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Cigarette smoking among schoolboys in Beijing, China
Journal of Adolescence 1999, 22, 621±625 Article No. jado.1999.0257, available online at http://www.idealibrary.com on
Cigarette smoking among schoolboys in Beijing, China XIAOMING LI, XIAOYI FANG
AND
BONITA STANTON
The current study was designed to assess the recent rate of cigarette smoking and to examine the association of cigarette smoking with individual factors and problem behaviors using data collected in December 1997 from 323 middle school students (43% females) in Beijing, China. About 15% of the study sample (23% males and 5% females) reported having ever smoked. The data in the current study confirmed findings from our earlier study (Li et al., 1996, Substance Use and Misuse, 31, 545±563) that the prevalence of cigarette smoking among Chinese adolescents was higher among males, increased with advancing age and was associated with participation in other problem behaviors and with poorer self-perceived academic performance. The data underscore the need for smoking-prevention programs targeting Chinese children and adolescents. # 1999 The Association for Professionals in Services for Adolescents
Introduction While the rates of cigarette smoking have declined over the past three decades in the U.S.A., Canada, and other western nations, tobacco use rates have remained stable or increased in many Asian countries, including China (World Health Organization, 1996). In spite of this alarming trend, the progression and determinants of cigarette smoking among Chinese have not been well documented (Chapman, 1994). There are few empirical data available regarding cigarette smoking among Chinese children and adolescents. In 1991, as part of a larger, longitudinal study examining cigarette smoking among Chinese adolescents, we administered questionnaires to 1040 sixth, eighth and tenth grade students from five schools serving the general public in Beijing, China. Based on these data, we reported that (Li et al., 1996): one-fifth of the sample (mean age of 13?65 years) had smoked, although most were occasional smokers; smoking was more prevalent among males than females (29 vs. 11%, p50?00001); more than one-third of males had tried cigarettes by the age of 13; smoking prevalence increased with age (p50?0001); smokers were more likely than non-smokers to report poor school performance; and smokers were more likely than non-smokers to report problem behaviors. Since our collection of the data in 1991, several significant events have occurred in China related to tobacco use. First, in 1994 China officially opened its tobacco market to major overseas tobacco companies (Mackay, 1997). At the same time, the Chinese government has implemented some anti-smoking measures targeting the general population, including banning all cigarette advertising in the public media. In addition, numerous local governments, including 71 cities and three provinces, have banned smoking in public areas such as trains, buses, schools, cinemas and theaters (Mackay, 1997). The confluence of tobacco-related events is associated with both economic and scientific data indicating an increase in cigarette production and consumption in recent years. For example, the tax revenue which Chinese government generated from cigarettes increased from $5 billion in 1993 to $10 billion in 1996 (Chinese Association on Smoking and Health, Reprint requests and correspondence should be addressed to Xiaoming Li, Ph.D., Department of Pediatrics, West Virginia University, PO Box 9214, Morgantown, WV 26506-9214, U.S.A. (E-mail: [email protected]). 0140-1971/99/050621+05 $3000/0
# 1999 The Association for Professionals in Services for Adolescents
622
X. Li et al.
1997). A recent Chinese national survey conducted among adults in 1996 indicated that on average both males and females started smoking 3 years earlier compared to 1984 data. The survey also indicated that the average daily consumption of tobacco increased from 11 cigarettes in 1984 to 15 in 1996 for males, and from 9 to 10 for females (Mackay, 1997). In light of the changes related to cigarette smoking among the general population in recent years in China, it would be of interest to see whether (and how) the rate and patterns of cigarette smoking had changed among adolescents residing in China, as well as whether our previous findings based on the 1991 data can be replicated with another independent sample. Accordingly, the current study was designed to assess the recent rate of cigarette smoking among adolescents in Beijing and to examine the association of cigarette smoking with individual factors and problem behaviors.
Method Sample
Following recruitment procedures similar to those described for the 1991 survey (Li et al., 1996), data were gathered in December 1997. Subjects were seventh, eighth and ninth grade students at a typical public middle school in Beijing. All classes in the seventh grade participated and we randomly selected three classes among five classes in each of grades eight and nine. Permission was received from the school principal before we came to the school and in writing individually from students. Of the students, 323 gave their consent and 23 refused. A self-administrated questionnaire was distributed to each participant by research personnel during regular class time. The school teachers were asked to leave the classroom during the survey. The participants were assured of the confidentiality of their responses.
