Physicians' role in advancing tobacco control in ... - Wiley Online Library

Thoracic Cancer ISSN 1759-7706

MINI REVIEW

Physicians’ role in advancing tobacco control in China

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Kylie J. Lindorff & David J. Hill

1 Quit Victoria and VicHealth Centre for Tobacco Control, Cancer Council Victoria, Melbourne, Australia 2 Cancer Council Victoria, Melbourne, Australia and International Union Against Cancer (UICC)

Keywords FCTC; physicians; smoking; tobacco; tobacco control. Correspondence Kylie Lindorff, Quit Victoria and VicHealth Centre for Tobacco Control, Cancer Council Victoria, Melbourne, 3053 Australia. Tel: +61 3 9635 5518 Fax: +61 3 9635 5030 Email: [email protected] Received: 15 December 2009; accepted 8 January 2010. doi: 10.1111/j.1759-7714.2010.00002.x

Abstract China has ratified the FCTC and is working towards implementing tobacco control measures to combat the massive health and economic consequences of tobacco use. Physicians will need to play a leading role in this fight as they have done in countries such as Australia where measures to address the tobacco epidemic are more advanced. At present in China barriers such as physicians’ own smoking status and underestimation of the impact interventions with their patients can have means that their potentially positive contribution is far from realised. Physicians have a responsibility to lead in tobacco control. This should begin with their own behaviour and practices including quitting smoking if a smoker and counselling patients and families of patients to not smoke. Advocating to make hospitals and medical facilities smokefree should also be a priority for physicians. As centres where people attend to improve their health and receive treatment for illness, allowing a practice such as smoking is completely incongruous. Responsibility also rests with the facilities in which physicians work and the professional bodies who represent them, physicians should be provided with information, training and support to assist them to address their own and their patients tobacco use.

Introduction Smoking is the single largest cause of preventable death globally and is a risk factor for six of the eight leading causes of death in the world.1 In China, as many as 100 million men who are currently under the age of 30 will die from tobacco use.2 As a party to the World Health Organization (WHO) Framework Convention on Tobacco Control (FCTC), China is working towards implementing tobacco control measures to combat the massive health and economic consequences of tobacco use. Physicians can, and in fact will need to, play a leading role in this fight. At present, however, barriers such as their own smoking status and underestimation of the impact intervention can have, means that their potentially positive contribution is far from realized.

20% of the world’s population, yet of the 6 trillion cigarettes produced worldwide, China consumes around 37% of them.3 A national survey in 1996 found that 63% of men in China smoked cigarettes and 4% of women.4 By 2002, these national figures had not significantly improved, male smoking had in fact increased to 66% and female smoking decreased slightly to 3%.5 This contrasts with trends in Western countries such as USA, Canada, UK, and Australia, in which the prevalence of tobacco use has fallen markedly in recent decades. Some rapidly developing economies, such as Brazil, have shown that the prevalence of smoking can be reduced by strong tobacco control policies and information distribution.6 Such successes encourage the belief that China, given the political commitment and resources, will be able to reduce smoking prevalence.

Smoking in China Cigarette consumption in China increased rapidly from just under 500 000 million in 1970 to more than1 500 000 million in 1990. From 1990 to 2005, cigarette consumption further increased to around 1 800 000 million.1 China represents

The health effects of smoking The serious harm to health from smoking cigarettes is indisputable. Evidence of smoking’s link to lung cancer had emerged by the 1950s.7 Lung cancer was conclusively

Thoracic Cancer 1 (2010) 17–22 © Tianjin Lung Cancer Institute and Blackwell Publishing Asia Pty. Ltd

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Physicians’ role in tobacco control in China

K.J. Lindorff & D.J. Hill

identified as caused by smoking more than 40 years ago.8 Smoking is a cause of heart disease, stroke and respiratory diseases and a growing body of research shows that smoking is a causal factor in an increasing number of cancers.9 Tobacco is the major cause of lung cancer, with global estimates that it causes up to 90% of all cases.3 The prognosis for those with lung cancer is poor even in developed countries like Australia, with only around 11% of males and 14% of females surviving for five years after diagnosis.9 Innovations in cigarette manufacturing, such as the introduction of filter tips and lower levels of machine-measured tar and toxins that claim to reduce exposure to harmful constituents in cigarette smoke, have done little to reduce lung cancer death rates. These innovations may have lead to changes in the type of cancers seen in smokers, with adenocarcinoma now the most frequently diagnosed cancer type rather than squamous cell carcinoma, seen in the early stages of a smoking epidemic.9 While ex-smokers have a reduced risk of developing lung cancer compared to those who continue to smoke, their risk remains higher for many years after they have quit than those who have never smoked.9 Lung cancer due to smoking usually takes around 20 years or more to develop, thus death rates from lung cancer today reflect smoking prevalence in a community two to three decades ago. Smoking is also a cause of laryngeal cancer, cancers of the oral cavity and pharynx, esophageal cancer, pancreatic cancer, stomach cancer, kidney and bladder cancers, cervical cancer and acute myeloid leukemia. It is also strongly associated with liver cancer and colorectal (bowel) cancer. There are 69 known carcinogens in tobacco smoke; these are absorbed through the lungs and then travel to the rest of the body through the bloodstream. Smoking also impacts on metabolism and enzyme activity which may affect carcinogenesis.9

