Emerging tobacco hazards in China: 1. Retrospective proportional mortality study of one million deaths

BMJ 1998;317:1411-1422 ( 21 November )

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Emerging tobacco hazards in China: 1. Retrospective proportional mortality study of one million deaths

Editorial by Lopez and Paper p 1423

Bo-Qi Liu, professor, ^a Richard Peto, professor, ^b Zheng-Ming Chen, reader in epidemiology, ^b Jillian Boreham, senior research fellow, ^b Ya-Ping Wu, research fellow, ^a Jun-Yao Li, epidemiologist, ^a T Colin Campbell, professor, ^c Jun-Shi Chen, director. ^d

^a Department of Epidemiology, National Cancer Institute, Chinese Academy of Medical Sciences, Panjiayuan, Chaoyang District, Beijing 100021, People's Republic of China, ^b Clinical Trial Service Unit and Epidemiological Studies Unit, Nuffield Department of Clinical Medicine, Radcliffe Infirmary, Oxford OX2 6HE, ^c Division of Nutritional Sciences, Cornell University, Ithaca, NY 14853, USA, ^d Institute of Nutrition and Food Hygiene, Chinese Academy of Preventive Medicine, Beijing 100050, People's Republic of China

Correspondence to: Professor Liu or Professor Peto gale.mead{at}ctsu.ox.ac.uk

Objective: To assess the hazards at an early phase ofthe growing epidemic of deaths from tobacco inChina.
Design: Smoking habits before 1980 (obtained fromfamily or other informants) of 0.7 million adults who had diedof neoplastic, respiratory, or vascular causes were compared withthose of a reference group of 0.2 million who had died of othercauses.
Setting: 24 urban and 74 rural areas ofChina.
Subjects: One million people who had died during 1986-8and whose families could beinterviewed.
Main outcome measures: Tobacco attributable mortality in middle orold age from neoplastic, respiratory, or vasculardisease.
Results: Among male smokers aged 35-69 there was a51% (SE 2) excess of neoplastic deaths, a 31% (2) excess of respiratorydeaths, and a 15% (2) excess of vascular deaths. All three excesseswere significant (P<0.0001). Among male smokers aged $>=$ 70 therewas a 39% (3) excess of neoplastic deaths, a 54% (2) excess ofrespiratory deaths, and a 6% (2) excess of vascular deaths. Fewerwomen smoked, but those who did had tobacco attributable risksof lung cancer and respiratory disease about the same as men.For both sexes, the lung cancer rates at ages 35-69 were aboutthree times as great in smokers as in non-smokers, but becausethe rates among non-smokers in different parts of China variedwidely the absolute excesses of lung cancer in smokers also varied.Of all deaths attributed to tobacco, 45% were due to chronic obstructivepulmonary disease and 15% to lung cancer; oesophageal cancer,stomach cancer, liver cancer, tuberculosis, stroke, and ischaemicheart disease each caused 5-8%. Tobacco caused about 0.6 millionChinese deaths in 1990 (0.5 million men). This will rise to 0.8million in 2000 (0.4 million at ages 35-69) or to more if thetobacco attributed fractionsincrease.
Conclusions: At current age specific death rates in smokersand non-smokers one in four smokers would be killed by tobacco,but as the epidemic grows this proportion will roughly double.If current smoking uptake rates persist in China (where abouttwo thirds of men but few women become smokers) tobacco will killabout 100 million of the 0.3 billion males now aged 0-29, withhalf these deaths in middle age and half in oldage.

Key messages

Of the Chinese deaths now being caused by tobacco, 45% are from chronic lung disease, 15% from lung cancer, and 5-8% from each of oesophageal cancer, stomach cancer, liver cancer, stroke, ischaemic heart disease, and tuberculosis
Tobacco now causes 13% (and will probably eventually cause about 33%) of deaths in men but only 3% (and perhaps eventually about 1%) of deaths in women as the proportion of young women who smoke has become small
Two thirds of men now become smokers before age 25; few give up, and about half of those who persist will be killed by tobacco in middle or old age
If present smoking patterns continue about 100 million of the 0.3 billion Chinese males now aged 0-29 will eventually be killed by tobacco
Tobacco caused 0.6 million deaths in 1990 and will cause at least 0.8 million in 2000 (0.7 million in men) and about 3 million a year by the middle of the century on the basis of current smoking patterns

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