INTRODUCTION

Globally in 2019, the overall number of global current smokers had reached 1.14 billion¹. Smoking tobacco use accounted for 7.69 million deaths and 200 million disability-adjusted life-years in 2019, which was one of the leading risk factors for death, especially for males¹. However, the irrational phenomenon of sharing and gifting cigarettes is still endemic.

As early as the late 15th century, tobacco was given as a gift from the Native Americans to Christopher Columbus, and soon introduced and spread in Europe². Cigarettes were used as appropriate Christmas gifts in the United States from the 1930s to the 1960s³. Since cigarettes were introduced to China, this practice has become increasingly popular across the country. China has a long history of strong influence from Confucian culture, which includes respecting superiors, emphasizing social ties (guanxi), and valuing reciprocity via gift exchange to maintain harmonious social bonds in Chinese society^4,5. Chinese tobacco manufacturers take full advantage of the cigarette gifting and sharing culture demonstrated by packs with imagery and terminology⁶. A recent online nationwide cross-sectional study showed most current smokers reported an experience of sharing (97%) and gifting (90%) cigarettes in China⁷. Understanding the determinants of cigarette sharing and gifting is an important issue for future tobacco control research. However, few empirical studies have been conducted to depict the status of cigarette sharing and gifting or examined the associated factors in China⁸.

Considering the potential hazardous effects, the assumption that cigarette sharing and gifting may promote smoking is plausibly effective through two pathways. Firstly, Health Belief Model and Cognitive Behavioral Theory both emphasize that beliefs are the key influencing factor for individual behaviors^9,10. Willingness to receive smoking-related gifts was associated with increased odds of being a smoker and exposure to secondhand smoke in China^11,12. But the mechanism how cigarette gifting beliefs influence gifting and sharing behavior, and whether these gifting behaviors in turn promote smoking behaviors is unknown. Secondly, the Behavioral Ecological Model also highlighted cultural and social factors as important determinants of behavior^11,13,14. Social participation is the process of socialization of individual behavior¹⁵. Individuals who are exposed to a wide range of social environments would learn from social norms. Social norms play a crucial role in individual behavior in China, where collectivist values are predominant¹⁵. According to Social Influence Theory and Behavioral Accessibility Theory, sharing and gifting cigarettes occurring during participation in all kinds of social activities may increase contact with cigarette smoking for both non-smokers and smokers attempting to quit¹⁵. That is why both the domestic and transnational tobacco industries promote the cigarette gifting custom in China as an essential strategy to expand tobacco marketing^4,16.

Given the fundamental differences in political, economic, societal and cultural concerns between countries, tobacco control efforts and evidence-based experience generated from foreign studies cannot be directly applicable to the situation in China. Cigarette sharing and gifting plays an important role in boosting the smoking epidemic in China. However, few studies have empirically tested the smoking behavioral outcomes attributable to cigarette gifting and sharing¹¹. Furthermore, these existing studies were restricted to qualitative studies with small sample sizes, and far from reflecting the cultural variability across different regions of China^5,7,17,18. In order to address the research gap in the existing literature on the phenomenon of cigarette sharing and gifting, quantitative studies with large sample data at the regional/provincial level are necessary to support evidence-based tobacco control practices for the consideration of cigarette gifting culture in China. The purpose of this study is to portray the patterns and prevalence of cigarette sharing and gifting, and to identify their associated factors across different regions of China, and to explore the effect of these social practices on smoking.

METHODS

RESULTS

DISCUSSION

This study depicts the phenomenon of cigarette sharing and gifting comprehensively, distinguishing the difference between actively offering and passively receiving behaviors. The prevalence of cigarette sharing and gifting in the current study was lower than that from a nationwide survey administered between 2017 and 2018⁷, but higher than that in research on tobacco utilization conducted in 2005, which indicated that over 23% of the smokers had either received or given cigarettes as gifts⁹. In addition, the International Tobacco Control (ITC) China Survey in 2007 revealed that the incidence of receiving cigarettes as a gift from the most recent cigarette acquisition was 3.5%⁸. Compared to previous studies, the distinction for inconsistent cigarette sharing and gifting prevalence might be induced by the different estimation methods, survey time, and targeting subjects. However, these data supported the assumption that cigarette sharing and gifting were still endemic in China. More interestingly, it was found that more than one-third of non-smokers (36.9%) reported they had received a single cigarette, which was similar to the results from a prior study⁷. This was also consistent with the results from the pattern of sharing cigarettes for mutual corroboration. Four-fifths of respondents reported their motivation for sharing cigarettes was to demonstrate basic meeting etiquette, welcoming guests, and social intimacy. Sharing cigarettes is a pervasive Chinese behavior in which people offer individual cigarettes to others in specific social settings, which has become an invaluable avenue for social communication²¹. That might explain why non-smokers could receive a single cigarette. In some social situations, people share cigarettes regardless of whether the recipients smoke or not. It provides caution that sharing cigarettes with non-smokers might increase the risk of boosting smoking initiation or inducing relapse.

Regarding cigarette sharing and gifting patterns, the results showed that friends were the most likely recipients of both sharing cigarettes and gifting cigarettes. At the same time, more than two-thirds of participants reported they had similar practices to their relatives. Nearly one-third would even give cigarettes to family members as a gift. These data support the assertion that gift-giving behavior has a role in maintaining family and social relationships and building social status in China⁴. Notably, more than 91% of participants in this study reported receiving gift cigarettes during festival occasions, which have become the most common occurrence. Our current quantitative data confirmed previous viewpoints that gifting cigarettes often occurs during weddings or festivals of the Chinese New Year, which cater to the tobacco companies’ marketing strategies by connoting their brands into festival values such as happiness, warmth, friendship, and celebration^4,6. Therefore, related tobacco control programs are urged to break social acceptance and change social norms toward gifting and sharing cigarettes.

