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Abstract
Background China has the largest population of smokers in the world. Little previous research has explored the cultural challenges in encouraging smoking cessation in China. This study aimed to explore and generate research questions about culturally distinctive beliefs and barriers to smoking cessation.
Methods A convenience sample of 21 smokers and ex-smokers selected from a Guangzhou hospital smoking cessation clinic and medical ward was interviewed about experiences with quitting smoking. Data were analysed to elucidate culturally distinctive obstacles to cessation that may warrant further study.
Results Three major obstacles to smoking cessation were identified: family and social influences, the myth that quitting smoking is dangerous to health and misinformation from health professionals.
Conclusions This study suggests that smoking cessation in China is made more challenging by a social context in which family, friends and even health professionals may discourage it. However, these identified barriers and beliefs about smoking cessation need to be confirmed in larger, more representative studies in the future.
- Chinese
- social context of smoking
- smoking cessation
- cessation
- qualitative study
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Introduction
Nearly one million tobacco-caused deaths occur annually in China.1–4 In many countries, smoking prevalence has fallen following efforts to change the cultural and social meaning of tobacco use through media campaigns, smoke-free policies and other population-level interventions.5–7 However, China may face special challenges in encouraging smoking cessation because tobacco is culturally associated with gifting traditions and social cohesion.8–10 Little previous research has explored these cultural factors. We interviewed a convenience sample of Chinese smokers and quitters to explore and generate research questions about possible culturally distinctive beliefs and barriers to smoking cessation.
Methods
A convenience sample of 21 smokers and ex-smokers selected from a Guangzhou hospital smoking cessation clinic and medical ward was interviewed in December 2008 about experiences with quitting smoking. Interviews were audio-recorded and transcribed verbatim in Chinese. Data were inductively coded and organised by themes. We offer exemplars of potentially culturally distinctive obstacles to cessation that may warrant further study. The study was approved by the institutional review board at the University of Hong Kong/Hospital Authority Hong Kong West Cluster and Guangzhou No 12 Hospital.
Results
Family/social influences
Family and social practices, especially Chinese cigarette gifting customs, were identified by several participants as obstacles to quitting. One smoker observed: “I smoke but I never have to buy cigarettes myself. All my sons and sons-in-law…when they came to visit me, they always brought cigarettes for me to show their respect. Why should I quit?” Even when smokers were ill, such social practices continued: “All of my friends and colleagues around me are smokers. I think I should quit because of my tracheitis, but…whenever we are together, they will offer me cigarettes, and it will be impolite to refuse them”. Smoking was associated with being socially connected, valued and skilled; quitting risked social and family disruption and being regarded as ill-mannered. Far from supporting cessation, friends were described as having ridiculed the idea: “When I told my friends that I wanted to quit, they didn't agree with me and even laughed at me. They said “Don't be silly, you are so old that it doesn't make any sense even if you quit. If you quit smoking, you are not a man any more”. Some of my close smoking friends left me after I quit”. Becoming tobacco-free thus risked loss of social resources. The manhood comment also suggests persistence of the myth that smoking is a mark of virility.11
Quitting smoking endangers health
Some participants worried that quitting smoking created health risks rather than reducing them. A smoker said: “I was told it is life-threatening for me to quit since I have smoked for more than 50 years. I can't live without nicotine any more… All of my son-in-laws, sons, and friends… insisted that I should smoke at least one cigarette a day to maintain the concentration of nicotine in my body”. Such comments show that health is valued by these smokers and their social networks. However, the misconception that quitting is dangerous led some to ‘protect’ their health by not doing so.
Misinformation from health professionals
Several participants described having received inaccurate or conflicting information from different health professionals, sometimes reinforcing myths such as the ideas that quitting smoking is futile or harmful. One smoker remarked: “The pharmacist told me it was harmful for people above 45 years old to quit completely. What they should do was just to reduce cigarette consumption”. Another said: “Some doctors insisted that I should quit completely, but others told me to just smoke less…I once got bronchitis, with much coughing. I told my doctor that I wanted to quit now, but he told me it was too late…”. Health professionals were reported by one participant as having encouraged smoking even after the individual had successfully stopped: “After I had quit for 7 months, I still felt uncomfortable, with serious pain in my back. The doctor thought such symptoms may be due to quitting, and he suggested to me to smoke a little, and I picked up smoking again, and I then felt better”. Messages such as these, if widely conveyed, could create significant disincentives to quitting.
Limitations
The small convenience sample precludes generalisation and included no interviewees from outside the hospital, potentially biasing our findings in unknown ways. Cultural variability among regions and ethnic groups could also limit the findings' relevance. The findings can be regarded only as highlighting potentially interesting phenomena which should be explored in further research.
Discussion
If these barriers and beliefs about smoking cessation were confirmed in larger, generalisable studies with representative samples, it would suggest that a social and cultural context in which family, friends and even health professionals sometimes actively discourage smoking cessation may create special challenges for Chinese smokers trying to quit. This exploratory study suggests several questions for future research, including:
How many smokers receive tobacco as a gift from family, friends or coworkers, and how often?
To what degree is smoking cessation success mediated by beliefs about reduced virility or social exclusion?
How prevalent is the belief among health professionals that quitting may be harmful to health, and does this vary by specialty/region?
Studies show that similar factors influence Chinese smokers' intentions to quit compared to smokers from Western countries, but that knowledge about tobacco's health risks is relatively low,12 13 indicating that more public education about health risks is essential. Regarding this, correcting misconceptions among Chinese health professionals and educating them about encouraging smokers to quit is essential.14 15 However, since the great majority of ex-smokers worldwide quit successfully without assistance,16 it is important to consider how social norms and norm change efforts may affect their ability to do so, particularly in countries where resources are limited. Media campaigns such as China's recent spring festival campaign, ‘Giving cigarettes=Giving harm’, could help re-frame the tobacco gifting custom9 17; future studies should assess the impact of these and other population-level interventions on smoking behaviour, including cessation, and on attitudes about tobacco gifting.
Acknowledgments
We would like to thank Cancer Research United Kingdom (CRUK) and the University of Hong Kong for their funding and support, and Dr Simon Chapman for guidance on revising this manuscript. The staff of the Guangzhou No 12 hospital assisted in subject recruitment.
References
Footnotes
Funding CRUK and the University of Hong Kong.
Competing interests None.
Patient consent Obtained.
Ethics approval This study was conducted with the approval of the Institutional Review Board at the University of Hong Kong/Hospital Authority Hong Kong West Cluster and the Guangzhou No12 Hospital.
Provenance and peer review Not commissioned; externally peer reviewed.