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.

US-China health exchange and collaboration following COVID-19.

Strong US-China collaboration on health and medicine is a crucial element of the global effort against COVID-19. We review the history of health collaboration and exchanges between the public and private sectors in the USA and China, including the long-lasting collaboration between governmental public health agencies of the two countries. Academic and scientific exchanges should be reinvigorated and the increasing valuable role of non-profit foundations acknowledged. The shared interests of the two countries and the magnitude of the pandemic necessitate both countries to collaborate and cooperate. We provide recommendations to the two governments and the global health community to control the ongoing COVID-19 pandemic and prepare for future threats. TRANSLATION: For the Chinese translation of the abstract see Supplementary Materials section.

Initial findings from a novel population-based child mortality surveillance approach: a descriptive study.

BACKGROUND: Sub-Saharan Africa and south Asia contributed 81% of 5·9 million under-5 deaths and 77% of 2·6 million stillbirths worldwide in 2015. Vital registration and verbal autopsy data are mainstays for the estimation of leading causes of death, but both are non-specific and focus on a single underlying cause. We aimed to provide granular data on the contributory causes of death in stillborn fetuses and in deceased neonates and children younger than 5 years, to inform child mortality prevention efforts. METHODS: The Child Health and Mortality Prevention Surveillance (CHAMPS) Network was established at sites in seven countries (Baliakandi, Bangladesh; Harar and Kersa, Ethiopia; Siaya and Kisumu, Kenya; Bamako, Mali; Manhiça, Mozambique; Bombali, Sierra Leone; and Soweto, South Africa) to collect standardised, population-based, longitudinal data on under-5 mortality and stillbirths in sub-Saharan Africa and south Asia, to improve the accuracy of determining causes of death. Here, we analysed data obtained in the first 2 years after the implementation of CHAMPS at the first five operational sites, during which surveillance and post-mortem diagnostics, including minimally invasive tissue sampling (MITS), were used. Data were abstracted from all available clinical records of deceased children, and relevant maternal health records were also extracted for stillbirths and neonatal deaths, to incorporate reported pregnancy or delivery complications. Expert panels followed standardised procedures to characterise causal chains leading to death, including underlying, intermediate (comorbid or antecedent causes), and immediate causes of death for stillbirths, neonatal deaths, and child (age 1-59 months) deaths. FINDINGS: Between Dec 10, 2016, and Dec 31, 2018, MITS procedures were implemented at five sites in Mozambique, South Africa, Kenya, Mali, and Bangladesh. We screened 2385 death notifications for inclusion eligibility, following which 1295 families were approached for consent; consent was provided for MITS by 963 (74%) of 1295 eligible cases approached. At least one cause of death was identified in 912 (98%) of 933 cases (180 stillbirths, 449 neonatal deaths, and 304 child deaths); two or more conditions were identified in the causal chain for 585 (63%) of 933 cases. The most common underlying causes of stillbirth were perinatal asphyxia or hypoxia (130 [72%] of 180 stillbirths) and congenital infection or sepsis (27 [15%]). The most common underlying causes of neonatal death were preterm birth complications (187 [42%] of 449 neonatal deaths), perinatal asphyxia or hypoxia (98 [22%]), and neonatal sepsis (50 [11%]). The most common underlying causes of child deaths were congenital birth defects (39 [13%] of 304 deaths), lower respiratory infection (37 [12%]), and HIV (35 [12%]). In 503 (54%) of 933 cases, at least one contributory pathogen was identified. Cytomegalovirus, Escherichia coli, group B Streptococcus, and other infections contributed to 30 (17%) of 180 stillbirths. Among neonatal deaths with underlying prematurity, 60% were precipitated by other infectious causes. Of the 275 child deaths with infectious causes, the most common contributory pathogens were Klebsiella pneumoniae (86 [31%]), Streptococcus pneumoniae (54 [20%]), HIV (40 [15%]), and cytomegalovirus (34 [12%]), and multiple infections were common. Lower respiratory tract infection contributed to 174 (57%) of 304 child deaths. INTERPRETATION: Cause of death determination using MITS enabled detailed characterisation of contributing conditions. Global estimates of child mortality aetiologies, which are currently based on a single syndromic cause for each death, will be strengthened by findings from CHAMPS. This approach adds specificity and provides a more complete overview of the chain of events leading to death, highlighting multiple potential interventions to prevent under-5 mortality and stillbirths. FUNDING: Bill & Melinda Gates Foundation.

Mortality Surveillance Methods to Identify and Characterize Deaths in Child Health and Mortality Prevention Surveillance Network Sites.

