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  • ISSN: 2373-9436
    J Cancer Biol Res 2(1): 1044.
    Submitted: 02 April 2014; Accepted: 24 April 2014; Published: 30 April 2014
    Special Issue entitled:
    Lung Cancer China
    Review Article
    Tobacco Control and Lung Cancer Prevention in China
    Xiu-Yi Zhi1*, Xiao-Nong Zou2, Mu Hu1, Yuan Jiang3 and You-lin Qiao4
    1Department of Thoarcaic Surgery Xuanwu Hospital, Capital Medical University, China
    2National Office for Cancer Prevention and Control, Cancer Institute/Hospital, China
    3Office of Tobacco Control, Chinese Center for Disease Control and Prevention, China
    4Department of Epidemiology, Chinese Academy of Medical Sciences, China
    *Corresponding author: Xiu-Yi Zhi, Department of Surgery, University of Capital Medical Sciences, China
    Abstract
    In recent decades the age-specific mortalities of lung cancer in China have been increased to 9 times in men and women and it become one of the most important public health issues. The high prevalence of smoking in men and more than 70% of nonsmokers, both men and women, could be the biggest contributable factor for those consequences. While the abundant evidence on the health risks of exposure to smoking were available in both international and domestic studies the awareness on the health hazards from tobacco use were quit low in Chinese peoples, even in the health providers. Changes in the contents and the process of the tobacco products in Chinese tobacco product markets were accompanied by increased numbers of the lung cancer cases, increased adenocarcinoma and decreased squamous cell carcinoma of the lung, rather than reducing the overall lung cancer cases. Those suggested that comprehensive smoking-free policy should be implemented in all public places and the process of smoking-free legislation should put forward to create the legal environment and provide effective protection for reducing the incidence of lung cancer. Popularized health education should be also enhanced to raise the public awareness on smoking hazards.
    Introduction
    Tobacco epidemic has been one of most important public health issues in China which kills more than 1.2 million deaths per year [1-3]. Lung cancer mortality in China, used to be ranked at sixth in 1970s with the age-adjusted (by world population) mortality of 7.41 per 100 000, has led the cancer mortalities in the new century. The age-adjusted (by world population) mortality of lung cancer increased incidence were 49.81 per 100 000 and 42.01 per 100 000 for the urban and rural residents of men, respectively, and 23.35 per 100 000 and 19.45 per 100 000 per 100 000 for the urban and rural residents of women in 2009 in the registration areas of China [2,4,5].
    Since the 1950s, abundant research data have documented the unequivocal causal relationship between cigarette smoking and lung cancer in developed and developing countries, including China [6-10]. In many cities in China, the regulations of smoking ban in public places have been issued since 1990s. Strict regulations of smoking ban have been well performed in the most public transportation tools across mainland China. However, the epidemic of the tobacco use in Chinese, particularly the cigarette smoking did not have great substantial reduction in the last 40 decades [1,11]. The overall current smoking rates in Chinese adults were reported as 33.7% in 1996, 28.5% in 2002 and 27.9% in 2010 while in Chinese males adults, the rates were reported as 63.0% in 1996, 57.4% in 2002, and 54.0% in 2010. In most public sites and indoor working areas smoking free policies had not been well implemented [11]. The awareness on the health hazards of tobacco use was generally low in the public audience [12,13].
    In this paper we present our analysis on the status of the research related to the control of tobacco use and the lung cancer risks in Chinese population.
    Lung cancer incidence in Chinese urban and rural population are rising rapidly
    On the data from National Cancer Registration, the age-specific incidence rates of lung cancer showed substantially increased over the ages in both the urban and rural areas of China (Table 1). In the males, the rates in the high age groups were always higher than the immediate low groups, from 17% (80-84 years versus 75-79 years) to 225% (40-44 years versus 35-39 years) while in the females, those were from 15% (40-44 years versus 35-39 years) to 211% (45-49 years versus 40-44 years). The rates of lung cancer in the males aged at 45 years or older of the urban residents (except 60-64 years), were 10% to 81% higher compared to the rates of the male rural residents. The male to female ratios were from 1.18 to 2.85 in the urban, and 1.18 to 2.80 in the rural, reflecting the much higher risks for lung cancer in the males than the females regardless the residential classes.
    Table 1 Age-specific incidence of lung cancer in Chinese population, 2009.
    (Data: National Cancer Center [1])

