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10.1136/bmjopen-2023-082717
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Original Research
Smoking and Tobacco
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Smoking prevalence among adults in China Mainland and their age of smoking initiation during adolescence: a national cross-sectional study
http://orcid.org/0000-0003-1679-6712
Deng Shumin 1dsm0796@163.com

https://twitter.com/h.li@whu.edu.cn
http://orcid.org/0000-0002-5155-4033
Li Hao 23h.li@whu.edu.cn

Zuo Wenjing 400033417@whu.edu.cn

Liu Zifeng 1*0liuzf@mail.sysu.edu.cn

http://orcid.org/0000-0001-9607-313X
Wu Yibo 50bjmuwuyibo@outlook.com

1 Big Data and Artificial Intelligence Center, The Third Affiliated Hospital of Sun Yat-Sen University, Guangzhou, China
2 School of Public Health, Wuhan University, Wuhan, China
3 Global Health Institute, Wuhan University, Wuhan, China
4 Taikang Medical School (School of Basic Medical Sciences), Wuhan University, Wuhan, China
5 School of Public Health, Peking University, Beijing, China
Supplemental material This content has been supplied by the author(s). It has not been vetted by BMJ Publishing Group Limited (BMJ) and may not have been peer-reviewed. Any opinions or recommendations discussed are solely those of the author(s) and are not endorsed by BMJ. BMJ disclaims all liability and responsibility arising from any reliance placed on the content. Where the content includes any translated material, BMJ does not warrant the accuracy and reliability of the translations (including but not limited to local regulations, clinical guidelines, terminology, drug names and drug dosages), and is not responsible for any error and/or omissions arising from translation and adaptation or otherwise.

None declared.

YiboWu; bjmuwuyibo@outlook.com
DrZifengLiu; liuzf@mail.sysu.edu.cn
ZL and YW contributed equally.

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18 9 2024
14 9 e08271705 12 2023
29 8 2024
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Abstract

Objectives

This study aims to calculate the national prevalence of smoking among Chinese adults and to describe the hazard of smoking initiation by age during their adolescence, as well as the disparities in sex, residence and age groups.

Design

A cross-sectional study.

Setting

The data were derived from a multistage sampling study conducted in 120 cities in China Mainland.

Participants

A total of 9963 participants aged ≥19 years were included.

Primary outcome measures

Survival analysis was used to quantify the hazards of smoking initiation by a single year of age during adolescence, and the log-rank test was used to compare the hazard curves across subgroups.

Results

The prevalence of current smoking among males and females was 27.7% and 2.0%, respectively, and 56.2% of current smokers began smoking at or before the age of 18. The hazard of smoking initiation during adolescence for females was less than 0.5%, and the hazard for males increased gradually before 14 years of age and increased sharply at age 15 (4.34%), then peaked at age 18 (6.24%). Males in rural experienced a higher hazard of smoking initiation than those in urban (χ2=5.35, p=0.02) and no such difference was found in females. By the age of 18 years, 11.7% of participants (1.8% for females and 23.4% for males) had ever smoked.

Conclusions

The prevalence of smoking among Chinese adults was lower than once reported. Males experienced higher hazards of smoking initiation at all ages than females. The hazard pattern suggests that the key focus for smoking prevention are males and adolescents aged 15–18 years, and future interventions should be delivered to the right target population at the appropriate time.

China
adolescent
behavior
health policy
Guangzhou Science and Technology Planning Project 202206080003
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pmcStrengths and limitations of this study

This study applies a survival model to analyse cross-sectional data from a national sample and examine the timing of smoking initiation during adolescence.

Smoking status and the age of smoking initiation were acquired by self-report, which may introduce recall bias or bias toward a socially desirable response.

The lack of the exact age of the participants at the time of the survey prevented this study from analysing the hazard of smoking initiation during adolescence for age ranges younger than 19 years.

Introduction

Tobacco use causes more than 8 million annual deaths and 200 million disability-adjusted life-years globally.1 2 It is a major preventable cause of morbidity and mortality worldwide. As the world’s largest producer and consumer of tobacco, China produced about 2432 billion cigarettes in 2022 and consumed approximately 40% of the world’s cigarettes.3 4 The number of deaths attributable to tobacco use in China soared from 1.5 million in 1990 to 2.4 million in 2019.2 China is facing a significant tobacco-attributable disease burden, including cardiovascular and respiratory diseases, over 20 different types of cancer and many other debilitating health conditions, as well as related economic costs (¥57–368 billion per year).5 Tobacco control in China remains a major concern for public health, and implementing culture-specific tobacco control interventions in China is of significance.

