Trends in smoking and quitting in China from 1993 to 2003: National Health Service Survey data

769 Research Bull World Health Organ 2010;88:769–776 | doi:10.2471/BLT.09.064709 Introduction About one in every three adults (or 1.1 billion adults) smokes worldwide, and 80% of smokers live in the developing world.1 China is the world’s largest cigarette consumer and producer.2 In 2002, about 350 million adults reported having smoked at some point and 300 million reported being smokers at the time.3 According to previous surveys, smoking prevalence and cigarette consumption increased during the 1980s and 1990s.4 By 1996, 63% of men and 4% of women > 15 years of age had smoked at least one cigarette per day at some point in their lives.4 By 2002, the fraction of men who smoked had risen to 66%, and the fraction of women smokers had dropped to 3.1%.3 Over 80 000 million packets of cigarettes were sold in China in 1998, or four times more than in 1970.5 According to serial surveys in Beijing, by the mid-1990s male smokers were consuming an average of 2 to 4 cigarettes more each day than in the mid-1980s,6 prob- ably as a result of increased economic prosperity, limited public health measures and poor anti-tobacco legislation in China.7 Most tobacco consumed in China is produced by the China State Tobacco Corporation.8 However, China’s entry into the World Trade Organization in 2001 marked the beginning of an increase in cigarette imports and a drop in the cost of foreign brands.8 Some fear that western marketing practices may increase smoking in China among young people in general and especially women, who still smoke relatively little.2 Smoking is a major cause of disability, premature death and loss of productivity.9–11 In China, the health risks of smoking appear to be as high as in Western countries, where the smoking epidemic started earlier.12–14 Approximately one-third to one-half of current male smokers in China are likely to have died from smoking-related diseases by 2030 if they do not quit.15,16 Many industrialized nations have witnessed substantial declines in smoking prevalence resulting from a greater aware- ness of the health risks, higher cigarette taxes,17 increased use of pharmacotherapy and other methods to quit smoking,18,19 and, most recently, bans on smoking in public places.20,21 In contrast, few Chinese people fully appreciate the harm that smoking can cause.4 In China cessation rates are low, few people intend to quit22,23 and relapse rates are high.24 We present data from large nationally-representative household surveys conducted in 1993, 1998 and 2003 to summarize smoking prevalence by sociode- mographic characteristics, cigarette consumption and smoking cessation over a 10-year period. National Smoking Prevalence Surveys3,4 (NSPS) have also been conducted in China, but they have been temporally far apart (1984, 1996, 2002) and the one in 2002 had a relatively small sample size (approximately 16 000). Our survey therefore complements the NSPS. Methods Data sources The methods used in the National Health Services Surveys (NHSS) have been described in detail elsewhere.25–28 In brief, multistage stratified cluster random sampling was used. The first stage sampled counties/districts, the second townships/ streets; the third stage randomly sampled two villages (rural areas) or residents’ committees (urban areas) in each township or street. The last stage randomly sampled 60 households in selected villages/residents’ committees; all household residents Une traduction en français de ce résumé figure à la fin de l’article. Al final del artículo se facilita una traducción al español. .ةلاقلما هذهل لماكلا صنلا ةياهن في ةصلاخلا هذهل ةيبرعلا ةمجترلا Objective China has about 350 million smokers, more commonly men. Using data from National Health Service Surveys conducted in 1993, 1998 and 2003, we (i) estimated trends in smoking prevalence and cessation according to sociodemographic variables and (ii) analysed cessation rates, quitting intentions, reasons for quitting and reasons for relapsing. Methods Data were collected from approximately 57 000 households and 200 000 individuals in each survey year. Household members > 15 years of age were interviewed about their smoking habits, quitting intentions and attitudes towards smoking. We present descriptive data stratified by age, sex, income level and rural versus urban residence. Findings In China, current smoking in those > 15 years old declined 60–49% in men and 5–3.2% in women over 1993–2003. The decline was more marked in urban areas. However, heavy smoking (≥ 20 cigarettes daily) increased substantially overall and doubled in men. The average age of uptake also dropped by about 3 years. In 2003, 7.9% of smokers reported intending to quit, and 6% of people who had ever smoked reported having quit. Of former smokers, 40.6% quit because of illness, 26.9% to prevent disease and 10.9% for financial reasons. Conclusion Smoking prevalence declined in China over the study period, perhaps due to the combined effect of smoking cessation, reduced uptake in women and selective mortality among men over 40 years of age. However, heavy smoking increased. People in China rarely quit or intend to quit smoking, except at older ages. Further tobacco control efforts are urgently needed, especially in rural areas. Trends in smoking and quitting in China from 1993 to 2003: National Health Service Survey data Juncheng Qian,a Min Cai,a Jun Gao,a Shenglan Tang,b Ling Xua & Julia Alison Critchleyc a Center for Health Statistics and Information, Ministry of Health, Beijing, China. b Special Programme for Research and Training in Tropical Diseases, Geneva, Switzerland. c Research Centre of Population Health, St George’s University of London, Cranmer