Cigarette Smoking and Its Risk Factors
among Elementary School Students
ABSTRACT
Objectives. This study investi­
gated patterns of and risk factors for
smoking among elementary school
children in Beijing, China.
Methods. In 1988, anonymous
questionnaires were administered to
a multistage stratified cluster sample
of 16 996 students. aged mostly 10 to
12, in 479 fourth- to sixth-grade
classes from 122 Beijing elementary
schools.
Results. Approximately 28% of
boys and 3% of girls had smoked
cigarettes. The most frequently cited
reasons for smoking initiation were
''to imitate others' behavior" and "to
see what it was like." Girls were
more likely to get cigarettes from
home than to purchase their own.
Having close friends who smoked
and being encouraged by close friends
to smoke were strong risk factors for
smoking. Smoking was also associ­
ated with lower parental socioeco­
nomic status; having parents, sib­
lings, or teachers who smoked; buying
cigarettes for parents; performing
poorly in school; and not believing
that smoking is harmful to health.
Conclusions. Gender differences
in smoking prevalence among adoles­
cents in China are larger than those
among US teenagers, whereas the
proximal risk factors for smoking are
similar. Major efforts are needed to
monitor and prevent smoking initia­
tion among Chinese adolescents, par­
ticularly girls. (Am J Public Health.
1996;86:368-375)
368 American Journal of Public Health
in Beijing
Introduction
Much of our current knowledge on
teenage smoking has come from Western
countries. Studies from these countries
show that most smokers start smoking
during their adolescent or early adulthood
ycars 1 --' and that the younger persons are
when they start to smoke. the more likely
they arc to become regular smokers as
adults. I.' In addition. persons who start to
smoke as young adolescents arc among
the heaviest tobacco users during adoles­
cence and adulthood 1 and thus experi­
ence higher mortality from smoking-related
discascs_ 1. -1-1, Therefore. researchers in
industrialized countries have repeatedly
stressed the importance of preventing
tobacco use among young pcople. 1·'
In Third World countries. however.
smoking among children has not received
as much attention. In China. a few studies
have been conducted on smoking preva­
lence among adults. 7-� To the best of our
knowledge. however. no population­
based data are currently available on
smoking behavior among children. Since
more than one fifth of the world"s popula­
tion and more than 300 million (approxi­
mately 30o/c) of the world's smokers live in
China.9·111 the success in achieving global
objectives in terms of smoking control as
well as health promotion largely depends
on how much progress in tobacco control
is made in that country. Therefore. accu­
rate documentation of the prevalence of
smoking among children and adolescents
in China. as well as its related behavioral
patterns and risk factors. would benefit
not only China but the entire world. To
provide such estimates. we surveyed a
stratified random sample of 16 996 el­
ementary school students in Beijing dur­
ing 1988. After reviewing the literature.
we believe that this is one of the largest
and most comprehensive studies ever
conducted on smoking among children of
this age.
Methods
Sample
In China. the school svstem is uni­
form across the country. Children typi­
cally enter elementary school at the age of
7 years and graduate at the age of 12
years. The law requires all children to
complete elementary school. Thus. el­
ementary school students virtually consti­
tute the entire population between the
ages of 7 and 12 years.
We recruited only children in grades
4 to 6. aged mostly IO to 12 years. because
this study involved a self-administered
questionnaire that required the respon­
dents to be of a substantial literaC\ lc,cl.
Bao-Ping Zhu is with the Center for Public
Health Research and E,·aluation. Battelk
Memorial Institute. Atlanta. Ga: the Ottice on
Smoking and Health. National Center for
Chronic Disease Prevention and Health Promo­
tion. Atlanta: and the Division of Social
Medicine and Public Health. Chinese Acad­
emy of Medical Sciences and Peking Union
Medical College. Beijing. China. Ming Liu is
with the Division of Social Medicine and Public
Health. Chinese Academ, of Medical Sciences
and Peking Union Medical College. and the
Department of Internal Medicine. Uni,ersity
of Michigan Medical Center. Ann Arbor. Dana
Shelton and Gary A. Giovino are with the
Office on Smoking and Health. and Simin Liu
is with the Division of Nutrition. National
Center for Chronic Disease Prevention and
Health Promotion.
Requests for reprints should be sent to
Bao-Ping Zhu. MD. PhD. Office on Smokin!!
and He-alth. National Center for Chroni�
Disease Prevention and Health Promotion.
Centers for Disease Control and Pre,·ention.
Mailstop K-50. -+770 Buford Hwy NE. Atlanta.
GA 303-+1-372-+.
This paper was accepted July 2:i. l l/9:i.
 Smoking among Chinese Children

