WHO Framework Convention on Tobacco Control in China: barriers, challenges and recommendations

The impact of specific health warning messages on Chinese young people's perception of smoking risks and quitting intentions

INTRODUCTION

Although a substantial body of research has analyzed the effectiveness of cigarette package warning labels in tobacco control, the very general health warnings messages (HWMs) on cigarette packaging in China have shown limited effectiveness in deterring youth from smoking. Therefore, this study investigates the impact of specific and more detailed warning text messages on Chinese young people's risk perception of smoking and their intention to quit.

METHODS

We employed a randomized survey experiment to examine the impact of specific text-based warning labels on Chinese young people's risk perception of smoking and intention to quit. The total effective sample size was 1064 participants. The subjects were divided into three groups: the first group served as the control group, which was shown the existing cigarette package warning labels; the second group was shown cigarette package warning labels related to cardiovascular, digestive, and respiratory diseases; and the third group was shown cigarette package warning labels related to sexual dysfunction.

RESULTS

The respiratory disease-related warnings significantly increased young people's awareness of smoking-related respiratory risks (p<0.01). The impact of warning labels for the three common diseases on enhancing young people's overall risk perception of smoking (p<0.05) and their intention to quit exhibited only weak statistical significance (p<0.05). In contrast, warning labels related to sexual dysfunction significantly increased young people's risk perception of smoking (p<0.001) and their intention to quit (p<0.001), with a much higher level of statistical significance compared to those related to the other three common diseases.

CONCLUSIONS

Detailed descriptions of the risks associated with all four diseases were positively correlated with awareness of smoking-related harm and the intention to quit. However, warnings related to sexual dysfunction had a greater level of statistical significance compared to those related to the other three common diseases. This stronger significance may be attributed to young people's heightened concern about sexual dysfunction.

Social Participation and Persistent Smoking Among Older Chinese With Smoking-Related Morbidity

OBJECTIVES

Chronic diseases are common in midlife and old age and smoking can pose more health and longevity challenges for older people with chronic illnesses. In China where smoking is highly prevalent, older adults are likely to continue smoking even after developing severe chronic diseases. We examined the national prevalence of persistent smoking among older adults. We also investigated the sociodemographic characteristics of persistent smoking among ever-smokers with chronic diseases and its association with social participation (of various types).

METHODS

We used data from a nationally representative sample of older adults aged 45-80 in the China Health and Retirement Longitudinal Study (2011-2018). Multinomial logistic and multilevel logistic models were fitted.

RESULTS

The national prevalence of persistent smoking was around 24% of older men and 3% of older women. Among those with a history of smoking and chronic illness, younger, nonmarried/partnered, nonretired, or less educated individuals are more likely to continue smoking. Social participation is significantly associated with persistent smoking among those with chronic diseases, but the association differs across different forms of activities. Although the most popular but sedentary activities in China (playing Mahjong, chess, or cards) are associated with an elevated risk of persistent smoking, physical social activities (community-organized dancing, fitness, and qigong) are associated with a reduced risk of persistent smoking.

DISCUSSION

Given the enormous burden of persistent smoking on individuals and society, public smoking cessation inventions should address sociocultural factors of persistent smoking and target older adults who participate in specific social activities.

Cigarette Gifting Among Nonsmokers in China: Findings From the International Tobacco Control China Survey

INTRODUCTION

Cigarette gifting is commonly practiced in China and has contributed to the social acceptability and high prevalence of cigarette smoking in the country. As a result, nonsmokers in China are particularly susceptible to smoking. While previous studies have examined cigarette gifting behaviors among smokers, little is known about cigarette gifting among nonsmokers.

AIMS AND METHODS

This study aimed to examine the percentage and correlates of giving and receiving cigarettes as gifts among adult nonsmokers in China. We analyzed nonsmokers (N = 1813) aged ≥18 years using data from the International Tobacco Control China Wave 5 Survey. Descriptive statistics summarized the characteristics of those who gave and received cigarettes as gifts. Multivariable logistic regression models were used to identify factors associated with the two behaviors.

RESULTS

Among nonsmokers, 9.9% reported giving cigarettes as gifts to family or friends in the last 6 months. A higher level of knowledge about smoking harms was associated with lower adjusted odds of gifting cigarettes. Nonsmokers aged 25-39 years, with middle income, positive attitude toward cigarette gifts, exposure to anti-smoking information, and exposure to smoking promotion, and those who reported receiving cigarettes as gifts from family or friends were more likely to give cigarettes as gifts. A total of 6.6% of nonsmokers reported receiving cigarettes as gifts in the last 6 months. High education, neutral or positive attitude toward cigarette gifts, exposure to anti-smoking information, exposure to smoking promotion, and having smoking friends were associated with receiving cigarettes as gifts.

CONCLUSIONS

It is concerning that Chinese cultural norms that support cigarette gifting have extended to giving nonsmokers cigarettes as gifts. Effective anti-smoking messages are needed. Changing the norms around cigarette gifting and increasing knowledge about smoking harms should help reduce cigarette gifting among nonsmokers.

IMPLICATIONS

Easy access to cigarettes received as gifts, along with the wide acceptance of smoking in China, places Chinese nonsmokers in a risky position. More educational campaigns targeting nonsmokers to proactively prevent them from smoking are called for. The ineffectiveness of existing anti-smoking information highlights the need for more effective anti-smoking messages. That attitude toward cigarette gifts is the strongest predictor of giving cigarettes as gifts suggests the need for interventions to reverse the positive attitude about cigarette gifting to decrease the popularity of this activity.

