Estimation of cancer incidence and mortality attributable to smoking in China

A 16-year evaluation of opportunistic lung cancer screening with low-dose CT in China: comparative findings between non-smokers and smokers

BACKGROUND

Although low-dose computed tomography (LDCT) screening effectively reduces LC mortality in high-risk individuals with a history of smoking in China, the feasibility and efficacy of lung cancer screening (LCS) in individuals who never smoked versus individuals who smoked remains unclear.

METHODS

We conducted a retrospective analysis of prospective cohort studies at the National Cancer Center (NCC) in China from January 2006 to December 2022. A comprehensive LCS initiative was undertaken, involving 30,468 participants (54.5% male). Participants underwent LCS using LDCT. Potential malignancies were managed through joint consensus between patients and their physicians. Epidemiology, screening eligibility criteria, and LC detection rates and survival outcomes were compared between individuals who smoked and individuals who never smoked.

RESULTS

Among 30,468 participants, 339 LCs were pathologically confirmed in 289 patients. The LC detection rate was 0.9% (289/30,468) overall, 0.8% in individuals who smoked (71/9,042), and 1.0% in individuals who never smoked (218/21,426). In individuals who smoked, LC detection rates were 0.5% (21/4516) and 1.1% (50/4526) in the < 20 and ≥ 20 pack-year subgroups, respectively (P = 0.001). Early-stage LC (stage 0 or I) was detected in 73.8% of the individuals who smoked and in 78.8% of individuals who never smoked, while advanced LC (stage III-IV) was found 8.8% of individuals who smoked and 4.2% of individuals who never smoked, respectively. Significant differences in histologic types were found between individuals who smoked and individuals who never smoked (P = 0.01), although adenocarcinoma was the most prevalent in both groups, at 83.0% and 78.8%, respectively. The median nodule size was 9.9 mm (IQR, 8.0-13.8) in individuals who smoked and 9.2 mm (IQR, 6.8-13.6) in individuals who never smoked (P = 0.228). Individuals who never smoked tended to favour surgical treatment alone (88.0%) more than individuals who smoked (81.3%). The 10-year survival rate was higher in individuals who never smoked (92.6%) than in individuals who smoked (88.8%). Only 15.6% (45/289) of patients with LC met the United States Preventive Services Task Force (USPSTF) criteria for LDCT eligibility, while 29.0% (84/289) met the China guideline for the screening and early detection of lung cancer (CGSL) criteria. Median follow-up for those followed was 25.4 (IQR, 13.7-43.3) months.

CONCLUSIONS

LDCT screening improves early LC detection and treatment outcomes for both individuals who smoked and individuals who never smoked. Significant differences exist in epidemiology, histologic type, and survival between these groups. The USPSTF and CGSL criteria miss a significant number of LC cases, particularly among individuals who never smoked. Integrating individuals who never smoked into LCS programs is essential, yet it comes with its own challenges, such as managing radiation risks, allocating resources effectively, and considering financial aspects. Consequently, there is an urgent need for LCS programs in China to better identify the "high-risk" non-smoker population susceptible to LC and to ensure that potential risks associated with screening are reduced.

Risk-Adapted Starting Age of Personalized Lung Cancer Screening: A Population-Based, Prospective Cohort Study in China

BACKGROUND

The current one-size-fits-all screening strategy for lung cancer is not suitable for personalized screening.

RESEARCH QUESTION

What is the risk-adapted starting age of lung cancer screening with comprehensive consideration of risk factors?

STUDY DESIGN AND METHODS

The National Lung Cancer Screening program, a multicenter, population-based, prospective cohort study, was analyzed. Information on risk factor exposure was collected during the baseline risk assessment. A Cox proportional hazards model was used to estimate the association between risk factors and lung cancer incidence. Age-specific 10-year cumulative risk was calculated to determine the age at which individuals with various risk factors reached the equivalent risk level as individuals aged ≥ 50 years with active tobacco use and a ≥ 20 pack-year smoking history.

RESULTS

Of the 1,031,911 participants enrolled in this study, 3,908 demonstrated lung cancer after a median follow-up of 3.8 years. We identified seven risk factors for lung cancer, including pack-years of smoking, secondhand smoke exposure, family history of lung cancer in first-degree relatives, history of respiratory diseases, occupational hazardous exposure, BMI, and diabetes. The 10-year cumulative risk of lung cancer for people aged ≥ 50 years with active tobacco use and a ≥ 20 pack-year smoking history was 1.37%, which was treated as the risk threshold for screening. Individuals who never smoked and those with active tobacco use and a < 30-pack-year history of smoking reached the equivalent risk level 1 to 14 years later compared with the starting age of 50 years. Men with active tobacco use, a ≥ 30-pack-year history of smoking, and concurrent respiratory diseases or diabetes should be screened 1 year earlier at the age of 49 years.

INTERPRETATION

The personalized risk-adapted starting ages for lung cancer screening, based on the principle of equal management of equal risk, can served as an optimized screening strategy to identify high-risk individuals.

Burden of tobacco-related cancers in urban, semi-urban and rural setting of Nepal: Findings from population-based cancer registries 2019

BACKGROUND

Nepal is one of the high prevalent countries for tobacco use in Southeast Asia regions. Tobacco related cancer share the major burden since a decade, however, population-based estimates is still lacking. This study provides results from population-based cancer registries on tobacco-related cancer (TRCs) burden in Nepal.

METHODS

The data were collected by population-based cancer registry conducted in nine districts by Nepal Health Research Council. The districts were categorized in urban, semi-urban and rural regions on the basis of geographical locations and facilities available in the regions. Analysis was done to identify tobacco-associated cancer incidence, mortality and patterns along with cumulative risk of having cancer before the age of 75 years.

RESULTS

Tobacco-related cancer was 35.3% in men and 17.3% in women. We found that every one in 36 men and one in 65 women developed tobacco-related cancer before age 75 in Nepal. Cancer of lung, mouth, esophagus and larynx were among the five most common tobacco-related cancers in both men and women. The incidence of tobacco-associated cancers was higher in urban region with age adjusted rate 33.6 and 17.0 per 100,000 population for men and women respectively compared to semi-urban and rural regions. Tobacco-associated cancer mortality was significantly higher compared to incidence.

CONCLUSION

The prevalence of tobacco-related cancer found high in Nepal despite of enforcement of tobacco control policy and strategies including WHO framework convention on tobacco control. Concerned authorities should focus towards monitoring of implemented tobacco control policy and strategies.

Trends of gastric cancer burdens attributable to risk factors in China from 2000 to 2050

Background

The incidence of gastric cancer (GC) decreased in past decades, which was thought largely attributable to risk factors control, yet China still accounts for 44% of global GC burdens. We aimed to estimate changing trajectories of proportions of GC burdens attributable to modifiable risk factors from 2000 to 2050 in China, to inform future targeted preventive strategies.

Methods

The incidence and new cases of GC were predicted to 2050 using Bayesian age-period-cohort model based on incidence data by anatomical subsites drawn from 682 cancer registries from National Central Cancer Registry. Population attributable fractions (PAFs) were calculated based on prevalence of risk factors and relative risks with GC. Temporal trends of PAFs were described by sex and categories of risk factors using joinpoint analysis.

Findings

We observed declining trends of PAFs of Helicobacter pylori (H. pylori) infection, smoking, pickled vegetable and alcohol consumption, but increasing trends of PAFs of unhealthy body mass index and diabetes for GC in China. The combined PAFs of these risk factors were estimated to decrease by 10.57% from 2000 to 2050 for GC. We estimated there will be 279,707 GC (122,796 cardia gastric cancer [CGC] and 156,911 non-cardia gastric cancer [NCGC]) cases in 2050. Out of these cases, 70.18% of GC cases could be attributable to modifiable risk factors, while H. pylori infection was predicted to be responsible for 40.7% of CGC and 62.1% of NCGC cases in 2050.

Interpretation

More than half of GC remained attributable to modifiable risk factors in China. Continued effective strategies on risk factors control are needed to reduce the burden of this highly life-threatening cancer in future.

Funding

Beijing Nova Program (No. Z201100006820069), CAMS Innovation Fund for Medical Sciences (CIFMS, grant No. 2021-I2M-1-023), CAMS Innovation Fund for Medical Sciences (CIFMS, grant No. 2021-I2M-1-010), Talent Incentive Program of Cancer Hospital Chinese Academy of Medical Sciences (Hope Star).

Healthy lifestyle scores associate with incidence of type 2 diabetes mediated by uric acid

BACKGROUND

Whether and to what extent serum uric acid (SUA) mediates the association between combined lifestyle behaviors and type 2 diabetes mellitus (T2DM) remain unclear. This study aimed to investigate the role of SUA in the relationship between healthy lifestyle scores (HLS) and the incidence of T2DM.

METHODS

This prospective study used data from Zhejiang Metabolic Syndrome cohort. A HLS (5-point scale including healthy waist circumference (WC), never smoking, high physical activity, healthy diet and moderate alcohol intake) was estimated in 13,919 participants, who had SUA at baseline examination in 2009-2014, and were followed-up to 2021-2022 to ascertain incident of T2DM. Cox proportional hazards models and mediation analysis were used to examine the associations between HLS, SUA and T2DM.

RESULTS

We included 13,919 participants aged 18 years or older without diabetes at baseline (mean age 54.6 [SD 13.9] years, 58.7% female). During a median follow-up of 9.94 years, 645 cases of T2DM occurred. Compared with participants with a poor HLS, those with 4-5 low-risk lifestyle factors showed a 60% reduction in the risk of developing T2DM (adjusted HR, 0.40; 95% CI: 0.28-0.57). Further, the population-attributable risk percent (95% CI) of T2DM for poor adherence to the overall healthy lifestyle (< 4 low-risk factors) was 43.24% (30.02%, 56.46%). The HLS was inversely associated with SUA level. With per score increased in HLS, the beta (95% CI) of SUA (log transformed) was - 0.03 (- 0.03, - 0.02), and the odds ratio (95% CI) of hyperuricemia was 0.82 (0.77, 0.86). The relationship between the HLS and risk of T2DM was mediated by SUA with a 13.06% mediation effect. There was no significant combined effect of HLS and SUA on risk of T2DM (P = 0.097).

