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Personal and social determinants sustaining smoking practices in rural China: a qualitative study Mao, Aimei; Yang, Tingzhong; Bottorff, Joan L; Sarbit, Gayl Feb 3, 2014

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RESEARCH Open AccessPersonal and social determinants sustainingsmoking practices in rural China: a qualitativestudyAimei Mao1*, Tingzhong Yang2, Joan L Bottorff1 and Gayl Sarbit1AbstractIntroduction: Tobacco use in China is disproportionally distributed among rural and urban populations with ruralpeople smoking more. While there is a wealth of evidence on the association between tobacco use among ruralpeople and their lower socio-economic status (SES), how social structural factors contribute to rural smoking is notwell understood. Guided by a socio-ecological model, the objective of this study was to explore the personal andsocial determinants that play a key role in sustaining smoking practices among Chinese rural people.Methods: An ethnographic study was conducted in a rural area of Central Jiangsu, China. Participants (n = 29) wererecruited from families where there was at least one smoking resident and there were young children. In-depthinterviews and unstructured observations were used to collect data, which were then analyzed with an interpretivelens.Results: Although individuals had limited knowledge about the risks of smoking and lack of motivation to quit,social factors were in effect the main barriers to quitting smoking. Cigarette exchange and cigarette giftingpermeated every aspect of rural family life, from economic activities to leisure pastimes, in family and wider socialinteractions. Traditional familism and collectivism interplayed with the pro-smoking environment and supportedrural people’s smoking practices at the community level. Living in the rural area was also a barrier to quittingsmoking because of the lack of information on smoking cessation and the influence of courtyard-based leisureactivities that facilitated smoking.Conclusion: Development of comprehensive smoking cessation interventions in rural China needs to extendbeyond an individual level to take into account the social determinants influencing smoking practices.Keywords: Smoking, Rural China, Social ecological model, Qualitative studyIntroductionAlthough China has become the second biggest economyin the world, only after the United States, it is still a coun-try in Stage Two of the tobacco epidemic, according tothe widely cited Four Stage Epidemic Model establishedby Lopez [1]. This stage is characterized by a high preva-lence of smoking in a context where the risks of tobaccosmoking are not widely understood and tobacco controlactivities are generally not well-developed [1]. At the sametime, China mirrors the global trend that smoking prevalenceis disproportionally distributed toward socio-economicallydisadvantaged groups, with a higher rate of smokingamong its rural population than its urban population[2,3]. Given that half of China’s 1.35 billion populationlives in rural areas [4], the countryside represents a largepool of smokers.Similar to the situation in other Asian countries, smok-ing is predominantly taken up by men in China, withmore than half of adult men smoking, while less than 3%of women smoke [2,3]. National surveys in China haveshown that men with a primary school background havethe highest smoking rate [3] and that farmers and machineoperators smoke at the highest rate among all occupations[2]. The differences in smoking prevalence between people* Correspondence: aimei.mao@ubc.ca1Faculty of Health and Social Development, University of British Columbia’sOkanagan campus, Kelowna V1V 1 V7, Canada© 2014 Mao et al.; licensee BioMed Central Ltd. This is an open access article distributed under the terms of the CreativeCommons Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, andreproduction in any medium, provided the original work is properly cited.Mao et al. International Journal for Equity in Health 2014, 13:12http://www.equityhealthj.com/content/13/1/12from different backgrounds are often interrelated. Themajority of people living in rural areas are farmers andfarmers are usually the least educated among all the oc-cupations [5,6]. While findings from previous researchhave added to the evidence linking disadvantaged socio-economic status (SES) with high smoking prevalence,how social structural factors contribute to smoking prac-tice is not well understood.It is sometimes hypothesized that people with higherSES are more interested in health matters and are ac-cordingly more likely to give up smoking [7]. However,qualitative studies on social class and health have shownthat health is considered equally important by all socialgroups [7]. Nonetheless, important differences have beenidentified among diverse SES groups. For example, peoplein lower SES groups usually endure more hardships intheir lives and they may cope with the stress by smokingcigarettes [8-10]. Interestingly, a population-based re-search study in China showed a lower level of stressamong rural people than their urban counterparts, des-pite the wide income gap between the two groups [11].Coping with stress may not be the trigger for a highersmoking prevalence in rural China.Although tobacco smoking is often framed as a per-sonal choice and studies have explored personal factorsprompting smoking, there are calls from researchers toexplore broader social factors [10,12,13]. These re-searchers argue that solely emphasizing tobacco smokingas a personal lifestyle choice, while neglecting social-structural factors, supports a victim-blaming ideology.Quite often, individually-oriented interventions instructpeople to be personally responsible for their health at atime when they are less capable as individuals to controltheir environment. Also, these interventions may notreach marginalized groups who are socially isolated,like people who live in rural and remote areas. Thereare suggestions that individually-oriented interventionsshould remain secondary to those addressing socio-structural factors [14,15].Social networks play an important role in smokingpractices in China because cigarette sharing and giftingis a ‘social currency.’ Consequently, social networks actas both a facilitator for smoking initiation and a hin-drance for smoking cessation (SC) [16-18]. However, re-searchers have reported contradictory findings related tothe impacts of social networks on smoking status inrural China [16]. On the one hand, rural people arefound to be more likely to quit smoking, supposedly dueto their fewer social connections; on the other hand,there is higher smoking prevalence in rural China, forwhich social networks are found to be an important de-terminant [16]. Qualitative research has been suggestedas a way to provide insight into the influence of complexsocial contexts on smoking in rural settings [10,16].Despite higher smoking prevalence in rural China andthe large rural population, studies on tobacco use inrural contexts are limited and have reported conflictingfindings. There is an overall lack of public health re-sources in China and these limited resources are dispro-portionally allocated to favor urban areas [19,20]. Evenexperts and leaders engaged in public health suggest thatthe issues of tobacco use in rural areas may only be ad-dressed after the issues in urban areas are resolved [16].Given the sparse data about tobacco use among ruralpeople in China, there are challenges as well as oppor-tunities for conducting research and guiding meaningfulinterventions. The objective of this qualitative study wasto explore the personal and social determinants that sus-tain the high prevalence of smoking in rural China. Asocio-ecological model (SEM) was used to guide thisstudy. In his widely cited article on SEM, Stokols definedthe term “ecology” as a study of “the relationships be-tween individuals and their environments” [15]. Specific-ally, Stokols’ SEM divides health behavior determinantsinto three different levels, including: 1) individual factors, 2)interpersonal factors and 3) environmental factors, as il-lustrated in Figure 1. This study used an ethnographic ap-proach because ethnography is founded on the belief thathuman behaviors are best understood in the fullest pos-sible context [21]. This holistic approach therefore fitswith socio-ecological perspectives. It is plausible that thereare unique contextual factors that support cigarette useamong rural dwellers and these factors need to be takeninto account in designing SC programs.MethodsStudy settingThe study was conducted in central Jiangsu, China, trad-itionally one of the key areas of agricultural production inChina. Located at the edge of Yangtze River Delta Eco-nomic Region, the most powerful engine of China’s eco-nomic development [22], Central Jiangsu has experiencedrapid development since the economic reforms in the late1970s. Income from off-farm activities, the participationof rural people in remunerative work away from theirfarmland, has replaced income from farming as the mainincome source for rural families. These more profitableactivities include working in privately owned townshipand village enterprises or other private services, workingas migrant workers in cities, running small family-basedbusinesses and working as local craftsmen such as car-penters, bricklayers and painters [23]. In 2009, off-farmincome, on average, constituted 78.5% of annual familymonetary revenues in rural Jiangsu [24].Following ethics approval from the University of Liver-pool, the primary researcher (AM) went to her hometown,a village in Central Jiangsu, to conduct the fieldwork fromOctober 2008 to August 2009. Participants were recruitedMao et al. International Journal for Equity in Health 2014, 13:12 Page 2 of 11http://www.equityhealthj.com/content/13/1/12from three villages and two countryside townships. Eachvillage was inhabited by about 500–800 people while thetwo townships covered a population of around 80,000. Inthe past, the townships were exclusively occupied bypeople with urban status. However, with the recent inflowof farmers, the townships are now a mix of urban andrural dwellers. The village residents and those people whowere officially registered as ‘rural citizenship’ but lived inthe townships were eligible for this study.Participant recruitmentResearch findings suggest that families who are expect-ing children or who have young children are more likelyto raise issues related to smoking (e.g., to protect infantsand young children from second-hand smoke) andsmokers in these families tend to change their smokingpractices [25-30]. Therefore, two criteria were applied inrecruiting participants: 1) participants came from a fam-ily with at least one preschool child aged six years oryounger; and 2) there was at least one resident who wascurrently smoking. Smokers, as well as non-smokerswho lived with smokers, were invited to participate inthe study. A combination of purposive and snowballsampling strategies was used to recruit participants. Pur-posive sampling is the technique in which the re-searchers select individual participants who would bemost likely to contribute appropriate data in terms ofrelevance and depth [31]. In this study, the researcherspaid attention to recruiting participants from variousdemographic and social economic backgrounds such asage, education, family income, children’s age, number ofsmokers, and degrees of home smoking restrictions. Thediversity of the participants provided rich data on personaland environmental determinants affecting men’s homesmoking and the establishment of smoking restrictions.Purposive sampling was concurrently carried out withsnowball sampling, in which the participants were askedby the researchers to assist with the recruitment of otherparticipants [32,33]. Initial participants were recruited byAM through her social connections in the community.These participants were then asked to provide informationabout the study to others in the community who met therecruitment criteria and could potentially contribute tothe study.Data collectionIn this study, AM connected with participants in theirnatural setting for a prolonged