Articles
Trends in smoking prevalence and implication for chronic diseases in China: serial national cross-sectional surveys from 2003 to 2013

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Summary

Background

China is the world's largest consumer of tobacco and has a large smoking-related chronic disease burden. In this nationwide study, we aimed to evaluate smoking prevalence and its implication on chronic diseases in the Chinese population.

Methods

We collected data from serial cross-sectional National Health Service Surveys done in China in 2003, 2008, and 2013. These surveys cover all 31 provinces, autonomous regions, and municipalities in mainland China, and use multistage stratified cluster sampling. We divided mainland China into east, central, and west regions and then sampled counties from each region stratified by urban and rural areas. All respondents aged 15 years or older in the selected households were eligible. We analysed the variation in smoking prevalence from 2003 to 2013, further identified risk factors for smoking, and assessed the association between smoking and chronic diseases by using multiple logistic regression.

Findings

The number of individuals interviewed and involved in the study was 153 450 in 2003, 145 223 in 2008, and 229 676 in 2013. The standardised smoking prevalence in China was consistently high, with a proportion of current smokers of 26·0% (95% CI 25·8–26·2) in 2003, 24·9% (24·8–25·1) in 2008, and 25·2% (25·1–25·4) in 2013 (p value for trend 0·5062). For men, prevalence was 48·4% (48·1–48·7) in 2003, 47·0% (46·6–47·4) in 2008, and 47·2% (46·9–47·5) in 2013. For women, prevalence was 3·1% (3·0–3·2) in 2003, 2·3% (2·2–2·5) in 2008, and 2·7% (2·6–2·8) in 2013. Smoking prevalence varied in different regions, and we identified four major patterns. While a consistently high proportion of Chinese men smoked, the standardised smoking prevalence in women younger than 40 years increased from 1·0% in 2003 to 1·6% in 2013. Moreover, the smoking prevalence among adolescent smokers aged 15–24 years increased from 8·3% in 2003 to 12·5% in 2013. Alcohol consumption was closely linked to smoking in adolescents (odds ratio 7·5, 95% CI 6·9–8·1). Risk factors for adolescent smoking were having older family members who smoke (1·9, 1·8–1·9) and low level education (1·3, 1·2–1·4). Increased risks of chronic diseases were related to smoking (1·1, 1·0–1·1), with higher risks related to early smoking initiation (1·1, 1·0–1·1) and long-term smoking (1·2, 1·2–1·3).

Interpretation

The implementation of tobacco control policies in China since the signing of the WHO Framework Convention on Tobacco Control in 2003 has not been effective in reducing smoking prevalence. Smoking prevalence among adolescents of both genders has increased substantially and there has been a steady increase among young women. More practical and effective policies targeting adolescents and women are urgently needed. Action is needed to prevent the large and growing smoking-related chronic disease burden further increasing as China's population ages.

Funding

National Health Commission of the People's Republic of China.

Introduction

In 2003, WHO launched a worldwide tobacco control campaign—the Framework Convention on Tobacco Control (FCTC)—with the aim of creating a tobacco-free world.1 Some high-income countries such as the USA and the UK have shown a remarkable decline in smoking prevalence in the past decade, whereas recent estimates suggest that many low-income and middle-income countries (LMICs) are not on track to achieve tobacco control targets. 2, 3 The Global Youth Tobacco Survey (GYTS)—a school-based survey of smoking prevalence in teenagers aged 12–15 years—has shown a prevalence of tobacco use of 13·6% and a prevalence of second-hand smoke exposure of 55·9% for adolescents in LMICs.4 China is the largest consumer of tobacco as well as the most populous LMIC in the world.5 Since the Chinese Government signed the WHO FCTC in 2003, China has issued a series of national and local rules and regulations for tobacco control such as banning smoking in some public places, health warning labelling, and raising tobacco taxes.6 The efficacy of these policies in China remains to be elucidated. Several reports based on a single cross-sectional national survey have shown high smoking prevalence in China between 2004 and 2015.5, 7, 8, 9, 10, 11 However, no study based on serial national surveys has conducted a comprehensive evaluation of the efficacy of tobacco control policies during this period and provided solid data.

