A syndemic including cigarette smoking and sexual risk behaviors among a sample of MSM in Shanghai, China
Introduction
Researchers in Western societies have found that men who have sex with men (MSM) and gay and bisexual men tend to experience more psychosocial problems such as depression, suicide, and intimate partner violence than their heterosexual counterparts (Herrick et al., 2011, Mustanski et al., 2007, Operario and Nemoto, 2010, Safren et al., 2010, Senn et al., 2010, Walkup et al., 2008). MSM also exhibit higher rates of cigarette smoking, alcohol abuse and drug use, and infection rates of HIV and other STIs (Colfax et al., 2004, Klein, 2011, Marshal et al., 2008, Rhodes et al., 1999, Van Tieu and Koblin, 2009, Walkup et al., 2008). Due to the multiple co-occurring biosocial issues that these sexual minority men face, researchers have argued that these MSM are experiencing a syndemic of health issues. Syndemic refers to the concentration within a specific population of two or more diseases that reinforce one another, ultimately giving rise to other health problems (Singer and Clair, 2003).
A variant of the syndemic framework is the “Minority Stress Theory” (Meyer, 1995, Meyer, 2003), which posits that the stresses, including social discrimination against MSM, of being a minority are associated with adverse health outcomes, especially in the realm of mental health. Exposed to discrimination over time, these men are highly likely to experience stress, low self-esteem, and social isolation, all of which in turn compromise their health. Stall and colleagues have proposed a theory of “syndemic production” of health disparities among gay men in the urban United States, linking high rates of depression, substance use, and HIV/AIDS as intertwined epidemics among groups of gay men that arise from negative childhood or adolescent experiences associated with their emergent gay identities (Bruce and Harper, 2011, Friedman et al., 2008, Stall and Catania, 2008).
Western researchers have applied the syndemic framework to HIV research among MSM, finding considerable empirical support for a model in which co-occurring psychosocial problems such as substance use, depression, and intimate partner violence (IPV) are mutually reinforcing each other and together lower the health profile of gay men (Egan et al., 2011, Lee et al., 2009, Operario and Nemoto, 2010, Safren et al., 2010). For example, Storholm et al. (2011) found that young MSM (or YMSM) living in New York City were more likely to report cigarette smoking and that smoking was associated with using alcohol and a variety of illicit substances. In addition, YMSM who smoked cigarettes reported a greater number of casual sex partners and transactional sex partners than non-smokers.
Globally, tobacco use is the second leading cause of death (Ezzati et al., 2002) and the leading preventable cause of disease, disability, and death (WHO, 2009). Cigarette smoking causes approximately five million deaths per year, accounting for one in ten deaths among adults worldwide (WHO, 2009). China is home to nearly one-third of all smokers worldwide (Yang et al., 1999) and is the leading producer and consumer of tobacco products (Lam et al., 1997, O’Connor et al., 2010). Evidence has shown that tobacco use in China significantly increases the risk of many diseases such as chronic obstructive pulmonary disease (COPD) and respiratory tuberculosis (Zhang and Cai, 2003), and vascular and heart diseases (Chen et al., 1997, Gu et al., 2009, He et al., 2005). Additionally, smoking is responsible for a high burden of many cancers including lung, esophagus, stomach, and liver cancers (Chen et al., 2003, Chen et al., 1997, Gan et al., 2007, Liu et al., 1998, Qiu and Chen, 2009, Wang et al., 2010, Wang et al., 2000, Yang et al., 1999, Zhang and Cai, 2003, Zhong et al., 1999). Currently, more than one third of cancer deaths in China are attributable to smoking, while the number of smoking attributable deaths has declined in the US (Rostron, 2012, Wang et al., 2010). Over one million annual deaths in China have been attributed to smoking, and estimated mortality will reach two million by the year 2025 (Liu et al., 1998, Yan, 2008). Besides its impact on health outcomes, smoking also increases the economic burden on the country. While the tobacco industry itself is profitable in China, the negative economic consequences caused by tobacco use are undeniable. The total economic cost of smoking in China increased from U.S. $17.1 billion in 2003 to U.S. $28.9 billion in 2008, accounting for 0.7% of China's Gross Domestic Product and 3.0% of total national health expenditures (Yang et al., 2011).
Research in China has also shown that smoking is significantly related to education, occupation, income, and location (Yang et al., 1999). For example, prevalence among adult men is lowest among those with at least a college education (54.2%) and highest among those with no more than a primary school education (72.4%; Yang et al., 1999). In addition, more than 70% of Chinese smokers are farmers, factory or service workers, private company employees, self-employed, or members of the floating or itinerant population who lack a fixed residence (Yang et al., 1999). Other studies have found that smoking is more prevalent among lower-income populations, and that urban residents exhibit significantly lower rates of smoking and cigarette consumption (Anderson Johnson et al., 2006).
