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. 2025 Dec 5;33:101890. doi: 10.1016/j.ssmph.2025.101890

Unraveling the complexity of associations between tobacco culture in Chinese society and smokers' outcome expectancies: a network perspective

Yixin Zhao 1, Xiaoyan Wang 1, Shiyao Ling 1, Kexin Peng 1, Hongyu Li 1, Lian Yang 1,⁎
PMCID: PMC12743513  PMID: 41458452

Abstract

Background

Chinese unique sociocultural context surrounding tobacco reinforces smoking behaviors, potentially through its influence on smokers’ expectancies of smoking-related outcomes. Network analysis effectively explores the intricate relationship between social tobacco cultural attitudes and smoking outcome expectancies among Chinese smokers.

Methods

The study included 1382 current smokers. A mixed graphical model was employed to construct internal and combined networks of social tobacco cultural attitudes and smoking outcome expectancies. Additionally, node strength centrality, edge weights, and stability were analyzed.

Results

In the network of social tobacco cultural attitudes, sharing cigarettes (jingyan or sanyan) was identified as the central node (Str = 0.855). For smoking outcome expectancies, stimulus/state enhancement exhibits the highest strength centrality (Str = 0.860). In the total integrated network of smoking outcome expectancies and social tobacco cultural attitudes, social facilitation outcome expectancies demonstrated the highest strength centrality between the two variables (Str = 0.894).

Conclusions

In this study, social facilitation outcome expectancies were central in the combined network of social tobacco cultural attitudes and smoking outcome expectancies, showing a direct and positive link to multiple tobacco cultural attitudes. This finding illustrates how sociocultural factors are interconnected with individual expectancies of smoking outcomes, identifying the central positioning of social facilitation expectancies variables within the sociocultural attitudes–outcome expectancies network. These insights provide new perspectives for developing culturally adaptive tobacco control interventions, such as reshaping tobacco cultural symbols to promote “smoke-free weddings” and “refusing cigarette gifts.”

Keywords: Social cultural, Smokers, Outcome expectancies, Social facilitation, Network analysis, Bourdieu

Highlights

  • •

    Construction of network associations between Chinese tobacco cultural attitudes and smoking outcome expectations.

  • •

    Offering and sharing cigarettes are pivotal cultural symbols in China's tobacco-centric social communication.

  • •

    Social facilitation as the critical correlation between Chinese tobacco culture and smoking outcome expectations.

  • •

    Smoke-free weddings and similar interventions are effective strategies to curb tobacco use and consumption in China.

1. Introduction

Tobacco use is a major contributor to the global burden of disease, alongside air pollution, hypertension, and low birth weight/preterm births. It is a key preventable factor in chronic noncommunicable diseases and premature deaths worldwide (GBD 2019 Risk Factors Collaborators, 2020; GBD 2021 Risk Factors Collaborators, 2024). In 2022, around 1.25 billion adults globally smoked, with more than 70 % living in developing countries, according to the World Health Organization. China is the largest tobacco consumer globally, accounting for approximately 40 % of the world's total tobacco consumption, with an adult smoking prevalence of 29.4 % (67.7 % in males and 3.2 % in females) (China - Global, 2018; WHO global report on trends in prevalence of tobacco use 2000–2030, n.d.). As such, tobacco use carries a substantial health burden in China. Without effective tobacco control measures, approximately 2 million people are expected to die annually from tobacco-related diseases by 2030, rising to 3 million per year by 2050 (Chan et al., 2022).

1.1. Smoking outcome expectancies: key psychological factors

Smoking outcome expectancies are key psychosocial factors linked to tobacco addiction. These expectancies represent individuals' beliefs about the potential positive and negative outcomes of smoking (Cooper et al., 2016). They serve as key proximal mediators in studying smoking motivation and hold significant clinical intervention value. Individuals who hold stronger positive smoking outcome expectancies are at increased risk of tobacco dependence and are more likely to relapse after cessation attempts. Research indicates that dynamic changes in positive outcome expectancies significantly predict relapse (Gwaltney et al., 2005), potentially due to individuals’ beliefs that smoking provides positive outcomes such as improved mood, social facilitation, sensory experiences, and weight control (Halliday, Zawadzki, & Song, 2025; Patel et al., 2011). Most research on smoking outcome expectancies has been conducted in Western countries, with relatively few studies focusing on smoking populations in China (Lin et al., 2023; Wang, 2023).

