吸烟归因死亡分析与烟草控制政策评价研究
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摘要
研究背景
吸烟被认为是目前造成人类多种疾病和早死的主要的、可预防的致病危险因素。吸烟导致的健康影响、疾病负担和社会经济损失已经引起世界各国政府和国际卫生组织的广泛关注,并极大地激发全球性的综合控烟策略和统一行动去遏制烟草流行,以减少疾病负担,维护和促进人类健康。不同地域和人群的吸烟疾病效应和健康影响的评估研究是十分重要和必要的。随着世界卫生组织制定的第一部专门重点解决一个公共卫生问题的国际多边公约——《烟草控制框架公约》的正式通过,以及我国政府的签署和批准,有必要科学地评估人类健康影响的重要危险因素——吸烟对区域人群疾病效应和健康的影响程度,探索从“研究到行动”的决策情景和框架体系,从而进一步完善和有效执行我国控烟策略和措施。政策循环分析法是一种科学的、系统的分析方法,帮助确定问题、诊断原因、及政策发展和政治决策。本研究受国际发展研究中心资助,定量与定性调查研究于2006年在上海市徐汇区开展。
研究目的
全面分析区域人群健康状况、疾病流行特点和趋势,监测不同性别、年龄人群吸烟和戒烟行为,估算人群吸烟归因分值,从而定量评估吸烟危险因素的疾病效应。同时,深入研究大众人群吸烟行为、对烟草及控烟环境、控烟政策和措施的认知和反应,分析我国控烟环境、存在的问题和障碍,探询其中的根源,从而为进一步完善和有效执行综合控烟策略和措施提供科学数据和决策依据。
研究方法
本研究以吸烟归因效应评价和政策循环分析作为研究的基础,开展定量和定性调查研究,主要研究方法应用如下;
(1)死因分析和评价:通过研究现场5年人群全死因的系统监测和分析,掌握人群疾病死亡流行病学特征和变化趋势,评价人群健康状况及主要卫生问题。
(2)人群吸烟归因效应评价:估算区域不同性别、年龄人群吸烟归因分值,进一步评估人群吸烟归因死亡和潜在寿命损失年,综合评价吸烟的疾病效应。
(3)定性调查研究:采用焦点小组讨论和知情人深入访谈二种研究方法开展定性调查,共完成由9名学生和7名卫生人员组成的二组焦点小组讨论,以及6名知情人的深入访谈,访谈对象选择卫生行政、教育、烟草、街道的管理者、非政府控烟机构和杂志媒体负责人等代表人物。
(4)定量问卷调查:分别采用累计概率比例抽样法和固定样本量调查方法完成721份18岁以上社区成年人群和初中一、高中一年级及职校一年级480名在校青少年学生的二组研究样本人群的问卷调查。
主要发现
1.吸烟归因疾病效应和健康影响
吸烟对区域居民健康影响和疾病效应是严重的和明显的。2006年徐汇区≥35岁户籍人群中,因吸烟导致各种归因疾病死亡931人,占≥35岁人群总死亡的24.5%,占全人群总死亡的15.2%,男、女性人群疾病总死亡中,分别有26.1%和2.6%是吸烟导致的。在全人群疾病死因中,52.9%的呼吸系统疾病、20.8%的恶性肿瘤和8.8%的心脑血管疾病死亡的真正根本原因是吸烟。恶性肿瘤是人群吸烟归因死亡数最多的疾病,占全部吸烟归因死亡的44.0%。吸烟归因死亡数最多的前三位疾病死因分别是气管肺癌、慢性阻塞性肺病和支气管炎、肺气肿,吸烟归因潜在减寿年数损失最大的前三位疾病死因分别是气管肺癌、慢性阻塞性肺病和脑血管疾病。
2.影响居民健康的主要卫生问题
由于人口学效应、相对和绝对流行病学效应的综合作用,居民的疾病死亡率维持在较低水平。循环系病、肿瘤和呼吸系病成为影响居民健康的前三位主要疾病死因,这三者死亡人数占总死亡数的75.74%,人群寿命损失严重的前三位疾病死因分别是肿瘤、循环系统和损伤中毒,三者占全部疾病潜在寿命损失年数的78.02%。居民以与吸烟危险因素密切相关的慢性非传染性疾病为特点的疾病死亡模式,这已成为影响区域居民健康的主要卫生问题。
3.青少年学生吸烟状况、认知和行为的影响因素
青少年学生吸烟率为2.91%,尝试吸烟率为16.01%,不同性别、年龄和身份学生的吸烟率和尝试吸烟率差异具有统计学意义。吸烟率和尝试吸烟率均随年龄增长而上升,其中男生,尤其是职校男生和高中男生吸烟和尝试吸烟率较高。青少年尝试初始吸烟的主要原因是好奇和受别人影响,尝试初始吸烟获得途径最主要是来自朋友,青少年的认知和行为很容易受外界环境和周围人群行为的影响。青少年吸烟行为指标虽然处于低水平,但他们的吸烟行为和健康影响不容忽视,必须引起学校、家长、卫生部门和全社会的高度重视。
4.成年人群的吸烟状况和认知反应
大众人群吸烟现象仍然严重,重度吸烟比例较高,戒烟率仍然很低。吸烟危害健康的观念已被大多数人所认识和知晓,但对健康危害的严重程度的认识仍不足,对吸烟可导致心血管系统疾病如中风和冠心病的认知率相对较低,非吸烟者也缺乏强烈的自我保护健康的意识和环境健康的责任。成年人群的吸烟状况和认知反应不容乐观。
5.吸烟者的戒烟状况和戒烟信心
人群戒烟和打算戒烟的比例仍然较低,大部分吸烟者对戒烟信心不确定或缺乏。近一半吸烟者中不愿意戒烟和没有想过戒烟,38.5%吸烟者对自己能否戒烟不清楚,24.6%吸烟者对戒烟没有信心。约75%的调查对象认为政府应该提供规范的戒烟服务。
6.吸烟状况和控烟环境不容乐观的三个层面因素
造成目前我国吸烟状况和控烟环境不容乐观局面的主要原因是控制烟草的种植和生产领域(供应层面),控制烟草的市场流通、贸易领域(流通层面)和控制烟草的消费者使用领域(需求层面)三个层面的能力、技术、资源、组织等严重不足。
