Tobacco control in China and the road to Healthy China 2030

Exposure to anti- and pro-smoking messages among adults in China: Results from the Global Adult Tobacco Survey, 2018

SIGNIFICANCE

For decades, tobacco advertisements and promotions have been common in mass media and public places in China. In 2015, China amended the Advertising Law to prohibit the distribution of tobacco advertising, while also initiating waves of tobacco control media campaigns. This study investigates the associations between exposure to anti- and pro-smoking messages, smoking status, and people's smoking-related beliefs and willingness to support tobacco control policies.

METHODS

A secondary data analysis was performed with the 2018 Global Adult Tobacco Survey of 19,376 adults aged ≥15 years in China. Anti- and pro-smoking message exposures were measured as the sum of sources (media or places) where respondents have seen the messages. Multivariable logistic regression analyses were conducted to examine the relationships among smoking status, message exposure, and the outcome variables (health harm beliefs, support for increasing tax on cigarettes, support for using part of the increased tax on tobacco control) controlling for smoking status and demographic differences.

RESULTS

Overall, 63.3% of the respondents reported being exposed to anti-smoking messages from at least 1 source, while 18.1% were exposed to pro-smoking messages from at least 1 source. Adults who currently, formerly, and never smoked differed in their beliefs about smoking and willingness to support tobacco control policies. Greater reported exposure to anti-smoking messages was positively associated with belief that smoking is harmful, support for increased cigarette tax, and support for using increased tax revenue for tobacco control measures. Meanwhile, greater reported exposure to pro-smoking messages was negatively related to willingness to support cigarette tax increases.

CONCLUSIONS

While national and local tobacco control campaigns in China have reached a large proportion of the adult population, there is still room for improvement. China might consider expanding anti-tobacco campaigns, as reported exposure to these messages is associated with increased public awareness of the health hazards of smoking and support for increasing cigarette taxes.

Environmental exposure and child health in China

Chinese children are exposed to broad environmental risks ranging from well-known hazards, such as pesticides and heavy metals, to emerging threats including many new man-made chemicals. Although anecdotal evidence suggests that the exposure levels in Chinese children are substantially higher than those of children in developed countries, a systematic assessment is lacking. Further, while these exposures have been linked to a variety of childhood diseases, such as respiratory, endocrine, neurological, behavioral, and malignant disorders, the magnitude of the associations is often unclear. This review provides a current epidemiologic overview of commonly reported environmental contaminants and their potential impact on children's health in China. We found that despite a large volume of studies on various topics, there is a need for more high-quality research and better-coordinated regional and national data collection. Moreover, prevention of such diseases will depend not only on training of environmental health professionals and enhanced research programs, but also on public education, legislation, and networking.

Secondhand smoke exposure can increase the risk of first ischemic stroke: A 10.7-year prospective cohort study in China

INTRODUCTION

Passive smoking is considered a major public health issue in China. Prospective evidence regarding the link between secondhand smoke (SHS) and ischemic stroke in China is scarce.

METHODS

The China Kadoorie Biobank (CKB) study in Liuzhou City recruited 50,174 participants during 2004-2008. Of these 30,456 never-smokers were included in our study. The median follow-up period was 10.7 years. The incidence of ischemic stroke was obtained through the China Disease Surveillance Points (DSP) system and the Health Insurance (HI) database. Cox proportional risk models were used to evaluate the association between SHS exposure and ischemic stroke.

RESULTS

During 320,678 person-years of follow-up, there were 2059 patients with ischemic stroke observed and the incidence of ischemic stroke was 6.42 per thousand person-years. Participants exposed to SHS daily faced a 21 % higher risk of ischemic stroke (HR = 1.21, 95 %CI: 1.09-1.34) compared to those exposed to SHS less than once a week. Subgroup analyses revealed that daily SHS exposure was linked to heightened risk of ischemic stroke among women, non-employed, and non-weekly tea drinkers.

CONCLUSIONS

Daily SHS exposure was associated with higher risks of ischemic stroke. Proactive tobacco control strategies are necessary to decrease the risk of ischemic stroke in never smokers.

Changing profiles of the burden of Alzheimer's disease and other dementias attributable to smoking in the belt and road initiative countries: A secondary analysis of global burden of disease 2019

Objectives

This study was aimed at analyzing the burden and trend of Alzheimer's disease and other dementias attributed to smoking (SADD) in the Belt and Road Initiative (BRI) countries during 1990-2019.

Methods

Data from The 2019 Global Burden of Disease Study was used to extract information on the burden of SADD in terms of the numbers and age-standardized rate of mortality (ASMR) and disability-adjusted life years (ASDALR) in the BRI countries for 1990-2019. The average annual percent change (AAPC) was used to analyze the temporal trends of ASDALR from 1990 to 2019 and in the final decade by Joinpoint regression analysis.

Results

The DALYs of SADD were the highest in China, India, and the Russian Federation in 1990 and in Lebanon, Montenegro and Bosnia, and Herzegovina in 2019. From 1990 to 2019, the ASDALR in China had increased from 55.50/105 to 66.18/105, but decreased from 2010 to 2019, while that of India had declined from 32.84/105 to 29.35/105, but increased from 2010 to 2019. The ASDALR showed the fastest increase in the Russian Federation, with AAPC of 1.97% (95% confidence interval [CI]: 1.77%, 2.16%), and the fastest decline in Sri Lanka, with AAPC of -2.69% (95% CI: 2.79%, -2.59%). ASMR and ASDALR from SADD showed a substantial decline during 1990-2019 both globally and in the different socio-demographic index (SDI) regions (all P < 0.05, except for the high-middle-SDI region). Compared to the rates in males, the AAPC in ASDALR of females was significantly greater in 20 countries(all P < 0.05). In the age group of 20-54 years, the DALYs rate showed a decreasing trend only in 13 members in the low-SDI region (all P < 0.05).