Government statistics show that 99.7% of

children 7 years of age entered elemen- TABLE 1-Cigarette Smoking Patterns among Elementary School Students Who
tary schools in Beijing during 1988, and Reported Smoking during the Past 30 Days: Beijing, 1988
the annual dropout rate was about 3%.11
In total, 741 982 elementary school stu- Boys Girls
dents, of whom 318 648 were in grades 4
to 6, attended 3875 schools. Question and Response No. % No. %
We used a two-stage stratified cluster On average, how many cigarettes do you
sampling method. At the first stage, we smoke per day?
stratified the 3875 elementary schools into <1 1214 81.0 98 83.1
urban schools (i.e., those in the city 1-5 221 14.8 9 7.6
proper and the county towns) or rural 6-10 17 1.2 0 0.0
schools (i.e., those in the outlying areas of 11-15 21 1.4 2 2.0
16-20 16 1.1 9 7.4
the counties), and we randomly chose >20 9 0.6 0 0.0
schools from each stratum. At the second When you smoke, do you usually inhale
stage, we randomly selected classes from or not?
schools. We calculated the number of Inhale 114 6.0 14 9.4
classes to be chosen from each school Just take the smoke into my mouth 1443 76.6 119 81.0
such that the number of students for each Both, can't say which is more often 328 17.4 14 9.6
stratum was proportional to the stratum What kind of cigarettes do you usually
size. The mean class size in the sample smoke?
Filtered 627 34.8 50 39.8
was 35.5, with a standard deviation of 9.8. Nonfiltered 404 22.4 44 34.8
Once a class was selected, we surveyed all Both, can't say which is more often 773 42.8 32 25.4
students in the class. The sampling pro- Where do you usually get your cigarettes?
cess was similar to that used in a previous Home 386 21.8 51 40.0
report on junior high school students.12 In Buy them myself 119 6.7 5 3.7
total, 479 classes from 122 elementary Schoolmates/friends 967 54.7 39 31.0
Other 297 16.8 32 25.3
schools were chosen, and the total num-
ber of students surveyed was 17 035.
In a 1987 survey conducted in four
elementary school classes, 2.5% of the students. To reduce the possibility of practices, type of cigarettes (filtered or
students reported that they currently underreporting by smokers, the inter- nonfiltered) smoked, and usual source of
smoked (Beijing Education Bureau, un- viewer emphasized strongly that the sur- cigarettes. (We asked only students who
published data, 1987). Based on previous vey was anonymous and that individual had smoked during the previous 30 days
studies in China,7'8 we anticipated the responses would not be disclosed to to complete the smoking patterns portion
nonparticipation rate to be less than 10%. teachers or parents. The interviewer stayed of the questionnaire because, in a pilot
Using the formula provided by Snedecor in the classroom during the entire process study, many students who had not smoked
and William,13 we calculated the required to maintain order and answer the stu- during the previous 30 days skipped this
sample size to be approximately 17 000 in dents' questions. section.)
order for the "true" smoking prevalence We did not use biological markers to We classified students into four cat-
not to differ by more than 10% from the validate smoking status reported by re- egories based on their self-reported smok-
estimated prevalence (at a 95% confi- spondents because this would have enor- ing status. Daily smokers smoked every
dence level). Among the 17 035 students mously increased our costs, given the day (those who stopped daily smoking
selected, 26 were absent during the large sample size, and because most only on special occasions, such as when
survey; another 13 were excluded because practical biological markers are either they were sick, were included in this
their survey forms were unusable. The insensitive or nonspecific in detecting very category); weekly smokers smoked at
effective sample size was 16996 (8843 infrequent and light smoking. Also, tests least once a week but not daily; occasional
boys and 8153 girls), yielding a response based on biological markers among chil- smokers smoked less than once a week or
rate of 99.8%. dren can be easily biased by parental only on some special occasions or had
smoking. However, we attempted to mini- smoked just a few times; and never
Survey Methods mize possible underreporting by smokers smokers had never tried a cigarette. In the
Trained interviewers approached the by using a self-administered anonymous polychotomous logistic regression analy-
teachers of the selected classes and the questionnaire, strongly emphasizing the sis, we further collapsed daily and weekly
school principals 1 to 2 weeks before the anonymity of questionnaire responses, smokers into one category because the
survey to request cooperation and collabo- and asking the teachers to leave the small numbers in the separate subcatego-
ration with survey procedures. All se- classroom during the survey. ries would have resulted in unstable odds
lected schools agreed to participate. On We collected the following informa- ratio estimates. We refer to these students
the date of the survey, students in a tion: (1) social and demographic data; (2) as regular smokers. In addition, we de-
selected class were asked by their teacher smoking status; (3) familial and psychoso- fined students as current smokers if they
to meet in their classroom. After a brief cial risk factors for smoking; (4) age at, had smoked during the previous 30 days,
introduction, the teacher left the class- setting of, and reason for smoking initia- as inhaling smokers if they often inhaled,
room and the interviewer explained the tion; and (5) smoking patterns, including and as mouth smokers if they took smoke
purpose and process of the survey to the daily cigarette consumption, inhalation into their mouth and puffed out immedi-

