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

BACKGROUND: China is the largest producer and consumer of tobacco products worldwide. While direct marketing and advertisement of tobacco products is restricted, indirect marketing still exists under the guise of sponsorship and corporate social responsibility (CSR). This case study is focused on tobacco industry-sponsored elementary schools in Chinese rural areas. METHODS: Field visits were conducted in Yunnan province to interview students, teachers, school principals and parents to understand their perceptions of the tobacco industry and its sponsorship of schools. Interviews with tobacco control activists were conducted in Beijing to discuss national tobacco control efforts targeting tobacco industry sponsorship. Interview data were transcribed and coded, with key themes developed using thematic analysis. RESULTS: While health consequences of smoking are generally known, attitudes towards the tobacco industry and its CSR activities remain positive among the general public. Educators and parents do not perceive any impacts on schoolchildren from exposure to 'pro-tobacco propaganda' created by the industry's CSR activities. Attitudes among tobacco control activists were drastically different, with consensus that CSR activities constitute indirect marketing attempts that should be banned. CONCLUSION: National tobacco control legislation banning all forms of indirect marketing including CSR is needed in order to protect the health of future generations.

Impact of smoke-free legislation on acute myocardial infarction and stroke mortality: Tianjin, China, 2007-2015.

BACKGROUND: Smoke-free legislation is an effective way to protect the population from the harms of secondhand smoke and has been implemented in many countries. On 31 May 2012, Tianjin became one of the few cities in China to implement smoke-free legislation. We investigated the impact of smoke-free legislation on mortality due to acute myocardial infarction (AMI) and stroke in Tianjin. METHODS: An interrupted time series design adjusting for underlying secular trends, seasonal patterns, population size changes and meteorological factors was conducted to analyse the impact of the smoke-free law on the weekly mortality due to AMI and stroke. The study period was from 1 January 2007 to 31 December 2015, with a 3.5-year postlegislation follow-up. RESULTS: Following the implementation of the smoke-free law, there was a decline in the annual trends of AMI and stroke mortality. An incremental 16% (rate ratio (RR): 0.84; 95% CI: 0.83 to 0.85) decrease per year in AMI mortality and a 2% (RR: 0.98; 95% CI: 0.97 to 0.99) annual decrease in stroke mortality among the population aged ≥35 years in Tianjin was observed. Immediate postlegislation reductions in mortality were not statistically significant. An estimated 10 000 (22%) AMI deaths were prevented within 3.5 years of the implementation of the law. CONCLUSION: The smoke-free law in Tianjin was associated with reductions in AMI mortality. This study reinforces the need for large-scale, effective and comprehensive smoke-free laws at the national level in China.

Spatiotemporal variations in cardiovascular disease mortality in China from 1991 to 2009.

BACKGROUND: In China, the spatiotemporal variations in cardiovascular disease (CVD) mortality are seldom characterized to understand their epidemiological features. It would be helpful to evaluate the performance of CVD-related interventions for subsequent adjustments. METHODS: The 2010 Census data as well as the coronary heart disease (CHD) and stroke mortality data from the Disease Surveillance Points (DSPs) were used to calculate the age standardized death rates (ASDRs) of CVD in the DSP counties during 1991-1995, 1996-2000, 2004-2005, and 2006-2009. The ordinary kriging (OK) method was used to estimate the county-level death rates of CHD and stroke and achieved satisfactory results. RESULTS: The goodness-of-fit between measured and estimated values of CVD mortality was significant at the 0.01 level (0.34 < R2 < 0.98). The counties with high CHD death rates (> 75 per 105) were located in the Northwest, North, and Northeast in 1991-2000 and then extended toward the North, Central, and South, yielding an inverted-triangle-shaped area in 2004-2009. The counties with a CHD death rate increase greater than 100% were concentrated in the Northeast and South. The Northeast-Southwest regions with a high stroke death rate gradient (> 150 per 105) narrowed in1991-2000, was followed by a slight expansion during 2004-2005, finally reducing in 2006-2009. The counties with a stroke mortality increase greater than 100% were scattered across the Northeast, Northwest, Central, and South. CONCLUSION: The epidemiological characteristics of both CHD and stroke mortality in China was spatiotemporally featured on the county level during 1991-2009.