Despite reductions over the past 2 decades, childhood mortality remains high in low- and middle-income countries in sub-Saharan Africa and South Asia. In these settings, children often die at home, without contact with the health system, and are neither accounted for, nor attributed with a cause of death. In addition, when cause of death determinations occur, they often use nonspecific methods. Consequently, findings from models currently utilized to build national and global estimates of causes of death are associated with substantial uncertainty. Higher-quality data would enable stakeholders to effectively target interventions for the leading causes of childhood mortality, a critical component to achieving the Sustainable Development Goals by eliminating preventable perinatal and childhood deaths. The Child Health and Mortality Prevention Surveillance (CHAMPS) Network tracks the causes of under-5 mortality and stillbirths at sites in sub-Saharan Africa and South Asia through comprehensive mortality surveillance, utilizing minimally invasive tissue sampling (MITS), postmortem laboratory and pathology testing, verbal autopsy, and clinical and demographic data. CHAMPS sites have established facility- and community-based mortality notification systems, which aim to report potentially eligible deaths, defined as under-5 deaths and stillbirths within a defined catchment area, within 24-36 hours so that MITS can be conducted quickly after death. Where MITS has been conducted, a final cause of death is determined by an expert review panel. Data on cause of death will be provided to local, national, and global stakeholders to inform strategies to reduce perinatal and childhood mortality in sub-Saharan Africa and South Asia.

Clinical trial data sharing: here's the challenge.

OBJECTIVE: Anonymised patient-level data from clinical research are increasingly recognised as a fundamental and valuable resource. It has value beyond the original research project and can help drive scientific research and innovations and improve patient care. To support responsible data sharing, we need to develop systems that work for all stakeholders. The members of the Independent Review Panel (IRP) for the data sharing platform Clinical Study Data Request (CSDR) describe here some summary metrics from the platform and challenge the research community on why the promised demand for data has not been observed. SUMMARY OF DATA: From 2014 to the end of January 2019, there were a total of 473 research proposals (RPs) submitted to CSDR. Of these, 364 met initial administrative and data availability checks, and the IRP approved 291. Of the 90 research teams that had completed their analyses by January 2018, 41 reported at least one resulting publication to CSDR. Less than half of the studies ever listed on CSDR have been requested. CONCLUSION: While acknowledging there are areas for improvement in speed of access and promotion of the platform, the total number of applications for access and the resulting publications have been low and challenge the sustainability of this model. What are the barriers for data contributors and secondary analysis researchers? If this model does not work for all, what needs to be changed? One thing is clear: that data access can realise new and unforeseen contributions to knowledge and improve patient health, but this will not be achieved unless we build sustainable models together that work for all.

mHealth Intervention is Effective in Creating Smoke-Free Homes for Newborns: A Randomized Controlled Trial Study in China.

Mobile-phone-based smoking cessation intervention has been shown to increase quitting among smokers. However, such intervention has not yet been applied to secondhand smoke (SHS) reduction programs that target smoking parents of newborns. This randomized controlled trial, undertaken in Changchun, China, assessed whether interventions that incorporate traditional and mobile-phone-based education will help create smoke-free homes for infants and increase quitting among fathers. The results showed that the abstinence rates of the fathers at 6 months (adjusted OR: 3.60, 95% CI: 1.41-9.25; p = 0.008) and 12 months (adjusted OR: 2.93, 95% CI: 1.24-6.94; p = 0.014) were both significantly increased in the intervention group compared to the control. Mothers of the newborns in the intervention group also reported reduced exposure to SHS at 12 months (adjusted OR: 0.53, 95% CI: 0.29-0.99; p = 0.046). The findings suggest that adding mHealth interventions to traditional face-to-face health counseling may be an effective way to increase male smoking cessation and reduce mother and newborn SHS exposure in the home.

Precisely Tracking Childhood Death.

Little is known about the specific causes of neonatal and under-five childhood death in high-mortality geographic regions due to a lack of primary data and dependence on inaccurate tools, such as verbal autopsy. To meet the ambitious new Sustainable Development Goal 3.2 to eliminate preventable child mortality in every country, better approaches are needed to precisely determine specific causes of death so that prevention and treatment interventions can be strengthened and focused. Minimally invasive tissue sampling (MITS) is a technique that uses needle-based postmortem sampling, followed by advanced histopathology and microbiology to definitely determine cause of death. The Bill & Melinda Gates Foundation is supporting a new surveillance system called the Child Health and Mortality Prevention Surveillance network, which will determine cause of death using MITS in combination with other information, and yield cause-specific population-based mortality rates, eventually in up to 12-15 sites in sub-Saharan Africa and south Asia. However, the Gates Foundation funding alone is not enough. We call on governments, other funders, and international stakeholders to expand the use of pathology-based cause of death determination to provide the information needed to end preventable childhood mortality.

The Effects of Antismoking Messages From Family, School, and Mass Media on Smoking Behavior and Smoking Intention Among Chinese Adolescents.

