Smoking in China: findings of the 1996 National Prevalence Survey

Folic Acid Supplementation During Early Pregnancy and the Risk of Gestational Hypertension and Preeclampsia

Emerging evidence has suggested that folic acid–containing multivitamins may markedly reduce the risk of gestational hypertension or preeclampsia. We examined whether maternal supplementation with folic acid alone during early pregnancy can prevent the occurrence of gestational hypertension and preeclampsia. The data are from a large population-based cohort study established to evaluate the effectiveness of the campaign to prevent neural tube defects with folic acid supplementation in China. We selected participants who were registered in 2 southern provinces, had exact information on folic acid use, and were not affected by chronic hypertension or diabetes mellitus before 20 weeks gestation. A logistic regression model was used to adjust for the effects of the main potential confounders, including age, body mass index, education, occupation, parity, and multiple births. The study size had 99.9% power (α=0.05) to detect a decrease of 10% over the unexposed rate of 9.4% for gestational hypertension. Among the 193 554 women (47.9% took folic acid, 52.1% did not), the overall incidence of gestational hypertension and preeclampsia was 9.5% and 2.5%, respectively. The incidence of gestational hypertension and preeclampsia was 9.7% and 2.5% for women who took folic acid, and 9.4% and 2.4% for women who did not use it. The adjusted risk ratio associated with folic acid use was 1.08 (95% confidence interval, 1.04–1.11) for gestational hypertension and 1.11 (95% confidence interval, 1.04–1.18) for preeclampsia. Our findings suggest that daily consumption of 400 μg folic acid alone during early pregnancy cannot prevent the occurrence of gestational hypertension and preeclampsia.

Serum pigment epithelium-derived factor levels are independently correlated with the presence of coronary artery disease

Background

Pigment epithelium-derived factor (PEDF) has been proved to be closely correlated with metabolic syndrome (MetS) and its components that are all risk factors of cardiovascular disease and may play a protective role against vascular injury and atherosclerosis. The present study was designed to investigate the relationship between serum PEDF and coronary artery disease (CAD).

Methods

A total of 312 consecutive in-patients (including 228 with CAD and 197 with MetS) who underwent coronary angiography were enrolled. Serum PEDF was measured by sandwich enzyme immunoassay and used to carry out multivariate stepwise regression analysis to assess correlation with patient demographic and clinical parameters. Multiple logistic regression analysis was performed to identify factors independently correlated with CAD.

Results

Patients with MetS had significantly higher levels of serum PEDF than non-MetS subjects (11.1(8.2, 14.2) vs. 10.1(7.6, 12.4) μg/mL; P < 0.05). Patients with CAD also had significantly higher serum PEDF than non-CAD subjects (11.0(8.1, 14.2) vs. 10.3(8.1, 12.8) μg/mL; P < 0.05). Triglyceride (TG), C-reactive protein (CRP), estimated glomerular filtration rate (eGFR), and hypoglycemic therapy were independently correlated with serum PEDF levels, and serum PEDF was independently positively correlated with CAD.

Conclusions

Serum PEDF levels are independently positively associated with CAD in a Chinese population. Elevated PEDF may act as a protective response against vascular damage and subsequent CAD.

Developmental trajectories of cigarette use and associations with multilayered risk factors among Chinese adolescents

INTRODUCTION

We aimed to identify developmental trajectories of cigarette use and risk factors associated with the distinct developmental courses of smoking in Chinese early adolescents from age 12 to 16 years.

METHODS

Analysis was conducted with secondary data from a longitudinal, prospective cohort of 3,521 Chinese adolescents randomly selected from 4 rural and 7 urban middle schools in Wuhan, China. A group-based growth mixture modeling approach was adopted to identify developmental trajectories of cigarette use. Multilayered intrapersonal (e.g., attitudes toward smoking) and interpersonal (e.g., parental smoking and perceived parental disapproval of smoking) risk factors selected from an ecological perspective were prospectively linked to the identified patterns of smoking trajectory.

RESULTS

Three trajectory patterns were identified from the whole cohort: nonsmokers (48.7%), stable light/occasional smokers (48.6%), and accelerating smokers (2.7%). After adjustments for gender, urban residence, and family socioeconomic status, adolescents with higher levels of problems in parent-child relationships and family disharmony, higher perceived norms of peer smoking, higher proportion of good friend smoking, having more troubles with teachers, poorer academic performance, and reporting more frequent depressive symptoms were significantly more likely to be in the trajectory group of either stable light/occasional smokers or accelerating smokers than in the group of nonsmokers. The probability of being in the accelerating smoking trajectory group was positively and significantly related to parental smoking and lack of school bonding.

CONCLUSIONS

Study findings help to advance knowledge of the distinct developmental courses of smoking behavior and their associations with multilayered risk factors among Chinese early adolescents.

Comparing the experience of regret and its predictors among smokers in four Asian countries: findings from the ITC surveys in Thailand, South Korea, Malaysia, and China

Introduction:

Nearly all smokers in high-income Western countries report that they regret smoking (Fong, G. T., Hammond, D., Laux, F. L., Zanna, M. P., Cummings, M. K., Borland, R., & Ross, H. [2004]. The near-universal experience of regret among smokers in four countries: Findings from the International Tobacco Control Policy Evaluation Survey. Nicotine and Tobacco Research, 6, S341–S351. doi:10.1080/14622200412331320743), but no research to date has examined the prevalence of regret among smokers in non-Western, low- and middle-income countries.

Methods:

Data were from the International Tobacco Control (ITC) Surveys of smokers in 4 Asian countries (China, Malaysia, South Korea, and Thailand); N = 9,738. Regret was measured with the statement: “If you had to do it over again, you would not have started smoking.”

Results:

Prevalence of regret in 3 countries (South Korea = 87%, Malaysia = 77%, and China = 74%) was lower than that found by Fong et al. in the United States, Australia, Canada, and the United Kingdom (89%–90%); but was higher in Thailand (93%). These significant country differences in regret corresponded with differences in tobacco control and norms regarding smoking. The predictors of regret in the Asian countries were very similar to those in the 4 Western countries: Regret was more likely to be experienced by smokers who smoked fewer cigarettes per day, perceived greater benefits of quitting and higher financial costs of smoking, had more prior quit attempts, worried that smoking would damage their health, and felt that their loved ones and society disapproved of smoking. Regret was also positively associated with intentions to quit (r = 0.23, p < .001).

Conclusions:

Across the Asian countries and high-income Western countries, the prevalence of regret varies, but the factors predicting regret are quite consistent. Regret may be an important indicator of tobacco control and is related to factors associated with future quitting.