Spatiotemporal analysis of PM2.5 and pancreatic cancer mortality in China.

BACKGROUND: Previous studies have reported that the development of pancreatic cancer (PC) may be associated with environment pollution. But the relationship between ambient air pollution and PC remains unclear. OBJECTIVES: This study aimed to examine the association between PC mortality and exposure of fine particular matter. METHODS: We used PC mortality data from 103 continuous points in national Disease Surveillance Point system from 1991 to 2009 in China. The annual concentrations of PM2.5 at 0.1°â€¯× 0.1° spatial resolution for each points were estimated based on the context of the Global Burden of Disease Study 2015. A spatial age-period-cohort model was used to examine the relative risks of PC mortality associated with PM exposure, after adjusting gender, urban/rural status, spatial variation as well as age, period and cohort effect. RESULTS: The relative risks of PC mortality related to 10 µg/m3 increase of PM2.5 were 1.16 (95% confidence interval (CI): 1.13, 1.20) for all the population, 1.08 (1.05,1.13) for those aged 40-64 years, 1.21 (1.17,1.25) for those aged 65-84 years, 1.14 (1.10,1.18) for the male, 1.19 (1.14,1.24) for the female, 1.23 (1.16,1.30) for the urban population and 1.29 (1.22, 1.37) for the rural population. CONCLUSIONS: Ambient PM2.5 may raise the risk of mortality from PC, especially in older population. Pollution control policy should be further strengthened to reduce the health damages.

Cause-specific mortality for 240 causes in China during 1990-2013: a systematic subnational analysis for the Global Burden of Disease Study 2013.

BACKGROUND: China has experienced a remarkable epidemiological and demographic transition during the past three decades. Far less is known about this transition at the subnational level. Timely and accurate assessment of the provincial burden of disease is needed for evidence-based priority setting at the local level in China. METHODS: Following the methods of the Global Burden of Disease Study 2013 (GBD 2013), we have systematically analysed all available demographic and epidemiological data sources for China at the provincial level. We developed methods to aggregate county-level surveillance data to inform provincial-level analysis, and we used local data to develop specific garbage code redistribution procedures for China. We assessed levels of and trends in all-cause mortality, causes of death, and years of life lost (YLL) in all 33 province-level administrative units in mainland China, all of which we refer to as provinces, for the years between 1990 and 2013. FINDINGS: All provinces in mainland China have made substantial strides to improve life expectancy at birth between 1990 and 2013. Increases ranged from 4.0 years in Hebei province to 14.2 years in Tibet. Improvements in female life expectancy exceeded those in male life expectancy in all provinces except Shanghai, Macao, and Hong Kong. We saw significant heterogeneity among provinces in life expectancy at birth and probability of death at ages 0-14, 15-49, and 50-74 years. Such heterogeneity is also present in cause of death structures between sexes and provinces. From 1990 to 2013, leading causes of YLLs changed substantially. In 1990, 16 of 33 provinces had lower respiratory infections or preterm birth complications as the leading causes of YLLs. 15 provinces had cerebrovascular disease and two (Hong Kong and Macao) had ischaemic heart disease. By 2013, 27 provinces had cerebrovascular disease as the leading cause, five had ischaemic heart disease, and one had lung cancer (Hong Kong). Road injuries have become a top ten cause of death in all provinces in mainland China. The most common non-communicable diseases, including ischaemic heart disease, stroke, chronic obstructive pulmonary disease, and cancers (liver, stomach, and lung), contributed much more to YLLs in 2013 compared with 1990. INTERPRETATION: Rapid transitions are occurring across China, but the leading health problems and the challenges imposed on the health system by epidemiological and demographic change differ between groups of Chinese provinces. Localised health policies need to be implemented to tackle the diverse challenges faced by local health-care systems. FUNDING: China National Science & Technology Pillar Program 2013 (2013BAI04B02) and Bill & Melinda Gates Foundation.