CONCLUSIONS

The relationship between overall healthy lifestyle behaviors and T2DM was reconfirmed and the association appeared to be mediated by SUA. The mediation effect of baseline SUA was more pronounced among women who were below 60 years old.

Lung cancer risk score for ever and never smokers in China

BACKGROUND

Most lung cancer risk prediction models were developed in European and North-American cohorts of smokers aged ≥ 55 years, while less is known about risk profiles in Asia, especially for never smokers or individuals aged < 50 years. Hence, we aimed to develop and validate a lung cancer risk estimate tool for ever and never smokers across a wide age range.

METHODS

Based on the China Kadoorie Biobank cohort, we first systematically selected the predictors and explored the nonlinear association of predictors with lung cancer risk using restricted cubic splines. Then, we separately developed risk prediction models to construct a lung cancer risk score (LCRS) in 159,715 ever smokers and 336,526 never smokers. The LCRS was further validated in an independent cohort over a median follow-up of 13.6 years, consisting of 14,153 never smokers and 5,890 ever smokers.

RESULTS

A total of 13 and 9 routinely available predictors were identified for ever and never smokers, respectively. Of these predictors, cigarettes per day and quit years showed nonlinear associations with lung cancer risk (Pnon-linear < 0.001). The curve of lung cancer incidence increased rapidly above 20 cigarettes per day and then was relatively flat until approximately 30 cigarettes per day. We also observed that lung cancer risk declined sharply within the first 5 years of quitting, and then continued to decrease but at a slower rate in the subsequent years. The 6-year area under the receiver operating curve for the ever and never smokers' models were respectively 0.778 and 0.733 in the derivation cohort, and 0.774 and 0.759 in the validation cohort. In the validation cohort, the 10-year cumulative incidence of lung cancer was 0.39% and 2.57% for ever smokers with low (< 166.2) and intermediate-high LCRS (≥ 166.2), respectively. Never smokers with a high LCRS (≥ 21.2) had a higher 10-year cumulative incidence rate than those with a low LCRS (< 21.2; 1.05% vs. 0.22%). An online risk evaluation tool (LCKEY; http://ccra.njmu.edu.cn/lckey/web) was developed to facilitate the use of LCRS.

CONCLUSIONS

The LCRS can be an effective risk assessment tool designed for ever and never smokers aged 30 to 80 years.

Disparity in Lung Cancer Screening Among Smokers and Nonsmokers in China: Prospective Cohort Study

BACKGROUND

Low-dose computed tomography (LDCT) screening is effective in reducing lung cancer mortality in smokers; however, the evidence in nonsmokers is scarce.

OBJECTIVE

This study aimed to evaluate the participant rate and effectiveness of one-off LDCT screening for lung cancer among smokers and nonsmokers.

METHODS

A population-based prospective cohort study was performed to enroll participants aged between 40 and 74 years from 2013 to 2019 from 4 cities in Zhejiang Province, China. Participants who were evaluated as having a high risk of lung cancer from an established risk score model were recommended to undergo LDCT screening. Follow-up outcomes were retrieved on June 30, 2020. The uptake rate of LDCT screening for evaluated high-risk participants and the detection rate of early-stage lung cancer (stage 0-I) were calculated. The lung cancer incidence, lung cancer mortality, and all-cause mortality were compared between the screened and nonscreened groups.

RESULTS

At baseline, 62.56% (18,818/30,079) of smokers and 6% (5483/91,455) of nonsmokers were identified as high risk (P<.001), of whom 41.9% (7885/18,818) and 66.31% (3636/5483) underwent LDCT screening (P<.001), respectively. After a median follow-up of 5.1 years, 1100 lung cancer cases and 456 all-cause death cases (116 lung cancer death cases) were traced. The proportion of early-stage lung cancer among smokers was 60.3% (173/287), which was lower than the proportion of 80.3% (476/593) among nonsmokers (P<.001). Among smokers, a higher proportion was found in the screened group (72/106, 67.9%) than the nonscreened group (56/114, 49.1%; P=.005), whereas no significance was found (42/44, 96% vs 10/12, 83%; P=.20) among nonsmokers. Compared with participants who were not screened, LDCT screening in smokers significantly increased lung cancer incidence (hazard ratio [HR] 1.39, 95% CI 1.09-1.76; P=.007) but reduced lung cancer mortality (HR 0.52, 95% CI 0.28-0.96; P=.04) and all-cause mortality (HR 0.47, 95% CI 0.32-0.69; P<.001). Among nonsmokers, no significant results were found for lung cancer incidence (P=.06), all-cause mortality (P=.89), and lung cancer mortality (P=.17).

CONCLUSIONS

LDCT screening effectively reduces lung cancer and all-cause mortality among high-risk smokers. Further efforts to define high-risk populations and explore adequate lung cancer screening modalities for nonsmokers are needed.

Female reproductive and hormonal factors and lung cancer mortality among never-smokers: A prospective cohort study of 287 408 Chinese women

There is growing, but inconsistent evidence suggesting oestrogen may play a key role in lung cancer development, especially among never-smoking women for whom lung cancer risk factors remain largely elusive. Using the China Kadoorie Biobank, a large-scale prospective cohort with 302 510 women aged 30 to 79 years recruited from 10 regions in China during 2004 to 2008, we assessed the risk of lung cancer death among self-reported never-smoking women who were cancer-free at baseline, in relation to age at menarche, age at menopause, time since menopause, prior use of oral contraceptives (OCP), number of livebirths, breastfeeding and age at first livebirth. Women were followed up to December 31, 2016 with linkage to mortality data. Hazard ratios (HR) and 95% confidence intervals (CI) were estimated using Cox regression, adjusting for key confounders including several socio-demographic, environmental and lifestyle factors. Among 287 408 never-smoking women, 814 died from lung cancer with a median follow-up of 10.3 years. Women who had used OCP within 15 years prior to baseline had a significantly higher hazard of lung cancer death compared with never-users: HR = 1.85 (95% CI: 1.14-3.00) and risk increased by 6% with each additional year of use: HR = 1.06 (1.01-1.10). Among parous women, the hazard of lung cancer death increased by 13% with each single livebirth: HR = 1.13 (1.05-1.23); and among post-menopausal women, the risk increased by 2% with each year since menopause: HR = 1.02 (1.01-1.04). These results suggest that reproductive factors which were proxies for lower endogenous oestrogen level, for example, longer duration of OCP use, could play a role in lung cancer development.

Risk-stratified Approach for Never- and Ever-Smokers in Lung Cancer Screening: A Prospective Cohort Study in China

Rationale: Over 40% of lung cancer cases occurred in never-smokers in China. However, high-risk never-smokers were precluded from benefiting from lung cancer screening as most screening guidelines did not consider them. Objectives: We sought to develop and validate prediction models for 3-year lung cancer risks for never- and ever-smokers, named the China National Cancer Center Lung Cancer models (China NCC-LC_m2021 models). Methods: 425,626 never-smokers and 128,952 ever-smokers from the National Lung Cancer Screening program were used as the training cohort and analyzed using multivariable Cox models. Models were validated in two independent prospective cohorts: one included 369,650 never-smokers and 107,678 ever-smokers (841 and 421 lung cancers), and the other included 286,327 never-smokers and 78,469 ever-smokers (503 and 127 lung cancers). Measurements and Main Results: The areas under the receiver operating characteristic curves in the two validation cohorts were 0.698 and 0.673 for never-smokers and 0.728 and 0.752 for ever-smokers. Our models had higher areas under the receiver operating characteristic curves than other existing models and were well calibrated in the validation cohort. The China NCC-LC_m2021 ⩾0.47% threshold was suggested for never-smokers and ⩾0.51% for ever-smokers. Moreover, we provided a range of threshold options with corresponding expected screening outcomes, screening targets, and screening efficiency. Conclusion: The construction of the China NCC-LC_m2021 models can accurately reflect individual risk of lung cancer, regardless of smoking status. Our models can significantly increase the feasibility of conducting centralized lung cancer screening programs because we provide justified thresholds to define the high-risk population of lung cancer and threshold options to adapt different configurations of medical resources.

The association between cigarette smoking and health care service utilization among middle-aged and elderly adults in China

Objective

To assess the associations between tobacco use and health care service utilization in Chinese individuals aged more or equal to 40 years old.

Method

This research was a cross-sectional study using data from eight provinces in China, and the final sample consisted of 4,733 observations (4,749 participants) aged more or equal to 40 years old. The dependent variable was health care utilization measured by outpatient and inpatient service utilization. Descriptive statistics were used to summarize the socio-demographic characteristics of the sample according to smoking status. The association between tobacco use and health care service utilization was examined by an instrumental variable (IV) probit model.

Results

Of the respondents interviewed in 2020, 3,116 (65.84%) were never smokers, 654 (13.82%) were smokers with the smoking index (SI) <400, and 963(20.34%) were smokers with SI≥400. Smokers with SI <400 reported a 6.80% higher probability of using outpatient services. Smokers with SI <400 and SI≥400 reported a 3.10 and 4.20% higher average probability of using ≥3 outpatient visits than never smokers, respectively. Additionally, smokers with SI <400 and SI≥400 reported a 6.30 and 6.20% higher average probability of using inpatient services than those who had not smoked. Moreover, smokers with SI≥400 were more likely to have had ≥2 hospital visits than nonsmokers.

Conclusions

Smokers make greater use of health care services. Control of smoking may ease the burden of related health care utilization.

Smoking trajectory and cancer risk: A population-based cohort study

INTRODUCTION

Smoking behavior can change with time and lead to different health outcomes. This study explored the trajectory of smoking and its relationship with cancer incidence and mortality among Korean male adults.