Conclusion

Under the premise of eliminating the differences, mobilizing resources in the country itself, the BRI organization, and globally will help reduce the global SADD burden and achieve healthy and sustainable development.

Tobacco control in China

Chinese men consume around 40% of the world's cigarettes, causing a substantial and growing burden of tobacco-attributed death and disease. In 2005, the Chinese Government ratified the WHO Framework Convention on Tobacco Control, and tobacco control measures have since increased nationwide. To assess tobacco control progress, obstacles, and opportunities, this Review describes the long-term evolution of cigarette consumption and the associated disease burden in mainland China, and the implementation of five important tobacco control strategies advocated by WHO. These strategies covered tobacco taxation; package warnings; advertising, promotion, and sponsorship bans; public smoking bans; and cessation services. Although only 2% of women in China now smoke, half of all adult men smoke cigarettes. By the 2010s, smoking accounted for about a fifth of all adult male deaths, and this proportion is rising, following a trajectory similar to that seen in the USA 40 years earlier. The self-regulating national tobacco monopoly and its influence on policy, the country's relatively low tobacco tax, and its weak package warnings and enforcement of other tobacco control strategies all highlight challenges in tobacco control. However, these challenges can also provide opportunities to discourage smoking initiation in young women and encourage cessation in men, assisting China's long march towards better health.

Trends and disparities in China's cardiovascular disease burden from 1990 to 2019

BACKGROUND AND AIMS

In order to find the exact strategies in the prevention of cardiovascular diseases (CVD), it is necessary to assess their risk factors systematically. Here, we used the Global Burden of Disease (GBD) to review the long-term trends and epidemiological characteristics among Chinese.

METHODS AND RESULTS

We comprehensively analyzed the burden of CVD for the Chinese population using GBD 2019, including prevalence, incidence, mortality, years of life lost (YLLs), years lived with disability (YLDs), and disability-adjusted life years (DALYs). Then, we analyzed trends over time, and predicted mortality and morbidity, using joinpoint regression, age-period-cohort (APC) model, and Bayesian APC approach. Finally, we analyzed the attributable burden of CVD. In 2019, the prevalence of CVD in China was 120 million, representing a 140.02% increase since 1990. The number of DALYs attributed to CVD increased by 52.56% compared to 1990. Joinpoint showed a fluctuating incidence downward, while mortality significantly declined. The APC fitting results indicated that recent generations have a higher prevalence than the past, and the prevalence has increased among individuals of the same age group. The BAPC predicted that CVD's prevalence and mortality in the Chinese would stabilize and decline between 2020 and 2030, with a significant decline among males. The main CVD-attributable burdens in 2019 were metabolic risks, especially high blood pressure.

CONCLUSION

Given China's large and rapidly aging population, the burden of CVD is a major concern. Practical strategies to prevent and manage CVD are urgently needed to address this public health challenge.

Epidemiological Analysis of Global and Regional Lung Cancer Mortality: Based on 30-Year Data Analysis of Global Burden Disease Database

The objective of this study was to understand dynamic global and regional lung cancer fatality trends and provide a foundation for effective global lung cancer prevention and treatment strategies. Data from 1990 to 2019 were collected from the Global Burden Disease (GBD) database and statistical analysis was conducted using Excel 2010. Standardization was based on the GBD's world population structure, and the Average Annual Percentage Change (AAPC) was calculated using Joinpoint 4.8.0.1 software. Bayesian age-period-cohort analysis (BAPC) predicted global lung cancer mortality from 2020 to 2030. In 2019, worldwide lung cancer deaths reached 2,042,600, a 91.75% increase from 1990 (1,065,100). The standardized age-specific death rate in 2019 was 25.18 per 100,000. Males had a rate of 37.38 while females had 14.99. Men saw a decreasing trend while women experienced an increase. High- and medium-high-SDI regions had declining rates (-0.3 and -0.8 AAPCs) whereas middle-, low-, and low-middle-SDI regions had increased mortality rates (AAPC = 0.1, AAPC = 0.37, AAPC = 0.13). Several regions, including Oceania, South Asia, East Asia, Western Sub-Saharan Africa, Southeast Asia, and Eastern Sub-Saharan Africa, witnessed rising global lung cancer mortality rates (p < 0.01). The global standardized mortality rate for lung cancer is expected to decrease from 2020 to 2030, but predictions indicate increasing female mortality and decreasing male mortality. Despite overall declines, rising female mortality remains a concern. Effective measures are essential to reduce mortality rates and improve patients' quality of life in the global fight against lung cancer.

Study on the participation of nursing staff in tobacco cessation support and related influencing factors: A survey from Chongqing, China

INTRODUCTION

Nursing staff's assistance for smokers to quit smoking can increase the rate of quitting. The smoking cessation help can be affected by many factors. This study surveyed the use of the 5As (Asking, Advising, Assessing, Assisting, Arranging) approach to support smoking cessation by the nursing staff in Chongqing, China, and analyzed the corresponding influencing factors.