1.2. Chinese tobacco culture: widespread social influences

Although smoking is often framed as an individual choice, researchers have increasingly emphasized the need to consider broader social influences (McLeroy et al., 1988). In China, the sociocultural environment surrounding tobacco significantly influences its use and consumption. In Chinese society, smoking is linked to positive imagery, making it a significant barrier to tobacco control. Cigarettes are seen as essential for nearly all social events, such as weddings and funerals (Yang et al., 2015). Cultural practices such as cigarette gifting (songyan), respectfully offering and lighting cigarettes (jingyan), and sharing cigarettes (diyan or sanyan) promote smoking behavior, symbolizing respect, celebration, goodwill, and generosity. Sharing premium cigarettes has become a means of gaining social recognition and dignity (mianzi, "face") (Wank, n.d.). Furthermore, a key ritual in Chinese wedding ceremonies involves guests offering monetary gifts and presents to the newlyweds to bestow good fortune. In return, guests receive wedding favors (li, or “etiquette”), which typically include alcohol and cigarettes (Trimble et al., 2022). The inclusion of cigarettes in these favors has evolved into a distinct cultural phenomenon known as "wedding cigarettes." This practice includes both smokers and nonsmokers. Widespread societal acceptance may lead to increased tobacco product consumption and use (Guo et al., 2012; Ma et al., 2008). Consequently, the exchange and gifting of cigarettes in Chinese society appear to constitute a distinct social system. Additionally, cigarettes function as a form of social currency in this system, used to build and maintain interpersonal relationships, thereby serving as a medium of social communication (Rich & Xiao, 2012). A recent nationwide cross-sectional study in China found that most smokers reported sharing (97 %) and receiving gifted (90 %) cigarettes. Research on cigarette sharing and gifting culture found that under 10 % of smokers viewed it negatively, a rate much lower than that of nonsmokers (Liao et al., 2022). Furthermore, studies have demonstrated a direct association between cigarette gifting and sharing in China and an increase in smoking behavior and exposure to secondhand smoke (Ding et al., 2009; Xu et al., 2016).

1.3. Construction of the theoretical framework

In cultural studies, there is a longstanding debate regarding the relationship between societal practices on the one hand and individual perceptions on the other. Bourdieu's theory of practice (Bourdieu, 2008) provides a useful analytical framework for understanding the interconnections between Chinese smokers' attitudes toward tobacco exchange, gifting, and cultural rituals and their smoking outcome expectancies. Crucially, Bourdieu highlights the interplay between agency and structure, uniting micro- and macro-level factors to explain behavior. This account of the dualism between structure and agency in shaping behaviors is fitting for smoking research. It bridges the divide between approaches where the cause of smoking is either attributed to the individual (agent), as evident in developmental psychology models, or to external social forces encountered within the smoking setting (structure) (Lunnay et al., 2011).

According to Bourdieu, attitudes and behaviors are learned and socialized through interpretation of the external social environment. In China, broader sociocultural norms surrounding smoking manifest as the reciprocal exchange of cigarettes among smokers, the high symbolic currency of tobacco as a gift, and the pivotal role of tobacco in social fields, etc. (Rich & Xiao, 2012). Among Chinese smokers, cultural norms become internalized and integrated into the social habitus due to pervasive social endorsement. Owing to this internalization of a broadly accepting attitude towards tobacco social culture, the smokers' habitus becomes a structure generating dispositions and inclinations that tend toward positive smoking expectancies (such as social facilitation, etc.) and a normalization of the behavior (MacArthur et al., 2017). Furthermore, social cognitive theory also emphasizes the influence of social environments and cognition on health behavior. This theory indicates that perceived social normative behavior and positive outcome expectancies are central factors affecting substance use. Both are considered learned from social environments and jointly shape smoking and drinking behaviors (Janssen et al., 2018; Wardell & Read, 2013; Liu and Wang, 2018). Evidence from Bourdieu's theory in the study of drinking behavior indicates that drinking behavior was rooted in the social culture world, with a key motivator to drinking being the possibility of gaining social capital and enhancing status (Brierley-Jones et al., 2014; Lunnay et al., 2011; MacArthur et al., 2017). In tobacco research, some findings indicate that young people frequently attribute social and cultural value to cigarettes and smoking. Most participants framed smoking as a social facilitation (Gagné et al., 2015; Hewer et al., 2021). Thus, we use Bourdieu's work as a heuristic, or conceptual “toolkit,” to elucidate key interconnections among multifaceted data dimensions pertaining to attitudes toward tobacco culture and smoking outcome expectancies. Specifically, this study hypothesizes that smokers with positive attitudes toward tobacco culture are more likely to be associated with positive outcomes of smoking (e.g., social convenience, stress relief), while showing no significant association or a negative correlation with negative outcomes (e.g., health risks, social disapproval).