In the last few decades, proactive tobacco control policies have been promoted in China. China introduced its first tobacco control law in the early 1990s, banning advertising in print and electronic media, packaging warnings and reducing tar.6 The WHO Framework Convention on Tobacco Control came into force in China on 9 January 2006, growing public awareness of the health hazards of smoking and legalising smoking-free laws in many cities.7 In the 12th Five-Year Plan (2011-2015), the Chinese government announced the full implementation of no smoking in public places, then in 2014, Beijing passed its strictest smoking control law, banning smoking in all indoor public and workplaces.8 In 2016, government released the Healthy China 2030 plan and set a clear goal of reducing the smoking rate of people aged 15 and above to 20% by 2030.9 Although tobacco control is improving, due to the economic importance of tobacco and the opposition to controls from a state tobacco monopoly, the pace of China’s tobacco control is slow and the reduction in the smoking rate is below the global average.

A national study called China Health and Nutrition Survey reported that the smoking rate of Chinese people aged 15 years and above had decreased among males from 60.6% in 1991 to 51.6% in 2011 and among females from 4.0% to 2.9%.10 Another survey conducted by China Chronic Disease and Risk Factor Surveillance (2018) among 624 568 people aged 18–69 showed that the prevalence of current smoking was 50.8% for men and around 2% for women.11 The 2019 Global Burden of Disease Study estimated that nearly 30% of tobacco smokers globally (341 million) living in China, accounting for 24% of China’s population and it was estimated that the smoking rate among Chinese people aged 15 years and above was 49.7% in males and 3.54% in females.2 Several studies investigated the prevalence of smoking in China, while there was a paucity of national survey data since 2020 due to the COVID-19 pandemic, and most of these studies focused on the smoking rate for a certain group or district.12 13 Previous studies have shown that most adult smokers began smoking during their adolescence, and adolescent smoking often occurs due to the influence of friends, family members and advertisements, etc, which represents a high-risk period for smoking initiation and tobacco use behaviour development.14 15 The earlier smoking initiation, the higher the risk for progressing to nicotine addiction and the less likelihood of quitting.16 17 Thus, preventing early smoking initiation among adolescents is one of the most promising strategies for tobacco control.

The aim of this study was to calculate the national prevalence of smoking among Chinese adults and to describe the hazard of smoking initiation by age during their adolescence, as well as the disparities in sex and residence, using survival analysis. This study may contribute to understanding adolescent smoking dynamics and providing information for determining the best age at which to implement smoking prevention programmes.

Methods

Study design, setting and participants

In 10 July 2021 to 15 September 2021, a multistage sampling cross-sectional study was conducted across China Mainland.18 19 Specifically, the capital cities and randomly selected 2–6 other prefecture-level cities of each province and autonomous region, as well as 4 municipalities, a total of 120 cities were involved in the survey. Next, citizens aged 12 years or older were openly recruited from each chosen city by quota sampling considering gender, age and urban-rural distribution, according to the demographic characteristics derived from the ‘7th National Census in 2021’. After the sampling, the professional Wenjuanxing platform (https://www.wjx.cn/) was used to distribute questionnaires one-on-one and face-to-face with participants. Detailed inclusion and exclusion criteria for this study had been illustrated in Zhang’s article.20 A total of 11 031 valid questionnaires were collected.

Patient and public involvement

This study is a population-based survey study. Patients and public were not involved.

Measures

The national survey assessed a wide range of socio-demographic characteristics and smoking behaviours. Socio-demographic characteristics included gender, age (≤18, 19–25, 26–30 … 56–59, ≥60), place of residence (urban/rural), ethnicity (Han/minority), educational background (junior high school or below, high school and junior college, college graduate or above), marital status (married/others), occupation (retired/unoccupied/students/occupied), income ((¥), ≤3000, 3001–6000, 6001–9000, >9000) and so forth. All participants were asked and classified as current smokers (currently smoking at the time of the survey), former smokers (previously smoking but no longer smoking at the time of the survey) and non-smokers (never smoked). Current and former smokers were counted as ever smokers, and their tobacco dependence was measured by the Fagerstrom Test for Nicotine Dependence Scale, which consisted of six items shown in online supplemental appendix table 1. Each answer was coded from 0 to 3, and the total score ranged from 1 to 10 (0–3 indicated low dependence; 4–6 indicated moderate dependence; ≥7 indicated severe dependence).21 22 One of the primary variables for this analysis is the age of smoking initiation. This variable was ascertained from ever smokers by asking ‘How old were you when you smoked your first whole cigarette?’, the response options ranged from (1) ‘≤10 years old’ to (10) ‘≥19 years old’ (ie, ‘≤10 years old’, ‘11 years old’ … ‘18 years old’, ‘≥19 years old’).