March 1996, Vol. 86, No. 3 American Journal of Public Health 369
Zhu et al.

that the variance estimates of the coeffi-

TABLE 2-First Cigarette Smoking Experience of Elementary School Students cients are somewhat larger than those
Who Reported Ever Smoking Cigarettes: Beijing, 1988 from direct fitting.
We constructed and diagnosed the
Boys Girls polychotomous logistic regression model
as proposed by Hosmer and Lemeshow.18
Question and Response No. % No. % After reviewing the literaturel12 and the
At what age did you first try a cigarette? responses from junior and senior high
<5y 144 6.9 20 11.6 school students in the study,2'22 we
5-9y 924 44.5 88 51.9 identified the following four variables as
10-14 y 1008 48.6 62 36.5 important risk factors for smoking among
From whom did you get your first cigarette? children: sex, school grade, response to
Father 78 5.5 9 8.3 the question "Do any of your close friends
Mother 9 0.6 1 0.9 encourage you to smoke?" and response
Brother 138 9.7 14 12.8
Sister 11 0.8 4 3.7 to the question "Do any of your close
Relative/neighbor 197 13.8 13 11.9 friends smoke?" We forced all four
Schoolmate 547 38.4 48 44.0 variables into the polychotomous logistic
Friend outside of school 301 21.1 8 7.3 regression model. We selected other
Teacher 5 0.4 1 0.9 variables in a forward stepwise fashion,
Other 140 9.8 11 10.1
using, as criteria for variable selection, the
Where did you first try a cigarette? likelihood ratio test and the change in
Home 469 31.3 84 58.7
School 137 9.2 4 2.8 coefficient estimates due to the inclusion
On the way to/from school 124 8.3 3 2.1 of a variable (as recommended by Green-
Home of a friend/relative 204 13.6 24 16.8 land23). However, we excluded the vari-
Other 563 37.6 28 19.6 able measuring students' attitude toward
Which was your primary reason for first cigarettes offered by others (i.e., response
trying a cigarette? to the question "In case someone offers
Believed smoking makes people 90 4.1 4 2.6
look elegant you a cigarette, what would be your
To imitate the behavior of others 760 35.1 66 39.2 typical response?"), even though it had a
To see what it was like 624 28.8 38 22.4 strong correlation with smoking status.
Encouraged by another person 221 10.2 13 8.0 We did so because willingness to accept a
Other 470 21.7 47 27.8 cigarette offer may, in fact, be a conse-
With whom did you first try a cigarette? quence of smoking (i.e., those who smoke
Alone 341 19.8 28 19.9 may be more willing to accept a cigarette
Friend/schoolmate 993 57.6 66 46.8
Relative/neighbor 196 11.4 12 8.5 offer) rather than a risk factor for smok-
Family member 100 5.8 30 21.3 ing. Finally, we examined all possible
Other 95 5.5 5 3.5 first-order interactions between variables
in the final model, but none were signifi-
cant. The Hosmer-Lemeshow test'8 sug-
gested that the model fit well.
ately. The reasons and settings for smok- nal scale.1820 In fitting the polychotomous
ing had mutually exclusive categories (i.e., logistic regression model, we grouped Results
each item could have only one answer). students into three categories based on
their smoking status: (1) regular (i.e., Smoking Prevalence and Pattems
StatisticalAnalysis daily or weekly) smokers, (2) occasional Of the 16 996 students (8843 boys
We used the statistical software smokers, and (3) never smokers. We did and 8153 girls) in the unweighted sample,
packages SAS'4 and SUDAAN'5 for data not fit a cumulative odds model2l for two 2731 (2465 boys and 266 girls) reported
analysis. We estimated all standard errors reasons. First, the proportional odds having smoked cigarettes at least a few
with SUDAAN to account for the com- assumption required by the cumulative times. In the weighted sample, 0.37% of
plex survey design in this study.'5'16 We odds model did not hold, regardless of the students reported smoking daily (95%
weighted all sample statistics using a how we organized the outcome variable. confidence interval [CI] = 0.25%, 0.49%),
weight inversely proportional to the prob- Second, the coefficients of the cumulative 0.82% reported smoking weekly (95%
ability of selection. odds models are more difficult to meaning- CI = 0.66%, 0.98%), and 15.39% re-
To assess risk factors for smoking, we fully explain. In addition, we fit the ported smoking occasionally (95%
first cross tabulated students' smoking polychotomous logistic regression model CI = 14.12%,16.66%).
status by their demographic, psychosocial, using individualized regressions, as pro- Current smokers were asked about
and familial variables and evaluated the posed by Begg and Gray,'9 because direct their cigarette smoking patterns. We
association using the chi-square test for fitting is not available with SUDAAN. found that a majority of current smokers
independence or the trend test (if the Begg and Gray'9 showed that coefficients (95.8% of boys and 90.7% of girls)
independent variable was on an ordinal estimated in this manner are consistent smoked no more than five cigarettes per
scale).'7 We then fit a polychotomous with those obtained through direct fitting day, and few of them inhaled while
logistic regression model with the out- under a variety of circumstances, although smoking, suggesting that most of these
come variable being arranged on a nomi- there is usually a slight loss of efficiency in children were only experimenting with