    year

    All areas

    Male   Female

    Urban areas

    Male   Female

    Rural areas

    Male   Female

    25-

    1.24

    30-

    1.73

    1.12

    1.44

    1.18

    2.26

    1.03

    35-

    3.88

    3.29

    3.92

    3.33

    3.80

    3.21

    40-

    12.60

    3.79

    12.17

    6.21

    13.46

    7.97

    45-

    24.52

    11.8

    25.42

    12.38

    22.45

    10.50

    50-

    54.39

    22.67

    55.71

    21.46

    50.79

    25.77

    55-

    91.32

    35.26

    93.52

    32.86

    86.22

    41.18

    60-

    142.14

    57.24

    141.23

    55.99

    144.05

    60.05

    65-

    231.06

    87.55

    246.42

    94.95

    201.72

    72.17

    70-

    370.06

    174.74

    386.39

    191.37

    331.97

    133.64

    75-

    530.35

    231.68

    563.67

    257.99

    442.23

    164.42

    80-

    619.54

    281.74

    677.90

    315.50

    464.62

    199.48

    85+

    602.55

    243.00

    684.16

    279.89

    377.22

    150.05

    Table 1 Age-specific incidence of lung cancer in Chinese population, 2009.
    (Data: National Cancer Center [1])

    ×
    Compared with the two national surveys in last century, the age-specific mortalities of lung cancer in China had been experienced continuous increases in both male and female population, shown in table 2. The mortalities in the ages of 25-79 years or older in 1990-1992 were higher in all same ages in 1973-1975, increased by 98% (35-39 years) to 362% (75-79 years) in males, and from 97% (35-39 years) to 267% (75-79 years) in females. Continued increases were found again in 2004-2005 when compared to the rates in 1990-1992, increased by 6% (45-49 years) to 132% (80-84 years) in males of 35-84 years, and 7% (35-39 years) to 115% (75-79 years) in female aged in 35-44 years and 50-54 years or older. Those changes in the age-specific rates of lung cancer could not be well explained by the contribution from aging alone. Environmental exposure must play important roles in the development and increase of lung cancer mortalities in Chinese population, particularly from the long term and highly epidemic exposures.
    Table 2 The age-specific mortalities of lung cancer in China from 1973 to 2005.
    (Data source: Chen WQ [4])

    Year

    1973-1975

    Male   Female

    1990-1992

    Male   Female

    2004-2005

    Male   Female

    25-

    0.60

    0.46

    1.43

    1.10

    1.16

    0.63

    30-

    1.28

    0.93

    2.91

    1.84

    2.62

    1.63

    35-

    2.96

    1.90

    5.87

    3.74

    6.59

    3.99

    40-

    5.98

    3.42

    12.14

    6.55

    13.33

    7.75

    45-

    11.43

    5.96

    22.44

    11.61

    23.80

    10.49

    50-

    18.99

    9.09

    40.57

    19.23

    54.82

    21.18

    55-

    28.66

    12.21

    71.92

    28.77

    93.55

    36.01

    60-

    38.34

    15.71

    122.82

    43.32

    137.53

    55.51

    65-

    46.68

    19.55

    145.33

    53.49

    199.88

    77.84

    70-

    49.04

    21.21

    186.50

    69.65

    300.11

    122.29

    75-

    40.15

    19.07

    185.54

    69.98

    370.37

    150.32

    80-

    29.08

    16.17

    172.63

    84.65

    400.06

    168.38

    85+

    170.96

    83.53

    340.19

    205.92

    Table 2 The age-specific mortalities of lung cancer in China from 1973 to 2005.
    (Data source: Chen WQ [4])

    ×
    Changes in histological subtypes of lung cancer in Chinese
    In a recent report, changes of histological subtypes of lung cancer in Chinese males 2000 to 2012, increased Adenocarcinoma (ADC) and decreased Squamous Cell Carcinoma (SCC), had been observed in the cases from different residential areas, including Beijing, Hebei, Neimengu, Shandong, Heilongjiang, Shanxi, Henan, Liaoning, and Jilin in China , shown as figure 1 [14]. While the cases with SCC were decreased from 39.11% to 32.23%, the cases with ADC were increased from 21.96% to 43.36% from 2000-2002 to 2009-2012. These histological changes of lung cancer in Chinese males were more likely the following the western countries where the changes of cigarette design, as the filtered cigarette or the low-tar cigarettes were more popular among the smokers [7-10]. Changing the designs of the tobacco products did not reduce the risks of lung cancer in western population and need to be confirmed in the Chinese.
    Figure 1 Changes of histological subtypes of lung cancer in the males identified in CIHCAMS from 2000 to 2012 (Data source: Zou XN [14]).

