The tobacco epidemic is one of the most crucial public health issues in the world, killing more than 7 million people a year(1). More than 6 millions of deaths as a result of direct tobacco use and roughly 890000 are as a result of being exposed to second-hand smoke(1). The mortality rate of lung cancer is about 23 times higher among male smokers and 13 times higher among female smokers than nonsmokers(2). On the basis of current trend it is projected that, 10 million people annually will die earlier as a result of tobacco use by 2030, two-thirds of these deaths will happen in low- and middle-income countries(3). And because of lack of effective global tobacco control, one billion people will die because of tobacco use in this century(3). In China, tobacco is also a major threat to public health. China has the largest tobacco consumption in the world(4). The latest available data reveals that the cumulative prevalence of smoking is 27.7% across China. The specific prevalence rates among Chinese men is 52.1% while that of women stands at 2.7% among Chinese women(5). The high smoking prevalence contributes to a high risk of death among smokers. The cigarette smoking is reason for 7.9 percent of the total premature mortality in China(4). In many developed countries, most smoker started using tobacco products before 18 years old(6). The prevalence of tobacco use of 13–15 years old students is 8.6%-14.6% in four major provinces in China, while the overall median percent is 18.7 in the world(6). Meanwhile, some study provided evidence that second-hand smoke exposure is very common in public places in China(7).
Smoking harms almost every organ of the body: causing many diseases especially lung cancer, cardiovascular disease, respiratory disease and reducing the health of smokers in general(8). The hazard of tobacco use endangers not only smokers but also non-smokers who are exposed to second-hand smoke in indoor environments(7). Second-hand smoke causes serious cardiovascular and respiratory diseases, including coronary heart disease and lung cancer among adults(1). Second-hand smoke exposure can also cause sudden death among infants. For pregnant women, it causes low birth weight(1).
Treatment for tobacco use and addiction is a decisive part of reducing tobacco use, and WHO recommends offering cessation services as part of primary health care(5). However, accessing cessation support is a challenge because it needs sustained commitment from governments that often find it difficult to identify sufficient resources for such programs(5). In China, there are three main challenges for tobacco control:
1. Education level.
Education level always influence people’s smoking behavior. Individuals who are less educated, poorer, and employed in stressful jobs are more likely to using tobacco and less likely to quit smoking than those with higher income and better education(2).
2. Barriers to implementation of tobacco control policies and accession of smoking cessation resources.
Although there are some regulations on the control of smoking in large cities like Beijing and Shanghai, tobacco control activities at villages were rare and infrequent. There are only smoking cessation-related posters and billboard bulletins at village gathering places or in village clinics. And participant always feel negative regarding the effectiveness of these activities(9).
3. Cigarette Sharing culture
The practice of giving and sharing cigarettes are acceptable and widespread throughout China.
People usually share cigarettes to each other in their daily life and special occasions or during holidays to express courtesy or blessing(10).
4. The interference of tobacco industry
The tobacco industry is increasingly using domestic and especially international trade litigation as an attempt to block progress on many tobacco control measures, such as smoke-free public places, pictorial health warnings, plain packaging and product regulation(5).
Most tobacco users want to quit smoking, especially if they are aware of the full range of harms caused by tobacco use(5). However, the extremely addictive nature of nicotine makes it difficult for most people to quit without some form of assistance(5). Three tobacco cessation interventions are highly recommended by WHO: Cessation advice in primary health care systems, Quitlines, and Pharmacological therapy.
To address the problem of smoking we hereby discuss the efforts that have been put in place in three Chinese regions and America based in universally agreed indicators by the WHO and the United Nations member states. The two interventions are presented hereunder:
1.Text to Quit China: An mHealth Smoking Cessation Trial
The major intervention in this study is 6-week text message–based smoking cessation intervention. Participants were randomly divided into the intervention or control group. Intervention group is the high-frequency text contact (HFTC) group which received one to three messages daily. Control group is the low-frequency text contact (LFTC) group received one weekly message. All the text messages came from a professional American text message library. After translation and adapting to the Chinese context, this library was reviewed by Chinese health communication and tobacco cessation experts. The study assessed smoking status of each group for four times which at 0, 1, 3, and 6 months after intervention.