1.4. Applicability of network methods

Current research predominantly focuses on isolated pairwise relationships, failing to model synchronous multivariate interactions across psychological and socio-environmental dimensions. Critically, dominant analytical approaches—such as correlational and regression analyses—assume linear relationships, thereby inadequately capturing the dynamic, reciprocal, and nonlinear feedback mechanisms postulated within sociological theories. This gap necessitates an analytical approach capable of modeling the complex systemic dynamics implied by these theories. Over the past few years, network theory emerged as an interdisciplinary framework to understand a wide range of phenomena that proved difficult to reconcile with latent variable models, such as mental disorders, personality, intelligence, social ideology, and attitudes (Borsboom, 2017; Dalege et al., 2016; Schlicht-Schmälzle et al., 2018). Although cross-sectional networks cannot establish causal relationships or determine the direction of influence, examining such networks reveals associations among variables within constructs and interactions between constructs. This study employs Mixed Graphical Models (MGMs) to conceptualize tobacco cultural attitudes and smoking outcome expectancies as an interconnected network system—rather than isolated variables—thereby capturing associations across dimensions of tobacco cultural attitudes and outcome expectancies. Furthermore, network centrality is measured via strength centrality, which quantifies a node's influence by summing the absolute edge weights of all its connections. Variables exhibiting high centrality may serve as putative causes underlying changes in other variables. The capacity to identify such central variables facilitates the determination of potential intervention targets (Valente, 2012).

2. Methods

2.1. Participants and procedure

This cross-sectional household-based survey was conducted in Sichuan Province, China, from January 2022 to April 2023. A stratified multi-stage sampling strategy was employed. Four representative regions were selected based on geographic distribution, economic development, and health indicators: Wenjiang District (Chengdu), Fushun County (Zigong), Qingchuan County (Guangyuan), and Xide County (Liangshan Prefecture). Within each region, two streets and two townships were sampled, followed by two communities per street and two villages per township.

The survey included 6189 participants (including nonsmokers). Given that the ultimate goal of tobacco control lies in modifying smoker behavior—and considering the unique urgency of China's tobacco epidemic—mapping cognitive networks among smokers facilitates prioritizing actionable intervention targets. Furthermore, all measurement tools selected for this study were developed and validated specifically within smoking populations, demonstrating enhanced reliability and validity. Consequently, our analysis was restricted exclusively to current smokers. To minimize self-reporting bias, current smokers were defined using both subjective and objective criteria: (1) self-reported lifetime cigarette consumption≥100 cigarettes and smoking within the past 30 days, and (2) salivary cotinine levels >10 ng/mL. A total of 1410 residents met both criteria (smoking prevalence: 22.78 %). Questionnaires with missing values were excluded to avoid estimation bias. Following multiple imputation for minor missing sociodemographic data, the study finalized an analytical sample of 1382 smokers, achieving a valid response rate of 98 %. Trained investigators conducted face-to-face interviews to collect data. All participants provided informed consent. The study protocol was approved by the Ethics Committee of Chengdu University of Traditional Chinese Medicine (Approval No. 2023 KL-134).

2.2. Measures

2.2.1. Sociodemographic characteristics

Participants' sociodemographic information was collected via questionnaire, including gender (male/female), age (15–34, 35–59, and 60∼), education level (illiterate, primary/secondary, high school, university or higher), residence (urban/rural), ethnicity (Han/other), and estimated annual income in Chinese yuan: low (<20,000), medium (20,000–50,000), and high (>50,000).

2.2.2. Smoking outcome expectancies

The Smoking Consequences Questionnaire (SCQ) (Brandon & Baker, 1991) assesses broad expectancies regarding the outcomes of smoking, grounded in the concept of “subjective expected utility.” Through several iterations and simplifications, the SCQ has been adapted for use among both adolescent and adult populations in general and clinical settings. It has been translated into Chinese and demonstrated good validity and reliability in Chinese samples (Copeland et al., 1995; Xiaoxiao et al., 2025). This study used the Brief Smoking Consequences Questionnaire-Adult (BSCQ-A), which comprises 25 questions across 10 subscales measuring smoking outcome expectancies. Seven subscales assess positive outcome expectancies: negative affect reduction, stimulation/state enhancement, taste/sensorimotor manipulation, social facilitation, weight control, craving/addiction, and boredom reduction. The remaining three assess negative outcome expectancies: health risks, negative physical feelings, and negative social impressions. Respondents rated each item on a 10-point Likert scale, indicating the extent to which they recognized each expectancies. In this study, the BSCQ-A scale demonstrated satisfactory internal consistency, with Cronbach's alpha coefficients for each dimension detailed in AppendixTab_1 (Rash & Copeland, 2008).

2.2.3. Chinese tobacco cultural attitudes

Referring to prior research, a self-reported questionnaire was developed to assess attitudes toward China's unique tobacco culture (Liao et al., 2022), including customs such as cigarette gifting, offering and sharing cigarettes (jingyan or sanyan), using cigarettes as a medium for social communication, and “wedding cigarettes” (xiyan). See AppendixTab_2.