Mortality trends for ischemic heart disease in China: an analysis of 102 continuous disease surveillance points from 1991 to 2009.

BACKGROUND: In the past 20 years, the trends of ischemic heart disease (IHD) mortality in China have been described in divergent claims. This research analyzes mortality trends for IHD by using the data from 102 continuous Disease Surveillance Points (DSP) from 1991 to 2009. METHOD: The 102 continuous DSP covered 7.3 million people during the period 1991-2000, and then were expanded to a population of 52 million in the same areas for 2004-2009. The data were adjusted by using garbage code redistribution and underreporting rate, mapped from international classification of diseases ICD-9 to ICD-10. The mortality rates for IHD were further adjusted by the crude death proportion multiplied by the total number of deaths in the mortality envelope, which was calculated by using logrt = a + bt. Age-standard death rates (ASDRs) were computed using China's 2010 census population structure. Trend in IHD was calculated from ASDRs by using a joinpoint regression model. RESULTS: The IHD ASDRs increased in total in regions with an average annual percentage change (AAPC) 4.96%, especially for the Southwest (AAPC = 7.97%) and Northeast areas (AAPC = 7.10%), and for male and female subjects (with 5% AAPC) as well. In rural areas, the year 2000 was a cut-off point for mortality rate with annual percentage change increasing from 3.52% in 1991-2000 to 9.02% in 2000-2009, which was much higher than in urban areas (AAPC = 1.05%). And the proportion of deaths increased in older adults, and more male deaths occurred before age 60 compared to female deaths. CONCLUSION: By observing a wide range of areas across China from 1991 to 2009, this paper concludes that the ASDR trend for IHD increased. These trends reflect changes in the Chinese standard of living and lifestyle with diets higher in fat, higher blood lipids and increased body weight.

The road to effective tobacco control in China.

The non-communicable disease burden in China is enormous, with tobacco use a leading risk factor for the major non-communicable diseases. The prevalence of tobacco use in men is one of the highest in the world, with more than 300 million smokers and 740 million non-smokers exposed to second-hand smoke. In the past decade public awareness of the health hazards of tobacco use and exposure to second-hand smoke has grown, social customs and habits have changed, aggressive tactics used by the tobacco industry have been revealed, and serious tobacco control policies have been actively promoted. In 2014, national legislators in China began actively considering national bans on smoking in public and work places and tobacco advertising. However, tobacco control in China has remained particularly difficult because of interference by the tobacco industry. Changes to the interministerial coordinating mechanism for implementation of the WHO Framework Convention on Tobacco Control are now crucial. Progress towards a tobacco-free world will be dependent on more rapid action in China.

Characterisation of gastric cancer and its relation to environmental factors: a case study in Shenqiu County, China.

This article presents the results of spatial analysis of gastric cancer and its relation to environmental conditions in Shenqiu County, China. Retrospective data on gastric cancer mortality (GCM) were analysed at various spatial scales, with its relation to environmental factors explored at an appropriate scale. The results considered 2 × 2 km(2) grid as the optimal level for characterising GCM due to the highest Moran's I (I = 0.68, p < 0.01). Then, three clustering regions were clearly identified. Meanwhile, GCM was obviously associated with topography (r = -0.11, p < 0.10), farmland (r = 0.11, p < 0.10), population density (r = 0.10, p < 0.10) and river density (r = 0.11, p < 0.10) in the buffered zones. It indicates that spatial grid technique is suitable for characterising GCM in Shenqiu County, and that GCM was geographically associated with environmental conditions. We suggest that preventive measures for controlling the environment-related malignant neoplasm should not be limited in the regions suffering from this disease but be reasonably extended to surrounding areas.

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.

Global, regional, and national levels of neonatal, infant, and under-5 mortality during 1990-2013: a systematic analysis for the Global Burden of Disease Study 2013.

