Awareness of tobacco advertising, perceived harms of smoking, and beliefs about tobacco control among a sample of Shanghainese in China

Abstract

Introduction

An estimated 28.1% (52.9% of men and 2.4% of women) of Chinese adults are smokers, making China the largest market for tobacco consumption in the world [1]. China’s population of smokers is characterized by both the young age at which its members first experiment with smoking and the low rate of smoking cessation [2]. As a result, smoking is the leading cause of preventable diseases in China, taking one million lives and costing an estimated 28 billion dollars per year [3].

Tobacco advertising is the promotion of tobacco products or their use (usually cigarette smoking) by the tobacco industry through a variety of media including sponsorships, particularly of sporting events. Research has shown that exposure to tobacco advertising significantly increases tobacco consumption among smokers and encourages smoking initiation among non-smokers, particularly youth [4]. Thus, global endeavours to prevent and control tobacco use must not ignore or underestimate the impact of tobacco advertising [5]. In October 2005, China took an important step in dealing with tobacco advertising by ratifying the WHO (World Health Organization) Framework Convention on Tobacco Control. Previously, the 1991 Tobacco Products Monopoly Law (Article 19) and 1994 Advertisement Law (Article 18) banned tobacco advertising during movies, on radio and television, and in newspapers and periodicals. The 1995 Tobacco Advertising Management Regulations prohibited tobacco advertising in waiting rooms, theatres, meeting halls, sports stadiums and other public places. Despite the aforementioned constraints on tobacco advertising, however, ‘soft’ and indirect advertising of tobacco products is commonplace in China.

Shanghai is one of the world’s largest cities, with an estimated population of 19 million (one-third of whom are migrants or individuals lacking official residency status) [6]. Shanghai Tobacco Group Corporation is one of the China’s largest tobacco companies. It produced 126 billion cigarettes in 2010 and was ranked 57 among China’s top 500 companies. Its products include popular brands such as Zhonghua, Hongshuangxi, Xiongmao, Shanghai and Zhongnanhai [7]. ‘Zhonghua’, which means China, is advertised using a theme of patriotism. The most well-known commercial for Zhonghua used the theme of ‘Loving my China’ and clearly attempted to associate patriotism with the use of this particular tobacco product.

However, the Zhonghua ad campaign is just one example in which smoking and patriotism have been conflated in China. Other examples include the naming of brands Hetianxia (which means ‘harmoniousness’), Liqun (benefiting all people) and Zhongnanhai (the name of the area that is home to China’s central government).

Although lower than in other parts of China, smoking rates in Shanghai are still estimated to be 26% for men and 1–5% for women [8]. Compared with other areas in China, Shanghai has made significant progress in tobacco control, recently launching several tobacco control efforts. For example, the Shanghai World Expo Bureau rejected a 200 million Yuan (US$29.3 million) donation from the Shanghai Tobacco Group Corporation [9]. Furthermore, the World Expo organizer committed to holding a smoke-free event, banning the use and advertising of tobacco products [10]. In March 2010, a law known as ‘Smoke-Free Public Areas Legislation in Shanghai’ was approved and enacted by the Shanghai’s municipal government. The law banned smoking in 12 types of public places including schools, hospitals, sport stadiums, public transport vehicles and Internet cafes [11]. Shanghai’s municipal government has enacted stricter controls of outdoor tobacco advertising than national standards require. For example, registered company trademarks (including fonts and images of cigarettes) cannot appear in outdoor advertising [12].

Thus, the juxtaposition of the tobacco industry’s marketing efforts and government’s tobacco control strategies has created a complicated tobacco control situation in Shanghai and across China. However, public opinion is considered when formulating and enacting new legislation in China. But currently little is known about the opinions of Shanghai’s residents when they are presented with both pro-tobacco and anti-tobacco messages. In addition, future research needs to confirm the impacts of tobacco marketing in China. Hence, the present study seeks to describe attitudes towards tobacco advertising and control policies among a sample of residents in Shanghai, China.

Methods

This study was part of a larger research project aiming to assess exposure to tobacco advertising and its effect on tobacco control in Shanghai. Relevant data were collected in September 2010 through a cross-sectional research design. To be eligible for participation, respondents had to be (1) living in Shanghai, (2) at least 16 years old, and (3) able to give verbal (in Mandarin) consent.