Measures Cigarette smoking. Two items were used to measure Chinese adolescent cigarette smoking. The first item asked students to identify their status related to smoking on a threepoint scale (``never smoked''; ``ex-smoker''; ``current smoker''). The second item asked how often students had smoked in the previous year (``never''; ``once''; ``several times''; ``often''). Because the correlation between these two questions was high (r 0?77; p 0?000), the first question was used as index of adolescent smoking in the analysis. The responses to the item were recoded to create a dichotomous measure (``never smoked'' vs. ``ever smoked''). The correlation between the original response and recoded response was 0?85 (p 0?000). School performance. Subjects were asked to categorize their school performance on a seven-point scale: 1 ``mostly below Ds''; 2 ``mostly Ds''; 3 ``mostly Cs and Ds''; 4 ``mostly Cs''; 5 ``mostly Bs and Cs''; 6 ``mostly As and Bs''; and 7 ``mostly As''. Parental education. Education levels for both father (or male guardian) and mother (or female guardian) were assessed on a five-point scale: 1 ``junior high school or less''; 2 ``some high school or completed high school''; 3 ``vocational school''; 4 ``some college or completed college''; 5 ``graduate school or more''. The higher level achieved by father or mother was retained as an index of parental education.
Cigarette smoking in Beijing
623
Educational expectation. The subjects were asked how much schooling they thought they would complete in the future on a five-point scale: 1 ``junior high school''; 2 ``high school''; 3 ``vocational school''; 4 ``college''; and 5 ``graduate school''. Pubertal development. Students were asked to describe the stage of their pubertal development on a four-point scale: 1 ``not yet begun''; 2 ``just started''; 3 ``under way for less than 6 months''; 4 ``under way for more than 6 months''. Perceived peer smoking. Each students was asked to list up to nine close or good friends and provide a description of smoking status for each friend they listed on a threepoint scale (``never smoked''; ``ex-smoker''; ``current smoker''). Similar to the main adolescent smoking index, these responses were re-coded to create a dichotomous measure (``never smoked'' vs. ``ever smoked''). Problem behaviors. Students were asked to describe on a four-point scale how often they had engaged in 20 problem behaviors in the previous year: 1 ``never''; 2 ``once''; 3 ``several times''; 4 ``often''. The responses to these items were recoded to create dichotomous measures (``never'' vs. ``at least once''). The Cronbach's alpha for 20 items with modified response choice was 0?84, indicating a good internal consistency. Total number of positive responses (i.e. ``at least once'') was retained as a overall measure of the involvement in problem behaviors.
Results About 15% of the sample reported having ever smoked cigarettes. Smoking was more prevalent among males than females (23 vs. 5%; p50?00001); as the number of smoking females was so small, analysis was restricted to males. As is shown in Table 1, cigarette smoking among male students was associated with older age, poorer school achievement, lower educational expectation, higher level of pubertal development and more tobacco use among friends. Parental education was not related to cigarette smoking. As is shown in Table 2, cigarette smoking was significantly associated with all problem behaviors. Table 1 Association between cigarette smoking and individual factors among schoolboys in Beijing, China N (%) Age (years) School achievement Educational expectation Pubertal development Parental education Perceived peer smoking *p50?05; **p50?01; ***p50?0001.
Never smoked
Ever smoked
135 (77) 13?33 (0?99) 3?68 (1.77) 4?17 (1?04) 2?11 (0?93) 2?23 (0?86) 0?07 (0?15)
40 (23) 13?79 (1?06)* 2?33 (1?56)*** 3?21 (1?13)*** 2?66 (0?87)** 2?05 (0?88) 0?31 (0?32)***
624
Table 2
X. Li et al.
Association between cigarette smoking and problem behaviors
N (%) Drank beer Drank wine Drank hard liquor Rode bike dangerously Fought Mischief at school Suspended or expelled Detained by teacher after school Cheated on test Plagiarized on homework Cut school for a whole day Missed classes Lied to parents about activities Forged signature Damaged property on purpose Doodled on public buildings Threatened to hurt someone Shoplifted Stolen Arrested by police Mean (S.D.) of problem behaviors
Never smoked
Ever smoked
135 (77) 42 (31) 39 (29) 3 (2) 44 (33) 54 (40) 70 (52) 6 (5) 62 (47) 29 (22) 50 (38) 3 (2) 7 (5) 28 (31) 14 (10) 9 (7) 9 (7) 21 (16) 2 (2) 1 (1) 1 (1) 3?66 (3?10)
40 (23) 32 (80)**** 18 (46)* 14 (35)**** 21 (53)* 27 (68)** 29 (73)* 6 (15)* 26 (67)* 19 (49)** 31 (82)**** 9 (23)**** 15 (39)**** 26 (67)**** 15 (39)**** 13 (33)**** 15 (39)**** 17 (44)*** 5 (13)** 5 (13)** 4 (10)** 8?68 (4?57)****
*p50?05; **p50?01; ***p50?001; ****p50?0001.