The prevalence of adolescent smoking has been increasing rapidly in China. Expanding adolescent exposure to antismoking messages may be an effective approach to prevent tobacco use among this population. Using a cross-sectional sample of 8,444 high school students in four Chinese cities, this study assessed the relation between self-reported exposure to antismoking messages from families, schools, and mass media and the rate of past 30-day smoking and smoking intention among junior and senior high school students. Results from logistic regression suggested that antismoking messages delivered via school and media inhibited both tobacco use and the intention to smoke. The effects of familial warnings about harmful effects of smoking, in contrast, were at best insignificant.

Obesity is associated with an increase in pharmaceutical expenses among university employees.

OBJECTIVE: To examine costs associated with obesity in an employee population and factors associated with increased costs. METHODS: We used data from the Physical Activity and Life Style (PALS) study, a randomized prospective design evaluating three interventions to increase physical activity among physically inactive nonfaculty university employees (n = 454). The primary exposure variable, obesity (measured by body mass index), was obtained from the in-person baseline survey. Covariates were obtained from the baseline survey and included demographic characteristics and health status. Data from the baseline survey was linked with administrative data to determine pharmaceutical, inpatient, outpatient, and total health care costs for three years. Average monthly expenditures for obese and nonobese individuals were compared using t-tests and a two-part multivariate regression model adjusted for demographic and socioeconomic characteristics and health behaviors. RESULTS: Although in-patient and outpatient expenses were not associated with obesity, pharmaceutical expenditures were $408 or 87.2% higher per year ($468 versus $876) for obese individuals than for nonobese individuals, which reflected poorer health behaviors and health status of obese adults. CONCLUSION: Awareness of the costs associated with obesity among employees can stimulate employers to make the investment in providing employer-sponsored wellness and health improvement programs to address obesity.

The role of cities in reducing smoking in China.

China is the epicenter of the global tobacco epidemic. China grows more tobacco, produces more cigarettes, makes more profits from tobacco and has more smokers than any other nation in the world. Approximately one million smokers in China die annually from diseases caused by smoking, and this estimate is expected to reach over two million by 2020. China cities have a unique opportunity and role to play in leading the tobacco control charge from the "bottom up". The Emory Global Health Institute-China Tobacco Control Partnership supported 17 cities to establish tobacco control programs aimed at changing social norms for tobacco use. Program assessments showed the Tobacco Free Cities grantees' progress in establishing tobacco control policies and raising public awareness through policies, programs and education activities have varied from modest to substantial. Lessons learned included the need for training and tailored technical support to build staff capacity and the importance of government and organizational support for tobacco control. Tobacco control, particularly in China, is complex, but the potential for significant public health impact is unparalleled. Cities have a critical role to play in changing social norms of tobacco use, and may be the driving force for social norm change related to tobacco use in China.

Can China diminish its burden of non-communicable diseases and injuries by promoting health in its policies, practices, and incentives?

China has rapidly progressed through epidemiological and demographic transitions and is now confronting an increasing burden from non-communicable diseases and injuries. China could take advantage of what has been learnt about prevention and control of non-communicable diseases and injuries, which is well summarised in the WHO best buys (a set of affordable, feasible, and cost-effective intervention strategies in any resource setting), to improve individual and population health. Implementation of these strategies could allow China to exceed the incremental gains in decreasing non-communicable diseases and injury burdens of high-income countries, and greatly shorten the interval needed to achieve decreased morbidity and mortality in its population. With the lessons learnt from other countries and its own programmes and policies, China could provide a health model for the world.

Tobacco smoking among government employees in six cities in China.

OBJECTIVE: Employer-based tobacco control interventions have been highly successful in developed countries, and, recently, Chinese officials announced a focus on quitting among government employees. However, there are few data offering estimates of smoking prevalence among government workers from developing nations. In this study, we investigate smoking behaviours among government workers in six Chinese cities stratified by educational attainment and occupational grade. DESIGN: Individual-level study of Chinese government employees. DATA SOURCES: Tobacco-Free Cities Initiative of China Tobacco Control Partnership. ANALYSIS: Employed adults aged 18-61 at government worksites in six cities were included (N=6176). Prevalence of current and former smoking across educational (postgraduate, graduate, high school, secondary school or less) and occupational (senior executives, mid-level managers, workers) groups were compared. RESULTS: Overall prevalence of male current smoking was 40.7% (95% CI 39.1% to 42.4%). Age-adjusted smoking prevalence was lowest among those with a postgraduate degree (26.2% (95% CI 21.0% to 31.4%)) compared with those with lower levels of education (college (39.8%; 37.7% to 41.8%); high school (51.0%; 95% CI 45.0% to 57.0%); secondary or less (45.1%; 95% CI 40.3% to 49.8%)). There was no evidence of an association between current smoking and occupational grade. Prevalence of smoking was low in women (1.5%). CONCLUSIONS: Smoking prevalence among male government employees at all levels of education was high and patterned by educational attainment. Government initiatives to address tobacco control among employees should consider targeted interventions for different educational levels.