Caught in a dilemma: why do non-smoking women in China support the smoking behaviors of men in their families?

Smoking prevalence, exposure to secondhand smoke, and factors associated with smoking among medical, dental, and pharmacy students in a public university in Malaysia

INTRODUCTION

Smoking among medical, dental, and pharmacy students is an issue in every university worldwide, which will impact future smoking cessation services as they are future healthcare providers. This study investigates the smoking prevalence, exposure to secondhand smoke, and factors associated with smoking among medical, dental, and pharmacy students at a public university in Malaysia.

METHODS

The self-administered online survey utilized in this cross-sectional study was derived from the Global Health Professions Students Survey (GHPSS), which involved medical, dental, and pharmacy students. A total of 328 participants completed a questionnaire from June to August 2022, with a response rate of 91.1%.

RESULTS

The overall smoking prevalence was 4.6% among the medical, dental, and pharmacy students who participated in this study; 46.7% of current smokers were exposed to secondhand smoke at home compared to 17.6% of non-smokers (p=0.011); and 66.7% of smokers were exposed to secondhand smoke in public compared to 40.3% of non-smokers (p=0.043). In all, 99.1% of respondents supported the smoking ban and 46.7% of current smokers supported the smoking ban in discos/bars/pubs, compared to 82.0% of non-smokers (p=0.002). Of the participants, 96.6% received lessons on the danger of tobacco, and 65.5% received smoking cessation training. Among factors associated with current smoking was gender; male students had a 19-fold higher likelihood of smoking than female students (adjusted odds ratio, AOR=19.25; 95% CI: 4.25-87.19, p<0.001). In addition, home exposure to secondhand smoke was four times more common for current smokers (OR=4.11; 95% CI: 1.43-11.79, p=0.009).

CONCLUSIONS

Although smoking prevalence was low among the students in this study, there was a higher percentage of them exposed to secondhand smoke at home and in public.

Sex Differences in Outcomes after Endovascular Thrombectomy for Patients with Acute Ischemic Stroke

INTRODUCTION

Endovascular thrombectomy (EVT) is the standard of care for patients with large-vessel occlusion acute ischemic stroke (AIS). There may be differing recanalization effectiveness based on patients' sex, and understanding such variations can improve patient outcomes by adjusting for differences. We aimed to assess the sex differences in outcome after EVT for patients with AIS.

METHODS

We retrospectively analyzed 250 consecutive AIS patients who underwent EVT from July 2019 to February 2022 across two large comprehensive tertiary care stroke centers in China. Outcomes of male patients were compared to females, where poor outcome was defined as a modified Rankin score (mRS) of 3-6 at 90 days.

RESULTS

Male patients had higher rates of symptomatic intracranial hemorrhage (sICH) (12.50% vs. 4.05%, p = 0.042) and higher hospitalization costs (114,541.08 vs. 105,790.27 RMB, p = 0.024). Male patients also had a longer median onset-to-needle time (ONT) (146.00 [104.00, 202.00] versus 120.00 [99.25, 144.75], p = 0.026). However, there were no differences in hospitalization length (p = 0.251), 90-day favorable outcome (p = 0.952), and 90-day mortality (p = 0.931) between the sexes.

CONCLUSION

Female patients had lower hospitalization costs and sICH rates than males after EVT for AIS. Identifying such differences and implementing measures, including adaptations to workflow optimization, would help to reduce the ONT and last known normal-to-puncture time seen in males to improve patient outcomes. Despite such variations, favorable outcomes and mortality are similar in female and male AIS patients.

Differences in Smoking Behavior by Nativity, Race/Ethnicity, and Education among Women Diagnosed with Breast Cancer

BACKGROUND

We evaluated smoking differences across nativity and race/ethnicity among women diagnosed with breast cancer.

METHODS

In our Northern Californian pooled population of 5,653 [670 Asian, 690 Hispanic, and 4,300 non-Hispanic White (White)] women diagnosed with breast cancer, we evaluated smoking differences across nativity, race/ethnicity, and acculturation and effect modification of nativity by race/ethnicity and education.

RESULTS

Foreign-born women currently smoked less than US-born women [odds ratio (OR) = 0.46, 95% confidence limit (CL): 0.29-0.72]. Hispanic (OR = 0.50; 95% CL: 0.32-0.78) women currently smoked less than White women. Among those who ever smoked (n = 2,557), foreign-born women smoked 5.23 fewer pack-years (PY) than US-born women (95% CL: -2.75 to -7.70). Furthermore, Asian (-4.60, 95% CL: -0.81 to -8.39) and Hispanic (-6.79, 95% CL: -4.14 to -9.43) women smoked fewer PY than White women. Associations were generally suggestive of greater smoking with greater acculturation (immigration age, US years, survey language). Finally, associations for nativity differed by education but not race/ethnicity, with a higher likelihood of smoking in US-born women only among those with less than a bachelor's degree (OR = 2.84, 95% CL: 2.15-3.77; current smoking: P = 0.01, PY: P = 0.05).

CONCLUSIONS

Asian and Hispanic (vs. White) and foreign-born (vs. US-born) breast cancer survivors reported fewer smoking behaviors. Smoking differences across nativity and education were driven by higher rates of smoking in US-born women with lower educational attainment.

IMPACT

Smoking behavioral patterns were similar among breast cancer survivors and the general population, informing potential smoking interventions.

Perceptions of Barriers and Facilitators to Reducing Exposure to Secondhand Smoke in the Home: A Qualitative Study With Palestinian-Arab Women in Israel

INTRODUCTION

Smoking is a collective and complex problem in the Palestinian-Arab community in Israel, where women and children are particularly vulnerable to exposure to secondhand smoke (SHS), especially in the home.

AIMS AND METHODS

We undertook this study to better understand women's experiences with SHS exposure in the home and to identify pathways for intervention. Using the grounded theory approach, seven focus groups were conducted with 66 women in different localities across Israel. Purposive and snowball sampling techniques were applied to recruit women who have currently or previously been exposed to smoking in the home. Focus groups were audio-recorded and transcribed verbatim, and data were then coded and analyzed using the constant comparison analysis method to identify emergent themes and subthemes.

RESULTS

Three core themes emerged from the discussions. These include women's perceptions of smoking among men and exposure to SHS in the home, the implications of smoking on spousal and social relationships, and the women's experiences in coping with this situation and their suggestions for interventions. We identified additional sub-themes, including the consequences to women's and children's health, as well as the complex interaction between smoking in the home and women's social position, agency, and home ownership.

CONCLUSIONS

Women exposed to SHS in the home experience consequences that affect their health and their spousal and social relationships. They also face several personal and societal challenges in tackling this issue. Culturally tailored interventions targeting both communities and households can raise awareness and impact smoking behaviors in the home.

IMPLICATIONS

The findings of this study demonstrate the far-reaching consequences of SHS exposure in the home among women who are exposed. The findings contribute to our understanding of smoking contingencies among men and smoking behaviors in the home. This study lays the groundwork for future community and household-based research and interventions. We suggest several critical junctures that may increase response to smoking cessation interventions and to reduce smoking in the home, such as at the time of marriage when the home policy is set, and the adverse effects of exposure on children and other family members, especially those with illness.

National and regional economic inequalities in first- and second-hand tobacco consumption among women of reproductive ages in Iran

INTRODUCTION

The epidemic of tobacco consumption is one of the major public health threats the world has been facing so far. This study was performed to investigate the economic inequalities in tobacco consumption among women of reproductive ages at national and regional levels in Iran.

METHODS

We used data from 10,339 women of reproductive ages (18-49 years) who participated in Iran's 7th Non-Communicable Disease Risk Factor Surveillance (STEPS). Wagstaff normalized concentration index and decomposition method were applied to measure economic inequalities in first- and second-hand tobacco consumption and determine their corresponding contributory factors, respectively.

