Noncommunicable Diseases Attributable To Tobacco Use In China: Macroeconomic Burden And Tobacco Control Policies

Portable spirometer-based pulmonary function test willingness in China: A nationwide cross-sectional study from the "Happy Breathing Program"

BACKGROUND

Understanding willingness to undergo pulmonary function tests (PFTs) and the factors associated with poor uptake of PFTs is crucial for improving early detection and treatment of chronic obstructive pulmonary disease (COPD). This study aimed to understand willingness to undergo PFTs among high-risk populations and identify any barriers that may contribute to low uptake of PFTs.

METHODS

We collected data from participants in the "Happy Breathing Program" in China. Participants who did not follow physicians' recommendations to undergo PFTs were invited to complete a survey regarding their willingness to undergo PFTs and their reasons for not undergoing PFTs. We estimated the proportion of participants who were willing to undergo PFTs and examined the various reasons for participants to not undergo PFTs. We conducted univariable and multivariable logistic regressions to analyze the impact of individual-level factors on willingness to undergo PFTs.

RESULTS

A total of 8475 participants who had completed the survey on willingness to undergo PFTs were included in this study. Out of these participants, 7660 (90.4%) were willing to undergo PFTs. Among those who were willing to undergo PFTs but actually did not, the main reasons for not doing so were geographical inaccessibility ( n  = 3304, 43.1%) and a lack of trust in primary healthcare institutions ( n  = 2809, 36.7%). Among the 815 participants who were unwilling to undergo PFTs, over half ( n  = 447, 54.8%) believed that they did not have health problems and would only consider PFTs when they felt unwell. In the multivariable regression, individuals who were ≤54 years old, residing in rural townships, with a secondary educational level, with medical reimbursement, still working, with occupational exposure to dust, and aware of the abbreviation "COPD" were more willing to undergo PFTs.

CONCLUSIONS

Willingness to undergo PFTs was high among high-risk populations. Policymakers may consider implementing strategies such as providing financial incentives, promoting education, and establishing community-based programs to enhance the utilization of PFTs.

A COM-B analysis of facilitators of and barriers to smoking cessation among Chinese smokers: A qualitative study

INTRODUCTION

Smoking prevalence remains high in China with a low cessation motivation level, despite the government's tobacco control efforts. There is a lack of research specifically examining perceptions, attitudes, and behaviors related to smoking cessation in this region, particularly from a theory-based deductive perspective. Utilizing the COM-B (Capability, Opportunity, Motivation-Behavior) model as a theoretical framework, this study aimed to identify facilitators and barriers to smoking cessation among Chinese smokers.

METHODS

The study employed semi-structured individual interviews with 40 participants. Each interview spanned approximately 30 minutes. The participants, constituting both current and former smokers, were all aged ≥18 years (n=40). Interview data were then examined using a directed content analysis approach.

RESULTS

Analysis revealed three interrelated themes. Capability: Smokers face challenges when resisting peer pressure and dealing with life after quitting. They also lack knowledge about smoking, quitting techniques, and withdrawal symptoms. Opportunity: Changing societal attitudes towards smoking create opportunities for quitting, but these are hindered by inadequate cessation services and a lack of family support. Motivation: Smokers' motivation to quit is mainly driven by health concerns. Resistance to quitting often stems from the belief that smoking is a personal choice or just a habit. Excessive emphasis on willpower may hinder motivation to quit.

CONCLUSIONS

To enhance smoking cessation efforts in China, three key aspects should be considered: capability, opportunity, and motivation. Publicity and educational campaigns should target common misconceptions about smoking as a personal freedom, correct the overemphasis on willpower, and widely promote available cessation services. A crucial aspect is shifting societal norms to foster anti-smoking sentiments. Effective strategies may involve using real-life stories to illustrate smoking's health consequences, disseminating information about cessation services in maternity centers, enhancing services through mobile health initiatives, and empowering families to support smokers in their quit attempts.

