Is the Mortality Trend of Ischemic Heart Disease by the GBD2013 Study in China Real?

To determine the reason for the different mortality trends of ischemic heart disease (IHD) for China between Global Burden of Disease (GBD) 2010 and GBD2013, and to improve garbage code (GC) redistribution. All data were obtained from the disease surveillance points system, and two proportions for assigning chronic pulmonary heart disease (PHD) as GC to IHD were from GBD2010 and GBD2013, which were different for years before 2004. By using the GBD2013 approach, the age-standard mortality rate (ASMR) increased by 100.21% in 1991, 44.81% in 1996, and 42.47% in 2000 in comparison with the GBD2010 approach. The different methods of chronic PHD redistribution impacted the trend of IHD mortality, which elevated it in the earlier 1990s by using the GBD2013 approach. Thus, improving the redistribution of GC as a key step in mortality statistics is important.

Increased lung cancer mortality rates in the Chinese population from 1973-1975 to 2004-2005: An adverse health effect from exposure to smoking.

BACKGROUND: Lung cancer incidence and mortality rates have increased substantially in China despite improvements in clinical diagnosis and treatment approaches as well as significant advances in the implementation of tobacco-control policies in recent decades. METHODS: Age-standardized mortality rates and age-specific rates of lung cancer in China were estimated for the periods 1973 to 1975, 1990 to 1992, and 2004 to 2005 using data from 3 National Death Surveys. Among patients with lung cancer who were identified from a hospital-based information system, the percentages of ever-smokers were analyzed according to histologic and demographic variables. RESULTS: Age-standardized mortality from lung cancer in China dramatically increased from 7.30 per 100,000 during 1973 through 1975 to 27.62 per 100,000 during 2004 through 2005. Increases in lung cancer age-standardized mortality were consistent among men and women in urban and rural populations. Among men ages 75 to 79 years, lung cancer mortality increased remarkably to 453.67 per 100,000 in 2004 and 2005 (from 246.78 per 100,000 during 1990-1992 and from 53.65 per 100,000 during 1973-1975). Among 6674 patients with lung cancer who were identified from 2003 to 2007 from a hospital-based database, 82.97% of men were ever-smokers (73.35% of men with adenocarcinoma and 91.8% of men with squamous cell carcinoma), and 11.18% of women were ever-smokers (6% of women with adenosquamous carcinoma and 39.02% of women with squamous cell carcinoma). Differences in the numbers of ever-smokers were observed between age groups but not according to the year of diagnosis. CONCLUSIONS: The consistent and rapid increases in lung cancer mortality rates observed in the Chinese population and the high prevalence of exposure to smoking in China prompt a strong call for the implementation of a comprehensive tobacco-control policy and specific public health educational strategies.

Spatial distribution of liver cancer incidence in shenqiu county, henan province, china: a spatial analysis.

Liver cancer is a common and leading cause of cancer death in China. We used the cancer registry data collected from 2009 to 2011 to describe the spatial distribution of liver cancer incidence at village level in Shengqiu county, Henan province, China. Spatial autocorrelation analysis was employed to detect significant differences from a random spatial distribution of liver cancer incidence. Spatial scan statistics were used to detect and evaluate the clusters of liver cancer cases. Spatial clusters were mapped using ArcGIS 10.0 software in order to identify their physical location at village level. High cluster areas of liver cancer incidence were observed in 26 villages of 7 towns and low cluster areas were observed in 16 villages of 4 towns. High cluster areas of liver cancer incidence were distributed along the Sha Ying River which is the largest of tributary of the Huai River. Role of water pollution in Shenqiu County where the high cluster was found deserves further investigation.

Histological subtypes of lung cancer in Chinese males from 2000 to 2012.

