A Qualitative Exploration of Youth in the “New” China: Perspectives on Tobacco Use From Adolescents in Southwest China

Abstract

School-based prevention programs are not common in China and the attempts to modify successful Western prevention programs have largely shown little effect. Distinct cultural and social systems differences could explain why modified programs have been unsuccessful. Smoking behavior is examined from the perspective of Chinese adolescents as part of the development of a large intervention trial. A total of 16 focus groups with 128 participants were conducted in Chengdu in Sichuan province of China. Impressions of adolescent smokers were mixed, most seeing the behavior as common among boys. Smokers were seen as being overwhelmed and stressed. Girls’ smoking was mostly seen as universally “bad” and reflecting poorly on a girl’s character. However, a small portion of focus group participants suggested that female smoking was fashionable and trendy. With social norms changing rapidly in the “new” China, understanding what the new generation of Chinese youth thinks about smoking is critical in determining how to address and tailor prevention efforts.

Introduction

Although the prevalence of smoking decreased slightly among the entire Chinese population from 1996 to 2002, it increased among people 15 to 24 years of age.¹ Especially disturbing are the sharp increases in tobacco use recently documented among Chinese women and adolescents.² Past research among adolescents found between 28% and 43% of males and 1% and 11% of females in China identified themselves as smokers³; however, the average age of smoking initiation is decreasing rapidly.⁴ Therefore, smoking prevention efforts targeted to adolescents have been identified as an important tool for reducing the burden of future tobacco-related morbidity and mortality in China. The prevention of smoking in young Chinese is seen by some as the single greatest opportunity for preventing noncommunicable disease in the world today.

Tobacco use among adolescents is an increasing global public health problem. Urbanization and the declining influence of traditional values has resulted in the smoking prevalence among girls, particularly in urban environments, to begin catching up with boys, whereas smoking prevalence in girls in rural areas remains low in China.³ Preventing youth from smoking has become an important public health objective, particularly when considering that the majority of smokers become daily smokers during adolescence, before reaching age 25.^2,5 Previous studies have found that Chinese youth who had at least experimented with tobacco use thought that smoking improved mood, increased confidence and popularity, and calmed nerves more often than nonsmokers did.² Others have found that smoking increases during adolescence for Chinese youth, in part because social responsibilities and obligations become more important during this period, and tobacco use has become a means of social interaction and a gesture of friendship in China.⁴ Smoking is an addiction that begins in childhood and adolescence, which makes understanding youth smoking of critical importance.

Potential Impact of Cultural Change and the “New” China on Adolescent Health Behavior

Change has been occurring in China for the past 2 decades at an astounding pace. With the picture of the potential costs of adolescent tobacco use in China coming into focus, it has become more important than ever to examine the role of rapid social, economic, and cultural change on tobacco use and related health practices. There is perhaps no group at greater risk of becoming, in some ways, victims of this change than adolescents. Adolescence is a time when youth are more susceptible to both positive and negative influences on health behavior, of which social and cultural norms are a part. Changes in these norms, such as the social and cultural changes currently occurring in China, could potentially have a greater impact on youth than other groups because of this developmental susceptibility. Therefore, identifying significant cultural and social factors affecting Chinese adolescents’ tobacco use behavior can contribute to the development of both effective primary and secondary prevention efforts.

Much of the research on youth tobacco use has been conducted in Western countries. Therefore, Western researchers have a wealth of experience to draw on in developing and implementing health behavior research studies. However, there are important considerations that need to be taken into account when attempting to draw comparisons between the behaviors of adolescents in Western countries with those in China. These differences could potentially be important predictors of the initiation, experimentation, and continuation of youth smoking behaviors in China and should not be overlooked. For example, small family size because of limitations on the number of children that are allowed could possibly have both negative and positive influences on tobacco use. On the positive side, youth may have more parental attention and monitoring, which could be protective against smoking. However, more negatively, adolescents may feel additional pressure and stress due to high parental expectations, which may increase their risk of smoking. Current and future research examining smoking behavior, as well as designing effective prevention programming, needs to make greater and continued efforts to understand tobacco use behavior from the unique viewpoint of the Chinese adolescent.