METHODS

A stratified random cluster sampling method was used to select nursing staff from 8 tertiary hospitals, 5 secondary hospitals, 12 community health centers, and 35 township health centers in different geographical regions of Chongqing. A questionnaire survey was conducted among the nursing staff to investigate their participation in smoking cessation. Binary logistic regression analysis was employed to analyze the influencing factors of smoking cessation 5As behavior of the nursing staff.

RESULTS

The 1669 participants were 44 males (2.6%) and 1625 females (97.4%), with an average age of 37.00 ± 10.89 years. Among the participants, 55.2% were from tertiary hospitals, 23.2% from secondary hospitals, 14.2% from township health centers, and 7.4 from community health centers. The often or always used behaviors were: Asking, 69.2%; Advising, 53.0%; Assessing, 39.5%; Assisting, 33.7%; and Arranging, 25.1%. The factors that affected all the 5As were: smoking cessation training (AOR=1.60; 95% CI: 1.22-2.11), knowledge of smoking cessation guidelines (AOR=1.75; 95% CI: 1.32-2.32) and the use of smoking cessation Apps (AOR=1.50; 95% CI: 1.09-2.06), and smokers' willingness to quit (AOR=2.20; 95% CI: 1.60-3.02).

CONCLUSIONS

Smoker's motivation to quit smoking and nurses' knowledge of tobacco cessation resources affected nurses' participation in smoking control behavior. While encouraging smokers to quit smoking, clinical nursing staff should be provided with related resources to advocate smoking cessation. Guided by the Chinese Clinical Tobacco Cessation Guidelines, smoking control knowledge and skills training should be provided for nursing staff to increase their positive attitude towards smoking control, so as to promote their active participation.

An Analysis of Public Perception and Concern Toward Electronic Cigarettes: Exploring Attitudes and Profiles

Introduction The emergence of electronic cigarettes (e-cigarettes) poses a new challenge to tobacco control efforts. With their increasing popularity, particularly among youth, public concerns have been raised in Mainland China. Further investigation is necessary to fully understand the safety and potential adverse effects of e-cigarettes. Methods The Baidu search index (BSI) was employed using e-cigarette related terms from January 1, 2011, to April 4, 2022. The search volume for each term was recorded and analyzed for the search trend module, geodemographic module, search-demand module, regional preferences, demographic preferences, and user demand. Results According to our analysis, the total BSI for the 18 e-cigarette related search keywords was 39,027,819. The average annual percentage change of BSI indicated an upward trend for each of these categories, including health issues (p < 0.05), definition (p < 0.05), product and promotions (p < 0.05), and policy and regulations. Of all inquiries, 59.38% originated from females and 40.62% from males. The total valid BSI for e-cigarette related words was 165,076,588, and 11.59% of all search inquiries were from individuals aged 19 years and younger. Our analysis also revealed that the public's primary concerns regarding e-cigarettes were related to their quality and potential health issues. Conclusions E-cigarettes enjoy great popularity nationwide, but product quality and safety are major public concerns. Regulation of e-cigarettes for their standard production, quality control, advertisement, and target customers should be implemented promptly, and the public needs to have a clear perception of e-cigarettes, especially adolescents. E-cigarette related health damages or consequences require further investigation, and advertisements and promotions for e-cigarettes should be strictly controlled by the government.

Attitudes and influencing factors associated with smoking cessation: An online cross-sectional survey in China

INTRODUCTION

Quitting smoking, the critical path to reach the global targets of reducing tobacco use, can bring major and immediate health benefits to smokers. Exploring factors that help individuals to quit smoking is of great importance. The present study explored influencing factors on smoking cessation, in order to provide comprehensive reference for tobacco control policies.

METHODS

Ex-smokers and current smokers were recruited online in this cross-sectional survey, from 1 October to 31 November 2022, in China. The observational data were collected using a questionnaire to collect information with respect to sociodemographic characteristics of smokers, attitudes towards smoking cessation, details of smoking cessation, and different potential factors related to smoking cessation through open-ended questions.

RESULTS

A total of 638 smokers from 30 provinces were recruited as eligible respondents, with a mean age of 37.3 ± 11.7 years and a mean smoking history of 15.9 ± 13.7 years. The percentage of males was 92.3%. Of the 638 respondents, only 3.9% had no intention to stop smoking. Among 155 subjects who had quitted smoking successfully, willpower (55.5%) was considered as the most important contributing factor. Among 365 subjects who tried to quit but failed, lack of willpower (28.2%), tobacco dependence (16.2%), influence of surrounding smokers or smoking environments (15.9%), bad moods (9.9%), stress from work or life (7.9%), habits (7.1%), socialization (4.1%), and easy availability of tobacco (2.7%) were considered as the adverse factors leading to failure in quitting smoking.

CONCLUSIONS

Willpower and support from family members were the vital factors that lead to successful smoking cessation. Future tobacco control policies should also focus on addressing withdrawal symptoms and creating smoke-free environments as well as other factors.