政策建议
1.准确识别、系统监测和全面评估人群疾病死亡的真正根本原因
加强对影响区域人群健康的重要疾病及致病危险因素流行状况和变化趋势的准确识别、系统监测和科学分析,全面评价人群健康水平,同时,充分认识到这些主要致病危险因素的严重性、危害性和可预防性,针对人群疾病模式变化特点,结合致病危险因素的健康影响,确定疾病预防控制的优先领域,加强NCD及其吸烟等重要致病危险因素的预防、干预和控制策略和措施。
2.以吸烟归因疾病效应评估为依据,完善和有效执行控烟策略和措施
加强区域人群吸烟危险因素的疾病死亡效应和健康影响的综合识别和评估体系,明确吸烟这一重要的致病危险因素对健康的危害性和干预的必要性,以吸烟归因疾病效应评估为依据,进一步完善和有效执行控烟策略和措施,为FCTC提供可靠策略依据,并支持烟草控制策略、行动和决策,推动烟草控制工作的进展。
3.烟草控制工作是一项政策性很强的社会行动
烟草的疾病效应和社会影响是灾难性的,但是却是可预防的。必须建立强大、相互协作、支持的联盟,在综合性国家控烟策略中,要求政府把制定、完善有效的控烟法规、政策和措施置于优先位置。
4.加强青少年吸烟预防和干预,积极营造良好的无烟支持性环境
青少年吸烟预防和控制应作为全社会维护和促进青少年身心健康的重点和优先工作,针对各年龄段青少年的身心特点,开展形式多样的主题教育和同伴教育活动,强调学生主动接受正规的健康教育,以获得一系列与终身健康有关的知识和技能,同时全社会应该为青少年培养健康行为习惯提供一个良好的支持环境和积极向上的人文氛围,努力创造人人参与和共同行动的无烟环境。
5.采取综合、有效的控烟策略和措施是政府的责任和义务
综合烟草控制策略措施应同时从烟草的供应、流通和需求三个层面着手,依靠多部门的合作,采取综合治理,由政府组织发动、全社会的积极支持和参与,从组织上、规制上、经济上、行为上、技术能力上和国际合作上解决这个复杂的健康问题。
Background
Smoking is considered as the leading preventable cause of premature death and illness in China and worldwide.Smoking causes the adverse health effects,disease burdens and social economic lost which have arisen the great attentions of governments and international health organizations worldwide.It has inspired the global tobacco control strategies and prompt actions to count the epidemic,to reduce the disease burdens and promote the health of populations.It is crucial and necessary that assessment research of smoking attributable disease impacts and health effects among the different regions and populations be taken.With the Framework Conventions of Tobacco Control adopted by WHO which is an historic international treaty to deal with one health issue,ratified and passed by Chinese government,it is necessary to assess the regional smoking attributable disease impacts and health effects,to explore the decision-making situation and framework system of "research to actions",to promote the implementation and enforcement of evidence-based tobacco control policies and interventions.The Political Policy Circle Analysis is a scientific and systemic analysis tool to guide the problem definition,causes diagnosis, policy development and political decision.The research program was funded by the IDRC.The quantity and quality investigations were conducted at Xuhui District, Shanghai,in 2006.