RESULTS

The prevalence of women's first-hand tobacco consumption, and their exposure to second-hand smoke in the home, and workplace were 3.6%, 28.3%, and 8.4%, respectively. First- and second-hand tobacco consumption was significantly more concentrated among low-economic women. Exposure to home second-hand smoke, education, and economic status had the largest contributions to the measured inequality in first-hand tobacco consumption (48.9%, 38.9%, and 30.8%, respectively). The measured inequality in women's secondhand smoke exposure at home was explained by their level of education (43.8%), economic status (30.3%), and residency in rural areas (18%), and at work by residency in rural areas (42.2%), economic status (38.8%), and level of education (32%). Our results also revealed diversity in the geographical distribution of inequalities in rural and urban areas and five regions of the country.

CONCLUSION

The present study highlighted the need for more enforcement of tobacco control rules and increasing tobacco taxes as general measures. Furthermore, there is a need for gender-sensitive initiatives at national and regional levels to educate, support, and empower low-economic women and households for tobacco cessation, and complying with restrictive smoking rules.

Understanding the effect of retirement on health behaviors in China: Causality, heterogeneity and time-varying effect

Retirement is an important turning point during the course of life, but few studies have examined the effects of retirement on a broad range of health behaviors in China. We use the longitudinal data of the China Health and Nutrition Survey (CHNS) from 2004 to 2015 to conduct empirical analysis. Fuzzy discontinuity regression was used to assess the association between retirement and health behaviors in the entire sample and subgroups based on gender and education. A time-varying effect model was used to measure the anticipatory effect, immediate effect and lag effect of retirement. We observed that the transition to retirement was associated with healthier lifestyle habits, such as reduced smoking and alcohol consumption and increased exercise motivation. However, the transition was associated with worse sedentary behavior. No significant statistical association was found between retirement and sleep duration. Men and those with higher education levels are more likely to experience the impact of retirement. The anticipatory effect suggests that as the statutory pension age is predictable, workers adjust their behaviors 4 and 5 years before retirement. The lagged effect indicates that it takes time to develop new habits; thus, retirees change their behaviors 2-3 years after retirement. The paper discusses possible reasons for our findings and proposes several policy implications from the perspectives of the government and society to facilitate the realization of healthy aging.

Diverging Trends and Expanding Educational Gaps in Smoking in China

Introduction: The male smoking rate in China declined moderately through the 1990s and early 2000s, but the decline has since stagnated. It is unclear why the decline stalled and whether it stalled uniformly across all social strata. Theories that view socioeconomic status as a fundamental cause of health predict that socioeconomic gaps in smoking may widen, but theories emphasizing the cultural context of health behavior cast doubt on the prediction. We investigated changes in the socioeconomic gaps in smoking during recent decades in China. Methods: We applied growth-curve models to examine inter- and intra-cohort changes in socioeconomic gaps in male smoking in China using data from a national longitudinal survey spanning 25 years. Results: We found diverging trends in smoking in men with different education levels among the post-1980 cohorts; for high-education men, smoking participation consistently declined, but for low-education men, the decline stopped and possibly reversed. The stagnation in the decline in overall smoking rate since 2010 was mostly due to the stalling of the decline of smoking among low-education men in the most recent cohorts. The diverging trends were a continuation of a general trend in expanding educational gaps in smoking that emerged in the cohorts born after 1960. Our analysis also identified widening educational gaps over age within each cohort. Conclusion: We identified a long-term widening in educational gaps in smoking in China. An effective way to reduce smoking, social inequality in smoking and possibly health disparities in China is to target the smoking behavior of vulnerable groups.

Nicotine metabolism predicted by CYP2A6 genotypes in relation to smoking cessation: A systematic review

INTRODUCTION

Identifying genetic factors associated with smoking cessation could inform precision cessation interventions. Of major interest is genetic variation in nicotine metabolism, largely predicted by CYP2A6 variations.

METHODS

We conducted a systematic literature review to summarize the population-based evidence of the association between CYP2A6 and smoking cessation.In the 12 studies meeting the inclusion criteria, the known functional metabolic effect of CYP2A6 variants was used to classify nicotine metabolism as normal (>75% metabolic activity), intermediate (50.1 - 75% activity), slow (25 - 50% activity), and poor (<25% activity). Summary odds ratios of smoking cessation were calculated across metabolic groups, stratified by ancestry and whether participants received pharmacotherapy or placebo/no treatment.

RESULTS

Among untreated people of European ancestry (n = 4 studies), those with CYP2A6 reduced metabolism were more likely to quit smoking than those with normal metabolism [Summary OR = 2.05, 95% CI 1.23 - 3.42] and the likelihood of cessation increased as nicotine metabolism decreased. Nicotine replacement therapy attenuated the association at end-of-treatment, while bupropion modified the association such that intermediate/slow metabolizers were less likely to quit than normal metabolizers [Summary OR = 0.86, 95% CI 0.79 - 0.94]. Among untreated Asian people (n = 3 studies), results differed compared to those with European ancestry: those with slow metabolism were less likely to have quit smoking than normal metabolizers [Summary OR = 0.52, 95% CI 0.38 - 0.71]. Evidence for people of African ancestry (n = 1 study) suggested the CYP2A6 association with cessation may differ compared to those of European ancestry.

IMPLICATIONS

Most studies included in this review were of European ancestry populations; these showed slower nicotine metabolism was associated with increased likelihood of smoking cessation in a dose-related manner. Pharmacotherapy appeared to attenuate or modify this association among people of European ancestry, but it is unclear whether the change in the association remains consistent after treatment ceases. This finding has implications for precision medicine cessation interventions. Based on only a few studies of people of Asian or African ancestry, the association between CYP2A6 variants and cessation may differ from that observed among those of European ancestry, but more evidence is needed.

Brief Advice, Nicotine Replacement Therapy Sampling, and Active Referral for Expectant Fathers Who Smoke Cigarettes: A Randomized Clinical Trial

IMPORTANCE

Pregnancy presents an opportunity to engage expectant fathers in smoking cessation, but evidence from randomized clinical trials is scarce.

OBJECTIVE

To evaluate the effectiveness of a proactive, combined intervention for smoking cessation in expectant fathers.

DESIGN, SETTING, AND PARTICIPANTS

This pragmatic randomized clinical trial in prenatal clinics in 7 public hospitals in Hong Kong proactively recruited and enrolled 1053 participants from October 10, 2018, to February 8, 2020. Included male adults were 18 years or older, smoked cigarettes daily in the past 3 months, had partners who were pregnant and nonsmoking in the past 30 days, and had a landline or mobile telephone number for follow-up. These participants were randomized to either the intervention group or the control group. The primary analyses used an intention-to-treat approach.

INTERVENTIONS

The intervention group received brief cessation advice, a 1-week free sample of nicotine replacement therapy (NRT), and active referral to a community-based smoking cessation service. The control group received only brief cessation advice with a leaflet on the hazards of perinatal exposure to tobacco smoke and the toll-free quitline telephone number.

MAIN OUTCOMES AND MEASURES

The primary outcome was biochemically validated tobacco abstinence at 6 months after intervention initiation defined by an exhaled carbon monoxide level of 3 parts per million or lower. The secondary outcomes included self-reported 24-week continuous abstinence at 6 months after intervention initiation as well as 7-day point prevalence abstinence, use of any NRT, and use of a smoking cessation service at 3 and 6 months after intervention initiation.

