This population-based study found that 3.5% of adult smokers in six Chinese cities received their most recent cigarettes as a gift. This estimate is substantially lower than estimates in previous surveys (ranging from 53% to 60%) [21, 22]. But those other surveys had asked smokers whether they had received cigarettes as a gift at any time over a much longer time frame (e.g., previous three months or previous six months). It is possible, however, to compare the incidence of cigarette gifts at the most recent procurement with the estimated incidence of receiving a cigarette gift at least once over a longer period. In our sample, the number of cigarettes smoked per day and the average number of packs or cartons most recently purchased suggests that smokers would purchase cigarettes an average of 2.8 times per week. If receipt of cigarettes as gifts is randomly distributed in the population, the probability of a smoker receiving cigarettes as gifts would be 0.73 in the previous 3 months (number of weeks = 13), and 0.35 if the time frame was in the past month (number of weeks = 4.3), using the formula P = 1-(1–0.035)^(number of weeks of the time period x 2.8 purchases/week). The receipt of gifts is unlikely to be random and so this formula likely overestimates the prevalence of cigarette gift receiving. However, it suggests some consistency between our estimation of incidence and previous prevalence estimates. Hence, our study confirms that the prevalence of smokers receiving cigarettes as gifts is high and cause for concern.
There is another way of understanding the implications of our findings that is not dependent on the non-randomness of who receives gifts. This is by focusing on the frequency of receiving cigarettes as gifts. If there is a .035 probability of receiving cigarettes as gifts, which implies that this occurs once every 1/.035 = 28.6 times that a smoker obtains cigarettes. Given the average rate of purchasing/obtaining cigarettes is 2.8 times per week, that would further imply that the average smoker in China receives a gift of cigarettes once every 28.6/2.8 = 10.2 weeks, that is, about five times a year (because of clustering, some smokers will receive gifts more often than others, but the average across all smokers will be once every 10.2 weeks).
It is noteworthy that the data collection period for our study did not significantly overlap with gift-giving festivals, such as Lunar New Year (February 7, 2008) and Mid-Autumn Festival (September 25, 2007) — only 2.3% (n=113) of participants were interviewed within 15 days before and after these two holidays. The 2.3% of participants represented a very small proportion (n=4) of the 3.5% who reported receiving the most recent cigarettes as gifts. After excluding participants who were interviewed around the two holidays, the incidence of receiving cigarette gifts remains similar (3.5%). Other studies have been conducted during times when the reporting period would contain these important periods in which gifts (of any kind) are very common. This difference in time of year between the present study and those of past studies likely contributes further to lower reported incidence of receiving cigarettes as gifts.
Our findings showed that the self-reported influence of receiving cigarettes as gifts on brand selection was relatively low, especially when considered alongside other reasons for brand selection (i.e., taste, price, quality). However, these data may underestimate the influence that gifts may have on brand selection due to recall issues, as shown by higher percentages of gifting influences found among those participants who smoked their preferred brand for less than one year (7.9%). Participants may have been more likely to remember taste and other factors that continue to provide a conscious influence over the smoking experience. Another reason why there may be a low linkage between receiving cigarettes as gifts and current brand is because many gift givers may well know the brand choice of the recipient and will choose that brand to give; in such situations, the smoker would report that receiving the gift was not a factor in their brand choice because brand choice had preceded the gift. Future studies should focus only on smokers who had switched brands, and examine the probability that a gift was mentioned as a reason for switching brands.
Compared to smokers in other cities, a significantly higher proportion of smokers in Beijing reported that they received their most recent cigarette as gifts (7.5% vs. 1.0 to 4.0%). This may be due to the high concentration of central governmental offices and business headquarters in Beijing, as people who work and interface with these settings appear more likely to practice cigarette gifting [3]. Shanghai smokers were significantly less likely to report that they chose their preferred brand based on cigarette gifts than Beijing smokers, perhaps partly because Shanghai smokers had the lowest incidence of receiving cigarette gifts. However, Guangzhou participants had the second highest proportion of choosing the preferred brand based on cigarette gifts despite the lowest incidence of receiving cigarette gifts among six cities, which is consistent with Guangzhou’s relatively lower prevalence of giving cigarettes as gifts in previous study [30]. Other unmeasured differences in characteristics of smokers across cities, such as specific meanings of cigarette gifts may also have influenced our findings and merit further research, particularly if tobacco control strategies are developed to change these meanings.
