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Background and aims More than 20 cities in China have enacted local smoke-free laws that prohibit smoking in public places. Only two of these cities have examined the health impact of the law. Enacted in 2013, Qingdao's smoke free-law was stricter than most other municipal smoke-free laws because it did not allow designated smoking rooms. This study aimed to estimate the impact of Qingdao's smoke-free legislation on acute myocardial infarction (AMI) and stroke. Design, setting and participants We used an interrupted time-series design adjusting for underlying secular trends, seasonal patterns and meteorological factors to estimate the impact of the smoke-free law on AMI and stroke events among permanent residents aged 35 years or older in Qingdao, China. The study period was from 1 January 2010 to 31 December 2015, with a post-ban follow-up of approximately 2.5 years. Measurement Outcome measures were weekly numbers of hospitalizations and deaths due to AMI/stroke. Findings A total of 10 371 and 56 101 patients were hospitalized, with a principal discharge diagnosis of AMI and stroke, respectively; 32 196 AMI and 49 711 stroke deaths occurred during the study period. Following the smoke-free legislation, an incremental 20% [95% confidence interval (CI) = 14-26%] and 8% (95% CI = 3-13%) decrease per year was observed in AMI and stroke hospitalization rates, respectively. Neither the immediate nor gradual change in AMI nor stroke mortality rates associated with the law was statistically significant (P > 0.05). Post-hoc subgroup analyses indicated that statistically significant reductions in AMI hospitalizations were evident among both the 35-64 (18% per year, 95% CI = 12-27%) and 65-84 (20% per year, 95% CI = 12-27%) age groups. Statistically significant reductions in stroke hospitalization were only in the older subgroup (13% per year, 95% CI = 8-18%). Conclusions The 2013 smoke-free legislation in Qingdao, China was associated with reduction in hospitalization from acute myocardial infarction and stroke among permanent residents aged 35 years or older. There was no statistically significant reduction in mortality from acute myocardial infarctions or stroke.

Background China is the largest producer and consumer of tobacco products worldwide, with 16.5% of all deaths attributed to tobacco use in 2010. While direct marketing and advertisement of tobacco products has been 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 and discusses the success story of a major tobacco control campaign to remove tobacco-related branding and logos from school buildings. Methods Field visits were undertaken to 3 tobacco industry-sponsored elementary schools in Yunnan in 2012, and semi-structured interviews were conducted with students, teachers, school principals and parents to understand their perceptions of the tobacco industry and its sponsorship of schools. In 2016, semi-structured interviews with tobacco control activists were conducted in Beijing, where respondents discussed the outcome of those field visits and the resulting work in petitioning government sectors to remove tobacco-related branding from school buildings. Interview data was transcribed and coded, and key themes were developed using thematic analysis. Results While health consequences of smoking were generally known, attitudes towards the tobacco industry and its CSR activities remained positive among the general public. Educators and parents did 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. Conclusions The successful removal of branding from tobacco industry-sponsored schools shows that meaningful action is possible even in the absence of relevant legislation, and can be achieved through the mobilization of stakeholders, including academics and civil society organizations. National tobacco control legislation banning all forms of indirect marketing including sponsorship and CSR activities is needed in order to protect the health of the future generations.

BackgroundSmoke-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.MethodsAn 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.ResultsFollowing 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.ConclusionThe 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.

The COVID-19 pandemic has caused staggering human and economic costs. We outline four key lessons learned from efforts to address the pandemic in China and the US. First, effective surveillance, reporting, and contact tracing are needed to contain an epidemic at its emergence and to mitigate its impact at a later stage. Second, multi-sectoral efforts to offer incentives for those with no or minor symptoms to seek care and to quarantine themselves are critical, which would need concerted efforts from payers, providers, and public health. Third, sustained and routine prevention efforts involving both the public and the health systems will prove to be useful in times of a pandemic. Fourth, a strong public health system is essential and will be appreciated at times of urgency. Concerted multi-sectoral efforts are required to address COVID-19 pandemic with strong leadership from the public health sector.

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 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.

Summary 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.