370 American Journal of Public Health March 1996, Vol. 86, No. 3
 Smoking among Chinese Children

cigarettes (Table 1). Although most of the

children usually obtained their cigarettes TABLE 3-Demographic and Psychosocial Factors Associated wih Smoking
from home or from their schoolmates and among Elementary School Students: Beijing, 1988
friends, some of them (6.7% of boys and
3.7% of girls) bought their own cigarettes. % Students, by Smoking Status
In comparison with boys, girls were No.
Variable Daily Weekly Occasional
significantly more likely to obtain ciga-
rettes from home (40.0% vs 21.8%), less Sexa
likely to buy cigarettes for themselves Male
(3.7% vs 6.7%), and less likely to obtain Overall 0.55 1.42 26.77 8 854
cigarettes from their schoolmates or Grade 4b 0.35 0.99 21.44 2916
friends (31.0% vs 54.7%). Grade 5b 0.53 1.38 28.39 3 140
In reviewing the responses of stu- Grade 6b 0.74 1.91 30.57 2 785
Female
dents who had ever smoked, we found Overall 0.17 0.17 3.02 8 143
that about 7% of the boys and 12% of the Grade 4 0.20 0.14 3.29 2 744
girls who had smoked cigarettes tried Grade 5 0.06 0.17 3.36 2 839
Grade 6 0.26 0.20 2.35 2 555
their first cigarette before the age of 5
years (Table 2). Approximately 38% of Type of schoolb,c
Magnate, city level 0.00 0.75 5.68 158
the boys and 44% of the girls obtained Magnate, district level 0.49 0.48 13.38 1 279
their first cigarettes from their school- Ordinary 0.36 0.85 15.65 15 546
mates. Friends outside of school were School performanceb
another major source of the first cigarette Top 10 in the class 0.15 0.53 10.59 4 435
for boys, whereas girls were more likely to Middle 0.27 0.71 14.94 9 176
get their first cigarette from family mem- Bottom 10 in the class 0.90 1.40 23.11 3 336
bers. Surprisingly, some students received Do any of your close friends
their first cigarette from teachers, al- encourage you to smoke?a
At least one 1.67 7.61 61.21 624
though the proportion was small. Nearly No 0.28 0.51 12.71 15 687
one third of the boys and two thirds of the
girls first tried a cigarette at home. For Do any of your close friends
smoke?a
both boys and girls, the most frequently At least one 1.62 4.50 56.14 1 941
cited reasons for first trying a cigarette No 0.15 0.27 7.69 12 553
were "to imitate the behavior of others" Do any of your teachers smoke?a
and "to see what it was like." Both boys At least one 0.39 0.80 16.96 10 789
and girls who had ever smoked cigarettes No 0.33 0.96 12.65 3 858
were more likely to first try a cigarette Do you agree that smoking is
with a friend or schoolmate than with any harmful to health?b
other person. A closer look at sex differ- Agree 0.31 0.66 14.33 14 476
Have no idea 0.75 1.98 28.85 1 005
ences revealed that a significantly higher Don't agree 0.64 1.55 16.63 1 498
proportion of girls than boys obtained
In case someone offers you a ciga-
their first cigarette from family members rette, what would be your
(father, mother, brother, and sister com- typical response?b
bined) (25.7% vs 16.6%) and first tried a Accept, happily 6.44 14.86 73.08 90
cigarette at home (58.7% vs 31.3%), a Accept, willingly 4.61 11.44 83.95 368
Accept, unwillingly 0.91 4.52 92.62 903
pattern similar to that for current smokers. Firmly refuse 0.20 0.27 8.87 15 587
Risk Factors
aChi-square test for independence: P < .01.
We also examined the relationship bTestfortrend:P < .01.
between the students' smoking behavior cAmong the three types of schools, magnate schools of city level are the most privileged regarding
teachers' experience, equipment, and government funding; ordinary schools are the least
and their demographic, psychosocial, and privileged.
familial characteristics. Smoking was sub-
stantially more likely among boys than
among girls. Among boys, smoking rates
increased with school grade; among girls, close friends who encouraged them to had no close friends who smoked. Stu-
the relationship between smoking rates smoke had 6 times the daily smoking dents' attitude toward cigarettes offered
and school grade was unclear because of rates, more than 10 times the weekly by others was also strongly correlated with
the small number of smokers in the smoking rates, and approximately 5 times smoking. Whether students would accept
sample. Of all of the variables we investi- the occasional smoking rates of students a cigarette offered by others almost
gated, the two variables reflecting peer who had no close friends encouraging completely separated ever smokers from
pressure (i.e., having close friends who them to smoke. Similarly, students who never smokers. In addition, smoking was
encouraged the student to smoke and had close friends who smoked had more positively associated with having teachers
having close friends who smoked) were than 10 times both the daily and the who smoked and not believing that smok-
among the strongest risk factors for weekly smoking rates and 7 times the ing is harmful to health. Conversely,
cigarette smoking. Students who had occasional smoking rates of students who students attending magnate schools or

