuracy of the translation. The response option ranged from 1 = ‘strongly disagree’ to 4 = ‘strongly agree’. The Cronbach's alpha was 0.78 for the study sample.
Other health risk involvement
In addition to cigarette smoking, the students were also asked whether they had engaged in sex, had sex without a condom, had two or more sexual partners, visited pornographic websites or consumed alcoholic beverages (beer, wine and liquor). Two composite scores (i.e. sexual risk and alcohol use) were created using the sum of the positive response to relevant risk behaviors. The sexual risk composite score ranged from 0 (engaged in none of the risks) to 4 (engaged in all four mentioned risks). Likewise, the alcohol use composite score ranged from 0 (no use of alcohol) to 3 (consumed all three types of alcoholic beverage).
Family and peer smoking
Participants' subjective norms of smoking were measured using six items including three asking for current smoking status (yes/no) of their family members (father, mother and relatives) and three asking for the proportion (none, very few, some, about half and most) of their peers (good friends, friend and classmates) who were currently smoking. Separate indices were created for ‘parents smoking’, ‘relatives smoking’, ‘friends smoking’ and ‘classmates smoking’ by summing responses to relevant items. For each index, a higher score indicates a greater number of smokers among family members or peers.
Perceived benefit of smoking
Five items were employed to measure the students' perception of potential benefits of smoking (e.g. ‘smoking can help with social interaction’, ‘smoking will make youth look more mature’). The response option for these items ranged from 1 (strongly disagree) to 4 (strongly agree). The Cronbach alpha for this five-item scale was 0.81.
Pro-smoking attitudes
Three items were employed to assess students' pro-smoking attitudes (e.g. ‘I will smoke if my financial situation permits’, ‘smoking does no harm if you do not smoke too much’). The response option for these items ranged from 1 (strongly disagree) to 4 (strongly agree). The Cronbach alpha was 0.77 for the study sample.
Self-efficacy
Resistance self-efficacy was measured using seven items about their personal confidence on their ability to refuse or to control the use of tobacco or other substances (e.g. ‘I do not have to smoke even if all my friends do’, ‘if I smoke, I can control myself from becoming addicted’). These items had a response option ranging from 1 (strongly disagree) to 4 (strongly agree). The Cronbach alpha for the scale was 0.54.
Perceived cost of non-smoking
Students were asked about their perceived potential personal cost if they do not smoke (or quit smoking). The perception was measured using three items with a four-point response option (ranging from 1 = strongly disagree to 4 = strongly agree). The examples of these items are ‘it is not polite if you do not accept a cigarette offered by others’ and ‘I will miss an important experience if I do not smoke’. Cronbach alpha for this three-item scale was 0.77.
Other individual factors
Students were also asked about their ethnicity (Han majority or other ethnic minorities), perceived health, academic performance, education expectation and family constellation. For perceived health, students were asked to rate their health on a four-point scale ranging from ‘poor’ to ‘excellent’. Students were asked about their relative standing in their classes in terms of their academic performance with a five-point response option (‘bottom’, ‘below average’, ‘average’, ‘above average’ and ‘top’). The education expectation was measured using a question about the highest education attainment the students expected themselves to accomplish (‘2 or 3 year college’, ‘4 year college’, ‘master degree’ or ‘doctoral degree’). For family constellation, students were asked about adult figures whom they lived with before they came to college (e.g. birth parents, stepparents, foster parents or grandparents).
Statistical analysis
First, chi-square test (for categorical variables) and analysis of variance (for continuous variables) were employed to examine the gender differences in individual characteristics, smoking practice, smoking intention and psychosocial factors among the study sample. The same analytic procedures were also used to examine the bivariate associations of smoking practice (i.e. never, past and current) and smoking intention (i.e. likely, unlikely) with individual characteristics and psychosocial factors. To facilitate the item-level bivariate analyses of the perceptional and attitudinal measures (i.e. perceived benefit of smoking, pro-smoking attitudes, self-efficacy and perceived cost of non-smoking), ‘strongly agree’ and ‘agree’ responses were combined to represent the respondents’ endorsement to each of the statements.
