Objective The purpose of this study was to determine to what extent Chinese media coverage of tobacco issues in 17 Chinese cities comprises messaging known to motivate healthy behaviour.
Methods This study involved a content analysis of 4821 articles that contained at least one full paragraph focused on tobacco issues from newspapers published in cities that participated in the Tobacco-Free City—Gates Tobacco Control Project in China between 1 January 2008 and 30 June 2011.
Results The number of tobacco-focused articles increased over the study period. The number of articles varied considerably among different newspapers and cities. Education, prevention and cessation programs (35%) were the most frequent theme. There was also considerable variation in the volume of coverage each month. News articles were the most frequent article type (70%). The majority of the articles (72%) were positive for tobacco control. There were significant differences between party newspapers and local newspapers in prominence, article type, slant and fear appeal. One quarter (n=729) of the articles mentioned the severity of tobacco use, while only 10% of the articles referred to susceptibility to the threat.
Conclusions The coverage of events was predominantly positive toward tobacco control. However, media reports could better support tobacco control efforts if they did a better job at provoking an emotional response to the harms of tobacco use and promoting a sense among smokers that they can succeed in quitting smoking.
- Low/Middle income country
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News media play a key role in informing the public and are important in promoting tobacco control goals.1 The news media work directly (by informing the public about the items being reported) and indirectly to shape notions of the importance of particular issues and events.2–5 Recent studies have identified the importance of media advocacy in advancing tobacco control objectives.1 ,2 ,5–9 In addition, news coverage of tobacco issues is much more cost-effective than paid advertising, can be continuously available, and potentially leads to a greater exposure than mass media campaigns.10 Furthermore, accumulating evidence suggests that news coverage of tobacco issues is an important factor in setting the agenda for policy change11–13 and can influence individual attitudes and behaviours regarding tobacco use and cessation.1 ,6 ,9 ,12 ,14 ,15 Consequently, news media have become important components of comprehensive tobacco-control programs.16
Print media—especially newspapers, with their advantages of low price, multiple pages, extensive content and wide range of different perspectives–have become one of the most important ways for the public to obtain health knowledge and information.17 ,18 Several studies have focused on the effect that print media coverage of tobacco-related issues has on the implementation of tobacco control campaigns.15 ,19 For example, Niederdeppe et al15 examined the influence of Florida daily newspapers’ coverage of the Florida Tobacco Control Program (FTCP). Evidence indicated that FTCP newspaper coverage contributed to the observed declines in smoking. Other studies examined the news coverage of particular tobacco control issues and events, such as passive smoking and youth smoking,20–22 and studied the tobacco-related issues in targeted media.23 However, few studies have provided a systematic survey of tobacco news coverage throughout a country or across countries.4 ,10 ,12 ,14 ,24–27
China is the biggest producer and consumer of tobacco in the world. There are more than 300 million Chinese smokers who consume an estimated 1.7 trillion cigarettes per year, or 3 million cigarettes every minute.28 More than 1 million people died from smoking, and 100 000 people died from exposure to second-hand smoke.29 The Chinese Centre for Disease Control and Prevention (China CDC) recently released a report titled Tobacco Control and China's Future,30 which comprehensively evaluated the tobacco control efforts in China and found that these efforts were lower than the results for other signatory countries of the Framework Convention on Tobacco Control (FCTC). China, as a party to the FCTC, has obligations to implement effective tobacco control interventions, should pay immediate attention to tobacco control.
The Tobacco-Free City—Gates Tobacco Control Project, a project implemented by the Emory University Global Health Institute (USA) and funded by the Bill & Melinda Gates Foundation, is a new attempt to improve the course of tobacco control. At present, 17 cities are participating in this campaign in China. Selected project cities must meet the following criteria: (a) the city must be supported by the government and have its government's commitment to tobacco control; (b) the government must provide monetary and non-monetary support for the project; (c) the project requires the responsibility of a specialised department, and this department must be able to organise and implement the project; (d) the city must have an appropriate project leader, a stable workforce, and an adequate time investment. Thus, the government plays a crucial role in the project's implementation.