Similar to the results from prior research⁷, our study also showed gender differences in the behaviors of sharing cigarettes, especially for receiving behaviors. One potential explanation may be the smoking prevalence of gender differences. Another possible explanation might be that social sharing is generally reserved for adult men and is often associated with the workplace and other professional interactions where women are by and large exempt from situations requiring cigarette sharing²¹. In line with the results generated by previous studies, married people were more likely to share and gift cigarettes than unmarried people⁷. Chinese cultural practices of family collectivism particularly reinforce the responsibility and duty of married couples during festival seasons, and gift exchanges have served important functional purposes in this regard.

The phenomenon of cigarette sharing and gifting in Shaanxi, one of the northwestern inland provinces of China, was found to be more widespread than it is in Guangdong, a highly developed coastal province in southern China. It is partially explained by the regional differences in smoking prevalence²⁵. Besides, regional differences in economic development and social culture might contribute the substantial variation. Culturally, the north has been influenced by nomadic culture and the south by an agrarian one²⁶. Generally, residents living in the south have benefited from the faster economic development. Economic imbalances and education inequality may reflect an individual’s health-related literacy and capacity to make health-conscious decisions such as tobacco use¹⁴. Meanwhile, the northern residents were deeply influenced by Confucianism which highlights etiquette. The practices for giving and receiving gifts to create relationships frequently occurs in the north of China²⁷. Moreover, north-south regional and cultural differences in psychosocial characteristics may also partially explain this disparity²⁸.

Smoking status was closely associated with cigarette sharing and gifting. From the viewpoint of Behavioral Susceptibility Theory, conducting a given behavior becomes convenient, and this behavior will gradually increase²³. Smokers would bring their own cigarettes with them where cigarettes were available to share and gift to others. Additionally, smokers tend to smoke cigarettes, especially prestigious ones with displays of social and cultural values of respect and personal honor⁴. Sharing and gifting cigarettes has been an indispensable way for smokers to gain social approbation and build and maintain interpersonal relationships. Furthermore, smokers may be more receptive and enjoyable to the cigarette culture of courtesy reciprocity than non-smokers.

The present study found that beliefs about gifting cigarettes was associated with both cigarette sharing and gifting. Thus, our research supports the strong connection between beliefs and behaviors^7,23,29. Moreover, smokers had a higher agreement on cigarette gifting than non-smokers, which in turn enhanced the relationship between smoking and cigarette gifting. Remarkably, the evidence that more than one-fifth of people still hold irrational beliefs about cigarette gifting, should be paid more attention by researchers and the authorities.

Another interesting finding in the current study disclosed that social participation was significantly associated with cigarette gifting, but not related to cigarette sharing. This finding implied that gift-giving behaviors might play a more critical role in social relationships than sharing behaviors. Meanwhile, the results align with the assumptions of the dark side of social participation, indicating that social participation in collective activities may unintentionally facilitate at-risk behaviors such as cigarette gifting behavior³⁰.

Regarding behavioral outcomes of cigarette sharing and gifting behaviors, the current study demonstrated these practices were the key contributors to smoking, as implicitly suggested by a previous study¹¹. It is noteworthy that the behavior of actively sharing cigarettes was significantly predicting smoking. Receiving a single cigarette or packs of cigarette gifts were both associated with increased odds of being a smoker, which confirmed and amplified the previous results from the male participants to general people including both genders¹¹. The results from the current study also reflected that smoking socially is frequently occurring by exchanging cigarettes.

Overall, the results of this study provided some policy implications for intervention and prevention. Firstly, the tobacco control programs in the Chinese context should not neglect the culture of cigarette sharing and gifting when introducing the experience of foreign countries in tobacco control due to the relatively rare phenomenon of these social practices in other cultures. This study may also contribute a literature basis on substance sharing and gifting for some similar cultures of other countries. Secondly, given their potential side effects on smoking, the identification of specific factors associated with cigarette sharing and gifting is beneficial when aiming to understand the onset and course of sharing and gifting behaviors, and further for preventing increases in these behaviors that may subsequently lead to more disease burden and loss from smoking. Thirdly, recognizing the key contributors to these exchanging behaviors of cigarettes is a crucial step in enhancing the efficiency of tobacco control initiatives. The perspectives from specific populations such as male and married smokers in the northern region, individual social participation, and cigarette gifting beliefs should be incorporated into the intervention measures. These include advancing public and media advocacy for ‘refusing to offer a single cigarette to others’ or ‘say No to receiving cigarette gifts’ during social participation to break the cigarettes-social reinforcement link, and changing the image of cigarette packaging with graphic warnings to change social acceptance of cigarette gifts, starting with some northern pilot studies.

CONCLUSIONS

This study provides population-based estimates of the prevalence and associated factors of cigarette gifting and sharing utilizing a large sample size across different regions of China, with subdivisions of offering and receiving behaviors. Cigarette sharing and gifting were especially pervasive among male smokers and married people in Shaanxi Province. Beliefs about cigarette gifting and its impact on sharing and gifting behaviors were confirmed. Social participation was significantly associated with cigarette gifting. The potentially harmful behavioral outcomes attributable to cigarette gifting and sharing were also quantitatively assessed. Cigarette sharing behaviors and receiving gift cigarettes were found to predict tobacco use significantly. This study provides evidence-based data to support the design and implementation of pertinent tobacco control programs for the denormalization of the cigarette gifting and sharing culture.