Second, multinominal logistic regression (for three-category dependent variable of smoking practice) and multiple logistic regression (for dichotomous measure of smoking intention) were employed to assess the relative strength of various individual and psychosocial factors in predicting smoking practice and smoking intention among Chinese college students. Adjusted odds ratios and their 95% confidence intervals were calculated for each of the predictors in the full model of logistic regression. Because of the considerable gender difference in smoking practice, both multivariate analyses were repeated within each gender group. All statistical analyses were performed using SPSS for Windows v11.5.
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Results |
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Sample characteristics
The study sample consisted of 27% freshmen, 42% sophomores, 25% juniors and 6% seniors. Detailed demographic characteristics including age, ethnicity, gender, perceived general health, academic standing in school, their own educational expectation, and family constellation are presented in Table I. There were significant gender differences with regard to a number of individual characteristics. Females were younger than males (19.55 years versus 20.07 years, P < 0.05). More males perceived themselves to be in excellent/good health than females (P < 0.0001). More females than males reported top school performance (P < 0.0001) and an expectation of finishing graduate school level education (P < 0.05). Females perceived a higher family SES than males in terms of paternal occupation (P < 0.0001), maternal occupation (P < 0.01) and monthly family income (P < 0.0001). Compared with female students, male students reported a higher level of depressive symptoms (P < 0.01) and social alienation (P < 0.01).
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Smoking practice and intention
As shown in the lower portion of Table I, 53% of the participants reported ever having smoked in their lifetime (70% male and 31% female, P < 0.0001) and 29% of them reported having smoked in the past 30 days (49% male and 5% female, P < 0.0001). The age and gender trends of ever smoking and past 30 days smoking are depicted in Fig. 1. About 30% of the sample (27% male and 39% female, P < 0.01) who ‘ever smoked’ had smoked the first whole cigarette before 13 years of age and nearly half of them had ever tried to quit. Among those who reported smoking in the previous month, 21% of them reported smoking at least one-third of the time (i.e. at least 10 days) and 44% (46% male and 19% female, P < 0.01) reported smoking at least one cigarette daily on the days that they had smoked. About one-fourth of the sample thought they were likely to smoke in next 6 months (44% male and 6% female, P < 0.0001).
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Smoking-related perceptions and attitudes
As shown in Table II, a small number of students (3%) reported that their mothers were currently smoking, whereas most of the participants reported their fathers (60%) and relatives (76%) were currently smoking. About one half (more males than females) of the students reported that some of their friends or good friends were smoking. Eighty percent of the students reported that some of their classmates smoked.
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Fifty-eight percent of the students reported that smoking was good for social interactions. Twenty-six percent perceived that smoking would help thinking. About two-tenths thought that smoking would make youth look more mature or more masculine. Forty-five percent thought that smoking would help people to relax. There was a significant gender difference in terms of perceived benefit of smoking with more males than females believing that smoking would be beneficial in several aspects of their lives. While students generally had a low level of personal pro-smoking attitudes, there was a significant gender difference regarding these perceptions with males having a higher level of pro-smoking attitudes than females.
The majority of students had a high level of resistance self-efficacy regarding smoking and alcohol. However, <20% believed that they could control themselves if they used drugs. In general, more females than males thought they could resist the pressure from their friends regarding smoking and drinking.
There was a wide variation in perceived personal costs for non-smoking. About one-fifth agreed that they would miss a very important experience if they did not smoke. Four-tenths thought it would be impolite not to accept cigarettes offered by others. The majority of the sample (60%) considered it improper not to offer cigarettes back if they had smoked others’ cigarettes.
Bivariate association between individual characteristics and cigarette smoking
As shown in Table III, both smoking status and smoking intention were associated with advancing age, male gender, school performance, educational expectation, and perceived health. However, there was no association between various family constellation measures and smoking status or smoking intention except that more students who were the single child in their family had tried smoking either in the past or currently (P < 0.01). Family SES measures were strongly associated with both smoking practice and smoking intention. More students from families with a relatively lower SES (e.g. lower parental education, non-professional parental occupations, lower income or a rural residence) had tried smoking or intended to smoke in the near future.