Preventable burden of head and neck cancer attributable to tobacco and alcohol between 1990 and 2039 in China

Tobacco use and heavy alcohol consumption are risk factors for head and neck cancer (HNC), including oral, pharynx, and larynx cancer. No study has investigated the preventable burden of HNC attributable to tobacco and alcohol in China. We extracted data from 1990 to 2019 from the Global Burden of Disease. The preventable burden attributable to tobacco and alcohol was estimated by subtracting the overlapping fraction derived from a literature search. Descriptive analyses were performed initially, followed by joinpoint regression and age-period-cohort (APC) analysis. The future burden was forecasted using a Bayesian APC model. The crude burden increased significantly, while the age-standardized rates showed a downward trend from 1990 to 2019 in China. Both all-age and age-standardized population attributable fractions rose significantly, potentially due to the poor prognosis of tobacco- and alcohol-associated HNC. The absolute burden would continue to climb in the next 20 years from 2019, largely due to population aging. For site-specific burden, compared with total, pharynx, and larynx cancer burden, the substantial upward trend of oral cancer burden indicated a strong interaction with risk factors such as genetic susceptibility, betel nut chewing, oral microbiota, and human papillomavirus. The burden of oral cancer attributable to tobacco and alcohol is a major concern and is anticipated to become more severe than cancer in other anatomic sites. Altogether, our study provides useful information to rethink the current restrictions on tobacco and alcohol, lean healthcare resources, and develop effective HNC prevention and control strategies.

Cigarette, e-cigarette and waterpipe cognitions and use among university students in Guangzhou, China

INTRODUCTION

There is currently little research on polytobacco use in China. The present study examined cognitions that predicted the use of cigarettes, e-cigarettes and waterpipes in a Chinese sample of students.

METHODS

A convenience sample of 281 university students, obtained using snowball sampling, completed an online survey during the 2019-2020 academic year in Guangzhou, China.

RESULTS

Men more strongly agreed, than women, with the possible advantages of using alternative nicotine and tobacco products, including: young people who smoke have more friends, smoking makes young people look cool, smoking makes young people feel more comfortable, smoking helps relieve stress, and it would be easy to quit. Factors significantly associated with regular cigarette use were the cognitions: 'I would smoke if my best friend offered', 'Young people who use these products have more friends', and 'It would be easy to quit these products' (global good classifications= 80.1%). In the case of waterpipes, agreement with the cognition: 'The product helps people relieve stress' was significantly associated with its use (global good classifications=80.1%). In the case of e-cigarettes, agreement with the cognitions: 'I would smoke if my best friend offered' and 'It would be easy to quit using these products' were significantly associated with the use of e-cigarettes (global good classifications=74.7%).

CONCLUSIONS

The results highlight the need to develop prevention programs that prepare young Chinese people to resist social pressure from friends to use tobacco products. There is also evidence of the need to facilitate and disseminate rigorous scientific information among young people about the possible negative health effects of alternative tobacco products. There were also gender differences in the use of these products and in the cognitions towards their use, so it is important to take the gender perspective into account in the analysis of the results and when writing future questionnaire items.

Assessing the association between smoking and hypertension: Smoking status, type of tobacco products, and interaction with alcohol consumption

Background

The association between tobacco use and hypertension risk has been extensively researched but remains controversial, and few existing studies have considered the role of tobacco type and dosage response in this association. In this context, this study aims to provide epidemiological evidence for the possible relationship between tobacco smoking and future hypertension risk, with the tobacco type and consumption dose into consideration.

Methods

This study was based on 10-year follow-up data from the Guizhou Population Health Cohort conducted in southwest China. Multivariate Cox proportional hazards regression models were used to estimate hazard ratios (HRs) and 95% confidence intervals [95% confidence intervals (CIs)], and restricted cubic spline analyses were performed to visualize the dose-response association.

Results

A total of 5,625 participants (2,563 males and 3,062 females) were included in the final analysis. Heavy smokers of machine-rolled cigarettes had an elevated hypertension risk compared with non-smokers (HR: 1.50, 95% CI: 1.05-2.16). The interaction effects of heavy smoking-heavy drinking patterns increased the future hypertension risk, with an adjusted HR of 2.58 (95% CI: 1.06-6.33).

Conclusion

This study did not find a significant association between overall tobacco use status and the risk of hypertension. However, heavy machine-rolled cigarette smokers had a statistically significant increased risk of hypertension compared with non-smokers, and a J-shape association has been found between the average daily consumption of machine-rolled cigarettes and the risk of hypertension. Besides, tobacco and alcohol consumption jointly increased the long-term hypertension risk.

Trends in Socio-economic Inequality in Smoking Among Middle-aged and Older Adults in China: Evidence From the 2011 and 2018 China Health and Retirement Longitudinal Study

INTRODUCTION

Socio-economic inequalities in smoking and related health problems are a public health concern worldwide. To support the development of effective tobacco control policies, this study examines trends in smoking rates according to socio-economic status (SES) in China.

AIMS AND METHODS

We analyzed data from repeated cross-sectional China Health and Retirement Longitudinal Study (CHARLS) on adults aged ≥45 years for the years 2011 and 2018, which involved 16 471 participants in 2011 and 19 367 in 2018. We then estimated the SES of individuals based on four types of wealth-related variables, namely, education, occupation, household characteristics, and durable consumer goods. Principal-component analysis was conducted to measure SES, and the Erreygers normalised concentration index (ECI) was used to calculate socio-economic inequality in current smoking by gender, age, and region.

RESULTS

The overall ECI (95% confidence interval) for women was -0.042 (-0.054 to -0.031) and -0.038 (-0.047 to -0.029) for 2011 and 2018, respectively. The ECI (95% confidence interval) for men was -0.077 (-0.101 to -0.050) and -0.019 (-0.042 to 0.005) for 2011 and 2018, respectively. The inequality in smoking by SES for adults aged < 60 years in the Northeast region increased during 2011-2018, from -0.069 (-0.144 to 0.006) to -0.119 (-0.199 to -0.038) for women and from 0.009 (-0.115 to 0.132) to -0.164 (-0.296 to -0.032) for men.