Discussion The data in the current study confirmed findings from our 1991 data that the prevalence of cigarette smoking among Chinese adolescents was higher among males, increased with advancing age, and was associated with participation in other problem behaviors and with poorer self-perceived academic performance. There is no consistent relationship between smoking and educational level of the parents. In contrast to our earlier findings, a significant association between smoking and the educational aspirations of the youth was found in this sample. In addition, the current data indicate that cigarette smoking is associated with increased perception of peer smoking and advanced pubertal development. While efforts were taken to ensure a representative sample of the study population, the fact that the sample was recruited from a single school in Beijing limits the generalizability of findings. However, the similarity of the findings between the current study and our previous study (Li et al., 1996) strengthened the current study. Among comparably aged youth (i.e. 12±15 years old), the prevalence of smoking was somewhat lower in the present study than in our previous sample (Li et al., 1996) (i.e. 20% in 1991 and 15% in 1997). However, this decrease reaches statistical significance only among females (11% at 1991 and 5% at 1997, p0?021). The smoking rate among male students remained similar between 1991 and 1997 (28 vs. 23%). Coupled with our earlier findings, the data in the current study again underscore the importance of prevention/intervention efforts among adolescents residing in China.
Cigarette smoking in Beijing
625
Acknowledgements We are grateful to our colleagues at the West City District Institute of Educational Research, Beijing, and the Institute of Developmental Psychology at the Beijing Normal University, Beijing, China for their assistance in collecting the data for this study.
References Chapman, S. (1994). Tobacco and deforestation in the developing world. Tobacco Control, 3, 191±193. Chinese Association on Smoking and Health (1997). Tobacco Tax in China, 1996. Beijing: Chinese Association on Smoking and Health. Li, X., Fang, X. and Stanton, B. (1996). Cigarette smoking among Chinese adolescents and its association with demographic characteristics, social activities, and problem behaviors. Substance Use and Misuse, 31, 545±563. Mackay, J. (1997). Beyond the cloudsÐtobacco smoking in China. Journal of the American Medical Association, 278, 1531±1532. World Health Organization (1996). Tobacco or Health: first global status report. Geneva, Switzerland: World Health Organization.
Cigarette smoking among schoolboys in Beijing, China XIAOMING LI, XIAOYI FANG
AND
BONITA STANTON
The current study was designed to assess the recent rate of cigarette smoking and to examine the association of cigarette smoking with individual factors and problem behaviors using data collected in December 1997 from 323 middle school students (43% females) in Beijing, China. About 15% of the study sample (23% males and 5% females) reported having ever smoked. The data in the current study confirmed findings from our earlier study (Li et al., 1996, Substance Use and Misuse, 31, 545±563) that the prevalence of cigarette smoking among Chinese adolescents was higher among males, increased with advancing age and was associated with participation in other problem behaviors and with poorer self-perceived academic performance. The data underscore the need for smoking-prevention programs targeting Chinese children and adolescents. # 1999 The Association for Professionals in Services for Adolescents
Introduction While the rates of cigarette smoking have declined over the past three decades in the U.S.A., Canada, and other western nations, tobacco use rates have remained stable or increased in many Asian countries, including China (World Health Organization, 1996). In spite of this alarming trend, the progression and determinants of cigarette smoking among Chinese have not been well documented (Chapman, 1994). There are few empirical data available regarding cigarette smoking among Chinese children and adolescents. In 1991, as part of a larger, longitudinal study examining cigarette smoking among Chinese adolescents, we administered questionnaires to 1040 sixth, eighth and tenth grade students from five schools serving the general public in Beijing, China. Based on these data, we reported that (Li et al., 1996): one-fifth of the sample (mean age of 13?65 years) had smoked, although most were occasional smokers; smoking was more prevalent among males than females (29 vs. 11%, p50?00001); more than one-third of males had tried cigarettes by the age of 13; smoking prevalence increased with age (p50?0001); smokers were more likely than non-smokers to report poor school performance; and smokers were more likely than non-smokers to report problem behaviors. Since our collection of the data in 1991, several significant events have occurred in China related to tobacco use. First, in 1994 China officially opened its tobacco market to major overseas tobacco companies (Mackay, 1997). At the same time, the Chinese government has implemented some anti-smoking measures targeting the general population, including banning all cigarette advertising in the public media. In addition, numerous local governments, including 71 cities and three provinces, have banned smoking in public areas such as trains, buses, schools, cinemas and theaters (Mackay, 1997). The confluence of tobacco-related events is associated with both economic and scientific data indicating an increase in cigarette production and consumption in recent years. For example, the tax revenue which Chinese government generated from cigarettes increased from $5 billion in 1993 to $10 billion in 1996 (Chinese Association on Smoking and Health, Reprint requests and correspondence should be addressed to Xiaoming Li, Ph.D., Department of Pediatrics, West Virginia University, PO Box 9214, Morgantown, WV 26506-9214, U.S.A. (E-mail: [email protected]). 0140-1971/99/050621+05 $3000/0