METHODS

We used 2002–2018 data from the National Health Insurance Service (NHIS). Smoking status was repeatedly measured in four waves of general health examinations provided by the NHIS between 2002 and 2009. Cancer incidence and mortality were tracked from 2010 to 2018. Trajectory analysis was used to identify the patterns of smoking. The hazard ratio was calculated using Cox proportional regression models.

RESULTS

For the 2448548 men (≥20 years), 137788 cases of cancers and 41146 cancer deaths were found. We identified six trajectory groups: never smokers, former smokers, new current smokers, decreasing light smokers, steady moderate smokers, and steady heavy smokers. All smoking groups had an increased risk of cancer. The steady heavy smokers showed higher cancer incidence and mortality rate than the steady non-smokers (hazard ratio, HR=1.53; 95% CI: 1.49–1.58 and HR=2.64; 95% CI: 2.50–2.79, respectively). The cancer-specific analysis showed that the larynx and lung cancer incidence and mortality rate of the smoking group were higher than in never smokers.

CONCLUSIONS

Smoking, even at low doses, increases the risk of most cancers in men. Quitting or reducing smoking, especially at a young age, can lower cancer incidence and mortality. This study may provide more objective results on the relationship between smoking and cancer, because smoking behavior was examined at multiple time points.

LncRNA in tumorigenesis of non-small-cell lung cancer: From bench to bedside

Lung cancer has been one of the leading causes of cancer-related death worldwide, and non-small-cell lung cancer (NSCLC) accounts for the majority of lung cancer morbidity, yet the pathogenesis of NSCLC has not been fully elucidated. Recently, long-chain non-coding RNA (lncRNA) has attracted widespread attention. LncRNA is a type of non-coding RNA whose transcript length exceeds 200 nucleotides. After constant research, academics updated their understanding of lncRNA, especially its role in the biological processes of cancer cells, including epigenetic regulation, cell proliferation, and cell differentiation. Notably, examination of lncRNAs could serve as potential hallmarks for clinicopathological features, long-term prognosis, and drug sensitivity. Therefore, it is necessary to explore the functions of lncRNA in NSCLC and innovate potential strategies against NSCLC based on lncRNA-related research. Herein, we reviewed the functions of lncRNA in the occurrence, diagnosis, treatment, and prognosis of NSCLC, which not only help promote a comprehensive view of lncRNA in NSCLC, but also shed light on the potential of lncRNA-based diagnosis and treatment of NSCLC.

Global, regional, and national burden of cancers attributable to tobacco smoking in 204 countries and territories, 1990-2019

BACKGROUND

Cancers are leading causes of mortality and morbidity, with smoking being recognized as a significant risk factor for many types of cancer. We aimed to report the cancer burden attributable to tobacco smoking by sex, age, socio-demographic index (SDI), and cancer type in 204 countries and territories from 1990 to 2019.

METHODS

The burden of cancers attributable to smoking was reported between 1990 and 2019, based upon the Comparative Risk Assessment approach used in the Global Burden of Disease (GBD) study 2019.

RESULTS

Globally, in 2019 there were an estimated 2.5 million cancer-related deaths (95% UI: 2.3 to 2.7) and 56.4 million DALYs (51.3 to 61.7) attributable to smoking. The global age-standardized death and DALY rates of cancers attributable to smoking per 100,000 decreased by 23.0% (-29.5 to -15.8) and 28.6% (-35.1 to -21.5), respectively, over the period 1990-2019. Central Europe (50.4 [44.4 to 57.6]) and Western Sub-Saharan Africa (6.7 [5.7 to 8.0]) had the highest and lowest age-standardized death rates, respectively, for cancers attributable to smoking. In 2019, the age-standardized DALY rate of cancers attributable to smoking was highest in Greenland (2224.0 [1804.5 to 2678.8]) and lowest in Ethiopia (72.2 [51.2 to 98.0]). Also in 2019, the global number of DALYs was highest in the 65-69 age group and there was a positive association between SDI and the age-standardized DALY rate.

CONCLUSIONS

The results of this study clearly illustrate that renewed efforts are required to increase utilization of evidence-based smoking cessation support in order to reduce the burden of smoking-related diseases.

Impacts of Built Environment on Risk of Women's Lung Cancer: A Case Study of China

Built environment factors such as air pollution are associated with the risk of respiratory disease, but few studies have carried out profound investigation. We aimed to evaluate the association between the built environment and Chinese women’s lung cancer incidence data from the China Cancer Registry Annual Report 2017, which covered 345,711,600 people and 449 qualified cancer registries in mainland China. The air quality indicator (PM2.5) and other built environment data are obtained from the China Statistical Yearbook and other official approved materials. An exploratory regression tool is applied by using Chinese women’s lung cancer incidence data (Segi population) as the dependent variable, PM2.5 index and other built environment factors as the independent variables. An apparent clustering region with a high incidence of women’s lung cancer was discovered, including regions surrounding Bohai bay and the three Chinese northeastern provinces, Heilongjiang, Liaoning and Inner Mongolia. Besides air quality, built environment factors were found to have a weak but clear impact on lung cancer incidence. Land-use intensity and the greening coverage ratio were positive, and the urbanization rate and population density were negatively correlated with lung cancer incidence. The role of green spaces in Chinese women’s lung cancer incidence has not been proven.

Evaluating risk factors for lung cancer among never-smoking individuals using two Australian studies

PURPOSE

Lung cancer (LC) in never-smoking individuals would rank as Australia's eighth most deadly cancer, yet risk factors remain uncertain. We investigated demographic, lifestyle and health-related exposures for LC among never-smoking Australians.

METHODS

Using the prospective 45 and Up Study with 267,153 New South Wales (NSW) residents aged ≥ 45 years at recruitment (2006-2009), we quantified the relationship of 20 potential exposures with LC among cancer-free participants at baseline who self-reported never smoking. Adjusted hazard ratios (HR) and 95% confidence intervals (CI) for incident LC were estimated using Cox regression. The NSW Cancer, Lifestyle and Evaluation of Risk (CLEAR) Study, a case-control study including 10,781 NSW residents aged ≥ 18 years (2006-2014), was used to examine 16 potential LC exposures among cancer-free never-smoking participants. Adjusted odds ratios (OR) and 95% CI of LC were estimated using logistic regression.

RESULTS

There were 226 LC cases among 132,354 cancer-free 45 and Up Study participants who reported never smoking, with a median follow-up of 5.41 years. The CLEAR Study had 58 LC cases and 1316 cancer-free controls who had never smoked. Analyses of both datasets showed that Asian-born participants had a higher risk of LC than those born elsewhere: cohort, adjusted HR = 2.83 (95% CI 1.64-4.89) and case-control, adjusted OR = 3.78 (1.19-12.05). No significant association with LC was found for other exposures.

CONCLUSION

Our findings support the growing evidence that never-smoking, Asian-born individuals are at higher risk of developing LC than those born elsewhere. Ethnicity could be considered when assessing potential LC risk among never-smoking individuals.

Burden of cancer attributable to modifiable factors in Japan in 2015

The This study estimated the cancer burden attributable to modifiable factors in Japan in 2015 using the best available epidemiological evidence and a standard methodology. We selected the following factors for inclusion in the estimates, namely tobacco smoking (active smoking and secondhand smoking), alcohol drinking, excess bodyweight, physical inactivity, infectious agents (Helicobacter pylori, hepatitis C virus, hepatitis B virus, human papilloma virus, Epstein-Barr virus, and human T-cell leukemia virus type 1), dietary intake (highly salted food, fruit, vegetables, dietary fiber, red meat, processed meat), exogenous hormone use, never breastfeeding and air pollution, given that these were considered modifiable, in theory at least. We first estimated the population attributable fraction (PAF) of each cancer attributable to these factors using representative relative risks of Japanese and the prevalence of exposures in Japanese around 2005, in consideration of the 10-year interval between exposure and cancer outcomes. Using nationwide cancer incidence and mortality statistics, we then estimated the attributable cancer incidence and mortality in 2015. We finally obtained the PAF for site-specific and total cancers attributable to all modifiable risk factors using this formula, with statistical consideration of the effect of overlap between risk factors. The results showed that 35.9% of all cancer incidence (43.4% in men and 25.3% in women) and 41.0% of all cancer mortality (49.7% in men and 26.8% in women) would be considered preventable by avoidance of these exposures. Infections and active smoking followed by alcohol drinking were the greatest contributing factors to cancer in Japan in 2015.

Lung cancer risk in never-smokers: An overview of environmental and genetic factors

Lung cancer is the leading cause of cancer-related mortality globally, accounting for 1.8 million deaths in 2020. While the vast majority are caused by tobacco smoking, 15%-25% of all lung cancer cases occur in lifelong never-smokers. The International Agency for Research on Cancer (IARC) has classified multiple agents with sufficient evidence for lung carcinogenesis in humans, which include tobacco smoking, as well as several environmental exposures such as radon, second-hand tobacco smoke, outdoor air pollution, household combustion of coal and several occupational hazards. However, the IARC evaluation had not been stratified based on smoking status, and notably lung cancer in never-smokers (LCINS) has different epidemiological, clinicopathologic and molecular characteristics from lung cancer in ever-smokers. Among several risk factors proposed for the development of LCINS, environmental factors have the most available evidence for their association with LCINS and their roles cannot be overemphasized. Additionally, while initial genetic studies largely focused on lung cancer as a whole, recent studies have also identified genetic risk factors for LCINS. This article presents an overview of several environmental factors associated with LCINS, and some of the emerging evidence for genetic factors associated with LCINS. An increased understanding of the risk factors associated with LCINS not only helps to evaluate a never-smoker's personal risk for lung cancer, but also has important public health implications for the prevention and early detection of the disease. Conclusive evidence on causal associations could inform longer-term policy reform in a range of areas including occupational health and safety, urban design, energy use and particle emissions, and the importance of considering the impacts of second-hand smoke in tobacco control policy.

