A Cross-Sectional Survey on Prevalence and Behaviour of Smokeless Tobacco Use Among Tobacco Users in China

In general, tobacco users in those China cities were mainly smoking traditional cigarettes at the time of this survey, while e-cigarettes had a certain popularity among young people and women in the first-tier cities. This was followed by cigars and heated tobacco products. ST prevalence in the first-tier cities was at 2.8% (Table 1).

The majority of the tobacco users who reported mixed tobacco use, used traditional cigarettes more frequently than other types of tobacco products (Table 1). Among dual users who used both ST and cigarettes, the proportion of ST use was 42.4% (Table 2). In the mixed use of ST, cigarettes, and electronic cigarettes, the ST use ratio (31.7%) was slightly higher than the use of electronic cigarettes (29.1%), but less than of cigarettes (39.1%). In the dual use of electronic cigarettes and ST, ST use was 57.5%. Table 1 shows that the 91.4% (2052 of 2246) male smokers and the 91.8% (692 of 745) female smokers. The two percentage numbers were calculated from the two datasets and hence the proportion of men and women who used traditional cigarettes was similar, although there is a large difference in the number of men and women surveyed. The majority of mixed tobacco users combined cigarette smoking with either e-cigarettes and/or ST use, although this work did not distinguish them.

As with the Chinese cigarette smokers, the majority of ST users were male; still the 32.1% of female ST users was sinificantly higher than their equivalent in female cigarette users (Table 3). In terms of age groups, those aged 30–39 were the largest group, accounting for 53.3%; this was followed by those aged 18–29, accounting for 30.6%, and finally the users aged 40–60, accounting for 16.1%. In terms of household income level, ST users generally had a higher income level. In terms of educational level, ST users were primarily those with a college degree or higher. In terms of occupation, the proportion of ST users in management positions of private enterprises was relatively high.

The FTND-ST score results were used to measure the level of nicotine dependence on smokeless tobacco products in each of the population group surveyed. There was no significant difference (p > 0.05) in the degree of nicotine dependence between the first-tier cities and the second-tier cities (Table 4). The nicotine dependence for the 18–29 years old group was significantly higher than that of the other age groups (p < 0.05), and the degree of nicotine dependence for the female group appeared to be significantly higher than that of the male group (p < 0.05). The effects of age and gender on the FTND-ST scores were investigated. The results showed that the overall differences of average FTND-ST score among age categories was significant (p = 2.1 ×10⁻⁷), while the 18–29 age group possessed the highest (5.9) average score. The average FTND-ST score of the female group was significantly higher than that of male participants (p = 0.010).

For the 801 adult ST users, the results indicated that the use of ST was consistent with the degree of nicotine dependence and their need for relieving nicotine craving. The ST users’ dependence increased over time, which was significantly positively correlated with the FTND-ST score. The FTND score of Chinese daily smokers was 3.49 (95% CI: 3.35–3.63), and the average FTND-ST score of ST users (5.29) was thus higher than that of smokers of traditional cigarettes. This indicated that the dual use of cigarettes and ST products could result in a higher a higher degree of nicotine dependence and a potentially higher toxicant intake, this has been reported by previous researchers (49, 50).

ST products were mainly used at home, commuting to and from work, traveling, at work places, in catering and entertainment venues, and in meetings and other places where it was inconvenient, impolite or illegal to use cigarettes (Figure 1). In the first-tier cities, young people and female users were most likely to use ST on these occasions mentioned above.

Figure 1.

The respondents with the number of 801 who used the ST products daily were mostly concerned about the taste and the rewarding effects of the ST used, followed by the convenience of carrying them and their perceived image (Table 5). Young people were most concerned about the taste and place of production, while the older people were more concerned about the taste and nicotine impact. Men paid more attention to the taste, nicotine's physiological strength, and the packaging than women, who paid more attention to the product reputation and the origin of production.