# 1999 The Association for Professionals in Services for Adolescents
622
X. Li et al.
1997). A recent Chinese national survey conducted among adults in 1996 indicated that on average both males and females started smoking 3 years earlier compared to 1984 data. The survey also indicated that the average daily consumption of tobacco increased from 11 cigarettes in 1984 to 15 in 1996 for males, and from 9 to 10 for females (Mackay, 1997). In light of the changes related to cigarette smoking among the general population in recent years in China, it would be of interest to see whether (and how) the rate and patterns of cigarette smoking had changed among adolescents residing in China, as well as whether our previous findings based on the 1991 data can be replicated with another independent sample. Accordingly, the current study was designed to assess the recent rate of cigarette smoking among adolescents in Beijing and to examine the association of cigarette smoking with individual factors and problem behaviors.
Method Sample
Following recruitment procedures similar to those described for the 1991 survey (Li et al., 1996), data were gathered in December 1997. Subjects were seventh, eighth and ninth grade students at a typical public middle school in Beijing. All classes in the seventh grade participated and we randomly selected three classes among five classes in each of grades eight and nine. Permission was received from the school principal before we came to the school and in writing individually from students. Of the students, 323 gave their consent and 23 refused. A self-administrated questionnaire was distributed to each participant by research personnel during regular class time. The school teachers were asked to leave the classroom during the survey. The participants were assured of the confidentiality of their responses.
Measures Cigarette smoking. Two items were used to measure Chinese adolescent cigarette smoking. The first item asked students to identify their status related to smoking on a threepoint scale (``never smoked''; ``ex-smoker''; ``current smoker''). The second item asked how often students had smoked in the previous year (``never''; ``once''; ``several times''; ``often''). Because the correlation between these two questions was high (r 0?77; p 0?000), the first question was used as index of adolescent smoking in the analysis. The responses to the item were recoded to create a dichotomous measure (``never smoked'' vs. ``ever smoked''). The correlation between the original response and recoded response was 0?85 (p 0?000). School performance. Subjects were asked to categorize their school performance on a seven-point scale: 1 ``mostly below Ds''; 2 ``mostly Ds''; 3 ``mostly Cs and Ds''; 4 ``mostly Cs''; 5 ``mostly Bs and Cs''; 6 ``mostly As and Bs''; and 7 ``mostly As''. Parental education. Education levels for both father (or male guardian) and mother (or female guardian) were assessed on a five-point scale: 1 ``junior high school or less''; 2 ``some high school or completed high school''; 3 ``vocational school''; 4 ``some college or completed college''; 5 ``graduate school or more''. The higher level achieved by father or mother was retained as an index of parental education.
Cigarette smoking in Beijing
623
Educational expectation. The subjects were asked how much schooling they thought they would complete in the future on a five-point scale: 1 ``junior high school''; 2 ``high school''; 3 ``vocational school''; 4 ``college''; and 5 ``graduate school''. Pubertal development. Students were asked to describe the stage of their pubertal development on a four-point scale: 1 ``not yet begun''; 2 ``just started''; 3 ``under way for less than 6 months''; 4 ``under way for more than 6 months''. Perceived peer smoking. Each students was asked to list up to nine close or good friends and provide a description of smoking status for each friend they listed on a threepoint scale (``never smoked''; ``ex-smoker''; ``current smoker''). Similar to the main adolescent smoking index, these responses were re-coded to create a dichotomous measure (``never smoked'' vs. ``ever smoked''). Problem behaviors. Students were asked to describe on a four-point scale how often they had engaged in 20 problem behaviors in the previous year: 1 ``never''; 2 ``once''; 3 ``several times''; 4 ``often''. The responses to these items were recoded to create dichotomous measures (``never'' vs. ``at least once''). The Cronbach's alpha for 20 items with modified response choice was 0?84, indicating a good internal consistency. Total number of positive responses (i.e. ``at least once'') was retained as a overall measure of the involvement in problem behaviors.
