Search

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.

The purpose of the study is to investigate the status of eutrophication, the polluted situation of algae and microcystins in different water bodies of X County in the Huai River Basin.Superficial water and sediment samples were taken from S River, Y River and a representative ditch in May 2010 (median-water period) and August (high water period ). Chemical oxygen demand (COD), total nitrogen (TN), total phosphorus (TP), chlorophyll a (Chl a) and algal density were detected by the recommended methods of national standard microcystin-LF/LR/LW/RR/YR in water (dissolved form), algal cells and sediments were detected by solid phase extraction and HPLC.Water pollutions in rivers and ditches of X County were serious, and total nitrogen and total phosphorus significantly exceed to the national standard for surface water quality. Most indexes of the water quality ranged from grade III to worse than grade V of national standard. Total nitrogen (4.78 mg/L) was most serious pollutions in the mainstream of S river, the water quality in high water period was better than in median-water period (P0.05). However, water quality in inner river Y and ditch in high water period was worse than in median-water period. Maximum chlorophyll a in ditch water reached 648.4 mg/ m3. The percent of cyanobacteria in various water bodies was less than 10% in median-water period, increased sharply to 40% and became dominant species in high water period. The maximum percentage of cyanobacteria was 44% in ditch. Microcystin-RR was the main toxin detected in water (dissolved form), algal cells and sediments. Maximum MC-RR in water and sediments reached 17.731 microg/L and 0.802 microg/g, respectively. The detected frequencies and concentrations of MC-LF/LR/LW/YR in most samples were low.Water bodies in X County were between middle eutrophication and hyper-eutrophication. Microcystin-RR of sediments in high water period were significant higher than in median-water period (P0.05).

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.

Background: Cause of death data are a critical input to formulating good public health policy. In the absence of reliable vital registration data, information collected after death from household members, called verbal autopsy (VA), is commonly used to study causes of death. VA data are usually analyzed by physician-coded verbal autopsy (PCVA). PCVA is expensive and its comparability across regions is questionable. Nearly all validation studies of PCVA have allowed physicians access to information collected from the household members' recall of medical records or contact with health services, thus exaggerating accuracy of PCVA in communities where few deaths had any interaction with the health system. In this study we develop and validate a statistical strategy for analyzing VA data that overcomes the limitations of PCVA. Methods and Findings: We propose and validate a method that combines the advantages of methods proposed by King and Lu, and Byass, which we term the symptom pattern (SP) method. The SP method uses two sources of VA data. First, it requires a dataset for which we know the true cause of death, but which need not be representative of the population of interest; this dataset might come from deaths that occur in a hospital. The SP method can then be applied to a second VA sample that is representative of the population of interest. From the hospital data we compute the properties of each symptom; that is, the probability of responding yes to each symptom, given the true cause of death. These symptom properties allow us first to estimate the population-level cause-specific mortality fractions (CSMFs), and to then use the CSMFs as an input in assigning a cause of death to each individual VA response. Finally, we use our individual cause-of-death assignments to refine our population-level CSMF estimates. The results from applying our method to data collected in China are promising. At the population level, SP estimates the CSMFs with 16% average relative error and 0.7% average absolute error, while PCVA results in 27% average relative error and 1.1% average absolute error. At the individual level, SP assigns the correct cause of death in 83% of the cases, while PCVA does so for 69% of the cases. We also compare the results of SP and PCVA when both methods have restricted access to the information from the medical record recall section of the VA instrument. At the population level, without medical record recall, the SP method estimates the CSMFs with 14% average relative error and 0.6% average absolute error, while PCVA results in 70% average relative error and 3.2% average absolute error. For individual estimates without medical record recall, SP assigns the correct cause of death in 78% of cases, while PCVA does so for 38% of cases. Conclusions: Our results from the data collected in China suggest that the SP method outperforms PCVA, both at the population and especially at the individual level. Further study is needed on additional VA datasets in order to continue validation of the method, and to understand how the symptom properties vary as a function of culture, language, and other factors. Our results also suggest that PCVA relies heavily on household recall of medical records and related information, limiting its applicability in low-resource settings. SP does not require that additional information to adequately estimate causes of death.

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.