CONCLUSIONS

smoking inequality by socio-economic among adults aged ≥45 years declined in recent years in China. However, smoking inequality by SES increased in other population groups.

IMPLICATIONS

Our research indicated that socio-economic inequality of current smoking among residents aged 45 years and older declined in 2018 when compared with 2011 numbers, particularly for men aged ≥ 60 years. Women in the Northeast region displayed more significant smoking inequality by SES than women in other regions did. During the study period, there was an increase in inequality in smoking by SES for adults aged < 60 years in the Northeast region. Thus, tobacco control policies and interventions should be targeted at high-risk subpopulations with lower SES, particularly in Northeast China.

China's Smoke-free Policies in Public Place and the Smoking Cessation Status of Smokers

INTRODUCTION

Smoking remains a major health risk factor and China is the world's largest consumer of tobacco. Smoke-free policies in public places are a powerful weapon in tobacco control. Therefore, the aim of this study was to assess the association between smoke-free policies in public places and smoking cessation among smokers in China from 2012 to 2020.

METHODS

In this study, we assessed the impact of smoke-free public places policies on smoking cessation situation among smokers aged 16 years and older. We do this by conducting a difference-in-differences analysis using data from the China Family Panel Study (CFPS) 2012-2020.

FINDINGS

By 2020, about 60.2% of the cities were covered by partial smoke-free policies and about 38.5% by comprehensive smoke-free policies. Based on the results of the study, we found that the medium-term effect model (Model 2, 2012:2016; Model 3, 2012:2018) of the impact of partial smoke-free policies on smoking cessation was not statistically significant using 2012 as the study baseline; the short-term effect model (Model 1; 2012:2014; P< .01) and the long-term effect model (Model 4; 2012:2020; P< .05) were statistically significant; the effect of a comprehensive smoke-free policy on smoking cessation (Model 5; 2012:2020; P<.05) was statistically significant.

CONCLUSION

China's existing comprehensive smoke-free policies have had a modest impact on smoking cessation among the smoking population, and a strong, comprehensive national smoke-free law is urgently needed to achieve greater public health outcomes.

IMPLICATIONS

Smoke-free policies are an important intervention to influence smoking behavior. This study demonstrates that comprehensive smoke-free policies in public places in China can effectively influence smoking behavior and show long-term trends in smoke-free behavior, while also reflecting the need to promote comprehensive smoke-free policies. This study provides a basis for the implementation of comprehensive smokefree policies into law and also provides a basis for policy makers.

Temporal Trends and Projections of Bladder Cancer Burden in China from 1990 to 2030: Findings from the Global Burden of Disease Study

PURPOSE

Identifying disease burden and risk factors of bladder cancer and projecting its epidemiological trend in China, which can provide reference data to formulate measures for its management and prevention.

METHODS

We analyzed the incidence, mortality, and disability-adjusted life-years (DALYs) data of bladder cancer in China from 1990 to 2019 and predicted to 2030 based on the Global Burden of Disease Study 2019. We also estimated the proportion of risk factors contributing to bladder cancer DALYs. The average annual percentage change (AAPC) in both sexes was calculated to quantify the temporal trends.

RESULTS

In China, the age-standardized incidence rate of bladder cancer increased from 3.3/100,000 in 1990 to 5.16/100,000 in 2019 (AAPC of 1.47), while the age-standardized mortality rate and age-standardized DALYs rate declined slightly (AAPC of -0.58 and -0.65, respectively). The burden of bladder cancer increased with age, which reached a peak over 85 years old. The main risk factor for bladder cancer was smoking, and the contribution of high fasting plasma glucose increased from 1990 to 2019, with an AAPC of 0.85 in males and 0.61 in females. We predicted total incident cases, deaths and DALYs will increase to 150,372 and 53,520 and 1043,688 in 2030, respectively. The disease burden of bladder cancer in males will consistently higher than that in females from 2020 to 2030.

CONCLUSION

Although mortality and DALYs rates showed downward trends, the disease burden remained heavy in China at present. More effective and long-term health policies are needed to develop for early prevention and treatment of bladder cancer.

Trends and predictions of lung cancer incidence in Jiangsu Province, China, 2009–2030: a bayesian age-period-cohort modelling study

Background

Lung cancer is currently the most frequent cancer in Jiangsu Province, China, and the features of cancer distribution have changed continuously in the last decade. The aim of this study was to analyse the trend of the incidence of lung cancer in Jiangsu from 2009 to 2018 and predict the incidence from 2019 to 2030.

Methods

Data on lung cancer incidence in Jiangsu from 2009 to 2018 were retrieved from the Jiangsu Cancer Registry. The average annual percentage change (AAPC) was used to quantify the trend of the lung cancer age-standardized rate (ASR) using Joinpoint software. Bayesian age-period-cohort models were used to predict lung cancer incidence up to 2030.

Results

In Jiangsu, the lung cancer crude rate increased from 45.73 per 100,000 in 2009 to 69.93 per 100,000 in 2018. The lung cancer ASR increased from 29.03 per 100,000 to 34.22 per 100,000 during the same period (AAPC = 2.17%, 95% confidence interval [CI], 1.54%, 2.80%). Between 2019 and 2030, the lung cancer ASR is predicted to decrease slightly to 32.14 per 100,000 (95% highest density interval [HDI], 24.99, 40.22). Meanwhile, the ASR showed a downward trend in males and rural regions while remaining stable in females and urban regions.