The macroeconomic burden of noncommunicable diseases and mental health conditions in South America

Noncommunicable diseases and mental health conditions (referred to collectively as NMHs) are the greatest cause of preventable death, illness, and disability in South America and negatively affect countries' economic performance through their detrimental impacts on labor supply and capital investments. Sound, evidence-based policy-making requires a deep understanding of the macroeconomic costs of NMHs and of their distribution across countries and diseases. The paper estimates and projects the macroeconomic burden of NMHs over the period 2020-2050 in 10 South American countries. We estimate the impact of NMHs on gross domestic product (GDP) through a human capital-augmented production function approach, accounting for mortality and morbidity effects of NMHs on labor supply, for the impact of treatment costs on physical capital accumulation, and for variations in human capital by age. Our central estimates suggest that the overall burden of NMHs in these countries amounts to $7.3 trillion (2022 international $, 3% discount rate, 95% confidence interval: $6.8-$7.8 trillion). Overall, the macroeconomic burden of NMHs is around 4% of total GDP over 2020-2050, with little variation across countries (from 3.2% in Peru to 4.5% in Brazil). In other words, without NMHs, annual GDP over 2020-2050 would be about 4% larger. In most countries, the largest macroeconomic burden is associated with cancers. Results from the paper point to a significant macroeconomic burden of NMHs in South America and provide a strong justification for investment in NMH prevention, early detection, treatment, and formal and informal care.

The global economic burden of chronic obstructive pulmonary disease for 204 countries and territories in 2020-50: a health-augmented macroeconomic modelling study

BACKGROUND

Chronic obstructive pulmonary disease (COPD) is the third leading cause of death worldwide and imposes a substantial economic burden. Gaining a thorough understanding of the economic implications of COPD is an important prerequisite for sound, evidence-based policy making. We aimed to estimate the macroeconomic burden of COPD for each country and establish its distribution across world regions.

METHODS

In this health-augmented macroeconomic modelling study we estimated the macroeconomic burden of COPD for 204 countries and territories over the period 2020-50. The model accounted for (1) the effect of COPD mortality and morbidity on labour supply, (2) age and sex specific differences in education and work experience among those affected by COPD, and (3) the impact of COPD treatment costs on physical capital accumulation. We obtained data from various public sources including the Global Burden of Disease Study 2019, the World Bank database, and the literature. The macroeconomic burden of COPD was assessed by comparing gross domestic product (GDP) between a scenario projecting disease prevalence based on current estimates and a counterfactual scenario with zero COPD prevalence from 2020 to 2050.

FINDINGS

Our findings suggest that COPD will cost the world economy INT$4·326 trillion (uncertainty interval 3·327-5·516; at constant 2017 prices) in 2020-50. This economic effect is equivalent to a yearly tax of 0·111% (0·085-0·141) on global GDP. China and the USA face the largest economic burdens from COPD, accounting for INT$1·363 trillion (uncertainty interval 1·034-1·801) and INT$1·037 trillion (0·868-1·175), respectively.

INTERPRETATION

The macroeconomic burden of COPD is large and unequally distributed across countries, world regions, and income levels. Our study stresses the urgent need to invest in global efforts to curb the health and economic burdens of COPD. Investments in effective interventions against COPD do not represent a burden but could instead provide substantial economic returns in the foreseeable future.

FUNDING

Alexander von Humboldt Foundation, National Natural Science Foundation of China, CAMS Innovation Fund for Medical Science, Chinese Academy of Engineering project, Chinese Academy of Medical Sciences and Peking Union Medical College project, and Horizon Europe.

TRANSLATIONS

For the Chinese and German translations of the abstract see Supplementary Materials section.

Beyond GDP: Using healthy lifetime income to trace well-being over time with estimates for 193 countries

We measure well-being across 193 countries from 1990 to 2019 using a new indicator: healthy lifetime income (HLI). Apart from the income component as captured by standard per capita gross domestic product, HLI incorporates health as a second important component. Overall, HLI can be interpreted as the income of the average person in an economy during the years in which the person is in good health. We show that HLI has particular strengths as compared with other measures such as the Human Development Index. These include requiring only easily accessible data for its construction, having an immediate economic interpretation and unit of measurement, not needing the application of arbitrary weights of subcomponents, and not being bounded from above. As compared with using per capita gross domestic product as a metric for well-being, we find that countries with better population health tend to fare better in the rankings. This provides a rationale for investments in health and helps shift the focus from material well-being (as an instrumental indicator of well-being) toward health (as an intrinsic goal).

Estimates and Projections of the Global Economic Cost of 29 Cancers in 204 Countries and Territories From 2020 to 2050

Importance

Cancers are a leading cause of mortality, accounting for nearly 10 million annual deaths worldwide, or 1 in 6 deaths. Cancers also negatively affect countries' economic growth. However, the global economic cost of cancers and its worldwide distribution have yet to be studied.

Objective

To estimate and project the economic cost of 29 cancers in 204 countries and territories.

Design, Setting, and Participants

A decision analytical model that incorporates economic feedback in assessing health outcomes associated with the labor force and investment. A macroeconomic model was used to account for (1) the association of cancer-related mortality and morbidity with labor supply; (2) age-sex-specific differences in education, experience, and labor market participation of those who are affected by cancers; and (3) the diversion of cancer treatment expenses from savings and investments. Data were collected on April 25, 2022.