Statistical analysis

Survival analysis was used to quantify the hazards of smoking initiation by a single year of age during adolescence. The reported age of first smoking was treated as time t, and the initiation of smoking as the event. Participants who had not yet initiated smoking at the time of the survey were counted as censored. The hazard of initiation at any given age H(t) was defined as the ratio of the new smokers in the age over the total numbers of non-smokers at the beginning of this age, so that it provided an estimation of an instantaneous probability of smoking initiation by age. With this modelling approach, the age of these participants at the survey time was included for analysis to fully use the information provided by these participants.23 Nevertheless, since the exact age of participants at the time of the survey, age of smoking initiation before 10 years old and after 19 years old were not accessible in the survey, only the hazards of smoking initiation at 11–18 years of age among participants over 18 years old could be accessed. Therefore, data from 9963 participants who were aged over 18 years were analysed in this study.

Plots of –log(S(t)) over age and log(–log(S(t))) against log (age) were constructed to verify empirically whether the distribution of the hazard of smoking initiation by age follows an exponential or a Weibull model.16 The log-rank test was used to test if the estimated H(t) differs by various subgroups. Given H(t) derived from the survival model, a survival function S(t) can be estimated, which is the probability that a person has been a non-smoker from birth to age t. Thus, 1–S(t) indicates an estimation of smoking prevalence by age from birth to any age t. Conceptually, the rate is a standardised smoking rate, for it is independent of the observed population age structure and can be used directly for comparisons with other samples or studies.16

Descriptive analysis was conducted to examine the distribution of demographic and smoking characteristics. Count data were presented as percentage. All statistical analyses were performed with R software V.4.0.2. Two-sided p<0.05 was considered statistically significant.

Results

Baseline characteristics of participants

Demographic characteristics of the participants are presented in table 1. Of the 9963 participants, 46.1% were males and 58.2% resided in urban areas. More than one-third (36.1%) were aged 19–30 years. Among the participants, 2156 (21.6%) reported that they had ever smoked a whole cigarette and 1380 (13.9%) were still smoking.

Table 1 Prevalence of smoking status of the participants by demographic characteristics