Objectives
This research study is to analyze the characteristics and trends of health status and diseases patterns in the district,to monitor the smoking behaviors among different age and gender,to assess the population smoking attributable fraction and the disease impact from smoking.The research is to investigate and assess the general public's opinions and perceptions toward smoking and tobacco control strategy,to analyze the national tobacco control situation,and conduct policy diagnosis and analysis to map out barriers and obstacles for policy development in order to provide the evidence and stimulate decision-making around implementation and enforcement of tobacco control.
Research Methods
Quantity and quality research methods were applied based on the smoking attributable disease impact and political policy circle analysis.The main research methods are as follows:
(1) Disease surveillance and analysis:monitor and analyze five-year mortality of population,master the epidemiological characteristics and trends,evaluate the health status of the target population.
(2) Population attributable risk assessment:considering the risk relatives and smoking prevalence,the population smoking attributable fraction was estimated to analyze the smoking attributable mortality and potential years of life lost,to assess the population smoking attributable impact.
(3) Qualitative research:focus group interviews and key informants interviews were conducted.The two focus groups consist of 9 students and 7 health professionals. 6 key informants were selected as a health administrator,an education supervisor,a representative of tobacco business,a local government official,NGO representative and a journalist and Editor in chief of Magazine.
(4) Quantitative research:a multistage-sampling questionnaire survey with PPS method and sample investigation were undertaken respectively.A total of 721 residents and 480 students from grade one of primary school,high school and professional school were surveyed.
Main Findings
1.Smoking attributable disease impacts and health effects
The smoking attributable disease impacts and health effects to local people are severe and evident.During year 2006,the smoking attributable mortality is 931, accounting for 24.5%of total deaths of population over 35 years old,15.2%of total deaths of whole population.Among the total deaths of whole population,26.1%of male deaths and 2.6%of female deaths were caused by smoking.The actual cause of death from 52.9%respiratory diseases,20.8%malignant neoplasms and 8.8% cardiovascular diseases is smoking.Malignant neoplasm is the most popular smoking attributable disease,accounting for 44.0%of total smoking attributable mortality.The three leading SAM are lung cancer,COPD and bronchitis & emphysema.The three leading smoking attributable PYLL are lung cancer,COPD and cerebrovascular disease.
2.Main health issues that affect the health status of local population
Due to the impacts of demography,relative and absolute epidemiology disease effects,the mortality of local population remains the lower lever during recent five years.The cardiovascular diseases,malignant neoplasms and respiratory diseases become three main causes of deaths,accounting for 78.74%of total deaths.The leading three causes of deaths from potential years of life lost are malignant neoplasms,Cardiovascular Diseases and injuries,accounting for 78.02%The NCDs and injury become the main issues that affect the health of population.