Trends in smoking and lung cancer mortality in Japan, by birth cohort, 1949-2010

OBJECTIVE

To determine smoking trends in Japan in comparison with lung cancer mortality.

METHODS

Age-specific smoking prevalence among cohorts born between 1897 and 1985 were determined for the period 1949-2010. The percentages of the cohorts born between 1893 and 1979 who initiated smoking early (e.g. before the age of 20 years) were determined. The results were compared against lung cancer mortality rates in people aged 40-84 years belonging to cohorts born between 1868 and 1968.

FINDINGS

In males, smoking prevalence was generally high, particularly among those born before the late 1950s, and early initiation was fairly uncommon. Early initiation was most common among recent birth cohorts of males, who showed relatively low prevalences of smoking. In females, the prevalence of smoking was generally low and early initiation was very uncommon, particularly among those born in the late 1930s and before the late 1940s, respectively. Recent cohorts of females showed relatively high prevalences of smoking and relatively high percentages of early initiation. In both sexes, lung cancer mortality was generally low but increased over the study period.

CONCLUSION

Lung cancer mortality in Japanese males was relatively low given the high prevalence of smoking, perhaps because early initiation was fairly uncommon. Over the last four decades, however, early initiation of smoking has become more common in both sexes. The adverse effect this is likely to have on lung cancer mortality rates has probably not been observed because of the long time lag between smoking initiation and death from lung cancer.

Indoor air pollution and risk of lung cancer among Chinese female non-smokers

PURPOSE

To investigate indoor particulate matter (PM) level and various indoor air pollution exposure, and to examine their relationships with risk of lung cancer in an urban Chinese population, with a focus on non-smoking women.

METHODS

We conducted a case-control study in Taiyuan, China, consisting of 399 lung cancer cases and 466 controls, of which 164 cases and 218 controls were female non-smokers. Indoor PM concentrations, including PM(1), PM(2.5), PM(7), PM(10), and TSP, were measured using a particle mass monitor. Unconditional logistic regression models were used to calculate odds ratios (ORs) and 95 % confidence intervals after adjusting for age, education, annual income, and smoking.

RESULTS

Among non-smoking women, lung cancer was strongly associated with multiple sources of indoor air pollution 10 years ago, including heavy exposure to environmental tobacco smoke at work (aOR = 3.65), high frequency of cooking (aOR = 3.30), and solid fuel usage for cooking (aOR = 4.08) and heating (aOR(coal stove) = 2.00). Housing characteristics related to poor ventilation, including single-story, less window area, no separate kitchen, no ventilator, and rarely having windows open, are associated with lung cancer. Indoor medium PM(2.5) concentration was 68 μg/m(3), and PM(10) was 230 μg/m(3). PM levels in winter are strongly correlated with solid fuel usage for cooking, heating, and ventilators. PM(1) levels in cases are more than 3 times higher than that in controls. Every 10 μg/m(3) increase in PM(1) is associated with 45 % increased risk of lung cancer.

CONCLUSIONS

Indoor air pollution plays an important role in the development of lung cancer among non-smoking Chinese women.

Epidemiology of smoking among Malaysian adult males: prevalence and associated factors

BACKGROUND

Three National Health and Morbidity Surveys (NHMSs) had been conducted in Malaysia in 10-year intervals from 1986-2006. Based on the latest NHMS survey in 2006, we describe the prevalence of smoking and identify the social and demographic factors associated with smoking among adult males in Malaysia.

METHODS

A cross-sectional study among 15,639 Malaysian adult males aged 18 years and above was conducted using proportional to size stratified sampling method. The socio-demographic variables examined were level of education, occupation, marital status, residential area, age group and monthly household income.

RESULTS

The prevalence of smoking among adult males in Malaysia was 46.5% (95% CI: 45.5-47.4%), which was 3% lower than a decade ago. Mean age of smoking initiation was 18.3 years, and mean number of cigarettes smoked daily was 11.3. Prevalence of smoking was highest among the Malays (55.9%) and those aged 21-30 years (59.3%). Smoking was significantly associated with level of education (no education OR 2.09 95% CI (1.67-2.60), primary school OR 1.95, 95% CI (1.65-2.30), secondary school OR 1.88, 95% CI (1.63-2.11), with tertiary education as the reference group). Marital status (divorce OR 1.67, 95% CI (1.22-2.28), with married as the reference group), ethnicity (Malay, OR 2.29, 95% CI ( 1.98-2.66; Chinese OR 1.23 95% CI (1.05-1.91), Other Bumis OR 1.75, 95% CI (1.46-2.10, others OR 1.48 95% CI (1.15-1.91), with Indian as the reference group), age group (18-20 years OR 2.36, 95% CI (1.90-2.94); 20-29 years OR 3.31 , 95% CI 2.82-3.89; 31-40 years OR 2.85 , 95% CI ( 2.47-3.28); 41-50 years OR 1.93, 95% CI (1.69-2.20) ; 51-60 years OR 1.32, 95% CI (1.15-1.51), with 60 year-old and above as the reference group) and residential area (rural OR 1.12 , 95% CI ( 1.03-1.22)) urban as reference.

CONCLUSION

The prevalence of smoking among Malaysian males remained high in spite of several population interventions over the past decade. Tobacco will likely remain a primary cause of premature mortality and morbidity in Malaysia. Continuous and more comprehensive anti-smoking policy measures are needed in order to further prevent the increasing prevalence of smoking among Malaysian men, particularly those who are younger, of Malay ethnicity, less educated, reside in rural residential area and with lower socio-economic status.

Attributable causes of liver cancer mortality and incidence in china

OBJECTIVES

To estimate the proportion of liver cancer cases and deaths due to infection with hepatitis B virus (HBV), hepatitis C virus (HCV), aflatoxin exposure, alcohol drinking and smoking in China in 2005.

STUDY DESIGN

Systemic assessment of the burden of five modifiable risk factors on the occurrence of liver cancer in China using the population attributable fraction.

METHODS

We estimated the population attributable fraction of liver cancer caused by five modifiable risk factors using the prevalence data around 1990 and data on relative risks from meta-analyses, and large-scale observational studies. Liver cancer mortality data were from the 3rd National Death Causes Survey, and data on liver cancer incidence were estimated from the mortality data from cancer registries in China and a mortality/incidence ratio calculated.

RESULTS

We estimated that HBV infection was responsible for 65.9% of liver cancer deaths in men and 58.4% in women, while HCV was responsible for 27.3% and 28.6% respectively. The fraction of liver cancer deaths attributable to aflatoxin was estimated to be 25.0% for both men and women. Alcohol drinking was responsible for 23.4% of liver cancer deaths in men and 2.2% in women. Smoking was responsible for 18.7% and 1.0% . Overall, 86% of liver cancer mortality and incidence (88% in men and 78% in women) was attributable to these five modifiable risk factors.

