School-Based Tobacco-Use Prevention -- People's Republic of China, May 1989-January 1990

Tobacco consumption has increased markedly in the People's Republic of China (PRC) since the 1960s (1,2). In 1984, when the prevalence of cigarette smoking was 61% among men and 7% among women, approximately 250 million persons in PRC smoked tobacco products (1). In 1988, among junior high school students in PRC, 34% of boys and 4% of girls reported smoking at least occasionally (3). To increase public knowledge of the health consequences of cigarette smoking, promote healthier attitudes among elementary school students, and motivate fathers who smoke to quit, the Zhejiang Center for Health Education developed and implemented a school-based smoking-intervention program in the Jiangan district of Hangzhou from May 1989 through January 1990. This report summarizes an assessment of this program.

The Gongshu district of Hangzhou served as the reference site. The intervention group comprised 10,395 students in grades 1-7 from 23 primary schools and their fathers. The reference group comprised 9987 students in grades 1-7 from 21 primary schools and their fathers. Students' knowledge of the health consequences of tobacco use and attitudes about smoking were assessed through self-reported questionnaires administered to both the intervention and reference groups in May 1989 and January 1990. Responses to the questionnaires were graded, and average scores were calculated for each group.

In the intervention community, a tobacco-use prevention curriculum was incorporated into the health education programs in schools; the curriculum emphasized the harmful social and health consequences of tobacco use and the training of students in refusal skills. Schools were encouraged to implement smoking-control policies to severely limit or restrict smoking in schools, and teachers were encouraged to be nonsmoking role models. Students whose fathers smoked monitored their fathers' smoking status by asking them daily whether they had smoked, recording their fathers' responses daily in a chart, and submitting monthly reports of their fathers' daily smoking status to the schools.

For the baseline assessment, self-reported questionnaires measuring the fathers' smoking status were sent home with students to be completed by fathers and returned to school. Of the 9953 fathers in the intervention group, 6843 (68.8%) were current smokers at baseline, compared with 6274 (65.5%) of the 9580 fathers in the reference group. Cessation materials based on the stages of change theory (4) were developed and distributed to students in the intervention group to take home to their fathers. A letter, signed by the student, was sent to each father, asking him to quit smoking. In January 1990, fathers who had stopped smoking for 180 or more days, as indicated by the students' daily recordings, were visited by health educators to confirm their smoking status by direct interview.

Although preintervention scores were similar for the two groups (Table 1), at follow-up, scores of students in the intervention group were significantly higher than both the reference group follow-up scores and the intervention group baseline scores. Scores for the reference group were similar in May 1989 and January 1990.

Based on the daily recordings maintained by the students in the intervention group, in January 1990, 1037 (15.2%) fathers had not smoked cigarettes for 180 or more days. In comparison, based on the interviews of health educators, 800 (11.7%) fathers reported that they maintained cessation for that period. From May 1989 through January 1990, the reported smoking rate for fathers in the intervention group decreased from 68.8% to 60.7% (p<0.05) while the reported rate remained approximately the same among fathers in the reference group. Approximately 90% of the fathers in the intervention group who were smokers in May 1989 were reported to have quit smoking for at least 10 days. The 6-month cessation rate for fathers in the intervention group was 11.7% compared with 0.2% in the reference group (Table 2).

Reported by: D Zhang, MD, X Qiu, MD, Center for Health Education, Hangzhou, People's Republic of China. Office on Smoking and Health, National Center for Chronic Disease Prevention and Health Promotion, CDC.

Editorial Note

Editorial Note: Tobacco sales are a primary source of income for PRC (5), and transnational tobacco companies have aggressively employed Western-style advertisement and promotion practices (1,5) (e.g., billboard advertisement of foreign tobacco and sponsorship of sporting and recreational events by tobacco companies {1,3}). Foreign tobacco corporations also have established joint cigarette production factories with Chinese companies and are increasing local cigarette production (1,5).

Lung cancer mortality is one of the five leading causes of death and the leading cause of cancer-related death in PRC (5). By the year 2025, an estimated 900,000 lung cancer deaths and a total of 2 million smoking-related deaths will occur among Chinese men (6,7). In addition, an estimated 200 million children currently living in PRC will become smokers, and 50 million of them will die prematurely from smoking-attributable diseases (6). Therefore, widespread implementation of prevention and cessation programs and tobacco-control policies that target adolescents and their families are needed to reduce the present and future health burden of smoking in PRC.

The findings in this report suggest that school-based tobacco-use prevention curricula and policies are effective in increasing knowledge among students in PRC about the health consequences of tobacco use. Furthermore, by including fathers in prevention activities, these programs suggest an additional strategy for motivating adults to quit smoking. These findings are also consistent with the understanding that, in PRC, adolescent smoking behavior is correlated with familial smoking behaviors (3) and underscore the importance of involving families and peers in tobacco-use prevention programs.

The first tobacco law in PRC became effective on January 1, 1992, and regulates many aspects of the national tobacco monopoly, including distribution, licensing, sales, importation, and exportation. Numerous health provisions also were mandated, such as reducing tar and nicotine levels, requiring warning labels, and restricting smoking in public places (5,8). A national health education effort in PRC will emphasize the health hazards associated with smoking, coordinate research, disseminate materials, and institute a National Stop Smoking Day each year (5). With a population of more than one billion persons and limited resources for health promotion, outreach and education remain substantial challenges.

References

1. Yu JJ, Mattson ME, Boyd GM, et al. A comparison of smoking patterns in the People's Republic of China with the United States. JAMA 1990;264:1575-9.

2. US Department of Agriculture. World tobacco situation. Washington, DC: US Department of Agriculture, Foreign Agricultural Service, 1992. (Circular series no. FT-12-92).

3. Zhu BP, Liu M, Wang SQ, et al. Cigarette smoking among junior high school students in Beijing, China, 1988. Int J Epidemiol 1992;21:854-61.

4. DiClemente CC, Prochaska JO, Fairhurst SK, Velicer WF, Velasquez MM, Rossi JS. The process of smoking cessation: an analysis of precontemplation, contemplation, and preparation stages of change. J Consult Clin Psychol 1991;59:295-304.

5. Mahaney FX. One woman begins fight to eliminate China's massive smoking problem. J Natl Cancer Inst 1989;81:392-4.

6. Novotny TE. Estimates of future adverse health effects of smoking in China. Public Health Rep 1988;103:552-3.

7. Peto R. Tobacco: U.K. and China {Letter}. Lancet 1986;2:1038.

8. Anonymous. China's landmark tobacco law {Editorial}. BMJ 1991;303:381-2.

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