Summary Background The Global Burden of Disease, Injuries, and Risk Factor study 2013 (GBD 2013) is the first of a series of annual updates of the GBD. Risk factor quantification, particularly of modifiable risk factors, can help to identify emerging threats to population health and opportunities for prevention. The GBD 2013 provides a timely opportunity to update the comparative risk assessment with new data for exposure, relative risks, and evidence on the appropriate counterfactual risk distribution. Methods Attributable deaths, years of life lost, years lived with disability, and disability-adjusted life-years (DALYs) have been estimated for 79 risks or clusters of risks using the GBD 2010 methods. Risk–outcome pairs meeting explicit evidence criteria were assessed for 188 countries for the period 1990–2013 by age and sex using three inputs: risk exposure, relative risks, and the theoretical minimum risk exposure level (TMREL). Risks are organised into a hierarchy with blocks of behavioural, environmental and occupational, and metabolic risks at the first level of the hierarchy. The next level in the hierarchy includes nine clusters of related risks and two individual risks, with more detail provided at levels 3 and 4 of the hierarchy. Compared with GBD 2010, six new risk factors have been added: handwashing practices, occupational exposure to trichloroethylene, childhood wasting, childhood stunting, unsafe sex, and low glomerular filtration rate. For most risks, data for exposure were synthesised with a Bayesian metaregression method, DisMod-MR 2.0, or spatial-temporal Gaussian process regression. Relative risks were based on meta-regressions of published cohort and intervention studies. Attributable burden for clusters of risks and all risks combined took into account evidence on the mediation of some risks such as high body-mass index (BMI) through other risks such as high systolic blood pressure and high cholesterol. Findings All risks combined account for 57·2% (95% uncertainty interval [UI] 55·8–58·5) of deaths and 41·6% (40·1–43·0) of DALYs. Risks quantified account for 87·9% (86·5−89·3) of cardiovascular disease DALYs, ranging to a low of 0% for neonatal disorders and neglected tropical diseases and malaria. In terms of global DALYs in 2013, six risks or clusters of risks each caused more than 5% of DALYs: dietary risks accounting for 11·3 million deaths and 241·4 million DALYs, high systolic blood pressure for 10·4 million deaths and 208·1 million DALYs, child and maternal malnutrition for 1·7 million deaths and 176·9 million DALYs, tobacco smoke for 6·1 million deaths and 143·5 million DALYs, air pollution for 5·5 million deaths and 141·5 million DALYs, and high BMI for 4·4 million deaths and 134·0 million DALYs. Risk factor patterns vary across regions and countries and with time. In sub-Saharan Africa, the leading risk factors are child and maternal malnutrition, unsafe sex, and unsafe water, sanitation, and handwashing. In women, in nearly all countries in the Americas, north Africa, and the Middle East, and in many other high-income countries, high BMI is the leading risk factor, with high systolic blood pressure as the leading risk in most of Central and Eastern Europe and south and east Asia. For men, high systolic blood pressure or tobacco use are the leading risks in nearly all high-income countries, in north Africa and the Middle East, Europe, and Asia. For men and women, unsafe sex is the leading risk in a corridor from Kenya to South Africa. Interpretation Behavioural, environmental and occupational, and metabolic risks can explain half of global mortality and more than one-third of global DALYs providing many opportunities for prevention. Of the larger risks, the attributable burden of high BMI has increased in the past 23 years. In view of the prominence of behavioural risk factors, behavioural and social science research on interventions for these risks should be strengthened. Many prevention and primary care policy options are available now to act on key risks. Funding Bill & Melinda Gates Foundation. Background The Global Burden of Disease, Injuries, and Risk Factor study 2013 (GBD 2013) is the fi rst of a series of annual updates of the GBD. Risk factor quantifi cation, particularly of modifi able risk factors, can help to identify emerging threats to population health and opportunities for prevention. The GBD 2013 provides a timely opportunity to update the comparative risk assessment with new data for exposure, relative risks, and evidence on the appropriate counterfactual risk distribution. Methods Attributable deaths, years of life lost, years lived with disability, and disability-adjusted life-years (DALYs) have been estimated for 79 risks or clusters of risks using the GBD 2010 methods. Risk–outcome pairs meeting explicit evidence criteria were assessed for 188 countries for the period 1990–2013 by age and sex using three inputs: risk exposure, relative risks, and the theoretical minimum risk exposure level (TMREL). Risks are organised into a hierarchy with blocks of behavioural, environmental and occupational, and metabolic risks at the fi rst level of the hierarchy. The next level in the hierarchy includes nine clusters of related risks and two individual risks, with more detail provided at levels 3 and 4 of the hierarchy. Compared with GBD 2010, six new risk factors have been added: handwashing practices, occupational exposure to trichloroethylene, childhood wasting, childhood stunting, unsafe sex, and low glomerular fi ltration rate. For most risks, data for exposure were synthesised with a Bayesian metaregression method, DisMod-MR 2.0, or spatial-temporal Gaussian process regression. Relative risks were based on meta-regressions of published cohort and intervention studies. Attributable burden for clusters of risks and all risks combined took into account evidence on the mediation of some risks such as high body-mass index (BMI) through other risks such as high systolic blood pressure and high cholesterol. Findings All risks combined account for 57·2% (95% uncertainty interval [UI] 55·8–58·5) of deaths and 41·6% (40·1–43·0) of DALYs. Risks quantified account for 87·9% (86·5−89·3) of cardiovascular disease DALYs, ranging to a low of 0% for neonatal disorders and neglected tropical diseases and malaria. In terms of global DALYs in 2013, six risks or clusters of risks each caused more than 5% of DALYs: dietary risks accounting for 11·3 million deaths and 241·4 million DALYs, high systolic blood pressure for 10·4 million deaths and 208·1 million DALYs, child and maternal malnutrition for 1·7 million deaths and 176·9 million DALYs, tobacco smoke for 6·1 million deaths and 143·5 million DALYs, air pollution for 5·5 million deaths and 141·5 million DALYs, and high BMI for 4·4 million deaths and 134·0 million DALYs. Risk factor patterns vary across regions and countries and with time. In sub-Saharan Africa, the leading risk factors are child and maternal malnutrition, unsafe sex, and unsafe water, sanitation, and handwashing. In women, in nearly all countries in the Americas, north Africa, and the Middle East, and in many other high-income countries, high BMI is the leading risk factor, with high systolic blood pressure as the leading risk in most of Central and Eastern Europe and south and east Asia. For men, high systolic blood pressure or tobacco use are the leading risks in nearly all high-income countries, in north Africa and the Middle East, Europe, and Asia. For men and women, unsafe sex is the leading risk in a corridor from Kenya to South Africa. Interpretation Behavioural, environmental and occupational, and metabolic risks can explain half of global mortality and more than one-third of global DALYs providing many opportunities for prevention. Of the larger risks, the attributable burden of high BMI has increased in the past 23 years. In view of the prominence of behavioural risk factors, behavioural and social science research on interventions for these risks should be strengthened. Many prevention and primary care policy options are available now to act on key risks. Funding Bill & Melinda Gates Foundation.

The mean baseline BMI was 21.7 kg/m 2 , and 2,145 lung cancer deaths were recorded during 15 years of follow-up. The prevalence of smoking was strongly inversely associated with BMI, but no apparent relationship was seen between amount smoked (or other measures of smoking intensity) and BMI among smokers. Overall there was a strong inverse association between BMI and lung cancer mortality (p < 0.0001 for trend) after excluding the first 3 years of follow-up. This association appeared to be confined mainly to current smokers, with no apparent relationship in nonsmokers (p < 0.001 for difference between slopes). Among current smokers, the inverse association appeared to be log-linear, with each 5 kg/m 2 lower BMI associated with a 35% (95% confidence interval: 24–46%; p < 0.0001) higher lung cancer mortality, and it persisted after excluding those who had reported poor health status or history of any disease or respiratory symptoms at baseline. In this relatively lean Chinese male population, low BMI was strongly associated with increased risk of lung cancer only among current smokers. ' 2009 UICC Lung cancer is among the commonest types of cancer throughout China, causing some 400,000 deaths annually. During the last few decades the disease rate has risen steadily, especially among males, as a consequence of the recent large increase in cigarette consumption. 1,2 Despite the rise in smoking-related diseases, the emerging tobacco hazard in China remains at an early stage due to the delayed effect of increase in cigarette consumption, with only about 12% of male adult deaths being attributed to smoking during the 1990s, a proportion similar to that in the USA during the early 1950s. 3 Currently about two-thirds of men aged 15 or over in China smoke, compared to fewer than 5% of women. 3,4 Although there is little variation in the smoking prevalence between different regions of China, the absolute lung cancer rate varies considerably, with the nonsmoker lung cancer rate in some parts of China being about 10 times greater than that among US nonsmokers. 3 This suggests that factors other than smoking contribute significantly to disease risk in the population. 3,5,6 Several observational studies have examined the relationship between lung cancer and body mass index (BMI), an indirect but useful measure of body fatness. 7‐23 Most of these studies have shown BMI to be inversely associated with the risk of lung cancer, with particularly high excess risk among very lean people (BMI < 18.5 kg/m 2 ). Questions remain, however, about the nature of the association, particularly the relevance to it of smoking. Some studies have attributed the inverse association of BMI and lung cancer risk entirely to incomplete control of confounding by smoking and/or of reverse causality due to pre-existing dis

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.This study aimed to examine the association between PC mortality and exposure of fine particular matter.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 PMThe relative risks of PC mortality related to 10 μg/mAmbient PM

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.