In China, there has been a dramatic increase in the news coverage on health issues in recent years. However, little comprehensive analysis or evaluation of related coverage in China has been conducted. We conducted this study to determine the extent and nature of newspaper coverage of tobacco-related issues in 17 project cities between 2008 and 2011. We aimed to acquire an overall grasp of the characteristics, themes, slants, and use of fear appeals in the print media coverage of tobacco issues that could be used to improve the use of the media for tobacco control in China. Fear appeals were any triggers that elicited fear. Specifically, our research questions were as follows: (1) What was the proportion of coverage for each tobacco-related theme, specifically themes related to the tobacco industry and farming, as China is one of the largest tobacco producers and consumers of tobacco? (2) Are article volumes, slants, themes and the use of fear appeals related to the type of newspaper?
We chose the cities that participated in the Tobacco-Free City—Gates Tobacco Control Project because that project's criteria allowed us to select cities whose efforts were representative of tobacco control policies. In China, the government directs news coverage in both party and local newspapers. We examined party and local newspapers to examine the different attitudes of the government and local media toward tobacco control. The party newspaper is the mouthpiece of the government; it reflects the government's tobacco control efforts. In comparison, the local newspaper is the print medium with which the public has the most contact, and it reflects public concerns.
We included only articles that contained at least one full paragraph focused on tobacco issues (thus eliminating articles that merely mentioned tobacco but focused on other issues) that appeared in 17 Chinese cities published between 1 January 2008 and 30 June 2011. We selected one party newspaper and one local newspaper that accounted for the largest circulation in each city. Articles were obtained from the electronic newspaper; if we could not access it, we accessed the articles using the Database of Important Chinese Newspapers (http://www.cnki.net). We excluded BaYannur City, whose newspapers were not available, and Karamay City's local newspaper, which was also unavailable. Because we focused on cities that participated in the Tobacco-Free City Project, we did not substitute other cities’ newspapers for the unavailable newspapers. A total of 31 newspapers and 4821 articles were included in this study. The following newspapers were not available for certain time periods: Yanzhao Metropolis Daily: 1 January 2008–30 July 2008; Qianshan Evening News: 1 January 2008–30 June 2008; Peninsula Morning Post: 1 January 2008–30 July 2008; Yangtze Evening Post: 1 January 2008–30 June 2008.
The coding system we used in this study was based on the framework developed by Clegg Smith and colleagues 31 and revised by the author according to the newspapers in China. The system consisted of five variables: article descriptors, prominence indicators, themes, slants and fear appeals (see Appendix 1). Each of the variables was recorded for every article. The descriptive variables were the publication date and newspaper name. The prominence variables were related to whether the article appeared on the front page and whether it was accompanied by an image or photograph. Content was assessed in terms of 14 tobacco-related themes, and each article was coded for one of the themes. The slant variable consisted of two distinct parts: event slant, which represented the impact of the reporting of a particular event; and opinion slant, which represented the author's or journalist's viewpoint. Both slant variables could be coded in one of the following four ways: positive, negative, mixed, or neutral for tobacco control. In combination, these coding variables enabled us to establish how often tobacco-related articles appeared in the news, how prominent they were, in what type of articles they appeared, what the main content areas or themes were and what their slants were.
This study also examined the use of fear appeals in the coverage of smoking issues in Chinese newspapers. Fear appeals were any triggers that elicited fear. They were persuasive communications that attempted to arouse fear to promote ‘precautionary motivation’ and ‘self-protective action’.32 We used four fear appeal variables: (1) severity of the threat, (2) susceptibility to the threat, (3) response efficacy, and (4) self-efficacy. In this study, ‘severity of the threat’ mainly referred to the negative effect of smoking on health and the economy (eg, statements such as ‘smoking may cause cancer’). ‘Susceptibility to the threat’ addressed the reader's feelings about the probability that his/her health might be harmed by smoking (ie, whether the individual perceived that he/she was personally vulnerable). ‘Response efficacy’ addressed a person's beliefs about whether the recommended actions would actually eliminate the threat (eg, statements such as ‘Smoking cessation is an effective way for smokers to avoid disease’). ‘Self-efficacy’ is the belief that one is capable of performing certain actions or behaviours to attain specific goals (eg, statements such as ‘It is very helpful for you to quit smoking if you follow these directions’).33
Coding procedures and analysis
The articles were coded by one of two trained coders. The coding manual was refined, and 10% of articles were randomly chosen and coded by both coders to assess intercoder reliability using Cohen's κ index. The median κ value across the coded variables was 0.93 (range: 0.61–0.98), reflecting almost perfect concordance between coders. The data were entered into Microsoft Access and analysed with SPSS 18.0. The χ2 statistic was used to assess differences between party newspapers and local newspapers.