Data were collected by the Fudan University Media and Opinion Research Center (FMORC) via random digit dialling and computer-assisted telephone interviewing (CATI) techniques. Telephone numbers were randomly selected from the FMORC CATI database (which covers nearly 100% of households in Shanghai). Undergraduate and graduate students from Fudan University were trained to be interviewers for the study. When placing a call, the interviewer identified herself/himself as calling from the FMORC survey research centre and explained the study’s purpose, procedures and confidentiality details. If an interviewee did not meet the minimum age requirement, another family member in the household was solicited for participation. The household was removed from the study if no eligible or willing family member was found. Each selected phone number was attempted three times before a replacement number was chosen.

The sample size was calculated by estimating the prevalence of exposure to tobacco advertisement among Chinese people. The previous study in China showed that 39% of respondents could recall some tobacco advertisement encourage smoking [13]. It was estimated that 457 participants were needed in order to obtain an α level of 5% with statistical power of 90%. Considering the likely variations we enlarged the sample size to 500 to be safe.

A total of 3812 phone numbers were called and 2545 (67%) households were reached, of which 602 (24%) agreed to participate. Altogether, 518 (20%) participants were eligible and completed the survey, with an estimated sampling error of ±3% at the 95% confidence interval.

Measures

Participants’ characteristics

Demographic information on age, gender and education level (elementary school or less, high school, college or above) was collected. Participants were also asked if they smoked and, if so, which tobacco brands (either Shanghai or non-Shanghai brands) they preferred.

Awareness of tobacco advertising

Participants’ level of awareness of tobacco advertising was assessed using three sets of questions. First, participants were asked if they had heard of the following popular Chinese tobacco brands: Zhonghua, Hongshuangxi, Xiongmao, Shanghai and Zhongnanhai. Participants were also asked whether they had seen or heard of the widely disseminated ‘Love China’ ad campaign for Zhonghua cigarettes at any time in the past 2 years, as well as their perceptions of the campaign’s influence on smoking-related behaviours such as cessation, initiation and buying tobacco as a gift. We also asked participants for their opinions about prohibiting ‘Love China’ advertisements.

Perceived harms of smoking

Perceived harms of smoking were assessed using three questions on the harms of smoking, harms of passive smoking (second-hand smoke) and benefits of smoking cessation. Response options ranged from very serious/significant to not at all serious/significant on a four-point Likert scale.

Opinions of smoking cessation

Participants’ opinions on smoking cessation were evaluated based on three possible responses: (i) smoking cessation is beneficial to one’s health; (ii) the negative health consequences of smoking have already occurred, so cessation would not be very significant; and (iii) people who have smoked for several years may become sick if they cease smoking. A dichotomous index was created, where response (i) was coded as beneficial, and responses (ii) and (iii) were combined and coded as not beneficial.

Beliefs concerning tobacco control policies

Participants’ beliefs concerning tobacco control policies were assessed using two questions. They were asked about their level of support for legislation prohibiting smoking in public places as well as legislation prohibiting tobacco advertising in public places. Questions were rated on a five-point scale from (1) strongly agree/strongly support to (5) strongly disagree/do not support at all. Responses of [strongly agree/strongly support] and [agree/support] were combined for each question, as were responses of [disagree/do not support], [strongly disagree/strongly do not support] and [neither agree nor disagree] to facilitate logistic regression analyses.

Data analysis

Data were stratified by smoking status and gender, and by awareness of tobacco advertising, perceived harms of smoking, opinions of smoking cessation and beliefs concerning tobacco control policies. Logistic regression analyses were used to examine associations between demographic characteristics and awareness of tobacco advertising, perceived harms of smoking, opinions of smoking cessation and beliefs concerning tobacco control policies. All data analyses were performed using spss software (version PASW Statistics18) (Chicago, IL) [14].

Results

Of the 518 residents who participated in the study, about half were males, 14% were under 25 years of age, and 50% were at least 45 years of age. Just over half of participants had at least a high school education and 43% had at least a college education. A total of 21% were current smokers (42% of males), whereas the remaining 79% had never smoked or had quit smoking (63% of females).

Table I displays participants’ awareness of tobacco brands and advertising. Levels of awareness of the five tobacco brands we listed were very high, ranging from 81% to 96% for each brand. Most participants (86%) had heard of at least four of the tobacco brands on our list. Half (51%) had seen or heard of the ‘Love China’ ad campaign at some point in the past 2 years (66% of smokers and 47% of non-smokers). Additionally, when asked about their initial impression of the ‘Love China’ ad campaign, 39% of participants said they knew it was an advertisement for Zhonghua brand cigarettes. Among smokers, that percentage was 48%. Overall, 59% of participants believed that the campaign would influence people to buy the more expensive Zhonghua brand cigarettes as a gift, and 30% of the sample believed that it would encourage smoking. There was no significant difference between smokers’ and non-smokers’ perceptions of the campaign’s effect on the public. Overall, 66% of respondents did not believe that the ‘Love China’ ad campaign was appropriate as a tobacco advertisement and 67% would support prohibiting ‘Love China’ advertisements. Even among smokers, nearly 60% believed that it was inappropriate and would support prohibiting this ad campaign.