Projection of Premature Cancer Mortality in Hunan, China, Through 2030: Modeling Study

BACKGROUND

The United Nations Sustainable Development Goals for 2030 include reducing premature mortality from noncommunicable diseases by one-third. Although previous modeling studies have predicted premature mortality from noncommunicable diseases, the predictions for cancer and its subcategories are less well understood in China.

OBJECTIVE

The aim of this study was to project premature cancer mortality of 10 leading cancers in Hunan Province, China, based on various scenarios of risk factor control so as to establish the priority for future interventions.

METHODS

We used data collected between 2009 and 2017 from the Hunan cancer registry annual report as empirical data for projections. The population-attributable fraction was used to disaggregate cancer deaths into parts attributable and unattributable to 10 risk factors: smoking, alcohol use, high BMI, diabetes, physical inactivity, low vegetable and fruit intake, high red meat intake, high salt intake, and high ambient fine particulate matter (PM2.5) levels. The unattributable deaths and the risk factors in the baseline scenario were projected using the proportional change model, assuming constant annual change rates through 2030. The comparative risk assessment theory was used in simulated scenarios to reflect how premature mortality would be affected if the targets for risk factor control were achieved by 2030.

RESULTS

The cancer burden in Hunan significantly increased during 2009-2017. If current trends for each risk factor continued to 2030, the total premature deaths from cancers in 2030 would increase to 97,787 in Hunan Province, and the premature mortality (9.74%) would be 44.47% higher than that in 2013 (6.74%). In the combined scenario where all risk factor control targets were achieved, 14.41% of premature cancer mortality among those aged 30-70 years would be avoided compared with the business-as-usual scenario in 2030. Reductions in the prevalence of diabetes, high BMI, ambient PM2.5 levels, and insufficient fruit intake played relatively important roles in decreasing cancer premature mortality. However, the one-third reduction goal would not be achieved for most cancers except gastric cancer.

CONCLUSIONS

Existing targets on cancer-related risk factors may have important roles in cancer prevention and control. However, they are not sufficient to achieve the one-third reduction goal in premature cancer mortality in Hunan Province. More aggressive risk control targets should be adopted based on local conditions.

The development and progress of health literacy in China

Limited health literacy is a serious public health problem. It is strongly associated with increased hospital admissions and readmission, poorer self-management, and health outcomes. It can lead to poor management of chronic disease, lower health care quality, increased mortality, and higher healthcare expenditures. Understanding China's current situation and the progress of health literacy levels are critical to achieving practical solutions for improving population health. This paper intended to provide a concise overview of the key milestones and specific practices in health literacy in China. We summarized the characteristics and changing profile of health literacy from 2008 to 2020 in China. We developed an intervention framework based on social ecosystem theory for improving health literacy in China. Meanwhile, some multi-level actionable recommendations were proposed. The study revealed that China has made progress in improving health literacy in the last decades. Health literacy levels increased from 6.48% of the population in 2008 to 23.15% in 2020. Geographic disparities were substantial. The East performed better health literacy than the Central and West, and cities had higher adequate health literacy than rural areas. Social development index, age, and education level were highly associated with health literacy. A global joint effort to improve health literacy will be required. And we advocate a whole-of-society approach that involves the participation of the entire ecosystem around the targeted population.

Health Taxes on Tobacco, Alcohol, Food and Drinks in Low- and Middle-Income Countries: A Scoping Review of Policy Content, Actors, Process and Context

BACKGROUND

Taxation of tobacco, food, alcohol and other beverages has gained renewed attention in responding to non-communicable diseases (NCDs). While largely built on evidence from high-income countries (HICs), the projected economic and health benefits of these measures have increased calls for their use in price-sensitive low- and middle-income countries (LMICs). However, uptake has been sporadic and there remains little research on why and how LMICs utilise fiscal measures in response to NCDs.

METHODS

This scoping review analyses factors influencing the design and implementation of health-related fiscal measures in LMICs. Utilising Arksey and O'Malley's scoping review methodology and Walt and Gilson's policy triangle, we considered the contextual, procedural, content and stakeholder-related factors that influenced measures.

RESULTS

We identified 75 papers focussing on health-related fiscal measures, with 47 (63%) focused on tobacco, 5 on alcohol, 6 on soft drink and 4 studies on food-related fiscal regulation. Thirteen papers analysed multiple measures and most papers (n = 66, 88%) were less than a decade old. Key factors enabling the design and implementation of measures included localised health and economic evidence, policy championing, inter-ministerial support, and global or regional momentum. Impeding factors encompassed negative framing and retaliation by industry, vested interests and governmental policy disjuncture. Aligning with theoretic insights from the policy triangle, findings consistently demonstrated that the interplay between factors - rather than the presence or absence of particular factors - has the most profound impact on policy implementation.

CONCLUSION

Given the growing urgency to address NCDs in LMICs, this review highlights the need for recognition and rigorous exploration of political economy factors influencing the design and implementation of fiscal measures. Broader LMIC-specific empirical research is needed to overcome an implication noted in much of the literature: that mechanisms used to enact tobacco taxation are universally applicable to measures targeting foods, alcohol and other beverages.