BACKGROUND: Remarkable financial and political efforts have been focused on the reduction of child mortality during the past few decades. Timely measurements of levels and trends in under-5 mortality are important to assess progress towards the Millennium Development Goal 4 (MDG 4) target of reduction of child mortality by two thirds from 1990 to 2015, and to identify models of success. METHODS: We generated updated estimates of child mortality in early neonatal (age 0-6 days), late neonatal (7-28 days), postneonatal (29-364 days), childhood (1-4 years), and under-5 (0-4 years) age groups for 188 countries from 1970 to 2013, with more than 29,000 survey, census, vital registration, and sample registration datapoints. We used Gaussian process regression with adjustments for bias and non-sampling error to synthesise the data for under-5 mortality for each country, and a separate model to estimate mortality for more detailed age groups. We used explanatory mixed effects regression models to assess the association between under-5 mortality and income per person, maternal education, HIV child death rates, secular shifts, and other factors. To quantify the contribution of these different factors and birth numbers to the change in numbers of deaths in under-5 age groups from 1990 to 2013, we used Shapley decomposition. We used estimated rates of change between 2000 and 2013 to construct under-5 mortality rate scenarios out to 2030. FINDINGS: We estimated that 6·3 million (95% UI 6·0-6·6) children under-5 died in 2013, a 64% reduction from 17·6 million (17·1-18·1) in 1970. In 2013, child mortality rates ranged from 152·5 per 1000 livebirths (130·6-177·4) in Guinea-Bissau to 2·3 (1·8-2·9) per 1000 in Singapore. The annualised rates of change from 1990 to 2013 ranged from -6·8% to 0·1%. 99 of 188 countries, including 43 of 48 countries in sub-Saharan Africa, had faster decreases in child mortality during 2000-13 than during 1990-2000. In 2013, neonatal deaths accounted for 41·6% of under-5 deaths compared with 37·4% in 1990. Compared with 1990, in 2013, rising numbers of births, especially in sub-Saharan Africa, led to 1·4 million more child deaths, and rising income per person and maternal education led to 0·9 million and 2·2 million fewer deaths, respectively. Changes in secular trends led to 4·2 million fewer deaths. Unexplained factors accounted for only -1% of the change in child deaths. In 30 developing countries, decreases since 2000 have been faster than predicted attributable to income, education, and secular shift alone. INTERPRETATION: Only 27 developing countries are expected to achieve MDG 4. Decreases since 2000 in under-5 mortality rates are accelerating in many developing countries, especially in sub-Saharan Africa. The Millennium Declaration and increased development assistance for health might have been a factor in faster decreases in some developing countries. Without further accelerated progress, many countries in west and central Africa will still have high levels of under-5 mortality in 2030. FUNDING: Bill & Melinda Gates Foundation, US Agency for International Development.

[Cancer prevention and tobacco control].

The paper summarized briefly the evidences for tobacco use as a cause of cancer based on hundreds of epidemiologic and biomedical studies carried out over the past 50-60 years, as well as overviewed the carcinogens in tobacco products and mechanisms of neoplasm induction by tobacco products. So, tobacco control is the important measure for cancer prevention.

[Investigation on under-reported deaths in Xuanwei Yunnan province, during 2011-2013].