In general, participants exhibited high levels of awareness of the harms of smoking: 93% of participants considered smoking to be seriously harmful and 94% considered passive smoking to be a serious health risk. However, there were still 18% of participants do not believe that smoking cessation would benefit one’s health which reflected the misunderstanding of cessation among the public. Overall, non-smokers exhibited greater knowledge and support for smoking cessation than smokers (P < 0.01).

Participants not only broadly supported the prohibition of tobacco advertising but also indicated a high level of support for tobacco control and smoking prevention legislation. Over 75% of participants expressed support for legislation prohibiting all types of tobacco advertising in public places, and 88% would support legislation prohibiting smoking in public places (Table II).

Table III shows logistic regression analyses by smoking status, gender, age, education, perception of smoking cessation benefit, and exposure to tobacco advertising for supporting the prohibition of smoking in public places and banning tobacco advertising. Smokers were less supportive of legislation prohibiting smoking in public places (OR = 0.42, 95% CI = 0.21–0.84; P < 0.05). Older participants more than 50 years were more supportive of both legislation limiting tobacco advertising (OR = 1.95, 95% CI = 1.05–4.27; P < 0.05) and banning public smoking (OR = 2.24, 95% CI = 1.27–3.96; P < 0.01). Similarly, those who have accepted college and above education were more supportive of both legislation of tobacco advertisement control (OR = 1.69, 95% CI = 1.00–3.22; P < 0.05) and smoke-free legislation (OR = 2.33, 95% CI = 1.31–4.17; P < 0.01). Female participants who perceived smoking cessation to be beneficial were more likely to support both tobacco control measures.

Discussion

This study examined tobacco-related beliefs among a sample of Shanghai residents. We found that tobacco advertising was perceived to be influential among our sample. The ‘Love China’ ad campaign, which conflates tobacco consumption and patriotism, was widely recognized by our sample and was perceived to have a significant impact on the public by influencing gift choices, encouraging smoking initiation and discouraging cessation. However, such advertising also fostered discontent among our sample. Two-thirds of participants thought that such advertising was inappropriate for a tobacco product and would support the banning of the ‘Love China’ campaign. In fact, comprehensive tobacco advertising bans can act as an effective intervention strategy if well implemented. A study of 102 countries showed sharp declines in tobacco consumption after enactment of a comprehensive ban on tobacco advertising [15]. Although the current study suggests high recall of tobacco advertising among the public in Shanghai, another study involved in 4763 smokers and 1259 non-smokers in five cities in 2006 has shown that recall of tobacco advertisement in Shanghai is still lower than in other cities such as Beijing, Shenyang and Changsha, but higher than Guangzhou and Yinchuan [13]. This result at least partly reflects the interaction from tobacco industry and public health. Local tobacco industry plays an important role in tobacco advertising: Shenyang, Shanghai and Changsha have greater presence of the tobacco industry. There is a smaller tobacco production in Guangzhou and no local tobacco industry in Yinchuan. Cities with tobacco industries may face greater challenges implementing tobacco control and limiting tobacco marketing activities. However, prior to this survey, Shanghai was the only city that had implemented local legislation on smoke-free public areas. Levels of public awareness of tobacco promotion have been found to be consistent with levels of advertising and promotion [16], so the relatively lower level of recall might be a reflection of the strict limitations placed on outdoor tobacco advertisements in Shanghai by the local authorities. Still, cross-national comparisons have shown that only comprehensive bans effectively reduce tobacco consumption, whereas partial bans had little or no effect [16]. Findings from the current study suggest broad support for more stringent control of tobacco advertising in China.

The Zhonghua ‘Love China’ ad campaign is hardly unique for China’s tobacco industry, which consistently exploits loopholes and ambiguities in the laws [17]. Imbuing a specific tobacco brand with broader political or social connotations is the common marketing strategy. In this way, the broader connotation acts as an indirect advertisement for the brand. Some representatives in the National People’s Congress have suggested that the government prohibits the use of Zhongnanhai as a tobacco brand name, or the use of names associated with national cultural landmarks or images, such as Huanghelou (the famous Yellow Crane Tower), Huangshan (a storied mountain range in eastern China) or Xiongmao (panda) [18]. Results from this study suggest broad public support for regulating brand naming of tobacco products as one facet of a comprehensive advertising ban.

