Smoking in China: findings of the 1996 National Prevalence Survey

Contemporary smoking habits among nurses in Mainland China

Although China is the world's largest consumer of tobacco and tobacco-related products, the epidemiology of smoking has not been well studied among nurses. Given this serious gap in the literature, we considered it necessary to investigate tobacco smoking habits among a large cross-section of contemporary Chinese nurses, by means of a questionnaire survey. A total of 509 replies were obtained from 520 nurses (response rate: 97.9%). The overall prevalence of smoking was 2.6% (95%CI 1.5 - 4.3). When stratified by gender, the prevalence rate among male nurses was 52.2% (33.0 - 70.8). Of those who smoked, the median number was 11 smokes per day for a period of 25.0 years. When categorized by severity, 15.4% were light smokers, 69.2% moderate smokers and 15.4% heavy smokers. When stratified by age there were no smokers under 25 years, with the prevalence between 25 and 34 years similarly low, at 1.1%. The highest smoking rate was seen among nurses aged 45 to 50 years (10.1%), even though they only comprised 9.8% of the total workforce. Although our study suggests that tobacco usage is relatively uncommon among Chinese nurses overall, the rate among male nurses was alarmingly high. The distribution of smoking by age was not uniform however, with a high proportion being concentrated in the older age ranges. As such, future preventive measures will need to consider the individual situation of Chinese nurses who smoke, particularly those who occupy the older age groups.

Healthy Aging in China

China has aged rapidly and the rate is accelerating in decades to come. We review positive and negative forces for healthy aging in China now and in the future. The most positive force is the spectacular growth in education over time especially for Chinese women, which should improve all dimensions of cognitive and physical health and eliminate vast gender disparities in healthy aging that currently exist. Other positive forces include increasing detection and treatment of disease and the availability of health insurance and health services so that diseases like hypertension and diabetes do not remain silent killers in China. Transparency is eased on the research level by publicly available data such as CHARLS, a sharp departure from prior scientific norm in China. Negative forces center on disturbing trends in personal health behaviors such as growing rates of smoking (among men) and obesity (for both genders), and pollution-,especially in urban centers. Public health campaigns and incentives are needed on all these fronts so that predictable long-term consequences of these behaviors on older age disease are not realized. There will not be a simple demographic fix to healthy aging in China as fertility rates are unlikely to rise much, while migration will likely continue to rise leaving growing numbers of elderly parents geographically separated from their adult children. Government policy will have to allow migration of elderly parents to live with their adult children while reducing the rigid connection of policy (health insurance and health services) with place of residence.

Reported exposures to anti-smoking messages and their impact on Chinese smoker's subsequent quit attempts

BACKGROUND

It is important to monitor whether anti-smoking messages (if any) are noticed by the public in China and whether they have any impact on smokers’ quitting behaviours over time.

PURPOSE

This study aimed to examine Chinese smokers' exposure to anti-smoking messages in a range of channels and to determine if exposure was associated with subsequent quit attempts.

METHOD

A prospective cohort design was employed. Participants were 6,509 adult smokers who completed at least one of the first three waves (2006-2009) of the International Tobacco Control (ITC) China Survey sampled from six Chinese cities. The main measures were reported exposure to anti-smoking messages in a range of channels and smokers' subsequent quit attempts. Generalized Estimating Equations (GEE) modelling was used to combine respondents from all three waves while accounting for inherent within-person correlation.

RESULTS

The overall exposure levels to anti-smoking messages were low and varied between cities and from one channel to another. Television was the medium with the greatest overall exposure (over 50% in almost all the cities across all the waves). After controlling for a range of covariates, higher level of combined exposure were positively related to higher subsequent quit attempts (adjusted odds ratio=1.03, 95% CI 1.02~1.05, p <.001); among the individual channels, exposures in newspapers and on posters were significant in their own right.

CONCLUSION

The findings suggest that anti-smoking warning messages have the potential to stimulate Chinese smokers to make quit attempts, but they also indicate that the levels and strength of warning messages in China need to be increased. China should consider adopting proven international practices, including mandating pictorial health warnings on cigarette packages, adopting prominent point-of-sale warnings, and carrying out strong and ongoing mass media campaigns.

An early-stage epidemic: a systematic review of correlates of smoking among Chinese women

BACKGROUND

Despite the historically low smoking prevalence among Chinese women, there is a trend of future increase.

PURPOSE

We systematically reviewed the correlates of smoking among Chinese girls and women.

METHOD

We conducted a systematic review of literature on correlates of smoking among Chinese women using Medline and China Academic Journals databases. Following the PRISMA statement, two investigators independently searched for literature, identified and reviewed papers, assessed the quality of the papers, and extracted information. The characteristics of studies and correlates of smoking were synthesized separately for youth and adults.

RESULTS

A total of 15 articles (11 on adults, 4 on youth) met the inclusion criteria. Based on these studies, peer smoking was the most consistent correlate of smoking among Chinese girls. Among Chinese women, partner smoking, job-related stress, and exposure to cigarettes made for women were consistent correlates of smoking. Knowledge of harms and negative attitudes towards smoking were found to be negatively associated with smoking.

CONCLUSION

Overall, the evidence base for smoking among Chinese women is limited. Although smoking among Chinese women is still at an early stage, it is becoming more prevalent among specific population subgroups, such as rural-to-urban migrant workers. Although further research is needed, findings from the current study provide a roadmap for research and policy on prevention of smoking among Chinese girls and women.

Serum adipocyte fatty acid binding protein levels are positively associated with subclinical atherosclerosis in Chinese pre- and postmenopausal women with normal glucose tolerance

CONTEXT

Recent studies highlight a critical interaction between adipocyte fatty acid binding protein (A-FABP) and cardiovascular disorders. However, associations of A-FABP with subclinical atherosclerosis in a population with normal glucose tolerance remain unknown.

OBJECTIVE

The study aimed to evaluate the relationship between A-FABP and carotid intima-media thickness (C-IMT) in a Chinese population with normal glucose tolerance.

DESIGN AND SETTING

A cross-sectional analysis was conducted of 2253 cardiovascular disease-free normal glucose tolerance subjects (835 men, 1418 women; 20-78 years old) from the Shanghai Obesity Study.

MAIN OUTCOME AND MEASURES

C-IMT was measured by B-mode ultrasound and used to assess subclinical atherosclerosis. Serum A-FABP levels were quantified by a sandwich ELISA.

RESULTS

The median serum level for A-FABP was 4.0 ng/mL (interquartile range: 2.6-6.0 ng/mL), and significantly higher in women than men (P < .001). After adjusting for age and body mass index (BMI), a partial correlation analysis showed that A-FABP levels correlated with C-IMT in men, premenopausal, and postmenopausal women (P = .024, .006, and .016, respectively). Furthermore, C-IMT increased along with quartile A-FABP values (all P for trend <.001). Regression analyses demonstrated that A-FABP was associated with C-IMT only in women (P = .044 and .001 for pre- and postmenopausal, respectively). Moreover, A-FABP was identified as a risk factor for C-IMT in pre- and postmenopausal women with a normal BMI (P < .001 and P = .012, respectively).

CONCLUSIONS

Serum A-FABP levels independently and positively correlate with subclinical atherosclerosis in pre- and postmenopausal Chinese women with normal glucose tolerance after adjustments for the traditional risk factors.

Prevalence of and factors influencing smoking among medical and non-medical students in Tbilisi, Georgia

OBJECTIVE:

Smoking is a serious problem that has a devastating impact on health. The objective of this study was to describe the prevalence of and factors influencing smoking among medical and non-medical students in Tbilisi, Georgia, as well as to determine whether medical education has an impact on smoking.

