控烟中国最具可行性与挑战的疾病防控手段（英文版）

Tobaccocontrol:themostfeasibleandchallengingdisease-preventionmeasureinChinaNationalClinicalResearchCenterforRespiratoryDiseases,China-JapanFriendshipHospitalWHOCollaboratingCenterforTobaccoCessationandRespiratoryDiseasePreventionChenWANG,DanXIAOJuly2017,GuangzhouContentsTobaccoinChina123TobaccocontrolinChinaFuturechallengesGlobaladultssmokingprevalencedroppedfrom24%in2015

to

21%in2007Tobaccokillsmorethan7millionpeopleeachyearPrevalenceareexpectedtobe17%in2030Middle-andlow-incomecountriesdeclineslowlyGlobaladultssmokingprevalenceGlobalAdultsSmokingPrevalence,2007

to2015ThepredictionofGlobalAdultsSmokingPrevalence，2015

to2030Monitoroftobaccouse3WHOTobaccoEpidemicReport,20174Chinaproducemorethan40%ofglobalcigaretteDevelopingcountriesaremainsourceofcigaretteproductiongrowthIn2015,China'scigaretteproductionwas2.59trillion,reducedby0.80%comparedwith2014Accountingfor43.16%ofglobalproductionofcigarette(6trillion)ThecigaretteproductioninChina,1949-2015TheprocessingoftobaccoinChinaDatafromtheNationalBureauofStatisticsChina:largesttobaccoproducer5316millionsmokersinChina,smokingrate:27.7%Highersmokingrateamongmalesandloweducationpopulation;initiationageofsmokingbecomesearlierThenumberofsmokersincreasedby15millionbetween2010and2015Onaverageof22cigarettesperday,increaseof50%over1980ChinahasthehighesttobaccoconsumptionintheworldResultsofChinasurveysofsmokingChineseAdultTobaccoSurvey,2015TheBillChinaCannotAfford:HEALTH,ECONOMICANDSOCIALCOSTSOFCHINA’STOBACCOEPIDEMIC,2017China:largesttobaccouserTheHealthConsequencesofInvoluntarySmoking.AReportoftheSurgeonGeneral,2006ChinaSmokingHazardHealthReport，People'sMedicalPublishingHouse,2012AreportofSurgeonGeneralSmokingharmsnearlyeveryorganofthebody,causingmanydiseasesandreducingthehealthofsmokersingeneralChinaReportontheHealthHazardsofSmokingBasedon30,000researcharticles,thesolidscientificevidenceshowthatsmokingisharmforhealth6SmokingisharmfultohealthIndisputablehealthhazardsofsmokingIschemicheartdiseaseHemorrhagicstrokeCOPDIschemicstrokeLungcancerDiabetesSmokingwastheleadingriskfactorfor

chronicrespiratorydiseasesSmokingprevalenceandattributablediseaseburdenin195countriesandterritories,1990-2015.Lancet,2017ThenumberofdeathscausedbymajorchronicdiseasesinChina(2013)7IschemicheartdiseaseHemorrhagicstrokeCOPDIschemicstrokeLungcancerDiabetesSmokingistheleadingriskfactorforchronicrespiratorydiseasesIn2014,thenumberofcancerdeathsduetosmoking

intheUnitedStatesexceeded16.7millionincluding1.03millionmenand0.64millionwomenaccountingfor28.6%oftotalcancerdeathsLowestinUtah:21.8%HighestinKansas:39.5%Smokingcausescancerdeathsmainlyinthesouth8State-LevelCancerMortalityAttributabletoCigaretteSmokingintheUnitedStates,JAMAInternalMedicine,2016SmokingistheleadingriskfactorforcancerinUnitedStatesThenumberofcancerdeathsattributabletosmokingwashighestforlungcancer,followedbyliver,gastric,andesophagealcancerPAFwas43%forlungandonly13%-15%foreachofthelatter3cancersitesNumberandproportionofcancerdeathsattributabletoinChina(2013)CancerdeathsandcasesattributabletolifestylefactorsandinfectionsinChina,2013.AnnalsofOncology,20179PopulationattributableriskDeathsSmokingistheleadingriskfactorfordeathoflungcancer第三篇TheincidenceandmortalityofcancerinChinaareontheriseSmokingcauses