OBJECTIVE: To characterize the histological and epidemiological features of male lung cancer patients in China. METHODS: The demographic and histological information about male lung cancer patients identified from 2000-01-01 to 2012-12-31, was collected from the Cancer Hospital of the Chinese Academy of Medical Sciences. Relative frequencies (RF) were estimated for major histological subtypes and compared according to the years of diagnosis and birth. RESULTS: The RF of adenocarcinoma (ADC) increased from 21.96% to 43.36% and the RF of squamous cell carcinoma (SCC) decreased from 39.11% to 32.23% from 2000 to 2012 in the 15 427 male lung cancer patients included in this study (Z=17.909, P<0.0001; Z=-6.117, P<0.0001). The RF of ADC increased from 28.72% in 2000-2004, 36.88% in 2005-2008 to 48.61% in 2009-2012 in patients born after 1960. The age-adjusted RF of ADC in 2007-2012 increased consistently in all the investigated areas. CONCLUSION: The increased RF of ADC in male lung cancer patients highlights the need for further investigation of the etiologic factors of these tumors. Smoke-free policies rather than modifying tobacco products should be enforced.

[Assessment of the strength of tobacco control on creating smoke-free hospitals using principal components analysis].

OBJECTIVE: To explore the relationship between the strength of tobacco control and the effectiveness of creating smoke-free hospital, and summarize the main factors that affect the program of creating smoke-free hospitals. METHODS: A total of 210 hospitals from 7 provinces/municipalities directly under the central government were enrolled in this study using stratified random sampling method. Principle component analysis and regression analysis were conducted to analyze the strength of tobacco control and the effectiveness of creating smoke-free hospitals. RESULTS: Two principal components were extracted in the strength of tobacco control index, which respectively reflected the tobacco control policies and efforts, and the willingness and leadership of hospital managers regarding tobacco control. The regression analysis indicated that only the first principal component was significantly correlated with the progression in creating smoke-free hospital (P<0.001), i.e. hospitals with higher scores on the first principal component had better achievements in smoke-free environment creation. CONCLUSIONS: Tobacco control policies and efforts are critical in creating smoke-free hospitals. The principal component analysis provides a comprehensive and objective tool for evaluating the creation of smoke-free hospitals.

[Cross-sectional survey on smoking and smoking cessation behaviors among Chinese adults in 2010].

OBJECTIVE: To describe the prevalence of smoking and smoking cessation in Chinese adults in 2010. METHODS: A face-to-face questionnaire survey was carried out in 162 surveillance points to collect information on non-communicable diseases related risk factors. Multi-stage stratified cluster random sampling method was used to select 98 712 individuals aged 18 and over to be interviewed and 98 526 records were included in the analysis of smoking and smoking cessation. Sample was weighted to represent the population of Chinese adults. Indicators such as current smoking and smoking cessation among different population were calculated. RESULTS: Current smoking rate of our sample was 26.4% (26 047/98 526). With complex weighting, current smoking rate in Chinese adults aged 18 and above was 28.3% (95%CI: 27.2% - 29.4%), which is much higher among men (53.3%, 95%CI: 51.4% - 55.2%) than in women (2.5%, 95%CI: 1.9% - 3.0%) (P < 0.05). Most male current smokers (88.3%, 95%CI: 87.3% - 89.3%) smoked every day and average daily manufacture cigarettes consumption of male adults was (17.8 ± 9.3) cigarettes. Only 14.8% (95%CI: 13.8% - 15.8%) of male ever smokers quitted smoking and 10.7% (95%CI: 9.9% - 11.5%) quitted smoking. Only 38.8% (95%CI: 36.9% - 40.8%) of male current smokers intended to quit smoking. For current smokers aged from 18 to 24, proportion of those who intended to quit smoking was highest (50.5%, 95%CI: 46.1% - 54.8%), but proportion of those who quitted smoking (7.1%, 95%CI: 5.2% - 8.9%) was lowest comparing with other age groups (P < 0.05). CONCLUSION: Prevalence of smoking in Chinese adults was high and only a few smokers quit smoking. Prevalence of smoking in Chinese male adults was still high. Fairly low proportion of male current smokers intend to quit smoking and even lower proportion of them quit smoking successfully.

