Emerging tobacco hazards in China: 2. Early mortality results from a prospective study

Objective To monitor the evolving epidemic of mortality from tobacco in China following the large increase in male cigarette use in recent decades. Design Prospective study of smoking and mortality starting with 224 500 interviewees who should eventually be followed for some decades. Setting 45 nationally representative small urban or rural areas distributed across China. Subjects Male population aged 40 or over in 1991, of whom about 80% were interviewed about smoking, drinking, and medical history. Main outcome measure Cause specific mortality, initially to 1995 but later to continue, with smoker versus non-smoker risk ratios standardised for area, age, and use of alcohol. Results 74% were smokers (73% current, only 1% former), but few of this generation would have smoked substantial numbers of cigarettes since early adult life. Overall mortality is increased among smokers (risk ratio 1.19; 95% confidence interval 1.13 to 1.25, P < 0.0001). Almost all the increased mortality involved neoplastic, respiratory, or vascular disease. The overall risk ratios currently associated with smoking are less extreme in rural areas (1.26, 1.12, or 1.02 respectively for smokers who started before age 20, at 20-24, or at older ages) than in urban areas (1.73, 1.40, or 1.16 respectively). Conclusion This prospective study and the accompanying retrospective study show that by 1990 smoking was already causing about 12% of Chinese male mortality in middle age. This proportion is predicted to rise to about 33% by 2030. Long term continuation of the prospective study (with periodic resurveys) can monitor the evolution of this epidemic.