Female Smokers in China

Female smokers are still relatively uncommon in Asia and there are generally strong negative perceptions toward female smokers.⁶ Past research examining trends in tobacco use among Chinese youth, as compared with adolescents in Western cultures, have found larger gender differences in smoking prevalence,⁷ as well as differences in the social acceptability of smoking behaviors for boys as compared with girls.⁸ However, because smoking rates for women are currently low, the tobacco industry has determined they are the perfect new market and has begun efforts to aggressively market to women in Asian countries.⁹ Chinese females are becoming more independent and are breaking away from traditional social norms, similar to what occurred in North America in the first part of the 20th century when cigarette smoking among women became more prevalent,¹⁰ and cigarette companies are reacting in a similar manner. Tobacco companies are attempting to associate femininity, independence, style, and sophistication as part of the smoking culture for women in China. It is unclear whether these new images of female smokers will be more appealing to young women, but trends toward more gender equality in smoking among adolescents as compared with current adult rates has been noted in several recent studies.^9,11 This trend has not been examined thoroughly in the literature to date, but if this is the case, then an increase in smoking among adult women would be expected in the near future. Increased smoking rates among younger females in high-population countries could be one of the most threatening potential developments of the global tobacco epidemic’s growth.¹² Therefore, gaining greater understanding of current and changing perceptions of female smoking among Chinese adolescents has become increasingly important for future preventive efforts.

Present Study

Currently, the data on smoking attitudes and behavior among young Chinese are limited, which also limits the development of informed and relevant prevention programming. Therefore, because of the importance of culture in smoking behaviors and prevention efforts, it is important that current research examine the underlying reasons for smoking initiation, experimentation, and progression from a Chinese adolescent’s perspective so that more effective strategies for intervention can be developed. Four primary research questions guided the study:

1. What are the general characteristics of youth smokers?

2. How are boys and girls who smoke characterized?

3. Why do Chinese youth smoke?

4. Where do youth go to smoke?

Methods

Sampling

Unlike in the United States, China has 2 primary high school types, academic (regular) and professional (vocational). Students are tested in middle school and scores from those tests determine which school type they will attend. Generally, those attending academic schools have a rigorous schedule of courses for 3 years of high school (10th through 12th grades), designed to increase the chances students will pass college entrance exams. Those attending professionals schools are enrolled in a career track, such as computers/IT or public relations and will complete an internship during their final year(s) in high school with the goal of entering the workforce once they have completed high school. Both school types were included in the study, with an equal number of schools and students from each school type.

This study was part of developmental work conducted in 4 Chinese high schools with the purpose of informing curriculum development for a large, school-based randomized control trial for a smoking prevention program. Tenth grade classes from 4 high schools in the city of Chengdu in Sichuan province were invited to participate in the pilot, 2 academic high schools and 2 professional high schools. Schools were selected from a list of high schools in the city that groups schools according to high, medium, and low academic achievement, which was provided by local education committees. To get the most representative sample for this small pilot study, the academic schools included one high academic achievement school and one mid-to-low achievement school. The 2 professional schools included one mid-to-high achievement school and one low achievement school. The majors of the students in the professional schools that participated were computer technology and public relations.

Data Collection

Written informed consent was obtained from parents and verbal consent from the student participants. Data collection included 2 paper-and-pencil surveys and focus groups with behavioral observations. The first paper-and-pencil survey was administered a few weeks prior to the focus groups.

Peer groups for Chinese adolescents in high school tend to be predominantly same gender; therefore, focus groups were conducted separately for males and females so that students could feel more comfortable discussing sensitive topics. Survey data on smoking were used to select participants for focus group participation in order to have an equal mix of smokers and nonsmokers in each group.

A total of 16 focus groups were conducted: 4 per school with half of the groups male and half female, with approximately 8 participants per group. Therefore, there were a total of 8 academic groups and 8 professional groups, including 124 students. Behavioral observations were made of all groups.

Moderator and Observer Training

Focus groups were conducted by trained moderators with each moderator team consisting of 3 graduate students from the local university public health program. Each team had 2 moderators and 1 person who was the designated note taker and was also in charge of audio taping each focus group. All moderators and observers attended 2 day-long trainings prior to conducting the focus groups.