OBJECTIVE: To evaluate the completeness of the death registration system, so as to understand the death patterns in Xuanwei. METHODS: The investigation on under-reported deaths was conducted in 30 villages selected with a multi-stage random sampling strategy. Participants were asked about changes of their family members (family members born or dead) during past 3 years with door to door visit. Then, death cases obtained in our investigation were matched with those from routine death registration system and under-reported rate of deaths during 2011-2013 was calculated employing capture-recapture method. RESULTS: Total under-reported rate of deaths was 31.88%. For people aged between 0-14, 15-39, 40-69 and 60 above, under-reported rates of death were 33.35%, 34.93%, 29.10%, and 32.88%, respectively. And they were 31.72% and 32.02% for males and females, respectively. There was no significant difference shown in under-reported rates among deaths in different age groups (χ² = 7.24, P = 0.065) and genders (χ² = 0.06, P = 0.803). The under-reported rates in high-mortality, medium-mortality and low-mortality regions were 17.48%, 38.01%, and 36.22%, respectively with a significant difference (χ² = 213.25, P < 0.001). Death in local regions with mortality rate higher than 600.00/10(5), between 400.00/105 and 600.00/105 and lower than 400.00/105 were adjusted with under-reported rates in three regions above respectively. The total adjusted morality rate in Xuanwei during 2011-2013 was 776.47/105. For males and females, they were 918.73/105 and 617.46/105, respectively. CONCLUSION: Overall under-reported rate of death was high in death registration system in Xuanwei. It was necessary to adjust mortality data reported with under-reported rate of death to estimate death patterns in this area.

Rapid health transition in China, 1990-2010: findings from the Global Burden of Disease Study 2010.

BACKGROUND: China has undergone rapid demographic and epidemiological changes in the past few decades, including striking declines in fertility and child mortality and increases in life expectancy at birth. Popular discontent with the health system has led to major reforms. To help inform these reforms, we did a comprehensive assessment of disease burden in China, how it changed between 1990 and 2010, and how China's health burden compares with other nations. METHODS: We used results of the Global Burden of Diseases, Injuries, and Risk Factors Study 2010 (GBD 2010) for 1990 and 2010 for China and 18 other countries in the G20 to assess rates and trends in mortality, causes of death, years of life lost (YLLs), years lived with disability (YLDs), disability-adjusted life-years (DALYs), and healthy life expectancy (HALE). We present results for 231 diseases and injuries and for 67 risk factors or clusters of risk factors relevant to China. We assessed relative performance of China against G20 countries (significantly better, worse, or indistinguishable from the G20 mean) with age-standardised rates and 95% uncertainty intervals. FINDINGS: The leading causes of death in China in 2010 were stroke (1·7 million deaths, 95% UI 1·5-1·8 million), ischaemic heart disease (948,700 deaths, 774,500-1,024,600), and chronic obstructive pulmonary disease (934,000 deaths, 846,600-1,032,300). Age-standardised YLLs in China were lower in 2010 than all emerging economies in the G20, and only slightly higher than noted in the USA. China had the lowest age-standardised YLD rate in the G20 in 2010. China also ranked tenth (95% UI eighth to tenth) for HALE and 12th (11th to 13th) for life expectancy. YLLs from neonatal causes, infectious diseases, and injuries in children declined substantially between 1990 and 2010. Mental and behavioural disorders, substance use disorders, and musculoskeletal disorders were responsible for almost half of all YLDs. The fraction of DALYs from YLDs rose from 28·1% (95% UI 24·2-32·5) in 1990 to 39·4% (34·9-43·8) in 2010. Leading causes of DALYs in 2010 were cardiovascular diseases (stroke and ischaemic heart disease), cancers (lung and liver cancer), low back pain, and depression. Dietary risk factors, high blood pressure, and tobacco exposure are the risk factors that constituted the largest number of attributable DALYs in China. Ambient air pollution ranked fourth (third to fifth; the second highest in the G20) and household air pollution ranked fifth (fourth to sixth; the third highest in the G20) in terms of the age-standardised DALY rate in 2010. INTERPRETATION: The rapid rise of non-communicable diseases driven by urbanisation, rising incomes, and ageing poses major challenges for China's health system, as does a shift to chronic disability. Reduction of population exposures from poor diet, high blood pressure, tobacco use, cholesterol, and fasting blood glucose are public policy priorities for China, as are the control of ambient and household air pollution. These changes will require an integrated government response to improve primary care and undertake required multisectoral action to tackle key risks. Analyses of disease burden provide a useful framework to guide policy responses to the changing disease spectrum in China. FUNDING: Bill & Melinda Gates Foundation.