CONCLUSIONS

HBV, HCV, aflatoxin, alcohol drinking and tobacco smoking were responsible for 86% of liver cancer mortality and incidence in China in 2005. Our findings provide useful data for developing guidelines for liver cancer prevention and control in China and other developing countries.

The role of cognitive attributions for smoking in subsequent smoking progression and regression among adolescents in China

Previous studies have documented that cognitive attributions are correlated with adolescent smoking. The present study further explored whether cognitive attributions for smoking influenced adolescents' future smoking behaviors, especially transitions to more advanced stages of smoking. Participants were 12,382 middle and high school students (48.5% males and 51.5% females) in seven large cities in China. They completed two waves of surveys one year apart. Cognitive attributions for smoking and three smoking behavior outcomes (lifetime smoking, past 30-day smoking, and daily smoking) were assessed. Changes in smoking, including progression from lower stages to higher stages and regression from higher stages to lower stages, over a one-year period, were defined longitudinally. Polychotomous logistic regression was used to examine associations between cognitive attributions for smoking and changes in smoking status over one year, adjusting for demographic characteristics and other plausible confounders. Seven out of eight cognitive attributions for smoking were associated with subsequent smoking behaviors (p<0.05). Curiosity, autonomy, social image, social belonging, and coping influenced earlier stages of smoking, whereas mental enhancement and engagement influenced later stages of smoking. Curiosity, autonomy, social image, and mental enhancement preceded smoking progression; social belonging prevented smoking regression; and coping and engagement both preceded smoking progression and prevented smoking regression. This study demonstrates that different cognitive attributions influence smoking at different stages in different ways. These findings could inform smoking prevention and cessation programs targeting Chinese adolescents.

Mother's environmental tobacco smoke exposure during pregnancy and externalizing behavior problems in children

BACKGROUND

While the impact of active maternal smoking during pregnancy on child health has been well investigated, the association between maternal passive smoking, or environmental tobacco smoke (ETS), or second-hand smoke, and behavioral development of offspring is less clear. This study examines the association between maternal ETS exposure during pregnancy and child behavior problems.

METHODS

Cross-sectional data of 646 mother-child pairs from the Jintan China Cohort Study were used in the analyses. Mother's exposure to tobacco smoking at home, the workplace, and other places during pregnancy (for the determination of maternal ETS exposure) and children's behaviors (via Child Behavior Checklist) were assessed when the children were 5-6 years old. Logistic regression models were constructed to examine associations between maternal exposure to ETS during pregnancy and internalizing and externalizing behavior problems, adjusting for potential cofounders including child sex and parental characteristics.

RESULTS

37% of mothers reported ETS during pregnancy. Children of mothers exposed to ETS during pregnancy had higher scores for externalizing and total behavior problems, with 25% of children whose mothers were exposed to ETS compared to 16% of children of unexposed mothers. After adjusting for potential confounders, ETS exposure was associated with a higher risk of externalizing behavior problems in offspring of exposed mothers (OR=2.08, 95% confidence interval [CI] 1.27-3.43). Analysis after multiple imputations and sensitivity analysis further verified the association, but no dose-response relationship was found. ETS exposure, however, was not associated with internalizing or total behavior problems.

CONCLUSION

This study suggests that maternal ETS exposure during pregnancy may impact child behavioral development, particularly externalizing behaviors.

An updated review on asbestos and related diseases in China

BACKGROUND

Asbestos is an industrial mineral that can cause diseases such as asbestosis, lung cancer, and mesothelioma. Asbestos consumption in China has increased steadily since the 1960s and is currently at half a million tonnes per year. Work conditions in the asbestos-related industries are poor and exposure levels frequently exceed the occupational exposure limit.

OBJECTIVE

To provide an updated overview on asbestos production and consumption in China and discuss what is known about the resulting burden of asbestos-related diseases.

FINDINGS

China is the world's top chrysotile consumer and second largest producer. Over a million people may be occupationally exposed, yet reliable disease statistics are unavailable and the national burden of asbestos-related disease (ARD) is not well known. Nevertheless, ARD prevalence, incidence, and mortality are expected to be high and will increase for many decades due to the volume of asbestos consumed historically, and a long latency period.

CONCLUSIONS

Government policies to prevent ARD have been implemented but more actions are necessary to ensure compliance and ultimately, the complete elimination of asbestos to prevent a heavy future disease burden.

Association between environmental tobacco smoke exposure and dementia syndromes

OBJECTIVES

Environmental tobacco smoke (ETS) has a range of adverse health effects, but its association with dementia remains unclear and with dementia syndromes unknown. We examined the dose-response relationship between ETS exposure and dementia syndromes.

METHODS

Using a standard method of GMS, we interviewed 5921 people aged ≥60 years in five provinces in China in 2007-2009 and characterised their ETS exposure. Five levels of dementia syndrome were diagnosed using the Automated Geriatric Examination for Computer Assisted Taxonomy instrument. The relative risk (RR) of moderate (levels 1-2) and severe (levels 3-5) dementia syndromes among participants exposed to ETS was calculated in multivariate adjusted regression models.

RESULTS

626 participants (10.6%) had severe dementia syndromes and 869 (14.7%) moderate syndromes. Participants exposed to ETS had a significantly increased risk of severe syndromes (adjusted RR 1.29, 95% CI 1.05 to 1.59). This was dose-dependently related to exposure level and duration. The cumulative exposure dose data showed an adjusted RR of 0.99 (95% CI 0.76 to 1.28) for >0-24 level years of exposure, 1.15 (95% CI 0.93 to 1.42) for 25-49 level years, 1.18 (95% CI 0.87 to 1.59) for 59-74 level years, 1.39 (95% CI 1.03 to 1.84) for 75-99 level years and 1.95 (95% CI 1.34 to 2.83) for ≥100 level years. Significant associations with severe syndromes were found in never smokers and in former/current smokers. There were no positive associations between ETS and moderate dementia syndromes.

CONCLUSIONS

ETS should be considered an important risk factor for severe dementia syndromes. Avoidance of ETS may reduce the rates of severe dementia syndromes worldwide.

Incidence of ischaemic and haemorrhagic stroke and the association with smoking and smoking cessation: a 10-year multicentre prospective study in China

OBJECTIVES

To examine the effects of cigarette smoking and smoking cessation on the incidence of ischaemic and haemorrhagic stroke in a multicentre prospective cohort study among Chinese.

