The World Health Organization reported that approximately 1.3 billion people smoke, of which more than five million people die globally each year because of smoking. More than 80% of tobacco-attributable deaths are predicted to occur in developing countries [1
]. China, as the largest developing country in the world, is also the largest producer and consumer of tobacco, accounting for approximately 40% of the global production and one-third of the global consumption [2
]. Treatment of smoking-related diseases accounts for almost 6% of the total medical expenses in China [3
Tobacco use is one of the behavioral risk factors for many chronic diseases, including cardiovascular diseases, diabetes, and inflammatory diseases [4
]. One in six chronic disease deaths is caused by tobacco use [6
]. Scholars have proposed effective interventions to reduce the prevalence of chronic diseases, of which tobacco control is identified as the most urgent and immediate priority [6
]. The three main pillars of chronic disease prevention are healthy diet, physical activity, and avoidance of tobacco smoking [8
]. On the one hand, the occurrence of chronic diseases can be prevented if people do not smoke. On the other hand, chronically ill residents who have been smokers can manage their disease well if they quit smoking successfully. However, smoking prevalence among residents with chronic diseases has not been properly documented [9
Chronic diseases are becoming a serious public health concern in China [10
]. The prevalence of chronic diseases is rapidly increasing in rural areas, especially in rural western China which is characterized by low economic status, inadequate health resources, and distinctive historical and cultural backgrounds [11
]. Previous studies attributed the low health literacy and some health-related risk factors (tobacco use, drinking, lack of exercise, unreasonable dietary structure) as the important contributors to chronic diseases [13
]. For example, rural residents in the northwest minority areas of China smoke heavily and consume alcohol excessively because of the cold living environment [15
]. Considering that smoking behavior is one of the risk factors for chronic diseases, this study aims to investigate the smoking prevalence and behavior of smokers with chronic diseases in rural western China.
Studies reported the smoking prevalence in different populations, such as migrant workers [16
] and medical students [18
], in China and examined the determinants of tobacco smoking. However, minimal information is known about smoking prevalence in patients with chronic diseases and the factors affecting smoking behavior in rural China. Several studies also presented triggers for quitting smoking and factors associated with smoking cessation [19
]. However, factors contributing to successfully quitting smoking among the chronically ill have yet to be characterized. This study aims to investigate smoking prevalence in chronically ill residents and their smoking behavior in western rural China. We also identified factors associated with success in quitting smoking to provide appropriate intervention strategies for tobacco control.
Our study shows that the current smoking prevalence among chronically ill residents is 26.2%. Furthermore, 48.3% and 2.1% of the male and female patients were currently smoking cigarettes, respectively. The gender difference in smoking prevalence in our sample is similar to that reported in previous studies [31
]. The current smoking prevalence among males in this study is lower than that of the national prevalence reported in the 2010 Global Adult Tobacco Survey (52.9%) [33
]. Another study reported a higher smoking rate in the rural male population (66.8%) compared with urban residents (56.5%) [34
]. However, in the present study, the number of current smokers with chronic diseases in rural areas is lower than that of the general population. This finding could be due to age structure and health status. In the present study, patients with chronic diseases surveyed were mostly middle-aged and elderly people because many young rural laborers move to urban areas to find jobs. These patients experienced multiple health issues. One study, which was designed to evaluate national-level tobacco control policies, reported the smoking rate of Chinese residents aged 55 and older was 33.4% [35
Among chronically ill patients, those in rural areas with a relatively high educational level were likely to smoke. This result differs from a previous study that showed rural residents with a low educational level and those who engage in farm labor were likely to smoke [36
]. The discrepancy could be due to the fact that residents with a high educational level have more demands for social interactions through cigarette smoking, which is known as a traditional Chinese gesture of goodwill. In addition, patients who did not take a physical examination and medicine on time were likely to smoke. This observation indicates that health literacy is a significant factor affecting smoking prevalence. Health literacy is composed of a complex set of skills, including making decisions that are helpful to health-related problem-solving [37
]. Improved health literacy is associated with reductions in risk behaviors (including smoking behavior) for chronic diseases [38
]. Therefore, health education and promotion programs should be delivered continuously and should focus on changes in health behavior.