Terrace, London SW17 0RE, England. Correspondence to Julia Alison Critchley (e-mail: jcritchley@sgul.ac.uk). (Submitted: 27 March 2009 – Revised version received: 9 March 2010 – Accepted: 10 March 2010 – Published online: 16 April 2010 ) Bull World Health Organ 2010;88:769–776 | doi:10.2471/BLT.09.064709770 Juncheng Qian et al.Smoking and smoking cessation in China, 1993–2003 Research were included. The surveys encompassed all 31 provinces in mainland China. The 1993 survey included 92 counties, 55 000 households and 215 163 people. The 1998 survey sampled 95 counties, 57 000 households and 216 101 people. The 2003 survey included 95 counties, almost 57 000 households and 193 698 people. Face-to-face interviews were conducted by trained, local investigators. Informa- tion was collected on sociodemographic variables, medical histories, health risk behaviours and medical care utilization and expenditures. Every person over 15 years of age in the household completed a questionnaire that covered smoking behaviour. Data quality checks included repeat interviews on a random sample of households. Response rates were con- sistently very high owing to the use of local interviewers, local sampling frames with replacement for empty households, and use of proxy respondents within the household. In 2003, over 99% of house- holds initially selected agreed to take part, and 99.6% of respondents answered the smoking-related questions. The NHSS samples were consistent with census es- timates in terms of age and sex structure and household size (Appendix A, avail- able from: http://www.ncl.ac.uk/ihs/ research/project/1635). Definitions Respondents were questioned on current smoking habits, age at uptake, attempts to quit, intention to quit, main reason for quitting and main reason for relapsing (2003 survey only). Those individuals who reportedly smoked at the time of the survey and who had smoked at least 100 cigarettes during their lifetime were defined as “current smokers”. Those who either smoked at the time of the survey or who had previously smoked but had quit were defined as “ever smokers”. The 1993 questions were more limited than those in later surveys and included cur- rent smoking prevalence only; they did not cover smoking history, attempts or intention to quit, age at uptake or the number of cigarettes smoked daily. The 2003 survey included an additional question to identify current smokers who had smoked at least 1 cigarette daily for a continuous period of at least 6 months. The prevalence estimate using this defini- tion is presented separately. A question on the number of cigarettes smoked daily was included in both the 1998 and 2003 surveys, but in 1998 it was formulated in broad categories only (< 10, 10–19, 20+), whereas in 2003 the exact number was requested. The 2003 data were therefore divided into three categories, and the coding change may have introduced slight bias. Heavy smokers were defined as those smoking at least 20 cigarettes daily. Similarly, the length of time since former smokers had quit the habit was coded in months in 2003 and in years in 1998. We defined as “successful quitters” those individuals who had not smoked at all over the previous 24 months or more. We chose this stringent definition because the relapse rate was expected to be high, many people smoked occasionally, and the definition was consistent with the categories reported in the NSPS in China.4 We defined as “current quitters” those individuals who reported having quit within the previous 24 months. We present these results separately as well as combined with the results for “successful quitters” (and labelled the combination variable as “total quitting”.) Data analysis We estimated the proportion of cur- rent and ever smokers; average cigarette consumption; cessation rates; quitting attempts, and attitudes towards quit- ting by age, sex, sociodemographic and economic variables (income, educational level), rural or urban location and survey year. Substantial differences exist between rural and urban parts of China in terms of household income (approximately three times higher in urban areas),29 occupation (predominantly agricultural, including tobacco farming, in rural areas,) and mortality (30% higher in rural areas).30 For consistency with other research conducted in China,4,31 we applied the definitions of the Ministry of Health to stratify urban and rural areas. We used logistic regression with robust standard errors (adjusting for “clustering” of smokers within households) to estimate associations between smoking, quitting, gender and socioeconomic variables, after controlling for possible confounders (Ap- pendix B, available at: http://www.ncl. ac.uk/ihs/research/project/1635). Finally, for validation we assessed the level of agreement between current smoking prevalence in 1998 and a vari- able combining the prevalence of current smoking in 2003 with the proportion of ever smokers who had quit in the preced- ing 5 years, stratified by gender and 5-year age group. All analyses were performed using SAS statistical software version 9.1 (SAS Institute, Inc., Cary, United States of America). Results Trends in smoking prevalence In 2003, 27.7% of the Chinese popula- tion aged 15 years or over had smoked cigarettes at some point, and 26.0% were smoking at the time they were interviewed (Table 1). The prevalence of current smok- ing fell from 32.2% in 1993, to 28.9% in 1998, to 26.0% in 2003. When the stricter definition of smoking was introduced in 2003 (at least 6 continuous months of smoking a minimum of 1 cigarette daily), prevalence for that year dropped from 26.0% to 20.6%. Smoking prevalence has decreased among both men and women in all age groups (Fig. 1). In 1993, 59.6% of men and 5.1% of women were