    Figure 1 Changes of histological subtypes of lung cancer in the males identified in CIHCAMS from 2000 to 2012 (Data source: Zou XN [14]).

    ×
    Exposure to passive smoking was consistently critical
    Passive smoke contains hundreds of kinds of ingredients Harmful to human body, of which at least 69 species of carcinogens. Passive smoke harm to the health of people is very serious, temporary contact will cause harm to the body. Indoor comprehensive smoking free is the most effective method from second-hand smoke. According to news reports, February 20, 2014-25 PM2.5 concentrations, Beijing continues to be up to 583 micrograms per cubic meter, pollution is very serious, caused the public great attention and concern. Studies show that one cigarette can make indoor PM2.5 concentrations of up to 800 micrograms per cubic meter; three cigarettes more make indoor PM2.5 concentrations reach 1700 microgram/cubic meter. The vast majority of secondhand smoke generated particles will bePM2.5, including a large number of polycyclic aromatic hydrocarbon compound Content, arsenic and benzene and high carcinogenic nitrosamines. When Smoking, indoor PM2.5 stems mainly from second-hand smoke. In 2010 global Grass investigation, aged 15 and over 15 non-smokers, 72.4% are suffering from secondhand smoke exposure in China. According to this estimates, China has 560 million adult non-smokers in secondhand smoke exposure, while there are 180 million adolescents as well. Public places are worst for secondhand smoke exposure. In restaurants the exposure rate is as high as 89%; 67% in the family; 58% in the government building; about 35% in schools, hospitals, transportation. In addition, hotels, bars, workplace secondhand smoke exposure is also very worrying. National smoke-free environment legislation should not be delayed.
    In 2010, the prevalence of exposure to Second Hand Smoking (SHS) was particularly high among Chinese nonsmoking adults, 72.4% reported exposed to SHS in the past 30 days and 38.0% being exposed almost every day [5]. Exposure to SHS was especially high among leaders of organizations (85.8%), and business and service employees (83.1%). Then, in China, there could be more than 500 millions nonsmokers had exposed to SHS at least once a week. No significant difference had been found in the prevalence of exposure to SHS between men (74.1%) and women (71.6%), nor between the residents in rural (74.2%) and urban (70.5%).
    Awareness on Health Hazards of Tobacco use was Generally Low
    We conducted a survey on the awareness of health hazards of tobacco use in the staff in a cancer institution at Beijing in 2010. Analysis on the data from 159 responds showed that the scores of the tobacco knowledge were lower in the smokers than the nonsmokers for a number of questions, including concerning the quantities of smoking, low-tar cigarettes, passive smoking, and awareness the health consequences of tobacco use, such as prostatitis, hypertension, Osteoarthritis, shown in Table 3. Of 26 questions interviewed, only 7 had scores higher than 0.9 (full score is 1.0) in nonsmokers and none in smokers, suggested that the health hazards of tobacco use should be highlight and put as an important priorities of the health education programs for both the public and the health providers in China.
    Table 3 Scores of awareness of tobacco control among smoking and non-smoking staff.
    1:The ideal value is 1.0.

    Awareness questions

    Average score1

    (±standard deviation)

    Smokers    Non-smokers

    Comparison of smokers with non-smokers

    Z

    P

    Smoking behavior

     

     

     

     

    Less smoking and little harm

    0.6±0.3

    0.8±0.3

    4.69

    <0.001

    Lower tar means less harmful

    0.5±0.3

    0.8±0.3

    4.11

    <0.001

    Passive smoking is less harmful

    0.8±0.3

    0.9±0.2

    3.57

    0.004

    Patients with a long time smoking should smoking less rather quit

    0.5±0.3

    0.5±0.3

    1.04

    0.297

    As a chronic disease, smoking addiction needs medical treatment

    0.6±0.3

    0.7±0.3

    1.71

    0.087

    Smokers with quit will could quit succeed

    0.5±0.3

    0.4±0.3

    -1.24

    0.216

    Physicians should set the example to refuse smoking

    0.8±0.3

    0.9±0.2

    2.71

    0.007

    Smoking should be completely forbid in every hospitals

    0.8±0.2

    0.9±0.2

    2.25

    0.025

    Smoking could be fine when staffs have no direct contacts with patients

    0.7±0.3

    0.9±0.2

    4.87

    <0.001

    Health risks of active smoking

     