Estimation of cancer incidence and mortality attributable to smoking in China.

BACKGROUND: Tobacco smoking, as a cause of cancer, is common in China. Few studies have been conducted to assess the burden of tobacco-related cancer in the Chinese population. METHODS: We calculated the proportion of cancers attributable to tobacco smoking to estimate the burden of tobacco-related cancer. Population attributable fraction was calculated based on the assumption of total avoidance of smoking. Data on smoking prevalence were from two large-scale national surveys of representative samples of the Chinese population. Data on relative risk were derived from the meta-analyses and large-scale studies. Cancer mortality and incidence were originated from the third national death cause survey and cancer registries in China. RESULTS: We estimated that a total of 405,112 deaths of cancer were attributable to smoking in China in 2005, including 372,264 among men (32.7% of all cancer deaths) and 32,848 among women (5.0%). A total of 495,221 cancer cases were attributable to smoking, including 454,785 among men (30.0% of all cancer cases) and 40,436 among women (3.9%). Involuntary smoking was responsible for 11,507 lung cancer deaths (11.1%) among non-smoking women. CONCLUSION: Tobacco smoking is responsible for one-third of the total cancer deaths among men. Involuntary smoking is an important individual risk factor for lung cancer among non-smoking women. There is a need to continue and strengthen tobacco-control programs and initiatives to reduce smoking-related cancer burden in China.

Population-based survey of secondhand smoke exposure in China.

OBJECTIVE: To determine the extent of secondhand smoke exposure in China, and to explore the potential associated factors. METHODS: This study was a nationally representative household survey examining secondhand smoke exposure of non-institutionalized men and women aged 15 and older using a global standardized geographically clustered sample design. A total of 13,354 people completed the individual questionnaire with questions on gender, age, educational level, residence, profession, potential factors associated with secondhand smoke exposure, and workplace smoking policy. The data were used to determine whole population estimates of secondhand smoke exposure. RESULTS: Among non-smokers aged 15 years and older, it was estimated that 72.4% (556 million) were exposed to secondhand smoke, with 52.5% (292 million) exposed to secondhand smoke daily. The prevalence of secondhand smoke exposure was 74.1% for men, 71.6% for women, 70.5% for urban populations, and 74.2% for rural populations. The rates were 67.3%, 63.3%, and 72.7% respectively, within the household, indoor workplaces and public places. Secondhand smoke exposure was significantly reduced in workplaces with a smoking ban but not in workplaces with a partial smoking ban. CONCLUSION: Although China has made some progress toward a smoke-free environment there remains a high degree of exposure to secondhand smoke.

Awareness of tobacco-related health hazards among adults in China.

OBJECTIVE: To determine the level of awareness of the hazards of tobacco smoking and secondhand smoke inhalation among adults in China. METHODS: Household surveys were conducted with a total of 13,354 respondents aged 15 years or over from 100 counties of 28 Chinese provinces using a stratified multi-stage geographically clustered sample design. RESULTS: The findings revealed that 81.8% of the population was aware that smoking causes serious diseases, and 27.2% and 38.7% were aware that smoking causes stroke and heart attack, respectively. Only 64.3% of respondents were aware that secondhand smoke can cause serious diseases, and 27.5%, 51.0%, and 52.6% were aware that secondhand smoke causes heart disease in adults, lung disease in children and lung cancer in adults, respectively. Awareness regarding smoking-related hazards across all participants was significantly associated with several factors, including gender, smoking status, urban/rural residency, education level and exposure to tobacco control publicity in the last 30 days. Awareness regarding tobacco-related hazards in smokers was significantly associated with urban/rural residency, education level, exposure to tobacco control publicity in the last 30 days, and physician's advice. Awareness relating to the hazards of inhaling secondhand smoke was associated with smoking status, urban/rural residency, age, education level, and exposure to tobacco control publicity in the last 30 days. Medical professionals were found to know more about the health hazards of tobacco compared with people in other types of employment. CONCLUSIONS: Overall awareness of the health hazards of tobacco has improved in the last 15 years in China, but is still relatively poor. Improved means of communicating information and more effective warning labels on cigarette packaging are necessary for increasing public awareness of tobacco hazards, particularly among rural residents and people with less education.