period of time. AM be-came an active participant and an observer as she focusedon the social-cultural experiences and practices of the par-ticipants. In-depth, open-ended interviews with all partici-pants were the primary method of data collection. A topicguide for the interviews was developed based on the pur-pose of the study and critical readings of relevant litera-ture [34]. The guide covered four areas: 1) smokingpractices in the homes; 2) knowledge about risks of to-bacco smoking and attitudes towards smoking; 3) opin-ions on reasons an individual continued to smoke; and 4)strategies used by family members to restrict home smok-ing. Questions asked in the interviews included: “Pleasedescribe smoking behaviors in your home;” “What do youthink about the impacts of tobacco smoke on the healthof smokers and non-smokers?” “Which factors do youthink help to keep smokers smoking?” “Which factorshelp smokers quit or reduce smoking?” “How does yourfamily deal with smoking behaviors at home?” Familymembers who smoked were asked: “How do you changeyour smoking when there are non-smoking familymembers around you?” and “How do you feel about therestrictions on smoking in your home?” If there were nouiooIndividualInfluences:knowledge, attitudes, behavior, self-concept and skills.InterpersonalInfluences: parent and peer influences and attitudes, and characteristics ofrelationships.EnvironmentalInfluences:community characteristics, media influences, legislation and policy.Figure 1 The socio-ecological model (based on Stokols’ theory).Mao et al. International Journal for Equity in Health 2014, 13:12 Page 3 of 11http://www.equityhealthj.com/content/13/1/12restrictions at home the smokers were asked: “Do youthink it is necessary to restrict smoking at home? Why(or why not)?” A brief questionnaire was used to gatherbasic demographic information and family members’smoking situations, which included age, education, oc-cupation, family income, number of children in thehousehold, children’s age, number of smokers in thehousehold, and whether there were restrictions onhome smoking. An honorarium of 50 RMB (1RMB =0.16 USD) was offered to participants in recognition oftheir contributions.Initially, two rounds of interviews were conductedwith the participants. The second interview took placeany time from one week to one month after the firstinterview, and aimed to supplement and clarify any am-biguities resulting from the initial interviews. Data col-lection and analysis were concurrent and the interviewguide was dynamic and iterative [35]. The additionalquestions for the second interviews were informed bythe first interviews and the concepts and themes fromthe initial analysis were tested in the second interviews.Therefore, the questions were different with differentparticipants. For example, one mother might be asked:“Last time you mentioned that your husband did notsmoke near your child. Can you demonstrate how far hewas away from the child? I have found people have dif-ferent ideas about what it means to smoke ‘near thechild’.” Another mother was asked: “You once helpedyour husband quit smoking. But some mothers said thattheir husbands deserved to smoke because they earnedmoney for the family. What do you think of this belief?”Despite the value of the second interviews, preliminaryanalyses revealed much repetition of information be-tween the two rounds of interviews. Therefore, afterhaving finished two rounds of interviews with all 16mothers of young children, who were the first inter-viewees, it was decided that one interview would sufficefor the remaining participants. However, this decisiondid not affect the dynamic nature of the interview guide,as identifying and refining important concepts is a keypart of the iterative process of qualitative research. Par-ticipants from the same family were interviewed separ-ately. All the interviews were conducted by AM at thelocations chosen by the participants, mostly at theirhomes. The interviews lasted from 30 to 90 minutes.Direct, first-hand observations of daily life provided asupplemental source of data for this study. AM lived inthe field and used unstructured observations to collectinformation about smoking behaviors and people’s reac-tions to tobacco smoking in various contexts. Unstruc-tured observations are not guided by an observationguide and therefore enable the observer to exercise flexi-bility on observing activities relevant to the study [36].As such, observations for this study were not limited tothe behaviors of the participants, but also included thoseof other people in the community. AM recorded fieldnotes of the events and phenomena relevant to the pur-pose of the study. These field notes were later includedas part of the data for analysis. The ten months of field-work provided sufficient data for a comprehensive exam-ination of the multiple factors that sustain high smokingprevalence in rural China.Data analysisOnce all the data were collected, the interviews and ob-servation notes were organized and transcribed. A sys-tematic and rigorous analysis of the data, guided byStokols’ Socio-ecological Model [15], was undertaken toidentify salient themes, recurring ideas or language, andpatterns of belief that linked the people and settings to-gether. The comprehensive initial analysis was followedby additional readings of the data to determine relation-ships between the concepts.FindingsTwenty-nine family members from 22 families were re-cruited, including 16 mothers of young children, four fa-thers, five grandmothers and four grandfathers. The 21female participants were non-smokers while the eightmale participants were smokers. The demographics andsmoking status of the participants and their families areshown in Table 1. Notably, those individual familymembers who farmed, without engaging in other eco-nomic activities, classified their occupation status as “nojob” (没有工作). This reflected their perceptions of howminimal farming contributed to their families’ economy.Also of interest is that no single family relied solely onfarming for their livelihood. Two families ran businesses(i.e., a