March 1996, Vol. 86, No. 3 American Journal of Public Health 371
Zhu et al.

In the polychotomous logistic regres-

TABLE 4-Familial Factors Associated with Smoking among Elementary School sion analysis, we found that the two
Students: Beijing, 1988 variables reflecting peer pressure-having
close friends who smoked and having
% Students, by Smoking Status close friends who encouraged the student
to smoke-were strongly associated with
Variable Daily Weekly Occasional No. both regular and occasional smoking after
Father's occupationa adjustment for other variables in the
Teacher/scientist 0.19 0.44 10.19 1 580 model (Table 5). For students having
Physician 0.65 1.09 11.15 273 close friends who smoked, in comparison
Government official 0.08 0.29 10.03 2 177 with students having no close friends who
Worker (blue collar) 0.42 0.89 15.59 6433 smoked, the odds ratio for regular smok-
Farmer 0.51 1.16 21.97 3 676
Self-employed 0.57 0.21 18.80 480 ing was 12.6 (95% CI = 8.1, 19.5), and the
odds ratio for occasional smoking was 7.6
Mother's occupationa
Teacher/scientist 0.07 0.33 8.63 1 495 (95% CI = 6.5, 9.0). Similarly, for stu-
Physician 0.45 0.33 9.56 558 dents having close friends who encour-
Government official 0.00 0.33 9.26 663 aged them to smoke, in comparison with
Worker (blue collar) 0.21 0.71 13.13 4 991 students having no close friends who
Farmer 0.54 1.07 20.22 6 516 encouraged them to smoke, the odds ratio
Self-employed 1.09 0.76 20.74 340
for regular smokingwas 7.4 (95% CI = 4.5,
Father's educationb 12.2), and the odds ratio for occasional
University/college 0.15 0.34 9.14 2 619
Vocational senior high 0.70 4.00 15.15 104 smoking was 3.7 (95% CI = 3.0, 4.7). In
High schoolc 0.32 0.70 14.67 7 715 addition, father's educational background
Elementary school 0.53 1.00 19.94 2 525 was strongly associated with regular smok-
No school 2.77 4.80 26.09 229 ing of students. The odds ratios for
Mother's educationb regular smoking were 9.3 (95% CI = 2.2,
University/college 0.08 0.31 7.50 1 334 39.9) for students whose fathers had a
Vocational senior high 0.00 0.00 18.27 61
vocational senior high school education
High schoolc 0.17 0.72 13.25 7 077
Elementary school 0.55 0.90 17.93 3 840 and 8.4 (95% CI = 3.9, 18.4) for students
No school 0.66 1.66 21.81 748 whose fathers never formally attended
Father's smoking statusb school, in comparison with students whose
Daily 0.51 1.09 18.77 8594 fathers had a college education. The sex
Weekly 0.38 1.01 13.54 2327 of the student was also strongly associated
Occasional 0.22 0.71 14.69 1 563 with both regular and occasional smoking.
Former 0.12 0.27 11.63 1 513
Never 0.16 0.23 9.32 2 948 In comparison with girls, boys were 4.2
Mother's smoking statusb
times (95% CI = 2.6, 6.6) as likely to be
Daily 0.79 1.02 27.46 636 regular smokers and 8.4 times (95%
Weekly 1.10 1.78 21.93 416 CI = 6.9, 10.1) as likely to be occasional
Occasional 0.40 1.90 27.50 777 smokers.
Former 0.00 1.90 23.91 274 Finally, we examined these associa-
Never 0.33 0.71 13.87 14 752
tions in each stratum of the sample (i.e.,
Buy cigarettes for parentsb urban schools and rural schools) when-
Often 1.11 1.49 26.14 1 264
ever sample size permitted. We found the
Occasionally 0.41 1.14 19.48 7 108
Never 0.21 0.45 10.43 8606 associations to be of similar strength in
Do any of your brothers or sisters the subsamples (data not shown).
smoke?a
At least one 0.88 3.07 36.32 1 504
None 0.32 0.65 13.55 9 678 Discussion
I am the only child 0.16 0.40 10.84 5 174
China leads the world in tobacco
aChi-square test for independence: P < .01. production and consumption.10'2426 The
bTestfortrend:P < .01. situation is being further worsened by
cCombined category of junior high school, senior high school, and teachers' training school. international tobacco corporations that
are marketing their tobacco products in
China, establishing cigarette production
factories jointly with Chinese companies,
having good school performance were less having parents or siblings who smoked, and increasing local cigarette produc-
likely to smoke than their counterparts and having parents who asked students to tion.27 As a result, lung cancer mortality
attending ordinary schools or performing buy cigarettes for them. We observed a has become one of the five leading causes
poorly in school (Table 3). dose-response relationship demonstrat- of death and the leading cause of cancer-
When we analyzed familial factors, ing that the more frequently parents related death in China.28 If no action is
we found that smoking was positively asked their children to buy cigarettes, the taken to reduce tobacco use in China, an