Background: National vital registration systems are the principal source of cause specific mortality statistics, and require periodic validation to guide use of their outputs for health policy and programme purposes, and epidemiological research. We report results from a validation of cause of death statistics from health facilities in urban China. Methods: 2917 deaths from health facilities located in six cities in China constituted the study sample. A reference diagnosis of the underlying cause was derived for each death, based on expert review of available medical records, and compared with that filed at registration. Sensitivity, specificity and positive predictive value were computed for specific causes/cause categories according to the International Classification of Diseases (ICD), including analyses based on quality of evidence scores for each cause. Patterns of misclassification by the registration system were studied for individual causes of death. Results: The registration system had good sensitivity in diagnosing cerebrovascular disease and several site specific cancers (lung, liver, stomach, colorectal, breast and pancreas). Sensitivity was average (50-75%) for some major causes of adult death in China, namely ischaemic heart disease (IHD), chronic obstructive lung disease (COPD), diabetes, and liver and kidney diseases, with compensatory misclassification patterns observed between several of them. Sensitivity was particularly low for hypertensive disease. Conclusions: Although diagnostic misclassification is not uncommon in urban death registration data, they appear to balance each other at the population level. Compensating misclassification errors suggest that caution is required when drawing conclusions about particular chronic causes of adult death in China. Investment is required to improve the quality of cause attribution for health facility deaths, and to assess the validity of cause attribution for home deaths. Periodic assessments of the quality of cause of death statistics will enhance their usability for health policy and epidemiological research. © Published by Oxford University Press on behalf of the International Epidemiology Association

ObjectiveTo assess the impact of urbanisation on the prevalence of the metabolic syndrome in Chinese adults.DesignAs part of a community-based cross-sectional survey conducted in 2002, a sample from rural and urban populations in East China was obtained. The metabolic syndrome is defined by the National Cholesterol Education Program Adult Treatment Panel III criteria (ATP III) and the modified ATP III, which recommended a lower waist circumference cut-off for Asians.SettingField sites in Jiangxi and Anhui provinces and the Jing'an District of Shanghai, China.SubjectsA total of 529 non-pregnant, non-lactating urban and rural adults, aged 20–64 years without diagnosed diabetes.ResultsDwelling in urban areas was associated with higher dietary fat intake and slightly lower total energy intake, and with significantly lower occupational physical activity. Using the ATP III criteria, the prevalence of the metabolic syndrome was significantly higher for urban than rural men (12.7 vs. 1.7%, P P = 0.17). These urban–rural differences were greatly enhanced when the modified ATP III criteria for the syndrome were used, for men (34.3 vs. 2.7%, P P = 0.07). The Asian waist circumference cut-offs (90 and 80 cm for men and women, respectively) had a better combination of sensitivity and specificity in identifying other metabolic disorders, which included high glucose, high blood pressure, high triglycerides and low high-density lipoprotein cholesterol, for this population.ConclusionFor the Chinese population, urban dwelling was associated with higher prevalence of the metabolic syndrome, especially in men.

Background With rapid economic development in China, disease patterns have changed in the past two decades. This study considered mortality trends for ischaemic heart disease and stroke using data from 102 continuous disease surveillance points from 1991 to 2009. Methods We analysed 102 continuous disease surveillance points, covering 7·3 million people in 1991–2000 and expanded to a population of 52·0 million in the same areas in 2001–2009. The data were adjusted using garbage code redistribution and under-report rate, and mapped from the International Classification of Diseases revision 9 (ICD9) to ICD10. The mortality rates for ischaemic heart disease and stroke were further adjusted by crude death proportion multiplied by the envelope of total death, which was calculated using log r t = a + bt , where r t denotes the mortality rate at time point t . The trend b was estimated from the logarithm of the annual mortality rate (log rt ) using Poisson regression. Age-standardised death rates were computed using China's 2010 census population structure. We obtained agreement from the Chinese Center for Disease Control and Prevention to use data from the Disease Surveillance Point System. Patient consent and ethics approval were not necessary because all data analysed have previously been published. Findings Ischaemic heart disease age-standardised mortality rates increased in all regions, from 38·24 per 100 000 people in 1991 to 88·72 per 100 000 people in 2009 (log r t =–94·9602+0·0495× t ), especially in northeast, central, and southwest China. Before 2007, the rates for both sexes in urban areas were higher than in rural areas, but after 2007, the rates were higher in rural areas than in urban areas. For stroke, the overall age-standardised mortality rates remained stable in 1991–2009; however, the rates increased in northeast and central China but decreased in north and east China. The mortality rates in rural areas increased by 6% every year from 1991 to 2009, whereas in urban areas, mortality rates slowly rose for women ( b =1·6%) and fluctuated for men. For people younger than 70 years, the proportions of deaths were 30·9% for ischaemic heart disease and 32·6% for stroke in 2006–09, which is a substantial decline from 42·7% and 40·9%, respectively, in 1991–95. Interpretation By observing relatively unchanged areas (ie, the same surveillance points that were expanded to cover larger areas) from 1991 to 2009, the overall age-standardised mortality rate for ischaemic heart disease increased and that of stroke remained stable. These trends are likely to be a result of increased fat content in diets, blood lipid concentrations, and body weights. The different patterns of ischaemic heart disease and stroke in different geographical regions, and divergences in urban and rural areas, are an indication of varying health control strategies and health-care services. Funding China Medical Board Grant on CMB-CP in Burden of Diseases in China (12-107).