Although there were some differences in beliefs among non-smokers and smokers, our sample of Shanghainese indicated strong support overall for tobacco control policies. Another study of six Chinese cities found that smokers in Shanghai were less supportive than smokers elsewhere of allowing tobacco companies to advertise and promote cigarettes without restrictions [13]. Still, 23.2% of participants would not support prohibiting tobacco advertising and 12% disagreed with banning smoking in public places. In China, tobacco companies are state-owned. Thus, there seems to be some level of expectation among the public that the government guides the tobacco industry according to the interests of the public. Support from the public might act as a cornerstone for the implementation of tobacco control policies, yet opposition from the tobacco industry to such policies should be expected. Such opposition might take indirect forms, akin to the tobacco industry’s current charitable endeavours in donating to education, which aims to improve their image among the general public. However, China's top legislature is now considering the country's first national tobacco control legislation. The results of this study provide evidence for establishing a strict policy creating smoke free environments, monitoring them and controlling tobacco promotion and marketing.

Overall, our sample showed high levels of support for tobacco control policies, either by prohibiting smoking or by prohibiting tobacco advertising in public places. The timing of the study suggests that legislators’ recent tobacco control efforts are in line with their constituents’ beliefs. Thus, it is reasonable to assume that legislators and the general public would both lend their support to expanding control efforts in the near future. Together with other findings in China [19, 20], we can conclude that comprehensive smoke-free polices have grown in popularity in China and that, if implemented, such policies likely would receive broad support from the public.

While being a smoker predictably lessened one’s support for smoke-free legislation, it did not influence one’s support for restricting tobacco advertisement. This is likely due to the differing impacts these policies would have on smokers if implemented: with increasing the extent of smoke-free legislation likely placing more limits on smoking behaviours. We did not find a direct relationship between exposure to tobacco advertising and support for tobacco control policies. Other studies have found that tobacco advertisements increased positive brand image [21], changed perceptions of the harms of tobacco [22], and was positively associated with smoking [23]. Those who are better educated and better understand the benefits of smoking cessation were more likely to endorse tobacco control and smoking prevention policies. This finding is consistent with results from other studies showing that knowledge of the harms of smoking among the public can lead to support for tobacco control policies [24–26]. This study also shows that greater efforts must be made to increase smokers’ knowledge of the harms of smoking and the benefits of smoking cessation. Thus, at this stage, education and cessation programmes must remain a top priority for China’s tobacco control and prevention efforts. Efforts to promote smoking cessation and education in health care settings and among members of China’s medical community should be strengthened so that they can be positioned as key leaders in the fight against tobacco use in China [27–29].

Computer-assisted telephone interviewing-based methods have been seldom applied to health surveys in China. However, several other studies using CATI have been conducted in Hong Kong, with responses rates varying from 37% to 48% [30–32]. The response rate in this study was lower than other studies and further efforts should be made to improve the response rates of future studies. One possible reason is that telephone interviews in China are commonly used by commercial organizations, with the public likely not familiar with this method as a public health research method. However, the advantages of CATI as a rapid, flexible, cost-effective public health surveillance system remain for public health surveys [33, 34]. Although there are several methodological challenges to using CATI in China, it is still recommended for cross-sectional public health studies of the general population.

This study has several strengths. To our knowledge, this is the first study to evaluate participants’ exposure to and opinions of the ‘Love China’ advertising campaign. Another of this study’s strengths is its relevance to recent policy actions in Shanghai, as it provides a metric of the public’s support for these measures. The study also successfully used a CATI design with random sampling to survey residents of this large city of 19 million residents. There are limitations as well. The response rate was low which may have led to selection bias and may not represent the full opinions of the general public in Shanghai. In addition most respondents were well educated compared with the general population, which may skew their perceptions of the effectiveness of tobacco control policies. Therefore, even though we randomized sampling in this study, our results may not be generalizable to other groups or the general public. Also, the belief items presented to participants do not represent the full range of possible beliefs concerning tobacco control policies.

Conclusions

Overall, this study allowed us to explore support for prohibiting tobacco advertising and banning smoking in public places in a city that has recently begun enacting tobacco control measures. Our findings suggest that those wishing to further anti-tobacco policies and educational programmes can assume that residents of Shanghai will support restrictions on tobacco advertising and use.

Acknowledgement

We thank the Beijing ThinkTank Research Center for Health Development for supporting this research.

Conflict of interest statement

None declared.

References