Rural-urban disparities in smoking patterns among Chinese adults: a social-ecological approach

China has a long history of smoking behavior. Currently, nearly 26% of Chinese citizens smoke daily. This research used a nationally representative database to study the urban and rural disparities on smoking patterns applying the social-ecological model. Using the 2011 China Health and Nutrition Survey, the study sample included adult participants who were at least 18 years of age (n = 12,688). A subanalysis was carried out to investigate smoking cessation duration among smoking quitters (n = 519). Multinomial logistic regression was used to examine participants' smoking status. Zero-inflated negative binomial regression was applied to investigate participants' number of cigarettes smoked per day, and multivariable logistic regression was used to examine nondaily smoking behavior. Negative binomial regression was carried out to assess the duration of smoking cessation for individuals who quit smoking. Urban residents had lower odds of reporting current smoking status (AOR [adjusted odds ratio] = 0.83, 95% CI [0.74, 0.95]) as compared to rural residents. Urban residents also had higher odds of reporting nondaily smoking status (AOR = 1.17, 95% CI  [1.04, 1.32]) and smoked fewer cigarettes per day (IRR [incidence rate ratio] = 0.93, 95% CI  [0.89, 0.98]) as compared to rural participants. The disparity between urban and rural areas was not observed for smoking cessation duration. Further efforts should target the disparity between urban and rural regions regarding smoking prevention.

Premature deaths caused by smoking in Sichuan, Southwest China, 2015-2030

Smoking has a substantial impact on deaths from non-communicable chronic diseases (NCDs). Quantitatively measuring the impact of tobacco control on population health is of great theoretical and practical importance, for governments to make health policy decisions. Focusing on premature deaths, we predicted the deaths by 2030 from major NCDs caused by smoking among people aged 30–69 years in Sichuan Province, Southwest China. We extracted data for 1990–2015 from the Global Burden of Disease Study 2015 and calculated the population attributable fraction, to estimate the proportion of deaths caused by smoking. Four different tobacco control standards were used to estimate 2030 projections for the prevalence of smoking and premature mortality. If smoking prevalence were reduced by 30% from 2015 levels, premature mortality could be expected to decline by 24.4% in 2030, achieving 81.3% of the World Health Organization target for reducing premature mortality by 30%. Compared with the continuation of historical trends, the strongest tobacco control policy scenario would reduce premature mortality by 6.6%, prevent 23,600 deaths, reduce mortality by 7.8%, and increase life expectancy at birth by 0.3 years. Smoking bans represent an important action toward achieving national health goals.

Implications for farmers of measures to reduce sugars consumption

Objective

To estimate the impact of reduced consumption of free sugars in line with World Health Organization recommendations, on sugar farmers globally.

Methods

Using multiregion input-output analysis, we estimated the proportional impact on production volumes of a 1% reduction in free sugars consumption by the public. We extracted data on sugar production from the Food and Agriculture Organization of the United Nations database for the top 15 sugar-cane- and beet-producing countries globally, and created a custom multiregion input-output database to assess the proportions of production going to human consumption, drawing on household expenditure surveys and national input-output databases (data valid for years 2000-2015). We also considered the impact on production volumes in relation to countries' gross domestic product.

Findings

A high proportion of current sugar production from these countries goes to human consumption, and would thus be impacted by reduced consumption of sugars. The largest impacts on cane sugar production, and thus on farmers, would likely occur in Brazil, China, India and Thailand and on beet production in Belarus, Germany, Russian Federation and United States of America.

Conclusion

A global opportunity exists for public health leadership to bring together the health, economic, environmental and agriculture sectors to collaborate and build capacity for promotion of alternative livelihoods for sugar farmers. Lessons regarding strategy and the importance of political economy factors can be learnt from tobacco control measures. Further research to quantify the impact of reductions in sugars consumption would provide useful insights for designing policies to complement and strengthen efforts to improve diets and health.

The effect of smoke-free legislation on the mortality rate of acute myocardial infarction: a meta-analysis

Background

Several studies have demonstrated that smoke-free legislation is associated with a reduced risk of mortality from acute myocardial infarction (AMI). This study aimed to examine and quantify the potential effect of smoke-free legislation on AMI mortality rate in different countries.

Methods

Studies were identified using a systematic search of the scientific literature from electronic databases, including PubMed, Web of Science, ScienceDirect, Embase, Google Scholar, and China National Knowledge Infrastructure (CNKI), from their inception through September 30, 2017. A random effects model was employed to estimate the overall effects of smoke-free legislation on the AMI mortality rate. Subgroup analysis was performed to explore the possible causes of heterogeneity in risk estimates based on sex and age. The results of meta-analysis after excluding the studies with a high risk of bias were reported in this study.

Results

A total of 10 eligible studies with 16 estimates of effect size were included in this meta-analysis. Significant heterogeneity in the risk estimates was identified (overall I² = 94.6%, p < 0.001). Therefore, a random effects model was utilized to estimate the overall effect of smoke-free legislation. There was an 8% decline in AMI mortality after introducing smoke-free legislation (RR = 0.92, 95% confidence interval (CI): 0.90–0.94). The results of subgroup analyses showed that smoke-free legislation was significantly associated with lower rates of mortality for the following 5 diagnostic subgroups: smoke-free in workplaces, restaurants and bars (RR = 0.92, 95% CI: 0.90–0.95), smaller sample size (RR = 0.92, 95% CI: 0.89–0.95), study location in Europe (RR = 0.90, 95% CI: 0.85–0.94), regional study area (RR = 0.92, 95% CI: 0.89–0.94), and no previous local smoke-free legislation (RR = 0.91, 95% CI: 0.90–0.93). However, there was not much difference in AMI mortality rates after the legislation between the longer (RR = 0.92, 95% CI: 0.86–0.98) and shorter follow-up duration subgroups (RR = 0.92, 95% CI: 0.89–0.94).