STUDY DESIGN

A multicentre population-based prospective cohort study.

METHODS

The incidence of, and deaths from, stroke were monitored among 26,607 participants (12,560 men and 14,047 women) who were enrolled in 1986 and free from stroke until 2000. Cox's proportional hazard model was performed to obtain the hazard ratio (HR) of cigarette smoking for stroke risk after adjustment for major confounders.

RESULTS

After an average of 9.5 years of follow-up, 1108 subjects developed stroke. The excess risk of all types of stroke (total stroke) among male current smokers [HR 1.39, 95% confidence interval (CI) 1.15-1.67] was mainly due to a significantly elevated risk of ischaemic stroke (HR 1.49, 95% CI 1.17-1.90). A significantly increased risk for total stroke and ischaemic stroke was observed among men who smoked >15 cigarettes/day and men who had smoked for >25 years. The rate of smoking cessation was very low among Chinese men (7.2%) and women (1.5%). Smoking cessation did not appear to reduce the risk of haemorrhagic stroke, but may reduce the risk of ischaemic stroke; however, the possibility that this result was due to chance cannot be excluded (HR 0.74, 95% CI 0.26-2.08).

CONCLUSION

This study confirmed that cigarette smoking is a major determinant for the incidence of ischaemic and haemorrhagic stroke in Chinese men, and emphasizes the need for improved strategies to help people quit smoking.

Secondhand smoke exposure predicted COPD and other tobacco-related mortality in a 17-year cohort study in China

BACKGROUND

Prospective evidence on the association between secondhand smoke (SHS) and COPD and ischemic stroke is scarce.

METHODS

We prospectively examined the relationship between SHS and major tobacco-related deaths, particularly COPD and stroke, in 910 Chinese (439 men, 471 women) who never smoked from a 17-year follow-up study in Xi’an, China. SHS exposure was defi ned as exposure to another person’s tobacco smoke at home or in the workplace.

RESULTS

At baseline among the 910 subjects, 44.2% were exposed to SHS at home, 52.9% in the workplace, and 67.1% at home, work, or both. From March 1, 1994, to July 1, 2011, 249 (150 men,99 women) died within 14,016 person-years. Those who were exposed to SHS had increased mortality due to coronary heart disease (adjusted relative risk [RR], 2.15; 95% CI, 1.00-4.61), ischemic stroke (RR, 2.88; 95% CI, 1.10-7.55), lung cancer (RR, 2.00; 95% CI, 0.62-6.40), COPD (RR, 2.30;95% CI, 1.06-5.00), and all causes (RR, 1.72; 95% CI, 1.29-2.20), with significant dose-response relationships between cumulative SHS exposure at home and work and the increased risk of cause-specific and total mortality (P for linear trend ranged from .045 to , .001).

CONCLUSIONS

This study shows dose-response relationships between SHS and major tobacco-related mortality and provides new evidence to support causation for COPD and ischemic stroke.

Prenatal secondhand smoke exposure and infant birth weight in China

Epidemiologic evidence provides some support for a causal association between maternal secondhand smoke (SHS) exposure during pregnancy and reduction in infant birth weight. The purpose of this cross-sectional study is to examine the magnitude of this association in China, where both prevalence and dose of SHS exposure are thought to be higher than in U.S. populations. Women who gave birth in Beijing and Changchun September 2000–November 2001 were interviewed to quantify self-reported prenatal SHS exposure. Their medical records were reviewed for data on pregnancy complications and birth outcomes. Non-smoking women who delivered term babies (≥37 weeks gestation) were included in the study (N = 2,770). Nearly a quarter of the women (24%) reported daily SHS exposure, 47% reported no prenatal exposure, and 75% denied any SHS exposure from the husband smoking at home. Overall, no deficit in mean birth weight was observed with exposure from all sources of SHS combined (+11 grams, 95% CI: +2, +21). Infants had higher mean birth weights among the exposed than the unexposed for all measures of SHS exposure. Future studies on SHS exposure and infant birth weight in China should emphasize more objective measures of exposure to quantify and account for any exposure misclassification.

Social, psychological, and environmental-structural factors associated with tobacco experimentation among adolescents in Shanghai, China

OBJECTIVE

To estimate the prevalence and social, psychological and environmental-structural determinants of tobacco experimentation among adolescents in Shanghai, China.

METHODS

We conducted a cross-sectional study based on a two-stage cluster sample design by using the Chinese version of the Global Youth Tobacco Survey (GYTS) to investigate smoking behavior among 19,117 students from 41 junior and senior high schools in Shanghai, China. The association between potential factors and tobacco experimentation were assessed using complex samples procedure logistic regression.

RESULTS

Of the 19,117 respondents, 10.5% (15.3% boys and 6.2% girls) reported the tobacco experimentation. The main social, psychological, and environmental-structural factors associated with tobacco experimentation were having close friends who smoke (AOR = 8.21; 95% CI: 6.49-10.39); one or both parents smoking (AOR 1.57; CI: 1.39-1.77); a poor school tobacco control environment (AOR 1.53; CI: 1.37-1.83); a high acceptance level of tobacco use (AOR 1.44; CI: 1.28-1.82); and a high level of media tobacco exposure (AOR 1.23; CI: 1.10-1.37). Peer smoking might contribute to smoking experimentation among girls (AOR 8.93; CI: 5.84-13.66) more so than among boys (AOR 7.79; CI: 5.97-9.94) and media tobacco exposure had no association with tobacco experimentation among female students.

CONCLUSIONS

Social, psychological, and environmental factors are closely associated with tobacco experimentation among adolescents. Prevention programs aimed at reducing teen tobacco experimentation should be conducted at home and school with support by parents, peers and teachers. Our findings should prove useful for future development of intervention strategies among adolescents in Shanghai, China.

Smoking in elderly Koreans: prevalence and factors associated with smoking cessation

The aims of this study were to investigate the prevalence of smoking and to explore the factors associated with smoking cessation. 1118 Koreans were randomly sampled from the residents aged 65 years or older living in Seongnam, Korea. Structured face-to-face interviews with neurological and physical examinations were conducted to the 714 respondents. A current smoker was defined as a person who had been smoking at least one cigarette per day for 1 year, and a past smoker as a person who used to smoke but had not smoked in the past 1 year. Nicotine dependence was defined as having the Fagerström Test for Nicotine Dependence (FTND) score of 4 or higher. Age- and gender-standardized prevalence of ever smoker, past smoker and current smoker among the elderly Koreans aged 65 and over were estimated to be 36.3% (95% CI=32.7-39.8), 24.4% (95% CI=21.2-27.5) and 11.9% (95% CI=9.5-14.3), respectively. Current smokers were much more prevalent in men (23.3%) than in women (3.9%), but did not decline with advancing age in both genders. 36.0% (21 men, 10 women) of the current smokers were nicotine-dependent. The smokers with depression or alcohol use disorder (AUD) were less likely and those who were educated more or inhaled smoke more deeply were more likely to quit smoking. Thus, smoking is common in the elderly men, and treatments of depression and AUD may be helpful in increasing smoking cessation rate among elderly Koreans.