Measures

Quantitative data.

Basic demographic information was collected in the paper-and-pencil survey, such as gender, age, school type, and academic performance. The measure used in this study to identify smokers for sampling purposes was a simple dichotomous measure of ever smoking: “Have you ever tried cigarette smoking, even a few puffs?”

Focus groups.

After a brief introduction of the moderating team and the study, focus groups were told they would be participating in a 45- to 60-minute discussion about student life and health behaviors. Moderators were instructed to spend about 5 minutes per question. Although the focus of this study is the discussion about smoking behaviors, other topics discussed in the focus groups included social competence and good social skills, alcohol use behaviors, and stress.

Students were asked a general question about what kinds of people smoke, and then they were asked about what kinds of teenagers smoke. Within this discussion, students were further asked what characteristics smokers have and then they were asked to characterize boy and girl smokers separately. Students were also asked why teens smoke and where students smoke.

Behavioral observations.

The observational ratings of students’ focus group behavior were used as a quality control measure. Each focus group observer completed a rating sheet during and after each focus group. Each participant was rated on 5 questions about behavior they displayed during the focus group using a 5-point scale of 1 (low) to 5 (high). Behaviors rated were participation in the discussion, interaction with classmates (either verbal or nonverbal), paying attention to classmates, shy and/or withdrawn behavior, and disruptive behavior (verbal and nonverbal). Observers were also asked to note any students that were particularly dominant in the discussion and those that were particularly withdrawn during the discussions.

Focus Group Protocol

Students were seated according to their study ID number to facilitate linking focus group participation with the survey and observational data. The group observer knew which seat belonged to each ID number, though they were not given any other details about the students, and made their observational notes about behavior during the focus group without being given students names, to maintain confidentiality. Behavior in the focus groups, such as acting shy or trying to dominate the discussion, was then linked by ID to the rest of the quantitative data. Students were assured that although anonymity could not be guaranteed, confidentiality would be carefully guarded and every effort would be made to keep the content of the focus groups, any statements they made or opinions expressed, anonymous. Although observations regarding behavior during the course of the focus group were not anonymous, no efforts were made to link focus group discussion content to specifics students.

Data Analysis

All focus groups were audio taped. Notes were taken during the interviews and the audiotapes were then transcribed and all sensitive or identifying information was deleted. A standard thematic analysis was used both prior to translation into English and after translation to analyze the transcripts. Thematic analysis consists of examining the text by identifying and grouping themes and coding, classifying, and developing categories in a systematic manner.^13,14 Translated transcripts were back-translated into Chinese to ensure quality, and then the English versions were checked against the Chinese transcripts a final time by a bilingual research assistant.

After creating broad categories based on the moderator guide, interview notes, and review of the transcriptions, the English transcripts were systematically content-coded by 4 research assistants using the categories. The main coding categories included characteristics of youth smokers in general, characteristics of boys who smoke, characteristic of girls who smoke, why student smoke, and where students most commonly smoke. Each focus group transcript was coded by 2 separate research assistants working independently to reduce the risk of investigator bias.¹⁵ After each transcript was content-coded twice, the primary author reviewed all transcripts and coding schemes and resolved any discrepancies between coders. Quantitative data, both paper-and-pencil survey and behavioral observations, were also analyzed to provide basic descriptive statistics for the sample.

Results

Sample Characteristics

The study sample consisted of 124 students from 4 high schools, 2 academic and 2 professional, in the city of Chengdu in Sichuan province of China. Characteristics of the sample are reported in Table 1. Because of sampling, there were equal numbers of boys and girls and academic and professional students who participated. The average age in the academic schools was 16.1 (0.50) and 16.3 (0.63) years in the professional schools. Ever smoking, which was used to select students for participation, among boys was 43.3% in academic and 56.7% in professional schools. For females, in academic schools, the percentage who had ever smoked a cigarette was 28.1% and 37.5% in professional schools.

Table 1.