Conclusion

We predict that the incidence of lung cancer in Jiangsu will decrease in the next 12 years, mainly due to the decrease in males and rural areas. Therefore, future lung cancer prevention and control efforts should be focused on females and urban regions.

Prevalence, frequency, intensity, and location of cigarette use among adolescents in China from 2013-14 to 2019: Findings from two repeated cross-sectional studies

BACKGROUND

The burden of disease caused by tobacco use is a grave public health concern in China. Preventing smoking initiation among adolescents will lower the prevalence of adult tobacco use later. Surveillance of tobacco use among adolescents helps set priorities in developing tobacco control policies. We aim to ascertain the prevalence and differences of cigarette use across sex, grade, and region among middle and high school students in 2019 and associated changes from 2013-14 to 2019 among middle school students.

METHODS

Using a multistage stratified cluster-randomized sampling design with national and provincial representativeness, we conducted two school-based cross-sectional surveys in 2013-14 and in 2019. A total of 155 117 middle school students in grades 7-9 in 2013-14 and 288 192 middle and high school students in grades 7-12 in 2019 were interviewed. Self-reported experimental and current (past 30-day) cigarette use among middle school and high school students; frequent use (≥20 days in the past 30 days) and intensity (>20 cigarettes per day) of smoking among current cigarette users; and location of smoking among current cigarette users were investigated. All estimates were weighted based on the complex sampling design.

FINDINGS

The 2013-14 survey (overall response rate: 98.1%) included 155 117 middle school students (47.1% girl). The 2019 survey (overall response rate: 98.7%) included 147 270 middle school students (46.5% girl), 106 432 academic high school students (50.8% girl) and 34 490 vocational high school students (43.8% girl). In 2019, the prevalence rate of experimental and current cigarette use was 12.9% and 3.9% for middle school students, 21.6% and 5.6% for academic high school students, and 30.3% and 14.7% for vocational high school students, respectively, with large sex and regional differences. The prevalences of smoking on 20 or more days and daily cigarette use in the past 30 days were higher in vocational high school (5.9%, 4.1%) than in academic high school (1.8%, 1.2%) and middle school (0.7%, 0.5%), and higher among boys than girls. The proportions of current cigarette users smoking more than 20 cigarettes per day in the past 30 days for girls were higher than for boys in academic high school. Students usually smoke at school and at home. Boys were more likely to use cigarettes in an internet cafe, while girls often smoked at social venues. From 2013-14 to 2019, the prevalences of experimental and current cigarette use declined by 5.0% and 2.0% (percentage points), respectively, among middle school students but increased by 1.4% and 0.5% (percentage points) among rural girls. Among current cigarette users in middle school students, the proportions of heavy cigarette use (>20 cigarettes per day) have increased by 1.8 percentage points, mainly among boys, by 2.2% (percentage points).

INTERPRETATION

From 2013-14 to 2019, the prevalences of experimental and current cigarette use among middle school students decreased overall but increased among rural girls, while the intensity of cigarette use rose among boys. Cigarette use among Chinese adolescents differs across sex and regions, with higher rates among boys, in rural areas, and in the Western region (low socioeconomic status). Smoking is much more prevalent in vocational high schools than the other settings. Effective targeted tobacco control interventions among adolescents are urgently needed in China.

FUNDING

Dr. Zhuo Chen is supported by National Natural Science Foundation (Grant#: 72174098) through the University of Nottingham Ningbo China.

Trends of cancer mortality in Xi'an City, China: 2005-2020

PURPOSE

Describe and predict the malignant tumor deaths in Xi'an so as to provide evidence for the government to formulate the prevention and treatment plans.

METHODS

Overall malignant tumor death in Xi'an in the past 16 years was described. The multi-decrease life table was used to calculate cumulative mortality risk by cause and life expectancy reduction years by cause of malignant tumors in 2020. The join point regression models were used to analyze the change trend of standard mortality of malignant tumors in Xi'an from 2005 to 2020. The appropriate gray models were selected to predict the death of malignant tumors in Xi'an in the next decade.

RESULTS

The mortality of total malignant tumors in Xi'an showed that men are higher than women and the elderly are higher than other groups. As for 2020, lung cancer had the highest risk of death for both men and women, while leukemia had the highest life expectancy reduction years by cause. From 2005 to 2020, standardized mortality of majority malignant tumors showed downward trends, which were particularly obvious in recent years. The prediction results of several major malignant tumors showed that in the next decade, the mortality of most malignant tumors had downward trends, but combined with the increase of population in the future, the number of malignant tumor deaths in Xi'an will continue to increase.

CONCLUSIONS

Malignant tumors in Xi'an have decreasing mortality trends in recent years, and effective measures to prevent and treat tumors should be strengthened in the future.

Identifying credible attribution sources for cigarette health warning labels in China: results from a cross-sectional survey of Chinese adults

OBJECTIVE

The Framework Convention on Tobacco Control recommends health warning labels (HWLs) include an attribution source. Little is known regarding the perceived credibility and effectiveness of different message sources. This study examined perceptions of four HWL attribution sources among adults in China - the world's largest consumer of cigarettes.

DESIGN

Cross-sectional experimental survey design.

