The report on the baseline survey of CMB- China Medical Tobacco Initiative School of Public Health, Sichuan University

Contents 1 Background 2 Methods 3 Results 4 Conclusions 5 Suggestions 6 Challenges

Tobacco consumption is a critical public health problem in China. Behaviors of doctors, teachers, political leaders and celebrities play a very important role in tobacco control CMB initiated “China Medical Tobacco Initiative” in 2010, interventional means of tobacco consumption were carried out in medical college of 13 universities around China, to support further implementation of tobacco control around China

1 Background 2 Methods 3 Results 4 Conclusions 5 Suggestions 6 Challenges

Subjects ： Universities : 13 CMB-grantee universities 3 Control universities Populations : Male students (2nd and 3rd-year students major in medicine) Male teachers (work on teaching or researching) Male doctors (physician, surgeon, gynecologist, pediatrician)

Sampling ： Questionnaire survey : cluster sampling Environmental observation: simple random sampling

Survey methods ： questionnaire survey environmental observation tobacco control material reference group discussion on specific topics

Contents tobacco use cessation exposure to second-hand smoking awareness of tobacco harm attitude to tobacco control tobacco control regulation tobacco advertisement and sponsorship Questionnaire survey Environmental observation Policy evaluation campus environment hospital environment estimation on smokers implementation of tobacco control

PopulationSurvey number Response rate (%) Student Teacher Doctor Table1. The response rate of each population The response rate of questionnaire survey for each population is showed in the following table:

1 Background 2 Methods 3 Results 4 Conclusions 5 Suggestions 6 Challenges

Tobacco Use

Universities StudentTeacherDoctor CMB-grantee Universities Tibetan University Ningxia Medical University Xi'an Jiaotong University Sichuan University Jiujiang College Zhongnan University Harbin Medical University Fudan University China Medical University Peking Union Medical College Zhongshan University Peking University — Zhejiang University Control Universities Chengdu Medical College Beijing TCM Medical College Hangzhou Normal University Table 1: Smoking Prevalence of differnt Groups(%)

Smoking rates of all groups from most CMB-grantee universities is lower than general male, while the smoking rates from several universities are comparatively high (compared with the result of the fourth National Health Service Survey, the smoking rate of male population aged between years old is 14.9%, and that of the general male population is 48.0%).

（%）（%） Smoking Prevalence among all population groups in CMB- grantee universities are all lower than those in control universities

Among the CMB-grantee universities, the smoking rate in prestige schools is lower than that in non- prestige schools (%)

In CMB-grantee universities ： More than half students have experience of smoking, among which 30% have smoked a whole cigarette after their entry in college. Regional Difference E.g among medical students from prestige universities: smoking rate in western region is the highest, and then the north-eastern region.

Cessation

more than 60% smokers of all groups plan to quit smoking rates of quiting from smoking or quitting for more than 2 years among smokers of all groups is low The relapse rates of all groups are about 79% （%）（%） In CMB-grantee universities:

Second-hand Smoking Exposure

The second-hand smoking exposure rate among students from CMB-grantee universities is lower than that from control universities. （%）（%）

Among CMB-grantee universities: second-hand smoking exposure rate among students from prestige universities is lower than that from non-prestige universities （%）（%）

In CMB-grantee universities, Teaching Building and Administration Building are the main location of students and teachers’ second-hand smoking exposure （%）（%）

In the affiliated hospital of CMB-grantee universities, Outpatients Department /Inpatients Building are the main location of second-hand smoking exposure （%）（%）

Awareness of tobacco harm

（%）（%） （%）（%） In CMB-grantee universities : Only 27.6% students are aware that smoking can cause stroke, heart attack and lung cancer; 44.2% students are aware that second-hand smoking can cause adult heart attack, lung cancer and children lung diseases

In CMB-grantee universities : 47.4% teachers are aware that smoking can cause stroke, heart attack and lung cancer; 52.9% teachers are aware that second-hand smoking can cause adult heart attack, lung cancer and children lung diseases （%）（%） （%）（%）

In affiliated hospitals of CMB-grantee universities, about 30% doctors are not fully aware the harm of smoking and second- hand smoking exposure （%）（%） （%）（%）

Attitude toward tobacco control

76.8% students, 84.5% teachers and 87.5% doctors agree that it is their own responsibility to reject smoking 83.2% students, 89.4% teachers and 91.7% doctors agree that their own group should play a main role in tobacco control campaign 80.6% students, 79.8% teachers and 88.3% doctors agree that their own group are responsible for persuading public to quit smoking In CMB-grantee universities :

31 However More than 80% students agree that smoking can ease stress and anxiety More than 60% students agree that smoking can bring excitement and pleasure About 30% students agree that smoking can express their personality

Tobacco Advertisement and Sponsorship

Within previous 30 days, 22.0% students, 13.8% teachers and 19.2% doctors of project colleges have noticed tobacco advertisements or events sponsored by tobacco companies on campus/in hospitals