The most striking feature of Chinese smokers is that the vast majority of them are adult males. Smoking prevalence ranges from 52.4% to 64% among males over 15 years old (Anderson Johnson et al., 2006, Li et al., 2011, Shi et al., 2008, Wang, 2006, WHO, 2009, Zhang et al., 2011) versus 2.4% to 6.4% among females (Li et al., 2011, Shi et al., 2008, Wang, 2006, Zhang et al., 2011). Tobacco use also accounts for more than 50% of gender differences in life expectancy (Wang et al., 2010).
Among male smokers in China, certain sub-groups justify particular attention. One such sub-group are MSM. As indicated above, Western and international literature have consistently documented higher prevalence of smoking among MSM than their heterosexual counterparts (Stall et al., 1999, Tang et al., 2004). However, the reach of Chinese governmental health initiatives into the gay community remains limited due to continued social stigma and fear of experiencing discrimination, which discourages MSM from engaging health authorities (Daily, 2010). Only one study has assessed smoking and other substance use behaviors among a sample of MSM in Shanghai, China. This study found that smoking prevalence and cigarette consumption were higher among MSM than adult males in general (Berg et al., 2011), suggesting the need for further research into smoking among this population.
Guided by the syndemic framework and findings from previous research, in this study we aimed to (1) identify and describe the psychosocial correlates for cigarette smoking among a sample of MSM in China; (2) compare the associations of these correlates (e.g., alcohol and drug use, depression, IPV, sexual attitudes, and gay identity) on levels of smoking to examine the associations among these behavioral and psychosocial factors; and (3) explore the syndemic associations of substance use and psychosocial problems with sexual risks.
Section snippets
Data source
The data used were part of a larger study examining the characteristics of HIV/STIs, sexual risks, and health issues among MSM in Shanghai, China. Using a cross-sectional design, data were collected between February and April 2009 using respondent-driven sampling (RDS) during Phase I of the study (Abdul-Quader et al., 2006). Using RDS, a social network methodology used to estimate population characteristics, eight initial seeds (four “money boys” and four general MSM) were selected based upon
Results
We examined homophily (similarity) and heterophily (social distance) to explore recruitment patterns resulting from the RDS (e.g., seeds are theoretically more likely to recruit participants similar to themselves). Results indicated extremely high recruitment homophily and corresponding heterophily, i.e., almost 97% of the time money boys recruited other money boys, and over 95% of general MSM recruited fellow general MSM. Based on these results and the significant differences in personal
Conclusions
Findings from this study are consistent with previous studies from Western countries indicating a high prevalence of cigarette smoking among MSM. The strong association found between education level and smoking is consistent with previous research in China, suggesting the importance of health interventions for MSM smokers with lower education levels. Smokers were more depressed and more likely to use alcohol and drugs. Although we did not formally test for a dose–response effect, the point
Role of funding source
Funding for this study was provided by a grant from the Eunice Shriver National Institute on Child Health and Human Development (R01HD056956) to Frank Y. Wong (last author). Preparation of this study was supported in part by the Emory Center for AIDS Research (P30AI050409) to both the second and last authors. The funders had no further role in study design; in the collection, analysis and interpretation of data; in the writing of the report; or in the decision to submit the paper for
Contributors
This paper was based in part on a master's thesis of the first author co-chaired by Sullivan and Wong. Nehl served as a member on the thesis committee. Wong, Nehl, Zheng, and He are members of an ongoing study from which the data were drawn. Berg, Lin, Tran and Lemieux contributed to the interpretation of findings.
Conflict of interest
No conflict declared.
References (56)
- et al.
Tobacco use among youth and adults in Mainland China: the China Seven Cities Study
Public Health
(2006) - et al.
Selected major risk factors and global and regional burden of disease
Lancet
(2002) - et al.
The intersection of violence, substance use, depression, and STDs: testing of a syndemic pattern among patients attending an urban STD clinic
J. Natl. Med. Assoc.
(2010) - et al.
Implementation and analysis of respondent driven sampling: lessons learned from the field
J. Urban Health
(2006) - et al.
Prevalence and correlates of tobacco use among a sample of MSM in Shanghai, China
Nicotine Tob. Res.
(2011) - et al.
Operating without a safety net: gay male adolescents and emerging adults’ experiences of marginalization and migration, and implications for theory of syndemic production of health disparities
Health Educ. Behav.
(2011) - et al.
Early health effects of the emerging tobacco epidemic in China. A 16-year prospective study
JAMA
(1997) - et al.
Smoking and liver cancer in China: case–control comparison of 36,000 liver cancer deaths vs. 17,000 cirrhosis deaths
Int. J. Cancer
(2003) - et al.
Social discrimination, concurrent sexual partnerships, and HIV risk among men who have sex with men in Shanghai, China
AIDS Behav.
(2008) - et al.
Substance use and sexual risk: a participant- and episode-level analysis among a cohort of men who have sex with men
Am. J. Epidemiol.
(2004)