23~25%

cancerdeathsinChinaLungcancer

becomesthebiggestthreat733thousandnewcasesand610thousanddeathcasesItishighlyrelatedtothelargesmokingpopulationinourcountry10SmokingishighlyrelatedtolungcancerinChinaUnhealthydiet（16.3%）,HBP（12.0%）,Smoking（9.5%）TheanalysisofDALYsinChina,2010111——TheGlobalBurdenofDiseaseStudyin2010(GBD2010)RapidhealthtransitioninChina,1990–2010:findingsfromtheGlobalBurdenofDiseaseStudy2010,Lancet,2013SmokingisthemainriskfactorofDALYsTobaccocontains

nicotine,

whichcausetobaccodependencecausingdopaminerelease,resultinginpleasureleadingtowithdrawalsymptomsTobaccodependenceisachronic,addictivediseaseICD-10:F17.2NicotinemolecularstructureGuidelinesforclinicalsmokingcessationinChina（2015）TobaccoDependenceDiagnosticCriteria

Strongdesireforsmoking

DifficulttocontrolsmokingbehaviorWhentostopsmokingorreducesmokingmaycausewithdrawalsymptomsTheemergenceoftobaccotolerance

Abandonorreduceotheractivitiesandhobbiesforsmoking

Continuesmoke

regardlessoftherisk12TobaccodependenceisachronicdiseaseTheanteriorcingulateandinsulaPrefrontalcortexOccipitalcortexEpencephalSmokingcausebrainstructurechangesgraymatterdecreasedseverityassociatedwithamountofsmokingSmokingcausebrainfunctionchangesnerveactivityabnormalitiesofFrontallobe,temporallobedecreasedfunctionalconnectivityofinsula-orbitofrontalcortex,insula-superiorfrontalgyrus,insula-temporalassociatedwithnicotinedependence13Spontaneousbrainactivityinchronicsmokersrevealedbyfractionalamplitudeoflowfrequencyfluctuationanalysis,ChinMedJ,2014Brain-volumechangesinyoungandmiddle-agedsmokers:aDARTEL-basedvoxel-basedmorphometrystudy,CRJ,2015Effectofsmokingonresting-statefunctionalconnectivityinnon-deprivedsmokers:anfMRIstudy,Respirology,2016SmokingchangesbrainstructureandfunctionSmokingcause20%ofalladultmaledeathsinChinaduring2010sAnnualnumberofdeathsinChinathatarecausedbytobaccowillrisefromabout1millionin2010to2millionin2030and3millionin2050,unlessthereiswidespreadcessation.Halfofsmokerswilldieearlyiftheycontinuetosmoke14Contrastingmaleandfemaletrendsintobacco-attributedmortalityinChina,

Lancet,,2015Smokingcausesmorethan1milliondeathsinChina15SecondhandsmokeisthemainsourceofindoorPM2.5PM2.5producedbyindoorsmokingisdifficulttodetectNote:thedistancebetweentheinstrumentandsmokeris1.5meters,thespacevolumeis122.5cubicmeters,andthenumberofsmokersis1Secondhandsmokeisharmfultohealth16Directcostoftreatingtobacco-relatedillnessinChinain2014was¥53billion(US$9billion)equaltoaround1.5%ofthe¥3.5trillion(US$538billion)spentonhealthcareinChinain2014Indirectcostoftreatingtobacco-relatedillnessinChinawas¥296.5billion(US$48.3billion)ThelossofproductivitycausedbysmokingisparticularlyworryingTobaccousetothetotaleconomiclossesinChina(2000-2014)

TheBillChinaCannotAfford:HEALTH,ECONOMICANDSOCIALCOSTSOFCHINA’STOBACCOEPIDEMIC,2017TotaleconomiccostsoftobaccouseinChinaContentsTobaccoinChina123TobaccocontrolinChinaFuturechallenges18Dr.MargaretChanFormerWHOdirectorgeneralTobaccouseistheworld’snumberonepreventablekiller.Inaworldundergoingeconomicupheaval,withpopulationsageing,chronicdiseasesontherise,andmedicalcostssoaring,tacklingahugeandentirelypreventablecauseofdiseaseanddeathbecomesallthemoreimperative.——Speechatthe15thWorldTobaccoorHealthConferenceTobaccouseisNo.1preventablekillerAmericanCancerSocietysetanambitiousgoal:tohalvecancermortalityratein1990bytheyear2015.Resultsarepublishedin20161Results