Regarding the physiological strength of ST, 75.0% of the consumers interviewed in the survey preferred the moderate nicotine strength. Physiological intensity was closely related to the nicotine content. Of the ST users, 86.1% users preferred ST with a nicotine content of less than 20 mg/g of tobacco, of which 58.6% preferred products with 1–10 mg/g nicotine (Table 6). The first-tier population group and the female group were more inclined to use products with a nicotine content of less than 10 mg/g and the use rate was 67.3% and 69.2%, respectively. The products used were mainly snus type. A subset of the samples was tested for nicotine concentrations and was found to be within 7–19 mg/g of tobacco (wet weight basis). It could be seen that the actual samples brought into the Chinese market were consistent with what the consumers preferred in the survey.

Swedish ST products were favoured by the vast majority of the consumers surveyed (Figure 2). The main reason was that Swedish ST products were believed to be safer and more reliable with better quality and advanced production technology. The main reason that the consumers cited in preferring Chinese made ST products was the convenience of purchase.

Figure 2.

As 91.0% of the ST users in this survey were dual or multiple tobacco product users, it was difficult to ascertain the process leading to mainly or exclusively smokeless usage. Nevertheless, such questions were asked among the 9.0% of the users reported using ST exclusively. Most dual users of the survey consumed ST on occasions where cigarette smoking was not possible. Among the consumers who exclusively used ST, 19.4% of the users developed their habit using ST products exclusively from the beginning, while the other 80.6% of the users switched from either dual or multiple tobacco usage.

The switching time was based on the participants’ answers on how long did it took them to use ST: 0–1 month, 1–2 months, 2–3 months, 4–6 months, and longer than 6 months. The switching time to the exclusive use for this group varied greatly, with the average time being about 3 months.

We identified six main occasions for the consumers to try ST for the first time; the most common occasion resulted from it being a recommendation by peers/friends/family members, the second trying in response to the introduction of smoking restrictions, and the third being a response to new cultural trends (Figure 3).

Figure 3.

The remaining reasons, mentioned in the order of prevalence, were: trying stronger tobacco products, quitting smoking or cutting down the number of cigarettes smoked, and finally following social media recommendations. The main opportunity for the ST users of all the different ages to try ST for the first time was through friends/family member/peers (more than 58%). The main factor was to adapt to non-smoking occasions (p < 0.05, 95% CI: 0.10–0.30; p < 0.05, 95% CI: 0.04–0.21), quitting/replacing smoking (p < 0.05, 95% CI: 0.06, 0.20; p < 0.05, 95% CI: 0.02–0.14) predominantly for people aged 40–60, while young people aged 18–29 (p < 0.05, 95% CI: 0.04–0.16; p < 0.05, 95% CI: 0.03–0.17) were most likely to state their main reason as to following new trends or social media. These results on the pattern of ST use should be considered as a transient rather than an established ST phenomenon.

There were many reasons given on why the ST users used ST. Aside from the refreshing effect and relieving nicotine craving, the fact that ST need not to be ignited, creates no second-hand smoke, is more environmentally friendly, and is suitable for many occasions also attracts tobacco users to use it (Figure 4).

Figure 4.

In addition, ST users reported being initially attracted by the choices of taste, small packaging, ease of carry, and ease of use. Additional reason to use ST products was for health and to help with smoking cessation. More young users aged 18–29 (p = 1.8 × 10⁻⁸, 95% CI: 0.16–0.32; p = 0.00009, 95% CI: 0.10–0.29) and female users (p = 0.0002) stated that smokeless tobacco was a way to refresh themselves. More men than women used smokeless tobacco for claimed health reasons (p = 0.012, 95% CI: 0.046, 0.171) and to help them quit smoking (p = 0.014, 95% CI: 0.080, 0.184).

As the prevalence of ST was low in China at the time of this survey, the purchase channels were also relatively limited, mainly through e-commerce and agent purchase (Supplement, Figure 1). Most of those who bought from e-commerce channels were residents of the first-tier cities (p < 0.05), young people (p < 0.05), and women (p < 0.05).