Lung cancer risk in non-smoking females with a familial history of cancer: a multi-center prospective cohort study in China

Familial risk of lung cancer has been widely studied but whether this association holds in non-smoking females is largely unknown. We sought to determine the relationship between a family history of cancer and lung cancer risk among Chinese non-smoking females based on a multi-center prospective population-based cohort study involving 547,218 individuals between 2013 and 2019. A total of 1620 lung cancer cases occurred during a median follow-up of 3.9 years. Multivariable Cox regression showed that a family history of lung cancer in first-degree relatives significantly increased the risk of lung cancer (HR: 1.50, 95%CI: 1.29, 1.75, P<0.001). Relative to those with no relatives affected, the risk of lung cancer was 51% higher in females with one relative affected (HR: 1.51, 95%CI: 1.29-1.76, P<0.001), 123% higher in females with two relatives affected (HR: 2.23, 95%CI: 1.57-3.15, P<0.001) and 143% higher in females with three or more relatives affected (HR: 2.43, 95%CI: 1.21-4.91, P=0.013). Two nested case control studies stratified by age at diagnosis were conducted to verify potential disparities in this association between the early or late onset of lung cancer. A family history of lung cancer in first-degree relatives was significantly correlated with an elevated risk of lung cancer for both cases before and after age 65 (OR: 1.36, 95%CI: 1.07-1.74, P=0.013; OR: 1.64, 95%CI: 1.15-2.33, P=0.006). Our analysis confirmed the importance of familial history of cancers on lung cancer risk in non-smoking females and highlighted the possibility of interaction between genetic and environmental effect on lung cancer.

Predicting the mortality of smoking attributable to cancer in Qingdao, China: A time-series analysis

Smoking is the leading preventable cause of death and disability from cancer in China. To provide a scientific basis for tobacco control strategies and measures, this study investigated cancer deaths attributed to smoking from 2005 to 2017 and predicted mortality trends from 2018 to 2020 in Qingdao. We used time series analysis to evaluate the number of deaths attributed to smoking among residents over 35 years old in Qingdao and predicted mortality trends. The number of cancer deaths attributed to smoking in Qingdao from 2005 to 2016 was between 170 and 407, showing an upward trend and a certain periodicity. The best model is the ARIMA (2,1,0)×(3,1,0)₁₂, with the lowest BIC (6.640) and the highest stationary R² (0.500). The predicted cancer deaths curve attributed to smoking in 2017 is consistent with the actual curve, with an average relative error of 5.74%. Applying this model to further predict the number of cancer deaths attributed to smoking in Qingdao from January 2018 to December 2020, the predicted results were 5,249, 5,423 and 6,048, respectively. The findings emphasized the need to further strengthen tobacco control measures to reduce the burden of disease caused by tobacco.

A Cross-Sectional Study on Benzene Exposure in Pediatric Age and Parental Smoking Habits at Home

After the introduction of the smoke-free legislation, household smoking has become the major source of environmental tobacco smoke (ETS) exposure for children. In our previous research, we found a strong association between urinary unmodified benzene (u-UB) levels and passive smoking exposure related to the home smoking policies (HSP). The aim of the study is to further investigate the impacts of several factors on ETS-exposure in childhood by using u-UB as tobacco-related carcinogen biomarker of exposure. Two cross-sectional studies were performed on the same target population of our previous research, in summer and winter season of the years 2017 and 2018, respectively. A questionnaire and a head space-solid phase micro-extraction/gas chromatography-mass spectrometry (HS-SPME/GC-MS) analytical method were used as investigative procedures. The improvement found in smoking habits, when compared to our previous surveys, reduced the levels of u-UB in children. However, significant differences related to the high number of smokers and smoked cigarettes, in total and at home, still persist. These differences are more relevant in the winter season. Finally, the only effective way for making homes completely smokefree is to develop public health policies for encouraging people to quit or drastically reduce smoking.

Province-specific smoking-attributable cancer mortality in China 2013

INTRODUCTION

Province-specific initiatives are at the forefront of tobacco control but limited studies have provided province-specific assessment of smoking-attributable cancer burden in China.

METHODS

We estimated the fraction of total and site-specific cancer mortality attributable to tobacco smoking in 31 provinces in mainland China. The population attributable fractions (PAFs) for cancer deaths due to smoking were calculated by Levin's formula using province-specific smoking prevalence data around 1998 (assuming a 15-year latency time) and relative risks from cohort studies and meta-analyses. The 95% confidence intervals (CIs) of PAFs were calculated by a Delta method. Cancer deaths were abstracted from cancer registry data of the 31 provinces in mainland China in 2013.

RESULTS

Overall, smoking contributed to a total of 421566 cancer deaths in mainland China in 2013 (19.46% of all cancer deaths), with 400701 of these deaths occurring in men (29.34%) and 20865 (2.61%) in women. The population attributable fractions ranged from 15.56% (95% CI: 9.12-21.82%) in Tibet to 35.09% (95% CI: 25.68-45.83%) in Guizhou among men, and from 0.28% (95% CI: 0.00-0.64%) in Hainan to 10.44% (95% CI: 4.86-16.32%) in Jilin among women. Cancers of lung and liver were the two main smoking-attributable cancers for both men and women.

CONCLUSIONS

Tobacco smoking was responsible for nearly 20% of all cancer deaths in mainland China, but the proportion of cancer deaths attributable to smoking varied substantially across provinces. More effective programs and innovative new strategies for local tobacco control are warranted to reduce the future burden of smoking-related cancers in all provinces of mainland China.

Cigarette Smoking and Its Associations with Substance Use and HIV-Related Sexual Risks among Chinese Men Who Have Sex with Men

China has the largest population of male smokers globally. Men who have sex with men (MSM) are at greater risk of cigarette smoking compared to the general population. Limited data are available regarding cigarette smoking and its associations with other health issues among Chinese MSM. Eligible MSM (n = 1100) were recruited from mainland China using an online national cross-sectional survey conducted in 2014-2015. Socio-demographic characteristics, smoking behavior, substance use, homosexual stigma and outness, HIV-related risk behavior, and HIV status were obtained. Logistic regression analyses were performed to evaluate predictors of current cigarette smoking frequency and the co-occurrence of smoking and drug use. Nearly 41% (n = 446) of participants had ever smoked cigarettes; 25% (n = 278) were current frequent smokers; and 13% (n = 138) were current infrequent smokers. Factors associated with a history of smoking included age, employment status, and monthly salary. Risk factors associated with current frequent smoking included self-identification as gay, having female sexual partners, binge drinking, drug use, higher levels of homosexual stigma, and being partially or fully "out" as gay. Adjusted multinomial analysis showed that human immunodeficiency virus (HIV) related risks, including risky sexual behaviors, lack of condom use, and a reported history of sexually transmitted infections (STIs), were associated with co-occurrence of current smoking and drug use. Cigarette smoking rates remain high among MSM in China. Cigarette smoking is associated with binge drinking, drug use, and HIV-related risks in this community. There is a clear opportunity for smoking cessation interventions to be linked with HIV and substance use prevention interventions, thereby addressing multiple health issues simultaneously for the MSM community in China.

Lung Cancer in Never-Smokers: A Multicenter Case-Control Study in North China

This study aimed at estimating the effects of epidemiological risk factors for lung cancer in never-smokers. A multicenter and matched case-control study was conducted in the cities of Shijiazhuang, Xingtai, Qinhuangdao, Baoding, and Chengde in North China. It comprised 1,086 cases and 2,172 healthy subjects as controls, all of whom had smoked fewer than 100 cigarettes in their lifetimes. Patients were newly diagnosed with lung cancer between January 2015 and December 2017. Each patient was matched to two control participants for sex and age (±5 years). Both univariate analysis and multivariate conditional logistic regression models were used to estimate the odds ratio (OR) and 95% confidence interval (95% CI). Subsequently, data were stratified by participant sex and different air quality conditions for analysis. Type of job, exposure to environmental tobacco smoke in the workplace or at home, above-average exposure to cooking oil fumes, depression, poor sleep quality, occupational exposure, cardiovascular diseases, and family history of cancer were revealed as significant risk factors for lung cancer in never-smokers. However, higher educational level, frequent use of a PM_2.5 mask, cooking using clean fuels, and consumption of dietary supplements and tea reduced the risk of lung cancer. Risk factors varied between males and females. In areas with air pollution, the number of risk factors was greater than elsewhere, and the magnitudes of their effects were different. Hence, focusing on these risk factors is important for the prevention and control of lung cancer in never-smokers.

Physical activity, exercise, and chronic diseases: A brief review

Chronic diseases are the leading cause of death worldwide with increasing prevalence in all age groups, genders, and ethnicities. Most chronic disease deaths occur in middle-to low-income countries but are also a significant health problem in developed nations. Multiple chronic diseases now affect children and adolescents as well as adults. Being physically inactive is associated with increased chronic disease risk. Global societies are being negatively impacted by the increasing prevalence of chronic disease which is directly related to rising healthcare expenditures, workforce complications regarding attendance and productivity, military personnel recruitment, and academic success. However, increased physical activity (PA) and exercise are associated with reduced chronic disease risk. Most physiologic systems in the body benefit positively from PA and exercise by primary disease prevention and secondary disease prevention/treatment. The purpose of this brief review is to describe the significant global problem of chronic diseases for adults and children, and how PA and exercise can provide a non-invasive means for added prevention and treatment.

Exploration of bladder cancer-associated methylated miRNAs by methylated DNA immunoprecipitation sequencing

BACKGROUND

The current study aimed to explore the association between two epigenomic components, miRNA and DNA methylation, in bladder cancer (BC).

METHODS

Eight paired samples of tumor tissue and matched adjacent normal tissues from BC patients were subjected to methylated DNA immunoprecipitation sequencing and sRNA-Seq for differentially methylated miRNA genes and differential miRNA analysis. The miRNAs regulated by DNA methylation were screened and their functions involved in BC were analyzed using Gene Ontology (GO) and the Kyoto Encyclopedia of Genes and Genomes (KEGG) as well as a miRNA-mRNA interaction network.