family-based shop and restaurant) without farm-ing while the other 20 were engaged in both on and off-farm activities.In total, 43 individual interviews were completed, in-cluding two rounds with mothers and one round withother family members. In general, findings from theseinterviews and the researcher’s observations suggest thatsmoking among men in this area was widespread. Al-though participants mentioned that some men aroundthem had never smoked, they stated that every mansmoked on certain occasions. Observations in the com-munity supported these perceptions. Cigarette smokingwas observed to be an important part of men’s gather-ings and people who had claimed to have never smokedor to have quit smoking received offers of cigarettes andsometimes even smoked with their peers. While smokersconstructed smoking as a personal pleasure for men andminimized the risks of smoking to their health, smokingwas described by both smokers and non-smokers as a“must” for a man in the current social environment.Mao et al. International Journal for Equity in Health 2014, 13:12 Page 4 of 11http://www.equityhealthj.com/content/13/1/12The determinants sustaining smoking practices wereframed according to multiple levels of behavioural influ-ence factors, which produced a hierarchy of the determi-nants of initiation and maintenance of cigarette smoking(Table 2). The following section will detail the personal,interpersonal and environmental determinants identifiedin the study.Personal determinantsSuperficial knowledge about harms of smokingAlthough all participants agreed with the statement‘smoking is harmful to health’ (吸烟有害健康), theirknowledge about risks of tobacco smoking was limitedto immediate physical reactions to tobacco smoke, in-cluding coughing, sneezing and irritation to the throatand eyes. While non-smokers presented these physicalsymptoms as harms caused by tobacco smoke, smokerstended to regard them as only temporary discomforts ra-ther than harms. One father who smoked stated: “I don’tbelieve that smoking is harmful. I think no smokers be-lieve that. Yes, coughing. We cough when we smoke.Can you say other harms? Nothing else.” When asked tolist the specific harms of tobacco smoke, two thirds ofthe participants acknowledged: “I only know that smok-ing is harmful to health. I know nothing else.”Benefits of smokingSmokers, and sometimes their non-smoking familymembers, listed a number of benefits of smoking, suchas killing time, coping with stress, being part of a group,and enjoying the feeling of happiness or relaxation.Younger smokers tended to associate their smoking withtheir jobs. One father, who was a taxi driver, said: “I feelterribly sleepy at 3 and 4 in the early morning when Iam at work. Smoking is the only way to keep me awake”.Some smokers said that smoking could make their brain“work fast” so that they could solve problems in theirwork. One grandfather who was a carpenter said that hissmoking helped him to do the calculations required inhis work.Table 1 Demographics and smoking situation in theparticipant familiesCategories NumberFamily level data 22Family income (RMB/year)>100000 450000–100000 420000–50000 13<20000 1Number of smokers at home1 72 15Household restrictionsNo smoking allowed inside the house 3Smoking allowed in certain rooms 12No restrictions 7Families with children* 6≤one year old 17> one year oldIndividual level data 29Family roles (In relation to young children)Mothers 16Fathers 4Grandmothers 5Grandfathers 4Age (years old)Mothers and fathers (21–34) 20Grandmothers and grandfathers (55–67) 9OccupationNo job (farming only) 11Off-farm activities 18EducationElementary school or below 6Middle school 14Senior high school or vocational school 7College 2University 01RMB = 0.16 USD. *A family with one child under one year old and the otherchild over one year old.Table 2 Factors sustaining smoking in different levelsLevel of hierarchy The themes supporting smokingPersonal determinants Superficial knowledge about harms ofsmokingBenefits of smokingLack of knowledge about quitting methodsNo immediate desire to quit smokingInterpersonaldeterminantsCo-smoking as happy family timeLimited or no restrictions on smoking athomeCigarettes as a normal gift for male familysmokersThe cost of smokingEnvironmentaldeterminantsCigarette as a facilitator in off-farm activitiesSmoking as a leisure activityNormalized violation of smoke-free bansMao et al. International Journal for Equity in Health 2014, 13:12 Page 5 of 11http://www.equityhealthj.com/content/13/1/12Lack of knowledge about quitting methodsLocal people believed that quitting smoking was entirelyup to the smokers and that other people could do littleto help with the quitting process. They had never heardof SC aids, such as nicotine replacement therapy (NRT)and counseling services. None of the smokers had eversought external help in their previous attempts to quitsmoking. However, they used such things as chewinggum, nuts, and sunflower seeds to help them fight theircravings when they were quitting smoking. Failures inquitting were often attributed to lack of determination,as one non-smoking mother said of her husband’s fail-ure, “I think it was because he didn’t really want to quit.We all know the old saying ‘Nothing is too difficult ifyou put your heart into it.’”No immediate desire to quit smokingAt least half of the participants explained that menwould usually temporarily quit smoking before or duringtheir wives’ pregnancies and resume to previous levelsby the time their children were old enough to go to kin-dergarten. Smokers and their family members talkedabout quitting smoking “someday”; however, plans forquitting were often in the distant future.Older smokers explained how hard it would be forthem to get rid of the old habit, as one grandfather said:“I have smoked for more than 40 years. If you ask menot to eat today, I can do it; if you ask me not to smoketoday, I can’t do it.” The younger smokers describedquitting smoking as “impossible” (不可能), “impractical”(不现实), explaining that “In today’s society, who doesn’tsmoke?” Non-smoking family members supposed that