Gonghuan Yang

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

Background China is the largest producer and consumer of tobacco products worldwide. While direct marketing and advertisement of tobacco products is restricted, indirect marketing still exists under the guise of sponsorship and corporate social responsibility (CSR). This case study is focused on tobacco industry-sponsored elementary schools in Chinese rural areas. Methods Field visits were conducted in Yunnan province to interview students, teachers, school principals and parents to understand their perceptions of the tobacco industry and its sponsorship of schools. Interviews with tobacco control activists were conducted in Beijing to discuss national tobacco control efforts targeting tobacco industry sponsorship. Interview data were transcribed and coded, with key themes developed using thematic analysis. Results While health consequences of smoking are generally known, attitudes towards the tobacco industry and its CSR activities remain positive among the general public. Educators and parents do not perceive any impacts on schoolchildren from exposure to ‘pro-tobacco propaganda’ created by the industry’s CSR activities. Attitudes among tobacco control activists were drastically different, with consensus that CSR activities constitute indirect marketing attempts that should be banned. Conclusion National tobacco control legislation banning all forms of indirect marketing including CSR is needed in order to protect the health of future generations.

In China, the spatiotemporal variations in cardiovascular disease (CVD) mortality are seldom characterized to understand their epidemiological features. It would be helpful to evaluate the performance of CVD-related interventions for subsequent adjustments. The 2010 Census data as well as the coronary heart disease (CHD) and stroke mortality data from the Disease Surveillance Points (DSPs) were used to calculate the age standardized death rates (ASDRs) of CVD in the DSP counties during 1991–1995, 1996–2000, 2004–2005, and 2006–2009. The ordinary kriging (OK) method was used to estimate the county-level death rates of CHD and stroke and achieved satisfactory results. The goodness-of-fit between measured and estimated values of CVD mortality was significant at the 0.01 level (0.34 < R2 < 0.98). The counties with high CHD death rates (> 75 per 105) were located in the Northwest, North, and Northeast in 1991–2000 and then extended toward the North, Central, and South, yielding an inverted-triangle-shaped area in 2004–2009. The counties with a CHD death rate increase greater than 100% were concentrated in the Northeast and South. The Northeast-Southwest regions with a high stroke death rate gradient (> 150 per 105) narrowed in1991–2000, was followed by a slight expansion during 2004–2005, finally reducing in 2006–2009. The counties with a stroke mortality increase greater than 100% were scattered across the Northeast, Northwest, Central, and South. The epidemiological characteristics of both CHD and stroke mortality in China was spatiotemporally featured on the county level during 1991–2009.

Background Smoke-free legislation is an effective way to protect the population from the harms of secondhand smoke and has been implemented in many countries. On 31 May 2012, Tianjin became one of the few cities in China to implement smoke-free legislation. We investigated the impact of smoke-free legislation on mortality due to acute myocardial infarction (AMI) and stroke in Tianjin. Methods An interrupted time series design adjusting for underlying secular trends, seasonal patterns, population size changes and meteorological factors was conducted to analyse the impact of the smoke-free law on the weekly mortality due to AMI and stroke. The study period was from 1 January 2007 to 31 December 2015, with a 3.5-year postlegislation follow-up. Results Following the implementation of the smoke-free law, there was a decline in the annual trends of AMI and stroke mortality. An incremental 16% (rate ratio (RR): 0.84; 95% CI: 0.83 to 0.85) decrease per year in AMI mortality and a 2% (RR: 0.98; 95% CI: 0.97 to 0.99) annual decrease in stroke mortality among the population aged ≥35 years in Tianjin was observed. Immediate postlegislation reductions in mortality were not statistically significant. An estimated 10 000 (22%) AMI deaths were prevented within 3.5 years of the implementation of the law. Conclusion The smoke-free law in Tianjin was associated with reductions in AMI mortality. This study reinforces the need for large-scale, effective and comprehensive smoke-free laws at the national level in China.

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

In the past 20 years, the trends of ischemic heart disease (IHD) mortality in China have been described in divergent claims. This research analyzes mortality trends for IHD by using the data from 102 continuous Disease Surveillance Points (DSP) from 1991 to 2009. The 102 continuous DSP covered 7.3 million people during the period 1991–2000, and then were expanded to a population of 52 million in the same areas for 2004–2009. The data were adjusted by using garbage code redistribution and underreporting rate, mapped from international classification of diseases ICD-9 to ICD-10. The mortality rates for IHD were further adjusted by the crude death proportion multiplied by the total number of deaths in the mortality envelope, which was calculated by using logrt = a + bt. Age-standard death rates (ASDRs) were computed using China’s 2010 census population structure. Trend in IHD was calculated from ASDRs by using a joinpoint regression model. The IHD ASDRs increased in total in regions with an average annual percentage change (AAPC) 4.96%, especially for the Southwest (AAPC = 7.97%) and Northeast areas (AAPC = 7.10%), and for male and female subjects (with 5% AAPC) as well. In rural areas, the year 2000 was a cut-off point for mortality rate with annual percentage change increasing from 3.52% in 1991–2000 to 9.02% in 2000–2009, which was much higher than in urban areas (AAPC = 1.05%). And the proportion of deaths increased in older adults, and more male deaths occurred before age 60 compared to female deaths. By observing a wide range of areas across China from 1991 to 2009, this paper concludes that the ASDR trend for IHD increased. These trends reflect changes in the Chinese standard of living and lifestyle with diets higher in fat, higher blood lipids and increased body weight.

To determine the reason for the different mortality trends of ischemic heart disease (IHD) for China between Global Burden of Disease (GBD) 2010 and GBD2013, and to improve garbage code (GC) redistribution. All data were obtained from the disease surveillance points system, and two proportions for assigning chronic pulmonary heart disease (PHD) as GC to IHD were from GBD2010 and GBD2013, which were different for years before 2004. By using the GBD2013 approach, the age-standard mortality rate (ASMR) increased by 100.21% in 1991, 44.81% in 1996, and 42.47% in 2000 in comparison with the GBD2010 approach. The different methods of chronic PHD redistribution impacted the trend of IHD mortality, which elevated it in the earlier 1990s by using the GBD2013 approach. Thus, improving the redistribution of GC as a key step in mortality statistics is important.

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