BACKGROUND: Cigarette packs in China are visually appealing and feature limited text health warnings. Since 2023, these packs have become increasingly popular among children, who repurpose them into cards for flip-and-win games, known as the cigarette card (CC) game. We examined Chinese adults' awareness and attitudes toward this phenomenon.
METHODS: We conducted a population-based survey in Shenzhen, China, from September to October 2023. 4525 adult respondents reported their awareness of the CC game. Among those who were aware and lived with children aged 7–12 years (n=349), we assessed whether the children had played the CC game in the past week, perceived reasons for participation, and sources of CCs. Those aware of the game (n=706) were asked about their perception of smoking initiation risk and their tolerance of the CC game. Factors associated with low-risk perception and tolerance were analyzed using multivariable logistic regression.
RESULTS: Overall, 15.6% (95% CI: 14.6%–16.7%) of respondents were aware of the CC game. Among those aware and living with children, 6.1% (4.8%–7.4%) reported that the children had played the game, mainly due to peer influence (76.8%) and curiosity (20.7%). Primary sources of CCs included peers (73.2%), trash bins/ground (46.3%), and parents who smoke (18.3%). Among those aware of the game, 19.1% perceived it as posing a low risk for smoking initiation, whereas 39.5% expressed tolerance toward it. Low-risk perception was associated with living with children (adjusted odds ratio 2.10, 95% CI: 1.35–3.23), tobacco advertising exposure (2.10, 1.35–3.29), and tolerance (2.91, 1.95–4.34). Tolerance was associated with being male (1.61, 1.13–2.29) and having a low-risk perception (2.86, 1.92–4.28).
CONCLUSIONS: The low awareness of the CC game, coupled with high tolerance, highlights the need for public health initiatives to address the game's potential risks in renormalizing and initiating smoking in children.