Conclusion

Smoke-free legislation could significantly reduce the AMI mortality rate by 8%. The reduction in the AMI mortality rate was more significant in studies with more comprehensive laws, without prior smoke-free bans, with a smaller sample size, at the regional level, and with a location in Europe.

Electronic supplementary material

The online version of this article (10.1186/s12889-019-7408-7) contains supplementary material, which is available to authorized users.

Situation, Impacts, and Future Challenges of Tobacco Control Policies for Youth: An Explorative Systematic Policy Review

Background: Tobacco use in youths is a major public health challenge globally, and approaches to the challenge have not been sufficiently addressed. The existing policies for tobacco control are not well specified by age. Objective: Our study aims to systematically investigate existing tobacco control policies, potential impacts, and national and international challenges to control tobacco use targeting the youth. Data sources: We used the statistics of the Global Youth Tobacco Survey (GYTS), studies, and approaches of tobacco control policies targeting youth. Considering country, continent, age, and significance, PubMed, Health Inter-Network Access to Research Initiative (HINARI), Scopus, the Cochrane Library, Google, and Google Scholar were searched. The related keywords were tobacco control, youth, smoking, smoking reduction policies, prevalence of tobacco use in youth, classification of tobacco control policies, incentives to prevent young people from using tobacco, WHO Framework Convention on Tobacco Control (FTCT), etc. The search strategy was by timeline, specific and popular policies, reliability, significance, and applicability. Results: We found 122 studies related to this topic. There were 25 studies focusing on situation, significance, and theoretical aspects of tobacco control policies associated with youth; 41 studies on national population polices and challenges; and 7 studies for global challenges to overcome the youth tobacco epidemic. All national policies have been guided by WHO-MPOWER strategies. Increases in tobacco tax, warning signs on packaging, restriction of tobacco product advertisements, national law to discourage young people, and peer-based approaches to quit tobacco are popular policies. Smuggling of tobacco products by youth and ignorance of smokeless tobacco control approach are major challenges. Limitation: Our study was flexible for the standard age of youth and we were not able to include all countries in the world and most of the studies focused on smoking control rather than all smokeless tobaccos. Conclusion: The policies of tobacco control adopted by many countries are based on the WHO Framework Convention on Tobacco Control but not necessarily focused on youth. Due to the physical and economic burden of tobacco consumption by youth, this is a high priority that needs to be addressed. Youth-focused creative policies are necessary, and more priority must be given to tobacco prevention in youth. Tobacco control should be a social, public health, and quality-of-life concern rather than a business and trade issue. Implication of key findings: There is limited research on how and in what ways tobacco control policies reach young people and their engagement with these policies from physical, physiological, and psychological aspects. Analysis of these aspects, popular polices practiced in different countries, and creative strategies support the need to review current practices and future ways to discourage youth from tobacco use.

'Pro-tobacco propaganda': a case study of tobacco industry-sponsored elementary schools in China

Background

China is the largest producer and consumer of tobacco products worldwide. While direct marketing and advertisement of tobacco products is restricted, indirect marketing still exists under the guise of sponsorship and corporate social responsibility (CSR). This case study is focused on tobacco industry-sponsored elementary schools in Chinese rural areas.

Methods

Field visits were conducted in Yunnan province to interview students, teachers, school principals and parents to understand their perceptions of the tobacco industry and its sponsorship of schools. Interviews with tobacco control activists were conducted in Beijing to discuss national tobacco control efforts targeting tobacco industry sponsorship. Interview data were transcribed and coded, with key themes developed using thematic analysis.

Results

While health consequences of smoking are generally known, attitudes towards the tobacco industry and its CSR activities remain positive among the general public. Educators and parents do not perceive any impacts on schoolchildren from exposure to ‘pro-tobacco propaganda’ created by the industry’s CSR activities. Attitudes among tobacco control activists were drastically different, with consensus that CSR activities constitute indirect marketing attempts that should be banned.

Conclusion

National tobacco control legislation banning all forms of indirect marketing including CSR is needed in order to protect the health of future generations.

Similarities and differences in health-related behavior clustering among older adults in Eastern and Western countries: A latent class analysis of global aging cohorts

AIM

To quantify variations in health-related behaviors (HRB) clustering of older adults in Western and Eastern countries.

METHODS

Using six aging cohorts from the USA, England, Europe, Japan, Korea and China, latent class analysis was applied to access the clustering of smoking, alcohol consumption, physical activity and social activity.