in2015,cancerdeathrateswere26%lowerthanin1990

malelungcancermortalitydecreasedby45%DeclineinlungcancermortalityalmostentirelyfromtobaccocontrolearlydiagnosisandtreatmentTheAmericanCancerSocietyChallengeGoaltoReduceUSCancerMortalityby50%Between1990and2015,CACANCERJCLIN,201625-yearinUnitedStates:tobaccocontrolismostimportanttodecreaseoflungcancermortality19AstudypublishedinCACANCERJCLINfurtheridentifiedtheroleoftobaccocontrolinreducinglungcancermortalityOverthepasttwodecades,dueto:increasedawarenessofhazardofsmokingimplementationoftobaccocontrolEarlydiagnosisandtreatmentBetween1990and2014,malelungcancerdeathratedropped43%Between2002and2014,femalelungcancerdeathratedropped17%ChangesincancermortalityintheUnitedStatesbetween1930and2014CancerStatistics,2017,CACANCERJCLIN,2017Tobaccocontrolreducedlungcancermortality20GlobalinitiativeforChronicObstructiveLungDisease（GOLD2017）IncludingdefinitionofCOPD,assessmentofthedisease,medicationtreatment,non-medicationtreatment,complicationsmanagementandotheraspectsItclearlydefined

theroleofsmokingandtobaccocessationinCOPDpreventionandtreatmentGlobalInitiativeforChronicObstructiveLungDisease,201721TobaccocessationisthemainpreventionandinterventionmethodforCOPD“Todate,

there

is

no

conclusiveclinicaltrialevidencethatanyexistingmedicationsforCOPDmodifythelong-termdeclineinlungfunction.”GlobalInitiativeforChronicObstructiveLungDisease,2017Smokingcessationforpeoplewithchronicobstructivepulmonarydisease,

CochraneDatabaseofSystematicReviews,2016“Smokingcessationistheonlyevidence-basedinterventionthatreducestheriskofdevelopingCOPDandslowstheaccelerateddeclineinlungfunctioninpeoplewithCOPD.”Cochrane

DatabaseofSystematicReviews（2016）22GlobalinitiativeforChronicObstructiveLungDisease（GOLD2017）TobaccocessationistheonlyinterventionthatcanslowtheaccelerateddeclineoflungfunctionUnitedStatesNationalCommissiononPreventionPrioritiespublished28evidence-basedclinicalpreventiveservicesPreventingteenagersfromsmokingandadultstobaccocessationarethebestpreventiveservicesIfimplemented,morethan100thousanddeathscanbeavoidedannuallyUpdatedprioritiesamongeffectiveclinicalpreventiveservices.

Annalsoffamilymedicine,2017Tobaccocontrol:thebestdiseasepreventiveservices23The21stcenturyhazardsofsmokingandbenefitsofstopping:aprospectivestudyofonemillionwomenintheUK,Lancet,2013AprospectivestudyofonemillionwomenintheUKAmongUKwomen,two-thirdsofalldeathsofsmokersintheir50s,60s,and70sarecausedbysmokingSmokersloseatleast10yearsoflifespanStoppingbeforeage40yearsavoidsmorethan90%oftheexcessmortalitycausedbycontinuingsmoking

Stoppingbeforeage30yearsavoidsmorethan97%ofit24Quitsmokingmayavoidprematuredeath2512Preventingnon-smokersfromsmokingPreventnon-smokers(especiallyteenagers)fromsmokingProtectthemfromexposuretosecond-handsmokeRaisepublicawarenessofthedangersofsmokingStrengthenlegislativeandpolicysupportRaisingtobaccotaxes,etc.HelpingsmokerstoquitEnhancingsmokersperceptionsoftheriskofsmokingandthebenefitsoftobaccocessationProvidingclinicaltobaccocessationtreatmentTobaccocontrolisthemostfeasibledisease-preventionmeasureinChinaThemeof2017ChinaNoTobaccoDay