The relationship between the ever-increasing cancer mortality and water pollution is an important public concern in China. This study aimed to explore the association between serious water pollution and increasing digestive cancer mortality in the Huai River Basin (HRB) in China. A series of frequency of serious pollution (FSP) indices including water quality grade (FSPWQG), biochemical oxygen demand (FSPBOD), chemical oxygen demand (FSPCOD), and ammonia nitrogen (FSPAN) were used to characterize the surface water quality between 1997 and 2006. Data on the county-level changing mortality (CM) due to digestive tract cancers between 1975 and 2006 were collected for 14 counties in the study area. Most of investigated counties (eight) with high FSPWQG (&gt, 50%) distributed in the northern region of the HRB and had larger CMs of digestive tract cancers. In addition to their similar spatial distribution, significant correlations between FSP indices and CMs were observed by controlling for drinking water safety (DWS), gross domestic product (GDP), and population (POP). Furthermore, the above-mentioned partial correlations were clearly increased when only controlling for GDP and POP. Our study indicated that county-level variations of digestive cancer mortality are remarkably associated with water pollution, and suggested that continuous measures for improving surface water quality and DWS and hygienic interventions should be effectively implemented by local governments.

Esophageal and gastric cancers share some risk factors. This study aimed to compare the long-term trends in mortality rates of esophageal and gastric cancers in China to provide evidence for cancer prevention and control. Mortality data were derived from 103 continuous points of the Disease Surveillance Points system during 1991–2009, stratified by gender and urban-rural locations. Age-period-cohort models were used to disentangle the time trends of esophageal and gastric cancer mortality. The downward slope of the period effect for esophageal cancer was steeper than that for gastric cancer in rural areas. Cohort effect patterns were similar between esophageal and gastric cancers, with an inverse U-shape peaking around the late 1920s and early 1930s. A second peak, appearing around the 1950s, was weaker than the first but apparent in males, especially for esophageal cancer. The more marked changes in period effect for esophageal cancer in rural areas suggest esophageal cancer screening practices are effective in reducing mortality, and similar programs targeting gastric cancer should be implemented. The similarities of the cohort effects in these two cancers support the implication of nutrition deficiency in early childhood in the development of upper gastrointestinal cancer.

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.

Summary 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.

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.

The China Health and Retirement Longitudinal Study (CHARLS) is a nationally representative longitudinal survey of persons in China 45 years of age or older and their spouses, including assessments of social, economic, and health circumstances of community-residents. CHARLS examines health and economic adjustments to rapid ageing of the population in China. The national baseline survey for the study was conducted between June 2011 and March 2012 and involved 17 708 respondents. CHARLS respondents are followed every 2 years, using a face-to-face computer-assisted personal interview (CAPI). Physical measurements are made at every 2-year follow-up, and blood sample collection is done once in every two follow-up periods. A pilot survey for CHARLS was conducted in two provinces of China in 2008, on 2685 individuals, who were resurveyed in 2012. To ensure the adoption of best practices and international comparability of results, CHARLS was harmonized with leading international research studies in the Health and Retirement Study (HRS) model. Requests for collaborations should be directed to Dr Yaohui Zhao (yhzhao@nsd.edu.cn). All data in CHARLS are maintained at the National School of Development of Peking University and will be accessible to researchers around the world at the study website. The 2008 pilot data for CHARLS are available at: http://charls.ccer.edu.cn/charls/. National baseline data for the study are expected to be released in January 2013.

Background and Purpose— Despite previous investigations, substantial uncertainty remains about the relation between body mass index (BMI) and stroke, especially in populations with a relatively low BMI but a high stroke rate. Methods— A nationally representative prospective study of mortality included 212 000 Chinese men 40 to 79 years old without known cardiovascular disease in 1990 to 1991 who were followed up for 10 years. Standardized hazard ratios were calculated for stroke mortality by baseline systolic blood pressure (SBP) and BMI. Results— Mean SBP and BMI were 124 mm Hg and 21.7 kg/m 2 , respectively. During 10 years of follow-up, 5766 stroke deaths were recorded. There were strong, positive relations between BMI and SBP and between SBP and stroke mortality, with a 3-mm Hg higher baseline SBP associated with a 5.6% (95% CI, 5.3% to 6.0%; P 25 kg/m 2 ( P 2 , and among them, BMI was not associated with stroke mortality despite its strong association with BP (which continued to a BMI 2 ). The relation with BMI was similar for ischemic and hemorrhagic stroke but appeared to be steeper among lifelong nonsmokers than among current smokers ( P =0.01 for difference between slopes) despite similarly positive relations between BMI and SBP and between SBP and stroke risk in both smoking categories. Conclusions— High BMI was strongly associated with increased stroke mortality only among men who were overweight or obese.

Background: Regular alcohol drinking contributes both favourably and adversely to health in the Western populations, but its effects on overall and cause-specific mortality in China are still poorly understood. Methods: A nationally representative prospective cohort study included 220 000 men aged 40-79 years from 45 areas in China in 1990-91, and >40 000 deaths occurred during 15 years of follow-up. Cox regression was used to relate alcohol drinking to overall and cause-specific mortality, adjusting for age, area, smoking and education. Results: Overall, 33% of the participants reported drinking alcohol regularly at baseline, consuming mainly distilled spirits, with an estimated mean amount consumed of 372 g/week (46.5 units per week). After excluding all men with prior disease at baseline and the first 3 years of follow-up, there was a 5% [95% confidence interval (CI) 2-8] excess risk of overall mortality among regular drinkers. Compared with non-drinkers, the adjusted hazard ratios among men who drank