METHODS:

A cross-sectional study was carried out at Tbilisi State Medical University and Tbilisi State University, both of which are located in Tbilisi, Georgia. A total of 400 4th-year students (200 students at each university) were asked to complete standardized questionnaires.

RESULTS:

Of the sample as a whole, 48.75% were identified as smokers and 51.25% were identified as nonsmokers. The mean age was 20.24 years among smokers and 20.26 years among nonsmokers. Of the medical students, 49.5% were smokers, as were 48.0% of the non-medical students. The male-to-female ratio in the study population was 0.9:1.1. Smoking was found to have a strong relationship with gender, males accounting for 65% of all smokers. Of the smokers, 56.9% stated that they would like to quit smoking (for health or financial reasons). Of the medical students, 59.5% expressed a willingness to quit smoking, as did 54.2% of the non-medical students.

CONCLUSIONS:

There is a need to improve smoking education for undergraduate students. Special attention should be given to the inclusion of anti-smoking education in undergraduate curricula, as well as to the implementation of smoking prevention campaigns at institutions of higher education. However, such measures will be effective only if tobacco control policies are strictly enforced on the national level as well.

Smoking, smoking cessation and tobacco control in rural China: a qualitative study in Shandong Province

Background

Smoking prevalence is high in China and even higher among rural residents. The aims of this study were: 1) to gain insights into the motivations of tobacco use and barriers to smoking cessation among rural village residents; 2) to understand the current tobacco control measures in the rural villages and barriers encountered or perceived for implementation.

Methods

Qualitative semi-structured face-to-face interviews and focus group discussions were conducted of 59 rural villagers including 37 village residents, 10 village leaders and 12 village doctors in three counties in Shandong Province, China.

Results

Smoking initiation was most often out of curiosity when seeing others smoke, but pressure from cigarette sharing and gifting custom was the major barrier to smoking cessation. The most important reason for quitting successfully was a detrimental health problem. Although many attempted to quit at the advice of other family members, relapses were common and few were able to quit completely and for long-term unless accompanied by significant health issues. Although doctor’s advice to quit is effective, many doctors do not offer advice to all patients. There is a lack of true understanding of the harm of smoking and second-hand smoking among the villagers and a lack of access to and knowledge of effective smoking cessation tools among both smokers and village doctors. Tobacco control activities at villages were rare and infrequent.

Conclusions

This study highlighted the need to develop tobacco control measures that reflect the unique culture in rural China. Smoking cessation measures are not likely to achieve large scale effect unless the prevailing cigarette sharing and gifting custom is drastically changed. More educations of the hazards of smoking and second-hand smoking to village residents and educations of effective smoking cessation treatment to both village residents and healthcare providers are needed.

Smoking and major depressive disorder in Chinese women

Objective

To investigate the risk factors that contribute to smoking in female patients with major depressive disorder (MDD) and the clinical features in depressed smokers.

Methods

We examined the smoking status and clinical features in 6120 Han Chinese women with MDD (DSM-IV) between 30 and 60 years of age across China. Logistic regression was used to determine the association between clinical features of MDD and smoking status and between risk factors for MDD and smoking status.

Results

Among the recurrent MDD patients there were 216(3.6%) current smokers, 117 (2.0%) former smokers and 333(5.6%) lifetime smokers. Lifetime smokers had a slightly more severe illness, characterized by more episodes, longer duration, more comorbid illness (panic and phobias), with more DSM-IV A criteria and reported more symptoms of fatigue and suicidal ideation or attempts than never smokers. Some known risk factors for MDD were also differentially represented among smokers compared to non-smokers. Smokers reported more stressful life events, were more likely to report childhood sexual abuse, had higher levels of neuroticism and an increased rate of familial MDD. Only neuroticism was significantly related to nicotine dependence.

Conclusions

Although depressed women smokers experience more severe illness, smoking rates remain low in MDD patients. Family history of MDD and environmental factors contribute to lifetime smoking in Chinese women, consistent with the hypothesis that the association of smoking and depression may be caused by common underlying factors.

Tobacco use among designated air pollution victims and its association with lung function and respiratory symptoms: a retrospective cross-sectional study

OBJECTIVES

We sought to elucidate the long-term association of tobacco use and respiratory health in designated pollution victims with and without obstructive pulmonary defects.

DESIGN

A retrospective cross-sectional study.

SETTING

The register of pollution victims in Kurashiki, Japan.

PARTICIPANTS

730 individuals over 65 years of age previously diagnosed with pollution-related respiratory disease. Patients were classified into four groups according to their smoking status and whether they had obstructive pulmonary disease. We then compared the prevalence of respiratory symptoms and lung function over time between groups.

PRIMARY OUTCOME MEASURES

Spirometry was performed and a respiratory health questionnaire completed in the same season each year for up to 30 years.

RESULTS

Rates of smoking and respiratory disease were high in our sample. Although respiratory function in non-smoking patients did not completely recover, the annual rate of change in lung function was within the normal range (p<0.01). However, smokers had worse lung function and were more likely to report more severe pulmonary symptoms (p<0.01).

CONCLUSIONS

Patients' respiratory function did not fully recover despite improved air quality. Our results suggest that, in the context of exposure to air pollution, tobacco use causes additional loss of lung function and exacerbates respiratory symptoms.

Parenting practices and adolescent smoking in mainland China: the mediating effect of smoking-related cognitions

This study examined the direct and indirect associations of general and smoking-specific parenting practices with Chinese adolescents' smoking behaviors. Adolescents aged 14-17 years (N = 658) and their parents were recruited from three high schools in mainland China. Adolescents completed an anonymous online survey on their smoking behaviors, perceptions of parenting behaviors, and smoking-related cognitions including attitude, subjective norm, and perceived behavioral control. Parents completed a paper-and-pencil questionnaire on their parenting behaviors. Results indicated that psychological control and frequency of communication about smoking were positively linked to adolescent smoking through the mediation of two smoking-related cognitions-attitude and subjective norm. Parental knowledge of adolescent activities, disapproval of adolescent smoking, and home rules were negatively linked to adolescent smoking through the mediation of attitude and subjective norm. Results suggest that parenting practices and smoking-related cognitions are critical components to be incorporated in prevention and intervention programs for adolescent smoking in China.

Loneliness and mortality among older adults in China

OBJECTIVES

To examine the relationships between loneliness, social and health behaviors, health, and mortality among older adults in China.

METHOD

Data came from a nationally representative sample of 14,072 adults aged 65 and older from the 2002, 2005, and 2008 waves of the Chinese Longitudinal Healthy Longevity Survey. A cross-lagged model combined with survival analysis was used to assess the relationships between loneliness, behavioral and health outcomes, and risk of mortality.

RESULTS

About 28% of older Chinese adults reported feeling lonely, and lonely adults faced increased risks of dying over the subsequent years. Some of the effect was explained by social and health behaviors, but most of the effect was explained by health outcomes. Loneliness both affects and is affected by social activities, solitary leisure activities, physical exercise, emotional health, self-rated health, and functional limitations over a 3-year period.

DISCUSSION

Loneliness is part of a constellation of poor social, emotional, and health outcomes for Chinese older adults. Interventions to increase the social involvement of lonely individuals may improve well-being and lengthen life.