The most popular brands among Chinese consumers were Lyft, General, and Ettan, especially in first-tier cities (Supplement, Figure 2). The brands Lyft and Ettan were more popular among women, while the brand General was more popular among the male consumers. Lyft launched a new white non-tobacco oral nicotine product, featuring a white nicotine-salt flavoured composite within a pouch. Ettan and General were traditional Swedish snus products, reported to contain 7.20 mg/g and 7.38 mg/g of nicotine, respectively.

This study has shown that although the prevalence of ST products in China is low, it is increasing, at around 2.07% in the first-tier cities. This contrasted the 4% usage rate for the U.S. tobacco users reported by the WHO in 2010 (37). In addition, the 2018 global adult tobacco survey found that the proportion of Chinese consumers using tobacco-free products was 0.9%, which was not significantly different from the statistical results we obtained through this study (38). In the Nordic region, from 2010 to 2018 (39, 40) the daily smoking rate among young people dropped from 5.9% to 1.5%, while the daily ST use rate rose from 13.4% to 19.9%. In Norway, ST use among women almost doubled during that period, from 10.9% to 19.2% (41). In Sweden, data from 2003 to 2011 (42) (n = 60,675) showed that 17.6% of men and 8.2% of women used ST (43). In contrast, in Finland, data from 1999 to 2010 (7, 11, 38) (n = 1,971) showed that 14.1% of men and 2.7% of women used ST (45). Therefore, from tobacco control perspective it is important to monitor the prevalence of ST use in China as the country increases its efforts on restricting public smoking and also uses other smoking prevention measures.

The Tobacco Products Directive (2014/40/EU) bans the sale and marketing of certain types of smokeless tobacco in the European Union (EU) with the exception of Sweden (51). ST products are also very popular in the USA. As mentioned before, policies relating to ST control has been a grey area in China as far as marketing and sales are concerned. Since the implementation of the “Public Places Smoking Regulations Act” in 2014, the potential for ST market in China appeared to increase, as reflected by the evidence gathered in this study, and thus deserved careful consideration. Our data also showed that young people and women were more likely to seek and use ST products in China. Among the factors investigated behind the 2.07% ST prevalence in China, age, income, education, and sales or purchase channels all had a significant impact on the prevalence. Comparing to markets like in African countries (47), similar factors were also found to be behind the tobacco use habits. The results in the U.S. showed that tobacco use for Christian respondents exceeded that of Muslim respondents (42). Among women, a majority of the elderly used ST and their level of education was low, which seems to be contrary to the situation in the findings in this study for the Chinese population. In terms of sales or purchase channels for ST products, oral tobacco was not listed as legal product to be sold in the Chinese market by the Tobacco Monopoly Law at the time of this survey. Therefore, the surveyed Chinese consumers chose online network (Tmall.com, JD.com), and other means to obtain STs. These channels appeared to be able to meet the demands for Chinese ST users under the current tobacco regulation.

Among tobacco users, most preferred cigarettes to ST and were also more willing to try ST than e-cigarettes. In ST markets such as Norway (38), dual use of cigarettes and ST has been low. There is evidence that more adolescents in Finland use ST, including dual use (45, 46). It is also common for former smokers to switch from one tobacco product to another because the replacement product may be considered as less harmful. In the same study, approximately one-third of former smokers reported daily use of ST, and for the non-smoker group more than 40% of ex-smokers used ST every day (47). The results of our study also showed that in most tobacco users who used multiple tobacco products, combustible cigarettes dominated. Like the ST users in these Scandinavian countries, the Chinese tobacco users who used a mix of tobacco products had a relatively high acceptance of their ST products.

The representative ST samples were analysed for the nicotine contents, which was compared with the results of population preference. The results indicated that people in first-tier cities and women were more inclined to use products with nicotine content lower than 10 mg/g, which was consistent with the results of the census range. Furthermore, the results indicated that the range of nicotine content that was preferred by the consumers was of moderate strength. Over 80% of the ST users in the survey used their ST containing less than 20 mg/g of nicotine. This may be explained by the slower nicotine metabolism in the population of Chinese Han smokers than that of Caucasian smokers (43).