current smokers; by 2003, the figures had fallen to 48.9% of men and 3.2% of women (Table 1). Smoking has declined more sharply among women (by 37.3%) than among men (by 18.0%), and smoking in men remains common. Over 60% of men aged 35–54 years reported being current smokers in 2003 (Fig. 1). Smoking was most frequent among men aged 35–64 years (55–61%) and among women 65 years of age or older (nearly 8%). Trends in consumption and age at uptake Between 1998 and 2003, the proportion of heavy smokers (≥ 20 cigarettes daily) among current smokers doubled (rose from 25.6% to 51.3%, Fig. 2), with the rise slightly greater in men than in women. In 2003, 17.1% of current smokers reported an increase in cigarette consumption, 13% reported a decrease and 70% reported no change. From 1993 to 1998, the age of smoking uptake among current smokers rose slightly, but it dropped from 1998 to 2003, although it remains higher in China than in developed economies, particularly among women. The age at uptake declined from 32.1 years in 1998 to 27.0 years in 2003 for women and from with 23.9 years to 21.5 for men. Intention to quit In 2003, 2.5% of men and 3.2% of women respondents were successful quitters (Fig. 1). An additional 3.6% of men and 3.9% of women were current quitters. Of current smokers, 15.8% reported having Bull World Health Organ 2010;88:769–776 | doi:10.2471/BLT.09.064709 771 Juncheng Qian et al. Smoking and smoking cessation in China, 1993–2003 Research tried to quit during the year before the survey, but the relapse rate was high; in both men and women, the mean duration of quitting was 5 months. Not surprisingly, quitting increased with age (Fig. 1), and there were more quitters in urban than in rural areas, but even in the latter cessation rates remained extremely low. Most worryingly, smoking cessation rates were lower in 2003 than in 1998 (Fig. 1). In 2003, only 7.9% of current smokers reported intending to quit over the next 2 years, and 62.1% of current smokers reported having no intention to quit smoking over this period (Table 2). Our data suggests that smoking prevalence fell over the period from 1993 to 2003, but that smoking cessation did not increase. Although this seems counter-intuitive, if one compares the prevalence of current smoking (and of having quit within the 5 previous years) in 1998 and 2003 by age and sex, the “missing smokers” appear to be mainly men over 40 years of age (Appendix C, available at: http://www.ncl.ac.uk/ihs/ research/project/1635). Reasons for quitting Successful quitters gave different reasons for quitting: 40.6%, cited illness; 26.9%, preventing disease; 10.9%, financial reasons; 5.3%, family disapproval, and 4.8%, physician’s advice (Fig. 3). Older people reported poor health as the main reason for quitting, whereas middle-aged people (ages 35–54) stated wanting to prevent disease. More people quit smoking for prevention in urban than in rural areas (28% versus 26%, respectively, P = 0.0028), and in rural areas more peo- ple quit for financial reasons (8% versus 13%, respectively, P = 0.0041). The results were similar for current quitters. Reason for relapses In the 2003 NHSS survey, 53.8% of all quitters who had relapsed reported as the reason that they had been unable to control their smoking, more than likely owing to physiological or psychological addiction. Social interactions and friends were also commonly given as reasons, presumably because smoking is common among their friends. About 6.8% of those who relapsed reported that they needed cigarettes for energy, and about 5% reported that their relapse had resulted from a change in health status, whether an improvement or a decline, after quitting smoking (Fig. 4). The influence of friends or of the social environment were given as reasons for relapsing by 30% of the men as op- posed to 13% of the women who had relapsed. These reasons for relapsing were also given more often by urban dwellers (32% in urban areas versus 27% in rural areas, P = 0.0002) and by younger people (42% at age 15–24, falling to 17% among those aged 65 or over; χ2 test for trend, P < 0.0001). Discussion Using data from a national survey, we analysed trends in smoking and smoking cessation in China over a 10-year time period. Although smoking prevalence declined significantly between 1993 and 2003, smoking remains very common among Chinese men. Smoking prevalence was low in women in 1993 and has fallen more in women than in men probably as a result of a cohort effect, since female smokers were older than males in 1993. Quitting is rare. In 2003, only 6% of in- dividuals who had ever smoked reported having quit, probably because relatively few national tobacco control measures were adopted between the late 1990s and 2003. Few current smokers (7.9%) reported intending to quit sometime in the 2 following years; and 15.8% of those who had previously quit reported having relapsed. The findings of other Chinese surveys are similar. In a study of urban, rural and migrant workers in Zhejiang, 9% of the men had quit for at Table 1. Trend in the prevalence of smoking, currently or ever in the past, by gender and urban or rural location, China, 1993–2003 Year n Ever smokersa (%) Current smokersb (%) Total Men Women Total Men Women Total Men Women Urban 1993 43 531 21 115 22 416 – – – 31.1 57.3 6.4 1998 45 898 22 397 23 501 30.3 55.8 5.9 27.2 50.3 5.1 2003 42 683 20 702 21 981 26.1 49.6 4.0 23.9 45.4 3.6 2003 42 683 20 702 21 981 – – – 19.0 36.3 2.7 Rural 1993 113 377 56 847 56 530 – – – 32.6 60.4 4.6 1998 119 327 60 669 58 658 31.4 58.0 3.9 29.5 54.5 3.6 2003 110 766 55 878 54 888 28.4 53.0 3.2 26.8 50.2 3.0 2003 110 766 55 878 54 888 – – – 21.3 40.0 2.2 Allc 1993 156 908 77 962 78 946 – – – 32.2 59.6 5.1 1998 165 225 83 066 