Volume and characteristics of the articles
A total of 31 newspapers and 4821 articles were included in the analyses (Appendix 2). The number of articles related to tobacco increased between 1 January 2008 and 30 June 2011. The coverage of tobacco issues varied substantially among the different newspapers and cities in China over the study's course (Appendix 2). The greatest number of articles was published in the Xinmin Evening News (n=318) in Shanghai, followed by the Yangtze Evening Post (n=298) in Nanjing.
However, as figure 1 shows, the volume of tobacco coverage fluctuated considerably between 2008 and 2011. The peak of the coverage may be connected to certain special events. For example, the first and second stages of the Tobacco-Free City—Gates Tobacco Control Project were launched in June 2009 and January 2011, respectively, and both generated increased coverage. Additionally, the volume of coverage varied according to the month, from a peak of 477 in May to a low of 263 in February. The total number of articles was highest between 30 May and 1 June because of press coverage of World No-Tobacco Day on 31 May. There was also substantial variation in the dominant theme of the articles. Articles covering education, prevention and cessation programs and the health effects of smoking together comprised almost half of all newspaper coverage of tobacco issues, followed by articles focused on second-hand smoke (12%).
As table 1 shows, news articles were the most frequent article type, comprising 70% of all tobacco-related coverage (n=4821). Ten per cent (n=475) of the articles were informational articles. Other types of article occurred infrequently and included 240 comments (5% of total coverage), 173 columns (4%), 80 letters (2%), and 77 cartoons (1%). It also revealed the characteristics of the themes for each article type. For example, over half of the information articles addressed the theme ‘health effects of smoking’. The prominence of the articles was measured using two variables: front-page placement and images. Table 1 shows that 3% of the articles appeared on the front page of the newspapers, and 25% of the articles included some kind of image. Moreover, the articles’ prominence, as measured by these two variables, also showed some variation depending on the theme. For instance, the most common themes of front-page articles were education and prevention issues, which represented 28% of all articles.
The majority of the articles (72%) reported on events that were positive for tobacco control, such as national and local anti-smoking campaigns, the negative health effects of tobacco use, and new legislation restricting tobacco products. As table 2 shows, education and prevention, health effects, second-hand smoke, economics, unintended damage, youth access and female smokers were the themes most positive toward tobacco control. Another 17% of articles reported events that were neutral toward tobacco control; these were mostly articles that addressed the themes of tobacco farming and tobacco-related crimes (ie, fake or smuggled tobacco). Articles that reflected the negative impacts of the tobacco control objectives were rare (8%), for example, articles on the tobacco industry. The remaining articles were coded as mixed (3%).⇓
Most of the opinions voiced in Chinese newspapers were neutral toward tobacco control (86%) and the majority of these were associated with the themes of tobacco farming and tobacco-related crimes. This may have resulted from the significant proportion of hard news articles. A large percentage (96%) of the hard news articles were coded as neutral for the opinion slant, as these pieces were written in a relatively unopinionated style. In contrast, 12% of the articles were coded as positive. The themes of these articles mainly concentrated on tobacco products, regulation issues, and education, prevention and cessation programs. Only a small number of articles reflected negative and mixed opinions for tobacco control (1% each). Most columns, in particular, expressed negative opinions about tobacco control.