RESULTS

All 1053 randomized participants were male adults with a mean (SD) age of 33.8 (6.9) years. The retention rate at 6-month follow-up was 80.7%. The primary outcome of biochemically validated tobacco abstinence at 6 months after intervention initiation was significantly higher in the intervention group than in the control group (6.8% [36 of 527 participants] vs 3.6% [19 of 526]; odds ratio [OR], 1.96; 95% CI, 1.11-3.46; P = .02). The main secondary outcomes of self-reported 24-week continuous abstinence at 6 months (OR, 1.87; 95% CI, 1.08-3.23; P = .03) and 7-day point prevalence abstinence at 3 months (OR, 1.48; 95% CI, 1.05-2.09; P = .03) and 6 months (OR, 1.74; 95% CI, 1.29-2.34; P < .001) were also significantly higher in the intervention group. The intervention group had a significantly higher increase in perceived family harmony (score range, 0-10, with a higher score indicating a higher level of harmony) from baseline to 6 months (B = 0.28; 95% CI, 0.063-0.50; P = .01).

CONCLUSIONS AND RELEVANCE

This trial found that combining brief advice with a 1-week sample of NRT and referral to smoking cessation programs nearly doubled the odds that expectant fathers who smoked would achieve validated abstinence compared with providing brief advice alone. The intervention was also effective in promoting family harmony.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT03671707.

Smoking Cessation Experience in Indonesia: Does the Non-smoking Wife Play a Role?

Objective

More than 63% of Indonesian men are smokers, and smoking has long been a part of Indonesian culture and the concept of masculinity in Indonesian culture. Given the pro-smoking environment, we were interested in examining why smokers would willingly quit and whether their wives played a role in their quitting process as social factors are mentioned second most frequent as a reason for quitting smoking.

Design

In-depth interviews.

Method

We interviewed 11 couples (N = 22)—ex-smoking husbands and non-smoking wives—in Yogyakarta, Indonesia. The data were analysed by using the thematic analysis approach.

Results

Four themes were discussed: (1) reasons for stopping smoking, (2) the process of quitting smoking, (3) the wives’ attitudes toward smoking, and (4) the families’ attempts to make the (ex-)smokers quit. The most commonly cited reasons for quitting were family and personal motivation. The (ex-)smokers preferred to quit without assistance and in private. The wives’ attitude toward smoking ranged from dislike to tolerance, and most did not know when their husbands were trying to quit. Both husbands and wives reported that the wives did not influence the smoking cessation process.

Conclusion

Indonesian ex-smokers often had multiple reasons for quitting smoking. The process was typically difficult and kept private. While wives had little influence on the cessation process, they provided support and could institute a smoking ban in the house.

Minority stress, depression, and cigarette smoking among Chinese gay versus bisexual men: a two-group structural equation model analyses

Background

Literature in the West suggested that bisexual men have a higher smoking rate compared to gay men. Data on patterns of smoking among gay and bisexual men are limited in Eastern Asian countries like China. This study examined the cigarette smoking prevalence for gay versus bisexual men in China and their unique minority stress - smoking pathways.

Methods

Between September 2017 and November 2018, we surveyed a convenience sample of 538 gay men and 138 bisexual men recruited from local sexual minority organizations in four metropolitan cities in China (i.e., Beijing, Wuhan, Nanchang, and Changsha). Measures included sexual orientation, sociodemographics, theory-based minority stressors, depressive symptoms, and past 30-day cigarette smoking. Two-group (gay men vs. bisexual men) structural equation modeling (SEM) was used to test possible distinct mechanisms between theory-based stressors, depressive symptoms, and cigarette smoking among gay men and bisexual men, respectively.

Results

The mean age of participants was 26.51 (SD = 8.41) years old and 76.3% of them had at least a college degree. Bisexual men reported a higher rate of cigarette smoking compared to gay men (39.9% vs. 27.3%). Two-group SEM indicated that the pathways for cigarette smoking were not different between gay and bisexual men. Higher rejection anticipation was associated with greater depressive symptoms (standardized β = 0.32, p < .001), and depressive symptoms were not associated with cigarette smoking.

Conclusions

Minority stress, specifically rejection anticipation, may be critical considerations in addressing depressive symptoms, but not smoking, among both gay and bisexual men in China.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12889-021-10888-5.

A behaviour change intervention to reduce home exposure to second hand smoke during pregnancy in India and Bangladesh: a theory and evidence-based approach to development

BACKGROUND

Home exposure to secondhand smoke (SHS) is highly prevalent amongst pregnant women in low- and middle-income countries like India and Bangladesh. The literature on the efficacy of behaviour change interventions to reduce home exposure to SHS in pregnancy is scarce.

METHODS

We employed a theory and evidence-based approach to develop an intervention using pregnant women as agents of change for their husband's smoking behaviours at home. A systematic review of SHS behaviour change interventions led us to focus on developing a multicomponent intervention and informed selection of behaviour change techniques (BCTs) for review in a modified Delphi survey. The modified Delphi survey provided expert consensus on the most effective BCTs in reducing home exposure to SHS. Finally, a qualitative interview study provided context and detailed understanding of knowledge, attitudes and practices around SHS. This insight informed the content and delivery of the proposed intervention components.

RESULTS

The final intervention consisted of four components: a report on saliva cotinine levels of the pregnant woman, a picture booklet containing information about SHS and its impact on health as well strategies to negotiate a smoke-free home, a letter from the future baby to their father encouraging him to provide a smoke-free home, and automated voice reminder and motivational messages delivered to husbands on their mobile phone. Intervention delivery was in a single face-to-face session with a research assistant who explained the cotinine report, discussed key strategies for ensuring a smoke-free environment at home and practised with pregnant women how they would share the booklet and letter with their husband and supportive family members.

CONCLUSION

A theory and evidence-based approach informed the development of a multicomponent behaviour change intervention, described here. The acceptability and feasibility of the intervention which was subsequently tested in a pilot RCT in India and Bangladesh will be published later.

Trajectory of smoking behavior change among Chinese immigrant smokers

BACKGROUND

The incidence and mortality rates of smoking-associated lung cancer are high among Chinese immigrant smokers. Coming from a country with different smoking policies, culture, and economic background than the U.S., Chinese smokers may change their smoking behaviors after immigrating to the U.S.

OBJECTIVES

This study aims to explore the trajectory of smoking behavior change among Chinese immigrant smokers migrating to the U.S.

METHODS

This qualitative study was guided by the Grounded theory. Semi-structured intensive individual interviews were conducted among 10 eligible participants. A purposive theoretical sampling method was used to recruit participants through a website. Individual interviews were conducted online, via telephone, or in-person in Mandarin. Data were transcribed verbatim in Mandarin, translated into English, and triangulated with follow-up interviews and dialogues among authors to enhance trustworthiness and consistency of the study. Process coding and content analysis were used to analyze data.

RESULTS

A total of 10 participants, 7 males and 3 females, were interviewed. Results showed the trajectory of smoking behavior change among Chinese immigrant smokers went through three phases: 1) Beginning to smoke, which included learning to smoke from others, trying to smoke and learning to smoke, and hiding their smoking behaviors from others; 2) maintaining smoking, which included setting boundary around smoking, smoking as a facilitator or barrier to social interaction, feeling pressures related to smoking behavior, and making others happy: Collective smoking and controlling smoking desire; and 3) changing smoking behaviors, which included experiencing life events that were triggers to changing smoking behavior, boredom as a reason for relapses, personal will as a key to quitting smoking, and quitting smoking for a loved one. Although some differences existed between male and female Chinese immigrant smokers' smoking behaviors, their trajectories of smoking behavior change were generally similar.

DISCUSSION

Findings from this study can help health care providers to extend their understanding toward smoking behavior change among Chinese immigrant smokers across different socio-cultural contexts.