2.3. Statistical analyses

2.3.1. Data description

First, descriptive statistical analyses of sociodemographic variables were performed. Chi-square was used to examine the differences in multi-dimensional tobacco cultural attitudes across various demographic characteristics. Second, the scores of each item of smoking outcome expectancies were described in a statistical context. All descriptive statistics were analyzed in SPSS Version 26.0 software, with a two-tailed significance threshold of p < 0.05 (two-tailed).

2.3.2. Network estimation

Network analysis was conducted using R version 4.4.3. Three networks were estimated: (1) an internal network of four dimensions of attitudes toward tobacco culture; (2) an internal network of the 10 subscales of smoking outcome expectancies; and (3) a combined network of tobacco cultural attitudes and smoking outcome expectancies. Networks were generated using the Mixed Graphical Model (MGM) via the “mgm” package, which handles ordinal, binary, and continuous variables (Haslbeck & Waldorp, 2020). The Extended Bayesian Information Criterion hyperparameter was set to γ = 0.5, ensuring high specificity by retaining only robust edges (Epskamp et al., 2018; Foygel & Drton, 2010). The R package qgraph was employed to calculate and visualize strength centrality indices for network centrality assessment. Node predictability was estimated using the “predict” function, quantifying the proportion of variance explained by other nodes in the model (range: 0–1; 1 = perfect predictability) (Haslbeck & Waldorp, 2018). Bootstrap analysis (1000 samples) assessed edge stability using the “resample” function. The “plotRes” function visualized edge stability, displaying the frequency of nonzero edges and the 5 % and 95 % quantiles of estimated parameters.

3. Results

3.1. Sample characteristics

Table 1 presents differences in attitudes toward four tobacco-related cultural constructs—gifting, jingyan/sanyan, social communication, and “wedding cigarettes”—across sociodemographic variables. Age significantly influenced attitudes toward gifting, jingyan/sanyan, and social communication (χ2 = 17.248, 25.459, 24.248; p < 0.05), with older smokers showing greater support. Gender differences emerged for jingyan/sanyan and social communication (χ2 = 23.716, 33.681; p < 0.001), with males expressing higher support (78.7 % vs. 59.3 %; 77.6 % vs. 50.0 %, respectively). Education level affected attitudes toward jingyan/sanyan, social communication, and “wedding cigarettes” (χ2 = 29.208, 18.274, 13.491; p < 0.05), with support decreasing as education increased (75.2 %–70.3 %; 74.4 %–72.1 %; 80.6 %–67.2 %, respectively). Rural residents expressed stronger support for jingyan/sanyan, social communication, and “wedding cigarettes” than urban residents (79.5 % vs. 72.6 %; 77.9 % vs. 71.1 %; 76.3 % vs. 70.1 %, respectively). See AppendixTab_3 for smoking outcome expectation scores.

Table 1.

Association of demographic characteristics with tobacco cultural attitudes: A descriptive and chi-square Analysis.