This four-country study examined salivary cotinine as a marker for nicotine intake and addiction among smokers in relation to numbers and types of cigarettes smoked. Smoking characteristics of cigarette smokers in Brazil, China, Mexico, and Poland were identified using a standard questionnaire. Cotinine concentration was measured using a saliva sample from each participant; its relationship with numbers and types of cigarettes smoked was quantified by applying regression techniques. The main outcome measure was salivary cotinine level measured by gas chromatography. In all four countries, cotinine concentration increased linearly with cigarettes smoked up to 20 per day [11.3 ng/mL (95% confidence interval, 10.5-12.2)] and then stabilized as the number of cigarettes exceeded 20 [6.8 ng/mL per cigarette (95% confidence interval, 6.3-7.4) for up to 40 cigarettes]. On average, smokers of regular cigarettes consumed more cigarettes and had higher cotinine levels than light cigarette smokers. Cotinine concentration per cigarette smoked did not differ between regular and light cigarette smokers. Results suggest a saturation point for daily nicotine intake and minimal or no reduction in nicotine intake by smoking light cigarettes. (Cancer Epidemiol Biomarkers Prev 2006;15(10):1799–804)

BACKGROUND: Increased body mass index (BMI) is known to be related to ischaemic heart disease (IHD) in populations where many are overweight (BMI>or=25 kg/m2) or obese (BMI>or=30). Substantial uncertainty remains, however, about the relationship between BMI and IHD in populations with lower BMI levels. METHODS: We examined the data from a population-based, prospective cohort study of 222,000 Chinese men aged 40-79. Relative and absolute risks of death from IHD by baseline BMI were calculated, standardized for age, smoking, and other potential confounding factors. RESULTS: The mean baseline BMI was 21.7 kg/m2, and 1942 IHD deaths were recorded during 10 years of follow-up (6.5% of all such deaths). Among men without prior vascular diseases at baseline, there was a J-shaped association between BMI and IHD mortality. Above 20 kg/m2 there was a positive association of BMI with risk, with each 2 kg/m2 higher in usual BMI associated with 12% (95% CI 6-19%, 2P=0.0001) higher IHD mortality. Below this BMI range, however, the association appeared to be reversed, with risk ratios of 1.00, 1.09, and 1.15, respectively, for men with BMI 20-21.9, 18-19.9, and