BACKGROUND: International studies of the health of Indigenous and tribal peoples provide important public health insights. Reliable data are required for the development of policy and health services. Previous studies document poorer outcomes for Indigenous peoples compared with benchmark populations, but have been restricted in their coverage of countries or the range of health indicators. Our objective is to describe the health and social status of Indigenous and tribal peoples relative to benchmark populations from a sample of countries.METHODS: Collaborators with expertise in Indigenous health data systems were identified for each country. Data were obtained for population, life expectancy at birth, infant mortality, low and high birthweight, maternal mortality, nutritional status, educational attainment, and economic status. Data sources consisted of governmental data, data from non-governmental organisations such as UNICEF, and other research. Absolute and relative differences were calculated.FINDINGS: Our data (23 countries, 28 populations) provide evidence of poorer health and social outcomes for Indigenous peoples than for non-Indigenous populations. However, this is not uniformly the case, and the size of the rate difference varies. We document poorer outcomes for Indigenous populations for: life expectancy at birth for 16 of 18 populations with a difference greater than 1 year in 15 populations; infant mortality rate for 18 of 19 populations with a rate difference greater than one per 1000 livebirths in 16 populations; maternal mortality in ten populations; low birthweight with the rate difference greater than 2% in three populations; high birthweight with the rate difference greater than 2% in one population; child malnutrition for ten of 16 populations with a difference greater than 10% in five populations; child obesity for eight of 12 populations with a difference greater than 5% in four populations; adult obesity for seven of 13 populations with a difference greater than 10% in four populations; educational attainment for 26 of 27 populations with a difference greater than 1% in 24 populations; and economic status for 15 of 18 populations with a difference greater than 1% in 14 populations.INTERPRETATION: We systematically collated data across a broader sample of countries and indicators than done in previous studies. Taking into account the UN Sustainable Development Goals, we recommend that national governments develop targeted policy responses to Indigenous health, improving access to health services, and Indigenous data within national surveillance systems.FUNDING: The Lowitja Institute.

The epidemic of lung cancer in Xuanwei City, China, remains serious despite the reduction of the risk of indoor air pollution through citywide stove improvement. The main objective of this study was to characterize the influences of topography on the spatiotemporal variations of lung cancer mortality in Xuanwei during 1990–2013. Using the spatially empirical Bayes method, the smoothed mortality rate of lung cancer was obtained according to the mortality data and population data collected from the retrospective survey (1990–2005) and online registration data (2011–2013). Spatial variations of the village-level mortality rate and topographic factors, including the relief degree of land surface (RDLS) and dwelling conditions (VDC), were characterized through spatial autocorrelation and hotspot analysis. The relationship between topographic factors and the epidemic of lung cancer was explored using correlation analysis and geographically weighted regression (GWR). There is a pocket-like area (PLA) in Xuanwei, covering the clustered villages with lower RDLS and higher VDC. Although the villages with higher mortality rate (>80 per 105) geographically expanded from the center to the northeast of Xuanwei during 1990–2013, the village-level mortality rate was spatially clustered, which yielded a persistent hotspot area in the upward part of the PLA. In particular, the epidemic of lung cancer was closely correlated with both RDLS and VDC at the village scale, and its spatial heterogeneity could be greatly explained by the village-level VDC in the GWR model. Spatiotemporally featured lung cancer mortality in Xuanwei was potentially influenced by topographic conditions at the village scale.

Epidemiologic evidence provides some support for a causal association between maternal secondhand smoke (SHS) exposure during pregnancy and reduction in infant birth weight. The purpose of this cross-sectional study is to examine the magnitude of this association in China, where both prevalence and dose of SHS exposure are thought to be higher than in U.S. populations. Women who gave birth in Beijing and Changchun September 2000–November 2001 were interviewed to quantify self-reported prenatal SHS exposure. Their medical records were reviewed for data on pregnancy complications and birth outcomes. Non-smoking women who delivered term babies (≥37 weeks gestation) were included in the study (N = 2,770). Nearly a quarter of the women (24%) reported daily SHS exposure, 47% reported no prenatal exposure, and 75% denied any SHS exposure from the husband smoking at home. Overall, no deficit in mean birth weight was observed with exposure from all sources of SHS combined (+11 grams, 95% CI: +2, +21). Infants had higher mean birth weights among the exposed than the unexposed for all measures of SHS exposure. Future studies on SHS exposure and infant birth weight in China should emphasize more objective measures of exposure to quantify and account for any exposure misclassification.

BACKGROUND: In China, there have been few large prospective studies of the associations of body mass index (BMI) with overall and cause-specific mortality that have simultaneously controlled for biases that can be caused by pre-existing disease and smoking. METHODS: Prospective cohort study of 224 064 men, of whom 40 700 died during follow-up between 1990-91 and 2006. Analyses restricted to 142 214 men aged 40-79 years at baseline with no disease history and, to further reduce bias from pre-existing disease, at least 5 years of subsequent follow-up, leaving 17 800 deaths [including 4165 stroke, 1297 coronary heart disease (CHD), 3121 chronic obstructive pulmonary disease (COPD)]. Adjusted hazard ratios (HRs) and 95% confidence intervals (95% CIs) per 5 kg/m(2) calculated within either a lower (15 to

Methods A survey of 11 095 urban and rural women attending high school or college, aged 14–24 years, in 6 Chinese provinces was conducted. Ever-smoking (ES), current smoking, established smoking and intention to smoke frequencies were calculated. Bivariate analyses were conducted to identify possible correlates of smoking, and those found to be significant at the p=0.1 level were included in a multivariate logistical regression model to obtain adjusted OR for correlates of ES. Results ES prevalence was 20.1%, with urban female students (UFS) at 22.0% and rural female students (RFS) at 19.0% (p

Objective: To study the prevalence of, and discuss factors contributing to, household second-hand smoke exposure in six counties in China, providing scientific support for the need to establish tobacco control measures in these areas. Methods: A cross-sectional survey was performed. Investigators conducted face-to-face interviews using a standardised questionnaire to collect information on demographics, passive smoking behaviours and knowledge, and attitudes towards tobacco control. The setting was six counties from the three provinces: Mianzhu and Xichong counties in Sichuan Province; Anyi and Hukou counties in Jiangxi Province; and Xinan and Yanshi counties in Henan Province. A total of 8142 non-smokers (aged 18–69) in 2004 were included in the data analysis. Household second-hand smoke exposure rate as defined as the proportion of household passive smokers in the non-smoker population was used as the measure of household second-hand smoke exposure. Results: The analysis of 8142 non-smokers revealed that, in these selected counties, the household second-hand smoke exposure rate was 48.3%. Respondents had positive attitudes towards tobacco control. Of 6972 respondents, 84.4% supported all the three tobacco control policies (banning smoking in public places, banning the selling of cigarettes to minors, banning all cigarette advertisements). In 3165 families with smokers, 87.2% of respondents reported that smokers would smoke in front of them. In 2124 families with smokers and children, 76.5% of respondents reported that smokers would smoke in front of children. As many as 42.1% of non-smokers would offer cigarettes to their guests, and only 46.8% of respondents would ask smokers to smoke outdoors. Only 6.3% of families completely forbade smoking at home. Multivariate logistic regression analysis revealed high second-hand smoke exposure for the following demographic groups: Jiangxi Province inhabitants, females, those with low education level, farmers and married respondents. Conclusions: Household second-hand smoke exposure rates in the selected counties were high. A high percentage of respondents reported that smokers would smoke in front of them and children. The pressure from non-smokers against smoking was relatively low, although offering cigarette was prevalent. Households that were completely smoking-free were rare, Further studies on these correlated factors could help us establish effective measures to reduce household second-hand smoke exposure.

