Geographical inequality in tobacco control in China : multilevel evidence from 98,058 participants

Background: We investigated the spatial patterning and correlates of tobacco smoking, exposure to second-hand smoke, smoking in public places, workplace smoking prohibition, proand counter-tobacco advertisements in mainland China. Methods: Choropleth maps and multilevel models were used to assess geographical variation and correlates of the aforementioned outcome variables for 98,058 participants across 31 provinces of China in 2010. Results: Current tobacco smoking prevalence was higher in the central provinces for men and in the north eastern provinces and Tibet for women. Second-hand smoke was higher for both genders in Qinghai and Hunan provinces. Workplace tobacco restrictions was higher in the north and east, whereas smoking in public places was more common in the west, central and far northeast. Pro-tobacco advertising was observed in public places more often by men (18.5%) than women (13.1%). Men (35.5%) were also more likely to sight counter-tobacco advertising in public places than women (30.1%). Awareness of workplace tobacco restrictions was more common in affluent urban areas. Lower awareness of workplace tobacco restrictions was in less affluent urban and rural areas. Sightings of tobacco smoking in public places was highest in restaurants (80.4% for men, 75.0% for women) and also commonly reported in less affluent urban and rural areas. Exposure to second-hand smoke was lower among women (but not men) where workplace tobacco restrictions was more common and higher regardless of gender in areas where smoking in public places was more commonly observed. Conclusions: Geographical and gender-sensitive targeting of tobacco prevention and control initiatives are warranted.