Variables(%)
 cigarette gifting
 offering and sharing cigarettes (jingyan or sanyan)
 cigarettes as a medium for social communication
 wedding cigarettes (xiyan)
Support N(%) Oppose N(%) χ2 P Support N(%) Oppose N(%) χ2 P Support N(%) Oppose N(%) χ2 P Support N(%) Oppose N(%) χ2 P
Age
15∼34(29.3) 163(40.2) 136(33.6) 17.248 <0.05 284(70.1) 53(13.1) 25.459 <0.001 277(68.4) 59(14.6) 24.248 <0.001 290(71.6) 115(28.4) 2.556 0.279
35∼59(41.5) 272(47.4) 204(35.5) 464(80.8) 67(11.7) 452(78.7) 75(13.1) 432(75.3) 142(24.7)
60∼(29.2) 199(49.4) 115(28.5) 323(80.1) 43(10.7) 320(79.4) 41(10.2) 307(76.2) 96(23.8)
Gender
Male(93.8) 598(46.1) 427(32.9) 1.156 0.561 1020(78.7) 150(11.6) 23.716 <0.001 1006(77.6) 152(11.7) 33.681 <0.001 963(74.3) 333(25.7) 0.252 0.616
Female(6.2) 36(41.9) 28(32.6) 51(59.3) 13(15.1) 43(50.0) 23(26.7) 66(76.7) 20(23.3)
Education level
Illiteracy(9.3) 65(50.4) 37(28.7) 7.497 0.277 97(75.2) 14(10.9) 29.208 <0.001 96(74.4) 16(12.4) 18.274 <0.05 104(80.6) 25(19.4) 13.491 <0.05
Primary/secondary(56.9) 373(47.5) 260(33.1) 648(82.4) 76(9.7) 626(79.6) 79(10.1) 604(76.8) 182(23.2)
High school(17.2) 98(41.2) 78(32.8) 165(69.3) 36(15.1) 162(68.1) 43(18.1) 167(70.2) 71(29.8)
University or higher(16.6) 98(42.8) 80(34.9) 161(70.3) 37(16.2) 165(72.1) 37(16.2) 154(67.2) 75(32.8)
Income
Low(43.3) 291(48.7) 180(30.1) 9.622 <0.05 463(77.4) 66(11.0) 5.709 0.222 454(75.9) 70(11.7) 2.141 0.710 452(75.6) 146(24.4) 3.043 0.218
Medium(27.5) 169(44.5) 143(37.6) 290(76.3) 56(14.7) 285(75.0) 51(13.4) 289(76.1) 90(23.9)
High(29.2) 174(43.1) 132(32.7) 318(78.7) 41(10.1) 310(76.7) 54(13.4) 288(71.3) 115(28.7)
Residence
Rural(70.7) 461(47.2) 319(32.7) 3.014 0.222 777(79.5) 97(9.9) 11.708 <0.05 761(77.9) 110(11.3) 7.915 <0.05 745(76.3) 232(23.7) 5.658 <0.05
Urban(29.3) 173(42.7) 136(33.6) 294(72.6) 66(16.3) 288(71.1) 65(16.0) 284(70.1) 121(29.9)
Ethnicity
Han(86.1) 539(45.3) 388(32.6) 4.165 0.125 922(77.5) 132(11.1) 7.720 <0.05 905(76.1) 146(12.3) 1.534 0.464 877(73.7) 313(26.3) 2.600 0.107
Other(13.9) 95(49.5) 67(34.9) 149(77.6) 31(16.1) 144(75.0) 29(15.1) 152(79.2) 40(20.8)
Total 634(45.9) 455(32.9) 1071(77.5) 163(11.8) 1049(75.9) 175(12.7) 1029(74.5) 353(25.5)
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3.2. Network structure of tobacco cultural attitudes

Figure_1 displays the network structure of attitudes toward four tobacco-related cultural constructs. Nodes represent measured variables. Blue and red lines denote positive and negative edges, with thickness indicating association strength. All nodes showed positive associations. Strength centrality was highest for attitudes toward jingyan/sanyan (Str = 0.855), followed by attitudes toward “wedding cigarettes” (Str = 0.832), social communication (Str = 0.641), and gifting (Str = 0.410) (Figure_1, left).

Fig. 1.

Fig. 1

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Network structure and strength centrality of tobacco cultural attitudes.

3.3. Network structure of smoking outcome expectancies

Figure_2 presents the network of 10 smoking outcome expectancies. Among 45 possible edges, 21 were significant. The strongest positive correlations were between stimulation/state enhancement and negative affect reduction, taste/sensorimotor manipulation and stimulation/state enhancement, and social facilitation and taste/sensorimotor manipulation. Strength centrality metrics identified stimulation/state enhancement (Str = 0.860), taste/sensorimotor manipulation (Str = 0.790), social facilitation (Str = 0.785), and negative affect reduction (Str = 0.785) as occupying the most dominant positions within the network (Figure_2, left).

Fig. 2.

Fig. 2

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Network structure and strength centrality of smoking outcome expectancies.

3.4. Network structure of tobacco cultural attitudes and smoking outcome expectancies

Figure_3 shows the integrated network structure linking attitudes towards Chinese tobacco-related cultural constructs with smoking outcome expectancies. Among the total of 91 possible edges, 32 demonstrated significant connections within this network. In the network, social facilitation outcome expectancies were directly and positively associated with attitudes towards cigarette gifting, jingyan/sanyan, and social communication. Social facilitation also showed positive associations with all positive outcome expectancies. Node strength was highest for social facilitation (Str = 0.894), followed by taste/sensorimotor manipulation (Str = 0.824), stimulation/state enhancement (Str = 0.824), and jingyan/sanyan attitudes (Str = 0.722). Predictability was highest for stimulation/state enhancement (44.5 %) and lowest for expected health risks (4.70 %) (Figure_3, left). (See AppendixFig_1, AppendixFig_2 and AppendixFig_3 for edge stability tests).

Fig. 3.

Fig. 3

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Network structure and strength centrality of tobacco culture attitude and smoking outcome expectancies.

4. Discussion

This study presents the first network analysis to explore the complex interplay between societal tobacco cultural attitudes and smoking outcome expectancies among Chinese smokers, identifying core nodes within their associative networks. These findings highlight the need for interventions focused on sociocultural and cognitive factors to tackle tobacco control issues in China.