“Smokeless·health·development”TwoaspectsoftobaccocontrolSubstantialincreaseintobaccotaxesProhibitionoftobaccomarketingHealthwarningsoncigarettepacksMassmediapublicitySmokingcessationSmoke-freelegislationProtectagainstsecond-handsmokeSmokingratesinChina(2015)andthepredictionof2025smokingratesifmeasureswereimplemented26ThemosteffectivewayistoimplementacomprehensivepolicyontobaccocontrolTobaccocontrolinChina:predictionofvarioustobaccocontrolmethodsTheBillChinaCannotAfford:HEALTH,ECONOMICANDSOCIALCOSTSOFCHINA’STOBACCOEPIDEMIC,2017100%smokingbansinpublicplacesinBeijing,ShanghaiandShenzhenToestablishaworkingmechanismandsystemforcomprehensivetobaccocontrol,ensurepublicfinancialinputReduce200thousandsmokers100%smokingbansinpublicplacesinBeijingobtainedobviouseffectafteroneyearimplementationTobaccocontrolinChina:100%smokingbansinpublicplaces2728ChinaReportontheHealthHazardsofSmokingIssuedbyformerMinistryofHealthofChinain2012ThefirstchinagovernmentreportonhealthrisksofsmokingandsecondhandsmokeStrongscientificevidencetothepublic,leadingtopositivetobaccocontrolactionsWHOremarks:animportantmilestoneinthehistoryofChina'spublichealthTobaccocontrolinChina:enhancepublicawarenessFeb,2013Apr,2013Jun,2013Aug,2013Oct,2013MassmediahadsignificantlyincreasedthenumberofcallstothenationaltobaccocessationhotlineinSenegal,2013TelevisionisthemosteffectivewayVisceralimagesaremosteffectiveSocialmediacampaignsChinaMassMediaTobaccoControlCommunicationsInitiativeProgramlaunchedfrom2008,withthepurposeofpromotingtobaccocontrolpublicityForeignExperience29TobaccocontrolinChina:massmediacampaignsThechapterofTheeffectsofsmokingontherespiratorysystemandthecontrolofsmokingwaswritteninthe"RespiratoryInternalMedicine“(MinistryofHealth"EleventhFive-YearPlan"teachingmaterials,theNationalHigherMedicalTextbookResearchInstituteplanningmaterials,andtheNationalHigherEducationGraduateSchoolofteachingmaterials).Itwasthefirsttimetowriteaspecialchapteroftobaccocontrolintonationalmedicaltextbooksandintegratedintonationalmedicaleducationsystem.30TobaccocontrolinChina:includedinthenationalmedicaleducationsystemPatientsstatusDoctorsmeasureSmokerBrieftobaccointervention:clearlyadvisesmokerstoquitWithoutintentiontoquit5RDesiretoquit5AStartofquittingGiveenoughaffirmation,emphasizethegreathealthbenefitsofquittingHelptoresolvetheproblemsencounteredintobaccocessationIntheprocessofquittingContinuefocusingontobaccocessationprocessInformthedoctorifyouhaveanytendencytorelapseAfterquittingTodiscusstheexperienceoftobaccocessationandtofurtherconsolidatethetobaccocessationstatusWarningtheencounterfactorsthatinducerelapseIfrelapseoccurs,don'tbeshyofreporting31TobaccocontrolinChina:roleofcliniciansSinceMay31,2012,22well-knowndomesticandforeignexpertshavebecometobaccocontrolambassadors32Rolemodel:tobaccocontrolambassadorsHighlightedtobaccodependenceasachronicdiseaseProposedtobaccodependencetreatmentplan——TobaccocessationtreatmentstandardsinChinaGuidelineonChinaclinicaltobaccocessation,2007Edition(TrialEdition)TheNationalHealthandFamilyPlanningCommissionpublishedandpopularizedtheguidelinestoprovincialHealthandFamilyPlanningCommissionsGuidelineonChinaclinicaltobaccocessation(2015Edition)33ThefirstandsecondguidelinesonChinaclinicaltobaccocessation34EstablishTobaccocessationclinicsandprovidepolicysupportThefirsttobaccocessationclinic:Stockholmin1956China-JapanFriendshipHospital:threefull-timespecialistdoctorsCarryoutsmokingcessationinterventionaccordingtoGuidelineonChinaclinicaltobaccocessation(2015Edition)Setupnationaltobaccocessationhotline4008085531Forminganationwidetobaccodependence

diagnosisandtreatmentsystemOutpatientandwardsmokingcessationsystemEquippedwithpersonnelandhardwarefacilitiesStandardclinicalinterventionDistributionoftobaccocessationclinicsinChinaTobaccocontrolinChina:tobaccodependencediagnosisandtreatmentsystem35OfficiallyapprovedbyWHOonMar21,2016LaunchedonMay26,2016TheonlycollaboratingcenterdedicatedtotobaccocessationandrespiratorydiseasepreventioninChinaTobaccoMedicineandTobaccoCessationcenterofTostrengthennationaltobaccocessationsysteminlinewithWHOFCTCArticle14guidelinesworldwide,particularlyinAsiaPacificRegionToconducttrainingandeducationalactivitiestopromoterespiratorydiseasesprevention,managementandtobaccocontrol,especiallyamonghealthprofessionalsToactasaclearinghouseforthedisseminationofWHOdevelopedinformationontobaccoorhealthwithinChinaResponsibilitiesofthecenterChina-JapanFriendshipHospitaltakesresponsibilityfortheworkWHOCollaboratingCenterforTobaccoCessationandRespiratoryDiseasePreventionCampaign“TobaccoCessation:DoctorsFirst”encouragesmokingdoctorstoquitanddrivepatientstoquitsmokinghelppatientsquit,integratesmokingcessationintoroutinehospitalworkpreventnon-smokersfromsmokingDistributionofChinaTobaccoCessationAlliancelaunchmeetingof“TobaccoCessation:DoctorsFirst”36ChinaTobaccoCessationAlliance