Results About 15% of the sample reported having ever smoked cigarettes. Smoking was more prevalent among males than females (23 vs. 5%; p50?00001); as the number of smoking females was so small, analysis was restricted to males. As is shown in Table 1, cigarette smoking among male students was associated with older age, poorer school achievement, lower educational expectation, higher level of pubertal development and more tobacco use among friends. Parental education was not related to cigarette smoking. As is shown in Table 2, cigarette smoking was significantly associated with all problem behaviors. Table 1 Association between cigarette smoking and individual factors among schoolboys in Beijing, China N (%) Age (years) School achievement Educational expectation Pubertal development Parental education Perceived peer smoking *p50?05; **p50?01; ***p50?0001.
Never smoked
Ever smoked
135 (77) 13?33 (0?99) 3?68 (1.77) 4?17 (1?04) 2?11 (0?93) 2?23 (0?86) 0?07 (0?15)
40 (23) 13?79 (1?06)* 2?33 (1?56)*** 3?21 (1?13)*** 2?66 (0?87)** 2?05 (0?88) 0?31 (0?32)***
624
Table 2
X. Li et al.
Association between cigarette smoking and problem behaviors
N (%) Drank beer Drank wine Drank hard liquor Rode bike dangerously Fought Mischief at school Suspended or expelled Detained by teacher after school Cheated on test Plagiarized on homework Cut school for a whole day Missed classes Lied to parents about activities Forged signature Damaged property on purpose Doodled on public buildings Threatened to hurt someone Shoplifted Stolen Arrested by police Mean (S.D.) of problem behaviors
Never smoked
Ever smoked
135 (77) 42 (31) 39 (29) 3 (2) 44 (33) 54 (40) 70 (52) 6 (5) 62 (47) 29 (22) 50 (38) 3 (2) 7 (5) 28 (31) 14 (10) 9 (7) 9 (7) 21 (16) 2 (2) 1 (1) 1 (1) 3?66 (3?10)
40 (23) 32 (80)**** 18 (46)* 14 (35)**** 21 (53)* 27 (68)** 29 (73)* 6 (15)* 26 (67)* 19 (49)** 31 (82)**** 9 (23)**** 15 (39)**** 26 (67)**** 15 (39)**** 13 (33)**** 15 (39)**** 17 (44)*** 5 (13)** 5 (13)** 4 (10)** 8?68 (4?57)****
*p50?05; **p50?01; ***p50?001; ****p50?0001.
Discussion The data in the current study confirmed findings from our 1991 data that the prevalence of cigarette smoking among Chinese adolescents was higher among males, increased with advancing age, and was associated with participation in other problem behaviors and with poorer self-perceived academic performance. There is no consistent relationship between smoking and educational level of the parents. In contrast to our earlier findings, a significant association between smoking and the educational aspirations of the youth was found in this sample. In addition, the current data indicate that cigarette smoking is associated with increased perception of peer smoking and advanced pubertal development. While efforts were taken to ensure a representative sample of the study population, the fact that the sample was recruited from a single school in Beijing limits the generalizability of findings. However, the similarity of the findings between the current study and our previous study (Li et al., 1996) strengthened the current study. Among comparably aged youth (i.e. 12±15 years old), the prevalence of smoking was somewhat lower in the present study than in our previous sample (Li et al., 1996) (i.e. 20% in 1991 and 15% in 1997). However, this decrease reaches statistical significance only among females (11% at 1991 and 5% at 1997, p0?021). The smoking rate among male students remained similar between 1991 and 1997 (28 vs. 23%). Coupled with our earlier findings, the data in the current study again underscore the importance of prevention/intervention efforts among adolescents residing in China.
Cigarette smoking in Beijing
625
Acknowledgements We are grateful to our colleagues at the West City District Institute of Educational Research, Beijing, and the Institute of Developmental Psychology at the Beijing Normal University, Beijing, China for their assistance in collecting the data for this study.
References Chapman, S. (1994). Tobacco and deforestation in the developing world. Tobacco Control, 3, 191±193. Chinese Association on Smoking and Health (1997). Tobacco Tax in China, 1996. Beijing: Chinese Association on Smoking and Health. Li, X., Fang, X. and Stanton, B. (1996). Cigarette smoking among Chinese adolescents and its association with demographic characteristics, social activities, and problem behaviors. Substance Use and Misuse, 31, 545±563. Mackay, J. (1997). Beyond the cloudsÐtobacco smoking in China. Journal of the American Medical Association, 278, 1531±1532. World Health Organization (1996). Tobacco or Health: first global status report. Geneva, Switzerland: World Health Organization.