Among the 4821 articles, approximately one quarter (729) mentioned the severity of tobacco use. The majority of these articles were related to health effects of smoking (51%), followed by unintended damage related to smoking. Such themes as the tobacco industry, farming, advertising and promotion, and tobacco-related crimes merely touched upon the dangers of smoking. In our study, only 10% of the articles involved information about susceptibility to the threat, and they included themes similar to those associated with severity. Articles related to response efficacy and self-efficacy comprised no more than 10% of the coverage.
Party newspaper and local newspapers
To ensure the accuracy of the data analysis, we excluded the cities whose newspapers contained data deficiencies or for which local newspaper data were unavailable. Nine cities were retained. As figure 2 shows, local newspapers had a higher coverage volume than party newspapers, which may be because local newspapers contain more pages (we found that local newspapers have 1.6 times more pages than party newspapers). table 4 shows the difference between party newspapers and local newspapers in prominence, article types, themes, slants and fear appeals. Compared with local newspapers, party newspapers were more likely to feature articles on the front pages (p<0.001). Furthermore, the distribution of the article types in the two kinds of newspaper was different. For example, local newspapers were likely to cover informational news, while the party newspapers tended to include more columns.
Regarding themes and coverage, the proportion of coverage relating to the tobacco industry (129.244, p<0.001), farming (254.845, p<0.001), and tobacco advertisement and promotion (17.328, p<0.001) was significantly greater in party newspapers than in local newspapers. The proportion of coverage focusing on education and smoking prevention (129.244, p<0.001), tobacco-related crimes (20.618, p<0.001), and unintentional tobacco-related harm (12.834, p<0.001) was greater in local newspapers.
The event slant analyses revealed significant differences between coverage in party newspapers and local newspapers (167.218, p<0.001). Articles about events that were positive toward tobacco control were the most common types in both newspaper types, but a significantly greater proportion of negative and neutral coverage (eg, of the tobacco industry and farming) was found in party newspapers. Regarding the opinion slant, the greatest proportion of articles in both party newspapers and local newspapers was neutral for tobacco control. Party newspapers devoted a significantly greater proportion of their coverage to neutral articles, whereas local newspapers were more likely than party newspapers to present a positive viewpoint.
Regarding fear appeals, local newspapers covered more articles about the severity of smoking (22.232, p<0.001). There were no significant differences between the two newspaper types in their coverage of susceptibility to the threat, response efficacy and self-efficacy (1.800, p>0.05).
Our study involved a systematic content analysis of 4821 tobacco-related articles in local and party newspapers from 17 cities in China. We found that press attention to tobacco in these cities showed an increasing trend, consistent with the research results of Yu Liu,26 indicating increasing attention paid to smoking-related matters in recent years.
The volume of tobacco coverage fluctuated considerably during the period from 2008 through 2011. As previous studies have also reported,4 ,10 ,26 ,34 this increase was clearly attributable to an increased number of tobacco-related events. On one hand, such special events serve to increase press coverage in the short term. World No Tobacco Day is a particularly strong example. The World Expo 2010, held in Shanghai, also increased press coverage in this city. On the other hand, project interventions work to increase press coverage in the medium term; because these projects received increased coverage over the years, more tobacco control projects could be implemented to further increase coverage.
Similar to the research results of Yu Liu,26 education, prevention and smoking cessation are the main themes of media coverage in China, accounting for 35% of the overall reports. Unlike results of Yu Liu, another focal point of the print media (12%) is second-hand smoking, including bans on smoking in public places, the foundation of smoking-free hospitals, and the dangers of second-hand smoke. We found more news related to fake and smuggled tobacco than has been reported in other studies, and special national circumstances may be responsible for this phenomenon.
News related to the tobacco industry and tobacco farming attracts media attention in China. China is the biggest tobacco-producing and consuming country in the world. National Bureau of Statistics data show that the Chinese tobacco industry's total sales revenue was 1.01 114 trillion yuan in 2011, and commercial profits were more than 2000 billion yuan. The tax revenue from tobacco was 752.956 billion yuan, of which 600.118 billion yuan were turned over to the state.35 As a whole, the tobacco industry exerts a great influence on economic development and state revenue in China, so it is inevitable that the media pay close attention to the industry. Thus, to improve tobacco control, the media should balance the proportions of tobacco-related news by increasing the proportion of health-related tobacco news, including more images to attract readers’ attention to such stories and publishing more tobacco control-related news on the front page.