RESULTS

A total of 104 552 participants (55% women) aged ≥50 years in 2010 were included. Despite a different number of clusters identified, three consistent cluster profiles emerged: "Multiple-HRB" (ex-/never smoking, moderate drinking, frequent physical and social activity); "Inactives" (socially and physically inactive without other risk behaviors); and "(ex-)Smokers with Risk Behaviors". Sex and cohort variations were shown. For men in Western cohorts, "Multiple-HRB" was the predominant cluster, whereas their Asian counterparts were more likely to be members of the "Smokers with risk behavior" and "Inactives" clusters. Most women, particularly those in Asian cohorts, were never smokers and non-drinkers, and most of them belonged to the socially "Inactives" cluster.

CONCLUSIONS

We provide a person-centered understanding of HRB clustering of older adults over selected countries by sex, informing tailored health promotion for the target population. Geriatr Gerontol Int 2019; 19: 930-937.

Effects of global and domestic tobacco control policies on cigarette consumption per capita: an evaluation using monthly data in China

INTRODUCTION

China consumes 44% of the world's cigarettes. Robust tobacco control measures are needed to contain the trend of increasing cigarette consumption. This paper examines the effectiveness of policy interventions introduced in China on reducing the country's tobacco use.

METHODS

The paper uses data on China's monthly cigarette consumption per capita from January 2000 to June 2017 to estimate the impact of specific policies on China's tobacco consumption. Tobacco consumption is calculated from monthly sales data from the China National Tobacco Corporation and demographic data from the China National Bureau of Statistics. The policies studied include the WHO Framework Convention on Tobacco Control (FCTC), national tobacco-related policy changes and two tobacco tax increases implemented in China during the study period. Segmented regression analysis is used to estimate the immediate effects of the policies studied and changes in the time trends resulted from these policy changes.

FINDINGS

The impact of national policy changes in China is almost 20 times greater than the impact of the WHO FCTC treaty itself, and national policy changes in tobacco control are a determining factor in reversing the trend of increasing tobacco consumption in China. The 2015 tax increase, which raised retail cigarette prices, produced both immediate and trend effects, with a total incremental effect 7.8 times that of the 2009 tax increase, which did not result in higher cigarette prices for the consumer.

INTERPRETATIONS

Translating global tobacco control policies into domestic policies will generate a much greater impact on reducing average cigarette consumption, and tobacco taxes that are reflected in the retail prices of cigarettes will be more effective in reducing cigarette consumption.

Perceptions and use of electronic cigarettes among young adults in China

INTRODUCTION

Little is known about the perception and use of e-cigarettes by the Chinese, particularly the young people. This study reveals the awareness, attitudes, and use of e-cigarettes among young adults in China, examines the relationship between smoking behavior and e-cigarette perception and use, and demonstrates the phenomenon of e-cigarette gifting.

METHODS

We used results from a mobile app-based survey conducted in November 2015 that included 10477 young Chinese adults aged between 19 and 29 years. Bivariate tests were conducted to analyze perception and use of e-cigarettes by respondents of different smoking status. Multivariate logistic regressions were applied to examine the correlates of e-cigarette use and perception and e-cigarette gifting behavior, particularly the factors of tobacco smoking status and quitting behavior.

RESULTS

Among the surveyed young adults, 88.40% were aware of e-cigarettes, and nearly a quarter of all respondents had used e-cigarettes by the time of our survey. Multivariate regression results demonstrated that current smokers with quitting experience were more likely to be aware of and to use e-cigarettes than current smokers with no quitting experience. Smokers with quitting experience also were more inclined to promote e-cigarettes to others by either recommending them or giving them as gifts.

CONCLUSIONS

E-cigarettes have gained popularity among young adults in China and smokers, especially those who had tried quitting, were more likely to have known and used e-cigarettes. More empirical research on the relationship between e-cigarette use and smoking cessation is warranted to better inform a potential regulatory framework in China.

The Impact of Tobacco Consumption on Rural Household Expenditure and Self-rated Health Among Rural Household Members in China

OBJECTIVES

To estimate how tobacco consumption affects household expenditure on other goods and services in rural China and to assess the tobacco consumption affects self-rated health among rural household members in China.

METHODS

A Seemingly Unrelated Regression was used to assess the impact of tobacco consumption on rural household expenditure. To detect tobacco consumption causing heterogeneity in self-rated health among adults in rural China, this study employed a random effects generalized ordered probit model. 2010-2014 China Family Panel Studies was used for the analysis. The data set included 3,611 households and 10,610 adults in each wave.

RESULTS

Tobacco consumption households assign significantly lower budget shares to food, health care, dress, and education in rural China. Moreover, self-rated health factor has a significantly positive coefficient with respect to non-smokers and ex-smokers, that is, when the individuals is a non-smoker or ex-smoker, he/ she will be more likely to report his/her health status as positive.

CONCLUSIONS

The first analysis showed that tobacco consumption crowds out expenditures on food, dress, health care, and education for rural households in China, and the second analysis indicated that non-smokers and ex-smokers are more likely to report their health status as better compared with last year. The results of the present study revealed that Chinese policymakers might consider controlling tobacco consumption since tobacco control can improve not only rural household welfare but also rural household members' health status. Therefore, the tobacco tax policy and brief clinical interventions by the doctor should be implemented in rural China.

The tobacco endgame: The neglected role of place and environment

An increasing number of countries across the world are planning for the eradication of the tobacco epidemic. The actions necessary to realise this ambition have been termed the tobacco endgame. The focus of this paper is on the intersection between the tobacco endgame with place, a neglected theme in recent academic and policy debates. We begin with an overview of the key themes in the literature on endgame strategies before detailing the international landscape of engame initiatives, paying particular attention to the opportunities and challenges of endgame strategies in low and middle income countries. Finally, we critically assess the current endgame debates and suggest a novel agenda for integrating geographical perspectives into research on the endgame that provides enhanced understanding of the challenges associated with this important global health vision.