Attributable causes of esophageal cancer incidence and mortality in China

BACKGROUND

To estimate the contribution of tobacco smoking, alcohol drinking, low vegetable intake and low fruit intake to esophageal cancer mortality and incidence in China.

METHODOLOGY/PRINCIPAL FINDINGS

We calculated the proportion of esophageal cancer attributable to four known modifiable risk factors [population attributable fraction (PAF)]. Exposure data was taken from meta-analyses and large-scale national surveys of representative samples of the Chinese population. Data on relative risks were also from meta-analyses and large-scale prospective studies. Esophageal cancer mortality and incidence came from the 3(rd) national death cause survey and population-based cancer registries in China. We estimated that 87,065 esophageal cancer deaths (men 67,686; women: 19,379) and 108,206 cases (men: 83,968, women: 24,238) were attributable to tobacco smoking, alcohol drinking, low vegetable intake and low fruit intake in China in 2005. About 17.9% of esophageal cancer deaths among men and 1.9% among women were attributable to tobacco smoking. About 15.2% of esophageal cancer deaths in men and 1.3% in women were caused by alcohol drinking. Low vegetable intake was responsible for 4.3% esophageal cancer deaths in men and 4.1% in women. The fraction of esophageal cancer deaths attributable to low fruit intake was 27.1% in men and 28.0% in women. Overall, 46% of esophageal cancers (51% in men and 33% in women) were attributable to these four modifiable risk factors.

CONCLUSIONS/SIGNIFICANCE

Tobacco smoking, alcohol drinking, low vegetable intake and low fruit intake were responsible for 46% of esophageal cancer mortality and incidence in China in 2005. These findings provide useful data for developing guidelines for esophageal cancer prevention and control in China.

The Decline of Smoking among Female Birth Cohorts in China in the 20(th) Century: A Case of Arrested Diffusion?

The smoking prevalence by age of women in China is distinct from most other countries in showing more frequent smoking among older women than younger. Using newly developed birth cohort histories of smoking, the authors demonstrate that although over one quarter of women born 1908-1912 smoked, levels of smoking declined across successive cohorts. This occurred despite high rates of smoking by men and the wide availability of cigarettes. The analysis shows how this pattern is counter to that predicted by the leading theoretical perspectives on the diffusion of smoking and suggests that it arose out of a mix of Confucian traditions relating to gender and the socio-economic and political events early in the 20(th) century which placed emerging women's identities in conflict with national identities. That a similar pattern of smoking is evident in Japan and Korea, two countries with strong cultural affinities to China, is used to buttress the argument.

Smoking and air pollution exposure and lung cancer mortality in Zhaoyuan County

BACKGROUND

Simultaneous exposure to high levels of air pollution and high tobacco consumption at the same place is rare. The aim of the present study was to evaluate the impact of the two factors on the risk of developing lung cancer.

METHODS

Data on the number of deaths due to lung cancer and on population from 1970 to 2009 were obtained from Zhaoyuan County. Data on the smoking populations were obtained at random sampling survey during the time in Zhaoyuan. Data on the components of atmospheric surveillance were obtained from the local environmental protection offices. Logarithmic linear regression and general log-linear Poisson age-period-cohort (APC) models were used to estimate age, period, cohort, gender, smoking, and air pollution effects on the risk of lung cancer mortality.

RESULTS

The standardized mortality rates of lung cancer drastically increased from 8.43 in per 100 000 individuals in the 1970-1974 to 25.67 in per 100 000 individuals in the 2005-2009 death survey. The annual change of lung cancer mortality was 3.20%. In the log linear regression model, the age, proportion of smokers, gender, period, and air pollution are significantly associated with lung cancer mortality. The APC analysis shows that the relative risks (RRs) of gender, smoking, and air pollution are 2.29 (95% confidence interval (CI): 2.16-2.43), 3.05 (95% CI = 2.76-3.36), and 1.42 (95% CI = 1.19-1.69), respectively. Compared with the period 1970-1974, high RRs were found during 1995-2009. Compared with the birth cohort 1950-1954, the RRs increased in the birth cohorts of 1910 to the 1940. Compared the aged 35-59 and 60-84 in the 1980-1984 death survey (not exposed to air pollution) with that in the 2005-2009 death survey (exposed to air pollution), The two age groups exposed to air pollution, 25 years later, had an increased mortality rates for lung cancer by 2.27 and 3.55 times for males and by 1.47 and 3.35 times for females.

CONCLUSION

The mortality rates of lung cancer drastically increased in the past 35 years. The trend of lung cancer mortality may be in a great extent possibly due to the effects of combined smoking and air pollution exposure.

What proportion of lung cancer in never-smokers can be attributed to known risk factors?

Though tobacco smoking is the primary risk factor for lung cancer, a significant fraction of lung cancer deaths occur in lifetime nonsmokers. In this article, we calculate the burden of lung cancer in never-smokers attributable to previously identified risk factors in North America, Europe and China, using population-based estimates of exposure prevalence and estimates of relative risk derived from recently published meta-analyses. Population attributable fractions (PAFs) for individual risk factors ranged from 0.40 to 19.93%. Because of differences in the prevalence of exposures, the PAFs associated with several of the risk factors varied greatly by geographical region. Exposure to the selected risk factors appeared to explain a much larger proportion of lung cancer cases in never-smokers in China than in Europe and North America. Our results demonstrate the geographic variability of the epidemiology of lung cancer in never-smokers and highlight the need for further research in this area, particularly in Europe and North America.

Anti‐smoking practice in hospitals

Purpose

This study aims to examine whether, in the opinion of patients selected in 13 hospitals of Hubei province, China, hospitals are smoke free. Patients were also asked whether their physicians had inquired about their smoking status.

Design/methodology/approach

Patients were recruited through an intercept method (i.e. stopped by the interviewer while in the hospital); data were collected through interviews, with a response rate of 96.1 percent.