Research in context

Evidence before this study

We searched PubMed for articles published up to May, 2018, using the terms “smoking” OR “tobacco use” AND “chronic diseases” AND “trend” OR “prevalence” and retrieved a total of 14 324 papers. Among them, 866 papers included data from China. None of these papers reported nationwide trends of tobacco use and its association with chronic diseases in China after 2003. We also searched PubMed using (“smoking”[MeSH Major Topic] AND prevalence [Title/Abstract]) AND China [Title/Abstract]) and retrieved 242 articles. We identified six national surveys for smoking prevalence after 2003. Four surveys of Chronic Disease Risk Factor Surveillance in China were carried out in 2004, 2007, 2010, and 2013. Three of them surveyed individuals aged 18 years or older whereas only one surveyed individuals aged 15–69 years, meaning the trends of smoking prevalence in adolescents aged 15–18 years could not be well studied in these surveys. Two national surveys were carried out in 2010 and 2015 with a relatively smaller sample size of around 15 000 people, using the same survey method of the Global Adult Tobacco Survey (GATS). All surveys we found used an individual-based approach whereas our study used a household-based approach. We estimated familial aggregation by using multistage household cluster sampling. Only the 2010 GATS was reported on a global scale, whereas the other five surveys have not been reported globally. Researchers in the Global Burden of Diseases, Injuries, and Risk Factors Study 2015 estimated daily smoking prevalence by sex and age group for 195 countries from 1990 to 2015. Additionally, Bilano and colleagues investigated smoking prevalence and cigarette consumption in 173 countries for men and 178 countries for women from 1980 to 2012. However, none of these studies explored the most recent trends of smoking prevalence and chronic disease burden in China. Moreover, all of them were either a single cross-sectional study or on the global scale instead of focusing on China.

Added value of this study

Our national study, covering all the provinces in mainland China and spanning from 2003 to 2013, presents the most recent patterns of smoking prevalence and its relationship with NCDs in China since the WHO FCTC launched globally. Our results show that smoking prevalence in China remained at a high plateau during the studied decade. The smoking prevalence in some regions was significantly higher than the national average. In particular, we show a rapid increase in smoking prevalence in adolescents in China. Moreover, our study indicated an increase in smoking prevalence in women younger than 40 years. We identified the number of older family members who smoke—especially when the family members are female—as a risk factor for smoking in adolescents. We show a non-linear, negative correlation between chronic diseases and smoking initiation age, suggesting that individuals who started smoking earlier had a higher risk of chronic diseases.

Implications of all the available evidence

China has failed to fulfil the WHO FCTC fully in the studied decade. The increase in smoking prevalence among adolescents and women, combined with the association of female family members who smoke with increased adolescent smoking prevalence, implies that the Chinese Government should establish more stringent policies and enforce the law more strictly, with a strong focus on stopping and reversing the increased prevalence in adolescents and women.

Tobacco use is one of the most important preventable causes of chronic non-communicable diseases (NCDs) and premature deaths worldwide.12 The United Nation's Sustainable Development Goals aim to reduce mortality from NCDs-attributed premature death by a third by 2030.13 NCDs accounted for more than 80% of total deaths in 2013 in China.14 A nationwide study15 has shown that about 99·9 million Chinese adults aged 20 years or older have chronic obstructive pulmonary disease (COPD).15 Controlling smoking prevalence is considered to be one of the most effective ways for the reduction of four major NCDs, including ischaemic heart disease, cancer, chronic respiratory diseases, and diabetes.16 However, the association between smoking and chronic diseases prevalent in China has yet to be reported. The Chinese Government aims to reduce smoking prevalence to 20% in the Chinese population aged 15 years or older by 2030.17 To achieve this goal, it is essential to evaluate the efficacy and implementation of tobacco control strategies periodically. Here, we present the trends in smoking prevalence from 2003 to 2013 and an assessment of the association between smoking and chronic NCDs in China.

Section snippets

Data sources and sampling

We based our study on the latest three rounds (done in 2003, 2008, and 2013) of the National Health Services Survey (NHSS), which have been organised by the National Health Commission (NHC) of the People's Republic of China at 5-year intervals since 1993. The NHSS is a serial cross-sectional survey covering all 31 provinces, autonomous regions, and municipalities in the mainland of China that aimed to provide information about Chinese individuals' health to aid policy makers (see appendix p 3

Results

We sampled 57 023 households from 28 counties in urban areas and 67 counties in rural areas in 2003, 56 456 households from 28 urban counties and 66 rural counties in 2008, and 93 613 households from 78 urban counties and 78 rural counties in 2013. The number of individuals interviewed and involved in the study was 153 450 in 2003, 145 223 in 2008, and 229 676 in 2013 (figure 1). Individuals were comparable for most demographic and socioeconomic variables and health-related behaviours across

Discussion

Our serial surveys indicate the temporal trends of smoking prevalence in China since the WHO FCTC was launched worldwide. Although health care improved substantially in China during these years,18 smoking prevalence has remained consistently high, at 25·2% in 2013, and no trend of decline was observed over the period 2003–13. Furthermore, gender-standardised smoking prevalence in adolescents increased from 8·3% in 2003 to 12·5% in 2013; increases among adolescents were observed in both the

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