Variable	Total	Female (N=5372)	Male (N=4591)	
Current smokers	Former smokers	Non-smokers	Current smokers	Former smokers	Non-smokers	
N	9963 (100.0)	109 (2.0)	93 (1.7)	5170 (96.2)	1271 (27.7)	683 (14.9)	2637 (57.4)	
District								
 Northeast	308 (3.1)	10 (6.0)	8 (4.8)	150 (89.3)	45 (32.1)	25 (17.9)	70 (50.0)	
 North China	2139 (21.5)	26 (2.2)	27 (2.3)	1134 (95.5)	260 (27.3)	142 (14.9)	550 (57.8)	
 East China	3761 (37.7)	27 (1.3)	26 (1.3)	1967 (97.4)	437 (25.1)	266 (15.3)	1038 (59.6)	
 South China	541 (5.4)	8 (2.8)	7 (2.5)	267 (94.7)	68 (26.3)	29 (11.2)	162 (62.5)	
 Central China	1123 (11.3)	9 (1.5)	7 (1.1)	600 (97.4)	139 (27.4)	75 (14.8)	293 (57.8)	
 Northwest	1116 (11.2)	8 (1.4)	8 (1.4)	559 (97.2)	162 (29.9)	77 (14.2)	302 (55.8)	
 Southwest	975 (9.8)	21 (4.0)	10 (1.9)	493 (94.1)	160 (35.5)	69 (15.3)	222 (49.2)	
Residence								
 Urban	5795 (58.2)	66 (2.1)	57 (1.8)	2967 (96.0)	705 (26.1)	406 (15.0)	1594 (58.9)	
 Rural	4168 (41.8)	43 (1.9)	36 (1.6)	2203 (96.5)	566 (30.0)	277 (14.7)	1043 (55.3)	
Age (years)								
 19–30	3599 (36.1)	36 (1.8)	26 (1.3)	1994 (97.0)	279 (18.1)	82 (5.3)	1182 (76.6)	
 31–40	1732 (17.4)	26 (2.7)	18 (1.9)	911 (95.4)	246 (31.7)	76 (9.8)	455 (58.6)	
 41–50	2480 (24.9)	21 (1.6)	15 (1.1)	1298 (97.3)	404 (35.3)	185 (16.1)	557 (48.6)	
 51–59	1006 (10.1)	13 (2.8)	12 (2.6)	437 (94.6)	190 (34.9)	133 (24.4)	221 (40.6)	
 ≥60	1146 (11.5)	13 (2.3)	22 (3.9)	530 (93.8)	152 (26.2)	207 (35.6)	222 (38.2)	
Ethnic								
 Han	9399 (94.3)	99 (2.0)	86 (1.7)	4871 (96.3)	1179 (27.1)	657 (15.1)	2507 (57.7)	
 Minority	564 (5.7)	10 (3.2)	7 (2.0)	299 (94.6)	92 (37.1)	26 (10.5)	130 (52.4)	
Education background								
 Junior high school or below	2239 (22.5)	27 (2.2)	32 (2.6)	1169 (95.2)	401 (39.7)	232 (22.9)	378 (37.4)	
 High school and junior college	3009 (30.2)	35 (2.3)	38 (2.5)	1442 (95.2)	509 (34.1)	264 (17.7)	721 (48.3)	
 College graduate or above	4715 (47.3)	47 (1.8)	23 (0.9)	2559 (97.3)	361 (17.3)	187 (9.0)	1538 (73.7)	
Marital status								
 Widowed/divorced/single	3739 (37.5)	50 (2.4)	37 (1.8)	2024 (95.9)	299 (18.4)	129 (7.9)	1200 (73.7)	
 Married	6224 (62.5)	59 (1.8)	56 (1.7)	3146 (96.5)	972 (32.8)	554 (18.7)	1437 (48.5)	
Occupational status								
 Retired	883 (8.9)	8 (1.8)	18 (4.0)	423 (94.2)	102 (23.5)	157 (36.2)	175 (40.3)	
 Unoccupied	2186 (21.9)	28 (2.3)	34 (2.7)	1176 (95.0)	351 (37.0)	182 (19.2)	415 (43.8)	
 Students	2270 (22.8)	22 (1.7)	13 (1.0)	1260 (97.3)	101 (10.4)	40 (4.1)	834 (85.5)	
 Occupied	4624 (46.4)	51 (2.1)	28 (1.2)	2311 (96.7)	717 (32.1)	304 (13.6)	1213 (54.3)	
Average monthly income (￥)								
 ≤3000	2865 (28.8)	32 (1.9)	29 (1.7)	1614 (96.4)	347 (29.2)	205 (17.2)	638 (53.6)	
 3001–6000	3884 (39.0)	39 (1.9)	33 (1.6)	2034 (96.6)	495 (27.8)	258 (14.5)	1025 (57.6)	
 6001–9000	1679 (16.9)	23 (2.7)	19 (2.2)	824 (95.2)	218 (26.8)	124 (15.3)	471 (57.9)	
 >9000	1535 (15.4)	15 (2.1)	12 (1.7)	698 (96.3)	211 (26.0)	96 (11.9)	503 (62.1)	

Prevalence of smoking status

Table 1 also shows the prevalence of smoking status of male and female participants. Among 4591 male participants, 1271 (27.7%) were current smokers, 683 (14.9%) were former smokers, compared with 109 (2.0%) current smokers and 93 (1.7%) former smokers among 5372 female participants. The prevalence of former smoking among males significantly increased with age, with 5.3% in 19–30 years and 35.6% in those over 60 years old. Males aged 31–59 years had higher current smoking rates than other age groups. Males with college graduate or above education background had lower rates of current and ever smoking (17.3% and 26.3%) than those with lower education levels. Compares with occupied, unoccupied or retired participants, students had a lowest prevalence of current smoking. It also show that 56.2% of current smokers began smoking at or before the age of 18 (online supplemental table 2).

