China CDC: E-Cigarette Use Among Secondary Students Rose Sharply in 2019

May 31, 2020, marks the 33rd World No Tobacco Day, with the theme in China being "Protecting Youth from Traditional Tobacco Products and E-Cigarettes." The Chinese Center for Disease Control and Prevention released the results of the 2019 Tobacco Survey among Chinese Secondary School Students, indicating a significant decrease in cigarette use among middle school students, while e-cigarette use has risen sharply, highlighting the need for attention to tobacco control in vocational schools.

The survey utilized a multi-stage stratified cluster random sampling method, collecting data through self-administered paper questionnaires, covering 347 counties (cities, districts) across 31 provinces (autonomous regions, municipalities) in the country. A total of 288,192 students from 1,024 middle schools and 974 high schools (including 277 vocational schools) participated, with a response rate of 94.8%. The survey included questions on tobacco use, e-cigarette use, tobacco dependence and cessation, secondhand smoke exposure, access to and prices of tobacco products, tobacco control publicity, tobacco advertising and promotion, and perceptions and attitudes towards tobacco.

Results showed that over the past five years, the proportion of middle school students who have tried smoking and those currently smoking has significantly decreased. In 2019, the proportion of middle school students who had tried smoking was 12.9%, and the current smoking rate was 3.9%, down by 5 and 2 percentage points respectively compared to 2014.

Notably, the proportion of middle school students who have heard of e-cigarettes and those currently using e-cigarettes has significantly increased over the past five years. In 2019, 69.9% of middle school students had heard of e-cigarettes, and the current e-cigarette usage rate was 2.7%, up by 24.9 and 1.5 percentage points respectively compared to 2014.

This year, for the first time, the smoking situation among high school students was included in the tobacco survey for middle school students, revealing that the smoking rate among high school students is much higher than that of middle school students, with tobacco control in vocational schools being particularly concerning. In 2019, the proportions of high school students who had tried smoking, currently smoking, and currently using e-cigarettes were 24.5%, 8.6%, and 3.0%, all higher than those of middle school students. Among vocational school students, these figures were even higher at 30.3%, 14.7%, and 4.5%, with male vocational school students reaching 43.2%, 23.3%, and 7.1%.

The survey results also indicated that exposure to secondhand smoke among middle school students has improved, but remains serious, with instances of teachers smoking on campus still present. Compared to 2014, the proportion of middle school students who saw someone smoking at home, in indoor public places, outdoor public places, or on public transport in the past seven days has significantly decreased, with an overall decline of 9.7 percentage points, yet still at a high 63.2%. The proportions of students seeing someone smoking on campus in the past 30 days and seeing teachers smoking almost every day at school were 45.2% and 8.5%, respectively, both showing a decrease compared to 2014. High school and vocational school students reported higher proportions of seeing someone smoking in the aforementioned four categories of places, at 72.0% and 67.3%; in the past 30 days, the proportions of seeing someone smoking on campus were 57.3% and 58.6%, and the proportions of seeing teachers smoking almost every day were 13.0% and 9.4%.

Progress has been made in school tobacco control health education, but the awareness level among middle school students regarding smoking addiction urgently needs improvement. The proportion of middle school students who learned about the specific health hazards of tobacco use in class in the past 12 months was 58.6%, an increase compared to 2014. The proportions for regular high school and vocational school students were 51.3% and 60.0%, respectively. Only 35.0%, 25.6%, and 26.2% of middle school, regular high school, and vocational school students believe that it is difficult to quit once they start smoking.

The survey also found that factors influencing smoking among middle school students are still widespread. Firstly, the law prohibiting the sale of tobacco to minors has not been effectively enforced. The proportion of middle school, regular high school, and vocational school students who were not refused when trying to buy cigarettes due to age was as high as 76.5%, 87.6%, and 87.6%, respectively.

Secondly, cigarettes have become increasingly "affordable." The proportion of middle school, regular high school, and vocational school students who spent over 10 yuan on their last purchase of 20 cigarettes was 70.6%, 85.3%, and 77.0%, with average prices higher than those for adults. Meanwhile, 7.3% of middle school students, 2.8% of regular high school students, and 2.3% of vocational school students reported that the price of the cigarettes they bought was 5 yuan or less, with some even below 3 yuan.

Thirdly, tobacco advertising, promotions, and sponsorship activities are still widespread. In the past 30 days, the proportions of middle school, regular high school, and vocational school students who saw tobacco product advertisements or promotions at tobacco retail points were 48.9%, 42.0%, and 46.7%, respectively; among those who used the internet in the past 30 days, the proportions who saw tobacco product advertisements or videos online were 23.2%, 21.4%, and 27.7%; the proportions who received free tobacco products from tobacco company staff were 2.0%, 2.1%, and 2.8%; at the same time, 16.2% of middle school smoking students, 8.8% of regular high school smoking students, and 3.7% of vocational school smoking students reported that their last cigarette purchase was by the "stick."

Fourthly, smoking scenes in films and television shows have not been effectively controlled. In the past 30 days, the proportions of middle school, regular high school, and vocational school students who reported seeing someone smoking on television, video, or in movies were 69.5%, 72.9%, and 77.4%, respectively.