Active and passive smoking with breast cancer risk for Chinese females: a systematic review and meta-analysis

Previous studies suggested that smoking and passive smoking could increase the risk of breast cancer, but the results were inconsistent, especially for Chinese females. Thus, we systematically searched cohort and case-control studies investigating the associations of active and passive smoking with breast cancer risk among Chinese females in four English databases (PubMed, Embase, ScienceDirect, and Wiley) and three Chinese databases (CNKI, WanFang, and VIP). Fifty-one articles (3 cohort studies and 48 case-control studies) covering 17 provinces of China were finally included in this systematic review. Among Chinese females, there was significant association between passive smoking and this risk of breast cancer [odds ratio (OR): 1.62; 95% confidence interval (CI): 1.39-1.85; I2 = 75.8%, P < 0.001; n = 26] but no significant association between active smoking and the risk of breast cancer (OR: 1.04; 95% CI: 0.89-1.20; I2 = 13.9%, P = 0.248; n = 31). The OR of exposure to husband's smoking and to smoke in the workplace was 1.27 (95% CI: 1.07-1.50) and 1.66 (95% CI: 1.07-2.59), respectively. The OR of light and heavy passive smoking was 1.11 and 1.41, respectively, for women exposed to their husband's smoke (< 20 and ≥ 20 cigarettes per day), and 1.07 and 1.87, respectively, for those exposed to smoke in the workplace (< 300 and ≥ 300 min of exposure per day). These results imply that passive smoking is associated with an increased risk of breast cancer, and the risk seems to increase as the level of passive exposure to smoke increases among Chinese females. Women with passive exposure to smoke in the workplace have a higher risk of breast cancer than those exposed to their husband's smoking.

Passive smoking exposure from partners as a risk factor for ER+/PR+ double positive breast cancer in never-smoking Chinese urban women: a hospital-based matched case control study

Background

The relationship between passive smoking exposure (PSE) and breast cancer risk is of major interest.

Objective

To evaluate the relationship between PSE from partners and breast cancer risk stratified by hormone-receptor (HR) status in Chinese urban women population.

Design

Hospital-based matched case control study.

Setting

Chinese urban breast cancer patients without current or previous active smoking history in China Medical University 1st Hospital, Liaoning Province, China between Jan 2009 and Nov 2009.

Patients

Each breast cancer patient was matched 1∶1 with healthy controls by gender and age (±2 years) from the same hospital.

Measurements

The authors used unconditional logistic regression analyses to estimate odds ratio for women with PSE from partners and breast cancer risk.

Results

312 pairs were included in the study. Women who endured PSE had significantly increased risk of breast cancer (adjusted OR: 1.46; 95% CI: 1.05–2.03; P = 0.027), comparing with unexposed women. Women who exposed to >5 cigarettes/day also had significant increased risk (adjusted OR: 1.99; 95% CI: 1.28–3.10; P = 0.002), as were women exposed to passive smoke for 16–25 years (adjusted OR: 1.87 95% CI: 1.22–2.86; P = 0.004), and those exposed to > 4 pack-years (adjusted OR: 1.71 95% CI: 1.17–2.50; P = 0.004). Similar trends were significant for estrogen receptor (ER)/progesterone receptor (PR) double positive subgroup(adjusted OR: 1.71; 2.20; 1.99; 1.92, respectively), but not for ER+/PR−, ER−/PR+, or ER−/PR− subgroups.

Limitations

limitations of the hospital-based retrospective study, lack of information on entire lifetime PSE and low statistical power.

Conclusions

Our findings provide further evidence that PSE from partners contributes to increased risk of breast cancer, especially for ER/PR double positive breast cancer, in Chinese urban women.

Landless female peasants living in resettlement residential areas in China have poorer quality of life than males: results from a household study in the Yangtze River Delta region

Background

Urbanization has accelerated in China, and a large amount of arable land has been transformed into urban land. Moreover, the number of landless peasants has continually increased. Peasants lose not only their land, but also a series of rights and interests related with land. The problems of landless peasants have been long-standing; however, only a few studies have examined their health or quality of life (QOL). This paper assesses the QOL of landless peasants in the Yangtze River Delta (YRD) region, analyzes gender differences, and explores health inequity.

Methods

Data are derived from household samples in six resettlement residential areas of three cities (Nanjing, Hangzhou, and Yangzhou) in the YRD region (N = 1,500; the effective rate = 82.4%). This study uses the short version of World Health Organization Quality of Life questionnaire (WHOQOL-BREF) scale to measure the QOL of landless peasants, and performs confirmatory factor analysis (CFA) and analyze gender differences in QOL on the basis of CFA.

Results and conclusion

First, we use Analysis of Variance and Non-parametric Tests to test if the differences of mean value of testing generals have statistical significances. Results shows significant differences occur between the impacts of different genders on the four domains of QOL (physical health, psychological health, social relationships, and environment). The internal reliability of the WHOQOL-BREF scale is good (Cronbach’s alpha > 0.8), and the four domains of QOL are connected with each other. Second, scores in each QOL domain are commonly low, whereas the scores of females are much lower, indicating a poorer QOL than that of males. Third, results of the CFA of the QOL domains and their related observed variables indicate a good model fit. Fourth, results imply that the order of importance of the four domains (psychological health (males = 26.74%, females = 27.17%); social relationships (males = 26.23%, females = 25.35%); environment (males = 25.70%, females = 24.40%); and physical health (males = 21.33%, females = 23.08%)) affecting QOL from high to low is the same for landless male and female peasants, whereas the proportion of importance is different between genders. The results highlight the importance of government intervention to improve the QOL of Chinese landless peasants, ultimately reducing health inequity.

Stroke-related knowledge, beliefs, and behaviours of chinese and European canadians: implications for physical therapists

PURPOSE

To improve cross-cultural health education on risk-reducing behaviour change by examining the stroke-related knowledge, beliefs, and behaviours of Chinese Canadians (CCs).

METHODS

Participants (103 first-generation CCs and 101 European Canadians [ECs] representing the dominant cultural group in Canada) completed a cross-sectional questionnaire about knowledge, health behaviours, and beliefs related to stroke.

RESULTS

Compared with ECs, CCs were less aware of risk factors, warning signs, and appropriate responses to stroke in others. Information sources about stroke included mass media, family, and friends. CCs were less likely to smoke and drink alcohol but were also less likely to be physically active or to participate in structured exercise, less likely to have a healthy diet, and more likely to report stress.

CONCLUSIONS

Theoretical dimensions of culture may explain variations in stroke-related knowledge, behaviours, and beliefs between CCs and ECs. Awareness of cultural differences can help physical therapists evaluate clients and appropriately tailor lifestyle-related health education.

Changes in smoking behavior and subsequent mortality risk during a 35-year follow-up of a cohort in Xi'an, China

Prospective evidence of the associations of smoking cessation with chronic obstructive pulmonary disease (COPD) and other causes of death in Asia is scarce. Previous studies, which were mostly based on baseline smoking behavior only, were subject to sick-quitter bias and misclassification resulting from changes in smoking behavior during follow-up. We followed up a cohort for 18 years (1976-1994) to assess changes in smoking behavior and then for an additional 17 years (1994-2011) to examine the relationships of continuing to smoke and new quitting with mortality risk in 1,494 Chinese people (961 men, 533 women). Of the baseline current smokers, 38.7% quit between 1976 and 1994. From 1994 to 2011, a total of 488 persons (359 men, 129 women) died. Ever smokers had increased risks of lung cancer, coronary heart disease, thrombotic stroke, and COPD, with dose-response relationships. For all tobacco-related mortality, the relative risk for new quitters compared with continuing smokers was 0.68 (95% confidence interval: 0.46, 0.99) for those who had quit 2-7 years previously and 0.56 (95% confidence interval: 0.37, 0.85) for those who had quit 8 years or more previously. The corresponding relative risks were 0.69 and 0.45 for lung cancer, 0.78 and 0.51 for coronary heart disease, 0.76 and 0.84 for thrombotic stroke, and 0.89 and 0.61 for COPD, respectively. Smoking increased tobacco-related deaths, and particularly deaths from COPD, in China, whereas quitting at middle age (at approximately 50 years of age) substantially reduced the risks of death from these causes. The benefits of smoking cessation were underestimated in previous studies that did not use repeated measures.