Main Outcomes and Measures

Economic cost of 29 cancers across countries and territories. Costs are presented in international dollars at constant 2017 prices.

Results

The estimated global economic cost of cancers from 2020 to 2050 is $25.2 trillion in international dollars (at constant 2017 prices), equivalent to an annual tax of 0.55% on global gross domestic product. The 5 cancers with the highest economic costs are tracheal, bronchus, and lung cancer (15.4%); colon and rectum cancer (10.9%); breast cancer (7.7%); liver cancer (6.5%); and leukemia (6.3%). China and the US face the largest economic costs of cancers in absolute terms, accounting for 24.1% and 20.8% of the total global burden, respectively. Although 75.1% of cancer deaths occur in low- and middle-income countries, their share of the economic cost of cancers is lower at 49.5%. The relative contribution of treatment costs to the total economic cost of cancers is greater in high-income countries than in low-income countries.

Conclusions and Relevance

In this decision analytical modeling study, the macroeconomic cost of cancers was found to be substantial and distributed heterogeneously across cancer types, countries, and world regions. The findings suggest that global efforts to curb the ongoing burden of cancers are warranted.

Factors Predicting Progression to Severe COVID-19: A Competing Risk Survival Analysis of 1753 Patients in Community Isolation in Wuhan, China

Most studies of coronavirus disease 2019 (COVID-19) progression have focused on the transfer of patients within secondary or tertiary care hospitals from regular wards to intensive care units. Little is known about the risk factors predicting the progression to severe COVID-19 among patients in community isolation, who are either asymptomatic or suffer from only mild to moderate symptoms. Using a multivariable competing risk survival analysis, we identify several important predictors of progression to severe COVID-19-rather than to recovery-among patients in the largest community isolation center in Wuhan, China from 6 February 2020 (when the center opened) to 9 March 2020 (when it closed). All patients in community isolation in Wuhan were either asymptomatic or suffered from mild to moderate COVID-19 symptoms. We performed competing risk survival analysis on time-to-event data from a cohort study of all COVID-19 patients (n = 1753) in the isolation center. The potential predictors we investigated were the routine patient data collected upon admission to the isolation center: age, sex, respiratory symptoms, gastrointestinal symptoms, general symptoms, and computed tomography (CT) scan signs. The main outcomes were time to severe COVID-19 or recovery. The factors predicting progression to severe COVID-19 were: male sex (hazard ratio (HR) = 1.29, 95% confidence interval (CI) 1.04-1.58, p = 0.018), young and old age, dyspnea (HR = 1.58, 95% CI 1.24-2.01, p < 0.001), and CT signs of ground-glass opacity (HR = 1.39, 95% CI 1.04-1.86, p = 0.024) and infiltrating shadows (HR = 1.84, 95% CI 1.22-2.78, p = 0.004). The risk of progression was found to be lower among patients with nausea or vomiting (HR = 0.53, 95% CI 0.30-0.96, p = 0.036) and headaches (HR = 0.54, 95% CI 0.29-0.99, p = 0.046). Our results suggest that several factors that can be easily measured even in resource-poor settings (dyspnea, sex, and age) can be used to identify mild COVID-19 patients who are at increased risk of disease progression. Looking for CT signs of ground-glass opacity and infiltrating shadows may be an affordable option to support triage decisions in resource-rich settings. Common and unspecific symptoms (headaches, nausea, and vomiting) are likely to have led to the identification and subsequent community isolation of COVID-19 patients who were relatively unlikely to deteriorate. Future public health and clinical guidelines should build on this evidence to improve the screening, triage, and monitoring of COVID-19 patients who are asymtomatic or suffer from mild to moderate symptoms.

Cross-sectional survey on cigarette smoking in Chinese high-income areas

OBJECTIVE

To evaluate smoking status and its influencing factors in high-income areas of China.

DESIGN

Cross-sectional.

SETTING

High-income areas in China.

PARTICIPANTS

4064 persons aged 15 years or older from the survey results in Global Adult Tobacco Survey-China 2018.

METHODS

Gross national income data were used to determine China's high-income economic regions, and the results of the survey in Global Adult Tobacco Survey-China 2018 were used for statistical analysis.