founded

inAug,2016first53hospitals,thenspreadto136hospitalscover27provinces,municipalitiesandautonomousregions(first18)ChinaTobaccoCessationAlliance

“TobaccoCessation:DoctorsFirst”37HoldSmokingCessationTrainingandResearchProgrammeinpast7yearsProposeamethodofclinicaltobaccocessationwithChinesecharacteristicsThetrainingcansignificantlyimprovetobaccocessationskillsamongclinicians

Evaluationof3-daysmokingcessationtrainingcoursefordoctorsfrom38citiesinChina,ChinMedJ,2012TobaccocontrolinChina:trainingphysiciansontobaccocessationEvidence-baseddatashowstobaccocessationhotlinedoesworkThefirstwaslaunchedinAustraliain1985ThefirstinChinawaslaunchedinHongkongin2000ThefirstinmainlandChinawaslaunchedinBeijingin2004EffectivelyhelpsmokersdealwithproblemsduringcessationSignificantlyincreasethesuccessrateoftobaccocessation38TobaccocontrolinChina:NationalprofessionalsmokingcessationHotline4008085531SmokingcessationtipsforoutpatientcasesSweepcigarettebuttsNon-smokingpatrolSmokingbaninhospitaltobaccocessationclinic39China-JapanFriendshipHospital:shouldbethebestsmoke-freehospitalContentsTobaccoinChina123TobaccocontrolinChinaFuturechallengesComprehensivenationalsmoke-freelegislationAstrongnationallegislation,consistentwiththeeightharticlesofWHOFCTC,hasbeenintroduced.AstrongnationallawenforcementprogrammewithfundingConcentrateontobaccocessationandcarryoutscientificresearchExpandingtobaccocessationinterventions,includingtheinclusionoftobaccocessationproductsandtreatmentintonationalhealthcarecatalogs,providingsupport,andintroducingnewapproachessuchasmobileanddigitaltechnology(mHealth)FurtherraisethetobaccotaxRaisingtobaccotaxesandpriceswillbethemosteffectivewaytoreducethediresocio-economicconsequencesofhighsmokingratesinChina,andtoreducetheburdenoftobaccoproductsProhibitionoftobaccoadvertisingandsponsorshipFurtherrestrictionsontobaccoadvertisinginlightofthenewadvertisinglaw,whichcameintoeffectinSeptember2015GraphichealthwarningforcigarettepacksGraphichealthwarningsfordisplayingtobaccohazardsbycoveringatleast50%areasofcigarettepacksEnhancesmokingawarenessofhealthhazardsThepublic'slackofawarenessofsmokingisaveryimportantfactorhinderingtobaccocontrol

Tobaccocontrol:themostchallengingdisease-preventionmeasureinChina41Ifwecanintroducea100%smoke-freelegislation,Chinawillbeabletoseizethehistoricopportunitytoturnthetide,asothercountriesstudyexample,sendamessagetotheworld:theinnocentpeopleexposedtodeadlysecondhandsmokeisabsolutelynotbetolerated,nomatterwhenandwhere.

——Dr.AngelaPrattWHOrepresentativeofficeinChinaBeijing,Shanghai,Shenzhen:100%smokingbansinindoorpublicplacesOtherareasofsmoke-freeregulationsarestillnotperfectAllowsmokinginsomeindoorpublicplacesLackoflawenforcementStateregulationshavenotyetpassedCulture,socialissuestobaccoindustryinterference…42100%smoke-freelegislation43IfChineseGovernmentincreasedaverageretailpriceofeachpackofcigarettesby50%,thiswouldavoided20millionprematuredeathsover50yearsIftaxesincreasedby100%,40millionprematuredeathswouldbepreventedover50yearsMostofthembelongtothelowestincome