The role of tobacco and alcohol use in the interaction of social determinants of non-communicable diseases in Nepal: a systems perspective

BACKGROUND

Tobacco and alcohol use are major behavioural risks in developing countries like Nepal, which are contributing to a rapid increase in non-communicable diseases (NCDs). This causal relationship is further complicated by the multi-level social determinants such as socio-political context, socio-economic factors and health systems. The systems approach has potential to facilitate understanding of such complex causal mechanisms. The objective of this paper is to describe the role of tobacco and alcohol use in the interaction of social determinants of NCDs in Nepal.

METHOD

The study adopted a qualitative study design guided by the Systemic Intervention methodology. The study involved key informant interviews (n = 63) and focus group discussions (n = 12) at different levels (national, district and/or community) and was informed by the adapted Social Determinants of Health Framework. The data analysis involved case study-based thematic analysis using framework approach and development of causal loop diagrams. The study also involved three sense-making sessions with key stakeholders.

RESULTS

Three key themes and causal loop diagrams emerged from the data analysis. Widespread availability of tobacco and alcohol products contributed to the use and addiction of tobacco and alcohol. Low focus on primary prevention by health systems and political influence of tobacco and alcohol industries were the major contributors to the problem. Gender and socio-economic status of families/communities were identified as key social determinants of tobacco and alcohol use.

CONCLUSION

Tobacco and alcohol use facilitated interaction of the social determinants of NCDs in the context of Nepal. Socio-economic status of families was both driver and outcome of tobacco and alcohol use. Health system actions to prevent NCDs were delayed mainly due to lack of system insights and commercial influence. A multi-sectoral response led by the health system is urgently needed.

Association of smoking behavior among Chinese expectant fathers and smoking abstinence after their partner becomes pregnant: a cross-sectional study

Background

Exposure to secondhand smoke (SHS) during pregnancy can cause pregnancy complications and adverse birth outcomes. About 40% of Chinese expectant fathers are smokers and they rarely attempt to quit smoking. There is a paucity of effective smoking cessation services targeting this population. In this study, we assessed the smoking behavior of Chinese expectant fathers and examined its association with smoking abstinence after their partner became pregnant, which is an essential prerequisite for designing effective smoking cessation interventions.

Methods

We conducted a cross-sectional survey in the obstetrics and gynecology clinic of three tertiary hospitals in China. Expectant fathers who smoked at least one cigarette per day for 1 month within the past 12 months were invited to participate in this study. The participants were asked to complete a structured questionnaire that assessed their smoking behaviors before and after their partner became pregnant.

Results

From December 2017 to March 2018, we recruited a total of 466 eligible expectant fathers, among whom 323 (69.3%) were identified as current smokers and 143 (30.7%) were ex-smokers. Using lasso regression, 19 features were selected from among 27 independent variables. The results of the selected multivariable logistic regression model showed that knowledge about the health hazards of smoking among smokers (odds ratio (OR) 1.39; 95% confidence interval (CI) 1.24 to 1.58; p < 0.001), knowledge about the health hazards of SHS to pregnant women (OR 1.46; 95% CI 1.09 to 1.97; p < 0.001), knowledge about harm to the fetus and newborn (OR 1.58; 95% CI 1.25 to 2.03; p < 0.001), and being a first-time expectant father (OR 2.08; 95% CI 1.02 to 3.85; p = 0.046) were significantly positively associated with smoking abstinence among expectant fathers after their partner became pregnant. Significantly negative associations were found for severe dysfunctionality in terms of family support (OR 0.48; 95% CI 0.24 to 0.95; p = 0.036) and smoking only outside the home (OR 0.81; 95% CI 0.26 to 0.98; p < 0.001).

Conclusions

In this study, we identified several factors associated with smoking abstinence among expectant fathers after their partner became pregnant. These findings can guide the development of effective interventions targeting expectant fathers, to help them quit smoking.

Chinese Hospitalized Cardiovascular Patients' Attitudes Towards Self-Management: A Qualitative Study

PURPOSE

This study is aiming to investigate cardiovascular patients' attitudes towards self-management during hospitalization in China.

PATIENTS AND METHODS

Twenty-nine individuals living with cardiovascular disease from one designated Cardiology Department in Hangzhou, China, were recruited through a purposive sampling procedure. A qualitative descriptive methodology was used. Semi-structured interviews were also used to gain attitudes toward self-management. The interviews were audio-recorded, transcribed and analyzed by thematic analysis to develop the results.

RESULTS

Four themes were identified from the qualitative data: (1): Responsibilities of self-management; (2): Reflections on self-management; (3): Acknowledgement of self-management support; (4): Challenges in implementing and adherence to self-management. Additionally, interview data were also given to illustrate these main themes emerging during the analysis. Patients gradually took their responsibilities to manage chronic symptoms. During their self-management process, they did reflections to help correct their regiments through supportive interactions. Health system responsiveness, health disparities, social capital, and cultural setting were the main external factors influencing better self-management implementation and adherence.

CONCLUSION

This study revealed the hospitalized cardiovascular patients' attitudes towards self-management in China. These findings emphasized the importance of patients' responsibility, reflections, and various social support receiving and pointed out specific external factors influencing the health outcomes and their quality of life. This study also proves the guide for the policymakers and health system better instructions to develop individually and culturally tailored advanced self-management interventions and programs.

Tobacco smoking and trends in histological subtypes of female lung cancer at the Cancer Hospital of the Chinese Academy of Medical Sciences over 13 years

BACKGROUND

Lung cancer is the leading cause of cancer mortality among women in China, and incidence and mortality continue to rise despite the fact that smoking prevalence is very low among Chinese women.

AIM

This study investigated tobacco smoking and trends in histological subtypes of female lung cancer in a central cancer hospital in China.

METHODS

Demographic, smoking history and histological information on female lung cancer patients diagnosed or treated from 2000 to 2012 was collected from the Cancer Hospital, Chinese Academy of Medical Science (CHCAMS). The classification of histological subtypes and clinical stages were conducted using the ICD-O-3 and Eighth AJCC Cancer Staging Manuals. Time-trends of histological subtypes were analyzed based on annual percentage change (APC).

RESULTS

Overall, 5870 female cases of lung cancer were included in the analysis. The number of female lung cancer patients increased from 509 (2000-2002) to 1744 (2011-2012). The most common histological type of lung cancer was adenocarcinoma (ADC) (72.93%), followed by small cell lung cancer (SCLC) (11.06%), squamous cell carcinoma (SCC) (8.38%) and other (7.63%). Among smokers, the proportion of SCC decreased from 40.5% to 23.7% (P = 0.005), while ADC increased from 35.7% to 50.7% (P = 0.009). In non-smokers, ADC increased from 63.1% to 80.6% (P = 0.006) and SCC decreased from 13.6% to 4.5% (P = 0.016). Among SCC cases, smokers made up a larger proportion of early stage (I/II: 47.1%) compared with late stages (III, 34.3%; IV, 18.6%).

CONCLUSION

The number of female lung cancer patients has increased in CHCAMS. In both smoking and non-smoking cases, the proportion of adenocarcinoma increased. Squamous cell carcinomas were more likely to be diagnosed in early stages among smokers.

Smoking Beliefs Among Chinese Secondary School Students: A Theory-Based Qualitative Study

Introduction

China has the world's greatest number of smokers but theory-based smoking interventions are rare. To develop an effective intervention, understanding the determinants of Chinese adolescent smoking is crucial. The Theory of Planned Behavior (TPB) is empirically supported to predict and assist in informing intervention strategies to change health-related behaviors. Based on the TPB, the elicitation of shared smoking beliefs among adolescents can inform future intervention designs among this at-risk population.

Methods

We investigated the beliefs from six focus groups (N = 30) of one senior secondary school in Kunming, Yunnan Province, China. We used semi-structured questions based on the TPB framework, including prompts about behavioral (advantages and disadvantages), normative (important referents), and control (barriers and facilitators) beliefs. Following the Consensual Qualitative Research (CQR) methodology, data were discussed until consensus was reached. Auditing was undertaken by an external researcher.