Hazards of smoking initiation by age

The estimated hazards of smoking initiation at each age using the survival model are presented in figure 1. The age pattern of estimated hazards for males was rather similar to that of the overall sample, and the hazard for females was rather low from age 11 to 18 (less than 0.5%), with a slight increase at ages 15 and 17 years. For males, however, the hazard increased gradually before 14 years of age and suddenly increased sharply at age 15 (4.34%), then peaked at age 18 (6.24%). The log-rank test indicated statistically significant gender differences in the estimated hazards of smoking initiation (χ2=2232, p<0.01).

Figure 1 Estimated age-specific hazards of smoking initiation: (A) overall sample, (B) by gender.

Figure 2 shows urban-rural differences in the estimated hazards of smoking initiation at each age of males (A) and females (B). As shown in figure 2A, males in rural experienced a significantly higher hazard of smoking initiation than those in urban areas during the age range 15–17 years (χ2=5.35, p=0.02). The urban-rural differences in females was not statistically significant (χ2=0.97, p=0.30).

Figure 2 Estimated age-specific hazards of smoking initiation by residence: (A) in males, (B) in females.

Estimated smoking rates by age

Based on the estimated age-specific hazard of smoking initiation, the cumulative rates of smoking from 10 to 18 years of age are presented in figure 3. The estimated prevalence rates of smoking showed an almost linear increase. By the age of 18 years, 11.7% of participants (1.8% for females and 23.4% for males) had ever smoked. The age patterns of smoking rates for urban and rural residents in different genders were almost the same (figure 4).

Figure 3 Cumulative smoking rate for adolescents ages 10–18: (A) overall sample, (B) by gender.

Figure 4 Cumulative smoking rate for adolescents ages 10–18 by residence: (A) in males, (B) in females.

Discussion

This study presented updated prevalence of cigarette smoking of adults in China Mainland and first examined the timing of smoking initiation during adolescence among various genders and residence groups with data from national sample of the Chinese population. As suggested by Chen and Unger,24 a survival model was applied to analyse the survey data, which has been demonstrated to be a good option for analysing smoking prevalence and initiation during adolescence with either longitudinal or cross-sectional, retrospective data.

Based on data collected from 120 cities in this national survey, the overall prevalence of current smoking in China in 2021 was 13.9%, which was far lower than 26.6% in the China Global Adult Tobacco Survey 2018 and 24% in the 2019 Global Burden of Disease Study.25 The low prevalence might be due to several reasons. On the one hand, a significant proportion of participants were females, recruited from eastern China, between the age of 19 and 30, or resided in urban areas, or had college graduate or above education background and groups with these characteristics were less likely to smoke, consistent with findings from other studies.26 27 Socioeconomic status may reflect an individual’s health-related knowledge and ability to make health-conscious decisions such as tobacco use.28 On the other hand, despite the demographic imbalance of participants, we observed lower smoking rates in almost all groups compared with previous studies.29 Hence we reckoned the decrease in prevalence could be attributed to cigarette unavailable or poor accessibility because of ‘zero Covid’ policy, which to some extent restricted people’s scope of activities. Meanwhile, people have higher awareness regarding the health risks of tobacco smoking, which might be driven by the COVID-19 pandemic and implement of tobacco control actions in the Healthy China Action Plan (2019–2030) issued on 9 July 2019.3032 As of July 2024, 24 cities legalised smoking-free laws and 15.9% of the total population (approximately 224 million people) was protected by smoke-free laws.33

The present study showed the sharp differences in the prevalence of smoking between males and females, but also revealed the gender and residence differences in smoking initiation age pattern. In line with other studies,23 it was dramatic that the smoking prevalence in males was rather high and the age pattern for males smoking initiation was almost identical to that of overall population. Males aged 31–59 years were found to have higher current smoking rates than other age groups, consistent with Zhang’s national study.11 By contrast, the smoking prevalence and hazard of smoking initiation for females were relatively low, which should be maintained or decreased. The disparity indicates that males, especially those aged 31–59 years, are still the key focus of smoking cessation and tobacco control in China.