By considering all nonresponders to be smokers, this study observed high reported quit rates (between 26.7% and 30.5%) at all of the follow-up time points for both HFTC and LFTC groups. However, there is no any difference in quit rates between HFTC and LFTC groups. Excluding those who did not report their smoking status, this study observed significantly greater 7-day point prevalence abstinence in the HFTC group compared with the LFTC group immediately after the intervention (66% vs. 58% for the HFTC and LFTC, respectively p<0.001); 1 month after the intervention (67% vs. 64% for the HFTC and LFTC, respectively; p<0.027); and at 6 months (67% vs. 63% for the HFTC and LFTC, respectively; p <0.032). Meanwhile, in view of the higher opt-out rate in the HFTC group compared with the LFTC group (42.9% and 15.4%, respectively). 2. A Social Network Family-Focused Intervention to Promote Smoking Cessation in Chinese and Vietnamese American Male Smokers: A Feasibility Study This study was a single-group feasibility trail by using a social-network family-focused intervention which was guided by the Social Cognitive Theory, the Transtheoretical Model of Change, and Social Network Theory and was also based on interviews of smoker-family. The study educated both smokers and family members by outreaching two small group education sessions and two individual telephone calls to strengthen progress and provide support. The intervention aimed to improve the smokers and family member's knowledge of tobacco–related health risks, smokers' self-efficacy and intention for quitting smoking, family members' self-efficacy and intention to help their smokers to quit smoking. The study assessed 7-day and 30-day point prevalence smoking abstinence and using condition of smoking cessation resources after the intervention. After the intervention, the 7-day point prevalence abstinence rate was 30.2% and the 30-day abstinence rate was 24.0%. Smokers' reports of making at least one 24-hour quit attempt increased from 22.9% at 3 months prior to the intervention to 59.4% at 3 months post-initiation of the intervention (P < 0.001). Smokers' utilization of any cessation resources (medication, quitline, or physician's advice) increased from 2.1% during the 3 months prior to the initiation of the intervention (as obtained by the baseline survey) to 60.4% at 3 months post-initiation of the intervention (P < 0.001). Assessment 1. This message–based smoking cessation intervention increased the cessation rate obviously. Using mobile technology to provide tobacco cessation advice is also highly recommended by WHO. This study promoted a successful smoking cessation text messages library in China. By using message as an intermediary can easily let smokers get smoking-related information. But there is no difference between the intervention group and control group. The reasons might be that all the participants were welling to quit smoking before joining this study. Another weakness of this study is losing of follow-up because too many messages might make people lose their patience. 2. This social-network family-focused intervention was highly successful and acceptable on the smoking cessation. The well trained lay health worker provided a professional counselling which can make participant accept the information easier. The key point of this intervention is the participation of smoker's families. Because of the encouragement and supervision, the smoking cessation among smokers can be more efficient. However, this study only has a small sample size that cannot prove the feasibility in other population. Work to be done Both these two programs promote message-based smoking cessation, thus showing that smoking related education among smokers and their families is an effective way to help smokers to quit tobacco use. In spite, the challenges mentioned above in relation to loss to follow-up, the intervention has potential to be improved and have greater effectiveness. Government needs to popularizing the using of advanced equipment to provide acceptable assistant to smokers in more area of China. Meanwhile, reinforce the spreading of smoking related information to non-smokers. So, they provide sustainable support for smokers and keep insisting on the use of smoking cessation resources and quitting smoking goals. If most smokers can improve their awareness of the risk of tobacco smoking, the challenge of implementation of tobacco control policies and cigarette sharing culture will also be solved.