PARTICIPANTS

Data were collected in 2017 from a convenience sample of 1999 adults across four cities in China; 80% of the sample were current smokers.

MAIN OUTCOME MEASURES

Participants viewed four versions of the same HWL, each with a different attribution source: the China Center for Disease Control (ref. group); the regulatory arm of China's domestic tobacco company (STMA); Liyuan Peng, China's first lady; and the WHO. Respondents indicated which HWL was the most: (1) credible, (2) effective at making people quit and (3) effective at preventing youth initiation.

RESULTS

Multinomial logistic regression models estimated adjusted relative risk ratios (aRRRs) of the three outcomes. Controlling for demographics and smoking status, HWLs attributed to STMA and Liyuan Peng, respectively, were perceived as significantly less credible (aRRR=0.81, p<0.001; aRRR=0.31, p<0.001), less effective at making people quit (aRRR=0.46, p<0.001; aRRR=0.24, p<0.001) and less effective at preventing young smoking (aRRR=0.52, p<0.001; aRRR=0.39, p<0.001) than the China CDC HWL. There were no significant differences in perceived effectiveness of between the WHO and China CDC HWLs. Participants viewed the WHO HWL as significantly more credible (aRRR=1.21, p<0.001) than the China CDC HWL.

CONCLUSION

Results suggest the unique role of health organisations in conveying smoking-related messages that appear credible and effective at motivating others to quit smoking or never start smoking in China. Findings can inform global recommendations regarding HWL attribution sources.

Health Effects of Tobacco at the Global, Regional, and National Levels: Results From the 2019 Global Burden of Disease Study

INTRODUCTION

The purpose was to quantify the health effects of tobacco using data from the 2019 Global Burden of Disease study.

AIMS AND METHODS

We collected detailed information on tobacco consumption overall as well as its individual aspects (smoking, secondhand smoke, and chewing tobacco) for the deaths and disability-adjusted life years (DALYs) for all-cause disease, cardiovascular disease, neoplasms, and chronic respiratory diseases, and their age-standardized rates (ASRs).

RESULTS

Tobacco was responsible for 8.71 million deaths and 229.77 million DALYs globally in 2019. The ASRs of all tobacco-related deaths and DALYs declined from 1990 to 2019, to 108.55 deaths per 100 000 population and 2791.04 DALYs per 100 000 population in 2019. During any year the ASRs of all tobacco-related deaths and DALYs were higher in males than in females. The ASRs of all tobacco-related deaths and DALYs were highest in countries with a low-middle sociodemographic index (SDI) and lowest in high-SDI countries in 2019. Cardiovascular disease, neoplasms, and chronic respiratory diseases were the three leading causes of tobacco-related mortality.

CONCLUSIONS

Although the ASRs of deaths and DALYs related to tobacco have declined, the absolute number remain high. Tobacco control policies need to be strengthened further in order to reduce the heavy health burden of tobacco.

IMPLICATIONS

This study provides a detailed description on the health effects of tobacco, including maps of the current global burden of tobacco-related disease. Although the ASRs of tobacco-related deaths and DALYs have declined, the absolute numbers remain high-tobacco was responsible for 8.71 million deaths and 229.77 million DALYs globally in 2019. The findings may have implications for tobacco control. Countries where progress has been slower in reducing tobacco-related disease burden should study and consider implementing policies and strategies that have been applied in countries like Singapore which show the greatest declines for recent decades.

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.

Incident Stroke and Its Influencing Factors in Patients With Type 2 Diabetes Mellitus and/or Hypertension: A Prospective Cohort Study

Objective

To understand the incidence of stroke in patients with type 2 diabetes mellitus (T2DM) and/or hypertension (HTN), and provide a basis for the prevention of stroke in these patients.

Methods

A prospective cohort study was performed for adults with T2DM and/or HTN. The follow-up period was 1 year. The incidence and recurrence rate of stroke was calculated and a multivariate Cox proportional hazard was used to analyze influencing factors of stroke occurrence and recurrence in the follow-up of patients with T2DM and/or HTN.

Results

Of the 1,650 patients with T2DM and/or HTN, 1,213 patients had no history of stroke. After 1 year of follow-up, 147 new stroke cases occurred, and the incidence rate of stroke was 12.1%. Among the patients who had stroke history (413), there were 116 cases of stroke with a recurrence rate of 26.5%. Seven risk factors were independently associated with stroke occurrence among patients without stroke history, included smoking, abnormal total cholesterol abnormal low-density lipoprotein patients with comorbid T2DM with HTN, physical inactivity, carotid artery stenosis (CAS), and higher scores of National Institutes of Health Stroke Scale (NIHSS). Higher scores of NHISS and CAS were independent risk factors for the recurrence of stroke among patients with stroke history.

Conclusions

Patients with T2DM and/or HTN have a higher rate of new stroke and recurrence after 1-year follow-up. Actively identifying the controllable risk factors, such as smoking and physical inactivity, will help reduce the risk of stroke and recurrence in patients with T2DM and HTN.

Changing trends of disease burden of gastric cancer in China from 1990 to 2019 and its predictions: Findings from Global Burden of Disease Study

Objective

China is one of the countries with the heaviest burden of gastric cancer (GC) in the world. Understanding the epidemiological trends and patterns of GC in China can contribute to formulating effective prevention strategies.