associated with having parents of low more likely that their children would be estimated 2 million smoking-related
educational and occupational statuses, smokers (Table 4). deaths-including 900 000 lung cancer

372 American Journal of Public Health March 1996, Vol. 86, No. 3
 Smoking among Chinese Children

deaths-will occur among Chinese men

by the year 2025. In addition, an estimated TABLE 5-Polychotomous Logistic Regression Analysis of Risk Factors
200 million children currently living in Associated with Cigarette Smoking among Elementary School
China will become smokers, and 50 Students: Beijing, 1988
million of them will die prematurely from
smoking-attributable diseases.29 There- Daily/Weekly vs Occasional vs
fore, widespread implementation of smok- Never Smoker Never Smoker
ing prevention and cessation programs Variable OR 95% Cl OR 95% Cl
and tobacco control policies that target
adolescents is urgently needed to reduce Sex
the present and future health burden of Male 4.2 2.6, 6.6 8.4 6.9,10.1
Female Referent Referent ...
smoking in China.
To develop and implement effective School grade
6 1.4 0.9, 2.3 1.1 0.9,1.4
measures of smoking control, one must 5 1.3 0.8, 2.1 1.2 1.0,1.6
understand the reasons and risk factors 4 Referent Referent
for smoking initiation. In this study of Father's education
smoking behaviors and related risk factors No school 8.4 3.9, 18.4 2.1 1.4, 3.2
among elementary school students in Elementary school 1.6 0.9, 3.1 1.7 1.3, 2.2
Beijing, 16.58% of students reported that High schoola 1.5 0.9, 2.6 1.4 1.2,1.7
Vocational senior high 9.3 2.2, 39.9 1.3 0.7, 2.8
they had smoked cigarettes. Don't know 1.9 1.0, 3.6 1.5 1.2,1.9
We found that smoking in elemen- University/college Referent Referent
tary school children was more likely to be Father's smoking status
related to availability of cigarettes from Daily 3.2 1.8, 5.7 1.7 1.4, 2.0
family members among girls than among Weekly 4.2 2.1, 8.5 1.4 1.1, 1.7
boys. We observed a higher proportion of Occasional 2.7 1.3, 5.6 1.7 1.3, 2.2
girls obtaining their first cigarette from Former 1.1 0.4, 3.5 1.1 0.9,1.4
Never Referent Referent
their family members and first trying a
cigarette at home. However, in our previ- Do any of your brothers or
sisters smoke?
ous reports on junior and senior high At least one 3.0 2.0, 4.6 2.4 2.0, 2.8
school students,12'22 we found that family Don't know 3.1 1.5, 6.5 2.0 1.6, 2.4
influence on smoking among girls was am the only child 0.6 0.3, 0.9 0.7 0.6, 0.9
minimal, probably because girls are more No Referent Referent
likely to be influenced by their families How do you describe your
during childhood than during adoles- current school perfor-
cence. As girls grow older and their social mance?
Bottom 10 in the class 1.9 1.2, 3.1 1.6 1.4, 2.0
contacts increase, familial influences tend Middle 1.3 0.9, 2.1 1.3 1.1, 1.5
to decrease, while influences from society Top 10 in the class Referent Referent
become increasingly important. This find- Do any of your close friends
ing suggests that different smoking preven- smoke?
tion strategies should be developed for At least one 12.6 8.1, 19.5 7.6 6.5, 9.0
am not sure 2.0 1.2, 3.4 2.3 2.0, 2.7
girls of different ages. For girls under 12 No Referent Referent
years of age, measures that are focused on
preventing familial influences on smoking Do any of your close friends
encourage you to
initiation should be stressed. For adoles- smoke?
cent girls and young women, peer resis- At least one 7.4 4.5,12.2 3.7 3.0, 4.7
tance and refusal training should be am not sure 2.0 1.0, 4.1 1.9 1.5, 2.3
emphasized. No Referent Referent
Conrad and colleagues30 reviewed 27 Do you agree that smoking is
prospective studies conducted between harmful to health?
Don't agree 2.0 1.3, 3.2 1.1 0.9,1.4
1980 and 1992 that examined predictors Have no idea 1.8 1.0, 3.1 1.5 1.3,1.8
of smoking initiation among children. Agree Referent Referent
Peer influences were found to be strong
predictors of smoking initiation in almost aCombined category of junior high school, senior high school, and teacher's training school.
all studies that included these measures. Note. The Hosmer-Lemeshow goodness-of-fit test results were as follows: C = 7.96, P = .44, for the
model of daily/weekly vs never smokers and C = 11.04, P = .20, for the model of occasional vs
Similar findings have been documented never smokers. OR = odds ratio; Cl = confidence interval.
by the surgeon general of the United
States.' Our data show that of the
variables we measured among Chinese
children, the two reflecting peer pressure occasional smoking. Similar results have the success of any future smoking control
(i.e., having close friends who smoked and been found in our previous reports on policies in China.
having close friends who encouraged the junior and senior high school students.12'22 As expected, smoking among elemen-
student to smoke) were among the stron- Therefore, efforts to encourage students tary school students correlated with hav-
gest risk factors for both regular and to resist peer pressure represent a key to ing parents of a lower socioeconomic