Smoking and its risk factors in Chinese elementary and middle school students: a nationally representative sample study

OBJECTIVE

The purpose of this study was to examine the prevalence of smoking in a nationally representative sample of Chinese elementary and middle school students and to investigate its risk factors from families and schools.

METHOD

The data were from the National Children's Study of China (NCSC), in which 24,013 fourth- to ninth-grade students were recruited from 100 counties in 31 provinces in China. Chi-square tests and one-way ANOVAs were used to analyze the relationships between smoking and the risk factors. Logistic regressions were used to calculate odds ratios.

RESULTS

The prevalence of ever smokers and current smokers were 19.0% and 5.4%. Focusing on current smokers, boys, middle school students, rural students, boarding students, non-only children and those owning parents with low educational levels reported smoking significantly more than girls, elementary school students, urban students, non-boarding students, only children and those owning parents with high educational levels. Lower trust and support from teachers and higher parent-child conflict positively predicted both smoking and smoking frequency. Lower trust and support from classmates was associated with higher possibility of smoking. However, higher trust and support from classmates was associated with higher smoking frequency. Teacher smoking and friend smoking were only predictive of smoking, but not of smoking frequency.

CONCLUSIONS

Boys, middle school students, rural students, boarding students, non-only children and those owning parents with low educational levels need special attention. The most risk factors for smoking and smoking frequency were lower trust and support from teachers and higher parent-child conflict.

Absolute and comparative cancer risk perceptions among smokers in two cities in China

INTRODUCTION

Knowledge about health effects of smoking motivates quit attempts and sustained abstinence among smokers and also predicts greater acceptance of tobacco control efforts such as cigarette taxes and public smoking bans. We examined whether smokers in China, the world's largest consumer of cigarettes, recognized their heightened personal risk of cancer relative to nonsmokers.

METHODS

A sample of Chinese people (N = 2,517; 555 current smokers) from 2 cities (Beijing and Hefei) estimated their personal risk of developing cancer, both in absolute terms (overall likelihood) and in comparative terms (relative to similarly aged people).

RESULTS

Controlling for demographics, smokers judged themselves to be at significantly lower risk of cancer than did nonsmokers on the comparative measure. No significant difference emerged between smokers and nonsmokers in absolute estimates.

CONCLUSIONS

Smokers in China did not recognize their heightened personal risk of cancer, possibly reflecting ineffective warning labels on cigarette packs, a positive affective climate associated with smoking in China, and beliefs that downplay personal vulnerability among smokers (e.g., I don't smoke enough to increase my cancer risk; I smoke high-quality cigarettes that won't cause cancer).

Periconceptional folic acid supplementation and the risk of preterm births in China: a large prospective cohort study

BACKGROUND

Folic acid-containing multivitamins have been associated with a reduced risk of preterm birth. We examined whether periconceptional use of folic acid alone reduced this risk.

METHODS

Data were derived from a large population-based cohort study conducted in China to evaluate the prevention of neural tube defects with folic acid supplementation. The sample comprised 207 936 singleton live births delivered at gestational ages of 20-42 weeks to women from two provinces in southern China. Healthcare workers recorded folic acid intake prospectively each month. Gestational age calculation was based on the first day of the last menstrual period. Preterm births were categorized into three clinical subtypes: iatrogenic preterm birth, preterm premature rupture of membranes (PPROM) and spontaneous preterm birth. Logistic regression was used to evaluate the association between folic acid use and the risk of preterm birth, adjusting for potential confounders.

RESULTS

The incidence of preterm birth was significantly lower among folic acid users (5.28%) than among non-users (6.10%). Folic acid use showed a 14% risk reduction for preterm birth overall [adjusted risk ratio (RR) = 0.86, 95% confidence interval (CI) 0.82-0.90]. This association was strongest for spontaneous preterm birth (adjusted RR = 0.81, 95% CI 0.78-0.86) and was not significant for iatrogenic preterm birth (adjusted RR = 0.97, 95% CI 0.88-1.07) or PPROM (adjusted RR = 1.07, 95% CI 0.93-1.23).

CONCLUSIONS

Daily intake of 400 μg folic acid alone during the periconceptional period was associated with a reduced risk of spontaneous preterm birth.

Particulate air pollution and mortality in a cohort of Chinese men

Few prior cohort studies exist in developing countries examining the association of ambient particulate matter (PM) with mortality. We examined the association of particulate air pollution with mortality in a prospective cohort study of 71,431 middle-aged Chinese men. Baseline data were obtained during 1990-1991. The follow-up evaluation was completed in January, 2006. Annual average PM exposure between 1990 and 2005, including TSP and PM10, were estimated by linking fixed-site monitoring data with residential communities. We found significant associations between PM10 and mortality from cardiopulmonary diseases; each 10 μg/m(3) PM10 was associated with a 1.6% (95%CI: 0.7%, 2.6%), 1.8% (95%CI: 0.8%, 2.9%) and 1.7% (95%CI: 0.3%, 3.2%) increased risk of total, cardiovascular and respiratory mortality, respectively. For TSP, we observed significant associations only for cardiovascular morality. These data contribute to the scientific literature on long-term effects of particulate air pollution for high exposure settings typical in developing countries.

The potential effects of tobacco control in China: projections from the China SimSmoke simulation model

OBJECTIVE

To use a computer simulation model to project the potential impact in China of tobacco control measures on smoking, as recommended by the World Health Organization Framework Convention on Tobacco Control (FCTC), being fully implemented.

DESIGN

Modelling study.

SETTING

China.

POPULATION

Males and females aged 15-74 years.

INTERVENTION

Incremental impact of more complete implementation of WHO FCTC policies simulated using SimSmoke, a Markov computer simulation model of tobacco smoking prevalence, smoking attributable deaths, and the impact of tobacco control policies. Data on China's adult population, current and former smoking prevalence, initiation and cessation rates, and past policy levels were entered into SimSmoke in order to predict past smoking rates and to project future status quo rates. The model was validated by comparing predicted smoking prevalence with smoking prevalence measured in tobacco surveys from 1996-2010.

MAIN OUTCOME MEASURES

Projected future smoking prevalence and smoking attributable deaths from 2013-50.

RESULTS

Status quo tobacco policy simulations projected a decline in smoking prevalence from 51.3% in 2015 to 46.5% by 2050 in males and from 2.1% to 1.3% in females. Of the individual FCTC recommended tobacco control policies, increasing the tobacco excise tax to 75% of the retail price was projected to be the most effective, incrementally reducing current smoking compared with the status quo by 12.9% by 2050. Complete and simultaneous implementation of all FCTC policies was projected to incrementally reduce smoking by about 40% relative to the 2050 status quo levels and to prevent approximately 12.8 million smoking attributable deaths and 154 million life years lost by 2050.

CONCLUSIONS

Complete implementation of WHO FCTC recommended policies would prevent more than 12.8 million smoking attributable deaths in China by 2050. Implementation of FCTC policies would alleviate a substantial portion of the tobacco related health burden that threatens to slow China's extraordinary gains in life expectancy and prosperity.