Marketing 'less harmful, low-tar' cigarettes is a key strategy of the industry to counter tobacco control in China.

While the 'low-tar' scheme has been widely recognised as a misleading tactic used by the tobacco industry to deceive the public about the true risks of cigarette smoking, a similar campaign using the slogan of 'less harmful, low tar' was launched by the Chinese tobacco industry, that is, State Tobacco Monopoly Administration/China National Tobacco Corporation and began to gain traction during the last decade. Despite the fact that no sufficient research evidence supports the claims made by the industry that these cigarettes are safer, the Chinese tobacco industry has continued to promote them using various health claims. As a result, the production and sales of 'less harmful, low-tar' cigarettes have increased dramatically since 2000. Recently, a tobacco industry senior researcher, whose main research area is 'less harmful, low-tar' cigarettes, was elected as an Academician to the prestigious Chinese Academy of Engineering for his contribution to developing 'less harmful, low-tar' cigarettes. The tobacco researcher's election caused an outcry from the tobacco control community and the general public in China. This paper discusses the Chinese tobacco industry's 'less harmful, low-tar' initiatives and calls for the Chinese government to stop the execution of this deceptive strategy for tobacco marketing.

[Evaluation study of the implementation of WHO Framework Convention on Tobacco Control in seven provinces/municipalities in China].

OBJECTIVE: To assess the implementation of World Health Organization Framework Convention on Tobacco Control (WHO FCTC) by organizations in seven provinces/municipalities in China. METHODS: A total of 901 organizations, including hospitals, schools, government departments, health administrative departments and public transportation facilities, were selected by multistage sampling method in five provinces and two municipalities in China, 2010 and 2012. Key informant interview and observation survey were conducted to collect data on implementation of WHO FCTC. Analysis was performed among three clusters of indexes, which were establishment of smoke-free environment, education and training on tobacco control, and tobacco cessation measures. RESULTS: The five types of organizations performed differently in creating smoke-free environment. The ratios of conducting complete smoke-free policy in hospitals, health administrative departments and schools were separately 83.3% (111/192), 81.6% (146/179) and 66.5% (121/182) in 2012, which were comparatively higher than those in governments (32.4%, 33/102) and public transport facilities (25.0%, 27/108) (χ(2) = 174.93, P < 0.01) . As for promotion and training programs of tobacco control information, the ratio of health administrative departments raised from 78.1% (150/192) to 100.0% (192/192), and the difference showed statistical significance (χ(2) = 42.00, P < 0.01). But those departments who provide training to social media only accounted for 11.8% (22/187), which was substantially lower than the percentage of those providing training to themselves (67.7%, 128/189) (χ(2) = 413.99, P < 0.01). Three indexes of tobacco cessation related work--offering help in tobacco use quitting, providing health workers with training on tobacco cessation skills and establishing tobacco cessation clinics, only reached as low as 41.1% (312/760) , 55.6% (104/187) and 45.9% (89/194), respectively. Among the seven provinces/municipalities, Shanghai did better than the others on most of the indexes. 27 out of 28 schools in Shanghai implemented complete smoke-free policy, which was the best among the seven, while only 3 out of 26 in Jiangxi, as the poorest (χ(2) = 47.63, P < 0.01). Meanwhile, all of the 24 schools in Shanghai had health education classes on tobacco control, followed by Zhejiang (23 out of 29), while Jiangxi was also the poorest, only 12 out of 26 (χ(2) = 17.95, P < 0.01). CONCLUSION: The implementation of WHO FCTC by the five types of organizations in the seven provinces/municipalities has improved to various degrees. Nevertheless, further actions should be taken to promote smoke-free environment especially in certain circumstances such as public transport facilities, to strengthen training programs of tobacco control for social media, and to enhance hospitals' abilities in providing tobacco cessation services.

The value of research as a component of successful tobacco control in China.