Findings from 2010 Global Adult Tobacco Survey: implementation of MPOWER policy in China.

OBJECTIVE: To assess the implementation of five key tobacco control policies in China: protection from second-hand smoke (SHS); offering help to quit; health warnings regarding tobacco use; the enforcement of bans on tobacco advertising, promotion, and sponsorship; and increasing tobacco taxes and prices. METHODS: Using 2010 Global Adults Tobacco Survey in China (GATS-China), 10 indicators are used to assess the implementation of five key tobacco control policies of MPOWER in China. RESULTS: Overall, 63.3% and 72.7% of adults noticed people smoking indoor workplaces and public places, respectively. Approximately 60% of smokers were not asked about their smoking habits and approximately 67% were not advised to quit on their visit to a health worker. Sixty percent of adults noticed health warning messages on cigarette packaging and in the media in the last 30 days, 63.6% stated that they would not consider quitting. Twenty percent of respondents noticed tobacco advertising, promotion, and/or sponsorship activities in the 30 days prior to the survey. Among them, 76.3% noticed the direct advertising and 50% noticed from TV programs. Although purchasing price of one pack of cigarettes ranged from 1 to 200 RMB, 50% of current smokers (about 150 million) spent 5 RMB or less on one pack of cigarette. The expenditure on 100 packets of cigarettes represents 2% of 2009 GDP per capita. CONCLUSION: The average score for the implementation of the 5 policies of MPOWER in China is 37.3 points, indicating tobacco control policies in China is poor and there is a large gaps from the FCTC requirements.

[Geographical distribution of cancer mortality in China, 2004-2005].

OBJECTIVE: To describe geographical distribution and its transition of mortality of cancers in China. METHODS: The information of 2 513 949 310 person years were collected in 1973-1975 and 142 660 482 person years in 2004-2005 respectively. Being standardizing the death rates of these two survey with 2000 national census population, the changes of mortality of main cancers was observed and the geographic distribution of cancers in 2004-2005 was analyzed. RESULTS: A total of 1 865 445 cancer deaths were collected in 1973-1975, the standardized death rate was 99.61/100 000, and 193 839 cancer deaths were collected in 2004-2005, the standardized death rate was 123.72/100 000, with growth of 24.20%. District mortality analysis showed that the provincial standardized cancer death rates varied greatly, with the highest in Heilongjiang (7443 cases, 183.34/100 000), and the lowest in Yunnan (2454 cases, 61.03/100 000). The highest standardized death rate of esophageal cancer, gastric cancer, liver cancer, colon cancer, lung cancer, nasopharyngeal cancer, leukemia, female breast cancer, cervical cancer was in Henan (3535 cases, 32.95/100 000), Gansu (1333 cases, 59.35/100 000), Heilongjiang (1640 cases, 38.63/100 000), Shanghai (390 cases, 11.58/100 000), Heilongjiang (2382 cases, 60.15/100 000), Hainan (36 cases, 7.04/100 000), Tianjin (161 cases, 5.45/100 000), Heilongjiang (179 cases, 8.09/100 000), Xinjiang (131 cases, 10.69/100 000) respectively; the lowest standardized cancer death rate of above-mentioned cancers was in Yunnan (63 cases, 1.59/100 000), Beijing (235 cases, 5.95/100 000), Tianjin (454 cases, 10.86/100 000), Tibet (3 cases, 0.82/100 000), Tibet (12 cases, 3.29/100 000), Qinghai (0 case, 0.00/100 000), Tibet (1 cases, 0.28/100 000), Tibet (6 cases, 2.88/100 000), Chongqing (27 cases, 1.02/100 000) respectively. CONCLUSION: Comparing the two surveys, the standardized mortality of cancers was increased. Most of cancers occurred obviously in cluster by geographical distribution.