4.1. Cognitive-sociocultural network analysis

Within Network 1, all node pairs exhibited positive associations, with attitudes toward jingyan/sanyan identified as the most central node. In China, the exchange of cigarettes occurs nearly daily among smokers. During initial meetings or encounters with acquaintances, smokers frequently share cigarettes (sanyan), typically using them immediately upon receipt (Wank, n.d.). Cigarette sharing represents the central custom within China's distinctive tobacco culture. This sharing process is essential for all related practices, including gift-giving, “wedding cigarette” customs, and using cigarettes as a means of social communication. This cultural phenomenon likely originates from the collectivist orientation in Chinese society (Rich & Xiao, 2012). Consequently, interventions that target smokers' attitudes toward cigarette sharing are both necessary and urgent. For instance, research among Chinese adolescents has shown that self-reported cigarette refusal skills strongly predicted future smoking status among males (Grenard et al., 2006). Changing smokers' attitudes about sharing cigarettes is essential for establishing healthier social norms, helping to reduce social pressures that hinder cessation and undermine quit attempts.

In Network 2, stimulation/state enhancement was the most central node of the whole network of outcome expectancies. Smokers with this expectation often believe that smoking can help them restore energy and relieve fatigue. There is evidence that fatigue symptoms may lead to more cigarette use, suggesting that nicotine may be used as a means of fighting fatigue (Hamidovic & de Wit, 2009). Biological studies also support this view, suggesting that nicotine acts as a stimulant to the central nervous system, thereby temporarily relieving fatigue-related symptoms (Boutrel & Koob, 2004; Pomerleau, 1992). This may lead to a general perception among smokers that smoking can help them relieve fatigue and restore energy, resulting in positive outcome expectancies. These outcome expectancies are particularly common among individuals in physically demanding or high-stress occupations, such as industrial workers, agricultural laborers, and service sector employees (Asfar et al., 2016). For smokers with such expectancies, nicotine replacement therapy may be a helpful intervention (Cahill & Lancaster, 2014; Kagabo et al., 2020).

Within Network 3, social facilitation outcome expectancies exhibited the highest strength centrality in the combined network of societal tobacco cultural attitudes and smoking outcome expectancies, serving as the network's central node. This suggests that, in the context of societal tobacco culture, the network structure of smoking outcome expectancies in China may be associated with distinct patterns. These findings validate our hypothesis: smokers' attitudes toward Chinese societal tobacco culture are directly and positively associated with social facilitation outcome expectancies. This diverges from Western research, which typically emphasizes individual-level factors—such as negative reinforcement, adverse physical sensations, weight control, or craving—as key determinants of outcome expectancies (Garey et al., 2018; Halliday, Zawadzki, & Song, 2025; Kristjansson et al., 2011; Potter et al., 2022; Zvolensky et al., 2023), while largely overlooking sociocultural influences. This divergence likely originates from Eastern–Western sociocultural differences. The results show the strongest positive correlation between the cultural attitudes of social communication media and the expectancies of social promotion results. Since tobacco's introduction to China, cigarette gifting and sharing practices have become increasingly popular. This behavior is often used as a social tool to express respect, signify economic status, and convey a range of Chinese traditional values, including “mianzi,” reciprocity, and relationship-building intentionality (Chu et al., 2011; Ding & Hovell, 2012). In this context, cigarettes are not only used for personal consumption but are also actively prepared and shared to maintain interpersonal relationships. According to Bourdieu's theory, we can view the social facilitation expectancies of tobacco as a product of Chinese smokers' habitus: this habitus emerges not through individual formation but through interactive structuration across diverse social spaces. We also found a significant positive correlation between attitudes toward gifting, jingyan/sanyan, and social facilitation outcome expectancies. Social capital, Bourdieu posits, is developed via “an unceasing effort of sociability, a continuous series of exchanges” (Bourdieu, 2011). A cigarette plays a role in courtesy or politeness between people in different social fields. Failure to accept an offered cigarette can be perceived as extremely rude (Ma et al., 2007; Zhang et al., 2012) and may result in exclusion from social groups, thereby undermining the accumulation of social capital. In keeping with this observation, reciprocal sharing arrangements involve both material exchange and the creation of obligations, whose recognition perpetuates the cycle. Thus, gifting, jingyan/sanyan, is more than a social activity: it actively constructs social relations by creating and fulfilling expectations of social facilitation. A survey shows that sharing cigarettes is a common behavior among Chinese smokers. Four-fifths of respondents said that their motivation to share cigarettes is to show basic meeting etiquette, welcome guests, and express social intimacy (Mao et al., 2014; Wu et al., 2022). In another study, more than 91 % of respondents reported receiving gift cigarettes on holidays or special occasions, which has become a common phenomenon. The practice of gifting cigarettes typically takes place during festivals like weddings or the Lunar New Year, aligning with tobacco companies' marketing strategies that combine brand connotations with festival values such as happiness, warmth, friendship, and celebration. Giving these cigarettes has become an important means to maintain social relationships and promote social facilitation (Ding & Hovell, 2012). In the current social context, it is not surprising that smoking behavior is expected to generate social facilitation.