onlysevere disease may trigger smokers to quit, “As long asthey are healthy, they will continue to smoke.” One grand-father participant, during his interview with the researcher,mentioned his intention to quit smoking in the nextmonth. However, the researcher saw him smoking on thestreet two months later. He laughed and acknowledgedthat he had no intention to quit smoking at present be-cause he was healthy.Interpersonal determinantsCo-smoking as happy family timeIn the 15 families where there was more than one smoker,it was common that the smokers smoked together. Thisco-smoking was regarded by both smokers and non-smokers as a way to build and maintain harmonious fam-ily relationships. So, non-smoking family members usuallydid not interfere with co-smoking behaviors. For example,a grandmother was unhappy with the co-smoking be-tween her husband and his brother, but acknowledgedthat the co-smoking enhanced their brotherly relationship,“These two have never got red face[angry]to each other.Every morning his elder brother comes here, and the twosit there. Then you give me a cigarette; I give you acigarette, and they smoke and chat. They get along verywell.” In another family, the father and his adult son weresmoking together when the researcher was conducting theinterview with the mother participant in their home. Sherevealed that the two smoked every evening and that shedid not want to intervene with her husband’s smoking be-cause “I don’t want to destroy the atmosphere there. Also,his father will be unhappy if I say something against smok-ing because he is smoking, too.”Limited or no restrictions on smoking at homeIn the local rural area it was normal practice for people toleave their house doors open during the day if there werefamily members at home. The researcher observed thecommon phenomenon of home smoking, even in the fam-ilies with young children. However, participants from 15of the 22 families in this study reported having some re-strictions on smoking in their homes. In these families,most of non-smoking women had successfully kept theirbedrooms a smoke-free place by restricting their hus-band’s smoking there. These women expressed negativeattitudes towards smoking, using negative terms whentalking about the smoking situations in their home, suchas ‘disgusting” ‘annoying”, ‘irritating”, etc. However, onlythree families had a complete restriction on indoor smok-ing and the non-smoking women in other families ex-pressed powerlessness in imposing a complete smokingban. In the local areas, the senior generations were re-ferred to by the juniors as shang-ren (上人), meaning thesuperordinate. It was difficult for junior women to regu-late senior family men’s smoking because “You can’t con-front your shang-ren”. Direct confrontation of the seniorswas perceived by local people as a misconduct of filialpiety (the moral practices the juniors should have for theseniors).It was quite normal in rural Jiangsu that young andmiddle aged family men worked in cities and only camehome occasionally. These men were believed to deservea smoke when they came home, as one mother said: “Noone says anything to their smoking. They only comehome once or twice a year.” Family members certainlywanted the returned men to enjoy happy family life andconfronting the men’s smoking would destroy the pleas-ant reunion time.Cigarettes as a normal gift for male family smokersIn the local area, cigarettes, along with alcohol, were themost common gifts that family members gave to theirmale relatives and friends. Family gatherings, like birth-day parties, wedding ceremonies, roof beam ceremonies(上梁, a ceremony for putting up the roof beam on anew house which is still under construction), and funeralgatherings, were consistently associated with smoking.Mao et al. International Journal for Equity in Health 2014, 13:12 Page 6 of 11http://www.equityhealthj.com/content/13/1/12For example, one neighbor of the researcher bought 30 car-tons of cigarettes (10 packs/carton and 20 cigarettes/pack)for a birthday party which was attended by about 200 rela-tives and fellow villagers.Cigarette gifting was particularly important for familyjuniors who were expected to show filial piety to seniorgenerations or family elders. For example, one womanrecounted that every time she and her husband visitedher parents, she would remind her husband to bring cig-arettes to her father who smoked. Another woman saidthat she bought her father cigarettes all year round asher way to thank him for helping with childcare.Non-smoking family members did not have difficultyreconciling cigarette gifting with their negative attitudestowards smoking. According to them, their practice ofcigarette gifting did not mean their support for familymen’s smoking, “If I don’t give him cigarettes, he wouldbuy them himself. My giving doesn’t affect his smoking.”The gifted cigarettes were almost always the ‘haoyan’(好烟), the more expensive cigarettes, and these ciga-rettes were believed to be less harmful to the health ofthe smokers than the cheaper ones the smokers usuallyconsumed.The cost of smokingAll the non-smokers believed that the money spent oncigarettes was a waste. However, for most of the families,the cost of cigarettes did not seem to have a significantimpact on family life. One mother listed her husband’sexpenses on smoking, “On average, he smokes up to 500RMB a month….His salary is 2000 a month, and mine is1000. Together we have 3000…. Right now we can man-age our life because we don’t pay for our meals in ourwider family [the extended family]” Another womandownplayed the financial burden of her father’s smoking,“My mum and I always persuade my dad to smoke lessand save the money for food and clothes. It is not thathe is short of food or clothes, but he can buy more andbetter clothes and food if he smokes less.” Apparently,the improved economic conditions in the past three de-cades meant that expenses of smoking did not affect thebasic needs of the rural families.Environmental determinantsCigarette as a facilitator in off-farm activitiesOff-farm economic activities were the most importantsource