RESULTS

The methylation levels of 212 genes were different between tumors and normal tissues with specific enrichment at transcription initiation and termination sites. Among these genes, 154 were hypermethylated and 58 were hypomethylated. GO and KEGG pathway enrichment analysis indicated that differentially methylated miRNA genes were mainly enriched in tumor-associated GO terms and signaling pathways. Pairwise statistical analysis of MeDIP-Seq and sRNA-Seq data showed that there are 154 and 165 candidate methylation-regulated genes in tumors and normal tissues, respectively. Notably, an interaction network indicated that the miRNAs regulated by methylation regulated a broad range of mRNAs associated with cancer development and progression. In particular, the most differentially expressed miRNAs were validated by qRT-PCR, such that miR-145-5p was downregulated and miR-182-5p was upregulated in patients with bladder cancer.

CONCLUSION

A large number of miRNA genes were modified by methylation in BC. Identification of changes in the expression of these miRNAs provides a great deal of important information for BC diagnosis.

Provincial-level cancer burden attributable to active and second-hand smoking in China

Background

Understanding disparities in the burden of cancer attributable to smoking is crucial to inform and improve tobacco control measures. In this report, we estimate the population attributable fraction (PAF) of cancers deaths attributable to smoking at the national and provincial levels in China.

Methods

Using cancer mortality data from 978 counties, smoking data from a nationwide survey and relative risks from a prospective study of 0.5 million adults in China, we calculated the absolute (non-standardised) and standardised numbers and proportions of cancer deaths among adults 30 years and older attributable to active and second-hand smoking in 2014 across all 31 provinces in Mainland China.

Results

The estimated number of cancer deaths attributable to smoking in China in 2014 was 342 854 among men and 40 313 among women, of which second-hand smoking accounted for 1.8% and 50.0%, respectively. Among men, the absolute PAF in China was 23.8%, ranging from 14.6% in Xinjiang to 26.8% in Tianjin; the overall standardised PAF was 22.2%, ranging from 15.7% in Xinjiang to 26.0% in Guizhou. Among women, the overall absolute and standardised PAFs were 4.8% and 4.0%, ranging from 1.8% and 1.6% in Jiangxi to 14.9% and 9.6% in Heilongjiang, respectively. Overall, provinces with the highest standardised PAFs among men were located in Southwest China and among women in the Northeast.

Conclusions

Comprehensive smoke-free policies in China should expand to all provinces, notably those with a higher burden of cancer attributable to smoking, instead of being mostly limited to Beijing and some other metropolitan areas.

Cancer mortality attributable to cigarette smoking in 2005, 2010 and 2015 in Qingdao, China

Introduction

Cigarette smoking is among the most important public health concerns worldwide and the leading preventable cause of illness and death associated with cancer, chronic obstructive pulmonary disease (COPD) and cardiovascular disease (CVD). Although Qingdao, China implemented smoking control measures in 2007 and smoke-free legislation in 2013, smoking-attributable cancer mortality remains at a high level. The present study aimed to facilitate changes in policy-making, intervention implementation, monitoring and evaluation by estimating and comparing the burden of smoking-attributable cancers in Qingdao during 2005, 2010 and 2015.

Methods

This study used the disease list from the Global Burden of Disease (GBD) study to quantify the burden of smoking-related cancer. Sex and age-specific smoking-attributable mortality data were collected from the Qingdao Municipal Center for Disease Control and Prevention using an online reporting system. The population-attributable fractions (PAFs) of smoking and smoking-attributable cancer mortality in 2005, 2010 and 2015 were estimated using the smoking impact ratio (SIR) and relative risks (RRs) and by multiplying the smoking-attributable fraction by total cancer mortality, respectively.

Results

The numbers of smoking-attributable cancer deaths increased from 2484 in 2005 to 2999 in 2010 and 4148 in 2015, with corresponding PAFs of 26.41%, 25.76% and 29.13%, respectively. The PAFs were higher among men (vs. women) for all cancers except cervical cancer. In 2005, lung, liver, esophageal and stomach cancers were most frequently associated with smoking-associated cancer mortality, and lung cancer had the greatest PAF, followed by nasopharyngeal, oral and esophageal cancers. Similar patterns were observed in 2010 and 2015. In 2015, 1 in 3 and 1 in 5 cancer deaths in men and women, respectively, were attributable to smoking, and 95% of these deaths were associated with lung, liver, esophageal or stomach cancer. Over time, downward and upward trends in smoking-attributable cancer deaths were respectively observed among people younger than and older than 50 years.

Conclusions

The smoking-attributable cancer burden in Qingdao remains considerable, despite the implementation of tobacco control and smoke-free measures. Tobacco control efforts should remain a major public health priority.

[Progress of Long Non-coding RNA in Non-small Cell Lung Cancer]

肺癌是世界上常见的恶性肿瘤之一，其发病率和死亡率都居全部恶性肿瘤的首位。长链非编码RNA（lncRNA）是一类转录长度超过200个核苷酸且无蛋白质编码功能的RNA，但在表观遗传学调控、细胞周期调控和细胞分化调控等众多生命活动中发挥重要作用。研究发现lncRNA在非小细胞肺癌（non-small cell lung cancer, NSCLC）组织和血液中异常表达，且对肿瘤细胞的增殖、迁移、侵袭和凋亡发挥了重要调节作用，与肿瘤的发生发展密切相关。探索lncRNA在NSCLC中的作用机制，有助于NSCLC的早期诊断，靶向治疗及改善预后。因此本文就lncRNA与NSCLC的发生、诊断、治疗和预后的最新研究进展做一阐述，以期为NSCLC的防治提供新思路。

Cigarette Initiation Among Chinese Male Teenagers in Early Smoking Interactions

To collect in-depth information regarding cigarette initiation interactions in the early smoking experimentation among male youth in China, twenty focus groups with male teenagers (N = 165) were conducted. Focus group discussions indicated a high prevalence of cigarette initiation among peers, and such initiation often translated into immediate smoking. Of the identified cigarette initiation appeals, "face" and normative pressure appeals were the most difficult to reject. Upon first initiation attempts, more teenagers accepted cigarettes than rejected them. The reasons behind both cigarette initiation and acceptance primarily related to facilitating social interaction. Upon being rejected, initiating teenagers (agents) who insisted on offering cigarettes often gained compliance. Profiles of peer agents were constructed in this study. Key practical implications suggest simultaneously prioritizing efforts to reduce cigarette initiation and encouraging cigarette refusal.

Environmental contributions to gastrointestinal and liver cancer in the Asia-Pacific region

In the Asia-Pacific region, gastric, colorectal, and hepatocellular (liver) cancer show substantial regional variation in incidence consistent with the presence of important environmental factors. For gastric cancer, global incidence is concentrated in Asia with substantially higher rates in East Asia than in South-East Asia and Australia. The differences in incidence rates for gastric cancer in the Asia-Pacific region may be due, in part, to differences in the prevalence of Helicobacter pylori infection and the prevalence of H. pylori virulence factors. Smoking is also correlated with gastric cancer risk and is responsible for the highest population attributable fraction among men in East Asia. Colorectal cancer has increased rapidly in incidence to become the third most common digestive cancer in Asia. According to cohort studies in Asia, smoking, alcohol use, obesity, and physical inactivity increase the risk of colorectal cancer. Unlike West Asia, East Asia and Australia have high incidence rates for colorectal cancer that correlates to a high Human Development Index and a high prevalence of alcohol consumption and obesity. Liver cancer is the second most common digestive cancer in Asia. The high incidence of liver cancer in East Asia and South-East Asia is concordant with the high prevalence of hepatitis B virus and hepatitis C virus infection. Other important risk factors include alcohol use, smoking, and diabetes. The identification of the earlier and other environmental factors (currently under investigation) is central to the development and implementation of effective cancer control programs for the region.

The Willingness to Change Risky Health Behaviors among Chinese Rural Residents: What We Learned from a Population-Based Esophageal Cancer Cohort Study

Background

The effectiveness of health interventions can be impaired by low socio-economic status and poor living conditions of the target population. However, the specifics of this problem in rural China are still unclear, and appropriate strategies should be explored.

Methods

In 2013, we conducted a questionnaire-based investigation among 410 participants from a population-based esophageal cancer cohort study in rural Anyang, China. Information regarding their demographic characteristics, levels of exposure to four health-risk behaviors, including smoking, alcohol consumption, risky dietary behaviors and poor hygiene, as well as willingness to change these behaviors, and data on potential predictors of willingness to change behaviors were collected.

Results

In this study, 33.3% (23/69), 25.0% (13/52), 60.7% (68/112) and 62.2% (237/381) of respondents reported that they were willing to change smoking, alcohol consumption, risky dietary behaviors and poor hygiene, respectively. Older people had higher exposure levels and less willingness to change these four health-risk behaviors. The levels of these four health-risk behaviors were negatively associated with willingness to change, while faith in people and behavioral change in surrounding people increased willingness to change risky behaviors.

Conclusions

In behavior-intervention-based health-promotion programs in rural China, the elderly and highly exposed populations should be the most difficult part and community- or household-based intervention would be more efficient.

Burden of cancer attributable to tobacco smoking in member countries of the Association of Southeast Asian Nations (ASEAN), 2012

BACKGROUND

Cancer is an increasing problem in ASEAN (Association of Southeast Asian Nations). Tobacco use is a well-established risk factor for many types of cancers. Evidence on burden of cancer attributable to tobacco is essential to raise public and political awareness of the negative effects of tobacco on cancer and to be used to stimulate political action aims at reducing smoking prevalence in ASEAN member countries. The objective of this study was to estimate burden of cancer attributable to tobacco smoking in ASEAN, 2012.