Smoking related deaths in China: current and predicted The main causes of death in China between 1991 and 2000 for men were (in order) malignant neoplasms, heart disease, cerebrovascular disease, accidents and infectious diseases. For women they were heart disease, cerebrovascular disease, malignant neoplasms, pneumonia and influenza, and infectious diseases.10 The three leading causes of death (diseases of the heart, malignant neoplasms and cerebrovascular disease) accounted for 66% of all deaths. Smoking is a major risk factor for all three leading causes of death. The top five cancer causes of deaths were malignant neoplasms of the lung, liver, stomach, esophagus, and colon and rectum. Smoking causes, or is strongly associated, with all of the top five cancer causes of death. Mortality attributable to cigarette smoking was higher among men than women and higher among those in urban 18

areas than rural, and was responsible for 7.9% of the total mortality, 12.9% in men and 3.1% in women. It is estimated that if cigarette smoking was eliminated in China, total mortality among men could be reduced by 10% and among women by 3.5%.10 A nationally representative study calculated the number of deaths attributable to smoking in 2005 in China.11 It estimated that in 2005 a total of 673 000 deaths were attributable to smoking, 538 200 in men and 134 800 in women. The leading three attributable causes of death were cancer (268 200 deaths), cardiovascular disease (146 200 deaths) and respiratory disease (66 800 deaths). The most significant specific diseases associated with these deaths were lung cancer (129 000 deaths), stroke (20 600 deaths) and chronic obstructive pulmonary disease (29 200 deaths). Together they accounted for approximately 45.1% of deaths attributable to smoking in men and 31.8% of those in women. These figures did not take into account deaths from passive smoking. With very high smoking rates among men in China, it can be expected that passive smoking also contributes significantly to both death and disease in the wider community. Passive smoking causes heart disease and lung cancer in adults who do not smoke, it induces and exacerbates a number of mild to severe respiratory illnesses in infants, children and adults, increases the risk of Sudden Infant Death Syndrome and a range of other serious health outcomes in young children.12 The US Surgeon General’s 2006 report on the health consequences of second-hand smoke (passive smoking) concluded that there is no level of exposure that is free of risk.13 Gan, et al. undertook a study to estimate the disease burden of adult lung cancer from passive smoking in China in 2002.14 They first estimated the number of deaths from lung cancer from active smoking, 13 000 in total in 2002 (114 700 for men and 15 300 for women). They then estimated the number of lung cancer deaths from passive smoking in 2002 and found 22 000 lung cancer deaths were attributable. Unlike active smoking, where 88% of deaths were men, women bear the greatest burden by far from passive smoking, accounting for 80% of deaths. The 22 000 deaths are only those from lung cancer attributable to passive smoking. Given there are an estimated 400 million passive smokers in China,14 it can be expected that other diseases and death associated with passive smoking, particularly for women and children, will also add to the significant health burden resulting from cigarette smoking in China. A number of studies have predicted the number of deaths that can be expected in China if current smoking patterns persist. Peto et al. predict that there are around 1 million deaths annually from tobacco at present and this will rise to around 3 million by 2050.15 They state that if current high rates of uptake and low rates of cessation do not change, during the first half of this century a total of 100 million deaths caused by tobacco will occur in China.



Economic impact The economic burden of smoking in China is substantial. It was estimated that in 2000 the economic cost of smoking was US$5.0 billion.16 Direct costs that include all health care expenditure for treating smoking-related illnesses were $1.7 billion, 34% of total smoking-related costs and 3.1% of China’s national health expenditure in 2000. With studies suggesting that, compared to developed countries, a much higher proportion of those of working age in China are affected by chronic disease, the economic impact of smoking takes on even greater significance.10