Synergistic effect of ALOX5AP polymorphisms and cigarette smoking on the risk of atherosclerotic cerebral infarction in a Northern Han Chinese population

The effect of activating 5-lipoxygenase (ALOX5AP) gene polymorphisms on stroke risk may be influenced by the coexistence of modifiable predisposing conditions. We explored the interactions of ALOX5AP polymorphisms and cigarette smoking in a case-control study of patients with atherosclerotic cerebral infarction (ACI). Three polymorphisms of the ALOX5AP gene (rs10507391, rs4769874, and rs9551963) were analyzed in 420 ACI patients and 488 unrelated healthy controls matched for age and sex from a Northern Han Chinese population. Among the three single nucleotide polymorphisms, only rs10507391 genotype TT/TA was observed to be associated with an increased risk of ACI on multivariate analysis (odds ratio [OR]=1.82, 95% confidence interval [CI]=1.14-2.92, p=0.012) compared with the AA genotype. However, after stratifying by smoking status, multivariate logistic regression analysis revealed that rs10507391 genotype TT/TA and rs9551963 genotype CC/CA had a 5.63-fold (OR=5.63, 95%CI=2.00-15.84, p=0.001) and a 2.71-fold (OR=2.71, 95%CI=1.28-5.73, p=0.009) increased risk for ACI patients who smoked compared with the AA genotype, respectively. Additionally, according to the haplotype analysis, the risk of haplotype TGC (OR=3.12, 95%CI=2.00-4.88, p<0.001, corrected p [pc]<0.001) increased for ACI patients who smoked compared to the data (OR=1.60, 95%CI=1.28-1.98, p<0.001, pc<0.001) in total samples. These results suggest that ALOX5AP polymorphisms are associated with ACI, and cigarette smoking along with ALOX5AP could increase the risk of ACI.

An assessment of health risks and mortality from exposure to secondhand smoke in Chinese restaurants and bars

INTRODUCTION

Smoking is generally not regulated in restaurants or bars in China, or the restrictions are not fully implemented if there are any, while the related hazard health effects are not recognized by the majority of the Chinese population.

OBJECTIVES

This study aims to assess the excess health risks and mortality attributed to secondhand smoke (SHS) exposure in restaurants and bars for both servers and patrons to provide necessary evidence for advancing tobacco control in this microenvironment.

METHODS

Two approaches were used for the assessment. One is a continuous approach based on existing field measurements and Repace and Lowrey's dose-response model, and the other is a categorical approach based on exposure or not and epidemiological studies.

RESULTS

Based on the continuous approach, servers were estimated to have a lifetime excess risk (LER) of lung cancer death (LCD) of 730 to 1,831×10(-6) for working five days a week for 45 years in smoking restaurants and 1,862 to 8,136×10(-6) in smoking bars, and patrons could have a LER of LCD of 47 to 117×10(-6) due to visiting smoking restaurants for an average of 13 minutes a day for 60 years, and 119 to 522×10(-6) due to visiting smoking bars. The categorical approach estimated that SHS exposure in restaurants and bars alone caused 84 LCD and 57 ischemic heart disease (IHD) deaths among nonsmoking servers and 1,2419 LCDs and 1,689 IHD deaths among the nonsmoking patron population.

CONCLUSIONS

SHS exposure in restaurants and bars alone can impose high lifetime excess risks of lung cancer death and ischemic heart disease deaths to both servers and patrons, and can cause a significant number of deaths each year in China. These health risks and deaths can be prevented by banning smoking in restaurants and bars and effectively implementing these smoking bans.

Serum lipocalin-2 levels positively correlate with coronary artery disease and metabolic syndrome

Background

The lipocalin-2 (LCN2) cytokine, primarily known as a protein of the granules of human neutrophils, has been recently reported to be implicated in metabolic and inflammatory disorders. This study was designed to evaluate the relationship between serum LCN2 levels and coronary artery disease (CAD).

Methods

Serum LCN2 levels of 261 in-patients who underwent coronary angiography were measured by sandwich enzyme immunoassay. Demographic (169 men and 92 postmenopausal women) and clinical (metabolic syndrome (MS), triglyceride (TG) and C-reactive protein (CRP) levels) characteristics were collected to assess independent factors of CAD (CAD: 188 and non-CAD: 73) and serum LCN2 levels by multiple logistic regression and multivariate stepwise regression analyses, respectively.

Results

Serum LCN2 levels were significantly higher in men (37.5 (27.4-55.4) vs. women: 28.2 (18.7-45.9) ng/mL, p < 0.01) and men with CAD (39.2 (29.3-56.5) vs. non-CAD men: 32.7 (20.5-49.7) ng/mL, p < 0.05), and showed significant positive correlation with CAD in men (odds ratio = 2.218, 95% confidence interval: 1.017-4.839). Similarly, serum LCN2 levels were significantly higher in men with MS (40.2 (31.9-59.4) vs. non-MS: 32.0 (21.7-47.6) ng/mL, p < 0.01) and showed a significant positive correlation with the number of MS components (p for trend < 0.05). No significant differences or correlations were seen in women. TG and neutrophils (standard β = 0.238 and 0.173) were independent factors of serum LCN2 levels in men, and only neutrophils (standard β = 0.286) affected levels in women (all p < 0.05).

Conclusions

Increased serum LCN2 levels are positively correlated with the presence of CAD and MS in a Chinese cohort.

Contributions of major smoking-related diseases to reduction in life expectancy associated with smoking in Chinese adults: a cross-sectional study

BACKGROUND

Cigarette smoking is a prominent risk factor for a wide range of diseases. The current study aimed to evaluate the impact of smoking on deaths from major smoking-related diseases (neoplasms, vascular diseases and respiratory diseases) in Chinese adults by estimating the potential gains in life expectancy (LE) that would accrue from eliminating deaths from these diseases, and to determine the contribution of each disease to the reduction in LE associated with smoking.

METHODS

Two cohorts of Chinese smokers and non-smokers were constructed from a retrospective national mortality survey that had been conducted in 1989-1991 and included one million all-cause deaths among adults during 1986-1988 in 103 geographical regions. For each cohort, potential gains in LE by eliminating deaths from each major smoking-related disease were estimated. The contributions of each disease to smoking-associated reduction in LE were assessed using the LE decomposition approach.

RESULTS

Among the major smoking-related diseases, it was estimated that elimination of vascular diseases would provide the greatest potential gain in LE (years), regardless of smoking status. The gains for smokers versus non-smokers in populations of urban men, urban women, rural men and rural women aged 35 years were 3.5 vs. 4.3, 3.8 vs. 4.1, 2.4 vs. 3.0, and 2.6 vs. 2.9 years, respectively. Respiratory diseases contributed most to smoking-associated LE reductions in urban women, rural men and rural women of 43.6%, 46.4%, and 62.9%, respectively. In urban men, neoplasms contributed most to smoking-associated LE reduction, their contribution being estimated as 45.8%.

CONCLUSIONS

Respiratory disease has the greatest influence on the LE reduction associated with smoking. Thus, smoking prevention could significantly reduce deaths from respiratory disease and improve LE.

Incidence trends of urinary bladder and kidney cancers in urban Shanghai, 1973-2005

Objectives

We examined the incidence trends of bladder and kidney cancers using a population-based cancer registration data.

Methods

Age-standardized incidence rates were analyzed using data from the Shanghai Cancer Registry during 1973 to 2005. Annual percentage changes and 95% confidence intervals were calculated to evaluate the incidence changes. Age-period-cohort analysis was further implemented to assess the contributions of age, period and cohort effects to the trends using the intrinsic estimator method.

Results

In total, 12,676 bladder and 5,811 kidney cancer patients were registered in urban Shanghai. The age-standardized rates of bladder cancer in males increased from 6.39 to 7.66 per 100,000, or 0.62% per year, whereas the rates in females increased from 1.95 to 2.09 per 100,000, or 0.33% per year. For kidney cancer, the age-standardized rates in males increased from 1.20 to 5.64 per 100,000, or 6.98% per year. Similarly in females, the rates increased from 0.85 to 3.33 per 100,000, or 5.93% per year. Age-period-cohort analysis showed increasing curves of age and period effects but generally decreasing cohort effects for bladder and kidney cancers.