82 159 31.1 57.4 4.5 28.9 53.4 4.0 2003 153 449 76 580 76 869 27.7 52.1 3.5 26.0 48.9 3.2 2003 153 449 76 580 76 869 – – – 20.6 39.0 2.3 a In all survey years, “ever smokers” were defined as those individuals who were either current smokers or who had smoked sometime in the past. b In 1993, 1998 and 2003, the category “current smokers” included those individuals who reported smoking at the time of the survey and had smoked at least 100 cigarettes in their lifetime. In 2003, the category was more stringently defined as individuals who, in addition to smoking at the time of the survey, had smoked at least one cigarette daily for a continuous period of at least 6 months. This explains the two sets of figures for 2003, the first of which complies with the broader and the second with the narrower definition. c Approximately 30% of the total sample was from urban areas and 70% from rural areas. Data obtained from China’s 1993, 1998 and 2003 National Health Services Surveys. Bull World Health Organ 2010;88:769–776 | doi:10.2471/BLT.09.064709772 Juncheng Qian et al.Smoking and smoking cessation in China, 1993–2003 Research least 1 month, and the percentage that attempted to quit was comparable with the 15.8% reported in the NHSS.23 Ac- cording to the NSPS, in 1996 2% of ever smokers had quit for over 2 years22, similar to the estimate derived from the NHSS. The major advantage of the NHSS surveys is their size, probabilistic nature and broad geographical coverage within China. As in many large surveys,4 smoking status was based on self-report, but this method appears to be generally accurate compared with the use of biochemical markers.32 Ideally, future surveys should include biochemical validation for a subsample of respondents. Our estimates of current smoking and of having smoked at some point are somewhat lower than estimated by the NSPS.3,4 In the 2002 NSPS, 66% of the men and 3.1% of the women over 15 years of age reported having smoked at some point,3 compared with 52.1% and 3.5%, respectively, in the 2003 NHSS. How- ever, the two surveys differ in many ways, including in their definition of current smoking, sampling frames, geographic coverage and age groups included. The NSPS was specifically designed to esti- mate smoking prevalence, but the NHSS surveys are larger and more frequent. The decline in smoking prevalence suggests that tobacco control efforts and improved education have been beneficial, particularly in urban areas, but certain trends are worrisome. First, the propor- tion of current heavy smokers doubled between 1998 and 2003; by 2003, over half of current smokers were heavy smok- ers. Lighter smokers may have found it easier to quit than heavy smokers, who may have been physiologically addicted. Perhaps more important, however, is the ability of current smokers to afford more cigarettes owing to China’s economic growth.33,34 Second, the self-reported age at which smoking begins has fallen. People who start smoking at a young age are more likely to become addicted and less likely to quit.35 Community and media interventions and the enforcement of laws against cigarette sales to minors are some- what successful in preventing uptake.36,37 Messages highlighting the opportunity costs of smoking may also be effective in preventing uptake among the young,23 although direct evidence is lacking. Third, overall smoking cessation fell over the period from 1998 to 2003. Although cigarette prices increased during the 1990s, cigarettes may have become more affordable owing to China’s economic growth and increased prosper- ity.33,34 Some restrictions on smoking in public places were implemented in 1996–1997,38 particularly in urban areas, and this may explain why attempts to quit smoking increased around 1998. Between 1998 and 2003, no substantial new tobacco control measures were imple- mented and some existing projects even contracted. It is also possible that smokers who quit many years before a survey was conducted self-reported as never smokers; in the 2003 survey, very few former smok- ers reported having quit more than 5 years before (data not shown). Despite some reduction in smoking, all these findings suggest that smoking-related diseases will continue to impose a major health burden on China for many decades to come. Finally, although smoking prevalence fell in 1998–2003, smoking cessation did not increase. These “missing smokers” are almost entirely men aged over 40 (Ap- pendix C) and selective mortality in this group is a possible explanation. There may be an increasing tendency for those who quit smoking in the distant past to self-report as never smokers, or for smok- ers to deny their habit for fear of social disapproval, although this seems unlikely Fig. 1. Proportion of current smokers,a successful quittersb and current quitters,c by age and sex, China, 1998 and 2003 0 Pe rc en ta ge 80 15 –2 4 Current quitters Successful quitters 60 Age group (in years) 40 20 Men Current smokers 25 –3 4 35 –4 4 45 –5 4 55 –6 4 65 + 15 –2 4 25 –3 4 35 –4 4 45 –5 4 55 –6 4 65 + Women 1998 0 Pe rc en ta ge 80 15 –2 4 Current quitters Successful quitters 60 Age group (in years) 40 20 Men Current smokers 25 –3 4 35 –4 4 45 –5 4 55 –6 4 65 + 15 –2 4 25 –3 4 35 –4 4 45 –5 4 55 –6 4 65 + Women 2003 a “Current smokers” were defined as those individuals who self-reported smoking at the time of the survey and who had smoked at least 100 cigarettes during their lifetime. b “Successful quitters” were defined as former smokers who reported not having smoked at all over the previous 24 months or more. c “Current quitters” were defined as former smokers who reported having quit smoking within the previous 24 months. Data obtained from China’s 1998 and 2003 National Health Services Surveys. Bull World