Smoking Still Takes a Heavy Toll in China

January 07, 2009

[January 7, 2009 (updated January 8, 2009)] (Beijing, China) — Smoking continues to be a major risk factor for mortality in China, with almost 700 000 premature deaths attributed to tobacco use in 2005, a new study shows [1]. Dr Dongfeng Gu (Fu Wai Hospital, Beijing, China) and colleagues report their findings in the January 8, 2009 issue of the New England Journal of Medicine.

Gu et al say this is the first proper estimate of the national burden of smoking in China. Although several prospective cohort studies have examined the relationship between smoking and mortality in Chinese populations, they were mainly conducted in regional or occupational groups, and so the number of deaths as a result of smoking in the country overall has previously been uncertain.

These data are a reminder of the urgent need for continued strengthening of national programs in China on smoking prevention and cessation.

With a population of 1.3 billion people and about 350 million smokers, China is both the largest producer and consumer of tobacco in the world, with a large percentage of the deaths attributable to smoking worldwide, Gu et al explain. These new estimates come hard on the heels of predictions that smoking will kill a million people prematurely in India by 2010, as reported by heartwire last year.

"The major preventable cause of death in China is smoking," Gu told heartwire . "These data are a reminder of the urgent need for continued strengthening of national programs in China on smoking prevention and cessation. These efforts should include the full set of strategies recommended by the 2008 WHO report on the global tobacco epidemic."

Most Deaths From Smoking Are in Men, But More Women Smoking Too

Gu et al conducted their large prospective cohort study in a nationally representative sample of almost 170,000 Chinese adults aged 40 or older, with baseline data on smoking and risk factors collected in 1991 as part of the China National Hypertension Survey. Follow-up was conducted in 1999 and 2000, and the investigators used multivariable-adjusted relative risk, prevalence of smoking, mortality, and population size in each age group, stratified according to sex, to calculate the number of deaths attributable to smoking in 2005.

They found a significant dose-response association between pack-years smoked and death from any cause in both men and women after they adjusted for multiple risk factors (p<0.001 for trend). They estimate that in 2005, 673 000 deaths were attributable to smoking in China (95% CI 564,700-781,400), the majority of which (538,200) were among men.

"The prevalence of tobacco smoking has been continuously high in adult men (around 60%)," Gu told heartwire . "Also, the average age of smoking initiation has been dropping and female smoking rate increasing during recent decades."

Estimates for the leading causes of smoking-related deaths were cancer (268,200), cardiovascular disease (146,200), and respiratory disease (20,300-113,300).

Relative Risk and Absolute Numbers of Deaths Attributable to Smoking in China, According to Sex and Cause of Death

Cause of death Men: Multivariable adjusted relative risk* Men: Deaths attributable to smoking, absolute n Women: Multivariable adjusted relative risk* Women: Deaths attributable to smoking, absolute n
Any cancer 1.55 240,400 1.62 27,800
Any respiratory disease 1.14 48,600 1.43 18,200
Any cardiovascular disease 1.17 126,600 1.21 19,600
Stroke 1.17 82,500 1.18 9,800
Coronary heart disease 1.21 30,400 1.41 7,300

size="1">*Data were adjusted for age at baseline, educational level, geographic region (north vs south), urbanization (rural vs urban), and the presence/absence of hypertension, overweight status, alcohol consumption, and physical inactivity; the presence/absence of diabetes was considered as a time-dependent covariate.

Government Must Resolve Conflicts to Move Ahead With Tobacco Control

These new estimates . . . document the potential human toll of inaction.

Gu et al say that, fortunately, "there is far more tobacco-control activity" in China than there was previously. "The government is moving forward with implementation of tobacco-control measures and has strengthened its tobacco-control capacity within the Chinese Center for Disease Control." But nevertheless, there is an inherent conflict, they note, because the government still sells tobacco through its state-owned company and relies on tobacco revenues.

"China's development could be threatened if high smoking rates continue," Gu asserts.

However, he says he believes that some of those in government are beginning to understand that revenue gained from tobacco taxation is far less than the healthcare costs associated with smoking.

Of paramount importance is the recognition of the role of smoking cessation and the implementation of smoking bans in public places, he adds.

Although the smoking quit rate in China has increased in recent years, with one study estimating this to be around 15%, this is countered by the fact that people are starting to smoke earlier and that more women are smoking, he notes.

And although some moves have been made toward smoking bans--Beijing banned smoking in most of its public places in May 2008--"the top priority is to adopt an antismoking law that bans smoking in all public areas in the country," Gu asserts.

"These new estimates on mortality attributable to smoking document the potential human toll of inaction," he and his colleagues conclude.

  1. Gu D, Kelly TN, Wu X, et al. Mortality attributable to smoking in China. N Engl J Med 2009; 360: 150-159.

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