Sample Characteristics (N = 124)

	Academic School (N = 62)		Professional School (N = 62)
	Frequency (%)	Range	Frequency (%)	Range
Demographic information
Mean age in years (SD)	16.1 (0.50)	15–17	16.3 (0.63)	15–18
Ever smoked a cigarette	35.5		46.8
Smoked in the past 30 days	3.28		11.5
Intention to smoke in the next 12 months	17.7		32.3
Observational behavior ratings, mean (SD)		1–5		1–5
Participated in the discussion	3.4 (1.0)		3.2 (1.0)
Interacted with classmates	3.2 (0.95)		3.1 (0.92)
Paid attention to classmates	3.2 (0.73)		3.3 (0.67)
Shy and withdrawn	2.2 (0.93)		2.2 (0.98)
Disruptive behavior or language	1.7 (0.55)		1.8 (0.64)
No. of students who were especially dominant	0.17 (0.29)	0–1	0.16 (0.32)	0–1
No. of students who were especially withdrawn	0.13 (0.26)	0–1	0.15 (0.29)	0–1

General Characteristics of Adolescent Smokers

Impressions of adolescent smokers were mixed, most seeing the behavior as fairly common among boys. Smokers were also seen as being overwhelmed and stressed. Many felt that smoking was associated with family support of smoking. Some parents allow their teens to smoke at home and around them. It seems this is usually accompanied by an attitude that adolescents are mature enough or adults now, so they can and/or should smoke. Not surprisingly, this attitude seemed to be reserved for males.

A student in our class said that his father allowed him to smoke because he would smoke and drink alcohol when he became an adult. (girl, professional school)

The family influence for girls smoking seemed to be more about a lenient attitude in general—letting them hang out with boys—and less parental supervision, not necessarily an open support for them to smoke. Parental divorce was also mentioned as a characteristic of smokers in general. In addition to parental smoking and support of smoking, less parental interest and involvement also appeared to be a risk factor for smoking. Those who smoke are also seen to be more rebellious and less diligent, though there were mixed opinions about the latter. Most seemed to think you could get good marks in school and smoke, but smokers couldn’t get the highest marks. Smoking for the purpose of social communication was mentioned repeatedly in the focus groups. All groups also discussed how it is rude to refuse a cigarette when offered one. This was mentioned by smokers and nonsmokers alike and has been an issue in past work when addressing refusal skills in prevention interventions among Chinese youth. This is a social norm that is seen in the adult world in China and has been passed to the adolescent realm. Most groups mentioned that it is often hard to distinguish between a smoker and a nonsmoker based on their appearance, friends, and behavior.

Social attitudes toward boys who smoke are more accepting than for girls. Almost all groups, from both school types, mentioned that it is normal and acceptable for boys to smoke.

Student 1: It doesn’t matter if boys smoke, only if they smoke around us. (girl, academic school)

Student 2: Yes, it doesn’t matter if boys smoke, but if girls smoke I am wondering why they would smoke? (girl, academic school)

As mentioned previously, in some cases, there is even parental support of smoking for males. The most often mentioned characteristic of boys who smoke was someone who wants others to think they are cool.

They want others to think they are cool. (boy, academic school)

Some mentioned that smokers were less motivated and more likely to hang out in a “gang.” This was a translated term for groups of guys who hang around the neighborhood, mostly outdoors. The old-fashioned terms of “hooligan” and “ruffian” were often used to describe them, but they do not necessarily appear to be associated with criminal behavior. They are seen as unmotivated young men who do not have steady jobs, are rebellious, and do not know what they want to do in life.

Some people who have very bad performance (in school) (girl, professional school)

They may be overwhelmed or in a stressful situation but do not know how to react appropriately or deal with things in a healthy way. And people who are usually angry at themselves. (girl, academic school)

Smoking among girls appeared at first glance to be universally frowned upon; however, there were some inconsistencies and contradictions mentioned in regards to attitudes toward female smokers.

I feel it is not very difficult to accept a boy who smokes and most parents have the same opinion. However, it is difficult to accept a smoking girl. In my opinion, smoking is related to a girl’s character . . .” (girl, academic school)

Participants tended to have more to say about female smokers than male smokers, since boys’ smoking is so accepted.

Those who feel depressed (boy, professional school)

As far as I know, girls smoke because they come across emotional problems. (boy, professional school)

Girls who smoke are seen to get along well and hang out with boys. Having more male friends and boyfriends and hanging out with the local “ruffians” mentioned above are risk factors for female smoking. Young women who smoke were seen as less intelligent and there is a common misbelief among academic school students that most of the girls attending professional schools probably smoke.