RESULTS

A total of 4064 people were included in our study, including 881 current smokers, 2884 who had never smoked and 299 who had quit smoking. Using the standardised rate method, the standardised smoking rates in high-income and non-high-income areas in China were calculated to be 23.56% and 27.77%, respectively. Men, high school education or below, knowledge of e-cigarette information, permission to smoke at home and people with poor smoking health literacy are the main influencing factors of smokers in high-income areas of China.

CONCLUSION

The smoking rate of people in China's high-income areas is lower than the overall smoking rate in China, and we should increase the public awareness that smoking is harmful to health, encourage the prohibition of smoking at home, increase investment in higher education and improve residents' smoking health literacy level. The purpose of this study was to encourage reduction in the rate of smoking and better control the prevalence of smoking.

Decomposition and Comparative Analysis of the Prevalence of and Factors Associated With Smoking Between the Rural and Urban Elderly Population in China: A National Cross-Sectional Study

This study aimed to compare and analyse the differences in smoking prevalence, and knowledge, attitudes, and factors associated with smoking between the rural and urban elderly population in China. In total, 6,966 participants aged 60 and above were included in this study, which assessed their smoking-related knowledge, attitudes, and perceptions toward tobacco control. The Chi-square test and logistic regression model were used for statistical analysis, and the Fairlie model was used for decomposition analysis. The overall prevalence of smoking was 25.6%; the rate was much higher in men than in women (overall: OR = 26.234; urban: OR = 31.260; rural: OR = 23.889). The rate of correct responses to all questions on smoking problems was significantly higher among the urban elderly than the rural elderly. Further, 64.18% of the participants supported printing photos of the health hazards of smoking on the cover of cigarette packs, and the rural elderly were more supportive of this. Moreover, only 36.52% of the participants supported increasing taxation and retail price of cigarettes; the urban elderly showed more support for this. Rules about smoking at home also played an important role, especially for families where smoking was not allowed at home, but with exceptions to the rule; however, this factor was only meaningful in urban families (urban: OR = 0.117). Through the Fairlie decomposition analysis, gender (-1.62%), age (-2.03%), region (13.68%), knowing about e-cigarettes (5.17%), rules about smoking at home (3.95%), and smoking-related knowledge scores (42.85%) were found to be associated with rural-urban disparities. This study focused on the differences in smoking between urban and rural areas in China. Smoking among the urban elderly was significantly less prevalent compared with the rural population. Factors including education, region, and smoking-related knowledge need to be addressed to reduce the gap between urban and rural health hazards in China.

A Study on China's Tobacco Taxation and Its Influencing Factor on Economic Growth

Tobacco is a significant product providing considerable economic benefits to countries worldwide, while its increased consumption causes health and socio-economic losses for smokers and non-smokers. This paper constructs a decomposition system of tobacco taxation: the population aging factor is included in the influencing factors of personal tax, and personal tax revenue is regarded as the product of tax structure, macro tax burden, regional economy, reciprocal aging, and the elderly population. This article conducts an empirical study on the relationship between taxation and economic growth. The estimated coefficients of business tax and corporate income tax are significant at the significance level of 0.1, with a consumption tax and time-variable coefficients reporting a 0.02 level of significance. The T statistic value and the explanatory degree of the variables involved in the model to the explained variables are also very high, reaching more than 95%. We find that increasing the macro tax burden negatively impacts economic growth. Therefore, the study suggests that for fostering the industry’s economic growth, the country needs to ensure the optimal macro tax burden of 17.5%, with different types of taxes influencing economic growth. Personal tax reform should pay attention to the phenomenon of aging, adjust the tax structure to increase personal tax income, provide policy support and guarantee for the elderly labor force, and encourage the re-employment of silver-haired people to alleviate the adverse impact of aging on taxation.

Smoking cessation and weight gain: Evidence from China

Cigarette smoking has long been viewed as a means to control body weight. However, studies on the association between smoking cessation and weight gain have reported mixed findings and, notably, there is limited evidence among the Chinese population - the world's largest smoker population. The extent to which smoking cessation is positively associated with body weight is of interest as excessive weight gain contributes to heart disease, diabetes, hypertension, musculoskeletal disorders, and some cancers. Additionally, concerns over weight gain may dissuade current smokers from quitting. Using data from the China Health and Nutrition Survey (CHNS), we examine the association between smoking cessation and body weight in China. To account for the nonrandom nature of smoking cessation, our research design relies on within-individual variation in smoking status to remove the influence of time-invariant unobserved differences across individuals that are correlated with both cessation and body weight. We find that smoking cessation is associated with a modest increase in weight (0.329 kg, 0.51 % off the mean) and no significant changes in the prevalence of overweight or obesity.