Socioeconomic, environmental and lifestyle factors associated with gestational diabetes mellitus: A matched case-control study in Beijing, China

Gestational diabetes mellitus (GDM) is a common health problem during pregnancy and its prevalence is increasing globally, especially in China. The aim of this study was to investigate socioeconomic, environmental and lifestyle factors associated with GDM in Chinese women. A matched pair case-control study was conducted with 276 GDM women and 276 non-GDM women in two hospitals in Beijing, China. Matched factors include age and pre-pregnancy body mass index (BMI). GDM subjects were defined based on the International Association of Diabetes Study Group criteria for GDM. A conditional logistic regression model with backward stepwise selection was performed to predict the odds ratio (OR) for associated factors of GDM. The analyses of data show that passive smoking at home (OR = 1.52, p = 0.027), passive smoking in the workplace (OR = 1.71, p = 0.01), and family history of diabetes in first degree relatives (OR = 3.07, p = 0.004), were significant factors associated with GDM in Chinese women. These findings may be utilized as suggestions to decrease the incidence of GDM in Chinese women by improving the national tobacco control policy and introducing public health interventions to focus on the social environment of pregnant women in China.

Awareness and compliance to anti-smoking law in South Bengaluru, India

INTRODUCTION

Tobacco smoke affects the health of non-smokers by exposure to second-hand smoke (SHS). The Indian Cigarettes and Other Tobacco Products (COTPA) Act 2003 Section 4 aims to reduce exposure to SHS. Awareness and compliance to COTPA are key to achieving its intended outcome. We assessed: a) awareness among persons responsible for compliance (PRC) and authorized officers (AO), and b) compliance of public places to COTPA in South Bengaluru, India.

METHODS

A cross-sectional assessment of public places in South Bengaluru was conducted using time-location sampling. The Johns Hopkins Bloomberg School of Public Health's observational and interview checklist was used to assess compliance of public places to COTPA and awareness of COTPA among PRC/AO, respectively.

RESULTS

Among 359 public places, one-third of the public places showed complete (1.9%) or partial compliance (28.1%). The majority (93%) of the PRCs and all AOs were aware of COTPA. However, they lacked information on the different provisions of the Act. Violations like persons smoking (3.9%), visible ashtrays (6%) and cigarette butts (13%) were noted more among eateries compared to other public places. Among those public places supposed to have designated smoking-areas, only 19% complied.

CONCLUSIONS

This is the first representative survey of awareness and compliance of COTPA in Bengaluru City. Low compliance, coupled with the lack of appropriate awareness among PRCs and AOs about COTPA, demands a comprehensive strategy to enhance awareness. Comprehensive efforts towards making all stakeholders understand the health impacts of smoking, and strict enforcement, might facilitate effective implementation of COTPA.

Can China achieve a one-third reduction in premature mortality from non-communicable diseases by 2030?

BACKGROUND

The United Nation's Sustainable Development Goals for 2030 include reducing premature mortality from non-communicable diseases (NCDs) by one third. To assess the feasibility of this goal in China, we projected premature mortality in 2030 of NCDs under different risk factor reduction scenarios.

METHODS

We used China results from the Global Burden of Disease Study 2013 as empirical data for projections. Deaths between 1990 and 2013 for cardiovascular disease (CVD), diabetes, chronic respiratory disease, cancer, and other NCDs were extracted, along with population numbers. We disaggregated deaths into parts attributable and unattributable to high systolic blood pressure (SBP), smoking, high body mass index (BMI), high total cholesterol, physical inactivity, and high fasting glucose. Risk factor exposure and deaths by NCD category were projected to 2030. Eight simulated scenarios were also constructed to explore how premature mortality will be affected if the World Health Organization's targets for risk factors reduction are achieved by 2030.

RESULTS

If current trends for each risk factor continued to 2030, the total premature deaths from NCDs would increase from 3.11 million to 3.52 million, but the premature mortality rate would decrease by 13.1%. In the combined scenario in which all risk factor reduction targets are achieved, nearly one million deaths among persons 30 to 70 years old due to NCDs would be avoided, and the one-third reduction goal would be achieved for all NCDs combined. More specifically, the goal would be achieved for CVD and chronic respiratory diseases, but not for cancer and diabetes. Reduction in the prevalence of high SBP, smoking, and high BMI played an important role in achieving the goals.

CONCLUSIONS

Reaching the goal of a one-third reduction in premature mortality from NCDs is possible by 2030 if certain targets for risk factor intervention are reached, but more efforts are required to achieve risk factor reduction.

The International Epidemiology of Lung Cancer: Latest Trends, Disparities, and Tumor Characteristics

INTRODUCTION

Our aim was to update global lung cancer epidemiology and describe changing trends and disparities.

METHODS

We presented country-specific incidence and mortality from GLOBOCAN 2012 by region and socioeconomic factors via the Human Development Index (HDI). Between- and within-country incidence by histological type was analyzed by using International Agency for Research on Cancer data on cancer incidence on five continents. Trend analyses including data from the International Agency for Research on Cancer, cancer registries, and the WHO mortality database were conducted using joinpoint regression. Survival was compared between and within countries and by histological type.