Findings

Among the intercepted patients, 48.3 percent reported having seen people smoking in hospitals; 22.3 percent had seen a doctor and/or nurse smoking; 23.8 percent had smelled tobacco in hospitals; 68.4 percent reported having seen “no‐smoking” signs in hospital settings; 42.6 percent reported having been asked about smoking status in their latest visit to a doctor and 23.8 percent reported receiving tobacco cessation counseling. Compared to hospitals in large cities, patients from medium/small city hospitals reported significantly higher levels of cigarette smoking among physicians, and poorer implementation of regulations for a smoking‐free hospital, and less smoking cessation counseling by physicians.

Originality/value

Findings of this study point to the need for greater efforts to be made in promoting a smoke free environment in hospitals, as well as encouraging physicians to provide more smoking cessation counseling to smoking patients, particularly physicians in small and medium hospitals.

Research and Standard Care: Lung Cancer in China

Overview:

China has an enormous burden from rising tobacco consumption and lung cancer incidence. Governmental intervention on lung cancer prevention is insufficient, and both incidence and mortality related to lung cancer are still on the rise. Treatment guidelines are available, but heterogeneity in the quality of care between centers, especially the disparity between urban and rural areas, have resulted in inconsistent care to patients with lung cancer. Despite knowledge on molecular-targeted therapy, only a small fraction of patients have access to routine EGFR mutation analysis. Platinum-based doublet chemotherapy remains the most commonly used regimen irrespective of mutation status. On a positive note, both clinical and translational research on lung cancer are in rapid progress. The Chinese Thoracic Oncology Group (CTONG) has already contributed substantially to the care of patients with lung cancer and is expected to continue in the trend.

'A real man smells of tobacco smoke'--Chinese youth's interpretation of smoking imagery in film

Previous studies have associated youth's exposure to filmic images of smoking with real-life smoking acquisition; initial research in low- and middle-income countries confirms this relationship. The present study in Yunnan, southwest China sought answers to the following questions: How do young people in China make sense of smoking imagery they have seen in film? How are these perceptions shaped by the cultural and social context of images? How do these understandings relate to real-life tobacco use? A study with focus groups and grounded theory was conducted in 2010 and 2011 (Sept-Jan) with middle-school students ages 12 and 13 (n=68, focus groups=12, schools=6). Films and media literacy were important means through which knowledge about smoking was constructed and communicated. Film representations of smoking concurred with Chinese social behaviour (Confucian social networks, face-making, and the notion of society as a harmonious social unit), and were interpreted as congruent with real-life smoking. This pattern, in turn, was intertwined with perceived gender identities of smokers, gender-specific social behaviour, and willingness of girls to explore issues of gender equity. These findings lend new insights into interaction between smoking imagery in film and Chinese youth's smoking beliefs. Tobacco control programs in China should consider young people's interpretations of smoking and the ways they are nested in cultural and social milieu.

Do cognitive attributions for smoking predict subsequent smoking development?

To develop more effective anti-smoking programs, it is important to understand the factors that influence people to smoke. Guided by attribution theory, a longitudinal study was conducted to investigate how individuals' cognitive attributions for smoking were associated with subsequent smoking development and through which pathways. Middle and high school students in seven large cities in China (N=12,382; 48.5% boys and 51.5% girls) completed two annual surveys. Associations between cognitive attributions for smoking and subsequent smoking initiation and progression were tested with multilevel analysis, taking into account plausible moderation effects of gender and baseline smoking status. Mediation effects of susceptibility to smoking were investigated using statistical mediation analysis (MacKinnon, 2008). Six out of eight tested themes of cognitive attributions were associated with subsequent smoking development. Curiosity (β=0.11, p<0.001) and autonomy (β=0.08, p=0.019) were associated with smoking initiation among baseline non-smokers. Coping (β=0.07, p<0.001) and social image (β=0.10, p=<.0001) were associated with smoking progression among baseline lifetime smokers. Social image (β=0.05, p=0.043), engagement (β=0.07, p=0.003), and mental enhancement (β=0.15, p<0.001) were associated with smoking progression among baseline past 30-day smokers. More attributions were associated with smoking development among males than among females. Susceptibility to smoking partially mediated most of the associations, with the proportion of mediated effects ranging from 4.3% to 30.8%. This study identifies the roles that cognitive attributions for smoking play in subsequent smoking development. These attributions could be addressed in smoking prevention programs.

Effect of environmental tobacco smoke on atopic dermatitis among children in Korea

The prevalence of atopic dermatitis is increasing in many countries. Several factors are known to be associated with childhood atopic dermatitis. Environmental tobacco smoke (ETS) is one of the most common indoor pollutants, and children are more vulnerable to ETS exposure than adults are. In this study, the possible association of ETS with atopic dermatitis was evaluated in 7030 individuals aged 6-13 years who participated in the Children's Health and Environment Research study. In addition, predictive factors, such as the allergic history of the parents, children's immunoglobulin E levels and children's history of rhinitis and its association with dermatitis, were assessed. After adjustment for possible confounding variables, atopic dermatitis was found to be highly correlated with ETS, especially among children whose mothers had smoked during pregnancy and/or in the first year after birth (OR=2.06, 95% CI: 1.01-4.22). In conclusion, our results show that childhood exposure to ETS is a major risk factor for atopic dermatitis.

A systematic review of smoking cessation intervention studies in China

INTRODUCTION

China has the highest number of tobacco smokers among the world's nations; however, no systematic review has been conducted of clinical trials on the efficacy of smoking cessation interventions in China. This paper summarizes findings of studies in order to compare the effect of pharmacotherapy, counseling, and Traditional Chinese Medicine (TCM) approaches on the abstinence rate.

METHODS

Clinical trials of smoking cessation interventions published in English or Chinese were extracted from an electronic search of PubMed and WanFang databases. The search yielded 234 studies from the PubMed and 78 studies from the WanFang.

RESULTS

Twenty-nine studies were included in this review. Of these, 11 (37.9%) were randomized controlled trials (RCTs) that assessed the following approaches: counseling (5 studies), TCM (3 studies), pharmacotherapy (1 study), a combination of pharmacotherapy and counseling (1 study), and physician advice (1 study). Pharmacotherapy alone or in combination with counseling generally resulted in a higher abstinence rate than counseling alone. TCM techniques such as acupuncture and ear point seed pressure yielded a much higher abstinence rate than pharmacotherapy and counseling. Findings are inconclusive, however, because most of the TCM studies were noncontrolled trials and did not provide a definition of "abstinence." Findings on the effectiveness of physician advice to quit smoking were also inconclusive.

CONCLUSIONS

A review of smoking cessation studies revealed that pharmacotherapy was effective in China. More RCTs of TCM approaches and physician advice are needed with long-term follow-up assessments and biochemical verification of self-reported abstinence before these approaches are adopted as evidence-based smoking cessation interventions in China.