METHODS

In this study, smoking prevalence was combined with Relative Risks (RRs) of cancer to obtain Smoking Attributable Fractions (SAFs). Cancer incidence and mortality data among individuals aged 15 years and older were derived from GLOBOCAN 2012. Fourteen types of cancer were included in the analysis. Sensitivity analyses were conducted to examine the impact of the use of alternative RRs and the use of alternative prevalence of smoking in some countries.

RESULTS

The findings showed that tobacco smoking was responsible for 131,502 cancer incidence and 105,830 cancer mortality in ASEAN countries in 2012. In other words, tobacco smoking was accounted for 28.4% (43.3% in male and 8.5% in female) of cancer incidence and 30.5% (44.2% in male and 9.4% in female) of cancer mortality in ASEAN. When looking at the types of cancer, lung cancer showed the strongest association with tobacco smoking. Incidence of cancer and cancer mortality attributable to tobacco smoking varied by countries due to the differences in size of population, background risk of cancer, and prevalence of smoking in each country. According to the sensitivity analyses, RRs of lung cancer, pharynx cancer, and larynx cancer used in the estimates have significant impact on the estimates.

CONCLUSIONS

As about one-third of cancer incidence and mortality in ASEAN are attributable to tobacco smoking ASEAN member countries are strongly encouraged to put in place stronger tobacco control policies and to strengthen the existing tobacco control measure in order to effectively control cancer.

Cancer incidence and mortality in Henan province, 2012

Objective

Population-based cancer registration data in 2012 from all available cancer registries in Henan province were collected by Henan Office for Cancer Research and Control. The numbers of new cancer cases and cancer deaths in Henan province with compiled cancer incidence and mortality rates were estimated.

Methods

In 2015, all registries’ data in Henan province were qualified for the national cancer registry annual report in 2012. The pooled data were stratified by area (urban/rural), gender, age group (0, 1.4, 5.9, 10.14, …, 85+) and cancer type. New cancer cases and deaths were estimated using age-specific rates and corresponding population of Henan province in 2012. The Chinese census data in 2000 and Segi’s population were applied for age-standardized rates. All the rates were expressed per 100,000 person-years.

Results

Qualified 19 cancer registries (4 urban and 15 rural registries) covered 16,082,688 populations of Henan province in 2012. The percentage of cases with morphologically verified (MV%) and death certificateonly cases (DCO%) were 69.84% and 2.30%, respectively, and the mortality to incidence rate ratio (M/I) was 0.64. It was estimated that there were 248,510 new cancer cases and 158,630 cancer deaths in Henan province in 2012. The incidence rate was 266.17/100,000 (288.61/100,000 in males and 241.86/100,000 in females), the age-standardized incidence rates by Chinese standard population (ASIRC) and by world standard population (ASIRW) were 208.95/100,000 and 206.41/100,000 with the cumulative incidence rate (0.74 years old) of 24.30%. The crude incidence rate in urban areas was higher than that in rural areas. However, after adjusted by age, the cancer incidence rate in rural was higher than that in urban areas. The crude mortality of all cancers in Henan province was 169.90/100,000 (201.23/100,000 in males and 135.95/100,000 in females). The age-standardized mortality rates by Chinese standard population (ASMRC) and by world standard population (ASMRW) were 131.20/100,000 and 130.80/100,000, respectively. Among the patients aged 0.74 years, the cumulative mortality rate was 15.03%. The crude cancer mortality rate in urban areas was higher than that of rural areas. However, the age-standardized rate in rural areas was higher than that of urban areas. Cancers of lung, stomach, esophagus, liver, female breast, colorectum, cervix, brain, uterus and ovary were the most common cancers, accounting for about 82.80% of all cancer new cases. Lung cancer, stomach cancer, esophageal cancer, liver cancer, colorectal cancer, female breast cancer, brain cancer, leukemia, pancreatic cancer and cervix cancer were the leading causes of cancer deaths, accounting for about 88.50% of all cancer deaths. The burden between urban and rural, males and females were different.

Conclusions

Registration data of Henan province was qualified to provide basic information on population-based cancer incidence, mortality for cancer prevention and control. The upper digestive tract cancer burden in Henan province, especially for males in rural areas, was higher. The incidence rate of female breast cancer was higher in urban areas. Targeted prevention, early detection and treatment programs should be carried out by health department to control the cancer burden.

Cancer incidence and mortality in Gansu province, 2012

Objective

Population-based cancer registration data in 2012 from all available cancer registries in Gansu province were collected by the Central Cancer Registry of Gansu. The numbers of new cancer cases and cancer deaths in Gansu province with compiled cancer incidence and mortality rates were estimated.

Methods

In 2015, data from 7 registries in Gansu province were qualified. The pooled data were stratified by area (urban/rural), gender, age group (0, 1.4, 5.9, 10.14, …, 85+) and cancer type. New cancer cases and deaths were estimated using age-specific rates and corresponding population of Gansu province in 2012. The Chinese census data in 2000 and Segi’s population were applied for age-standardized rates. All the rates were expressed per 100,000 person-years.

Results

Qualified 7 cancer registries (3 urban and 4 rural registries) covered 2,956,560 populations of Gansu province in 2012. The percentage of cases morphologically verified (MV%) and death certificate-only cases (DCO%) were 72.41% and 1.65%, respectively, and the mortality to incidence rate ratio (M/I) was 0.63. It was estimated that there were 575,600 new cancer cases and 331,300 cancer deaths in Gansu province in 2012. The incidence rate was 223.29/100,000 (244.14/100,000 in males and 201.50/100,000 in females), the age-standardized incidence rates by Chinese standard population (ASIRC) and by world standard population (ASIRW) were 208.95/100,000 and 206.41/100,000 with the cumulative incidence rate (0.74 years old) of 22.49%. The crude incidence rate in urban areas was equal to that in rural areas. However, after adjusted by age, the cancer incidence rate in urban was the same as that of rural areas. The crude mortality in Gansu province was 128.54/100,000 (135.04/100,000 in males and 124.43/100,000 in females), the age-standardized mortality rates by Chinese standard population (ASMRC) and by world standard population (ASMRW) were 109.54/100,000 and 108.44/100,000, respectively, and the cumulative mortality rate (0.74 years old) was 12.91%. The crude cancer mortality rate in urban areas was higher than that of rural areas. However, the agestandardized rate in urban areas was the same as that of rural areas. Cancers of stomach, liver, lung, esophagus, female breast, colorectum, cervix, brain, pancreas and ovary were the most common cancers, accounting for about 83.56% of all cancer new cases. Stomach cancer, liver cancer, lung cancer, esophageal cancer, female breast cancer, colorectal cancer, brain cancer, lymphoma, pancreatic cancer and cervix cancer were the leading causes of cancer death, accounting for about 85.58% of all cancer deaths. The burden between urban and rural, males and females was different.

Conclusions

Registration data of Gansu province were qualified to provide basic information on population-based cancer incidence, mortality for cancer prevention and control. The digestive tract cancer burden in Gansu province, especially for males in rural areas, was higher. The incidence rate of female breast cancer was higher in urban areas. Targeted prevention, early detection and treatment programs should be carried out by health department to control the cancer burden.

The fractions of cancer attributable to modifiable factors: A global review

Worldwide, the burden of cancer is rising, stimulating efforts to develop strategies to control these diseases. Primary prevention, a key control strategy, aims to reduce cancer incidence through programs directed towards reducing population exposure to known causal factors. Before enacting such strategies, it is necessary to estimate the likely effect on cancer incidence if exposures to known causal factors were reduced or eliminated. The population attributable fraction (PAF) is the epidemiological measure which quantifies this potential reduction in incidence. We surveyed the literature to document and summarise the proportions of cancers across the globe attributable to modifiable causes, specifically tobacco smoke, alcohol, overweight/obesity, insufficient physical activity, solar ultraviolet (UV) radiation and dietary factors (insufficient fruit, non-starchy vegetables and fibre; red/processed meat; salt). In total, we identified 55 articles that presented PAF estimates for one or more causes. Information coverage was not uniform, with many articles reporting cancer PAFs due to overweight/obesity, alcohol and tobacco, but fewer reporting PAFs for dietary factors or solar UV radiation. At all cancer sites attributable to tobacco and alcohol, median PAFs were markedly lower for women than men. Smoking contributed to very high median PAFs (>50%) for cancers of the lung and larynx. Median PAFs for men, attributable to alcohol, were high (25-50%) for cancers of the oesophagus, oral cavity/pharynx, larynx and liver. For cancers causally associated with overweight/obesity, high median PAFs were reported for oesophageal adenocarcinoma (men 29%, women 37%), gallbladder (men 11%, women 42%) and endometrium (36%). The cancer PAF literature is growing rapidly. Repeating this survey in the future should lead to more precise estimates of the potentially preventable fractions of cancer.

Chromosome 15q25 (CHRNA3-CHRNB4) Variation Indirectly Impacts Lung Cancer Risk in Chinese Males

Introduction

Recently, genome-wide association studies (GWAS) in Caucasian populations have identified an association between single nucleotide polymorphisms (SNPs) in the CHRNA5-A3-B4 nicotinic acetylcholine receptor subunit gene cluster on chromosome 15q25, lung cancer risk and smoking behaviors. However, these SNPs are rare in Asians, and there is currently no consensus on whether SNPs in CHRNA5-A3-B4 have a direct or indirect carcinogenic effect through smoking behaviors on lung cancer risk. Though some studies confirmed rs6495308 polymorphisms to be associated with smoking behaviors and lung cancer, no research was conducted in China. Using a case-control study, we decided to investigate the associations between CHRNA3 rs6495308, CHRNB4 rs11072768, smoking behaviors and lung cancer risk, as well as explore whether the two SNPs have a direct or indirect carcinogenic effect on lung cancer.