Conclusions

Our results show increasing incidence trends of bladder and kidney cancers in Chinese men and women, especially for kidney cancer.

Identifying the intergenerational effects of the 1959-1961 Chinese Great Leap Forward Famine on infant mortality

Using the 1959-1961 Chinese Great Leap Forward Famine as a natural experiment, this study examines the relationship between mothers' prenatal exposure to acute malnutrition and their children's infant mortality risk. According to the results, the effect of mothers' prenatal famine exposure status on children's infant mortality risk depends on the level of famine severity. In regions of low famine severity, mothers' prenatal famine exposure significantly reduces children's infant mortality, whereas in regions of high famine severity, such prenatal exposure increases children's infant mortality although the effect is not statistically significant. Such a curvilinear relationship between mothers' prenatal malnutrition status and their children's infant mortality risk is more complicated than the linear relationship predicted by the original fetal origins hypothesis but is consistent with the more recent developmental origins of health and disease theory.

Association of passive smoking with cognitive impairment in nonsmoking older adults: a systematic literature review and a new study of Chinese cohort

Association of passive smoking with cognitive impairment in older adults is unclear. We carried out a systematic literature review and a new study to determine the association. There were 3 cross-sectional studies published, showing a significant association of passive smoking with cognitive impairment (a relative risk (RR) of about 1.30-1.90). In the new cohort study, we interviewed 1081 never-smoking participants aged ≥ 65 years in China using a standard method of the Geriatric Mental State-Automated Geriatric Examination for Computer Assisted Taxonomy and found a significant association with dose response; multivariate adjusted RR was 1.02 (95% confidence interval 0.67-1.55) in > 0 to 49 exposure level years of passive smoking, 1.57 (1.00-2.47) in 50 to 99, and 2.12 (1.24-3.63) in ≥ 100, trend P = .008. The relationship seems not to be a reverse causality of the effect. Passive smoking could be considered an important risk factor for cognitive impairment in older adults. Avoiding exposure to passive smoking would help to preserve cognitive decline in later life.

The China Patient-Centered Evaluative Assessment of Cardiac Events (China PEACE) retrospective study of acute myocardial infarction: study design

BACKGROUND

Cardiovascular diseases are rising as a cause of death and disability in China. To improve outcomes for patients with these conditions, the Chinese government, academic researchers, clinicians, and >200 hospitals have created China Patient-Centered Evaluative Assessment of Cardiac Events (China PEACE), a national network for research and performance improvement. The first study from China PEACE, the Retrospective Study of Acute Myocardial Infarction (China PEACE-Retrospective AMI Study), is designed to promote improvements in acute myocardial infarction (AMI) quality of care by generating knowledge about the characteristics, treatments, and outcomes of patients hospitalized with AMI across a representative sample of Chinese hospitals during the past decade.

METHODS AND RESULTS

The China PEACE-Retrospective AMI Study will examine >18 000 patient records from 162 hospitals identified using a 2-stage cluster sampling design within economic-geographic regions. Records were chosen from 2001, 2006, and 2011 to identify temporal trends. Data quality will be monitored by a central coordinating center and will, in particular, address case ascertainment, data abstraction, and data management. Analyses will examine patient characteristics, diagnostic testing patterns, in-hospital treatments, in-hospital outcomes, and variation in results by time and site of care. In addition to publications, data will be shared with participating hospitals and the Chinese government to develop strategies to promote quality improvement.

CONCLUSIONS

The China PEACE-Retrospective AMI Study is the first to leverage the China PEACE platform to better understand AMI across representative sites of care and during the past decade in China. The China PEACE collaboration among government, academicians, clinicians, and hospitals is poised to translate research about trends and patterns of AMI practices and outcomes into improved care for patients.

CLINICAL TRIAL REGISTRATION

URL: http://www.clinicaltrials.gov. Unique identifier: NCT01624883.

Exhaled carbon monoxide and its associations with smoking, indoor household air pollution and chronic respiratory diseases among 512,000 Chinese adults

BACKGROUND

Exhaled carbon monoxide (COex) level is positively associated with tobacco smoking and exposure to smoke from biomass/coal burning. Relatively little is known about its determinants in China despite the population having a high prevalence of smoking and use of biomass/coal.

METHODS

The China Kadoorie Biobank includes 512,000 participants aged 30-79 years recruited from 10 diverse regions. We used linear regression and logistic regression methods to assess the associations of COex level with smoking, exposures to indoor household air pollution and prevalent chronic respiratory conditions among never smokers, both overall and by seasons, regions and smoking status.

RESULTS

The overall COex level (ppm) was much higher in current smokers than in never smokers (men: 11.5 vs 3.7; women: 9.3 vs 3.2). Among current smokers, it was higher among those who smoked more and inhaled more deeply. Among never smokers, mean COex was positively associated with levels of exposures to passive smoking and to biomass/coal burning, especially in rural areas and during winter. The odds ratios (OR) and 95% confidence interval (CI) of air flow obstruction (FEV1/FVC ratio<0.7) for never smokers with COex at 7-14 and ≥14 ppm, compared with those having COex<7, were 1.38 (1.31-1.45) and 1.65 (1.52-1.80), respectively (Ptrend<0.001). Prevalence of other self-reported chronic respiratory conditions was also higher among people with elevated COex (P<0.05).

CONCLUSION

In adult Chinese, COex can be used as a biomarker for assessing current smoking and overall exposure to indoor household air pollution in combination with questionnaires.

Making hospitals in China smoke-free: a prospective study of implementing the new standard

OBJECTIVES

In the run-up to all Chinese health care facilities becoming smoke-free, the feasibility of the new standard was assessed by monitoring its implementation in a sample of Chinese hospitals.

METHODS

Forty-one hospitals across 20 provinces were asked to ban smoking inside the hospital and provide advice and referral to stop-smoking treatment. Smoking status of more than 24,000 members of staff at 21 hospitals was surveyed at baseline (April 2009) and at follow-up (October 2010). Surveys monitored implementation of several specific aspects of the new standard to identify potential barriers to nationwide implementation.

RESULTS

All hospitals managed to implement the ban and most set up smoking cessation clinics. Routine recording of patients' smoking status proved more difficult to implement. The hospitals improved significantly in 8 out of 11 monitored policy parameters. Smoking prevalence among staff decreased from 14.8% to 10.7% (p < .001), suggesting an important collateral benefit of making hospitals smoke-free. Outdoor smoking areas facilitated the indoor ban. Staff education emerged as the key priority.

CONCLUSIONS

The smoke-free standard is feasible even in a country with a widespread acceptance of smoking inside health facilities. Several challenges need to be addressed when the new standard is disseminated across China.

A syndemic including cigarette smoking and sexual risk behaviors among a sample of MSM in Shanghai, China

OBJECTIVES

We explored possible correlates of cigarette smoking and their associations with levels of smoking among a sample of Chinese men who have sex with men (MSM). We also explored the syndemic associations of substance use and psychosocial problems on sexual risk behaviors.

METHODS

Cross-sectional data collection from 404 MSM in Shanghai, China.

RESULTS

MSM exhibit a high prevalence of smoking (66.3%). Both light and heavy smoking were associated with alcohol and drug use, depression, intimate partner violence, sexual attitudes, and gay identity (though the associations for light smokers were moderate compared to those for heavy smokers).

CONCLUSIONS

Our findings indicate the presence of a health syndemic among MSM, and suggest that smoking prevention and cessation and other substance abuse interventions should be integrated into efforts preventing sexual risk behaviors among MSM.

