Smoking cessation for Chinese men and prevention for women
Authors: Jeffrey Koplan, Michael Eriksen
Journal: The Lancet (2015)

Tobacco use is the largest preventable cause of death worldwide. It is estimated that more than 6 million people die every year from tobacco use, and that this growing toll will lead to more than a billion deaths in the 21st Century.1Mathers CD Loncar D Projections of global mortality and burden of disease from 2002 to 2030.PLoS Med. 2006; 3: e442Crossref PubMed Scopus (7699) Google Scholar, 2Jha P Avoidable global cancer deaths and total deaths from smoking.Nat Rev Cancer. 2009; 9: 655-664Crossref PubMed Scopus (381) Google Scholar China is at the epicentre of the global tobacco epidemic and accounts for 1 million of these deaths annually.3Chen Z Peto R Zhou M et al.for the China Kadoorie Biobank (CKB) collaborative groupContrasting male and female trends in tobacco-attributed mortality in China: evidence from successive nationwide prospective cohort studies.Lancet. 2015; 386: 1447-1456Summary Full Text Full Text PDF PubMed Scopus (283) Google Scholar If current rates of smoking in China continue unabated, 2 million people in China will die per year in 2030, contributing greatly to the global burden of disease. Complicating any efforts to reduce the public health burden of tobacco is the fact that China is the world's largest grower, manufacturer, and consumer of tobacco and has the largest workforce devoted to tobacco farming, manufacturing, and sales. Being a government monopoly, China Tobacco (the Chinese National Tobacco Corporation) provides over 7% of the Central Government's annual revenue through both taxes and net income.4Eriksen M Mackay J Schluger N Gomeshtapeh FI Drope J The tobacco atlas. 5th edn. The American Cancer Society, Georgia2015Google Scholar In The Lancet, the study by Zhengming Chen and colleagues3Chen Z Peto R Zhou M et al.for the China Kadoorie Biobank (CKB) collaborative groupContrasting male and female trends in tobacco-attributed mortality in China: evidence from successive nationwide prospective cohort studies.Lancet. 2015; 386: 1447-1456Summary Full Text Full Text PDF PubMed Scopus (283) Google Scholar reveals the extent of the tobacco challenge in China, its peculiar characteristics, and most importantly future implications unless aggressive public health actions are taken to promote smoking cessation in men. The study examines national trends in prevalence in two large cohorts during a period of about 14 years. Given the multi-year latency period from tobacco exposure to onset of various smoking-associated diseases, careful data-based projections of future burden are crucial for the planning, implementation, and assessment of policies aimed at smoking prevention and control. A striking characteristic of the tobacco epidemic in China is its gender distribution: 68% of men and 3·2% of women were smokers in Chen and colleagues' study3Chen Z Peto R Zhou M et al.for the China Kadoorie Biobank (CKB) collaborative groupContrasting male and female trends in tobacco-attributed mortality in China: evidence from successive nationwide prospective cohort studies.Lancet. 2015; 386: 1447-1456Summary Full Text Full Text PDF PubMed Scopus (283) Google Scholar (defined as ever regular users from the 2004–08 second cohort study). This distribution produces a correspondingly large effect on tobacco-attributed mortality, which is rising in men and falling in women. This effect has several implications. While men are at substantial risk of death and disease from active smoking, women are at risk from passive exposure at home and in the workplace.5Gan Q Smith KR Hammond SK Hu TW Disease burden of adult lung cancer and ischaemic heart disease from passive tobacco smoking in China.Tob Control. 2007; 16: 417-422Crossref PubMed Scopus (63) Google Scholar Although female smoking rates are associated with older ages, young Chinese women remain an attractive target for the tobacco industry, with the allure of increasing sales by crafting appeals based on themes of independence, glamour, sophistication, sexuality, and social acceptance. Such a focus on attracting female smokers has been used successfully in other countries during periods of social reform and changing roles for women. In the USA, Edward Bernays, while employed by the American Tobacco Company, encouraged smoking among women under the guise of emancipation by calling cigarettes "Torches of Freedom".6Tye L The father of spin: Edward L Bernays and the birth of public relations. Macmillan, New York2002Google Scholar While Chinese public health policies and programmes need to aggressively encourage men to quit smoking, they also need to guard assiduously against smoking initiation, not only among men, but also among adolescent girls and young adult women. A disturbing feature of the new study3Chen Z Peto R Zhou M et al.for the China Kadoorie Biobank (CKB) collaborative groupContrasting male and female trends in tobacco-attributed mortality in China: evidence from successive nationwide prospective cohort studies.Lancet. 