Health Organ 2010;88:769–776 | doi:10.2471/BLT.09.064709 773 Juncheng Qian et al. Smoking and smoking cessation in China, 1993–2003 Research because in China no stigma is attached to smoking among men. Few report a physician’s advice as the main reason for quitting, which suggests that in China few physicians promote smoking cessation. The smoking rate among male physicians is above 50%,2 and doctors may need training on brief interventions to promote cessation.39 Around 16% of those who have tried to quit smoking report having re- lapsed, and most start again because they “can’t control” their behaviour, which suggests they are dependent. Relapses for social reasons are common, perhaps not surprisingly since smoking is highly prevalent and tolerated in many public places in China, particularly among men. Chinese society has traditionally offered cigarettes to household guests as gifts to strengthen personal relationships. Qualitative research has also shown that social situations and peer influences are important in triggering smoking among Chinese men,24 a situation that highlights the challenges involved in reducing male smoking further. Smoking in women has remained relatively uncommon, and women smokers are somewhat more likely to quit the habit than men, both in this study and in other studies conducted in China.22,40 In China, smoking contributes to social inequities, both in terms of health and of financial status. Our previous work has shown that households that consume more tobacco spend less on education and medical care.41 Medical care costs are very high in households where someone has quit smoking, and the true costs are probably higher since health insurance coverage was very low in rural areas until recently42 and many poorer smokers may be foregoing health care.41 Smoking is more common in rural areas and among those who are less educated, yet many ru- ral areas of China have not been targeted by sustained tobacco control interven- tions or public education campaigns.43 Cessation clinics have now been opened in large cities, but support and pharma- cotherapy are not generally available in rural China. They should be promoted and provided under the health insurance schemes being rapidly developed in recent years. Other effective measures leading to smoking cessation, such as telephone support lines,44 are rare. Extending and enforcing smoke-free policies in public places20 or increasing taxes – a more controversial measure – have been shown Fig. 2. Cigarette consumption among current smokers, by sex, China, 1998 and 2003 W om en 1998 > 20 10–19 Percentage of current smokers < 10 2003 1998 2003 M en 0 10 20 30 40 50 60 No. of cigarettes Data obtained from China’s 1998 and 2003 National Health Services Surveys. Table 2. Past attempts to quit and intention to quit among current smokers, China, 2003 Area n No attempts, no intentiona No attempt but in- tending to quitb Quit but relapsedc Total 39 904 62.1 7.9 15.8 Urban 10 200 65.3 6.9 17.3 Rural 29 704 61.1 8.2 15.3 a Not quit in last year and no intention to quit in the next 2 years. b Not tried to quit in last year, but intending to in next 2 years. c Relapsed quitters (have tried to quit but relapsed). Data obtained from China’s 2003 National Health Services Survey. Fig. 3. Main reasons for having quit smoking reported by successful quitters,a China, 2003 Pe rc en ta ge Total Urban Rural 0 5 10 15 20 25 30 35 40 45 Illn es s Pr ev en tio n Co st Fa mi ly dis ap pro va l En vir on me nt Do cto r’s ad vic e Ot he r a “Successful quitters” were defined as former smokers who reported not having smoked at all over the previous 24 months or more. Data obtained from China’s 2003 National Health Services Survey. Bull World Health Organ 2010;88:769–776 | doi:10.2471/BLT.09.064709774 Juncheng Qian et al.Smoking and smoking cessation in China, 1993–2003 Research to reduce smoking prevalence in similar areas and may bring economic and health benefits to China.33,34 In May 2009, the Chinese Government announced a new tobacco tax structure intended to increase retail prices by 3.4%.45 This price increase, which appears to be a response to economic recession primarily, has not yet been passed on to the consumer. Still, it may reduce future consumption.45 Increased funding for tobacco control is also becoming available in China and other developing countries through partnerships such as the one between Bill Gates and Mayor Bloomberg of New York City.46 China’s ratification of the WHO Framework Convention on Tobacco Control has almost certainly provided additional leverage. For example, China has recently agreed to larger and more prominent written health warnings (but not pictorial warnings) on cigarette packs. However, policy implementa- tion has been slow, and few developing countries have made progress in imple- menting all six MPOWER policies to reduce smoking prevalence [(i) monitor tobacco use and prevention policies; (ii) protect people from tobacco smoke; (iii) offer help to quit tobacco use; (iv) warn about the dangers of tobacco; (v) enforce bans on tobacco advertis- ing, promotion and sponsorship, and (vi) raise taxes on tobacco].47 In general, tobacco use has either increased or re- mained stable in other low- and middle- income countries over the past decade48,, and substantial increases in consump- tion have been seen in some countries, such as Viet Nam and Thailand.48,49 In developing countries, tobacco control tends to begin with awareness and to progress from there to increased policy enactment, and then to enforcement of many strong anti-tobacco policies with both governmental and activist sup- port.49 While many developing countries have moved towards increasing tobacco control policies, enforcement is often problematic, particularly