Results

Seven domains (advantages, disadvantages, approvers, disapprovers, facilitators, barriers, and smoker images) were examined. Smoking as a gendered behavior, smoking as influenced by cultural and environmental contexts, smoking as a strategy to cope with stress, and awareness of the harm of smoking, are highlighted themes across domains. Data suggested an extended-TPB framework as an appropriate approach to adopt when addressing smoking beliefs among the target population.

Conclusions

These beliefs can be utilized to inform future school-based interventions and public health campaigns targeting smoking among Chinese adolescents.

Implications

A modified TPB approach has potential for future smoking interventions among Chinese adolescents. Beliefs elicited in this study form a strong basis for designing a location- and population-specific antismoking programme.

Tobacco and the lung cancer epidemic in China

China is in the midst of a lung cancer epidemic on an unprecedented scale. In 2015, there were an estimated 733,000 new lung cancer cases (17% of total cancer incidence) and 610,000 deaths (21.7% of total cancer mortality) in China. Lung cancer is the most commonly diagnosed cancer and the leading cause of cancer mortality in China. Tobacco smoke exposure is the primary factor driving current lung cancer trends. In 2015, smoking prevalence was 27.7% (52.1% among men and 2.7% among women). China has taken substantial steps to control tobacco use in recent years, including 19 cities implementing comprehensive smoke free laws and expansion of cessation services. However, significant challenges remain in order to meet the 2030 Healthy China goal of reducing smoking prevalence to 20%. In particular, ongoing attention is needed to continuing to control secondhand smoke exposure, to further enhance smoking cessation services, and to address novel alternative nicotine delivery devices (ANDS).

Exposure to secondhand smoke in Iranian pregnant women at home and the related factors

INTRODUCTION

Fetus health is of high importance in pregnant women and exposure to secondhand smoke (SHS) endangers maternal and fetal health. Therefore, in this study we examined the prevalence of exposure to SHS in pregnant women at home and the related factors.

METHODS

This cross-sectional study was conducted with 255 pregnant women who were referred to the Isfahan health care center from July to September 2018. A questionnaire that was designed by the research team was applied to collect data about the participants' prevalence of exposure, attitude-emotional dimension, perceived susceptibility, perceived severity, and perceived barriers. The questionnaire used was self-administered. The validity and reliability of the questionnaire were confirmed by a panel of experts. Cronbach's alpha of attitude-emotional dimension, perceived susceptibility, perceived severity, and perceived barriers were also calculated as 0.81, 0.91, 0.92, and 0.89, respectively. Statistically significant differences were examined using chi-squared test and Mann-Whitney test.

RESULTS

We found that the prevalence of exposure to SHS in pregnant women was 23.1%. The age of the husband (p=0.041), education level of the smoking husband (p=0.005), the education level of the pregnant woman (p=0.002), employment status of husband (p=0.010), and whether the pregnancy was planned (p=0.010) had significant association with the participant prevalence of exposure to SHS. Thus, older age of husbands, lower education levels of husbands and wives, unwanted pregnancies, and unemployment of husbands resulted in higher exposure to SHS. The mean scores of knowledge and perceptions were lower in women exposed to smoke than in non-exposed women (p<0.05).

CONCLUSIONS

The rate of SHS exposure was high in pregnant women. The knowledge and perception scores of exposed women to SHS were lower than those of non-exposed women. Low levels of education of husbands and women, unemployment and higher age of husbands, and unwanted pregnancies were considered as health risk factors. Therefore, effective training programs should be designed to educate pregnant women and their husbands.

Provincial-level cancer burden attributable to active and second-hand smoking in China

Background

Understanding disparities in the burden of cancer attributable to smoking is crucial to inform and improve tobacco control measures. In this report, we estimate the population attributable fraction (PAF) of cancers deaths attributable to smoking at the national and provincial levels in China.

Methods

Using cancer mortality data from 978 counties, smoking data from a nationwide survey and relative risks from a prospective study of 0.5 million adults in China, we calculated the absolute (non-standardised) and standardised numbers and proportions of cancer deaths among adults 30 years and older attributable to active and second-hand smoking in 2014 across all 31 provinces in Mainland China.

Results

The estimated number of cancer deaths attributable to smoking in China in 2014 was 342 854 among men and 40 313 among women, of which second-hand smoking accounted for 1.8% and 50.0%, respectively. Among men, the absolute PAF in China was 23.8%, ranging from 14.6% in Xinjiang to 26.8% in Tianjin; the overall standardised PAF was 22.2%, ranging from 15.7% in Xinjiang to 26.0% in Guizhou. Among women, the overall absolute and standardised PAFs were 4.8% and 4.0%, ranging from 1.8% and 1.6% in Jiangxi to 14.9% and 9.6% in Heilongjiang, respectively. Overall, provinces with the highest standardised PAFs among men were located in Southwest China and among women in the Northeast.

Conclusions

Comprehensive smoke-free policies in China should expand to all provinces, notably those with a higher burden of cancer attributable to smoking, instead of being mostly limited to Beijing and some other metropolitan areas.

Social Environmental Influences on Smoking and Cessation: Qualitative Perspectives Among Chinese-Speaking Smokers and Nonsmokers in California

This qualitative study examines the social environmental influences on smoking and cessation from the perspectives of Chinese smokers and household nonsmokers in California. Seven focus groups were conducted with 63 participants. Three culturally influenced levels of potential intervention emerged from constant comparative analysis. At the individual level, participants focused more on irritating odor than health harms of exposure and had inaccurate beliefs about harms of smoking and cessation. At the relational level, peers kept smokers connected to pro-smoking norms. There was conflict in the home about smoking and failed cessation, but smokers recognized the benefits of cessation for family harmony and children's health. Physicians encouraged cessation but this tended to be insufficient to prompt action unless a smoker felt ill. At the societal level, participants recognized changes in social acceptability and environmental regulation of smoking upon immigration. Better implementation of smokefree policies, plus culturally nuanced strategies for equipping both nonsmokers and smokers to become smokefree, are needed.

A Qualitative Study on Chinese Canadian Male Immigrants' Perspectives on Stopping Smoking: Implications for Tobacco Control in China

China has the largest number of smokers in the world; more than half of adult men smoke. Chinese immigrants smoke at lower rates than the mainstream population and other immigrant groups do. This qualitative study was to explore the influence of denormalization in Canada on male Chinese immigrant smoking after migration. Semistructured interviews were conducted with 22 male Chinese Canadian immigrants who were currently smoking or had quit smoking in the past 5 years. The study identified that, while becoming a prospective/father prompted the Chinese smokers to quit or reduce their smoking due to concern of the impacts of their smoking on the health of their young children, changes in smoking were also associated with the smoking environment. Four facilitators were identified which were related to the denomormalized smoking environment in Canada: (a) the stigma related to being a smoker in Canada, (b) conformity with Canadian smoking bans in public places, (c) the reduced social function of smoking in Canadian culture, and (d) the impact of graphic health messages on cigarette packs. Denormalization of tobacco in Canada in combination with collectivist values among Chinese smokers appeared to contribute to participants' reducing and quitting smoking. Although findings of the study cannot be claimed as generalizable to the wider population of Chinese Canadian immigrants due to the small number of the participants, this study provides lessons for the development of tobacco control measures in China to reverse the current prosmoking social environment.

mHealth Intervention is Effective in Creating Smoke-Free Homes for Newborns: A Randomized Controlled Trial Study in China

Mobile-phone-based smoking cessation intervention has been shown to increase quitting among smokers. However, such intervention has not yet been applied to secondhand smoke (SHS) reduction programs that target smoking parents of newborns. This randomized controlled trial, undertaken in Changchun, China, assessed whether interventions that incorporate traditional and mobile-phone-based education will help create smoke-free homes for infants and increase quitting among fathers. The results showed that the abstinence rates of the fathers at 6 months (adjusted OR: 3.60, 95% CI: 1.41-9.25; p = 0.008) and 12 months (adjusted OR: 2.93, 95% CI: 1.24-6.94; p = 0.014) were both significantly increased in the intervention group compared to the control. Mothers of the newborns in the intervention group also reported reduced exposure to SHS at 12 months (adjusted OR: 0.53, 95% CI: 0.29-0.99; p = 0.046). The findings suggest that adding mHealth interventions to traditional face-to-face health counseling may be an effective way to increase male smoking cessation and reduce mother and newborn SHS exposure in the home.