Summary China has experienced an epidemiological transition shifting from the infectious to the chronic diseases in much shorter time than many other countries. The pace and spread of behavioural changes, including changing diets, decreased physical activity, high rates of male smoking, and other high risk behaviours, has accelerated to an unprecedented degree. As a result, the burden of chronic diseases, preventable morbidity and mortality, and associated health-care costs could now increase substantially. China already has 177 million adults with hypertension; furthermore, 303 million adults smoke, which is a third of the world's total number of smokers, and 530 million people in China are passively exposed to second-hand smoke. The prevalence of overweight people and obesity is increasing in Chinese adults and children, because of dietary changes and reduced physical activity. Emergence of chronic diseases presents special challenges for China's ongoing reform of health care, given the large numbers who require curative treatment and the narrow window of opportunity for timely prevention of disease.

Several epidemiological studies have reported on the association between body mass index (BMI) and risk of esophageal cancer, but these were mostly in Western populations where many are overweight or obese. There is little direct evidence about the relationship in China where the mean BMI is relatively low and the disease rate is high. We examined the data from a populationbased prospective study of 220,000 Chinese men aged 40–79 without a previous history of cancer (mean BMI 21.7 kg/m 2 ), which included 1,082 esophageal cancer deaths during 10 years of follow-up. Adjusted hazard ratios for death from esophageal cancer by baseline BMI category were calculated using Cox proportional hazards models. Even among men with good self-assessed health and BMI 18.5 kg/m 2 , there was a strong inverse association between BMI and death from esophageal cancer, with each 5 kg/ m 2 higher BMI associated with 25% (95%CI: 11–36%) lower esophageal cancer mortality. This inverse association persisted when analysis was restricted to men who had never smoked or when the first 5 years of follow-up were excluded. The strength of the relationship was consistent with the pooled estimate for squamous cell carcinoma of the esophagus in a meta-analysis of prospective studies (31% lower relative risk per 5 kg/m 2 higher BMI; 95% CI: 25–37%), but contrasted with that for adenocarcinoma which showed a positive association with BMI. Together, these data provide reliable evidence that in many populations low BMI is associated with an increased risk of squamous cell carcinoma of the esophagus. ' 2007 Wiley-Liss, Inc.

Objective: To assess airborne nicotine concentrations as an indicator of second-hand smoke (SHS) exposure in public places in both urban and rural areas of China. Design: Measurement of vapour-phase nicotine concentration using a common protocol in all locations. A total of 273 samplers were placed for 7 days in urban and rural areas of China, including Beijing and the capital city, and a county (rural) area of the following provinces: Sichuan (Chengdu/Mianzhu), Jiangxi (Nanchang/Anyi) and Henan (Zhengzhou/Xin’an). Setting: Samplers were placed in hospitals, secondary schools, city government buildings, train stations, restaurants and entertainment establishments (internet cafes, mahjong parlours and karaoke bars) in each location. Main outcome measure: The time-weighted average airborne concentration of nicotine (μg/m 3 ) was measured by gas chromatography. Results: Airborne nicotine was detected in 91% of the locations sampled. Beijing had the highest nicotine concentrations in most indoor environments (median 3.01 μg/m 3 ) and Chengdu had the lowest concentrations (median 0.11 μg/m 3 ). Overall, restaurants and entertainment establishments had the highest nicotine concentrations (median 2.17 and 7.48 μg/m 3 , respectively). High nicotine concentrations were also found in government buildings and in train stations. Conclusions: The data collected in this study provide evidence that SHS exposure is frequent in public places in China. Environmental nicotine concentrations in China provide evidence for implementation and enforcement of smoke-free initiatives in public places in China and indicate the need for protecting the public from exposure to SHS.

Background: Death registration systems in rural China are in a developmental stage. The Disease Surveillance Points (DSP) system provides the only nationally representative information on causes of death. In this system, there are no standard procedures or instruments for ascertaining causes of death; hence available statistics require careful evaluation before use. Aim: To assess the reliability of data from the DSP. Methods: 14 DSP sites were selected through stratified sampling, enrolling 2482 deaths registered during June–November 2002. Defined verbal autopsy (VA) procedures were used to derive underlying causes of death. κ Measures of agreement between VA and registered diagnoses were computed. VA diagnoses were used as references to compute sensitivity and positive predictive values. Finally, patterns of cause-specific discordance between the two data sources were studied. Results: κ Scores indicate only moderate agreement for chronic obstructive pulmonary disease (COPD) and ischaemic heart disease (IHD). The results also suggest that COPD is undercounted in registration data. A significant degree of cross attribution of cause was found between the two data sources. Overall, the VA was successful in limiting deaths with ill-defined causes to Conclusions: Diagnoses based on structured symptom questionnaires in the VA approach seem plausible and reliable as compared with lay-reported diagnoses in registration data. Concerns with attribution of cause of death due to COPD, IHD and tuberculosis in registration data suggest caution in their use for research and health programme purposes. The VA methods tested in this study offer promise for implementation in the routine registration system.

The potential insensitivity to depression of translated diagnostic instruments makes it difficult to assess the relationship of depressive symptoms to suicide in non-Western cultures.Addition of culturally sensitive probes and other modifications were made to the depression section of the Chinese version of the SCID; the standard SCID probes and the expanded-probes are separately used to assess each symptom of depression, the resultant diagnoses and the overall severity of depression. This modified SCID was included in the psychological autopsy interviews with family members and, separately, close associates of 887 suicides and 721 non-suicidal decedents from 23 regions of mainland China.Compared to the standard interview, the expanded-probe method increased reported prevalence of major depressive episode among suicide decedents from 26.4% (234/887) to 40.2% (357/887) and for other deaths from 1.0% (7/721) to 2.1% (15/701). The additional 131 cases identified using the expanded-probe method had substantial social impairment and a greatly elevated risk of suicide compared to those with no depressive symptoms (OR=37.0, 95% CI=17.6-77.6). Inter-observer reliability for major depressive episode between the two independent interviews was greater for the expanded probe method (ICC=0.77 vs. 0.67, P0.001). For both interview methods there was a strong dose-response relationship between suicide risk and the number and severity of depressive symptoms.This study uses proxy informants to obtain information about the psychological status of deceased subjects; the value of this expanded-probe method for the diagnosis of depression in non-Western cultures needs to be confirmed with living subjects.Adding culture-appropriate probes about depressive symptoms to standardized diagnostic instruments identifies many Chinese subjects with unrecognized depression. Dimensional measures of depressive symptoms are more powerful predictors of suicide risk than categorical diagnoses.

