Awareness and attitudes towards children’s cigarette card gaming behaviour among adults aged 15 and above in Shenzhen, China: a population representative cross-sectional study

Abstract

<p><strong>Introduction</strong> Repurposing cigarette packs for flip-and-win games (cigarette card (CC) gaming) is increasingly popular among Chinese children. We examined adults’ awareness and attitudes towards this.</p><p><strong>Methods</strong> A population representative survey was conducted in Shenzhen, China, from September to October 2023, involving 4800 adults (aged 15 and above) with a 94.3% response rate. The sample was weighted to represent all Shenzhen residents older than 15. Respondents aware of the game reported their perceived risk of smoking initiation and their tolerance towards CC gaming. In households with children aged 7–12, respondents also reported whether children had played the game within the past week and identified perceived reasons and sources of CCs. Factors associated with low-risk perception and tolerance were analysed using multivariable logistic regression.</p><p><strong>Results</strong> The weighted adult awareness rate was 15.6% (95% CI 13.8% to 17.5%), while an estimated 3.9% (1.3 to 6.5%) of children played the game. Peer influence (76.8%) and curiosity (20.7%) were the main perceived reasons for participation, with peers (73.2%), trash bins/ground (46.3%) and smoking parents (18.3%) cited as primary sources. 21.5% of adults perceived the game as low risk, and 44.3% expressed tolerance towards it. Low-risk perception was associated with living with children (adjusted OR 2.07, 95% CI 1.37 to 3.13) and tolerance (2.92, 1.95 to 4.36). Tolerance was associated with male sex (1.59, 1.12 to 2.27), older age (65+ vs 15–24 years old, 0.26, 0.08 to 0.89) and low-risk perception (2.86, 1.92 to 4.27).</p><p><strong>Conclusions</strong> The high tolerance towards the CC game highlights the urgent need to shift adult attitudes in order to prevent its further spread.</p>