4.2. Implications for policy

Overall, the findings demonstrate that Chinese smokers' attitudes toward societal tobacco culture show associations with smoking outcome expectancies, with social facilitation as a central node. We recommend developing culturally adaptive tobacco control strategies and interventions that challenge these social meanings. First, we should systematically reshape the tobacco symbols in the traditional etiquette scene and promote health products or cultural souvenirs to replace cigarettes as a gift medium for festivals, weddings, and other celebrations by advocating “smoke-free weddings” and “rejecting cigarette gifts.” If cigarettes can be replaced by other healthy social gifts, it will be more beneficial to the health and well-being of the family than giving cigarette gifts. Additionally, in order to change attitudes toward tobacco gifting, it is suggested that graphic warnings (such as secondhand smoke hazard diagrams) be added to cigarette packaging to replace traditional Chinese cultural connotation packaging. This recommendation is aligned with the Framework Convention on Tobacco Control. International evidence suggests that graphic warning labels improve awareness of the dangers of smoking and reduce smoking rates in countries such as the United States, the United Kingdom, and Australia. In China, evidence shows that graphic warning labels can reduce the practice of cigarette gifting and increase opposition to cigarette gifting and sharing. In addition, the use of graphic warning labels can promote smokers' interest in quitting smoking (Qin et al., 2011). It is essential to enhance social environment interventions to break the tobacco dependence cycle in social settings. Stricter tobacco control regulations should be enforced in high-density areas such as restaurants and entertainment venues. This will help diminish smokers’ expectancies of social facilitation and reduce cigarette sharing and overall smoking rates. In conclusion, future research and the design of tobacco control strategies should consider the influence of local Chinese culture while also learning from the experiences of tobacco control in other countries.

5. Limitations and perspectives

This study has several strengths, including a large sample size and the use of network analysis to visualize the relationship between Chinese tobacco cultural attitudes and smoking outcome expectancies. This approach offers a novel lens through which to understand smoking behavior and identify culturally specific intervention targets. However, there are several limitations. First, the network structure of tobacco sociocultural attitudes and smoking outcome expectancies is based on cross-sectional data and hence cannot reveal a direct causal relationship. Second, all measures were self-reported or based on self-developed instruments, which may be subject to reporting or recall bias. Future research should consider using more objective methods to provide a more comprehensive and accurate assessment. Furthermore, the study sample was limited to Sichuan Province, China, and may not generalize to all Chinese smokers. Future research should involve different population samples to obtain more comprehensive results and improve the generalizability of the findings. Finally, although this study focuses exclusively on smokers—constructing their cultural-cognitive networks to identify intervention points—the broader tobacco cultural context crucially involves non-smokers. Prior research demonstrates that Chinese non-smokers actively participate in and endorse cigarette gifting rituals (Lyu et al., 2023). Non-smokers' high endorsement of socio-tobacco norms may constitute a latent factor that fosters positive expectancies and facilitates subsequent behavioral initiation. Consequently, future cultural investigations targeting non-smoker populations could yield novel insights regarding smoking behavior initiation and progression.

6. Conclusion

This study provides the first quantitative examination of network connections between multidimensional Chinese societal tobacco cultural attitudes and smoking outcome expectancies. Findings reveal that social facilitation is the most central variable among smoking outcome expectations, showing strong associations with distinctive features of China's tobacco culture. Diverging from Western research that emphasizes individual drivers of smoking (e.g., negative reinforcement), this study elucidates the unique sociocognitive mechanism through which culture affects smoking behavior. These insights establish a novel theoretical foundation for developing culturally adaptive tobacco control strategies tailored to the Chinese context.

CRediT authorship contribution statement

Yixin Zhao: Writing – review & editing, Writing – original draft, Visualization, Validation, Methodology, Data curation, Conceptualization. Xiaoyan Wang: Writing – review & editing, Validation, Investigation. Shiyao Ling: Writing – review & editing, Validation, Investigation. Kexin Peng: Validation, Investigation, Data curation. Hongyu Li: Investigation, Data curation. Lian Yang: Writing – review & editing, Supervision, Resources, Project administration, Data curation, Conceptualization.

Ethics

The study was approved by the Medical Ethics Committee of the Affiliated Hospital of Chengdu University of Traditional Chinese Medicine (2023 KL-134) Following the ethical standards required for conducting human research, this study followed the fundamental principles of the Declaration of Helsinki. Informed consent was obtained from all subjects involved in the study.

Fundings

This work was supported by the National Natural Science Foundation of China (NSFC) [grant number 72174032]

Declaration of competing interest

The authors declare that they have no known competing financial interests or personal relationships.