Interaction of smoking and metabolic syndrome on cardiovascular risk in a Chinese cohort

BACKGROUND

The high prevalence of smoking and metabolic syndrome (MS) and increased incidence of cardiovascular disease (CVD) in China indicates that there may be an interaction between smoking and MS on cardiovascular risk. Therefore, we aimed to examine the independent and combined effects of smoking and MS on risk of CVD in a Chinese cohort.

METHODS

We analyzed data from a population-based prospective cohort of 3598 participants aged 35-74 years from Jiangsu China who were free of diabetes and CVD at enrollment and were followed for cardiovascular events (including myocardial infarction, ischemic stroke, hemorrhagic stroke, and cardiovascular mortality) until 31 August 2008.

RESULTS

During 8 years (median 6.3 years) of follow-up, 82 participants developed CVD. After adjusting for age, sex, body mass index, alcohol consumption, family history of cardiovascular disease and MS, smoking significantly increased cardiovascular risk in a dose-response manner. After further adjustment for smoking status, the hazard ratio of CVD for participants with MS was 2.49 (95% confidence interval 1.59-3.90) compared with those without the syndrome. There was a statistically significant additive interaction between current smoking and MS on cardiovascular risk. The risk of CVD for current smokers with MS was 1.81 times as high as the sum of risks in participants with a single condition alone.

CONCLUSIONS

Both cigarette smoking and MS are strong risk factors of CVD in the Chinese population. Moreover, this study further demonstrates an additive interaction of current smoking and MS on cardiovascular risk.

Impacts of early smoking initiation: long-term trends of lung cancer mortality and smoking initiation from repeated cross-sectional surveys in Great Britain

OBJECTIVE

To show long-term trends of smoking initiation in Great Britain including unanalysed data and assess the impact of early smoking initiation on the lung cancer mortality in later ages focusing on birth cohorts.

DESIGN

Reanalysis of repeated cross-sectional surveys conducted 13 times during 1965-1987.

SETTING

Great Britain.

PARTICIPANTS

Men and women aged 16 years and over in each survey.

PRIMARY OUTCOME MEASURES

Smoking initiation for 1898-1969 birth cohorts and lung cancer mortality in 1950-2009.

RESULTS

In men, 1900-1925 birth cohorts showed high smoking initiation (>32%, >50% and >80% at 15, 17 and 29 years old, respectively). Correspondingly, the lung cancer mortality in these cohorts exceeded 1 per 1000 at a young age (50-54 years old). In women, smoking initiation increased clearly from the 1898 cohort to the 1925 cohort (2% to 12%, 4% to 24%, and 13% to 54% at 15, 17 and 29 years old, respectively). Correspondingly, the age at which the mortality exceeded 1 per 1000 became younger (75-79 to 60-64 years old). In both men and women, short-term decreases in initiation were seen from the late-1920s cohorts. Correspondingly, lung cancer mortality decreased. In women, initiation increased again after the mid-1930s cohorts, and mortality increased after they became 60-64 years old.

CONCLUSIONS

Clear relationships between smoking initiation and lung cancer mortality across birth cohorts were observed. Countries with rapid increases in initiation in teens should not underestimate the risk in the distant future. Because of the long time lags within cohorts compared with rapid changes in smoking habits across cohorts, age-specific measures focusing on birth cohorts should be monitored.

Perceptions of risk factors of cardiovascular disease and cardiac rehabilitation: a cross-sectional study targeting the Chinese population in the Midlands, UK

OBJECTIVES

To find out and explore the knowledge and opinion of Chinese people on cardiovascular disease and awareness of cardiac rehabilitation.

DESIGN

A cross-sectional study using 14-item bilingual (Chinese and English) questionnaires that include information on demographics, health status, cardiovascular disease related knowledge and perception, and awareness and understanding of the cardiac rehabilitation programme.

SETTING

Chinese community groups in the Midlands, UK from January to April 2008.

PARTICIPANTS

436 questionnaires from Chinese adults over 18 were obtained.

MAIN OUTCOME MEASURES

Current knowledge and attitude towards cardiovascular disease and awareness of cardiac rehabilitation.

RESULTS

Obesity was the most common risk factor identified by 80.7% of participants. Those originated from China had significantly less knowledge compared with subjects from other countries (p<0.001). People who have had exposure or experience of cardiac disease rated a higher risk of cardiac disease for Chinese living in the UK than people without experience. A majority (81.7%) used orthodox medicine and perceived it to be most effective against cardiac disease. Only 30% of participants were aware of cardiac rehabilitation.

CONCLUSION

The coronary artery disease (CAD) risk factors of Chinese population have increased significantly in the last decade. Cardiac rehabilitation awareness was poor among the sample population of this study and language barrier is still a problem. More large studies on Chinese population assessing CAD risk should be done to provide more evidence on CAD prevention for this growing population in the Western world.

Attributable causes of lung cancer incidence and mortality in China

The aims of our study were to estimate the contribution of known lung cancer risk factors, and provide evidence to support the National Cancer Prevention and Control Program in China. We calculated the proportion of lung cancer attributable to specific risk factors. Data on exposure prevalence were from meta‐analyses and large‐scale national surveys of representative samples of the Chinese population. Data on relative risks were from meta‐analyses and large‐scale prospective studies. Lung cancer mortality and incidence were taken from the Third National Death Survey and from cancer registries in China. We estimated that in China 285 304 lung cancer deaths and 327 465 cases were attributable to smoking, involuntary smoking (women only), occupational exposure, indoor radon, and low fruit intake in 2005. The proportion of lung cancer deaths attributable to smoking, involuntary smoking among non‐smoking women, occupational exposure, indoor radon and low fruit intake was 56.9%, 11.1%, 9.5%, 0.2% and 12.4%, respectively. About 41% of lung cancer mortality and incidence in women was caused by risk factors in our study. However, over half of lung cancer deaths and cases among women were not attributable to known risk factors. It is necessary to conduct large‐scale studies to identify additional risk factors of lung cancer in non‐smoking women.

Secular trends of macrosomia in southeast China, 1994-2005

Background

The rate of macrosomia (birth weight≥4, 000 g) increased over the past four decades in many parts of the world. Macrosomia is associated not only with higher risks of maternal and neonatal complications but also with health risks in adulthood. We examined trends in neonatal macrosomia and large-for-gestational-age (LGA) births among singleton, live, term and postterm births (≥37 complete weeks' gestation) in southeast China from 1994 to 2005 and explored possible causes of the temporal trends.