Smoking rates of Chinese physicians A number of studies have assessed smoking rates, smoking cessation practices and attitudes of physicians in China.17–20 A series of studies undertaken in 1987, 1996 and 2005 in Wuhan, capital city of the Hubei province, allow us to detect changes over time of these variables amongst physicians.18,20 Smoking rates amongst male physicians rose markedly between 1987 and 1996, from 50.9% to 61.3% and then decreased slightly to 58.0% in 2005. The story for female physicians is far more disturbing. In 1987 only 4.8% of female physicians smoked, this tripled in 1996 to 12.2% and then increased again by more than half to 18.8% in 2005. Comparisons were made in each of the studies between a physician’s smoking status and their likelihood to engage in anti-smoking counseling. In 1987, physicians’ smoking status highly correlated with their smoking cessation counseling, with non-smoking physicians significantly more likely to engage in counseling of their patients. However, in 1996 this was not the case, with no correlation found between smoking status and likelihood of smoking cessation counseling.20 In 2005 non-smoking physicians were again significantly more likely to engage in smoking cessation counseling, with 70.5% of non-smoking physicians often or always counseling their patients about cigarette smoking but only 48.6% of physicians who smoked doing so.18 A 2004 study also conducted in Hubei province, which looked at smoking status amongst rural physicians, provides some insight into differences between city and rural physicians.19 It found that smoking rates among rural male physicians were 31.9% and when stratified by sex, no rural female physicians were smokers. Smoking rates also varied by age, with those younger than 25 years of age having the lowest prevalence (6.3%) and those 50–54 years having the highest (31.6%). However, given the study took place in a teaching hospital, there is a chance of underreporting, particularly by any younger medical students on placement as they are not allowed to smoke.18 Differences in smoking status, cessation counseling behavior and attitudes are likely not only between rural and city


physicians, but also between physicians in different cities. A 2004 survey of hospital based physicians across six Chinese cities found smoking prevalence of 41.0% for men and 1.0% for women.17 These figures are substantially lower than those of the physicians in the city of Wuhan in the Hubei province.A more recent study from 2008 of almost 40 000 physicians from 977 hospitals found male smoking rates of 38.7% and female smoking rates of 1.1%, however smoking rates differed across regions.21 Identifying and understanding the implications of regional differences when implementing cessation support, training or education of physicians, in a country with a population as large as China is important for success. Differences have also been noted in smoking prevalence amongst physicians of different disciplines, for example between surgeons, gynecologists, pediatricians, traditional medicine doctors, orthopedics and intensive care.18,19 Taking into account the specialist orientation of the physician when implementing physician-based tobacco control programs will also be required.

Impact of physician’s smoking on tobacco control success The ongoing collection in China of data on physicians’ smoking status is important as it can act as a barometer indicating the effectiveness of current tobacco control measures. As role models for health, if physicians continue to smoke, it is unlikely the general public will be convinced of the need to quit smoking. Secondly, it has been suggested that the “maturity” of the tobacco epidemic in a country can be predicted by the smoking rates of physicians, as they tend to give up smoking earlier than the general population.22 The decline of smoking rates amongst Australian physicians provides a useful case study demonstrating this phenomenon. In the 1960s around a third of Australian physicians were smokers, with higher levels seen in the overall population – more than one third of women smoked and nearly two-thirds of men.23 By the mid to late 1970s, the smoking rates of physicians had almost halved and by the early 1980s only about one tenth of physicians smoked. By the 1990s this had declined even further to one in twenty. Although male smoking rates in the general population also declined in this period, it was not to the same degree as physicians, with general male smoking rates around one in four by the 1990s. Smoking rates among women initially rose between the 1960s and 1980s but by the 1990s had declined to around one in five.23 There is strong evidence that intervention from physicians can greatly influence patients’ likelihood of quitting smoking.24 There is also evidence from countries like Australia that show that as more physicians stop smoking, they are more likely to engage in smoking cessation counseling with their patients. In Australia in 1964, less than half of physicians were


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advising their patients to quit smoking but by 1982 91% of physicians were doing so.23 Thus, when physicians better exemplify healthy behavior as role models they are also more likely to encourage patients either to not take up or to quit smoking. Physicians are credible and authoritative sources of influence on patients. Yet it appears that in China many physicians have not yet accepted the significant role they can have in regards to role modeling healthy behavior and encouraging smoking cessation in their patients. It has been reported that 37% of physicians who smoke have done so in front of their patients17 and 51% did little or no smoking cessation counseling.18 Amongst all physicians, 21.1% disagreed that they should set an example for their patients by not smoking and only 21.4% thought the most influential person to help patients successfully quit was a physician.18

The responsibility for addressing tobacco smoking in China also rests with the organizations in which physicians work and the professional bodies who represent them. Administrators and managers of hospitals and medical facilities should be implementing smoke-free environments, ensuring screening and record keeping policies are in place to identify all patients who smoke and providing physicians with the necessary support they need to address smoking, for example by providing ongoing education and training. Professional bodies that represent physicians should also be vectors for change for their members, alerting physicians to the latest research on tobacco-related harm, encouraging them not to smoke and to be positive role models as well as using their authority as professional organizations to advocate to government for evidence-based tobacco control interventions.