RESULTS

In 2012, there were 1.82 and 1.59 million new lung cancer cases and deaths worldwide, respectively. Incidence was highest in countries with a very high HDI and lowest in countries with a low HDI (42.2 versus 7.9 in 100,000 for males and 21.8 versus 3.1 in 100,000 for females, respectively). In most countries with a very high HDI, as incidence in males decreased gradually (ranging from -0.3% in Spain to -2.5% in the United States each year), incidence in females continued to increase (with the increase ranging from 1.4% each year in Australia to 6.1% in recent years in Spain). Although histological type varied between countries, adenocarcinoma was more common than squamous cell carcinoma, particularly among females (e.g., in Chinese females, the adenocarcinoma-to-squamous cell carcinoma ratio was 6.6). Five-year relative survival varied from 2% (Libya) to 30% (Japan), with substantial within-country differences.

CONCLUSIONS

Lung cancer will continue to be a major health problem well through the first half of this century. Preventive strategies, particularly tobacco control, tailored to populations at highest risk are key to reducing the global burden of lung cancer.

Prevalence and patterns of tobacco smoking among Chinese adult men and women: findings of the 2010 national smoking survey

Background

China consumes about 40% of the world's cigarettes, predominantly by men, following a large increase in recent decades. We assess sex-specific prevalence and changing patterns of smoking in Chinese adults in the current decade.

Methods

A nationally representative survey of smoking was conducted in 2010 among 100 000 Chinese adults aged ≥18 years, using a multistage stratified cluster sampling method. Information on smoking frequency, type, amount, age started and quitting was collected. Sex-specific standardised prevalence and means were analysed and compared with estimates in the 1996 national survey.

Results

In Chinese men aged ≥18, 62.4% were ever-smokers in 2010, including 54.0% current smokers and 8.4% ex-smokers. The smoking prevalence was higher in rural than in urban men (63.9% vs 58.4%). In younger men, the age to start smoking was earlier and exclusive cigarette use was much higher. Among current smokers, only 17.3% intended to quit. Compared with a similar survey in 1996 among adults aged 30–69, more smokers had quit in 2010 than in 1996 (11.0% vs 4.2%), but the number of cigarettes smoked per current smoker was higher (17.9 vs 15.2). In Chinese women, only 3.4% ever smoked and there has been a large intergenerational decrease in smoking uptake rates. In 2010, there were 318 million current smokers in China, consuming an estimated 1740 billion cigarettes.

Conclusions

The prevalence of smoking remained extremely high in men, but low and falling in Chinese women. Tobacco smoking remains an important public health issue in China, and stronger and more efficient tobacco control is urgently needed.

Is this the end of the beginning for smoking in China? Challenges, context and change

Tobacco use in China is a substantial threat to global health and, after many years of poor implementation of tobacco control, attitudes are changing for the better and substantial actions may be about to follow. This commentary reviews the impact of tobacco and the recent history of tobacco control in China, the context and implications of new encouraging legislation.

Prevalence of passive smoking in the community population aged 15 years and older in China: a systematic review and meta-analysis

OBJECTIVES

To estimate the prevalence and distribution of passive smoking in the community population aged 15 years and older in China.

DESIGN

A systematic review and meta-analysis of cross-sectional studies reporting the prevalence of passive smoking in China and a series of subgroup, trend and sensitivity analyses were conducted in this study.

DATA SOURCE

The systematic review and meta-analysis, which included 46 studies with 381,580 non-smokers, estimated the prevalence and distribution of passive smoking in China. All studies were published between 1997 and 2015.

RESULTS

The pooled prevalence of passive smoking was 48.7% (95% CI 44.8% to 52.5%) and was relatively stable from 1995 to 2013. The prevalence in the subgroups of gender, area, age and time varied from 35.1% (95% CI 31.8% to 38.3%) in the elderly (≥60 years) to 48.6% (95% CI 42.9% to 54.2%) in urban areas. The prevalence was lower in the elderly (≥60 years) than in those between 15 and 59 years of age (OR 1.61, 95% CI 1.44 to 1.81). The difference between females and males in urban and rural areas was not statistically significant (OR: 1.27, 95% CI 0.93 to 1.74 and OR: 1.14, 95% CI 0.82 to 1.58, respectively). In addition, a significantly increasing trend was found among males from 2002 to 2010. Heterogeneity was high in all pooled estimates (I(2)>98%, p<0.001).

CONCLUSIONS

The high and stable prevalence of passive smoking in China is raising increasing national concern regarding specific research and tobacco control programmes. Attention should be focused on young, middle-aged and male non-smokers regardless of region.

Association of serum cotinine levels and the parameters of vascular structure and function in never-smoking adults

Passive smoking is now recognized to be associated with early arterial damage. The aim of this study was to assess the relationship between secondhand smoke (SHS) exposure, measured objectively by serum cotinine level, and the parameters used to assess vascular structure and function among never smokers in North China. From January 2008 to August 2008, 652 adults aged 20-70 years were enrolled. Brachial-ankle pulse wave velocity (baPWV), ankle-brachial index, and carotid intima-media thickness measurements were performed in all patients. All participants were required to respond to an interviewer-led questionnaire including medical histories and demographic data and to receive blood tests on biochemical indicators. We found that in nonsmokers, higher levels of serum cotinine were positively associated with higher baPWV and brachial pulse pressure after adjusting for heart rate, body mass index, and other confounders. Tests for linear trends for this association were statistically significant. In contrast, no association was present with ankle-brachial index and carotid intima-media thickness. In never smokers, higher SHS exposure measured objectively by serum cotinine levels was found to be associated with brachial pulse pressure and baPWV after adjusting for confounders.