Methods

Data from Perinatal Health Care Surveillance System in 12 cities and counties in southeast China were analyzed for trends in birth weight, neonatal macrosomia and LGA from 1994 to 2005. A total of 594, 472 singleton live births were included. We conducted multiple logistic regression analyses to relate these trends to changes in maternal and pregnancy characteristics.

Results

The rate of macrosomia rose from 6.00% in 1994 to 8.49% in 2000 and then levelled off to 7.83% in 2005. Similar trends were observed in mean birth weight. The incidence of LGA births increased continuously from 13.72% in 1994 to 18.08% in 2000, but the LGA rate remained relatively stable from 2002 to 2005. There was a decrease in gestational age and a significant increase in frequency of prelabor caesarean delivery from 1994 to 2005. In an adjusted multivariable model, the increase in LGA rate from 1994 to 2000 was associated with increasing net gestational weight gain, maternal age, maternal height and maternal education. But they didn't fully explain the increase. The trends of 2002-2005 LGA declined after adjusted for maternal and neonatal characteristics.

Conclusions

In southeast China, the incidence of macrosomia increased from 1994 to 2000 was mainly related to increasing net gestational weight gain. The incidence of macrosomia has levelled off in recent years partly due to increasing use of prelabor caesarean delivery and earlier delivery and partly due to moderation of gestational weight gain.

China Kadoorie Biobank of 0.5 million people: survey methods, baseline characteristics and long-term follow-up

BACKGROUND

Large blood-based prospective studies can provide reliable assessment of the complex interplay of lifestyle, environmental and genetic factors as determinants of chronic disease.

METHODS

The baseline survey of the China Kadoorie Biobank took place during 2004-08 in 10 geographically defined regions, with collection of questionnaire data, physical measurements and blood samples. Subsequently, a re-survey of 25,000 randomly selected participants was done (80% responded) using the same methods as in the baseline. All participants are being followed for cause-specific mortality and morbidity, and for any hospital admission through linkages with registries and health insurance (HI) databases.

RESULTS

Overall, 512,891 adults aged 30-79 years were recruited, including 41% men, 56% from rural areas and mean age was 52 years. The prevalence of ever-regular smoking was 74% in men and 3% in women. The mean blood pressure was 132/79 mmHg in men and 130/77 mmHg in women. The mean body mass index (BMI) was 23.4 kg/m(2) in men and 23.8 kg/m(2) in women, with only 4% being obese (>30 kg/m(2)), and 3.2% being diabetic. Blood collection was successful in 99.98% and the mean delay from sample collection to processing was 10.6 h. For each of the main baseline variables, there is good reproducibility but large heterogeneity by age, sex and study area. By 1 January 2011, over 10,000 deaths had been recorded, with 91% of surviving participants already linked to HI databases.

CONCLUSION

This established large biobank will be a rich and powerful resource for investigating genetic and non-genetic causes of many common chronic diseases in the Chinese population.

Effects of smoking and smoking cessation on life expectancy in an elderly population in Beijing, China, 1992-2000: an 8-year follow-up study

BACKGROUND

We assessed the effects of smoking and smoking cessation on life expectancy and active life expectancy among persons aged 55 years or older in Beijing.

METHODS

This study included 1593 men and 1664 women who participated in the Beijing Longitudinal Study of Aging, which commenced in 1992 and had 4 survey waves up to year 2000. An abridged life table was used to estimate life expectancy, in which age-specific mortality and age-specific disability rates were adjusted by using a discrete-time hazard model to control confounders.

RESULTS

The mean ages (SD) for men and women were 70.1 (9.25) and 70.2 (8.72) years, respectively; mortality and disability rates during follow-up were 34.7% and 8.0%, respectively. In both sexes, never smokers had the highest life expectancy and active life expectancy across ages, as compared with current and former smokers. Current heavy smokers had a shorter life expectancy and a shorter active life expectancy than light smokers. Among former smokers, male long-term quitters had a longer life expectancy and longer active life expectancy than short-term quitters, but this was not the case in women.

CONCLUSIONS

Older adults remain at higher risk of mortality and morbidity from smoking and can expect to live a longer and healthier life after smoking cessation.

Transnational tobacco industry promotion of the cigarette gifting custom in China

OBJECTIVE

To understand how British American Tobacco (BAT) and Philip Morris (PM) researched the role and popularity of cigarette gifting in forming relationships among Chinese customs and how they exploited the practice to promote their brands State Express 555 and Marlboro.

METHODS

Searches and analysis of industry documents from the Legacy Tobacco Documents Library complemented by searches on LexisNexis Academic news, online search engines and information from the tobacco industry trade press.

RESULTS

From 1980-1999, BAT and PM employed Chinese market research firms to gather consumer information about perceptions of foreign cigarettes and the companies discovered that cigarettes, especially prestigious ones, were gifted and smoked purposely for building relationships and social status in China. BAT and PM promoted their brands as gifts by enhancing cigarette cartons and promoting culturally themed packages, particularly during the gifting festivals of Chinese New Year and Mid-Autumn Festival to tie their brands in to festival values such as warmth, friendship and celebration. They used similar marketing in Chinese communities outside China.

CONCLUSIONS

BAT and PM tied their brands to Chinese cigarette gifting customs by appealing to social and cultural values of respect and personal honour. Decoupling cigarettes from their social significance in China and removing their appeal would probably reduce cigarette gifting and promote a decline in smoking. Tobacco control efforts in countermarketing, large graphic warnings and plain packaging to make cigarette packages less attractive as gifts could contribute to denormalising cigarette gifting.

Psychiatric epidemiological surveys in China 1960-2010: how real is the increase of mental disorders?

PURPOSE OF REVIEW

Community psychiatric epidemiological surveys over the last five decades have revealed a dramatic increase in the prevalence of mental disorders in China. This article summarizes the main surveys and attempts to interpret the increase of prevalence from a methodological perspective.

RECENT FINDINGS

Regional and national surveys conducted in China during 1960-1990 focused on severe mental disorders and revealed very low and stable rates of disorders. By contrast, those performed in the last decade, whether psychiatrists or lay interviewers were used, have shown much higher and more 'reliable' rates comparable to those found in high-income countries. This is especially so for depression and anxiety disorders.

SUMMARY

Given the sociopolitical turmoil that had previously plagued people in China, the dramatic rise in prevalence estimates of mental disorders in recent years cannot be simply interpreted as a substantive deterioration of mental health following rapid social change. Global and local factors that shape research methodology aimed at showing that mental disorders are common may play an important role in the dramatic increase. Future research in China should move beyond descriptive epidemiology. It should also address policy relevant issues in view of the limited resources available for mental health interventions.