Background Cause-specific mortality statistics remain scarce for the majority of low-income countries, where the highest disease burdens are experienced. Neither facility-based information systems nor vital registration provide adequate or representative data. The expansion of sample vital registration with verbal autopsy procedures represents the most promising interim solution for this problem. The development and validation of core verbal autopsy forms and suitable coding and tabulation procedures are an essential first step to extending the benefits of this method. Methods and Findings Core forms for peri- and neonatal, child, and adult deaths were developed and revised over 12 y through a project of the Tanzanian Ministry of Health and were applied to over 50,000 deaths. The contents of the core forms draw upon and are generally comparable with previously proposed verbal autopsy procedures. The core forms and coding procedures based on the International Statistical Classification of Diseases (ICD) were further adapted for use in China. These forms, the ICD tabulation list, the summary validation protocol, and the summary validation results from Tanzania and China are presented here. Conclusions The procedures are capable of providing reasonable mortality estimates as adjudged against stated performance criteria for several common causes of death in two countries with radically different cause structures of mortality. However, the specific causes for which the procedures perform well varied between the two settings because of differences in the underlying prevalence of the main causes of death. These differences serve to emphasize the need to undertake validation studies of verbal autopsy procedures when they are applied in new epidemiological settings., A procedure for recording verbal autopsy information was tested in two countries and found to be capable of providing reasonable mortality data. The need to undertake validation studies was also demonstrated., Editors' Summary Background. People living in developed countries take it for granted that when a loved one dies an accurate cause-of-death certificate will be issued. But for two-thirds of the deaths that occur worldwide, there are no certificates. Detailed information about what people die from is unavailable for more than 50% of countries, many of which have high death rates. This information is badly needed for public-health planning, for using scarce health resources wisely, and for monitoring the effect of new health initiatives. One way to improve knowledge about what people die from is a procedure called verbal autopsy (VA). Relatives or caregivers are interviewed about the symptoms experienced by the deceased before their death and the circumstances surrounding their death by trained personnel who use a standard form. Doctors then review the completed VA forms and assign a specific cause of death from a short version of the International Classifications of Diseases, or ICD, an internationally agreed on list of codes for hundreds of diseases. Why Was This Study Done? VA procedures are being developed in many countries, but each step in a VA can be affected by factors that vary from place to place, such as how long after the death the interview is done, the training that interviewers receive, how the questions are worded, and the locally common diseases, which tend to be recognized better than rare diseases. To ensure that the data collected are accurate and comparable between countries and also over time, VA procedures need to be standardized. In this study, the researchers describe their efforts to achieve this through the development and validation of core VA procedures. What Did the Researchers Do and Find? In 2001, the researchers refined the VA forms that were being used in Tanzania for deaths occurring around the time of birth and for deaths occurring in childhood and adulthood. They then translated the forms for use in China, adapting them slightly to allow for cultural differences in how symptoms are described. They also drew up a short list of ICD codes to use in tabulating and validating important causes of death. Then, for four years, they collected VA and medical record information for the same deceased individuals and measured how well the VA procedure agreed with the medical record information in both countries. They found that the procedure could be transferred between China and Tanzania but that it performed rather differently for different causes of death in the two countries. So, in both countries, the procedure accurately recorded tuberculosis, cerebrovascular diseases such as strokes, and transport accidents as causes of death. But some other causes of death were accurately recorded in one country only—generally the common diseases in that country—and many causes of death were inaccurately reported in both countries. What Do These Findings Mean? The researchers use their experience of developing VAs for use in Tanzania and China and the results of this study to make several recommendations about how to develop standardized VA procedures that will yield accurate cause of death. For example, they suggest that the VA form should contain a detailed core symptom duration checklist and only a short space for a narrative history (an open-ended description of the last illness provided by the relative or caregiver) because long narrative histories are hard to standardize. They discuss the need to adapt core VA forms when moving between countries to allow for linguistic differences and colloquial expression and also the need to consider cultural differences between countries—for example, how soon after bereavement a VA interview can occur. Most importantly, they strongly recommend that validation studies like theirs should be routinely done when VA procedures are applied in new countries or if the major cause of death in a country changes because of a new epidemic or health initiative. Provided this is done, write the researchers, although VA procedures can never be as accurate as proper medical certification at the time of death, they should provide important information about the causes of death for the many countries where this information would otherwise be completely missing. Additional Information. Please access these Web sites via the online version of this summary at http://dx.doi.org/10.1371/journal.pmed.0030268. • World Health Organization information on mortality and on the International Classification of Diseases • The United Nations' World Mortality Report 2005 • Information on the Tanzania Ministry of Health Adult Morbidity and Mortality Project, which used the VA procedures on which this study was based • A description of a standard VA method for investigating deaths in infants and children from the World Health Organization • The INDEPTH Network, an organization collecting health statistics from developing countries that provides standardized VA forms • MEASURE Evaluation, a USAID-funded project that, in collaboration with the US Census Bureau and the University of Queensland (Australia), supports countries to implement core VA procedures and sample/sentinel vital registration methods • The Health Metrics Network, a global collaboration focused on strengthening country health information systems to generate sound data for decision-making at country and global levels, is committed to improving sources of vital statistics and cause-of-death data