In our study, the coverage involving fear appeals was limited. Twenty-five per cent of the articles addressed the severity of tobacco-related disease, while susceptibility, which reinforces appeals to severity, was infrequently addressed and accounted for just 10% of the coverage. Research shows that information that evokes negative emotions, such as horror, disgust and depression, is more effective at stimulating people to quit smoking immediately than information that evokes positive emotions.36 A previous study showed that fear appeals can be effective persuasive devices if they generate strong perceptions of threat and fear and of the efficacy of the recommended response.37 In our study, coverage that involves response efficacy and self-efficacy accounted for no more than 10% of the sample, suggesting that the print media in the studied cities have a relatively low impact on changing the public's smoking behaviour. Media reports could be more effective for tobacco control if the number of articles that evoke fear of tobacco-related health harms and encourage self-efficacy for smoking cessation was increased. To encourage this form of reporting, tobacco control advocates need to keep this on the agenda. Research studies might be one way to continue to produce newsworthy alarming data/information.
We observed similarities and differences in the themes, article types and fear appeals that appeared in the party newspaper versus the local newspaper in each city. In the party newspaper, the themes varied more widely and included more articles about tobacco farming and the tobacco industry. In contrast, local newspaper coverage focuses mainly on popular content like social news, as these newspapers target readers from different social strata and diverse cultural backgrounds, and emphasise such topics as health education and tobacco control campaigns. The themes presented in each newspaper type were approximately similar and covered all of the tobacco-related areas.
There were several limitations to our study. First, we selected our sample from 17 cities between 1 January 2008 and 30 June 2011 and selected one party newspaper and one local newspaper from each city. However, we excluded the newspapers with data deficiencies for this analysis. Second, we had planned to compare news coverage in these cities before and after they joined the project. However, because we could not access newspapers before the year 2008, we reduced our study period to the years 2008 through 2011. Nevertheless, we were able to show the characteristics of newspapers in these cities during these years. Future research could compare the newspaper coverage in the project cities with other cities using a wider sample range and a larger sample size to allow for a more discerning statistical analysis. Third, although descriptive analyses of newspaper coverage of tobacco-related articles provide one important component of an overall evaluation of media advocacy efforts, other methods, such as public opinion surveys and surveys related to the prevalence of smoking in the city, can also contribute to a more thorough evaluation framework. Future studies could examine the link between policy agenda and media efforts for tobacco control. Other types of news media outlet/format could also be examined.
What this paper adds
The current situation of tobacco control in China is very severe.
Previous studies on newspaper coverage of tobacco issues in China were restricted to individual regions.
This paper involved a content analysis of newspapers published in 17 cities that participated in the Tobacco-Free City—Gates Tobacco Control Project in China, demonstrates that media reports could be more effective for tobacco control if the number of articles that evoke fear of tobacco-related health harms and encourage self-efficacy for smoking cessation was increased.
We would like to thank Xia Zi for her comments on a previous version of this paper. We would also to thank Qiong Li and Zaili Tang for their tireless efforts in sorting and sampling data and Yanzi Zhou for her assistance with data management and statistical analysis.
List of coded variables
The number of newspaper articles by year
Contributors XYL designed the study, analysed and interpreted the data. SWH participated in the whole study, and drafted the manuscript and revised it critically. QS, LJX and XLY helped draft the manuscript, and helped with sorting, sampling and analysing the data.
Funding Completion of this research was supported by grants from the Innovation Project of Central South University.
Competing interests None.
Patient consent Obtained.
Provenance and peer review Not commissioned; externally peer reviewed.
Data sharing statement (1) Research sample was obtained from the electronic newspaper, and some unavailable articles could be obtained from the Database of Important Chinese Newspapers (http://www.cnki.net). Anyone wishing to research the articles in depth can contact me by email. (2) The coding system developed by us will be available by contacting us by email.
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