March 1996, Vol. 86, No. 3 American Journal of Public Health 373
Zhu et al.
status in terms of education and occupa-
tion. However, one point warrants special
attention. That is, smoking prevalence
was exceptionally high among children
whose fathers attended vocational senior
high schools. In China, those who attend
such schools are usually unable to enroll
in universities (because they have not
passed the annual national college en-
trance examinations) and have little
chance to attend universities later in their
lives. After graduation, most of these
individuals will become blue-collar work-
ers. Furthermore, vocational high schools
are administered by labor departments,
which typically do not enforce smoking
control policies and other regulations as
strictly as education departments. No
data have been collected on smoking
prevalence among graduates of these
schools in China, but public health offi-
cials generally believe that the prevalence
is substantially higher than the average.
Data on smoking among children
between 10 and 12 years of age are sparse
in Western countries. In the United
States, the only data sources we are aware
of that have examined smoking patterns
among children of these ages are the first
and second Teenage Attitudes and Prac-
tices Surveys. The first survey, conducted
in 1989, involved children 12 to 18 years of
age.3 The second survey was carried out in
1993. In addition to following up respon-
dents in the original survey, this second
survey recruited a new cohort of children
10 to 15 years of age (National Center for
Health Statistics, unpublished data, 1994).
In comparing the prevalence of smoking
among children in Beijing and that from
the cross-sectional analyses of the two
cohorts of children in the first and second
Teenage Attitudes and Practices Surveys,
we found that, in both countries, most
smokers at this age smoked only occasion-
ally. Smoking prevalence appeared to be
higher among Chinese boys than among
their counterparts of the same age in the
United States, whereas smoking was less
prevalent among girls in China than in the
United States. However, these compari-
sons should be interpreted with caution
because of differences in survey methods
(the US surveys were household inter-
views, whereas our survey involved a
school-based, self-administered question-
naire), target population (the US data
were national estimates, whereas we
surveyed only children in Beijing), and
definition of smoking.3
Interestingly, despite the vast politi-
cal, social, economic, and cultural differ-
ences among Chinese students and those
374 American Journal of Public Health
in the United States and other Western
nations, the proximal risk factors for
smoking are surprisingly similar. As is
true in Western nations,l Z30 variables
reflecting peer pressure are strongly asso-
ciated with smoking among Chinese teen-
agers. In addition, performing poorly in
school, not believing that smoking is
harmful to health, having parents who
smoke, and having a low parental socioeco-
nomic status also play important roles in
smoking among Chinese adolescents. Be-
cause the resources that can be allocated
to smoking research in China are ex-
tremely limited, Chinese researchers
should take full advantage of well-
established theories and methods from
Western nations, test them, and adopt
them whenever practical. In addition,
internationally collaborative research on
smoking prevention should be strongly
encouraged.
Our data confirm the finding, in our
previous reports on junior and senior high
school students,1222 that smoking could
start as early as before 5 years of age.
Studies in the United States have demon-
strated that the earlier a person starts to
smoke, the more likely he or she is to
become a regular smoker.1-3 Major efforts
should be made to convey this message to
parents and teachers and to get them
involved in preventing children from
starting to smoke early. In addition,
strategies to prevent smoking initiation
among adolescents that have proved suc-
cessful in industrialized countries, includ-
ing tobacco tax increases, enforcement of