Background. Acts of suicide differ widely in the amount of planning preceding the act. Correlates of completed suicide in China identified in a previous investigation were re-examined to identify those that may be especially relevant to low-planned (impulsive) and high-planned suicidal behavior. The association of planning and method in completed suicide was also assessed.Method. A psychological autopsy study of 505 suicide decedents aged [ges ]18 years sampled to be representative of suicides in China was conducted. Multinomial regression analyses compared three levels of suicide planning (low, intermediate, high).Results. Women and younger individuals were more likely to carry out low-planned and intermediate-planned than high-planned acts of suicide. Greater acute stress distinguished low-planned from high-planned suicides. Ingestion of pesticides stored in the home was a more commonly employed method in low-planned than high-planned suicides.Conclusions. Low-planned suicides are more common in women, in younger individuals, and among those who are experiencing acute stress. Prevention strategies targeted at restricting access to pesticides may preferentially lower the rate of low-planned suicides.

Background Mortality statistics are key inputs for evidence based health policy at national level. Little is known of the empirical basis for mortality statistics in China, which accounts for roughly one-fifth of the world's population. An adequate description of the evolution of mortality registration in China and its current situation is important to evaluate the usability of the statistics derived from it for international epidemiology and health policy. Current situation The Chinese vital registration system currently covers 41 urban and 85 rural centres, accounting for roughly 8 % of the national population. Quality of registration is better in urban than in rural areas, and eastern than in western regions, resulting in significant biases in the overall statistics. The Ministry of Health introduced the Disease Surveillance Point System in 1980, to generate cause specific mortality statistics from a nationally representative sample of sites. Currently, the sample consists of 145 urban and rural sites, covering populations from 30,000 – 70,000, and a total of about 1 % of the national population. Causes of death are derived through a mix of medical certification and 'verbal autopsy' procedures, applied according to standard guidelines in all sites. Periodic evaluations for completeness of registration are conducted, with subsequent corrections for under reporting of deaths. Conclusion Results from the DSP have been used to inform health policy at national, regional and global levels. There remains a need to critically validate the information on causes of death, and a detailed validation exercise on these aspects is currently underway. In general, such sample based mortality registration systems hold much promise as models for rapidly improving knowledge about levels and causes of mortality in other low-income populations.

BACKGROUND: In China, tobacco smoking accounts for approximately 800 000 deaths annually and evidence suggests that tobacco use is rising. To improve tobacco control initiatives directed at youth, we conducted a population-based survey of children ages 11-20 years, both in and out of school. While there have been previous school-based studies on smoking prevalence and smoking-related knowledge, attitudes, and behaviours among adolescents in China, including the Global Youth Tobacco Survey, this survey also describes smoking behaviour among non-student youth. This population is important as approximately 40% of Chinese youths aged 15-19 years have already discontinued their studies. METHODS: A survey of smoking behaviour and smoking-related knowledge and attitudes was administered to 24 000 youths (students and non-students of middle school age) in 24 disease surveillance points in China, selected to include equal numbers of urban and rural children. RESULTS: The prevalence rates of experimenting were 47.8% for boys and 12.8% for girls. The prevalence of regular smoking among non-students was higher (8.3%) compared with students (5.2%). The strongest predictor of regular smoking was peer influence with 44% reporting that they obtained their first cigarette from peers. The majority of youths were aware that smoking was a cause of several diseases and addictive; however, non-students were less aware than students. CONCLUSIONS: The evidence highlights the need for tobacco control interventions aimed at youths in China including non-student youths. For males, prevention programmes should extend into young adulthood.

Eleven countries in the world have a population at or exceeding 100 million: Bangladesh, Brazil, China, India, Indonesia, Japan, Mexico, Nigeria, Pakistan, Russia, and the United States. Together, these diverse countries represent over 60% of the world’s population. In 1998, in response to critical trans-national health issues and the transition of global disease burden from communicable to non-communicable diseases (NCDs) (Murray and Lopez, 1996), the World Health Organization (WHO) formed a network among these countries to combine efforts towards improving world health. This network, called the Mega Country Health Promotion Network, was bora out of recognition that these highly populated countries have the potential to impact world health by working together to strengthen infra-structure for tackling common global health issues.