of wealth for every family and cigarettes playedan important role in those activities. This was prominentlyreflected in two ways: cigarettes as a type of payment, andcigarette gifting and sharing as a tool to establish andstrengthen economic ties.The use of cigarettes as a bonus payment to male em-ployees was a common practice in the local privateenterprises and services. Generally, male employees,even the non-smokers, got packs of cigarettes on a dailyor monthly basis. For example, as the local bus compan-ies had been privatized, all the bus drivers received twocartons of cigarettes from the owners of the buses at thebeginning of each month. Among local craftsmen hiredby individual families, it was a common practice for thecraftsmen to receive a pack of cigarettes each day fromtheir hosts. The offers of cigarettes were only for maleemployees and women employees, all of whom wereperceived as non-smokers, did not receive additionalpayments in any form for comparable work.The local people called cigarettes “the name card” (名片),or “the introduction card” (介绍信). Those who ran busi-nesses remarked that “No cigarettes, no business.” Not onlywere men engaged in cigarette exchanges with businesspartners or customers but non-smoking women also tookpart in the practices. A non-smoking mother who helpedwith her family business of selling cement said that she of-fered cigarettes to the customers when her husband wasnot in the shop.The jobs the rural people took on were usually short-term, and the end of these positions often coincidedwith the end of the Chinese Lunar Year, which usuallyfalls in late January or early February in the Gregoriancalendar. As a result, the Chinese New Year became abusy time for rural people to look for new jobs for thefollowing year. Every man, whether a smoker or not, aswell as non-smoking women, carried packs of cigarettesto visit local private employers or the labor contractorsfor projected jobs. Even those who were on a renewedcontract were also involved in cigarette gifting in orderto strengthen the relationship with their employers.Smoking as a leisure activityThere were almost no public entertainment facilities inthe countryside. Collective smoking in the local areahappened in people’s houses rather than in public placesand was part of men’s pastime activities. It was a com-mon scene in the local area that on a sunny day severalmen drank tea and smoked cigarettes while chatting inthe courtyard of a house.Playing Mahjong (打麻将) is a favorite pastime inChina. It is a table game with four players and is playedfor fun and money. For many of the local people, it wastheir only entertainment. Smoking was the usual com-panion for male players, “Every man smokes when theyplay Mahjong.” In addition, playing Mahjong was oftena trigger for relapse and an obstacle for quitting smok-ing, as one grandfather who smoked said: “I find it isimpossible for me to quit smoking. You can do that un-less you don’t play Mahjong. But what else can you doexcept play Mahjong?”Mao et al. International Journal for Equity in Health 2014, 13:12 Page 7 of 11http://www.equityhealthj.com/content/13/1/12Normalized violation of smoke-free bansSmoking was commonly observed in some places sup-posed to be smoke-free. For example, kindergartenswere designated to be smoke-free according to nationalregulations. However, the researcher found cigarettestubs both outside and inside the kindergartens in thetwo townships. The ‘no-smoking’ signs were visible in al-most every public vehicle but drivers often smoked in-side the vehicles when they were waiting for the nextturn at the end of a round. There were also cigarettestubs inside local small hospitals.People accepted cigarette smoking in these designated‘no-smoking’ areas and regarded it as a countryside fea-ture. For example, one mother participant who was akindergarten teacher talked about the fact that no infor-mation on risks of tobacco smoke was delivered to chil-dren and parents in her school: “No one pays attentionto the smoking problems in countryside kindergartens.Maybe urban kindergartens give the message to theirchildren.” The head of her kindergarten showed surprisewhen she heard of the researcher’s study on tobaccocontrol, saying: “Smoking? Isn’t it quite normal? Whycontrol it?”DiscussionThe findings from this study detailed the complex arrayof personal and social determinants that underpinnedsmoking practices in rural China. At the individual level,rural smokers advocated for the benefits of smokingwhile demonstrating an indifference to quitting. Thislack of motivation to quit smoking may be associatedwith another important finding – the fact that ruralsmokers had minimal knowledge about the health risksof tobacco smoking. They also lacked skills and informa-tion on quitting methods. Viewed from a socio-ecologicalperspective, the absence in rural China of health educationprograms related to SC interventions has likely contrib-uted to the low levels of knowledge and interest in SC.Although the lack of motivation to quit smoking was abarrier at the personal level, the most important barrierto quitting smoking in contemporary rural China wasthe enhanced social currency of cigarette smoking. Tworecent studies also showed the pervasiveness of cigaretteexchange and cigarette gifting in rural China [17,18].While these two studies focused on cigarette gifting andexchange between a family and its outside environment,our study was the first to reveal the implications ofcigarette gifting and exchange to intra-family relation-ships and to the economic prosperity of the family.Smoking and cigarette exchange appeared to be highlyintegrated into family life in the local rural area. Despitenegative attitudes towards smoking, non-smoking familymembers were caught in a dilemma between supportingand intervening in family men’s smoking [37]. Althoughthey agreed that smoking was bad for health, their ac-tions related to limiting men’s smoking was restricted byculturally framed role expectations to maintain familyrelationships and economic security. Maintaining a har-monious family relationship was viewed