A Clustered Randomized Controlled Trial to Reduce Secondhand Smoke Exposure Among Nonsmoking Pregnant Women in Sichuan Province, China

INTRODUCTION

Nonsmoking pregnant women in China have significant exposure to secondhand smoke (SHS). Few interventions have focused on pregnant women reducing their SHS exposure.

METHODS

This clustered randomized controlled trial, conducted at eight hospitals in Sichuan, China, compared a prenatal health education intervention with usual clinical care as a control. The primary outcome was self-reported "no SHS exposure" before and 3 months after birth. The intervention consisted of three large group educational sessions, standardized clinician advice, brief monthly follow-up calls, and educational materials and resources. A random sample of participants was biochemically validated before birth with hair nicotine, a long-term biomarker of smoke exposure.

RESULTS

Overall, 1181 participants were randomized to intervention (n = 526) and control (n = 655) groups. More participants in the intervention group than the control group reported no SHS exposure 3 months after birth (Total: 77.9% vs. 52.6%, P < .001; Home: 81.2% vs. 53.3%, P < .001). The intervention group also had greater changes in improved smoke-free homes and SHS knowledge and attitudes. Controlling for covariates, the intervention group was less likely to report SHS exposure than the control group (Total: OR = 0.47, 95% CI = 0.31 to 0.71; Home: OR = 0.33, 95% CI = 0.21 to 0.53), and this effect was sustained 3 months after birth. The adjusted log concentration of hair nicotine for the intervention group decreased by 0.28 log µg/g more than the control group.

CONCLUSIONS

Our smoke-free health education intervention for nonsmoking pregnant women significantly reduced SHS exposure before and after birth. This intervention model can become part of a standard protocol for the care of pregnant women in hospital settings.

The heterogeneous effects of cigarette prices on brand choice in China: implications for tobacco control policy

BACKGROUND

China has long kept its tobacco taxes below international standards. The Chinese government has cited two rationales against raising tobacco tax, namely, the unfair burden it places on low-income smokers and the ability of consumers to switch to cheaper brands.

OBJECTIVE

This study examines how different socioeconomic subgroups of Chinese smokers switch brands in response to cigarette price changes.

METHODS

We model smokers' choice of cigarette tier as a function of tier-specific prices. We examine heterogeneous responses to prices by estimating mixed logit models for different income and education subgroups that allow for random variation in smokers' preferences. We use data from three waves of the longitudinal International Tobacco Control China Survey, collected in six large Chinese cities between 2006 and 2009.

FINDINGS

Low-income and less educated smokers are considerably more likely to switch tiers (including both up-trading and down-trading) than are their high-socioeconomic status (SES) counterparts. For those in the second-to-lowest tier, a ¥1 ($0.16, or roughly 25%) rise in prices increases the likelihood of switching tiers by 5.6% points for low-income smokers and 7.2% points for less educated smokers, compared to 1.6% and 3.0% points for the corresponding high-SES groups. Low-income and less educated groups are also more likely to trade down compared to their high-SES counterparts.

CONCLUSIONS

Only a small percentage of low-income and less educated Chinese smokers switched to cheaper brands in response to price increases. Hence, the concern of the Chinese government that a cigarette tax increase will lead to large-scale brand switching is not supported by this study.

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

Background

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

Methods

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

Results

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

Conclusions

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

Cancer control programs in East Asia: evidence from the international literature

Cancer is a major cause of mortality and morbidity throughout the world, including the countries of North-East and South-East Asia. Assessment of burden through cancer registration, determination of risk and protective factors, early detection and screening, clinical practice, interventions for example in vaccination, tobacco cessation efforts and palliative care all should be included in comprehensive cancer control programs. The degree to which this is possible naturally depends on the resources available at local, national and international levels. The present review concerns elements of cancer control programs established in China, Taiwan, Korea, and Japan in North-East Asia, Viet Nam, Thailand, Malaysia, and Indonesia as representative larger countries of South-East Asia for comparison, using the published literature as a guide. While major advances have been made, there are still areas which need more attention, especially in South-East Asia, and international cooperation is essential if standard guidelines are to be generated to allow effective cancer control efforts throughout the Far East.

Cancer is a major cause of mortality and morbidity throughout the world, including the countries of North-East and South-East Asia. Assessment of burden through cancer registration, determination of risk and protective factors, early detection and screening, clinical practice, interventions for example in vaccination, tobacco cessation efforts and palliative care all should be included in comprehensive cancer control programs. The degree to which this is possible naturally depends on the resources available at local, national and international levels. The present review concerns elements of cancer control programs established in China, Taiwan, Korea, and Japan in North-East Asia, Viet Nam, Thailand, Malaysia, and Indonesia as representative larger countries of South-East Asia for comparison, using the published literature as a guide. While major advances have been made, there are still areas which need more attention, especially in South-East Asia, and international cooperation is essential if standard guidelines are to be generated to allow effective cancer control efforts throughout the Far East.