Results of Environmental Observation

Campus environment In CMB-grantee universities: rare to find smokers at tobacco control focus locations The proportion of finding cigarette butts in the following locations are higher than that of other locations: corridors/stairs of teaching building outside the teaching building gates corridors/stairs of the teachers' office building outside the male students' dorm building In CMB-grantee universities: corridors/stairs and male bathrooms in teaching buildings are main locations for tobacco control signal displaying, less are found in other locations Teachers' office and meeting rooms of teaching building in some CMB- grantee universities are placed with ash tray

Hospital Environment In the affiliated hospitals of CMB-grantee universities, it is rare to find smokers at tobacco control focus locations, except for the hospital yards In the affiliated hospitals of CMB-grantee universities, the proportion of finding tobacco control signals are higher at the corridors/stairs of the outpatients department and in-patients department In the affiliated hospitals of CMB-grantee universities, the proportion of finding cigarette butts are higher at corridors/stairs of the outpatient department and in-patients department and the hospital yards In the CMB-grantee universities: ash trays are placed in a few offices and meeting rooms within the outpatient department and in-patients department buildings

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Estimation of different groups’ smoking status and policy evaluation

Estimation of different groups' smoking status In most CMB-grantee universities, the smoking rates of students are low, except for some overseas students from few universities The smoking rate of older teachers is higher than that of the younger ones. The smoking rate of the administrative staff is higher than that of teachers in lecturing and researching positions Within hospitals, doctors with more pressure smoke more, for example, surgeons smoke more than internal medicine physicians

Situation of tobacco control Most CMB-grantee universities and their affiliated hospitals have held tobacco control campaign before this project Works after the initiation of this projects include: Established and improved the organizing committee for tobacco control Established certain tobacco control policies, evaluation, rewards and punishment system Established policies to encourage and help smokers to quit smoking Rejected inquiries from tobacco companies on campus and in hospitals Other special tobacco control activities

Analysis of factors related with smoking behavior

Factors which influenced students' smoking behavior include: Nationality prestige universities or not Smoking behavior of parents Smoking behavior of best friends attitude toward smoking of people around

Factors which influenced teachers' smoking behavior include: institutions (departments) prestige universities or not own attitude toward tobacco control co-workers' attitude toward smoking

Factors which influenced doctors' smoking behavior include: Whether the affiliated hospitals is of prestige universities or not own attitude toward tobacco control co-workers' attitude toward smoking

1 Background 2 Methods 3 Results 4 Conclusions 5 Suggestions 6 Challenges

General smoking rates of different groups from CMB-grantee universities are lower than that of general public, but some subject groups in CMB-grantee universities have serious smoking problem There are regional and prestige or non-prestige difference among CMB-grantee universities Non-smokers are seriously exposed to second-hand smoking, teaching building, office building and hospital outpatient/inpatient department buildings are the main locations of second-hand smoking exposure The situation of relapse is serious among subjects who have quitted smoking

Our survey subjects have certain awareness of the harm of smoking and second-hand smoking exposure, but their knowledge is not comprehensive The attitude towards tobacco control of our survey subjects is inconsistent The awareness and attitude toward harm of smoking are inconsistent with their behaviors Some non-smoking students may become smokers Some of the CMB-grantee universities and their affiliated hospitals need to improve their policy on tobacco control, and strength policy promotion and implementation Some CMB-grantee universities and their affiliated hospitals’ environment need to reinforce tobacco control

Problems during the tobacco control campaign in universities Focus on advocating and persuading, lack in constrain by policy and policy implementation Campus tobacco control focus on students, but neglect teachers Smoking rate among administrative staff is comparatively high Tobacco control activities are scattered, without consistence

1 Background 2 Methods 3 Results 4 Conclusions 5 Suggestions 6 Challenges

Put tobacco control campaigns in western and non-prestige medical universities as priority Further Planning and integration on tobacco control strategy and policies University leaders should be good examples on tobacco control, administrative staff should be the focus of the campaign Tobacco control activities targeting teachers and doctors should be prior to those to students Use evidence-based and vivid health education to improve teachers, doctors and students' awareness of the harm of smoking

Open tobacco control courses and lectures and adapt them into teaching plan of the universities Use effective measures to prevent people who have quitted smoking from relapse Motivate and support non-smokers to defend their rights of not being harmed by smoking To decrease second-hand smoking exposure, adapt some Transitional measures: for example, set up smoking area within hospitals Strengthening the anti-tobacco environment construction Improve tobacco control policy, reinforce their implementation

1 Background 2 Methods 3 Results 4 Conclusions 5 Suggestions 6 Challenges

Without official legislation of tobacco control in China, it is difficult to implement the tobacco control policies effectively in universities and hospitals There is no national legislation to forbid smoking in any public area or working area indoors There is no law to prevent second-hand smoking exposure There are legal constrains to prevent tobacco advertisements, but laws cannot prevent some "invisible" advertisements from tobacco companies

Patients and their family members are the main problem in tobacco control within hospitals Principles and policies from the hospitals mainly target medical workers The hospital principles are not legally binding which cannot constrain the behaviors of the patients and their family members It is hard to manage due to the patients' large number and mobility