They are fashionable, mature, bold, open . . . (girl, academic school)

Empty-headed and not very smart . . . stupid (girl, academic school)

In professional school, it is a miracle if you find someone who does not smoke (girl, academic school)

It is difficult for youth not to judge harshly a girl that smokes and smoking is seen to say something bad about your character if you are a girl, though this is not the case for boys. Female smoking was condemned by both boys and girls and for the most part is seen as unfeminine, not properly respectful of their duties, and overall as crass and disgusting.

Some wear little and are frivolous. Some are more conservative and they are okay. (girl, professional school)

I think they are indelicate, not very feminine. (girl, academic school)

Not attend to one’s proper work or duties. (boy, academic school)

However, perhaps one of the most interesting results of the focus groups, was the fact that after mentioning how unacceptable and bad it was for girls to smoke, many groups went on to later mention characteristics of adolescent female smokers that were positive. Girls who smoke, in addition to being of bad character, were also seen as fashionable, modern, open, and trendy. In one case, a student mentioned that they had seen some girls smoking gracefully.

Modern. (boy, academic school)

They wear make-up, different clothes, are fashionable. (boy, academic school)

Some girls I have seen smoking gracefully. (girl, professional school)

They follow the newest things. (boy, professional school)

Why Do Chinese Adolescents Smoke?

Even though the characteristics attributed to smokers differed by gender, the reasons students gave for why adolescents smoked were the same across genders. Curiosity was mentioned the most often and was always the first answer groups gave; “for fun” was another popular answer mentioned right away.

They are rebellious . . . and curious (girl, academic school)

To go with the stream. (girl, academic school)

This is the business of boys, we have no idea of this issue. (girl, academic school)

They want to be accepted. (girl, professional school)

However, more detailed answers usually followed, once participants thought about the question further.

Smoking could make you clear-headed. (girl, academic school)

They are seduced. (girl, academic school)

As with any adolescent behavior, image was often mentioned as being an influence; looking cool and mature were common reasons given for smoking and some mentioned smoking because it represents an adolescent’s particular style.

They think it stands for something. Think it represent their style. (girl, professional school)

They want to look mature. (girl, professional school)

Emotions and emotional frustrations are other reasons for smoking as well as not knowing how to cope or react to emotional fluctuations. Stress was mentioned, with particular stressors being family, school and studying, and friendships including romantic relationships. More mental health reasons were worry and anxiety, and depression was a very common response.

Worried person. Someone who is anxious. (girl, professional school)

When they are distracted—with studies, family, friends, relationships. (boy, professional school)

Emotional frustration. (boy, professional school)

It lets you feel easy and forget all your troubles. (boy, professional school)

Generally, they will smoke when they are thinking or in pain (emotional, mental). (boy, professional school)

Those who feel depressed. (boy, professional school)

When they have been dumped. (girl, academic school)

Family problems, for example, parents’ fighting. (girl, academic school)

When they are depressed or in a bad mood. (boy, academic school)

When they are in a bad mood, or bored. (girl, professional school)

When they are stressed, like with emotion or family . . . or studying. (girl, professional school)

Some felt that social pressure and communication was an important influence in smoking behavior, and as mentioned previously, social norms about refusal were brought up.

This is one way to express respect. Or say . . . a kind of social communication. When your friends give you a cigarette it is impolite to refuse. (boy, professional school)

When other people give you a cigarette for social communication needs. And when having a party. (boy, academic school)

Smoking while drinking also seems to be common and was often mentioned as a way some start smoking more regularly.

One might smoke when they are drunk. (boy, professional school)

Where Do Chinese Adolescents Smoke?

The most prominent feature, not surprisingly, of places where youth go to smoke in China was someplace with no adult supervision—particularly that of parents and teachers. To further elaborate, students mentioned locations that were “hidden,” “secret,” and “places where others cannot see.” Some adolescents are allowed to smoke at home because their parents allow it; these seemed to be parents who were smokers themselves. Some thought divorced parents were also more lenient about smoking and smoking in the home.