In utero and early childhood exposure to secondhand smoke in Taiwan: a population-based birth cohort study

OBJECTIVES

This study provides secondhand smoke (SHS) exposure data in utero and after birth when children were at 18 months, 36 months and 66 months old, and it identifies risk factors for the early childhood SHS among 18-month-old infants living in smoker and non-smoker households.

STUDY DESIGN

The data come from the Taiwan Birth Cohort Study, a longitudinal survey of a birth cohort born in 2005. This study used the survey wave when children were 18 months old (n=18 845) for statistical analysis of early childhood SHS exposure. Logistic regression was used to identify the risk factors of the SHS exposure.

RESULTS

Approximately 62% of the 18-month-old infants lived in a household with at least one smoker, with the father being the smoker in 84% of those households. Among these infants living in a smoker household, 70% were exposed to SHS and 36% were exposed to heavy SHS in utero, and the prevalence was approximately 66% and 17% after birth for SHS and heavy SHS, respectively. The number and the existence of smokers in the household, parents' smoking status, father's educational attainment and being a first-born baby are strong predictors of early childhood heavy SHS exposure.

CONCLUSIONS

Encouraging families to have a smoke-free home environment, empowering women to ensure their perspectives and rights are embedded into tobacco control efforts and educating families about the health risks from childhood SHS exposure, especially among people living in households with smokers, will protect non-smoking adults and children from SHS exposure.

Motivations, challenges and coping strategies for smoking cessation: Based on multi-ethnic pregnant couples in far western China

The present study aimed to clarify the smoking cessation motivations, challenges and coping strategies among pregnant couples. A qualitative design using a grounded theory approach was applied. Data were collected by individual semi-structured interviews with 39 married individuals (21 non-smoking pregnant women and 18 smoking or ever-smoking men with a pregnant wife) and 3 imams in an ethnically diverse region of far western China. The most common theme for smoking cessation motivation was "embryo quality" (i.e., a healthier baby), followed by family's health. Most interviewees reported that husband's withdrawal symptoms were the greatest challenge to smoking cessation, followed by the Chinese tobacco culture. Coping strategies given by the pregnant women typically involved combining emotional, behavioral and social interventions. Social interventions showed advantages in helping to quit smoking. Pregnancy appears to be a positive stimulus for pregnant couples' smoking cessation. Our results suggest that pregnancy, a highly important life event, may help to reduce barriers to smoking cessation at the social level (e.g., limiting access to cigarettes, avoiding temptation to smoke), but does little to help with the withdrawal symptoms. Professional guidance for smoking cessation is still necessary.

Family-Based Smoking Cessation Intervention for Smoking Fathers and Nonsmoking Mothers with a Child: A Randomized Controlled Trial

OBJECTIVE

To examine whether a family-based intervention targeting both smoking fathers and nonsmoking mothers in well-child health clinics is effective in increasing fathers' abstinence from cigarette smoking.

STUDY DESIGN

This parallel 2-arm randomized controlled trial recruited a total of 1158 families with a daily-smoking father, a nonsmoking mother, and a child aged 0-18 months from the 22 maternal and child health centers in Hong Kong. The intervention group received the family-based intervention, including 6 nurse-led individual face-to-face and telephone counseling sessions within 1 month after recruitment and a voluntary face-to-face family counseling session (FCS). The control group received a leaflet, a self-help booklet, and brief quitting advice only. Father-reported 7-day and 6-month abstinence, smoking reduction, quit attempts, mother-reported help and support, and child salivary cotinine level were assessed at 12 months. Generalized estimating equation models were used to compare these outcomes between the 2 study groups.

RESULTS

Compared with the control group, the intervention group reported a greater prevalence of 7-day (13.7% vs 8.0%; OR, 1.92; 95% CI, 1.16-3.17; P < .01) and 6-month self-reported abstinence (13.4% vs. 7.5%; OR, 2.10; 95% CI, 1.30-3.40; P < .01). Within the intervention group, compared with receipt of individual counseling only, participation in the FCS was associated with increases in fathers' self-reported abstinence (20.2% vs 12.3%; P = .02), mothers' help (66.1% vs 43.8%; P < .01), and support to the fathers (55.0% vs 45.4%; P < .01).

CONCLUSIONS

The family-based smoking cessation intervention for the families in the well-child healthcare setting was effective in increasing the fathers' self-reported abstinence. Additional participation in the FCS increased mothers' help and support to the fathers.

TRIAL REGISTRATION

Controlled-trials.com: ISRCTN99111655; Hkuctr.com: HKUCTR-465.

Smoking environments in transition: the experiences of recent Chinese migrants to Canada

International migrants experience first-hand differences between countries in terms of the social meanings, spatial regulation and prevalence of smoking. This research centred on the smoking-related perceptions, experiences and behaviours of recent migrants from China to Canada. Eight focus groups were held in Edmonton, Alberta, in July-October 2013 to explore migrants' understandings of the practices and meanings of smoking in both countries. There were 58 participants (37 non-smokers and 21 smokers), most of whom were international students. Qualitative content analysis of focus group transcripts was undertaken to identify key themes. Participants observed that smoking remains almost ubiquitous in China due to ineffective spatial restrictions and the social importance of smoking among men. By contrast, smoking bans in Canada were perceived as effective due to widespread compliance and expectations of enforcement. They were conscious that male smoking was both less prevalent and less socially valued in Canada; conversely, female smoking was perceived as more accepted in Canada than in China. There was broad agreement that smoking was tolerated in Canada, provided it occurred in appropriate places. Complying with widespread spatial restrictions brought about changes in smokers' behaviours: they smoked less often, and consumed fewer cigarettes. Because smoking was more difficult to perform, participants thought the Canadian context supported quitting. Non-smokers were enthusiastic about smoke-free environments in Canada, and had become acculturated to air that did not smell of smoke. These findings affirm the importance of comprehensive smoking bans, backed by enforcement, in contributing to the denormalisation of smoking and the protection of non-smokers.

"He Doesn't Listen to My Words at All, So I Don't Tell Him Anything"-A Qualitative Investigation on Exposure to Second Hand Smoke among Pregnant Women, Their Husbands and Family Members from Rural Bangladesh and Urban India

Second hand smoke (SHS) exposure during pregnancy is associated with poor pregnancy and fetal outcomes. To design interventions to reduce exposure, an in depth understanding of social and cultural factors of smoking behavior at home is important, especially in South Asia where SHS exposure is high. This study aimed to explore pregnant women's, their husbands' and other family members' knowledge, attitudes and practices regarding home SHS exposure. Semi-structured interviews were conducted with 33 participants in Comilla, Bangladesh and 31 in Bangalore, India (36 pregnant women, 18 husbands, and 10 family members). Data were analyzed using the Framework approach. Husbands smoked in various living areas inside the home, often in the presence of their pregnant wives. Most had never tried to stop smoking at home. Knowledge of the risks was generally poor. Most women had repeatedly asked their husband to smoke outside with little success and only few family members had reprimanded the husbands. Husbands who had stopped did so because of requests from children and their mother. Potential strategies to decrease SHS exposure at home were educating the husband about risks and supporting the pregnant women in negotiation. Interventions must also enlist family support to enhance the woman's self-efficacy.