Research has been shown to be a critical component of successful national tobacco control programmes. China currently has a small number of dedicated researchers addressing tobacco use and control. We encourage the growth of tobacco research as an academic and governmental field of inquiry. Such research would include multiple foci: biologic and toxicologic, epidemiologic, economic, health promotion, evaluation, policy and regulatory, and legal. Developing a community of tobacco researchers would elevate the tobacco issue on the public policy agenda, encourage transparency among key stakeholders and better identify strategies of tobacco control that could be effective in the Chinese context.

Development of policy performance indicators to assess the implementation of protection from exposure to secondhand smoke in China.

OBJECTIVE: To develop an approach for rapid assessment of tobacco control interventions in China. We examined the correlation between components of the Strength of Tobacco Control (SOTC) index and a proposed rapid evaluation indicator, the Policy Performance Indicator (PPI), which is based on protection of non-smokers from secondhand smoke (SHS). The PPI was used to assess the implementation of policies related to SHS at the provincial/municipal level in China. METHODS: Stratified random sampling was used to select five types of organisational and household respondents in two municipalities and five provinces in China (Shanghai and Tianjin, Heilongjiang, Henan, Guangdong, Zhejiang and Jiangxi, respectively). Data collection methods included key informant interviews, observation and intercept surveys (organisations), and a modified Global Adult Tobacco Survey (GATS) questionnaire (households). SOTC scores (SHS policy, capacity and efforts), PPI (no smoking in designated smoke-free places) and mid-term to long-term impact (knowledge, attitude and reduced exposure to SHS) were measured, and correlations among them were calculated. RESULTS: The PPI varied across the seven locations. Shanghai led in the component indicators (at 56.5% for indoor workplaces and 49.1% for indoor public places, respectively), followed by Guangdong, Tianjin and Zhejiang (at 30-35% for these two indicators), and finally, Henan and Jiangxi (at 20-25%). Smoke-free policies were more effectively implemented at indoor workplaces than indoor public places. The PPI correlated well with certain components of the SOTC but not with the long-term indicators. CONCLUSIONS: The PPI is useful for evaluating implementation of smoke-free policies. As tobacco control programmes are implemented, the PPI offers an indicator to track success and change strategies, without collecting data for a full SOTC index.

Acceptability and adoption of handheld computer data collection for public health research in China: a case study.

BACKGROUND: Handheld computers for data collection (HCDC) and management have become increasingly common in health research. However, current knowledge about the use of HCDC in health research in China is very limited. In this study, we administered a survey to a hard-to-reach population in China using HCDC and assessed the acceptability and adoption of HCDC in China. METHODS: Handheld computers operating Windows Mobile and Questionnaire Development Studio (QDS) software (Nova Research Company) were used for this survey. Questions on tobacco use and susceptibility were drawn from the Global Adult Tobacco Survey (GATS) and other validated instruments, and these were programmed in Chinese characters by local staff. We conducted a half-day training session for survey supervisors and a three-day training session for 20 interviewers and 9 supervisors. After the training, all trainees completed a self-assessment of their skill level using HCDC. The main study was implemented in fall 2010 in 10 sites, with data managed centrally in Beijing. Study interviewers completed a post-survey evaluation questionnaire on the acceptability and utility of HCDC in survey research. RESULTS: Twenty-nine trainees completed post-training surveys, and 20 interviewers completed post-data collection questionnaires. After training, more than 90% felt confident about their ability to collect survey data using HCDC, to transfer study data from a handheld computer to a laptop, and to encrypt the survey data file. After data collection, 80% of the interviewers thought data collection and management were easy and 60% of staff felt confident they could solve problems they might encounter. Overall, after data collection, nearly 70% of interviewers reported that they would prefer to use handheld computers for future surveys. More than half (55%) felt the HCDC was a particularly useful data collection tool for studies conducted in China. CONCLUSIONS: We successfully conducted a health-related survey using HCDC. Using handheld computers for data collection was a feasible, acceptable, and preferred method by Chinese interviewers. Despite minor technical issues that occurred during data collection, HCDC is a promising methodology to be used in survey-based research in China.

[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.