Outdoor locations seemed to be common, such as parks. Smoking while on school grounds was not common, but outside the school gate is a popular place to light up. It seemed that boys were more likely to smoke outside and alone as well as with groups. Places and locations that were for entertainment and where there would be peers around were the places mentioned for girls to smoke.

Other popular places to smoke were entertainment venues, such as Karaoke and Internet bars. Academic school students also mentioned that professional schools were places where more students were smokers and that they might be able to smoke there. This was not confirmed in the discussions with professional schools students; however, smoking was not allowed at any of the schools and the majority of youth find other locations to smoke.

Discussion

As international pressure to cut tobacco use mounts, the Chinese government struggles to balance advancing the country’s economy with maintaining the health of its society and garnering global support. This, combined with facing an enormous future burden of disease directly related to tobacco use that has major social and economic ramifications at both the national and international levels has led to a critical need for a focus on prevention, particularly among China’s youth.¹⁶ In the present study, the focus group methodology provided a wealth of rich information about teens’ perceptions of the social–contextual role of smoking in their daily lives. Although contradictions abound—and they can be difficult to sort out without further, confirmatory methods—some clear insights into why Chinese adolescents smoke and gender differences in smoking behavior rose to the surface.

Findings indicate students have mixed opinions about smoking and smokers. Both positive and negative images of smokers could indicate different influences on tobacco use behavior and norms, for example, peers and the media. With social norms changing rapidly in the “new” China, understanding what the new generation of Chinese youth thinks about smoking is critical in determining how to address and tailor prevention efforts.

Perhaps some of the more important findings were the inconsistencies in the view and attitudes about girls’ smoking. Some implied that opinions may be influenced by the attractiveness of the girl in question, which could perhaps begin to explain some of these contradictory opinions. Another possible explanation is a clash between traditional Chinese cultural beliefs and the newer, more “modern” and Western beliefs being introduced more and more frequently into the Chinese culture and to which young people could be particularly attuned to. Adolescents in China, maybe more than any other group, will need to figure out ways to reconcile the different and often opposing cultural values they are being taught. Understanding and addressing this dilemma will be important for future work. The slowly increasing rates of smoking among women in China, as well as the even slower social acceptance of female smoking, could be shifting opinions about adolescent girls’ smoking enough to cause concern and prevention efforts should take note of these early warning signs.

Limitations

The study was not without limitations. Foremost is the reminder that the data are qualitative and specific conclusions about the magnitude or strength of the findings cannot be made. The themes and findings noted in this article, though, were salient in that they were found across multiple schools and school types.

Another limitation of this research is the use of translated transcripts. By necessity, the authors needed to analyze transcript that had been translated from Chinese to English. Although every effort was made to ensure accuracy of the translations of the transcripts, there is no guarantee that details were not lost and subtle nuances of language were completely accurate.

Future Directions

Chinese adolescents live in family and school environments that are substantially different from American adolescents. These social differences may be important predictors of the uptake and progression of adolescent smoking stages in China. For example, the emphasized family values and small family size might bring both positive and negative influences into the development of Chinese adolescent behaviors, including tobacco use. How to delay or reverse the increasing tendency of adolescent smoking is a major challenge for public health. Accordingly, adolescent smoking prevention programs have been identified as important ways to combat this threat and most of them will use schools as the intervention settings. These school-based programs will not achieve full success until they are carefully designed address the needs of current adolescents and tailored to fit the changing culture in modern China.

This study suggests there might be a need for future prevention interventions to include different components to target boys and girls. It may also be important to target different subgroups of adolescents who may be at higher risk as suggested by the findings, such as those who are depressed, anxious, or stressed. This study represents the preliminary efforts in the development of a large, school-based tobacco prevention intervention for Chinese adolescents and identified several important constructs that should be addressed. One of the most notable implications is identification of cultural norms and attitudes regarding adolescent tobacco use in China that are both complex and unique, and the realization that just adapting successful Western prevention programs may not be what is needed to address the issues. However, using the methodology and experience gained from the development and implementation of these programs and combining it with exploratory and developmental work, such as the present study, as well as collaborations with local researchers and professionals could dramatically increase the chances of success.