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Bivariate association between psychosocial factors and cigarette smoking
As shown in the bottom section of Table III, all 12 psychosocial factors examined in this study were significantly associated with cigarette smoking practice except relatives smoking. Likewise, all 12 psychosocial factors were associated with smoking intention except relatives smoking and self-efficacy. Post hoc comparisons (data not shown in the table) using the least significance difference criterion revealed that the current smokers scored higher than the non-smokers on all 12 psychosocial factors except relatives smoking and scored higher than past smokers on all the psychosocial factors except relatives smoking and self-efficacy. The past smokers scored significantly higher than the non-smokers on seven of the 12 psychosocial factors (relatives smoking, friends smoking, perceived benefit of smoking, pro-smoking attitudes, perceived cost of non-smoking, self-efficacy and alcohol use).
Multivariate analysis
Table IV depicts the results of multinominal regression analyses. Seven factors remain significant in the comparison between ‘non-smoker’ and ‘current smoker’ for entire sample. Female gender, high family SES, perception of less peer smoking, fewer perceived benefits of smoking, lower level of pro-smoking attitude, lower level of perceived cost of non-smoking and less alcohol use were positively associated with being a non-smoker. Similar results were found for the comparison between ‘past smoker’ and ‘current smoker’ with the exception that family SES and perceived cost of non-smoking were no longer significant in differentiating the two groups. The same significant predictors were found in male-specific model as in the model for entire sample. However, for the female-specific model, only alcohol use was found to be a significant predictor in comparisons between non-smoker and current smoker and between past smoker and current smoker.
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The multivariate logistic regression analysis for smoking intention (Table V) for the entire sample revealed male gender, advanced age, more friends smoking, greater perceived benefits of smoking, higher pro-smoking attitudes and more risk involvement (sexual risk and alcohol use) being associated with the likelihood to smoke in the next 6 months. The gender-specific analyses revealed a striking difference between the male and the female samples. For the male sample, friends smoking, perceived benefits of smoking, pro-smoking attitudes and alcohol use were associated with smoking intention. For the female sample, perceived health, family SES, peer (friends or classmates) smoking, depression, social alienation, sexual risk and alcohol use were associated with their smoking intention.
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Discussion |
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The data in the current study suggest a strong association of cigarette smoking with peer smoking, positive personal attitudes toward smoking and engagement in other health risk behaviors, with these associations persisting even after controlling for potential confounders. These findings underscore a need for effective intervention prevention efforts targeting smoking initiation and smoking cessation among college students in China.
Although the overall rate of ever smoking was alarmingly high among college students (70% for male and 31% for female), almost half of these students had not smoked during at least the past 30 days. This finding suggests a substantial proportion of smoking experimentation among college students in China, which presents both a challenge and an opportunity to prevent a large proportion of experimenters from progressing to regular smokers.
Historically, smoking in China has been a male-dominated behavior with low smoking rates among women. Previous data suggested a more rapid increase in smoking rates among women than men, particularly among young and middle age professional women [2]. The data in the current study not only confirm the gender difference in smoking rates reported in a number of recent studies [31–34] but also suggest a bigger increase of smoking among female college students than male college students. While recent national data from comparable age and education groups are not available, the 1996 China National Tobacco Survey reported a current smoking rate of 18.47% among male college students and 0.75% among female college students [9]. The data in the current study (e.g. 49% male and 5% female smoked in recent 30 days) represent 165 and 566% increase in smoking for male and female college students, respectively. Although the rates of smoking reported in the current study might be inflated by some experimenters of smoking, the trend of increase among female college students certainly warrants attention from health researchers and health educators. Female smoking rates in China need to be monitored by researchers to identify any change in smoking trends among this group. The results in this study also suggest that smoking prevention programs are important for females to maintain low smoking rates, while smoking cessation programs should strongly focus on males to elicit cessation.