Children's Exposure to Secondhand Smoke during Ramadan in Jakarta, Indonesia

Secondhand smoke exposure (SHS) causes a disproportionate health burden for children, yet existing smoke-free laws are often poorly enforced. We monitored air quality while observing children and adult nonsmokers present in public venues during Ramadan, a period of Muslim religious observance marked by family and social gatherings, in Jakarta, Indonesia. A repeated-measures design was used to assess indoor air quality during and after Ramadan in 43 restaurants and in five smoke-free control venues. Fine particulate matter of 2.5 microns or less (PM_2.5) was sampled. The average number of children and active smokers present in each venue was also observed. PM_2.5 levels were significantly higher during Ramadan (mean 86.5 µg/m³) compared with post-Ramadan (mean 63.2 µg/m³) in smoking venues (p = 0.015). During Ramadan, there were more active smokers (p = 0.012) and children (p = 0.051) observed in venues where smoking occurred, compared with the same venues post-Ramadan. Poor enforcement of the smoke-free law in Jakarta has failed to protect children from SHS exposure in public venues during Ramadan. Collaboration between the government, NGOs (such as the Indonesian Cancer Foundation (YKI) and the Smoking Control Foundation (LM3)), religious leaders, and venue owners and managers must be developed to ensure that the comprehensive smoking bans apply to all venues, and that smoke-free laws are enforced.

A Qualitative Study on Unassisted Smoking Cessation Among Chinese Canadian Immigrants

It is well-known that majority of smokers worldwide quit smoking without any assistance. This is even more evident among Chinese smokers. The aim of this qualitative study was to explore how Chinese Canadian immigrant men who smoked cigarettes perceived smoking cessation aids and services and how they used any form of the smoking cessation assistance to help them quit smoking. The study was conducted in British Columbia, Canada. Twenty-two Chinese immigrants were recruited by internet advertisement and through connections with local Chinese communities. Ten of the 22 participants were current smokers and the other 12 had quit smoking in the past 5 years. Data were collected using semistructured interviews. Although all participants, including both the ex-smokers and current smokers, had made more than one quit attempt, they rarely used cessation aids or services even after they had immigrated to Canada. The barriers to seeking the cessation assistance were grouped into two categories: practical barriers and cultural barriers. The practical barriers included "Lack of available information on smoking cessation assistance" and "Difficulty in accessing smoking cessation assistance," while cultural barriers included "Denial of physiological addiction to nicotine," "Mistrust in the effectiveness of smoking cessation assistance," "Tendency of self-reliance in solving problems," and "Concern of privacy revelation related to utilization of smoking cessation assistance." The findings revealed Chinese immigrants' unwillingness to use smoking cessation assistance as the result of vulnerability as immigrants and culturally cultivated masculinities of self-control and self-reliance.

Individual and city-level determinants of secondhand smoke exposure in China

BACKGROUND

Second hand smoke (SHS) exposure is a severe public health problem, especially in low and middle countries, but no studies have examined both individual and city-level variables influencing exposure.

METHODS

A cross-sectional multistage sampling design was used to survey subjects from 21 cities in China. Using a standardized questionnaire individual level information was collected. City-level variables were retrieved from the National Bureau of Statistics database. Multilevel logistic regression analysis was used to assess SHS exposure variation at both the individual and city level.

RESULTS

SHS exposure prevalence among non-smokers was 28.1% (95% CI 27.1-29.0). At the individual level lower educational attainment and income and higher exposure to tobacco advertising were associated with higher SHS exposure. On the other hand richer cities, and those with more anti-smoking media news coverage, had less SHS exposure. The presence of city smokefree regulations was unrelated to exposure.

CONCLUSIONS

Given its human and economic costs, reducing SHS exposure should receive greater priority than it does in China. The results point to the need for the enactment of national smokefree laws in order to combat unacceptably high levels of SHS exposure.

Home smoking restrictions before, during and after pregnancy-a qualitative study in rural China

Worldwide, many nonsmokers (often women and children) are exposed to second-hand smoke (SHS) in home settings, as men retain their traditional power and control within their family and women and children have limited agency to intervene. This study, set up to explore home smoking management in rural China, found that some women were able to positively intervene to restrict men's smoking at three key stages: prior to conception, during their pregnancy and at the early years of their children's lives. By utilizing dominant social, health and political narratives about the importance of raising a healthy child supported by the One-Child Policy in China, combined with the fear of health risks of SHS to young children, the women were able to use their elevated status as bearer and carers of the only children to subvert the pre-eminence of men in domestic environments, enabling them to positively influence home smoking. While this study highlights the possibility for future smoking cessation initiatives in China by incorporating family carers' elevated awareness of protection of children's health in key stages of childhood, there is also a need for further health education, as family members were unsure why they needed to keep children smoke-free, which may partially explain why few households were smoke-free.

A qualitative study of Chinese Canadian fathers' smoking behaviors: intersecting cultures and masculinities

BACKGROUND

China is home to the largest number of smokers in the world; more than half of the male population smoke. Given the high rates of Chinese immigration to Canada and the USA, researchers have explored the effect of immigration on Chinese smokers. Reduced tobacco use among Chinese immigrants has been reported in the United States; however, little is known about the social factors underlying men's smoking practices in settings where tobacco control measures have denormalized smoking, and in the context of fatherhood. The purpose of this Canada-based study was to explore the smoking-related experiences of immigrant Chinese fathers.

METHODS

In this qualitative study, semi-structured telephone interviews were conducted with 22 Chinese Canadian fathers who smoked or had recently quit smoking, and had at least one child under the age of five years old.

RESULTS

The Chinese fathers had dramatically changed their smoking patterns due to concern for their children's health and social norms and restrictions related to smoking in Canada. The facilitators and barriers for men's smoking were intertwined with idealized masculine provider and protector roles, and diverse Canadian Chinese cultural norms related to tobacco use.

CONCLUSIONS

The findings have implications for the development of future smoking cessation interventions targeting Chinese Canadian immigrant smokers as well as smokers in China.

Getting over the patriarchal barriers: women's management of men's smoking in Chinese families

Chinese family is a patriarchal power system. How the system influences young mothers' agency in managing family men's smoking is unknown. Applying a gender lens, this ethnographic study explored how mothers of young children in Chinese extended families reacted to men's smoking. The study sample included 29 participants from 22 families. Semi-structured interviews and field observations were transcribed and analysis was conducted using open coding and constant comparison. The findings indicate that young mothers' interventions to reduce family men's home smoking were mediated by gendered relationships between the mothers and the smokers. The mothers could directly confront their husbands' smoking, although they were more conservative about their men's smoking in the presence of other family smokers. They experienced difficulty in directly confronting senior family men's smoking but found ways to skirt patriarchal constraints, either by persuading seniors to stop smoking in subtle ways, or more importantly, by using other non-smoking family members as 'mediators' to influence senior men's smoking. While future smoking cessation interventions should support mothers in protecting their children from tobacco smoke, the interventions should also include other family members who are in a better power position, particularly the grandparents of the children, to reduce home smoking.