     

     

     

    Prostatitis

    0.6±0.3

    0.7±0.2

    2.19

    0.028

    Hypertension

    0.7±0.3

    0.8±0.2

    2.29

    0.022

    Osteoarthritis

    0.5±0.2

    0.6±0.2

    2.38

    0.017

    Lung cancer

    0.8±0.2

    0.9±0.2

    3.46

    0.005

    Ischemic heart disease

    0.6±0.3

    0.7±0.4

    0.66

    0.508

    Sexual dysfunction

    0.7±0.3

    0.8±0.2

    2.13

    0.033

    Tuberculosis

    0.7±0.3

    0.8±0.3

    0.86

    0.390

    Type II diabetes

    0.5±0.2

    0.6±0.2

    1.83

    0.067

    Acute gingival necrosis or ulceration

    0.7±0.3

    0.8±0.2

    1.55

    0.122

    Emphysema

    0.8±0.3

    0.9±0.2

    2.41

    0.016

    Health risks of passive smoking

     

     

     

     

    Leukemia

    0.5±0.2

    0.7±0.3

    2.81

    0.005

    Lung cancer

    0.8±0.3

    0.9±0.1

    3.05

    0.002

    Ischemic heart disease

    0.6±0.3

    0.7±0.3

    1.79

    0.073

    Bronchitis

    0.8±0.3

    0.8±0.2

    1.57

    0.117

    Stroke

    0.6±0.3

    0.7±0.2

    2.81

    0.005

    bronchiolitis

    0.7±0.3

    0.8±0.2

    1.61

    0.107

    Asthma

    0.8±0.3

    0.8±0.2

    1.26

    0.209

    Table 3 Scores of awareness of tobacco control among smoking and non-smoking staff.
    1:The ideal value is 1.0.

    ×
    Actions against the tobacco use in China should be widely strengthened
    Since the Framework Convention on Tobacco Control (FCTC) was ratified in China, there has been a strong push for national legislation, and progress is being made at both the municipal and national levels. But there are some limitations: including banning smoking in limited places; the executive bodies of the law are not clear; and most laws are difficult to implement, the executive bodies of the law are not clear; no any punishment and most laws are difficult to implement. Since 2008, several cities have enacted smoke-free legislation and more are actively drafting such legislation. Currently, none of the mainland cities are in compliance with Article 8, but there is growing confidence in the public acceptance of this legislation and the feasibility of enforcement. At the national level, in 1991, the Ministry of Health issued the Implementation Guidelines of the Regulation on Public Places Health Management and Smoking in which implementation guidelines banned smoking in 13 types of public places. Based on these guidelines, industry specific regulations for smoke free public places have been developed and implemented since 1997. The most important national achievement is that in 2009 the Ministry of Health joined three other national health authorities to issue a Decision on smoke-free health facilities. The Minister of Education and the Ministry of Health jointly issued a similar Decision on smoke-free schools in 2010. Though not legally binding, these decisions and guidelines are being implemented and enforced with rigour. The most impressive measures of smoke free legislation and policies include: the Ministry of Health taking the lead and setting an example by building a smoke-free Ministry of Health; continued support of the smoke-free facilities efforts in various regions in partnership with the Central Government Subsidy to Regional Tobacco Control Projects; expert supervision of the building of a regional smoke-free health care system; implementation of China tobacco control mass media communication campaigns; third-party professional survey conducting inquiries into the nationwide building of smoke-free health care institutions. Although efforts were made, major breakthroughs still needed in the development and implementation of policies, regulations and laws on banning smoking in all indoor public places in China.
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    Cite this article: Zhi XY, Zou XN, Hu M, Jiang Y, Qiao YL (2014) Tobacco Control and Lung Cancer Prevention in China. J Cancer Biol Res 2(1): 1044.
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