as paramountand individual family members were expected to put thefamily’s interests over their own interests in order toachieve family harmony and prosperity.Unlike previous reports that farmers were isolatedfrom the outside world [16], this study revealed activesocial interactions between rural people and their fellowvillagers as well as the wider world in the expandingmarket economy. Researchers have described the signifi-cance of networks or Guangxi (关系) in private eco-nomic activities in a developing economy characterizedby an imperfect legal and financial system [38]. Thisstudy found that, due to the dominance of informal andrelationship-based contracts in the local area, employmentwas unstable, posing threats to both employers and em-ployees. Strengthening networks through cigarette giftingwas important to secure employment for employees andparticularly for job seekers. For the local small businessowners, networks could help them ease financial con-straints and provide needed contracts to survive the in-creasingly competitive but partially marketized economicenvironment. Others have warned that as rural China con-tinues to prosper, a significant portion of new wealth islikely to be spent on gifts of cigarettes, if no effective inter-ventions are developed [17].Although not directly examining the rural–urban in-equality, this study described some of the underlying fac-tors contributing to sustained smoking that are particularto rural China. Poorer infrastructure in rural areas limitedpeople’s choices for diverse pastime activities, giving wayto smoking-associated activities. A review has found anurban–rural division in the implementation of nationwidetobacco-related policies in developing countries includingChina [39]. While countries may be quite effective in en-forcing no-smoking rules and regulations in towns andcities, due to vast urban–rural differences in education,health care, knowledge, and state monitoring, the no-smoking rules and regulations may not be as effective insmall towns and villages, where tobacco-related laws areoften overlooked [39]. One interesting finding in the studywas that not only rural people ignored smoke-free regula-tions but they also identified smoking as a symbol of therural class. A social environment in which smoking is verycommon, and in a sense self-evident, may easily facilitateits continuance without disruption [40]. The internaliza-tion of smoking as part of rural life may have further con-tributed to the local people’s lack of motivation to changethe current smoking situation and their indifference tonon-smoking regulations.Mao et al. International Journal for Equity in Health 2014, 13:12 Page 8 of 11http://www.equityhealthj.com/content/13/1/12As an integral part of a socio-ecological perspective,understanding the role gender identities and gender rela-tions play in determining health behavior is essential[41]. Gender norms and roles influence attitudes and be-haviors in many areas, including relationships, parenting,schooling, work and health practices [13,42]. Genderroles can also create economic and cultural pressuresthat affect the health of females and males differently[13,25,26]. Research has shown that men’s smoking is re-lated to their masculine ideologies of independence,physical resilience to harmful substances and capacity toendure risk-taking [25,26,43]. This study indicated thatin the expanding economic market in rural China, men’srole as family provider was supported by smoking. Thestudy also showed the impacts of the traditional patri-archal power system on smoking-related family interac-tions. Numerous studies have shown the negative impactsof non-smokers on their family members’ smoking. How-ever, this study showed non-smoking women, particularlyyoung women, in Chinese families played a limited role inpreventing or regulating family men’s smoking. Address-ing barriers to quitting smoking at the individual, interper-sonal and environmental levels is necessary for enhancingthe effectiveness of SC programs in rural China.Implications for policy and researchThis study identified multi-level and inter-related factorsin supporting the high prevalence of smoking in ruralChina. The findings offer clear direction for future SCinterventions in some parts of China where the eco-nomic development is similar to Jiangsu Province, suchas other parts of eastern China and southern China. Per-sonal level interventions are needed to improve theknowledge of rural people about the risks of tobacco useand thus increase their motivation to quit smoking. Edu-cational programs are scarce in rural China and healthprofessionals should take advantage of ‘teachable mo-ments’, such as the time around women’s pregnancy orthe time of illness, to provide advice and support for SC.Studies with pregnant women and mothers of youngchildren who were ill showed that non-smoking womenplayed a role in reducing partners’ smoking shortly afterinterventions from medical professionals, although nolong-term positive results were observed [27-30]. Fur-ther research should be undertaken to develop similarinterventions that can be integrated into general clinicalpractices, in obstetrical departments and pediatric depart-ments, and these interventions can be applied repeatedlyto sustain effectiveness. Men should be involved to guidethe development of these interventions which are framedby gender relationships in Chinese families [37,44].According to socio- ecological perspectives, individual-level or family-based strategies may only be effective ifthe pro-smoking social environment is simultaneouslyaddressed. As shown in the study, traditional values offamilism and collectivism contribute to smoking. How-ever, these values become smoking facilitators only inspecific social environments. A large scale study inCalifornia showed that 52.5% of Chinese smokers quitsmoking after they went to the USA, although only17% of smokers in China quit smoking [45]. The sig-nificant difference in the quitting rates provides sup-port for denormalization of smoking practices as aneffective way to curb tobacco use.Addressing the