Methods

A total of 1025 males were interviewed using a structured questionnaire (204 male lung cancer patients and 821 healthy men) to acquire socio-demographic status and smoking behaviors. Venous blood samples were collected to measure rs6495308 and rs11072768 gene polymorphisms. All subjects were divided into 3 groups: non-smokers, light smokers (1–15 cigarettes per day) and heavy smokers (>15 cigarettes per day).

Results

Compared to wild genotype, rs6495308 and rs11072768 variant genotypes reported smoking more cigarettes per day and a higher pack-years of smoking (P<0.05). More importantly, among smokers, both rs6495308 CT/TT and rs11072768 GT/GG had a higher risk of lung cancer compared to wild genotype without adjusting for potential confounding factors (OR = 1.36, 95%CI = 1.09–1.95; OR = 1.11, 95%CI = 1.07–1.58 respectively). Furthermore, heavy smokers with rs6495308 or rs11072768 variant genotypes have a positive interactive effect on lung cancer after adjustment for potential confounding factors (OR = 1.13, 95%CI = 1.01–3.09; OR = 1.09, 95%CI = 1.01–3.41 respectively). However, No significant associations were found between lung cancer risk and both rs6495308 and rs11072768 genotypes among non-smokers and smokers after adjusting for age, occupation, and education.

Conclusion

This study confirmed both rs6495308 and rs11072768 gene polymorphisms association with smoking behaviors and had an indirect link between gene polymorphisms and lung cancer risk.

Cancer prevention and control: alarming challenges in China

China is geographically the third largest country in the world and the most populated low-to-middle-income country. Cancer incidence and mortality rates for some cancers in the USA and European countries have steadily decreased over the last decades, whereas the incidence and mortality of certain cancers in China have been increasing at an alarming speed. Rapid industrialization and urbanization in China have been accompanied by incredible changes in lifestyle and environment combined with an aging population. Mortality caused by lung, colorectal and breast cancers has been steadily increasing, whereas cancer mortality from gastric, esophageal and cervical tumors has tended to decrease. Similar to what has occurred in the United States, unhealthy lifestyles in China, including heavy smoking and poor diet combined with pollution, have contributed to increased cancer risk. China is facing many challenges in cancer treatment and prevention for the general population. The major areas that need to be addressed in the control of cancer in China include cancers associated with environmental pollution, tobacco use, occupational carcinogens, infection, excessive alcohol consumption, dietary deficiencies and obesity. In this perspective, we review the problems in each area and suggest ideas for future directions in cancer research and strategies and actions to reduce the incidence of cancer in China.

Using Monte Carlo simulation to assess variability and uncertainty of tobacco consumption in a city by sewage epidemiology

OBJECTIVE

To use Monte Carlo simulation to assess the uncertainty and variability of tobacco consumption through wastewater analysis in a city.

METHODS

A total of 11 wastewater treatment plants (WWTPs) (serving 2.2 million people; approximately 83% of urban population in Dalian) were selected and sampled. By detection and quantification of principal metabolites of nicotine, cotinine (COT) and trans-3'-hydroxycotinine (OH-COT), in raw wastewater, back calculation of tobacco use in the population of WWTPs can be realised.

RESULTS

COT and OH-COT were detected in the entire set of samples with an average concentration of 2.33 ± 0.30 and 2.76 ± 0.91 µg/L, respectively. The mass load of absorbed NIC during the sampling period ranged from 0.25 to 4.22 mg/day/capita with an average of 1.92 mg/day/capita. Using these data, we estimated that smokers in the sampling area consumed an average of 14.6 cigarettes per day for active smoker. Uncertainty and variability analysis by Monte Carlo simulation were used to refine this estimate: the procedure concluded that smokers in Dalian smoked between 10 and 27 cigarettes per day. This estimate showed good agreement with estimates from epidemiological research.

CONCLUSIONS

Sewage-based epidemiology may be a useful additional tool for the large-scale monitoring of patterns of tobacco use. Probabilistic methods can be used to strengthen the reliability of estimated use generated from wastewater analysis.

Health Disparity and Cancer Health Disparity in China

China is one of the largest and most populated countries in the world. It has undergone rapid economic growth in recent years. However, the development is not equitable, and the distribution of wealth significantly varies among the regions in China. Geographical and socioeconomic inequalities, together with the lack of an equitable national social support system, cause the high variance of health outcomes among the regions. Furthermore, the fast growth of the economy has evoked many environmental challenges and puts much pressure on the population. The severe environmental deterioration, especially of the atmosphere and water bodies, has affected the health of the people living in China. As a result, cancer has become a major public health issue, and an alarming increase in incidence and mortality has been reported. However, cancer incidence and mortality vary in different areas in China. Cancer and cancer treatment disparities have existed for years. This article will discuss the existing health and cancer disparities associated with the risk factors and how these disparities are managed in China.

Urinary N1, N12-diacetylspermine is a non-invasive marker for the diagnosis and prognosis of non-small-cell lung cancer

BACKGROUND

Early detection of non-small-cell lung cancer (NSCLC) and accurate prognostic risk assessment could improve patient outcome. We examined the significance of urinary N(1), N(12)-diacetylspermine (DiAcSpm) in the detection and prognostic stratification of NSCLC patients.

METHODS

A DiAcSpm/cutoff ratio (DASr) was established for 260 NSCLC patients, 99 benign lung disease patients, and 140 healthy volunteers, using colloidal gold aggregation methods. The DASr was compared between patients and healthy controls, and the prognostic significance of DASr was examined.

RESULTS

The median urinary DASr of NSCLC patients was significantly higher than that of healthy controls (0.810 vs 0.534, P<0.001). The DASr was higher in squamous cell carcinoma (SqCC) patients than in adenocarcinoma patients (1.18 vs 0.756, respectively, P=0.039). An increased urinary DASr value was significantly associated with pathological stage, other histological invasive factors and unfavourable outcomes in patients with completely resected NSCLC. Multivariate Cox regression analysis showed that increased urinary DASr was an independent prognostic factor (hazard ratio=4.652, 95% confidence interval (CI), 2.092-10.35; P<0.001).

CONCLUSIONS

Urinary DASr was significantly increased in NSCLC, especially in SqCC. Urinary DASr was an independent poor prognostic indicator in patients with completely resected NSCLC. The DASr could be a useful biomarker for detecting malignancies and predicting prognosis.

Contrasting male and female trends in tobacco-attributed mortality in China: evidence from successive nationwide prospective cohort studies

BACKGROUND

Chinese men now smoke more than a third of the world's cigarettes, following a large increase in urban then rural usage. Conversely, Chinese women now smoke far less than in previous generations. We assess the oppositely changing effects of tobacco on male and female mortality.

METHODS

Two nationwide prospective studies 15 years apart recruited 220,000 men in about 1991 at ages 40-79 years (first study) and 210,000 men and 300,000 women in about 2006 at ages 35-74 years (second study), with follow-up during 1991-99 (mid-year 1995) and 2006-14 (mid-year 2010), respectively. Cox regression yielded sex-specific adjusted mortality rate ratios (RRs) comparing smokers (including any who had stopped because of illness, but not the other ex-smokers, who are described as having stopped by choice) versus never-smokers.

FINDINGS

Two-thirds of the men smoked; there was little dependence of male smoking prevalence on age, but many smokers had not smoked cigarettes throughout adult life. Comparing men born before and since 1950, in the older generation, the age at which smoking had started was later and, particularly in rural areas, lifelong exclusive cigarette use was less common than in the younger generation. Comparing male mortality RRs in the first study (mid-year 1995) versus those in the second study (mid-year 2010), the proportional excess risk among smokers (RR-1) approximately doubled over this 15-year period (urban: RR 1·32 [95% CI 1·24-1·41] vs 1·65 [1·53-1·79]; rural: RR 1·13 [1·09-1·17] vs 1·22 [1·16-1·29]), as did the smoking-attributed fraction of deaths at ages 40-79 years (urban: 17% vs 26%; rural: 9% vs 14%). In the second study, urban male smokers who had started before age 20 years (which is now typical among both urban and rural young men) had twice the never-smoker mortality rate (RR 1·98, 1·79-2·19, approaching Western RRs), with substantial excess mortality from chronic obstructive pulmonary disease (COPD RR 9·09, 5·11-16·15), lung cancer (RR 3·78, 2·78-5·14), and ischaemic stroke or ischaemic heart disease (combined RR 2·03, 1·66-2·47). Ex-smokers who had stopped by choice (only 3% of ever-smokers in 1991, but 9% in 2006) had little smoking-attributed risk more than 10 years after stopping. Among Chinese women, however, there has been a tenfold intergenerational reduction in smoking uptake rates. In the second study, among women born in the 1930s, 1940s, 1950s, and since 1960 the proportions who had smoked were, respectively, 10%, 5%, 2%, and 1% (3097/30,943, 3265/62,246, 2339/97,344, and 1068/111,933). The smoker versus non-smoker RR of 1·51 (1·40-1·63) for all female mortality at ages 40-79 years accounted for 5%, 3%, 1%, and <1%, respectively, of all the female deaths in these four successive birth cohorts. In 2010, smoking caused about 1 million (840,000 male, 130,000 female) deaths in China.

INTERPRETATION

Smoking will cause about 20% of all adult male deaths in China during the 2010s. The tobacco-attributed proportion is increasing in men, but low, and decreasing, in women. Although overall adult mortality rates are falling, as the adult population of China grows and the proportion of male deaths due to smoking increases, the annual number of deaths in China that are caused by tobacco will rise from about 1 million in 2010 to 2 million in 2030 and 3 million in 2050, unless there is widespread cessation.

FUNDING

Wellcome Trust, MRC, BHF, CR-UK, Kadoorie Charitable Foundation, Chinese MoST and NSFC.

Emerging tobacco-related cancer risks in China: A nationwide, prospective study of 0.5 million adults

BACKGROUND

In China, cigarette consumption has increased substantially since the 1980s, almost exclusively in men. This study was aimed at assessing the emerging cancer risks.