Gender, smoking and tobacco reduction and cessation: a scoping review

Considerations of how gender-related factors influence smoking first appeared over 20 years ago in the work of critical and feminist scholars. This scholarship highlighted the need to consider the social and cultural context of women's tobacco use and the relationships between smoking and gender inequity. Parallel research on men's smoking and masculinities has only recently emerged with some attention being given to gender influences on men's tobacco use. Since that time, a multidisciplinary literature addressing women and men's tobacco use has spanned the social, psychological and medical sciences. To incorporate these gender-related factors into tobacco reduction and cessation interventions, our research team identified the need to clarify the current theoretical and methodological interpretations of gender within the context of tobacco research. To address this need a scoping review of the published literature was conducted focussing on tobacco reduction and cessation from the perspective of three aspects of gender: gender roles, gender identities, and gender relations. Findings of the review indicate that there is a need for greater clarity on how researchers define and conceptualize gender and its significance for tobacco control. Patterns and anomalies in the literature are described to guide the future development of interventions that are gender-sensitive and gender-specific. Three principles for including gender-related factors in tobacco reduction and cessation interventions were identified: a) the need to build upon solid conceptualizations of gender, b) the importance of including components that comprehensively address gender-related influences, and c) the importance of promoting gender equity and healthy gender norms, roles and relations.

Smoking, smoking cessation and tobacco control in rural China: a qualitative study in Shandong Province

Background

Smoking prevalence is high in China and even higher among rural residents. The aims of this study were: 1) to gain insights into the motivations of tobacco use and barriers to smoking cessation among rural village residents; 2) to understand the current tobacco control measures in the rural villages and barriers encountered or perceived for implementation.

Methods

Qualitative semi-structured face-to-face interviews and focus group discussions were conducted of 59 rural villagers including 37 village residents, 10 village leaders and 12 village doctors in three counties in Shandong Province, China.

Results

Smoking initiation was most often out of curiosity when seeing others smoke, but pressure from cigarette sharing and gifting custom was the major barrier to smoking cessation. The most important reason for quitting successfully was a detrimental health problem. Although many attempted to quit at the advice of other family members, relapses were common and few were able to quit completely and for long-term unless accompanied by significant health issues. Although doctor’s advice to quit is effective, many doctors do not offer advice to all patients. There is a lack of true understanding of the harm of smoking and second-hand smoking among the villagers and a lack of access to and knowledge of effective smoking cessation tools among both smokers and village doctors. Tobacco control activities at villages were rare and infrequent.

Conclusions

This study highlighted the need to develop tobacco control measures that reflect the unique culture in rural China. Smoking cessation measures are not likely to achieve large scale effect unless the prevailing cigarette sharing and gifting custom is drastically changed. More educations of the hazards of smoking and second-hand smoking to village residents and educations of effective smoking cessation treatment to both village residents and healthcare providers are needed.

Secondhand smoke exposure and maternal action to protect children from secondhand smoke: pre- and post-smokefree legislation in Hong Kong

Background

Smokefree legislation may protect children from secondhand smoke (SHS) in the home from smoking parent(s). We examined the effect of the 2007 smokefree legislation on children’s exposure to SHS in the home and maternal action to protect children from SHS exposure in Hong Kong.

Methods

Families with a smoking father and a non-smoking mother were recruited from public clinics before (2005–2006, n = 333) and after the legislation (2007–2008, n = 742) which led to a major extension of smokefree places in Hong Kong. Main outcomes included children’s SHS exposure in the home, nicotine level in mothers’ and children’s hair and home environment, mothers’ action to protect children from SHS, and their support to the fathers to quit.

Results

Fewer mothers post-legislation reported children’s SHS exposure in the home (87.2% versus 29.3%, p<0.01), which was consistent with their hair nicotine levels (0.36ng/mg versus 0.04ng/mg, p<0.01). More mothers post-legislation in the last month took their children away from cigarette smoke (6.3% versus 92.2%; p<0.01) and advised fathers to quit over 3 times (8.3% versus 33.8%; p<0.01). No significant change was found in the content of smoking cessation advice and the proportion of mothers who took specific action to support the fathers to quit.

Conclusions

SHS exposure in the home decreased and maternal action to protect children from SHS increased after the 2007 smokefree legislation. Maternal support to fathers to quit showed moderate improvement. Cessation services for smokers and specific interventions for smoking families should be expanded together with smokefree legislation.

Personal and social determinants sustaining smoking practices in rural China: a qualitative study

Introduction

Tobacco use in China is disproportionally distributed among rural and urban populations with rural people smoking more. While there is a wealth of evidence on the association between tobacco use among rural people and their lower socio-economic status (SES), how social structural factors contribute to rural smoking is not well understood. Guided by a socio-ecological model, the objective of this study was to explore the personal and social determinants that play a key role in sustaining smoking practices among Chinese rural people.

Methods

An ethnographic study was conducted in a rural area of Central Jiangsu, China. Participants (n = 29) were recruited from families where there was at least one smoking resident and there were young children. In-depth interviews and unstructured observations were used to collect data, which were then analyzed with an interpretive lens.

Results

Although individuals had limited knowledge about the risks of smoking and lack of motivation to quit, social factors were in effect the main barriers to quitting smoking. Cigarette exchange and cigarette gifting permeated every aspect of rural family life, from economic activities to leisure pastimes, in family and wider social interactions. Traditional familism and collectivism interplayed with the pro-smoking environment and supported rural people’s smoking practices at the community level. Living in the rural area was also a barrier to quitting smoking because of the lack of information on smoking cessation and the influence of courtyard-based leisure activities that facilitated smoking.

Conclusion

Development of comprehensive smoking cessation interventions in rural China needs to extend beyond an individual level to take into account the social determinants influencing smoking practices.

Will mothers of sick children help their husbands to stop smoking after receiving a brief intervention from nurses? Secondary analysis of a randomised controlled trial

Background

Second-hand smoke is a severe health hazard for children. Clinical guidelines suggest that nurses advise smoking parents to quit when they accompany their sick children to paediatric settings, but the guidelines did not mention what nurses can do if the parents are not with the children. This study examines the effectiveness of a low-intensity, nurse-led health instructional initiative for non-smoking mothers, to motivate them to take action to help their husbands stop smoking.

Methods

This was a randomised controlled trial and 1,483 non-smoking women, who were living with husbands who do smoke, were recruited when they accompanied with their sick children on hospital admission in general paediatic wards/outpatient departments of four hospitals in Hong Kong. The women were randomly allocated into intervention and control groups. The former received brief health education counselling from nurses, a purpose-designed health education booklet, a “no smoking” sticker, and a telephone reminder one week later; the control group received usual care. The primary outcome was the women”s action to help their smoking husbands stop smoking at 3-, 6- and 12-month follow-ups.

Results

A higher proportion of women in the intervention than the control group had taken action to help their husbands stop smoking at the 3-month (76% vs. 65%, P < .001), 6-month (66% vs. 49%, P < .001) and 12-month (52% vs. 40%, P < .001) follow-ups. Women who had received the intervention, had better knowledge of the health hazards of smoking, higher intention to take action, perceived their husbands’ willingness to stop/reduce smoking, had previously advised their husbands to give up smoking, were aware of their husbands’ history of smoking and, were aware that their husbands had made an earlier quit attempt and intended to help them stop smoking at the follow-ups.

Conclusions

A brief health education intervention by nurses in paediatric settings can be effective in motivating the mothers of sick children to take action to help their husbands quit smoking. We recommend adding the following to the clinical practice guidelines on treating tobacco use and dependence: ‘Nurses should offer every non-smoking mother of a sick child brief advice to encourage their husbands to stop smoking’.

Trial registration

Current Controlled Trials ISRCTN72290421.

Space and power: young mothers' management of smoking in extended families in China

Multigenerational co-residence is a widespread phenomenon in China but there is little knowledge about the impact of power dynamics on smoking behaviors among extended family residents. Using a gender lens, this ethnographic study explored how young mothers in extended families in mainland China managed the smoking of their husbands and other family members. Analysis of data resulted in a model of 'two units-three domains' to reflect gendered relationships between young mothers and other family members, and young mothers' participation in family management. Exploration of the mothers' efforts to deal with household smoking using the model provided an explanation for why the young mothers had limited control over household space and could only impose partial restrictions on home smoking in the extended family.