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.

The Fogarty International Center (FIC) initiative, “International Tobacco and Health Research Capacity Building Program” represents an important step in US government funding for global tobacco control. Low‐ and middle‐income countries of the world face a rising threat to public health from the rapidly escalating epidemic of tobacco use. Many are now parties to the Framework Convention on Tobacco Control (FCTC) and capacity development to meet FCTC provisions. One initial grant provided through the FIC was to the Institute for Global Tobacco Control (IGTC) at the Johns Hopkins Bloomberg School of Public Health (JHSPH) to support capacity building and research programmes in China, Brazil, and Mexico. The initiative's capacity building effort focused on: (1) building the evidence base for tobacco control, (2) expanding the infrastructure of each country to deliver tobacco control, and (3) developing the next generation of leaders as well as encouraging networking throughout the country and with neighbouring countries. This paper describes the approach taken and the research foci, as well some of the main outcomes and some identified challenges posed by the effort. Individual research papers are in progress to provide more in‐depth reporting of study results.

Objectives To explore the variations in the mortality trends, especially death due to lung cancer, from 1990 to 2013 in Xuanwei City. Materials and methods Mortality data were collected in Xuanwei during the 2nd and 3rd National Retrospective Sampling Survey on Mortality and Routine Death Registration System (DRS) during 2011–2013. According to the result of the survey on under-reported deaths, mortality data from DRS during 2011–2013 were adjusted. Disease specific mortality rate, age-standardized mortality rate (ASMR) and 45Q15 were calculated in Xuanwei and compared with those in rural areas of China. Results During three periods, 1990–1992, 2004–2005 and 2011–2013, lung cancer contributed to 56.86%, 58.45% and 63.03% of deaths from all cancers respectively with a much higher proportion than rural areas nationally. The ASMR of lung cancer for males surged from 41.43/10 5 to 88.17/10 5 during 1990–2005 and it surged from 37.70/10 5 to 74.45/10 5 for females. Although they declined slightly during 2011–2013 (82.53/10 5 and 62.62/10 5 for males and females respectively), the ASMR of lung cancer among males in Xuanwei was three times of that in rural areas in China, and it was six times higher among females. The 45Q15 of lung cancer for males in Xuanwei was 3–5 times of that in rural areas of China and for females it was 7–9 times. The high-mortality areas of lung cancer were still located in Laibin, Longchang, Wanshui and Shuanglong Communities. High-mortality areas of lung cancer expanded to their surrounding areas and those in southeast. Conclusions Although indoor air pollution caused by smoky coal has been fairly well controlled, patterns of death due to lung cancer have not obviously changed. The mortality rate of lung cancer among females was similar to that among males. Therefore, further studies should be conducted to comprehensively explore the risk factors of lung cancer in Xuanwei.

Background: Vital registration of causes of death in China is incomplete with poor coverage of medical certification. Information on the leading causes of mortality will continue to rely on verbal autopsy (VA) methods. A new international VA form is being considered for data collection in China, but it first needs to be validated to determine its operating characteristics. Methods: Detailed medical records and clinical evidence for 3290 deaths (mostly adults) among residents of six cities representative of the urban Chinese population were reviewed by a panel of physicians and coded by experts to establish a reference underlying cause of death. Independently, families of the deceased were interviewed using a structured symptomatic questionnaire and a separate death certificate was prepared for each matching case (2102). Validity of the VA procedure was assessed using standard measurement criteria of sensitivity, specificity, and positive predictive value. Results: VA methods perform reasonably well in identifying deaths from several leading causes of adult deaths including stroke, several major cancer sites (lung, liver, stomach, oesophagus, and colorectal), and transport accidents. Sensitivity was less satisfactory in detecting deaths from several causes of major public health concern in China including ischaemic heart disease, chronic obstructive pulmonary disease, diabetes, and tuberculosis, and was particularly poor in diagnosing deaths from viral hepatitis, hypertension, and kidney diseases. Conclusions: VA is an imprecise tool for detecting leading causes of death among adults. However, much of the misclassification generally occurs within broad cause groups (e.g. CVD, respiratory diseases, and liver diseases). Moreover, compensating patterns of misclassification would appear to suggest that, in urban China at least, the method yields population-level cause-specific estimates that are reasonably reliable. These results suggest the possible utility of these methods in rural China, to back up the low coverage of medical certification of cause of death owing to poor access to health facilities there.

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.

Summary Background Unlike almost every other country in the world, the prevalence of both schizophrenia and suicide in China is higher in women than in men. Schizophrenia and suicide are important public-health problems for China that might be related to each other. We present prevalence data for schizophrenia and estimate relative and attributable risk of suicide in people with schizophrenia in mainland China. Methods We used data from the national psychiatric epidemiology study, the Ministry of Health's mortality registry, the census, and the national psychological autopsy study to estimate frequencies and rates of schizophrenia, suicide, and suicide in people with schizophrenia aged 15 years and older in mainland China during 1995–99. Findings We estimated 4·25 million people with schizophrenia in China, and 284 614 suicides and 28 737 suicides in people with schizophrenia yearly. Prevalence of schizophrenia was higher in women than men (relative risk 1·77 [95% CI 1·15–2·72]), and greater in urban than rural areas (1·62 [1·10–2·40]). Risk of suicide was greater in women than men (1·22 [1·20–1·23]) and in rural than urban areas (3·61 [3·56–3·66]). Relative risk of suicide in individuals with schizophrenia compared with those without was 23·8 (18·8–30·2); the proportion of all suicides attributable to schizophrenia was 9·7% (7·7–12·1). Relative risk of suicide in rural residents with schizophrenia versus those without was higher in men than in women (ratio of two relative risks 2·02 [1·13–3·63]), but in urban residents with schizophrenia the ratio was lower in men than women (0·56 [0·21–1·49]). Interpretation Risk factors for suicide vary in people with different mental disorders, so identification of illness-specific risk profiles would improve prediction of suicide and help tailor prevention efforts. The difference in suicide rates by sex and residential location in individuals with schizophrenia might be one of several contributing factors to the unique epidemiological pattern of schizophrenia in China.