in rural areas. Rapid economic growth, as achieved in China over the past three decades, may facilitate tobacco control policy devel- opment. Whether the current global economic recession will impede the progress of tobacco control activities in the developing world or whether it will result in higher cessation rates requires careful monitoring and evaluation. ■ Acknowledgements We thank Pat Barker for her secretarial assistance. At the time this study was conducted, Shenglan Tang was affiliated with the International Health Research Group, Liverpool School of Tropical Medicine, Liverpool, England, and Julia Alison Critchley was affiliated with the Institute of Health and Society, Newcastle University, Newcastle, England. Funding: The analyses were funded by the International Development Re- search Centre, Canada, and the original survey was funded by China’s Ministry of Finance. Competing interests: None declared. Fig. 4. Main reason for relapsing reported by men and women who had quit smoking, China, 2003 Pe rc en ta ge Men Women 0 70 Ca n’t co ntr ol 60 50 40 30 20 10 He alt h g ett ing w ors e He alt h g ett ing be tte r So cia l n ee ds Infl ue nc e o f fr ien d or en vir on me nt Fa sh ion Re co ve r f rom fa tig ue Ot he r Data obtained from China’s 2003 National Health Services Survey. صخلم ةيحصلا تامدخلل ينطولا حسلما تايطعم :2003 لىإ 1993 نم ةترفلا في ينصلا في هنع علاقلإاو ينخدتلا لياجم في تاهاجتلاا .لاجرلا نم مهثركأ ،نخدم نويلم 350 لياوح ينصلا في دجوي فدهلا ةيحصلا تامدخلل ةينطولا تاحوسلما نم ةاقتسلما تايطعلما مادختسابو :ليي ابم نوثحابلا ماق ،2003 و ،1998و ،1993 ماوعلأا للاخ تيرجأ يتلا تافلاتخلال اقفو هنع علاقلإاو ينخدتلا راشتناب ةصاخلا تاهاجتلاا ريدقت )أ( لىع ةينلا دقعو ،علاقلإا تلادعم ليلحت )ب( و ،ةيفارغويمدلاو ةيعماتجلاا .ينخدتلل ةدوعلاو سكنلا بابسأو ،علاقلإا في عوشرلا ءارو ببسلاو ،علاقلإا نم تايطعلما تعمج ،تاونسلا هذه رادم لىع يرجأ حسم لك في قرطلا سرلأا دارفأ عم تلاباقم تيرجأ دقو .ًادرف 200.000و ةسرأ 57.000 لياوح ةينلا دقعو ينخدتلا تاداع لوح اهيف تاشقانلما ترادو ًاماع 15 نم بركلأا ةيفصو تايطعم نوثحابلا مدقو .ينخدتلا هاجت فقاولماو ،هنع علاقلإا لىع ةيفيرلا قطانلما في ةماقلإاو ،لخدلا ىوتسمو سنجلاو ،رمعلا بسحب ةفنصم .ةيضرحلا قطانلما في اهب ةنراقم تلادعم ينصلا في تضفخنا ،2003 و 1993 ينب ام ماوعلأا للاخ تادوجولما و 5%و ،لاجرلا في 49% و 60% رادقبم اماع 15 نم بركأ مه نلم ينخدتلا اذه .ةيضرحلا قطانلما في ضافخنلاا تلادعم ثركأ تناكو .ءاسنلا ينب 3.2% ةراجيس 20 نم ثركلأ( فيثكلا ينخدتلا تلادعم ،ةماع ةفصب ،تداز دقو هيف أدبي يذلا رمعلا لدعم ضفخنا ماك .لاجرلا ينب تفعاضتو )مويلا في نع يننخدلما نم 7.9% غلبأ ،2003 ماع فيو .تاونس ثلاث لياوح ينخدتلا مهعلاقإ نع يننخدلما نم اوناك نمم 6% غلبأ ماك ،هنع علاقلإا في مهتين ،ضرلما ببسب مهنم 40.6% علقأ دقف ،ينخدتلا مهل قبس نلم ةبسنلابو .هنع .ةيلام بابسلأ 10.9%و ،ضرلما نثارب في عوقولا ءاقتلا 26.9%و دقو ،ينصلا في ينخدتلا راشتنا تلادعم تضفخنا ،ةساردلا ةترف للاخ ةجيتنلا ضافخنا عم ،ينخدتلا نع علاقلإل ةكترشم تايرثأت لىإ كلذ في ببسلا عجري لاجرلا ينب ةاقتنلما تايفولا تلادعمو ،ينخدتلا في ءاسنلا طارخنا تلادعم Bull World Health Organ 2010;88:769–776 | doi:10.2471/BLT.09.064709 775 Juncheng Qian et al. Smoking and smoking cessation in China, 1993–2003 Research ينخدتلا تلادعم تدادزا دقف كلذ مغرو .رمعلا نم ينعبرلأا اودعت نمم مهيدل نوكت وأ ينخدتلا نع نونخدلما علقي نأ ينصلا في ردنيو ،فيثكلا ةجاح كانهف اذلو .رمعلا نم ةمدقتلما لحارلما ءانثتساب ،هنع علاقلإل ةين ةيأ قطانلما في مايسلاو ينخدتلا ةحفاكم دوهج نم ديزلما لذبل ةحلمو ةديدش .ةيفيرلا Résumé Évolution du tabagisme en Chine entre 1993 et 2003: Données des enquêtes du Service national de Santé Objectif La Chine compte près de 350 millions de fumeurs, qui sont le plus souvent des hommes. Utilisant les données des enquêtes du Service national de la Santé, menées en 1993, 1998 et 2003, nous avons (i) estimé les tendances de prévalence et d’arrêt du tabagisme en fonction des variables sociodémographiques et (ii) analysé les taux d’arrêt, les intentions d’arrêter, les raisons d’arrêter et les raisons de rechuter. Méthodes Les données ont été recueillies auprès d’environ 57 000 ménages et 200 000 individus par année d’enquête. Les membres des ménages âgés de plus de plus de 15 ans ont été interrogés sur leurs habitudes de fumeurs, sur leurs intentions d’arrêter et sur leur attitude à l’égard du tabagisme. Nous présentons des données descriptives stratifiées par âge, sexe, niveau de revenu et résidence rurale ou urbaine. Résultats En Chine, entre 1993 et 2003, le nombre de fumeurs chez les plus de 15 ans a chuté de 60 à 49% chez les hommes et de 5 à 3,2% chez les femmes. Cette baisse est plus marquée dans les régions urbaines. Toutefois, le tabagisme lourd (plus de 20 cigarettes par jour) a considérablement augmenté au total et a doublé chez les hommes. L’âge moyen de la première cigarette a également diminué de près de 3 ans. En 2003, 7,9% des fumeurs ont déclaré avoir l’intention d’arrêter et 6% de ceux ayant déclaré avoir fumé ont arrêté. Parmi les anciens fumeurs, 40,6% d’entre eux stoppent pour cause de maladie, 26,9% pour prévenir une maladie et 10,9% pour des raisons financières. Conclusion La prévalence du tabagisme a diminué en Chine au cours de la période d’étude, sans doute à cause d’un effet combiné de l’arrêt de la cigarette, de la réduction de la consommation chez les femmes et d’une mortalité sélective chez les hommes de plus de 40 ans. Cependant, le tabagisme lourd a quant à lui augmenté. Les Chinois arrêtent ou décident rarement d’arrêter de fumer, à l’exception des plus âgés. Des efforts en matière de contrôle du tabagisme sont nécessaires d’urgence, surtout dans les régions rurales. Resumen Tendencias en el tabaquismo y la deshabituación tabáquica en China entre 1993 y 2003: datos de las encuestas llevadas a cabo por el Servicio Nacional de Salud Objetivo China cuenta con unos 350 millones de fumadores, la