More significantly, our study identified that the hazard of smoking initiation sharply increased after 14 years of age and peaked at ages 15 and 18, which was similar to the studies conducted in Wuhan and Southwestern China.16 23 Smoking behaviours in adolescents are associated psychosocial and physical environment and personal characteristics.34 35 The sharp increase in smoking initiation from 15 years of age might be due to the imbalance between physical maturation and cognitive development, environmental change and emerging adulthood pressure.36 37 Specifically, individuals during this age period have just been admitted to high school or college, the psychosocial and physical environment changes encourage them to be curious and experience some risky behaviours such as smoking to appear ‘grown up’, ‘cool’ and relieve stress.38 Besides, offering cigarettes to others and smoking together have been examined as established social norms among Chinese male adults, which deeply influences the way adolescents interact,39 and peer smoking has been demonstrated to be strongly associated with adolescent smoking initiation.40 In addition, we found that rural males seemed to have a higher risk of smoking initiation than urban males and the rural–urban differences in the age patterns of smoking initiation among females was not significant, suggesting that the psychological and behavioural changes of adolescents in urban or rural areas were similar. Given that more than half of current smokers in this study began smoking at or before the age of 18 and the addictive nature of tobacco products,41 adolescence is the crucial life stage for tobacco control because ‘this is the time in life (roughly ages 10 through 18 years) when onset, regular use and dependence begin’.42 Preventive interventions during adolescence generally have greater benefits than interventions to reduce smoking risk in adulthood.

Our findings highlight the necessity of population-targeted strategies to promote smoking prevention and cessation. With reference to related studies and the socioecological model of factors influencing smoking initiation and maintenance proposed by Sara et al,4348 following tobacco control approaches are urgently needed: (1) Implement existing tobacco control policies more effectively. Specifically, increase the size of pictorial warnings to warn about the dangers of tobacco, and effectively enforce existing bans on tobacco sales and tobacco adverting to reduce the accessibility of tobacco to adolescents. (2) Create and extend more completely smoke-free public places through smoke-free legislation to reduce youth smoking and protect people from secondhand smoke. (3) Encourage setting up smoking cessation clinics and quit lines to provide smoking cessation services. (4) Set a ban on smoking in the home and school, for adolescents initiating cigarettes was found to be associated with the smoking behaviours of household members, teachers and peers. (5) Enforce antismoking communication and health education from senior elementary school to college, and strengthen adolescents’ self-control to resist temptation, so as to dissuade adolescents from cigarette initiation.

The nationally representative samples of this study were recruited from 120 cities with a diverse range of socio-demographic characteristics, and the findings provide important information on the prevalence of smoking among adults in China Mainland, as well as essential enlightenment for tobacco control on adolescents. However, there are several limitations. First, analysis on the age of smoking initiation here was based on cross-sectional data, and the results may not be as convincing as those from longitudinal data. Second, the log-rank test cannot provide information about the strength or magnitude of risk between the groups being compared. Third, smoking status and the age of smoking initiation were acquired by self-report, which may introduce recall bias or bias toward a socially desirable response,49 while the anonymous questionnaire might reduce these concerns. Further, the lack of the exact age of the participants at the time of the survey prevented this study from analysing the hazard of smoking initiation during adolescence for age ranges younger than 19 years, though participants in that age range accounted for 9.7% (1068/11031) of total participants recruited.

Conclusions

This study is the first to examine the hazard of smoking initiation by age during adolescence with data from a national sample around China Mainland. Findings of this study showed quite low smoking prevalence among Chinese adults, suggesting that Chinese government has made effective progress on tobacco control in the long run. Smoking was more prevalent among participants of lower educational backgrounds and less income, ethnic minorities and those residing in rural areas. Additionally, males experienced higher hazards of smoking initiation at all ages than females, and the findings suggested that 15–18 years of age was the crucial time for smoking prevention, thus intervention programmes should be delivered to the right target population at the appropriate time for better effect.

supplementary material

10.1136/bmjopen-2023-082717 online supplemental file 1

10.1136/bmjopen-2023-082717 online supplemental file 2

Acknowledgements

The authors sincerely thank all the participants of the study.

Data availability statement

Data are available upon reasonable request.

Review Process File
18 09 2024

Funding: This study was supported by the fund of Guangzhou Science and Technology Planning Project (No. 202206080003).

Prepub: Prepublication history and additional supplemental material for this paper are available online. To view these files, please visit the journal online (https://doi.org/10.1136/bmjopen-2023-082717 ).

Provenance and peer review: Not commissioned; externally peer reviewed.

Patient consent for publication: Not applicable.

Ethics approval: The study was approved by the Institutional Review Committee of Jinan University, Guangzhou, China (JNUKY-2021-018). Participants gave informed consent to participate in the study before taking part.

Data availability free text: The data sets analysed during the current study are available from the corresponding author on reasonable request.

Patient and public involvement: Patients and/or the public were not involved in the design, or conduct, or reporting, or dissemination plans of this research.
==== Refs
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