METHODS

A nationwide, prospective study recruited 210,259 men and 302,632 women aged 30 to 79 years from 10 areas of China from 2004 to 2008; approximately 18,000 incident cancers were recorded during 7 years of follow-up. Cox regression yielded adjusted risk ratios (RRs) comparing smokers (including those who had stopped because of illness but not those who had stopped by choice) with never-smokers.

RESULTS

Among men, 68% were smokers; their overall cancer risk was significantly increased (RR, 1.44; 95% confidence interval [CI], 1.37-1.53), and it was greater in urban (RR, 1.55; 95% CI, 1.41-1.70) than in rural areas (RR, 1.39; 95% CI, 1.30-1.49). This excess accounted for 23% of all cancers between the ages of 40 and 79 years, with significantly elevated risks of lung cancer (RR, 2.51; 95% CI, 2.18-2.90), liver cancer (RR, 1.32; 95% CI, 1.12-1.54), stomach cancer (RR, 1.34; 95% CI, 1.16-1.55), esophageal cancer (RR, 1.47; 95% CI, 1.24-1.73), and an aggregate of 5 other minor sites (RR, 1.52; 95% CI, 1.25-1.86). For lung cancer, the RRs were much greater for nonadenocarcinoma (RR, 5.83; 95% CI, 5.02-6.77) than for adenocarcinoma (RR, 1.78; 95% CI, 1.36-2.34). Among exsmokers (6.7%) who had stopped by choice, there was little excess cancer risk approximately 15 years after quitting. Among the few female smokers (3%), the overall cancer risk was also significantly increased (RR, 1.42; 95% CI, 1.28-1.57). Smoking was estimated to cause approximately 435,000 new cancers per year in China (approximately 360,000 in men and approximately 75,000 in women).

CONCLUSIONS

In China, smoking now causes a quarter of all adult male cancers. High male uptake rates before the age of 20 years and nearly universal use of cigarettes foreshadow substantial tobacco-attributed risks in China unless there is widespread cessation.

Dietary factors and risk of pancreatic cancer: a multi-centre case-control study in China

BACKGROUND

Pancreatic cancer is the sixth leading cause of cancer death with an increasing trend in China. Dietary intake is believed to play an important role in pancreatic cancer carcinogenesis. The aim of this paper was to evaluate associations between some dietary factors and risk of pancreatic cancer in a multi-centre case-control study conducted in China.

MATERIALS AND METHODS

Cases (n=323) were ascertained from four provincial cancer hospitals. Controls (n=323) were randomly selected from the family members of patients without pancreatic cancer in the same hospitals, 1:1 matched to cases by gender, age and study center. Data were collected with a questionnaire by personal interview. Odds ratios (OR) and 95% confidence intervals (95%CI) were estimated using conditional logistic regression.

RESULTS

Tea intake (OR =0.49; 95%CI: 0.30-0.80) was associated with a half reduction in risk of pancreatic cancer. Reduced vegetable consumption (P trend: 0.04) was significant related to pancreatic cancer. Although no significant association was found for meat and fruit, ORs were all above or below the reference group. A protective effect was found for fruit (OR=1.73 for consumption of 1-2 times/week vs more than 3 times/week; 95%CI: 1.05-2.86). A high intake of meat was associated to a higher risk of pancreatic cancer (OR=0.59 for consumption of 1-2 times /week vs. more than 3 times /week; 95%CI: 0.35-0.97).

CONCLUSIONS

The present study supports fruit consumption to reduce pancreatic cancer risk and indicates that high consumption of meat is related to an elevated risk. Direct inverse relations with tea and vegetable intake were also confirmed.

Cancer information seekers in china: a preliminary profile

Cancer is now the leading cause of death in China. Effective communication about cancer risk and prevention is an important component of cancer control. Yet, research in this area is very limited in China. This study used probability sample survey data from 2 Chinese cities (Beijing and Hefei, Anhui Province) to investigate potential predictors of self-initiated cancer information seeking. Analysis showed that cancer information seekers in China were likely to be married, relatively educated, earning modest incomes, living in rural areas, smoking occasionally, having a family cancer history, relatively trusting of the media for health information, somewhat knowledgeable about cancer, having nonfatalistic attitudes about cancer, and seeing a personal need for more cancer information. The pattern of results, particularly the lack of influence of personal health and risk perception factors, highlights the possibility that seeking for others might be more prevalent than seeking for self in China. Overall, findings suggest that emphasizing family need and mobilizing family support might be a productive approach to cancer communication interventions in China.

Population-based cancer incidence analysis in Beijing, 2008-2012

OBJECTIVE

To analyze the incidence of cancer during 2008-2012 in Beijing, China, and compare the cancer spectrum with that during 1998-1999.

METHODS

Data from the Beijing Cancer Registry (BCR), which covered 12 million residents and 16 administrative regions in Beijing, were checked and evaluated on basis of the criteria of data quality from the National Central Cancer Registry (NCCR) of China. Incidences were calculated stratified by cancer type, sex, areas (urban/rural), and age. The Chinese census population in 1982 and the world Segi's population were used for calculating the age-standardized incidences.

RESULTS

A total of 177,101 new cancer cases were diagnosed in Beijing between 2008 and 2012. The crude incidence rate (CR) of all cancers was 282.64/100,000 (290.71/100,000 in males and 274.45/100,000 in females). The age-standardized rates by Chinese standard population (ASR-China) and by world standard population (ASR-world) were 124.46/100,000 and 161.18/100,000, respectively. Female breast cancer was the most common cancer, followed by lung cancer, colorectal cancer, liver cancer, and stomach cancer, with the CR of 59.87/100,000, 59.21/100,000, 32.49/100,000, 19.81/100,000 and 17.96/100,000, respectively. In urban areas, female breast cancer (68.50/100,000) was still the most common cancer, followed by lung cancer (61.23/100,000), colorectal cancer (37.23/100,000), prostate cancer (20.49/100,000) and stomach cancer (20.07/100,000). In rural areas, lung cancer (55.94/100,000) was the most common cancer, followed by female breast cancer (45.87/100,000), colorectal cancer (24.77/100,000), liver cancer (20.68/100,000) and stomach cancer (14.52/100,000). Great changes of the cancer spectrum were found from the period of 1998-1999 to the period of 2011-2012 in Beijing.

CONCLUSIONS

The cancer burden in Beijing was heavier than the national average level. Cancer prevention and control strategies, especially for lung, colorectal, prostate and female thyroid cancers, should be enhanced.

Air nicotine levels in public places in ahmedabad, India: before and after implementation of the smoking ban

Aim:

To compare air nicotine levels in public places in Ahmedabad, India, before (June 2008) and after (January, 2010) the implementation of a comprehensive smoking ban which was introduced in October 2008.

Materials and Methods:

Air nicotine concentrations were measured by sampling of vapor-phase nicotine using passive monitors. In 2008 (baseline), monitors were placed for 5-7 working days in 5 hospitals, 10 restaurants, 5 schools, 5 government buildings, and 10 entertainment venues, of which 6 were hookah bars. In 2010 (follow-up), monitors were placed in 35 similar venues for the same duration.

Results:

Comparison of the overall median nicotine concentration at baseline (2008) (0.06 μg/m³ Interquartile range (IQR): 0.02-0.22) to that of follow-up (2010) (0.03 μg/m³ IQR: 0.00-0.13), reflects a significant decline (% decline = 39.7, P = 0.012) in exposure to second-hand smoke (SHS). The percent change in exposure varied by venue-type. The most significant decrease occurred in hospitals, from 0.04 μg/m³ at baseline to concentrations under the limit of detection at follow-up (%decline = 100, P < 0.001). In entertainment venues, government offices, and restaurants, decreases in SHS exposure also appeared evident. However, in hookah bars, air nicotine levels appeared to increase (P = 0.160).

Conclusion:

Overall, SHS exposure was significantly reduced in public places after the smoke-free legislation came into force. However, nicotine concentrations were still detected in most of the venues indicating imperfect compliance with the comprehensive ban.

Immigration, ethnicity, and avoidable mortality in Canada, 1991-2006

OBJECTIVE

Avoidable mortality is a well-recognized, but less studied indicator of the performance of the health system. First, the study seeks to establish whether immigrants overall and selected foreign-born ethnic groups (Western Europeans, South Asians, Chinese, and Filipinos) have an advantage over nonimmigrants in avoidable mortality. Second, it assesses the effect of sociodemographic and socioeconomic factors on any observed differences by duration of residence.

DESIGN

Deaths grouped by cause of death and by behavioral risk factors, namely smoking-related and alcohol-related, were derived from the 1991 Canadian Census Cohort: Mortality and Cancer Follow-up. The analysis estimated age-standardized mortality rates (ASMRs), rate ratios, and rate differences and also fitted hazard regression models for the overall Canadian-born population and for selected foreign-born ethnicities by sex. Predictors were assessed at baseline.

RESULTS

Compared to the Canadian-born persons, foreign-born men and women had lower ASMRs for overall avoidable mortality and also for selected causes of avoidable mortality. The only exception to this overall trend was for ischemic heart disease among South Asian women. Except for the order of prominence, the three leading causes of death for nonimmigrant and immigrant men and women overall were ischemic heart diseases, smoking-related diseases, and neoplasms. A similar pattern was observed among the ethnic groups, except for circulatory heart diseases replacing ischemic heart diseases and smoking-related diseases among Chinese and Filipino women, respectively. In the hazard regression analysis, the risk of avoidable mortality was lower for immigrants overall and selected ethnicities irrespective of the duration in Canada compared to nonimmigrants. These differences persisted even with adjustment for sociodemographic and socioeconomic factors.

CONCLUSION

Immigrants overall and the selected ethnicities enjoy an advantage over nonimmigrants in avoidable mortality. However, for certain causes of death especially ischemic heart disease mortality among South Asian women, immigrants appeared worse-off than nonimmigrants. The results suggest differential access to and use of health services, differences in protective health-related behavior, and the healthy immigrant effect.