Validity of diagnostic evidence for deceased cases in hospitals.

OBJECTIVE: To determine the validity of the diagnostic evidence for deceased cases in hospitals. METHODS: All information collected from medical records of the deceased cases in tertiary care health facilities was input into our database. Four diagnosis levels were determined based on level of diagnostic evidence: level I was based on autopsy, pathology or operative exploration, level II on physical and laboratory tests plus expert clinical judgment, level III on expert clinical judgment, level IV on postmortem assumptions. After the diagnostic evidence of each deceased case was reviewed by a panel of three experts, the diagnostic level of each diagnosis was determined. RESULTS: Among the 2102 medical cases for verbal autopsy study, only 26 (1.24%) afforded diagnostic evidence for level III. Among the level III evidence-based cases of death, the major causes of death were cardiovascular diseases, respiratory diseases, and gastroenterological diseases. According to some special symptoms and medical histories, these cases could be diagnosed by comprehensive clinical judgment. Only one case met the criteria for level IV. CONCLUSION: Level I diagnostic evidence is hard to attain in China because of the traditional concept and economic restriction. The causes for 2101 deaths can be validated by level II or III diagnostic evidence.

Exploring barriers to implementation of smoking policies: a qualitative study on health professionals from three county-level hospitals.

OBJECTIVE: This study was to identify factors limiting the implementation of smoking policies in county-level hospitals. METHODS: We conducted qualitative interviews (17 focus groups discussions and 6 one-to-one in depth interviews) involving 103 health professionals from three target county-level hospitals. A combination of purposive and convenience sampling was used to recruit subjects and gain a broad range of perspectives on issues emerging from ongoing data-analysis until data saturation occurred. The transcripts were analyzed for themes and key points. RESULTS: The main themes that emerged suggested that both smokers and non-smokers viewed smoking very negatively. However, it was clear that, underlying this acceptance of the health risks of smoking, there was a wide range of beliefs. Most of the health professionals pointed out that, as smoking was legal, addictive, and influenced by social norms, currently it was almost unrealistic to expect all smokers to give up smoking or not to smoke in the hospitals. Furthermore, they were concerned about the potentially detrimental effects of providing counseling advice to all smokers on the interpersonal relationship among colleagues or between doctors and patients. In addition, low level of employee participation influenced the sustainable implementation of smoking policies. CONCLUSIONS: Simply being aware of the health risks about smoking did not necessarily result in successful implementation of the smoking policies. Application of comprehensive intervention strategies such as implementing smoking policies in public places at the county level, creating supportive environments, promoting community participation, and conducting health education, may be more effective.

[The current status of passive smoking in Chinese families and associated factors].