2015; 386: 1447-1456Summary Full Text Full Text PDF PubMed Scopus (283) Google Scholar is the further documentation of the trend toward smoking initiation at an earlier age. Men born in the 1930s began smoking at about 25 years of age, but those born in 1970 started at an average age of about 20, implying that many started before age 20, and almost all used cigarettes. These extra years of cigarette smoking significantly increase the eventual risk from tobacco exposure. Several myths about tobacco and its use have limited the effectiveness of health education messages in China.7Ma S Hoang MA Samet JM et al.Myths and attitudes that sustain smoking in China.J Health Commun. 2008; 13: 654-666Crossref PubMed Scopus (51) Google Scholar These include the belief that protective biological mechanisms specific to Asian populations make smoking less hazardous, that it is easy to quit smoking, and that tobacco use is an intrinsic and ancient part of Chinese culture. The new study3Chen Z Peto R Zhou M et al.for the China Kadoorie Biobank (CKB) collaborative groupContrasting male and female trends in tobacco-attributed mortality in China: evidence from successive nationwide prospective cohort studies.Lancet. 2015; 386: 1447-1456Summary Full Text Full Text PDF PubMed Scopus (283) Google Scholar clearly shows the severe health consequences of tobacco use for premature mortality among Chinese men. One difference in the Chinese mortality pattern compared with that in western populations is that rates of chronic lung disease are relatively higher than coronary heart disease rates, possibly because of the larger role of indoor air pollution (from cooking and heating) compared with new forms of outdoor air pollution (produced by industry, power generation, and cars). To prevent millions of future deaths, the findings of the new study suggest some possible solutions. First, Chinese men need to quit smoking; they can receive great benefits if they quit before age 35 years (and preferably well before 35 years), but for those who have not yet developed a fatal disease, even quitting at later ages offers substantial gains. Secondly, the remarkably low level of smoking among Chinese women needs to be preserved, which will require sustained effort, especially since experimentation with tobacco among adolescent girls has increased substantially since the 1980s,8Han J Chen X A meta-analysis of cigarette smoking prevalence among adolescents in China: 1981–2010.Int J Environ Res Public Health. 2015; 12: 4617-4630Crossref PubMed Scopus (54) Google Scholar and exposure to secondhand smoke needs to be controlled. The greatest challenge in making progress to reduce the burden of mortality from smoking in China over the next few decades is to increase rates of smoking cessation. In their study population, Chen and colleagues3Chen Z Peto R Zhou M et al.for the China Kadoorie Biobank (CKB) collaborative groupContrasting male and female trends in tobacco-attributed mortality in China: evidence from successive nationwide prospective cohort studies.Lancet. 2015; 386: 1447-1456Summary Full Text Full Text PDF PubMed Scopus (283) Google Scholar noted that less than 10% of Chinese ever-smokers had quit by choice (as opposed to quitting because they were ill). By contrast, in many high-income countries, there are more ex-smokers than current smokers, suggested by quit rates in excess of 50%.9Giovino GA Mirza SA Samet JM et al.Tobacco use in 3 billion individuals from 16 countries: an analysis of nationally representative cross-sectional household surveys.Lancet. 2012; 380: 668-679Summary Full Text Full Text PDF PubMed Scopus (542) Google Scholar These sobering facts appropriately lead Chen and colleagues to conclude that "Widespread smoking cessation offers China one of the most effective, and cost-effective, strategies to avoid disability and premature death over the next few decades." A promising finding from another nationwide study10Liang X Report of China city adult tobacco survey 2013–14: a 14-city experience. CDC Foundation, Atlanta2015Google Scholar is evidence of increasing rates of quitting attempts and successful quitting in cities with active tobacco control programmes. Robust efforts at the municipal level, along with effective provincial and national policies, offer hope that the public health actions proven to be effective in some Asian locales, such as Hong Kong and Taiwan, can alter the trajectory of death and disease among men in mainland China, and change the social norm of widespread smoking and lost years of life and health. JK and ME have received funding from the Bill & Melinda Gates Foundation and Pfizer for promotion of tobacco control in China. Contrasting male and female trends in tobacco-attributed mortality in China: evidence from successive nationwide prospective cohort studiesSmoking will cause about 20% of all adult male deaths in China during the 2010s. The tobacco-attributed proportion is increasing in men, but low, and decreasing, in women. Although overall adult mortality rates are falling, as the adult population of China grows and the proportion of male deaths due to smoking increases, the annual number of deaths in China that are caused by tobacco will rise from about 1 million in 2010 to 2 million in 2030 and 3 million in 2050, unless there is widespread cessation. Full-Text PDF Open Access