The strong association between cigarette smoking and engagement in other health risk behaviors (including sexual risk) supports the applicability of ‘problem-prone theory’ [30] in Chinese settings. According to the problem-prone theory, a wide range of adolescent problem behaviors including alcohol consumption, cigarette smoking, marijuana use, use of other illicit drugs, delinquent behavior and early sexual onset are associated with each other, and that these behaviors constitute a ‘syndrome’ of problem behavior which, though varying by circumstances and age, characterizes the behavioral repertoire of the youth throughout their adolescence. Previous studies demonstrated a covariation among health risk behaviors in the Chinese adolescent population [35, 36]. The current study provides further empirical evidence for such a covariation among young adult population. The data also suggest that despite the ‘normative behavior’ belief of tobacco use in Chinese culture, cigarette smoking is indeed part of the health risk constellation among college students (both men and women).
In contrast to the existing literature in the United States [19] and elsewhere [37], the data in the current study did not show a strong relationship between self-efficacy and smoking practice among college students. One possible reason for the finding was the weak measure of self-efficacy in this study. The estimate of internal consistency was relatively low (Cronbach 
= 0.54) and the scale also contains items regarding use of other substances to which college students could have fundamentally different perceptions. Future studies using improved measures of resistance self-efficacy (ideally separate scales for initiation and quitting) may provide a better understanding of the relationship between self-efficacy and smoking practice.
There are a number of potential limitations in this study. First, the data are based on self-reporting by the college students and thus are subject to self-reporting bias. Second, our ability to generalize these findings to the other young adult populations or other geographic locations in China is limited, because only one-tenth of youth in China attended college during the years of data collection [38] and smoking rates vary substantially across different populations and geographic locations in China [31, 33]. Third, because of the space limitation in the survey questionnaire, data were not available in the current study regarding students’ exposure to tobacco promotion, which has shown a strong association with smoking practice among college students in both the United States and China [39, 40]. Finally, as with any cross-sectional data, causality cannot be inferred from the observed associations in the current study.
Several findings in this study can be used to inform the development of effective health promotion programs to prevent smoking among college students in China. First, the content of the health promotion and intervention needs to be gender specific. Because of the substantial gender difference in smoking practice and its psychosocial correlates, further antismoking health promotion efforts need to consider gender-specific approach and gender-specific content in order to meet the specific needs of men and women in college [41]. Second, the health promotion efforts need to incorporate both individual factors and environmental factors. Because subjective norms about peer smoking and positive personal attitudes toward smoking are the most important predictors of smoking practice and intention among college students, future efforts should focus on the change of these pro-smoking perceptions and attitudes through multifaceted approaches (e.g. health educations, prevention interventions, mass media campaigns, policies and/or laws that increase smoking-free places and restrict tobacco marketing). In addition, because most of these pro-smoking attitudes and perceptions are rooted in traditional Chinese culture [6], it is necessary for health promotion efforts to target the change at the societal level by altering the social norms and promoting an antismoking cultural environment [6]. Third, the health promotion should identify and target potential common determinants and correlates of smoking and other problem behaviors.
In order for health education programs to increase effectiveness in reducing health-related risks among adolescents and young adults and to be cost efficient, it is suggested that common determinants of health risk behavior (e.g. such as self-esteem issues, depression and social alienation) and essential behavioral skills (e.g. communication skills, negotiation skills) are taken into consideration when developing health promotion programs.
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World AIDS Foundation (218-00-014).
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Conflict of interest statement |
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TopAbstractIntroductionMethodsResultsDiscussionFundingConflict of interest statementAcknowledgementsReferences |
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None declared.
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Acknowledgements |
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TopAbstractIntroductionMethodsResultsDiscussionFundingConflict of interest statementAcknowledgementsReferences |
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The authors wish to thank colleagues and graduate students at the Nanjing University Institute of Mental Health for their assistance in data collection. The authors also want to thank Ambika Mathur and Joanne Zwemer for assistance in preparing the manuscript.
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References |
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Received on May 4, 2007; accepted on November 30, 2007
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