Acknowledgements

The authors would like to thank all the subjects who participated in this study.

Footnotes

Appendix A

Supplementary data to this article can be found online at https://doi.org/10.1016/j.ssmph.2025.101890.

Contributor Information

Yixin Zhao, Email: 15223598557@163.com.

Xiaoyan Wang, Email: 747920680@qq.com.

Shiyao Ling, Email: 2667946379@qq.com.

Kexin Peng, Email: 1343522214@qq.com.

Hongyu Li, Email: 2775427725@qq.com.

Lian Yang, Email: yyanglian@163.com.

9.Appendices

AppendixTab_1.

Cronbach's α Coefficients Across Dimensions of the Brief Smoking Consequences Questionnaire-Adult (BSCQ-A)

Smoking outcome expectancies Cronbach's α
Negative affect reduction 0.97
Stimulation/state enhancement 0.89
Health risks 0.85
Taste/sensorimotor manipulation 0.91
Social facilitation 0.90
Weight control 0.91
Craving/addiction 0.89
Negative physical feelings 0.80
Boredom reduction 0.91
Negative social impression 0.85
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AppendixTab_2.

A questionnaire to assess attitudes toward China's unique tobacco culture(n = 1382)

Item Disagree = 0(%) Neutral = 1(%) Agree = 2(%)
1.Cigarettes are good gifts for friends and family. 32.92 21.20 45.88
2.I approve of “jingyan” and “sanyan.” 11.79 10.71 77.50
3.Cigarettes serve as a medium for social communication. 12.66 11.43 75.90
4.I support the “wedding cigarettes” custom. 25.54 / 74.46
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AppendixTab_3.

Item score descriptions and predictability of smoking outcome expectancies(n = 1382)

Smoking outcome expectancies item M ± S predictability(%)
Negative affect reduction 20.08 ± 6.38 38.70
Smoking calms me down when I feel nervous 6.65 ± 2.21
When I'm feeling irritable, a smoke will help me relax 6.75 ± 2.14
When I'm angry, a cigarette can calm me down 6.68 ± 2.22
Stimulation/state enhancement 12.11 ± 4.92 44.50
Smoking a cigarette energizes me 5.95 ± 2.64
A cigarette can give me energy when I'm bored and tired 6.16 ± 2.55
Health risks 14.49 ± 3.93 4.70
The more I smoke, the more I risk my health 7.32 ± 2.10
By smoking I risk heart disease and lung cancer 7.17 ± 2.12
Taste/sensorimotor manipulation 18.45 ± 6.79 39.70
I will enjoy the flavor of a cigarette 6.27 ± 2.48
When I smoke, the taste is pleasant 5.98 ± 2.53
I enjoy the taste sensations while smoking 6.20 ± 2.38
Social facilitation 17.54 ± 7.08 37.60
I feel more at ease with other people if I have a cigarette 5.93 ± 2.51
Smoking helps me enjoy people more 5.86 ± 2.58
I feel like part of a group when I'm around other smokers 5.74 ± 2.68
Weight control 8.75 ± 7.08 18.70
Smoking keeps my weight down 3.06 ± 2.65
Smoking helps control my weight 2.77 ± 2.48
Cigarettes keep me from eating more than I should 2.93 ± 2.57
Craving/addiction 9.28 ± 5.38 20.50
Smoking will satisfy my nicotine cravings 4.61 ± 2.83
Nicotine "fits" can be controlled by smoking 4.67 ± 2.84
Negative physical feelings 10.53 ± 5.22 13.10
Smoking irritates my mouth and throat 5.54 ± 2.80
My throat burns after smoking 4.99 ± 2.91
Boredom reduction 12.96 ± 4.55 25.90
When I am alone, a cigarette can help me pass the time 6.53 ± 2.31
If I have nothing to do, a smoke can help kill time 6.42 ± 2.43
Negative social impression 8.91 ± 6.99 13.20
I look ridiculous while smoking 2.67 ± 2.59
Smoking makes me seem less attractive 2.95 ± 2.62
People think less of me if they see me smoke 3.28 ± 2.78
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AppendixFig_1.

AppendixFig_1

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Edge stability tests for tobacco cultural attitude networks.

AppendixFig_2.

AppendixFig_2

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Edge stability tests for smoking outcome expectancies networks.

AppendixFig_3.

AppendixFig_3

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Edge stability tests for tobacco cultural attitudes and smoking outcome expectancies networks.

Appendix A. Supplementary data

The following is the Supplementary data to this article:

Multimedia component 1
mmc1.docx (29.7KB, docx)

Data availability

Data will be made available on request.

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Supplementary Materials

Multimedia component 1
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Data Availability Statement

Data will be made available on request.

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