Relationship between knowledge about the harms of smoking and smoking status in the 2010 Global Adult Tobacco China Survey

BACKGROUND

This analysis estimates the association between smoking-related knowledge and smoking behaviour in a Chinese context. To identify the specific knowledge most directly related to smoking status, we used a novel latent variable analysis approach to adjust for the high correlations between different measures of knowledge about tobacco smoking.

METHOD

Data are from the Global Adult Tobacco China Survey, a nationally representative sample of 13 354 household-dwelling individuals 15 years of age or older. Multinomial logistic regressions estimated the association between smoking status (ie, never smoked, current smoker or past smoker) and four smoking-related beliefs: whether or not smoking causes lung cancer, heart attack and stroke, and whether or not low-tar cigarettes are less harmful. A latent variable approach reassessed these associations while taking into account the general level of knowledge about smoking.

RESULTS

After demographic variables and general knowledge about smoking had been controlled for, the belief that low-tar cigarettes are not less harmful was more prevalent in persons who had never smoked than in current smokers (OR=1.3 (95% CI 1.0 to 1.7) in men and OR=2.8 (95% CI 1.3 to 5.9) in women); this association was even stronger when past smokers and current smokers were compared (OR=2.1 (95% CI 1.5 to 3.0) in men and OR=5.0 (95% CI 1.3 to 20.1) in women).

CONCLUSIONS

Compared with those who have never smoked and those who have ceased smoking, current smokers in China are more likely to believe that low-tar cigarettes are less harmful than regular cigarettes.

Additive relationship between serum fibroblast growth factor 21 level and coronary artery disease

Background

Expression and activity of the fibroblast growth factor (FGF) 21 hormone-like protein are associated with development of several metabolic disorders. This study was designed to investigate whether serum FGF21 level was also associated with the metabolic syndrome-related cardiovascular disease, atherosclerosis, and its clinical features in a Chinese cohort.

Methods

Two-hundred-and-fifty-three subjects visiting the Cardiology Department (Sixth People's Hospital affiliated to Shanghai JiaoTong University) were examined by coronary arteriography (to diagnose coronary artery disease (CAD)) and hepatic ultrasonography (to diagnose non-alcoholic fatty liver disease (NAFLD)). Serum FGF21 level was measured by enzyme-linked immunosorbent assay and analyzed for correlation to subject and clinical characteristics. The independent factors of CAD were determined by multivariate logistic regression analysis.

Results

Subjects with NAFLD showed significantly higher serum FGF21 than those without NAFLD (388.0 pg/mL (253.0-655.4) vs. 273.3 pg/mL (164.9-383.7), P < 0.01). Subjects with CAD showed significantly higher serum FGF21, regardless of NAFLD diagnosis (P < 0.05). Serum FGF21 level significantly elevated with the increasing number of metabolic disorders (P for trend < 0.01). After adjustment of age, sex, and BMI, FGF21 was positively correlated with total cholesterol (P < 0.05) and triglyceride (P < 0.01). FGF21 was identified as an independent factor of CAD (odds ratio = 2.984, 95% confidence interval: 1.014-8.786, P < 0.05).

Conclusions

Increased level of serum FGF21 is associated with NAFLD, metabolic disorders and CAD.

Smoking experimentation among elementary school students in China: influences from peers, families, and the school environment

The aim of this study was to investigate experimentation with smoking among primary school students in China. Data were acquired from a recent survey of 4,073 students in grades 4 to 6 (ages 9–12) in 11 primary schools of Ningbo City. The questions were adapted from the Global Youth Tobacco Survey (GYTS). Results suggest that although the Chinese Ministry of Education (MOE) encourages smoke-free schools, experimentation with cigarettes remains a serious problem among primary school students in China. Peers, family members, and the school environment play important roles in influencing smoking experimentation among students. Having a friend who smoked, seeing a family member smoke, and observing a teacher smoking on campus predicted a higher risk of experimentation with smoking; the exposure to anti-tobacco materials at school predicted a lower risk of experimentation with smoking. The evidence suggests that public health practitioners and policymakers should seek to ensure the implementation of smoke-free policies and that intervention should target young people, families, and communities to curb the commencement of smoking among children and adolescents in China.

Maternal passive smoking during pregnancy and neural tube defects in offspring: a meta-analysis

PURPOSE

This study aims to examine the association between maternal passive smoking during pregnancy and the occurrence of neural tube defects (NTDs) in offspring.

METHODS

We retrieved studies published on the association between maternal passive smoking during pregnancy and the occurrence of NTDs in offspring. Meta-analysis was applied to calculate the pooled effect estimates and their 95% confidence intervals (CIs) using data from 10 case-control studies. The publication bias was assessed by the Egger's regression asymmetry test and Begg's rank correlation test with Begg's funnel plot.

RESULTS

The pooled effect estimate of maternal passive smoking was 1.82 (95% CI 1.46-2.27) for total NTDs; the effect estimates were 1.72 (95% CI 1.44-2.06), 1.52 (95% CI 1.29-1.79), and 2.32 (95% CI 1.34-4.01) for NTDs subtypes of anencephaly, spina bifida and encephalocele, respectively. Stratified by geographic region of the studies, the pooled effect estimates were 2.11 (95% CI 1.46-3.06), 1.65 (95% CI 1.16-2.34), 1.25 (95% CI 0.41-3.80) in China, USA and Iran, respectively.

CONCLUSIONS

This meta-analysis suggested that maternal passive smoking during pregnancy was associated with an increased risk of total NTDs and three NTDs subtypes in offspring. Specifically, the associations were also found to be significantly positive both in China and USA.

Smoking, heart rate, and ischemic stroke: a population-based prospective cohort study among Inner Mongolians in China

BACKGROUND AND PURPOSE

Smoking is a major public health challenge and an important risk factor for cardiovascular diseases. No previous studies have evaluated the association among smoking, heart rate, and ischemic stroke in an Inner Mongolian population. We aim to evaluate the cumulative effect of smoking and heart rate on ischemic stroke incidence in this population.

METHODS

A prospective cohort study from June 2003 through July 2012 was conducted among 2530 people ≥20 years of age from Inner Mongolia, China. We categorized the participants into 4 subgroups according to smoking status and heart rate. Cox proportional hazards models and receiver operating characteristic curves were used to evaluate the association among smoking, heart rate, and ischemic stroke.

RESULTS

The multivariate-adjusted hazard ratios (95% confidence intervals) of ischemic stroke incidence for nonsmokers with heart rate ≥80 bpm, smokers with heart rate <80 bpm, and smokers with heart rate ≥80 bpm were 1.42 (0.62-3.28), 2.11 (1.06-4.23), and 2.86 (1.33-6.14), respectively, compared with nonsmokers with heart rate <80 bpm. The area under receiver operating characteristic curve (area under the curve) for a model containing smoking status and heart rate, along with conventional factors (area under the curve=0.755), was significantly (P=0.018) larger than the one containing only conventional factors (area under the curve=0.739).

CONCLUSIONS

Our study indicated that smoking was an independent risk factor of ischemic stroke, and smokers with faster heart rate had the highest risk of ischemic stroke among Inner Mongolians. These findings suggest that smoking status and heart rate may be valuable in predicting ischemic stroke incidence.

The association between BMI and COPD: the results of two population-based studies in Guangzhou, China

BACKGROUND AND OBJECTIVE

An association between chronic obstructive pulmonary disease (COPD) and low body mass index (BMI) has been well established in cross-sectional studies. However, there have been few cohort studies investigating this issue. We therefore aimed to address this gap.

METHODS

Two population-based studies, a cross-sectional study including 1818 subjects and a subsequent 4-year cohort study consisting of 759 individuals without COPD, were conducted in Guangzhou, China. Every subject was 40 years old or older at the time of recruitment and completed questionnaire interviews, anthropometric measurements and spirometry testing. As a follow-up, each subject underwent annual pre-bronchodilator spirometry testing. Subjects with a pre-bronchodilator FEV1/FVC <0.7 were required to undergo post-bronchodilator spirometry testing. Subjects with a post-bronchodilator FEV1/FVC <0.7 were diagnosed with COPD.