In this 2010 national survey of Chinese adults, almost 53% of men and more than 2% of women were current smokers. On the basis of the survey results, the authors estimate that there are more than 300 million smokers in China.

OBJECTIVES To describe patterns of smoking and smoking cessation in China within the context of the stages of change model, using data from the 1996 national prevalence survey. DESIGN A cross sectional survey was carried out using the 145 preselected disease surveillance points, which provide a representative sample for the entire country. A standardised questionnaire on smoking was interviewer administered. SETTING The country of China. SUBJECTS 122 220 people aged 15–69 years. MAINTENANCE MEASURES Smoking cessation patterns, as defined by smoking status (current or former) and stage of change (precontemplation, contemplation, and action). RESULTS The sample included 45 995 ever smokers of whom 4336 had quit. About 72% of current smokers reported not intending to give up their smoking behaviour, and about 16% of current smokers said they intended to do so, but have not taken any action. Of all ever smokers, the percentage of former smokers was 9.5%, and 12% of current smokers had quit at least once, but relapsed by the time of the survey. The patterns were similar in men and women with regard to the stated intent to quit. Among males, the percentage of former smokers increased with age but the percentage intending to quit was constant at about 15% across age strata. The most common reason for quitting was illness. Participants with a university education were more likely to have made an attempt to quit. CONCLUSIONS The percentage of smokers contemplating quitting was low in China in 1996. The study shows that smokers in China must be mobilised to contemplate quitting and then to take action. Key points 72% of current smokers in China did not intend to give up smoking in 1996 About 10% of ever smokers in China have stopped smoking The relapse rate equals the rate of quitting Key professional groups (health workers and teachers) have similar cessation patterns to the general population The most common reason for quitting was illness Smokers in China should be mobilised to contemplate quitting and then to take action

This paper contains the results of the 1996 National Smoking Prevalence Survey. Of a representative sample of 120 000 adults aged 15 or over, 67% of the men and 4.2% of the women smoked. The rates for people aged 15–24 were lower, since it is in this age range that most smokers start the habit. Thus, 300 million people in China are current smokers. Among people aged 25–49, the prevalence of smoking was 69% among males (66% urban, 71% rural) and 2% among females (1% urban, 3% rural). In addition, 53% of non-smokers are exposed to passive smoking. Data from the prevalence survey were cross-tabulated by level of education, occupation, region, ethnic group and numerous variables related to knowledge and attitudes about smoking.

ContextAs the world's largest producer and consumer of tobacco products, China bears a large proportion of the global burden of smoking-related disease and may be experiencing a tobacco epidemic.ObjectiveTo develop an evidence-based approach supporting tobacco control initiatives in China.Design and SettingA population-based survey consisting of a 52-item questionnaire that included information on demographics, smoking history, smoking-related knowledge and attitudes, cessation, passive smoke exposure, and health status was administered in 145 disease surveillance points in the 30 provinces of China from March through July 1996.ParticipantsA nationally representative random sample of 128,766 persons aged 15 to 69 years were asked to participate; 120,298 (93.8%) provided data and were included in the final analysis. About two thirds of those sampled were from rural areas and one third were from urban areas.Main Outcome MeasuresCurrent smoking patterns and attitudes; changes in smoking patterns and attitudes compared with results of a previous national survey conducted in 1984.ResultsA total of 41,187 respondents smoked at least 1 cigarette per day, accounting for 34.1% of the total number of respondents, an increase of 3.4 percentage points since 1984. Current smoking continues to be prevalent among more men (63%) than women (3.8%). Age at smoking initiation declined by about 3 years for both men and women (from 28 to 25 years). Only a minority of smokers recognized that lung cancer (36%) and heart disease (4%) can be caused by smoking. Of the nonsmokers, 53.5% were exposed to environmental tobacco smoke at least 15 minutes per day on more than 1 day per week. Respondents were generally supportive of tobacco control measures.ConclusionThe high rates of smoking in men found in this study signal an urgent need for smoking prevention and cessation efforts; tobacco control initiatives are needed to maintain or decrease the currently low smoking prevalence in women.

