The findings indicate a high prevalence of smoking, and a high prevalence of exposure to SHS among non-smokers. There was also a high rate of SHS exposure among current smokers in public places, and a low rate of attempting to quit smoking among current smokers in rural southwest China. Individual SES was found to be independently associated with the prevalence of current smoking, exposure to SHS, and nicotine dependence.
It has been estimated that worldwide, men smoke more than women. Our finding is in concordance with other studies [16]. In this study, the prevalence of smoking among men was greater than the prevalence rate observed in 2010 China Global Adults Tobacco Survey (GATS, 56.1%) [17], other parts of rural China (66.8%) [10], adults from western countries [7, 8], and other Asian and African people [18–20]. Smoking has been very prevalent in the Chinese tobacco cultivating rural male population. In contrast to the high prevalence of smoking, our study reported a low prevalence of smokers who have previously attempted to quit smoking (18.2%), a rate that was much lower than reported by the 2010 China GATS survey (33.1%), in other cities of China (25.3%) [21], and in other western countries (40%) [22]. These data indicate that rural communities are in need of robust smoking cessation programs.
Several previous Chinese studies indicate that most Chinese smokers initiate smoking during adolescence, and the prevalence of adolescent smoking has been increasing rapidly in China [23, 24]. Our study is consistent with these prior studies, and demonstrates that over 80% of smokers start smoking during adolescence. These findings underscore an urgent need for tobacco control strategies in rural China for adolescents and young adults who are at high risk for becoming addicted to nicotine.
As shown in other Chinese studies, smoking cigarettes was the most popular form of tobacco use in rural southwest China [10, 25]. Furthermore, we found that consuming tobacco through hookah / water pipes was also common in the tobacco–cultivating, ethnically diverse, rural communities. Our findings indicate that cultural forces exert a strong effect on smoking habits, as has been demonstrated in previous studies [26].
Our study showed a high rate of exposure to SHS among current smokers, particularly in public places. The rate of exposure to SHS in public places observed in this study (81.1%) is much higher than the China national survey results of 2002 (67.0%) [3], as well as results from another Chinese study (72.7%) [27], indicating public places have become the worst places for SHS exposure in rural southwest China. Furthermore, our study showed that exposure to SHS among current smokers in households mostly occurred in front of children and pregnant women. While smoking among women in the study region was at a much lower level compared with men, over 75% of women were exposed to SHS, and the rate of exposure to SHS among women was higher than among men, indicating exposure to SHS is a serious health problem for women. The impact of SHS exposure on children’s and women’s health requires urgent attention. Evidence has shown that the implementation of comprehensive smoke-free policies decreases the exposure to SHS and its associated health hazards in non-smokers [28]. These results suggest it is essential to strengthen people’s awareness of tobacco hazards and to implement comprehensive smoke-free laws and legislations to protect people from SHS.
Our study found individuals who cultivated tobacco had higher prevalence rates of current smoking, exposure to SHS, and nicotine dependence than non-tobacco-cultivating people. This is possibly due to tobacco farmers having easier access to tobacco products. These results suggest tobacco cultivating status is an important consideration when developing tobacco control policies in rural China.
Ethnic minorities had a lower risk for exposure to SHS and nicotine dependence in this study. Genetic heritability and shared environmental influences have been reported to be related to cigarette smoking in a previous study [29]. This finding suggests that ethnicity is an important determinant for tobacco use.
Lower levels of education have been shown to be associated with higher risks of smoking, environmental tobacco exposure, nicotine dependence, and lower rates of quitting tobacco use, both in developed and developing countries [8, 9, 30]. In the present study, smoking, exposure to SHS, and nicotine dependence tended to be more prevalent in people who were less educated. Our result is in concordance with prior studies. Some previous Chinese studies also indicated an inverse association between education and smoking [2, 11, 12, 18]. Our findings suggest community-based tobacco control efforts need to increase the knowledge related to harm of tobacco use among people with low levels of education.
While several western studies have demonstrated that people with lower incomes are more likely to consume tobacco [6–9], our study showed no association between individual income and smoking or exposure to SHS in the Chinese rural adults. However, it did show a positive relationship between individual income and nicotine dependence. A previous Chinese study reported that people with higher annual income were more likely to smoke than those with lower income [18]. The reasons for an inconsistent association between income and smoking rates in Chinese adult smokers are unknown.
A strength of our study is the large sample size and the high response rate (over 98%) in the community survey. A limitation of the study is that smoking was self-reported and exposure to SES was based on recall. The lack of validation of smoking status with nicotine testing may underestimate the prevalence of smoking.