Background Identifying factors that affect cotinine levels in smokers may be useful for smoking cessation programs. Our aims were to characterize the distribution of salivary cotinine levels in Chinese smokers and to investigate factors that influence cotinine concentrations. Methods In a cross-sectional study, 600 Chinese adult smokers answered a questionnaire on smoking habits and provided a saliva sample for cotinine analysis. Modification of the relation between number of cigarettes smoked and cotinine concentration by individual characteristics, smoking behavior, and type of tobacco was evaluated. Results Quadratic model provided the best fit for the relation between number of cigarettes smoked in the previous 24 hours and salivary cotinine concentration. Among those smoking up to 20 cigarettes, the median cotinine concentration was higher among younger subjects, those smoking cigarettes without filter and regular rather than light cigarettes, and those inhaling frequently and deeply. Such trends were not observed among heavier smokers. The increase in cotinine per cigarette tended to be larger in those with lower median cotinine level. Conclusions Our findings show that smoking behavior-related factors modify the relation between number of cigarettes smoked and salivary cotinine concentration. This suggests that smokers may regulate their smoking behavior to achieve a certain optimum nicotine level.

Summary Background Suicide is the fifth most important cause of death in China, but the reasons for the high rate and unique pattern of characteristics of those who kill themselves are unknown. Methods We pretested, and then administered a comprehensive interview to family members and close associates of 519 people who committed suicide and of 536 people who died from other injuries (controls) randomly selected from 23 geographically representative sites in China. Findings After adjustment for sex, age, location of residence, and research site, eight significant predictors of suicide remained in the final unconditional logistic regression model. In order of importance they were: high depression symptom score, previous suicide attempt, acute stress at time of death, low quality of life, high chronic stress, severe interpersonal conflict in the 2 days before death, a blood relative with previous suicidal behaviour, and a friend or associate with previous suicidal behaviour. Suicide risk increased substantially with exposure to multiple risk factors: none of the 265 deceased people who were exposed to one or fewer of the eight risk factors died by suicide, but 30% (90/299) with two or three risk factors, 85% (320/377) with four or five risk factors, and 96% (109/114) with six or more risk factors died by suicide. Interpretation Despite substantial differences between characteristics of people who commit suicide in China and the west, risk factors for suicide do not differ greatly. Suicide prevention programmes what concentrate on a single risk factor are unlikely to reduce suicide rates substantially; preventive efforts should focus on individuals exposed to multiple risk factors.

To assess the implementation of World Health Organization Framework Convention on Tobacco Control (WHO FCTC) by organizations in seven provinces/municipalities in China.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.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, P0.01) . 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, P0.01). 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, P0.01). 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, P0.01). 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, P0.01).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.

Summary 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.

To apply Computer Assisted Telephone Interview (CATI) in evaluation on effectiveness of non-communicable diseases control and prevention among general population.Totally 2450 permanent residents aged 15 to 69 years old were interviewed by telephone in Xicheng District and Changping District, Beijing. Telephone numbers were selected by simple random sampling. CATI was used to collect data. Focus group interview was used to interview telephone interviewers in order to analyze the reason of the midway refusal.93,524 telephone numbers were dialed. Survey efficiency, response rate and successful completion rate were 3.8%, 26.2% and 75.1%, respectively. The main cause resulting in low survey efficiency and response rate were no answer, busy, and refusal to answer at the beginning. The main cause which influenced successful completion rate was midway refusal to answer.Successful completion rate in this survey was high, so CATI is suitable for this survey. However, survey efficiency and response rate were too low. The emphasis was to reduce the proportion of no answer, busy and refusal in the beginning in order to improve the efficiency of this survey.

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.

Background Forced expiratory volume in one second (FEV1) is inversely associated with mortality in Western populations, but few studies have assessed the associations of peak expiratory flow (PEF) with subsequent cause-specific mortality, or have used populations in developing countries, including China, for such assessments. Methods A prospective cohort study followed ∼170 000 Chinese men ranging in age from 40–69 years at baseline (1990–1991) for 15 years. In the study, height-adjusted PEF (h-PEF), which was uncorrelated with height, was calculated by dividing PEF by height. Hazard ratios (HR) for cause-specific mortality and h-PEF, adjusted for age, area of residence, smoking, and education, were calculated through Cox regression analyses. Results Of the original study population, 7068 men died from respiratory causes (non-neoplastic) and 22 490 died from other causes (including 1591 from lung cancer, 5469 from other cancers, and 10 460 from cardiovascular disease) before reaching the age of 85 years. Respiratory mortality was strongly and inversely associated with h-PEF. For h-PEF ≥ 250 L/min, the association was log-linear, with a hazard ratio (HR) of 1.29 (95% CI: 1.25–1.34) per 100 L/min reduction in h-PEF. The association was stronger but not log-linear for lower values of h-PEF. Mortality from combined other causes was also inversely associated with h-PEF, and the association was log-linear for all values of h-PEF, declining with follow-up, with HRs per 100 L/min reduction in h-PEF of 1.13 (1.10–1.15), 1.08 (1.06–1.11), and 1.06 (1.03–1.08) in three consecutive 5-year follow-up periods. Specifically, lower values of h-PEF were associated with higher mortality from cardiovascular disease and lung cancer, but not from other cancers. Conclusions A lower value of h-PEF was associated with increased mortality from respiratory and other causes, including lung cancer and cardiovascular disease, but its associations with the other causes of death declined across the follow-up period.

Microcystins (MCs) are potent hepatotoxins and have also implicated in liver tumor promotion. The present study investigates the temporal and spatial variations of MCs in different water bodies in the Huai River Basin in China. Water samples including rivers, ponds and wells were collected every quarter during December 2008 and December 2009. MCs were determined by high pressure liquid chromatography after solid phase extraction. MCs concentrations in river samples were 0.741±0.623μgL(-1) with maximum of 1.846μgL(-1). MCs in pond were 0.597±0.960μgL(-1) with maximum of 2.298μgL(-1). MCs were also detected in 51.7% of the groundwater samples, MCs in groundwater were 0.060±0.085μgL(-1) with maximum of 0.446μgL(-1). MCs concentrations in groundwater did not differ significantly among different depths or towns (Wilcoxon test, p0.05). The average MCs in groundwater in each sampling period were 0.068μgL(-1), 0.118μgL(-1), 0.052μgL(-1), 0.059μgL(-1) and 0.020μgL(-1). Through multi linear regression, the best fit model was built on MCs in groundwater with River B (R(2)=0.13, p0.05), rather than with pond water. The results suggested that MCs contamination in groundwater originated from rivers, causing potential health risk on population who drink groundwater directly.