youth access laws, youth-oriented mass
media campaigns, and school-based to-
bacco use prevention programs,' should
be considered in China.
We found that only 2.7% of the
students in our study would "happily" or
"willingly" accept cigarettes offered by
others and that only 4.1% of the boys and
2.6% of the girls who had smoked started
their first cigarette because they "believed
smoking makes people look elegant."
These results suggest that smoking is not
acceptable among elementary school stu-
dents in Beijing. The much lower smoking
prevalence among females than among
males observed in this and other stud-
ies'222 indicates that smoking among
adolescent girls is even less acceptable.
Studies among Chinese adults have also
revealed that smoking is much less preva-
lent among women than among men.7'8'31
However, as has been the case in most
industrialized nations, this gender differ-
ence will probably diminish as China
opens up to advertising, marketing, and
imports and as the negative image of
women smokers gradually disappears.2'32
In addition, Western tobacco companies,
especially those based in the United
States, are aggressively promoting smok-
ing among women as they expand their
market into the Western Pacific.33 Major
efforts are needed to monitor and prevent
smoking initiation among Chinese teenag-
ers, especially girls.
In designing this study, we used the
2.5% current smoking prevalence esti-
mated from a small pilot study to deter-
mine sample size. Because the prevalence
estimates of daily and weekly smoking in
this study were substantially lower than
2.5%, the confidence intervals for these
estimates were wide. Future studies should
consider using alternative sampling frames
to select smokers more efficiently (e.g.,
oversampling certain high-risk groups). In
addition, information on cigarette brand
preference should be collected in future
national and regional studies to monitor
the effect of transnational tobacco compa-
nies' promotional efforts on smoking
behaviors of Chinese adolescents. O
Acknowledgments
This study was supported by a grant from the
National Committee of the Patriotic Health
Campaign of the People's Republic of China.
This work is dedicated to the memory of
Professor Guan-Qing He, founder of modern
epidemiology in China.
We appreciate the encouragement and
help of Dr Minzhang Chen, minister of public
health of China. We thank our colleagues in
the Division of Social Medicine and Public
Health at the Peking Union Medical College in
China; Robert Merritt, Office on Smoking and
Health, US Centers for Disease Control and
Prevention; and Jeffrey Chrismon of the Or-
kand Corp for their assistance and comments.
We appreciate the administrative assistance
provided by the Beijing Education Bureau and
the education departments of the districts and
counties. Finally, we offer special thanks to Dr
William Kalsbeek, director of the Survey
Research Unit, University of North Carolina at
Chapel Hill, for his advice on setting up the
SUDAAN programs.
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Nominations Invited for 1996 Healthtrac Foundation Awards

The Healthtrac Foundation is currently accepting nomina­
tions for two awards to be presented in the fall of 1996. The
Healthtrac Prize is for major achievement in health improve­
ment. with emphasis on recent contributions to health. It will
be awarded to that individual who has done the most to
improve health, as judged by an expert and prestigious
selection jury. The winner will receive a prize of $50 000. The
Healthtrac Foundation Health Education Award is given to the
health educator who has made an outstanding contribution to
advancing the fields of health education or health promotion as
a result of innovation in research, program development, or
program delivery. The award amount is $25 000.
The deadline for entry is May 3, 1996. For further
information and nomination procedures, contact the Health­
trac Foundation, 525 Middlefield Rd, Suite 250, Menlo Park,
CA 94025; tel (415) 324-1749.

March I 996, Vol. 86, No. 3 American Journal of Public Health 375