mayoría, hombres. Utilizando datos de las encuestas llevadas a cabo por el Servicio Nacional de Salud en 1993, 1998 y 2003, (i) calculamos las tendencias en la prevalencia del tabaquismo y la deshabituación tabáquica según variables socio-demográficas y (ii) analizamos las tasas de deshabituación, los intentos de dejar de fumar, los motivos para dejar de fumar y los motivos para recaer. Métodos Se recopilaron datos de aproximadamente 57 000 hogares y 200 000 individuos en cada año de encuesta. Se entrevistó a los miembros menores de 15 años de dichos hogares acerca de sus hábitos tabáquicos, sus intenciones de dejar de fumar y sus actitudes frente al tabaquismo. Presentamos datos descriptivos estratificados por edad, sexo, nivel de ingresos y residencia rural frente a urbana. Resultados En China, el tabaquismo actual en menores de 15 años cayó entre el 60% y el 49% en hombres y entre el 5% y el 3,2% en mujeres durante el periodo entre 1993 y 2003. La caída fue más acusada en áreas urbanas. Sin embargo, el tabaquismo agudo (≥20 cigarrillos al día) aumentó sustancialmente en general y se duplicó en hombres. El promedio de edad de consumo también cayó en unos 3 años. En 2003, el 7,9% de los fumadores indicó que tenía intención de dejar el tabaco y el 6% de las personas que habían fumado alguna vez señaló haberlo dejado. De los ex-fumadores, el 40,6% había dejado el tabaco por una enfermedad; el 26,9%, para prevenir una enfermedad; y el 10,9%, por motivos económicos. Conclusión La prevalencia del tabaquismo cayó en China durante el periodo del estudio, quizá debido al efecto combinado de la deshabituación tabáquica, la reducción del consumo en mujeres y la mortalidad selectiva en hombres mayores de 40 años. Sin embargo, el tabaquismo agudo se incrementó. En China, las personas rara vez dejan o tienen intención de dejar de fumar, salvo en edades más avanzadas. Se necesitan más iniciativas para controlar el tabaquismo, especialmente en las áreas rurales. References 1. Boutayeb A. The double burden of communicable and non-communicable diseases in developing countries. Trans R Soc Trop Med Hyg 2006;100:191– 9. doi:10.1016/j.trstmh.2005.07.021 PMID:16274715 2. Mackay J, Eriksen M, Shafey O. The tobacco atlas. 2nd edn. Atlanta: American Cancer Society; 2006. 3. Yang GH, Ma JM, Liu N, Zhou LN. Smoking and passive smoking in Chinese, 2002 Zhonghua Liu Xing Bing Xue Za Zhi 2005;26:77–83. PMID:15921604 4. Yang G, Fan L, Tan J, Qi G, Zhang Y, Samet JM et al. Smoking in China: findings of the 1996 National Prevalence Survey. JAMA 1999;282:1247–53. doi:10.1001/jama.282.13.1247 PMID:10517427 5. The World Bank. China: the economics of tobacco – in brief. In: Economics of tobacco control. Washington, DC: WB; 1999. Available from: http://www1. worldbank.org/tobacco/pdf/country%20briefs/China.pdf [accessed 24 March 2010]. 6. Critchley J, Liu J, Zhao D, Wei W, Capewell S. Explaining the increase in coronary heart disease mortality in Beijing between 1984 and 1999. Circulation 2004;110:1236–44. doi:10.1161/01.CIR.0000140668.91896. AE PMID:15337690 7. Peto R, Chen Z-M, Boreham J. Tobacco: the growing epidemic in China. CVD Prev Contr 2009;4:61–70. doi:10.1016/j.cvdpc.2008.12.001 8. Hu TW, Mao Z, Ong M, Tong E, Tao M, Jiang H et al. China at the crossroads: the economics of tobacco and health. Tob Control 2006;15(Suppl 1):i37–41. doi:10.1136/tc.2005.014621 PMID:16723674 9. US Department of Health and Human Services. The health consequences of smoking: a report of the Surgeon General. Atlanta: Centers for Disease Control and Prevention, National Center for Chronic Disease Prevention and Health Promotion, Office on Smoking and Health; 2004. Bull World Health Organ 2010;88:769–776 | doi:10.2471/BLT.09.064709776 Juncheng Qian et al.Smoking and smoking cessation in China, 1993–2003 Research 10. Department of Health, Department of Health and Social Services Northern Ireland, The Scottish Office Department of Health, Welsh Office. Report of the Scientific Committee on Tobacco and Health. The Stationery Office; 1998. 11. Murray CJ, Lopez AD. Global mortality, disability, and the contribution of risk factors: Global Burden of Disease Study. Lancet 1997;349:1436–42. doi:10.1016/S0140-6736(96)07495-8 PMID:9164317 12. Lam TH, He Y, Shi QL, Huang JY, Zhang F, Wan ZH et al. Smoking, quitting, and mortality in a Chinese cohort of retired men. Ann Epidemiol 2002;12:316–20. doi:10.1016/S1047-2797(01)00258-7 PMID:12062918 13. Chen ZM, Xu Z, Collins R, Li WX, Peto R. Early health effects of the emerging tobacco epidemic in China. A 16-year prospective study. JAMA 1997;278:1500–4. doi:10.1001/jama.278.18.1500 PMID:9363969 14. Yuan JM, Ross RK, Wang XL, Gao YT, Henderson BE, Yu MC. Morbidity and mortality in relation to cigarette smoking in Shanghai, China. A prospective male cohort study. JAMA 1996;275:1646–50. doi:10.1001/ jama.275.21.1646 PMID:8637137 15. Niu SR, Yang GH, Chen ZM, Wang JL, Wang G-H, He X-Z et al. Emerging tobacco hazards in China: 2. Early mortality results from a prospective study. BMJ 1998;317:1423–4. PMID:9822394 16. Liu BQ, Peto R, Chen ZM, Boreham J, Wu YP, Li J-Y et al. Emerging tobacco hazards in China: 1. Retrospective proportional mortality study of one million deaths. BMJ 1998;317:1411–22. PMID:9822393 17. Gallus S, Schiaffino A, La Vecchia C, Townsend J, Fernandez E. Price and cigarette consumption in Europe. Tob Control 2006;15:114–9. doi:10.1136/ tc.2005.012468 PMID:16565459 18. Stead LF, Perera R, Bullen C, Mant D, Lancaster T. Nicotine replacement therapy for smoking cessation. Cochrane Database Syst Rev 2008;1:CD000146.