Objective To critically review the structure of tobacco control policy making in China, examine conflicts of interest within this structure, and consider how these affected the introduction of on-pack warnings. Methods Government policy documents and warning labels were obtained and critically reviewed. Results Few differences exist between the on-pack warnings formerly used in China and those introduced ostensibly to meet Framework Convention on Tobacco Control (FCTC) obligations. Comparison with tobacco manufactured for export or overseas consumption shows the new Chinese domestic on-pack warnings are demonstrably inferior to those required internationally. The inherent conflict of interest in the Chinese tobacco control agency structure, which must meet commercial and public health objectives, undermined the introduction of new health warnings. Conclusions To promote more effective tobacco control policies, the conflict of interest inhibiting the public health function of the State Tobacco Monopoly Administration (STMA) must be removed. Specifically, the public health function must be separated from oversight of commercial production, and packaging must be redesigned with pictorial warnings and messages compliant with Article 11 of the FCTC.

Author(s): Wan, Xia; Shin, Sanghyuk S; Wang, Qian; Raymond, H Fisher; Liu, Huilin; Ding, Ding; Yang, Gonghuan; Novotny, Thomas E | Abstract: BackgroundRural-to-urban migrant women may be vulnerable to smoking initiation as they are newly exposed to risk factors in the urban environment. We sought to identify correlates of smoking among rural-to-urban migrant women in China.Methods/principal findingsA cross-sectional survey of rural-to-urban migrant women working in restaurants and hotels (RHW) and those working as commercial sex workers (CSW) was conducted in ten provincial capital cities in China. Multiple logistic regression was conducted to identify correlates of smoking. We enrolled 2229 rural-to-urban migrant women (1697 RHWs aged 18-24 years and 532 CSWs aged 18-30 years). Of these, 18.4% RHWs and 58.3% CSWs reported ever tried smoking and 3.2% RHWs and 41.9% CSWs reported current smoking. Participants who first tried smoking after moving to the city were more likely to be current smokers compared to participants who first tried smoking before moving to the city (25.3% vs. 13.8% among RHWs, p = 0.02; 83.6% vs. 58.6% among CSWs, p = l0.01). Adjusting for other factors, "tried female cigarette brands" had the strongest association with current smoking (OR 5.69, 95%CI 3.44 to 9.41) among participants who had ever tried smoking.Conclusions/significanceExposure to female cigarette brands may increase the susceptibility to smoking among rural-to-urban migrant women. Smoke-free policies and increased taxes may be effective in preventing rural-to-urban migrant women from smoking initiation.

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 adultsnoticed 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.

Objective: To examine the Chinese tobacco industry's claim that herbal cigarettes are less harmful than regular cigarettes. Methods: The study design was a cross-sectional survey. One hundred thirty-five herbal cigarette smokers and 143 regular smokers from one city in China completed a questionnaire on smoking behavior and provided a urine sample. The main outcome measures were cotinine and trans-3′-hydroxycotinine in all samples, and polycyclic aromatic hydrocarbon metabolites (PAH; 1-hydroxypyrene, naphthols, hydroxyfluorenes, and hydroxyphnanthrenes) and the tobacco specific nitrosamine 4-(methylnitrosamino)-1-(3-pyridyl)-butanol (NNAL) and NNAL-glucuronide in randomly selected 98 samples (47 from the herbal smokers' group and 51 from the regular smokers' group). Values were normalized by creatinine to correct for possible variability introduced by dilution or concentration of the urine. Results: Health concern was among the main reasons that smokers switched to herbal cigarettes from regular cigarettes. Smokers reported increased consumption after switching to herbal cigarettes from regular cigarettes. For all the four markers analyzed (cotinine, trans-3′-hydroxycotinine, total NNAL, and total PAHs), we observed no significant difference in the levels (P = 0.169, P = 0.146, P = 0.171, and P = 0.554, respectively) between smokers of herbal cigarettes and smokers of regular cigarettes. Both total NNAL and total PAHs were significantly correlated with cotinine and trans-3′-hydroxycotinine (P < 0.001 for all four correlations). Conclusions: Our findings showed that herbal cigarettes did not deliver less carcinogens than regular cigarettes. The public needs to be aware of this fact, and the Chinese tobacco industry should avoid misleading the public when promoting herbal cigarettes as safer products. (Cancer Epidemiol Biomarkers Prev 2009;18(12):3497–501]

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.

Good public-health decisionmaking is dependent on reliable and timely statistics on births and deaths (including the medical causes of death). All high-income countries, without exception, have national civil registration systems that record these events and generate regular, frequent, and timely vital statistics. By contrast, these statistics are not available in many low-income and lower-middle-income countries, even though it is in such settings that premature mortality is most severe and the need for robust evidence to back decisionmaking most critical. Civil registration also has a range of benefits for individuals in terms of legal status, and the protection of economic, social, and human rights. However, over the past 30 years, the global health and development community has failed to provide the needed technical and financial support to countries to develop civil registration systems. There is no single blueprint for establishing and maintaining such systems and ensuring the availability of sound vital statistics. Each country faces a different set of challenges, and strategies must be tailored accordingly. There are steps that can be taken, however, and we propose an approach that couples the application of methods to generate better vital statistics in the short term with capacity-building for comprehensive civil registration systems in the long run.

BackgroundSuicide is the most common cause of death among youth in China.MethodA case-control psychological autopsy study in 23 geographically representative disease surveillance points around China collected information from family members and close associates of 114 persons aged 15–24 years who died by suicide (cases) and 91 who died of other injuries (controls).ResultsAmong the 114 suicides 61% were female, 88% lived in rural villages, 70% died by ingesting pesticides (most commonly stored in the home), 24% previously attempted suicide, and 45% met criteria of a mental illness at the time of death. Multivariate logistic regression identified several independent risk factors: severe life events within 2 days before death (OR 31.8, 95% CI 2.6–390.6), presence of any depressive symptoms within 2 weeks of death (OR 21.1, 95% CI 4.6–97.2), low quality of life in the month before death (OR 9.7, 95% CI 2.8–34.1), and acute stress at time of death (moderate: OR 3.1, 95% CI 0.8–11.9; high: OR 9.1, 95% CI 1.2–66.8). A significant interaction between mental illness at time of death and gender indicated that diagnosis was an important predictor of suicide in males (OR 14.0, 95% CI 2.6–76.5) but not in females (OR 0.3, 95% CI 0.0–3.6). Prior suicide attempt was related to suicide in the univariate analysis (OR 57.5) but could not be included in the multivariate model because no controls had made prior attempts.ConclusionsSuicide prevention efforts for youth in China must focus on restricting access to pesticides, early recognition and management of depressive symptoms and mental illnesses, improving resiliency, and enhancing quality of life.