OBJECTIVE: To understand the prevalence of passive smoking in Chinese families and discuss its associated factors, as to providing scientific evidence for establishing tobacco control measures in China. METHOD: Cross-sectional survey: from June to September, 2004, we randomly selected six counties in three different provinces ( Mianzhu and Xichong of Sichuan Province; Anyi and Hukou of Jiangxi Province; Xinan and Yanshi of Henan Province) and performed face-to-face questionnaire survey on citizens between 18 and 69 years old. All the data were double independently input by professional data entry company to ensure data accuracy. The prevalence of home passive smoking exposure in families with different demographic characteristics was described by using prevalence, and the possible correlated factors of home passive smoking exposure as independent variables, multiple factors were analyzed using Logistic Stepwise Regression Analysis method. RESULTS: The analysis on 8142 nonsmokers revealed that the rate of passive smoking was 28.42%, with 27.38% of male and 28.93% of female suffering from passive smoking. All 87.19% of the smokers would smoke in front of their families. As many as 42.14% of the nonsmokers would offer cigarettes to their guests, while about 46.82% of the nonsmokers would suggest smokers to smoke outdoor. Home restriction on tobacco was extremely rare and only 6.33% of all the families completely forbade smoking. Multivariate logistic regression analysis of non-conditions revealed that, there was a lower level of involuntary tobacco smoke exposure in female, older age group, lower education level, divorced, or widowed families. There was no difference in involuntary tobacco smoke exposure between town dwellers and county dwellers, but such difference did exist in different districts. CONCLUSION: The three provinces under investigation should have severe involuntary tobacco smoking exposure. Gender, age, literacy level, occupation and region should be all factors that influence the status of involuntary tobacco smoking exposure in different families. There is a high percentile that smokers would smoke in front of their families and kids and a relative low pressure against smoking from nonsmokers. Cigarette offering is very prevalence. The knowledge and attitude about passive smoking should be separated from the situation of passive smoking exposure.

[Detecting nicotine and its metabolite cotinine in human hair with capillary gas chromatography].

OBJECTIVE: To develop a rapid method for determination of nicotine and its metabolite cotinine in human hair with capillary gas chromatography with flame ionization detector. METHODS: The hair sample was digested by 1.5 mol/L sodium hydroxide solution. The nicotine and cotinine in the hair sample were extracted with a mixed solvent of dichloromethane-methanol (3:1). Aliquot of the extraction solution was vaporized with nitrogen flow and then methanol was added to dissolve the analysts. The analysts were tested with capillary gas chromatography. RESULTS: The detection limits (signal to noise ratio of 3:1) were 4.3 ng/mL for nicotine and 10 ng/mL for cotinine, respectively. The spiked recoveries were 90.33%-113.1% for nicotine with relative standard deviation (RSD) of 2.1%-7.0% and 92.92%-117.4% for cotinine with relative standard deviation (RSD) of 4.4%-8.9%, respectively. CONCLUSION: The proposed method is sensitive, simple, easy and rapid. It can be easily extended to large scale applications in tobacco epidemiology studies.

Conceptual model for automatic early warning information system of infectious diseases based on internet reporting surveillance system.

OBJECTIVE: To establish a conceptual model of automatic early warning of infectious diseases based on internet reporting surveillance system, with a view to realizing an automated warning system on a daily basis and timely identifying potential outbreaks of infectious diseases. METHODS: The statistic conceptual model was established using historic surveillance data with movable percentile method. RESULTS: Based on the infectious disease surveillance information platform, the conceptual model for early warning was established. The parameter, threshold, and revised sensitivity and specificity of early warning value were changed to realize dynamic alert of infectious diseases on a daily basis. CONCLUSION: The instructive conceptual model of dynamic alert can be used as a validating tool in institutions of infectious disease surveillance in different districts.

Passive smoking in China: contributing factors and areas for future interventions.

OBJECTIVE: To reduce tobacco consumption and exposure to passive smoking in China. METHODS: Discussion consisting of 80 focus groups and 35 interviews were held in three rural intervention counties of Jiangxi, Henan, and Sichuan Provinces. Participants came from hospitals, schools, rural areas, and urban areas. RESULTS: Tobacco use and exposure to passive smoking were widely prevalent in the investigated schools, hospitals, county towns, and rural areas. Knowledge of the risks for passive smoking on health is lacking, especially in rural areas. Barriers to the control of tobacco use in public places include reluctance of administrators to implement tobacco control policies, lack of consistent policies, difficulties with regulations and enforcement, and reluctance of non-smokers to exercise their right to clean air. CONCLUSION: To curb the current tobacco epidemic in China, tobacco control efforts must focus on reducing exposure to passive smoking. A strategy should be formulated to reduce the factors that contribute to tobacco use and exposure to passive smoking.