One striking finding is that female smokers were more likely than males to report receiving current cigarettes as gifts and to have chosen their preferred brand because of gifting, which suggests that social norms discouraging female smoking may be changing. Previous studies have focused on cigarette gifting among Chinese males perhaps because of the very low prevalence of female smoking (3%) [4, 19, 27]. It is notable that Chinese tobacco companies have started marketing attractive cigarette products and gift packaging that deliberately targets female smokers [33]. The greater prevalence of gifting and its influence on brand selection among women deserve further investigation into how social and gender norms around smoking may be changing.
Participants older than 55 years were more likely than young smokers to report receiving cigarette gifts, which likely reflects customs around gifting to elders, particularly fathers and fathers-in-laws, to show respect [4, 5]. Most participants in this age group were retired, indicating that occupation does not appear to drive cigarette gifting in this group. Participants with high education were also more likely to report receiving recent cigarette gifts than those with low education, which may also reflect differences in social status. Nevertheless, participants with low education were more likely to report that they chose their preferred brand because of cigarette gifts than participants with mid-level education. This subgroup of lowest educational attainment may pursue status symbols presented by cigarette gift brands to augment their self image [3, 4].
It is noteworthy that smokers who smoked daily and had higher HSI were less likely to report they received their most recent cigarette as gifts. Heavy smokers must purchase cigarettes more often to meet their consumption needs than people who smoke less regularly. The higher frequency of purchasing cigarettes from all kinds of sources would reduce chances that receiving the most recent cigarette would be a gift, whereas lighter smokers will have a pack for a longer period of time. To better understand the association between receiving cigarettes as gifts and characteristics of cigarette gift receivers, future research should ask smokers about receiving cigarette gifts over different periods of time. A more refined operationalization of measurement could better capture some of the nuances around this practice across subgroups who smoke at different frequencies.
Participants who smoked daily and had higher HSI were also less likely to report cigarette gifts were part of their decision to choose their preferred brand. There could be various reasons for this. Cigarette gifts may not provide a compelling reason for heavy smokers to switch brands because of inveterate smoking and purchasing habits due to their high nicotine dependency and high brand loyalty. Heavy smokers tend to buy less expensive cigarettes [34, 35] because they may bear more financial burden from their high demand of tobacco use than light smokers, so they are less likely to choose cigarette gift brands as the preferred brand since cigarette gifts are usually expensive [4, 29]. Price concern may also explain that smokers who chose the preferred brand because of gifts were less likely to smoke that brand more than one year. Smokers who are sensitive to cigarette price are more likely to switch to cheaper brands to maintain their smoking habit [36], thus being less loyal to specific brands over time.
Interpretation of our results is limited by a number of issues. For example, young smokers were undersampled, especially in the age group 18–24, due to their absence from sampled households because they were at school or work; however, our data suggest that this group is less likely than older groups to receive cigarettes as gifts. Smokers’ report of choosing their preferred brand because someone gave it to them as a gift may underestimate the real prevalence, due to recall bias and to competing more apparent preference factors, such as taste and quality. Because of the cross-sectional survey design, our data is unable to make causal links. The incidence of receiving cigarette gifts was derived from the measure used to assess the source of the most recent cigarettes that smokers obtained/purchased and was also affected by the timing of data collection, capturing a smaller sample of this subgroup. Future studies that measure gift receipt across a variety of reference periods and that collect data at different times of the year may be necessary to better estimate and monitor the prevalence of receiving cigarette gifts. The response categories for occupation did not appear to allow for the level of discernment necessary to adequately explore the role of occupation, as many smokers did not provide responses that fit within the given response options. Future studies should include more specific occupational categories, especially those that appear most highly associated with cigarette gifting, such as doctors [13, 19]. In addition to brand selection, the impact of receiving cigarettes gifts on smokers’ quit intentions, attempts or smoking relapse should be examined with a longitudinal cohort study design since it is one of major reasons that Chinese smokers find it hard to give up smoking [16, 29].