[REMOVED HYPERLINK FIELD] doi:10.1002/14651858. CD000146.pub3 PMID:18253970 19. Hughes JR, Stead LF, Lancaster T. Antidepressants for smoking cessation. Cochrane Database Syst Rev 2007;1:CD000031. doi:10.1002/14651858. CD000031.pub3 PMID:17253443 20. Fichtenberg CM, Glantz SA. Effect of smoke-free workplaces on smoking behaviour: systematic review. BMJ 2002;325:188. doi:10.1136/ bmj.325.7357.188 PMID:12142305 21. Hopkins DP, Briss PA, Ricard CJ, Husten CG, Carande-Kulis VG, Fielding JE et al.; Task Force on Community Preventive Services. Reviews of evidence regarding interventions to reduce tobacco use and exposure to environmental tobacco smoke. Am J Prev Med 2001;20(Suppl):16–66. doi:10.1016/ S0749-3797(00)00297-X PMID:11173215 22. Yang G, Ma J, Chen A, Zhang Y, Samet JM, Taylor CE et al. Smoking cessation in China: findings from the 1996 national prevalence survey. Tob Control 2001;10:170–4. doi:10.1136/tc.10.2.170 PMID:11387539 23. Hesketh T, Lu L, Jun YX, Mei WH. Smoking, cessation and expenditure in low income Chinese: cross sectional survey. BMC Public Health 2007;7:29. doi:10.1186/1471-2458-7-29 PMID:17335587 24. Yang T, Fisher KJ, Li F, Danaher BG. Attitudes to smoking cessation and triggers to relapse among Chinese male smokers. BMC Public Health 2006;6:65. doi:10.1186/1471-2458-6-65 PMID:16533411 25. Gao J, Tang S, Tolhurst R, Rao K. Changing access to health services in urban China: implications for equity. Health Policy Plan 2001;16:302–12. doi:10.1093/heapol/16.3.302 PMID:11527871 26. Gao J, Qian J, Tang S, Eriksson BO, Blas E. Health equity in transition from planned to market economy in China. Health Policy Plan 2002;17(Suppl):20–9. doi:10.1093/heapol/17.suppl_1.20 PMID:12477738 27. Tang S, Li X, Wu Z. Rising cesarean delivery rate in primiparous women in urban China: evidence from three nationwide household health surveys. Am J Obstet Gynecol 2006;195:1527–32. doi:10.1016/j.ajog.2006.03.044 PMID:16677593 28. Xu L, Wang Y, Collins CD, Tang S. Urban health insurance reform and coverage in China using data from National Health Services Surveys in 1998 and 2003. BMC Health Serv Res 2007;7:37. PMID:17335584 29. Yang DT. What has caused regional inequality in China? China Econ Rev 2002;13:331–4. doi:10.1016/S1043-951X(02)00088-3 30. Zimmer Z, Kaneda T, Spess L. Urban versus rural mortality among older adults in China. New York: Population Council; 2006. Available from: http:// www.popcouncil.org/pdfs/wp/214.pdf [accessed 24 March 2010]. 31. Yang G, Kong L, Zhao W, Wan X, Zhai Y, Chen LC et al. Emergence of chronic non-communicable diseases in China. Lancet 2008;372:1697–705. doi:10.1016/S0140-6736(08)61366-5 PMID:18930526 32. Patrick DL, Cheadle A, Thompson DC, Diehr P, Koepsell T, Kinne S. The validity of self-reported smoking: a review and meta-analysis. Am J Public Health 1994;84:1086–93. doi:10.2105/AJPH.84.7.1086 PMID:8017530 33. Guindon GE, Tobin S, Yach D. Trends and affordability of cigarette prices: ample room for tax increases and related health gains. Tob Control 2002;11:35–43. doi:10.1136/tc.11.1.35 PMID:11891366 34. Hu TW, Mao Z. Effects of cigarette tax on cigarette consumption and the Chinese economy. Tob Control 2002;11:105–8. doi:10.1136/tc.11.2.105 PMID:12035000 35. World Health Organization. Tobacco use by children: “a pediatric disease” (Fact Sheet No.197). Geneva: WHO; 1998. 36. Sowden A, Arblaster L, Stead L. Community interventions for preventing smoking in young people. Cochrane Database Syst Rev 2003;1:CD001291. doi:10.1002/14651858.CD001291 PMID:12535406 37. Stead LF, Lancaster T. Interventions for preventing tobacco sales to minors. Cochrane Database Syst Rev 2005;1:CD001497. doi:10.1002/14651858. CD001497.pub2 PMID:15674880 38. Tomlinson R. China bans smoking on trains and buses. BMJ 1997;314:769. 39. Lancaster T, Silagy C, Fowler G. Training health professionals in smoking cessation. Cochrane Database Syst Rev 2000;3:CD000214. doi:10.1002/14651858.CD000214 PMID:10908465 40. Sun S, Korhonen T, Uutela A, Korhonen HJ, Puska P, Jun Y et al. International Quit and Win 1996: comparative evaluation study in China and Finland. Tob Control 2000;9:303–9. doi:10.1136/tc.9.3.303 PMID:10982574 41. Xin Y, Qian J, Xu L, Tang S, Gao J, Critchley JA. The impact of smoking on household consumption patterns and household medical care costs in China. Tob Control 2009;18:150–5. doi:10.1136/tc.2008.026955 PMID:19158112 42. Hu S, Tang S, Liu Y, Zhao Y, Escobar ML, de Ferranti D. Reform of how health care is paid for in China: challenges and opportunities. Lancet 2008;372:1846–53. doi:10.1016/S0140-6736(08)61368-9 PMID:18930520 43. Yang T, Li F, Yang X, Wu Z, Feng X, Wang Y et al. Smoking patterns and sociodemographic factors associated with tobacco use among Chinese rural male residents: a descriptive analysis. BMC Public Health 2008;8:248. doi:10.1186/1471-2458-8-248 PMID:18644139 44. Stead LF, Perera R, Lancaster T. Telephone counselling for smoking cessation. Cochrane Database Syst Rev 2006;3:CD002850.[REMOVED HYPERLINK FIELD] doi:10.1002/14651858.CD002850.pub2 PMID:16855992 45. Hu T-W, Mao Z, Shi J. Recent tobacco tax rate adjustment and its potential impact on tobacco control in China. Tob Control 2010;19:80–2. doi:10.1136/ tc.2009.032631 PMID:19850552 46. Ledford H. Gates and Bloomberg team up to tackle tobacco epidemic. NATNEWS 2008. doi:10.1038/news.2008.980. 47. World Health Organization. WHO report on the global tobacco epidemic, 2008: the MPOWER package. Geneva: WHO; 2008. Available from: http:// www.who.int/tobacco/mpower/mpower_report_full_2008.pdf [accessed 24 March 2010]. 48. Shafey O, Eriksen M, Ross H, Mackay J. The tobacco atlas. 3rd edn. Atlanta: American Cancer Society; 2009. 49. Sussman S, Pokhrel P, Black D, Kohrman M, Hamann S, Vateesatokit P et al. Tobacco control in developing countries: Tanzania, Nepal, China, and Thailand as examples. Nicotine Tob Res 2007;9(Suppl 3):S447–57. doi:10.1080/14622200701587078 PMID:17978974