RESULTS

Compared to subjects with normal BMI (18.5 to 23.9 kg/m(2)), those with low BMI (<18.5 kg/m(2)) had a higher prevalence of COPD (21.1% vs. 7.5%), with an adjusted OR of 2.75 [95% confidence intervals (CI): 1.69 to 4.47]. Both low BMI and obese (≥ 28.0 kg/m(2)) subjects had lower FEV1 after adjustment. This association was further confirmed in the cohort study; non-COPD subjects with low BMI at baseline were more likely to develop COPD (RR = 2.88, 95% CI: 1.06 to 7.85), independent of smoking status and other confounders.

CONCLUSIONS

Low BMI was not only a systemic consequence of COPD but also an important risk factor for the development of COPD, which raises the possibility that early intervention in subjects with low BMI may reduce the incidence of COPD.

Does cigarette smoking exacerbate the effect of blood pressure on the risk of cardiovascular and all-cause mortality among hypertensive patients?

OBJECTIVE

To examine the risk of cigarette smoking on cardiovascular disease (CVD) and all-cause mortality among hypertensive patients.

METHODS

We conducted a prospective cohort study among 36,943 hypertensive patients aged at least 40 years. Data on smoking and other variables were obtained in 1991 and follow-up evaluation was conducted in 1999-2000.

RESULTS

During a median follow-up of 8.2 years, we documented 7194 deaths among 36 943 hypertensive patients. Compared with never-smokers, the multivariate-adjusted relative risks (MRRs) [95% confidence intervals (CIs)] for CVD mortality were 1.19 (1.07, 1.31) and 1.33 (1.23, 1.45) for those who smoked 0.1-19 pack-years and at least 20 pack-years (P for linear trends <0.001 for all). A similar pattern was observed for all-cause mortality. A dose-response association between pack-years smoked and risk of CVD and all-cause mortality (all P ≤ 0.01) was found among the SBP groups (140-159, 160-179, and ≥ 180 mmHg), DBP groups (<90, 90-94, and 100-109 mmHg), and pulse pressure groups (50-59, 60-69, and ≥ 70 mmHg). In addition, compared to never-smokers with stage 1 hypertension, MRRs of CVD and all-cause mortality for those who smoked at least 20 pack-years with stage 3 hypertension were remarkably increased to 3.06 (2.64, 3.54) and 2.51 (2.24, 2.80), respectively.

CONCLUSIONS

Smoking not only significantly increased the risk of CVD and all-cause mortality among hypertensive groups, but the synergistic effect on the risk of CVD and all-cause mortality existed between cigarette smoking and blood pressure category. Therefore, apart from hypertension management, smoking cessation should be an essential component for preventing deaths related to smoking.

Is There a Stroke Belt in China and Why?

Background and Purpose—

In 1960s, a stroke belt with high stroke mortality was discovered in the southeast United States. In China, where stroke is the leading cause of death, we aimed to determine whether a focal region of high stroke incidence (stroke belt) exits and, if so, the possible causal and modifiable factors.

Methods—

We systematically reviewed all studies of stroke incidence in China between 1980 and 2010, and included those which met our criteria for a high-quality study. Criteria for a provincial region of high stroke incidence were ranking in the top one third of all provinces for stroke incidence and ranking of more than one third of prefectural regions within the province in the top two sevenths of all prefectural regions for stroke incidence. We also reviewed regional distribution of major vascular risk factors, socioeconomic status, and demographic profiles in China.

Results—

Nine eligible studies provided data on the incidence of stroke in 32 of 34 provincial regions of China (with Hong Kong and Macao as exceptions) and 52% of the 347 prefectural regions. Nine provincial regions (Heilongjiang, Tibet, Jilin, Liaoning, Xinjiang, Hebei, Inner Mongolia, Beijing, and Ningxia) met our criteria for a region of high stroke incidence and constitute a stroke belt in north and west China. The incidence of stroke in the stroke belt was 236.2 per 100 000 population compared with 109.7 in regions outside the belt (rate ratio, 2.16; 95% confidence interval, 2.10–2.22). The mean population prevalence of hypertension and overweight (body mass index, >25) was greater in the stroke belt than that in other regions (15.3% versus 10.3%, P <0.001; 21.1% versus 12.3%, P =0.013, respectively). The prevalence of hypertension and overweight also correlated significantly with regional stroke incidence ( R =0.642, P <0.001; R =0.438, P =0.014, respectively, by Spearman rank correlation).

Conclusions—

A stroke belt of high stroke incidence exists in 9 provincial regions of north and west China. The stroke belt may be caused, at least in part, by a higher population prevalence of hypertension and excess body weight. Lowering blood pressure and body weight in the stroke belt may reduce the geographic disparity in stroke risk and incidence in China.

Smoking intensity among male factory workers in Kunming, China

INTRODUCTION

This study investigated the intensity of cigarette consumption and its correlates in China among urban male factory workers, a cohort especially vulnerable to tobacco exposure, one that appears to have benefitted little from recent public health efforts to reduce smoking rates.

METHODS

Data were collected from men working in factories of Kunming city, Yunnan, China, who are current daily smokers (N = 490). A multinomial logistic regression was conducted to examine the factors in association with smoking intensity in light, moderate, and heavy levels.

RESULTS

Light smoking correlated with social smoking, smoking the first cigarette later in the day, self-reported health condition, and quit intention. Heavy smoking was associated with purchase of lower priced cigarettes, difficulty refraining from smoking, and prehypertensive blood pressure.

CONCLUSION

Even in regions where smoking is highly prevalent, even among cohorts who smoke heavily, variation exists in how cigarettes are consumed. Analyses of this consumption, with special consideration given to smoking intensity and its correlates, can help guide tobacco-control strategists in developing more effective interventions.

Periconceptional paternal smoking and the risk of congenital heart defects: a case-control study

BACKGROUND

Maternal smoking during pregnancy has been consistently associated with an increased risk of congenital heart defects (CHDs). However, few studies have reported the association between paternal smoking during pregnancy and CHDs among offspring. This report presents the first case-control study to investigate the possible association between periconceptional paternal smoking and CHDs in China.

METHODS

From February 2010 through October 2011, 284 case fetuses with nonsyndromic CHDs and 422 control fetuses with no birth defects were recruited. The mothers of cases and controls were interviewed regarding whether the fathers of fetuses smoked and avoided the mothers while smoking during the periconceptional period. An unconditional logistic regression was used to calculate the adjusted odds ratios (AORs) and 95% confidence intervals (CIs) while controlling for potential confounders.

RESULTS

Light paternal smoking increased the risk of isolated conotruncal heart defects (AOR, 2.23; 95% CI, 1.05, 4.73). Medium paternal smoking seemed to be associated with septal defects (AOR, 2.04; 95% CI, 1.05, 3.98) and left ventricular outflow tract obstructions (AOR, 2.48; 95% CI, 1.04, 5.95). Heavy paternal smoking was also associated with isolated conotruncal heart defects (AOR, 8.16; 95% CI, 1.13, 58.84) and left ventricular outflow tract obstructions (AOR, 13.12; 95% CI, 2.55, 67.39). Paternal smoking with no avoidance behavior was associated with an increased risk of these CHDs subtypes.

CONCLUSIONS

Periconceptional paternal smoking increased the risk of isolated conotruncal heart defects, septal defects and left ventricular outflow tract obstructions. The avoidance behavior of paternal smokers may decrease the risk of selected CHDs.