social practice of cigarette sharing andgifting is the key to reducing the high smoking preva-lence in rural China. A mass media campaign called“Giving Cigarettes is Giving Harm” (送烟就是送危害)has been conducted in some cities [46]. However, nosimilar campaigns have been conducted in rural China.City-wide or community-wide campaigns against sharingand gifting of cigarettes can support local residents whodo not want to be seen as inhospitable in a culturewhere the exchange of tobacco has positive cultural as-sociations. Experiences from Project Quit Tobacco Inter-national showed that support from community groupscan enhance an individual’s or a family’s efficacy to re-duce smoking [47]. Given the more pervasive smokingat Chinese festivals, also reported in the study, community-based interventions can take advantage of Chinese festivalsto reach more rural people.Other strategies that hold potential at the populationlevel include health education to correct the misconcep-tion that more expensive cigarettes are less harmful tohealth than cheap ones and the use of mandated textand graphic warnings on all cigarette packages to makecigarettes culturally inappropriate for gifts [17,18]. TheWorld Health Organization strongly recommends tax-ation on tobacco products and smoking bans in publicplaces [48]. However, implementation of taxation andsmoking bans in rural China would be challenging be-cause of the perceived economic gains associated withsmoking and the blurring line between public places andprivate premises. Further research is needed to exploreeffective ways to enact these policies in the rural context.Another important issue for controlling smoking inrural China is to balance the distribution of health re-sources between rural and urban populations. Improvedinfrastructure in rural areas may help people engage inhealthier activities and move away from courtyard-basedcollective smoking practices. Directing health resourcesto tobacco control programs in rural areas would createa supportive social environment for SC.LimitationsThere are limitations with this study. First, given thesmall number of participants, findings from this studycannot be generalized beyond the local area of the study.Mao et al. International Journal for Equity in Health 2014, 13:12 Page 9 of 11http://www.equityhealthj.com/content/13/1/12Second, socio-economic variability in the vast rural areasof China also limits the findings’ generalizability. Specif-ically, this study took place in one of the most affluentprovinces in China and the socio-economic conditionsof the participants in this study may not be similar tothose of rural people living in poorer areas in westernChina or inland China. Impacts of smoking on familybudgets and family members’ attitudes toward smokingamong the participant families may be different fromthose of families in less developed areas. Third, some in-dividuals may not have been fully forthcoming in theirresponses, although the long-term fieldwork and tri-angulation of data resources have significantly enhancedthe credibility and trustworthiness of the findings.ConclusionThis study revealed unique features about tobacco use inrural China in a post-reform era. There are a multitudeof interrelated factors contributing to the high smokingprevalence in rural China, indicating the importance ofmulti-dimensional SC programs. This study calls for ur-gent action on smoking in rural China, rather than ignor-ing the issue until smoking in urban areas has beenresolved. Economic development in rural China is notresulting in a decline in tobacco use, as predicted byLopez’s theory of tobacco epidemic [1], but instead leadingto more prevalent smoking. Tackling smoking in ruralChina will be challenging due to the complicated personal,social and environmental barriers. This study has providedan initial look at these barriers, but more studies areneeded to inform evidence-based SC interventions.Competing interestsThe authors declared no potential conflicts of interest with respect to theresearch, authorship, and/or publication of this article.Authors’ contributionsAM undertook data collection and analysis and drafted the manuscript. TY,JB and GS helped to refine presentation of the analysis and contributed todevelopment of the manuscript. All authors read and approved the finalmanuscript.AcknowledgementsThe authors sincerely thank Dr. Jude Robinson and Dr. Katie Bristow for theirconstructive guidance in conducting the study. This doctoral study wassupported by the University of Liverpool through an Overseas ResearchScholarship and by a grant from the Sino-British Fellowship Trust, and apostdoctoral fellowship funded through the Investigating Tobacco andGender (iTAG) research team.Author details1Faculty of Health and Social Development, University of British Columbia’sOkanagan campus, Kelowna V1V 1 V7, Canada. 2Centre for Tobacco ControlResearch, School of Medicine, Zhejiang University, Hangzhou 310058, China.Received: 2 April 2013 Accepted: 31 January 2014Published: 3 February 2014References1. Lopez A, Collishaw N, Piha T: A descriptive model of the cigaretteepidemic in developed countries. Tob Control 1994, 3:242–247.2. Li Q, Hsia J, Yang G: Prevalence of Smoking in China in 2010. N Engl J Med2011, 364:2469–2470.3. 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Geneva: World Health Organization; 2008.doi:10.1186/1475-9276-13-12Cite this article as: Mao et al.: Personal and social determinantssustaining smoking practices in rural China: a qualitative study.International Journal for Equity in Health 2014 13:12.Submit your next manuscript to BioMed Centraland take full advantage of: • Convenient online submission• Thorough peer review• No space constraints or color figure charges• Immediate publication on acceptance• Inclusion in PubMed, CAS, Scopus and Google Scholar• Research which is freely available for redistributionSubmit your manuscript at www.biomedcentral.com/submitMao et al. International Journal for Equity in Health 2014, 13:12 Page 11 of 11http://www.equityhealthj.com/content/13/1/12

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