What support is available? What needs to be done? Does the solution to the escalating problem of tobaccorelated disease lie in better treatment or in better prevention? While the translation of new research into more effective treatments is vital, respected authorities plead for greater attention to prevention. Dr Margaret Chan, Director-General of the WHO has stated that “The cure for this devastating epidemic is dependent not on medicines or vaccines, but on the concerted actions of governments and civil society”.1 To this we would add that physicians need to take a responsible and leading role. Research in China has shown that along with physicians’ own smoking status, there are variables significantly associated with the frequency of physicians’ cessation counseling. These are their perceived responsibility, perceived success, perceived exemplary role and whether they believe they have a strong influence in persuading patients to quit smoking.18 Education and programs encouraging and supporting physicians to quit smoking themselves would be a first step to improving their likelihood of engaging in cessation counseling with their patients. Providing training to physicians on brief interventions for smoking cessation may serve a dual purpose, providing both information and motivation to encourage their own quit attempts, as well as the skills and confidence to address the issue with their patients. Physicians also have the ability to influence smoking behaviors and policy at the institutional and organizational level. They are able to use their positions as respected figures of authority and community leaders to advocate for proven tobacco control measures. Advocating making hospitals and medical facilities smoke-free should be a priority for physicians. As centers that people attend to improve their health and receive treatment for illness, allowing a practice such as smoking is completely incongruous. 20

Fortunately, there is a wealth of guidance for physicians, health care facilities, policy makers and government to assist in implementing evidence-based tobacco control measures. The WHO FCTC is a multilateral treaty with more than 165 parties that aims to fight against the global tobacco epidemic.25 It provides a blueprint for countries to reduce both the supply of and demand for tobacco. China has ratified the FCTC and as such has committed to protecting the health of Chinese citizens by joining the fight against tobacco. A number of guidelines have already been adopted under the FCTC that provide assistance to parties in meeting their obligations. They provide best available evidence and the experience of other parties who have successfully implemented tobacco control measures. Guidelines are available in Mandarin on: protection of public health policies with respect to tobacco control from commercial and other vested interests of the tobacco industry (Article 5.3); protection from exposure to tobacco smoke (Article 8); packaging and labeling of tobacco products (Article 11); and tobacco advertising, promotion and sponsorship (Article 13).26 Guidelines on education, communication, training and public awareness (Article 12) and demand reduction measures concerning tobacco dependence and cessation (Article 14) are also being developed. Further guidance for implementing the FCTC is provided by the set of six key tobacco control measures contained in the WHO Report on the Global Tobacco Epidemic, 2008: The MPOWER package.27 The 2008 report presents the first comprehensive worldwide analysis of tobacco use and control efforts. The second MPOWER report released in 2009 focuses on the status of the implementation of smoke-free policies.28 The report indicates that China is yet to provide smoke-free health care facilities.



In May 2009, the Ministry of Health of China and other relevant ministries and bureaus issued a policy document entitled Decisions on introducing a national comprehensive smoking ban in all medical and health institutions from 2011. This policy document provides details on strategies and measures to ensure that a total smoking ban will be achieved in all buildings and facilities in the health administrative sector and health institutions at all levels by 2011.29 Progress is slowly being made with model smoke-free hospitals in development all over China that will provide proof of concept and training grounds for others.30 To further assist physicians, the Smoking Cessation Guidelines for Clinicians were revised and re-issued in late 2009. The Guidelines are designed to help clinicians identify smokers, diagnose and treat tobacco dependence and provide timely cessation services.31 Physicians can play a powerful role in moving China quickly towards the stated smoke-free policy goal of the Ministry of Health and also to comply with its obligations under the FCTC.

Conclusion Physicians treating tobacco-related disease, particularly those treating lung cancer, have a responsibility to take a lead in tobacco control. This should begin with their own behavior and practices. They should quit smoking if a smoker, since continuing to smoke sends a message that the physician may not believe smoking is dangerous to health. They should actively counsel relatives of lung cancer patients against smoking – this is a good way to spread the message in the local community. They should work to create a smoke-free environment in treatment facilities and find out about tobacco advocacy activities conducted by tobacco control agencies and if possible, lend support. Physicians are crucial to the success of tobacco control in China. Their active engagement in solving the problem of high levels of tobacco use can help prevent millions of avoidable premature deaths.

Acknowledgements Thank you to Marina Haritos, Lin Li and Indra Haslam from the Cancer Council Victoria, Australia, for research assistance with this paper.

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