In many countries most deaths occur at home. Such countries often have civil registration systems that are limited or non-existent and therefore most deaths go unrecorded. Countries that cannot record the number of people who die or why they die cannot realize the full potential of their health systems. Health systems need reliable numbers and causes of death to function properly. But in these circumstances – in the absence of a complete picture of the population’s health – there are tools and techniques that can be used to obtain a fairly accurate representation of mortality trends. It takes a long time for countries to achieve a fully functioning civil registration system with medical certification of cause of death. In the meantime, more and more countries are using verbal autopsies (VA) to meet the information needs of their health systems.1 Verbal autopsy is a method of ascertaining probable causes of a death based on an interview with primary caregivers about the signs, symptoms and circumstances preceding that death. Different institutions have been researching and developing all aspects of the verbal autopsy process over the past two decades. We have also been working on this process, particularly to improve the questionnaire and the methods of analysing the resulting information. However, this has been a largely uncoordinated effort and one that has not reached consensus on what to cover in the interview and how to analyse the results, despite previous attempts to promote standard tools.2–4 The main consequence of this failure to agree on a standard approach is that now we cannot compare results from different countries. Currently, 36 Demographic Surveillance Sites (DSS) in 20 countries, the Sample Registration System (SRS) sites in India, and the Disease Surveillance Points (DSP) in China regularly use VA on a large scale, primarily to assess the causes-of-death structure of a defined population.1 Despite such a widespread use of verbal autopsy, we are unable to assess how consistent and reliable the data are. We are also unable to replicate procedures used to assign cause of death. Because verbal autopsy data sets are not widely shared, it is impossible to independently assess the quality of the assignment. Really useful validation studies are rare and verbal autopsy research is often done on small and non-representative samples of the population. The Millennium Development Goals (MDG) have put pressure on countries to track their progress in terms of population health. But to track that progress, countries need reliable numbers. In other words, they need a strong empirical basis for cause-specific mortality data. This is essential for evaluating the impact of disease control programmes and major global health initiatives. One way of dealing with incomplete information is to use models of mortality patterns. But cause-of-death information predicted by such models is not suitable for monitoring progress on what works and what does not.5 That leaves verbal autopsy as the only practical option in these countries and one that will play a key role in tracking progress towards the MDGs. Agreement on a core set of verbal autopsy tools (including technical standards and guidelines for their use) and their widespread adoption is needed now. To tackle this challenge, WHO led an expert group of researchers, data users, and other stakeholders, with sponsorship from the Health Metrics Network (HMN), in developing the necessary standards. The expert group systematically reviewed, debated, and condensed the accumulated experience and evidence from the most widely-used and validated procedures. This synthesis was done to achieve a high degree of consistency and comparability across verbal autopsy data sets. WHO has now published the results of this collaboration as: Verbal autopsy standards: ascertaining and attributing cause of death. The new standards include: Verbal autopsy questionnaires for three age groups (under four weeks; four weeks to 14 years; and 15 years and above); Cause-of-death certification and coding resources consistent with the International Classification of Diseases and Related health Problems, tenth revision (ICD-10); and A cause-of-death list for verbal autopsy prepared according to the ICD-10. The content is freely available on the WHO web site (www.who.int) and will be distributed in print; and incorporated into HMN’s resource kit. This is an important publication, but it is not the last word on verbal autopsy methods. Research is needed to validate these standard core procedures in several countries with different patterns of mortality. Other areas of research include further development of items included in questionnaires, and automated methods for assigning causes of death from verbal autopsy that remove human bias, while producing replicable and valid results.6 Operational issues need addressing: sampling methods and size when using verbal autopsy tools in research demographic surveillance sites; sample or sentinel registration; censuses; and household surveys. Research is also required when adapting these questionnaires to specific situations in different countries, taking into account relevant cultural, epidemiological and administrative considerations. WHO is working with partners to do this research and develop guidelines on these issues. With time, this guidance and experience will better inform the users of verbal autopsy, and improve the comparability and consistency of its results. For the present, we urge that these new international consensus standards become the foundation of verbal autopsy practices wherever possible. ■