Approximately 64.3% of ever smokers with chronic diseases attempted to quit smoking, 21.0% of which successfully quit. These two rates are higher than those reported in other studies targeting the general population; that is, approximately 20% to 25% of smokers attempted to quit but approximately half of them relapsed [31
], whereas only 11% of smokers quit smoking successfully [33
]. This result could be attributed to the fact that smokers with chronic diseases exhibited increased willingness to quit smoking and manifested more health concerns than ordinary people. We also found more than a third of current smokers with chronic diseases consume less than five cigarettes per day. It indicates that the degree of tobacco dependence of these smokers may not be very serious, and there are many potential possibilities to help them quit smoking. More research is needed into how to help the smokers with chronic diseases quit smoking by using tobacco-dependence treatment programs.
The primary reason for attempting to quit smoking among chronically ill patients is the effect on disease. Similarly, a previous study showed that health concerns are the foremost trigger for quitting or attempting to quit [19
]. However, we found that the patients easily become failed quitters if they have other diseases in addition to one chronic disease. Hence, chronically ill patients will be inclined to refuse to stop smoking when they suffer from several diseases at the same time. Comorbidity of diseases is a significant factor in the quitting process. We can infer that smoking is regarded as a way to relieve pain and smokers exhibit a negative attitude toward the health effects of smoking cessation. Moreover, a doctor’s advice is the second reason for quitting or attempting to quit smoking. Intervention and smoking cessation advice offered by medical professionals significantly affect the smoking behavior of patients [40
The regression model showed that smokers who were always restricted to smoking in public places are likely to quit smoking successfully. Although the state of existing tobacco control regulations in China and their enforcement remain at an early stage [41
], the effectiveness of tobacco control regulations in public places is supported by the results of this study. Smoking restrictions in public places can raise awareness of the health risks of smoking. Such restrictions can encourage smokers to attempt to quit [42
]. Therefore, the government needs to strengthen measures for controlling tobacco smoking in public places, especially in rural medical institutions. Current smokers with chronic diseases can improve their awareness about the health effects of smoking by accessing health services.
Although we tried to find the differences between failed and successful quitters among chronically ill patients, the missing distinction between daily and occasional smokers may introduce a bias in the comparative analyses. Participants who successfully stopped smoking daily and cut down to occasional smoking were denominated as failures, although they made a more qualified achievement and yielded greater health benefits than those “successful quitters” who just stopped occasional smoking. Therefore, future studies may further investigate the differences between daily and occasional smokers, and identify the factors associated with different stages or degrees of quitting smoking.
This study presents several limitations. First, the category “current smokers” might cause unanticipated ambiguity in the smoking status subcategories, and the missing distinction between daily and occasional smokers might influence the disparities in other variables. Second, the variables for smokers in the questionnaire are incomplete, because the object of this survey was mainly to investigate the health knowledge and behavior of patients with chronic diseases, as well as their health services utilization. The smoking condition is only a part of the investigation, and some relevant questions were not included. Third, the survey results only included patients with chronic hypertension or diabetes, and other chronic diseases were not studied. Fourth, the multicollinearity of the independent variables was not checked. Moreover, the sample size of this study was small because of the low population density and the complex terrain. Lastly, the health knowledge level may suffer from information bias caused by the use of close-ended questions, which may have allowed patients to guess the correct answer.
Tobacco use is one of the behavioral risk factors for many chronic diseases. In this study, we determined smoking prevalence in chronically ill residents and identified factors associated with success in quitting smoking in western rural China. The study revealed that the current smoking prevalence in patients with chronic diseases is low when compared to the general population. Moreover, the success rate of smoking cessation is higher in the studied population than that in the general population. In addition, if smokers with chronic diseases do not have comorbidity of diseases or they are restricted to smoking in public places, these smokers are likely to quit smoking successfully. This study suggests that health literacy, comorbidity of diseases, and psychological counseling should be considered when developing targeted tobacco prevention strategies. The government also needs to strengthen tobacco control measures in public places, especially in rural medical institutions.