Methods

The data on incidence, mortality, and disability-adjusted life-years (DALYs) of GC in China from 1990 to 2019 were obtained from the Global Burden of Disease Study (2019). The estimated annual percentage change (EAPC) was calculated to evaluate the temporal trends of disease burden of GC, and the package Nordpred in the R program was used to perform an age-period-cohort analysis to predict the numbers and rates of incidence and mortality in the next 25 years.

Results

The number of incident cases of GC increased from 317.34 thousand in 1990 to 612.82 thousand in 2019, while the age-standardized incidence rate (ASIR) of GC decreased from 37.56 per 100,000 in 1990 to 30.64 per 100,000 in 2019, with an EAPC of -0.41 [95% confidence interval (95% CI): -0.77, -0.06]. Pronounced temporal trends in mortality and DALYs of GC were observed. In the next 25 years, the numbers of new GC cases and deaths are expected to increase to 738.79 thousand and 454.80 thousand, respectively, while the rates of incidence and deaths should steadily decrease. The deaths and DALYs attributable to smoking were different for males and females.

Conclusions

In China, despite the fact that the rates of GC have decreased during the past three decades, the numbers of new GC cases and deaths increased, and will continue to increase in the next 25 years. Additional strategies are needed to reduce the burden of GC, such as screening and early detection, novel treatments, and the prevention of risk factors.

Lung cancer in China: current and prospect

PURPOSE OF REVIEW

To describe the current status of lung cancer in China, including incidence, prevention, molecular testing and treatment.

RECENT FINDINGS

Lung cancer presents a major public health issue and an enormous burden on society in China, because of its increasing incidence and high mortality. Several distinct gene profiles were associated with lung cancer in China: high EGFR mutation rate, low KRAS mutation rate and more comorbidity of HBV infection. Thus, local Chinese Society of Clinical Oncology Guidelines with more consideration of drug accessibility, regional development differences were highly recommended for clinical practice. For treatment, targeted therapy has achieved fruitful progress. Immunotherapy in China was a little bit lag behind previously and now there is a surge of immunotherapeutic drugs under investigation. For future, more preventive strategies and more trials considering chrematistics of Chinese lung cancer are needed.

SUMMARY

There are achievements and shortcomings for lung cancer prevention and treatment in China. More work considering distinct characteristic of lung caner in China are needed.

Roles of drinking and diet in the U-shaped relationship between smoking and BMI in middle-aged and elderly Chinese rural adults

The study aimed to investigate the relationship between smoking and BMI, from the perspective of the roles of alcohol drinking and dietary factors in a rural population. We analysed cross-sectional data from 10,837 middle-aged and elderly Chinese rural adults who completed a questionnaire that included questions on demographic characteristics, dietary intake, and detailed smoking and drinking status. Results showed that current smokers had lower BMI and consumed foods less frequently (except coriander, onion, garlic, hawthorn and fermented bean curd) than non-smokers. The relationship between smoking amount and the risk of overweight or obesity was U-shaped, and the trends were also similar by stratum of baseline age groups (all p for interaction < 0.001). Heavy smokers tended to have drinking habits, which was associated with increased BMI (all p for trend < 0.001). Additionally, despite the lower risk of overweight or obesity for current smokers, normal weight individuals were found to have the minimum smoking amount. In conclusion, smoking may cause suppression of appetite but smokers tend to have other unhealthy habits relating to increased BMI. Dietary factors and alcohol use play important roles in the U-shaped relationship between smoking behaviours and BMI in the middle-aged and elderly Chinese rural population.

Clinical characteristics and prognosis of anal squamous cell carcinoma: a retrospective audit of 144 patients from 11 cancer hospitals in southern China

Background

The incidence of anal squamous cell carcinoma (SCC) has been steadily growing globally in the past decade. Clinical data on anal SCC from China are rare. We conducted this study to describe the clinical and epidemiological characteristics of anal SCC in China and explore prognostic factors of outcomes among patients with anal SCC.

Methods

We audited demographic characteristics, relevant symptoms, risk factors, treatment modalities and outcomes for patients diagnosed with anal SCC at 11 medical institutions in China between January 2007 and July 2018.

Results

A total of 144 patients (109 females) were diagnosed with SCC during this period. Median age at initial diagnosis was 52.0 (interquartile range: 46.0–61.8) years. The most common symptoms were bleeding (n = 93, 64.6%), noticing a lump (n = 49, 34.0%), and pain (n = 47, 32.6%). The proportion of patients at the American Joint Committee on Cancer (AJCC) stages I-IV were 10 (6.9%), 22 (15.3%), 61 (42.4%) and 8 (5.6%), respectively, and AJCC stages in 43 (29.9%) patients were unknown. Thirty-six patients (25.0%) underwent abdominoperineal resection initially. Univariable analysis showed that T stage predicted recurrence-free survival (RFS) (Hazard ratio [HR] = 3.03, 95% Confidence interval [CI]: 1.10–8.37, p = 0.032), and age group (HR = 2.90, 95% CI: 1.12–7.49, p = 0.028), AJCC stage (HR = 4.56, 95% CI: 1.02–20.35, p = 0.046), and N stage (HR = 3.05, 95% CI: 1.07–8.74, p = 0.038) predicted overall survival (OS).

Conclusions

T stage was identified as prognostic factor of RFS, and age, AJCC stage, and N stage were identified as prognostic factors of OS. Improving symptom awareness and earlier presentation among patients potentially at risk for anal SCC should be encouraged. Familiarity with the standard treatment among health care providers in China should be further improved.