Macro-level efficiency of health expenditure: Estimates for 15 major economies

The coronavirus disease 2019 (COVID-19) pandemic highlights the importance of strong and resilient health systems. Yet how much a society should spend on healthcare is difficult to determine because additional health expenditures imply lower expenditures on other types of consumption. Furthermore, the welfare-maximizing ("efficient") aggregate amount and composition of health expenditures depend on efficiency concepts at three levels that often get blurred in the debate. While the understanding of efficiency is good at the micro- and meso-levels-that is, relating to minimal spending for a given bundle of treatments and to the optimal mix of different treatments, respectively-this understanding rarely links to the efficiency of aggregate health expenditure at the macroeconomic level. While micro- and meso-efficiency are necessary for macro-efficiency, they are not sufficient. We propose a novel framework of a macro-efficiency score to assess welfare-maximizing aggregate health expenditure. This allows us to assess the extent to which selected major economies underspend or overspend on health relative to their gross domestic products per capita. We find that all economies under consideration underspend on healthcare with the exception of the United States. Underspending is particularly severe in China, India, and the Russian Federation. Our study emphasizes that the major and urgent issue in many countries is underspending on health at the macroeconomic level, rather than containing costs at the microeconomic level.

The economic burden of COVID-19 in the United States: Estimates and projections under an infection-based herd immunity approach

OBJECTIVES

To assess the economic burden of COVID-19 that would arise absent behavioral or policy responses under the herd immunity approach in the United States and compare it to the total burden that also accounts for estimates of the value of lives lost.

METHODS

We use the trajectories of age-specific human and physical capital in the production process to calculate output changes based on a human capital-augmented production function. We also calculate the total burden that results when including the value of lives lost as calculated from mortality rates of COVID-19 and estimates for the value of a statistical life in the United States based on studies assessing individual's willingness to pay to avoid risks.

RESULTS

Our results indicate that the GDP loss associated with unmitigated COVID-19 would amount to a cumulative US$1.4 trillion by 2030 assuming that 60 percent of the population is infected over three years. This is equivalent to around 7.7 percent of GDP in 2019 (in constant 2010 US$) or an average tax on yearly output of 0.6 percent. After applying the value of a statistical life to account for the value of lives lost, our analyses show that the total burden can mount to between US$17 and 94 trillion over the next decade, which is equivalent to an annual tax burden between 8 and 43 percent.

CONCLUSION

Our results show that the United States would incur a sizeable burden if it adopted a non-interventionist herd immunity approach.

FUNDING

Research reported in this paper was supported by the Alexander von Humboldt Foundation, the Bill & Melinda Gates Foundation (Project INV-006261), and the Sino-German Center for Research Promotion (Project C-0048), which is funded by the German Research Foundation (DFG) and the National Natural Science Foundation of China (NSFC). Preparation of this article was also supported by the Value of Vaccination Research Network (VoVRN) through a grant from the Bill & Melinda Gates Foundation (Grant OPP1158136). The content is solely the responsibility of the authors.

Projection of premature mortality from noncommunicable diseases for 2025: a model based study from Hunan Province, China, 1990-2016

Background

In 2011, the United Nations set a target to reduce premature mortality from non-communicable diseases (NCDs) by 25% by 2025. While studies have reported the target in some countries, no studies have been done in China. This study aims to project the ability to reach the target in Hunan Province, China, and establish the priority for future interventions.

Methods

We conducted the study during 2019–2020. From the Global Burden of Disease Study 2016, we extracted death data for Hunan during 1990–2016 for four main NCDs, namely cancer, cardiovascular disease (CVD), chronic respiratory diseases, and diabetes. We generated estimates for 2025 by fitting a linear regression to the premature mortality over the most recent trend identified by a joinpoint regression model. We also estimated excess premature mortality attributable to unfavorable changes over time.

Results

The rate of premature mortality from all NCDs in Hunan will be 19.5% (95% CI [19.0%–20.1%]) by 2025, with the main contributions being from CVD (8.2%, 95% CI [7.9%–8.5%]) and cancer (7.9%, 95% CI [7.8%–8.1%]). Overall, it will be impossible to achieve the target, with a relative reduction of 16.4%. Women may be able to meet the target except with respect to cancer, and men will not except with respect to chronic respiratory diseases. Most of the unfavorable changes have occurred since 2008–2009.

Discussion

More urgent efforts, especially for men, should be exerted in Hunan by integrating population-wide interventions into a stronger health-care system. In the post lock-down COVID-19 era in China, reducing the NCD risk factors can also lower the risk of death from COVID-19.