Objective To investigate Chinese adult residents' awareness of smoking hazards in 2018 and the changes relative to 2013, and to explore associated influencing factors.

Methods Data were from 184 472 residents aged ≥18 years in the 2018 China Chronic Disease and Risk Factor Surveillance. Awareness rates were calculated for smoking's association with stroke, heart disease, and lung cancer, as well as with all three diseases combined. A multivariate logistic regression model based on complex sampling design was adopted to analyze the factors that might affect the awareness rate. All results were weighted based on the population from the 2010 Sixth National Population Census to better estimate the condition of Chinese adult residents.

Results In 2018, the awareness rates of Chinese adult residents regarding the association between smoking and stroke, heart disease, and lung cancer were 48.4% (95% confidence interval CI: 46.8%-49.9%), 50.9% (95%CI: 49.3%-52.4%), and 73.8% (95%CI: 72.3%-75.2%), respectively; the overall awareness rate of the link between smoking and these three diseases was 45.0% (95%CI: 43.3%-46.6%). Among current smokers, the corresponding awareness rates were 45.3% (95%CI: 43.7%-47.0%), 47.9% (95%CI: 46.3%-49.6%), and 71.0% (95%CI: 69.4%-72.5%), with an overall awareness rate of 42.0% (95%CI: 40.2%-43.8%). The results of the multi-factor logistic regression analysis showed that the awareness rate of recognizing the association between smoking and the three diseases was higher among people aged 18-59 years than those aged 60 years and above, higher among northern residents than southern residents, higher among individuals with junior high school education or above than those with primary school education or below, and higher among people with annual household per capita income of ≥12 000 yuan than those with an income of < 6 000 yuan. The awareness rate was also higher among managers and professionals as well as retirees than agricultural workers, and higher among individuals with two or more chronic diseases than those without chronic diseases. Additionally, the awareness of smoking hazards decreased with the increase in cigarette consumption (P < 0.05). Compared with 2013, the awareness rates of Chinese adult residents regarding the associations between smoking and the three diseases were significantly higher (P < 0.05).

Conclusion In 2018, Chinese adult residents' awareness of smoking-related hazards had improved compared with 2013; however, targeted public education on tobacco hazards should be prioritized among populations including residents aged ≥60 years, residents in southern China, those with primary school education or below, those with low annual household per capita income (< 6 000 yuan), current and former smokers, individuals with no intention to quit smoking, and heavy smokers (≥20 cigarettes/day).