3.The smoking of the adolescents and influencing factors of their cognition and behavior
The smoking prevalence of the adolescents is 2.91%,16.01%for experimental smoking.The smoking prevalence has significant difference among gender,age and grade.The smoking and experimental smoking prevalence rise with the development of the grade.For male students from high school and technical school,their smoking and experimental smoking prevalence are much higher.The main reasons for their initial smoking are curious and influenced by the others.The primary way for getting their initial cigarettes is from their peers.The cognition and behavior of the adolescent smoking are more easily influenced by the environmental factors and others behaviors. Although their smoking prevalence is not so high,the smoking behaviours for the adolescents and the health effects should not be ignored.It should arise the great emphasis from the school,parents,health departments and the whole society.
4.The smoking status and perception of the adults
The smoking is still epidemic among the public.The proportion of heavy smoking is much higher and quit rate is still low.The perception of adverse effects of smoking has been accepted by most adults.But the severity of the harmful effects of smoking is not clearly understood.Especially,the knowledge for smoking attributable disease,such as stroke and coronary heart diseases is low.Non-smokers are lack of responsibility of self-protection for their health and environment.The smoking status and perception of the adults are not optimistic.
5.Quitting status and confidence of the smokers
The proportions of quitting smoking and contemplation to quit are still low.Most of the smokers have no much confidence and confirmation to quit.Nearly half of them are unwilling to quit and thinking about quitting.38.5%of smokers are not sure their ability for quitting.24.6%of smokers have no confidence to quit.About 75%of respondents consider it government responsibility for providing the smoking-quitting service.
6.Three primary areas for baring the tobacco control strategies
The primary reasons that cause the situation of smoking and tobacco control strategies not optimistic were diagnosed and classified as three areas:1) the deficiency of tobacco controlling in supply area-tobacco planting and production;2) the deficiency of tobacco control in circulation area-tobacco marketing circulation, distribution and trade;3) the deficiency of tobacco control in consumption area—tobacco consumers' demand.
Recommendations
1.Accurate identification,systemic surveillance and comprehensive assessment of the actual causes of deaths
Accurate identification,systemic surveillance and comprehensive analysis about the patterns and trends of diseases and risk factors that affect the population health and quality of life in the district should be strengthened in order to evaluate the health status of target population.Meanwhile,it is crucial to fully recognize the significance, severity and prevention of the important risk factors,to determine the priority of disease prevention and controlling according to health effects of the risk factors,to strengthen the preventive strategies to NCDs and risk factors,such as smoking.
2.Reinforce the enacting and implementation of tobacco control policy based on the assessment of smoking attributable disease impacts.
The identification and assessment of population smoking attributable mortality and health effects in the district should be enhanced.It should be recognized that severity of smoking to the health and need of prevention.Based on the smoking attributable disease impacts,the tobacco control strategies and interventions should be enacted and implemented.It provides the evidence to the FCTC,support tobacco control strategies,actions and decisions,to promote the process of tobacco control.
3.Social action acquiring more political policy to tobacco control
The tobacco epidemic of disease impacts and social effects is devastating,but preventable.The powerful,cooperative and supportive union should be built.It is imperative to put enacting and implementation of tobacco control policy and regulations priority from the government among comprehensive national tobacco control strategies.
4.Strengthen smoking prevention and interventions among the adolescents to create the supportive,tobacco-free environment
Smoking prevention and interventions among the adolescents should be integrated to important priority program that requires the whole society to promote their health. According to the physical and psychological characteristics of different age,the theme education and peer activities should be conducted in order to acquire the health related knowledge and skills of life-lasting,which emphasize the positive participation to the formal health education.Meanwhile the supportive environment and positive cultural surrounding should be created for the adolescents to promote their healthy behaviors and habits.It is vital to build the tobacco-free environment for everyone participation and actions.
5.The responsibility and obligation of the government to adopt the comprehensive tobacco control strategies
The comprehensive tobacco control strategy should focus on the three areas: tobacco supply,circulation and consumption areas.Depending on the cooperation of multi-departments,government organization and the whole society support and participation,the effective implementation and enforcement of tobacco control policy lie on organization,regulation,financing,behaviour,capacity and international cooperation to counter the epidemic.
吸烟被认为是目前造成人类多种疾病和早死的主要的、可预防的致病危险因素。吸烟导致的健康影响、疾病负担和社会经济损失已经引起世界各国政府和国际卫生组织的广泛关注,并极大地激发全球性的综合控烟策略和统一行动去遏制烟草流行,以减少疾病负担,维护和促进人类健康。不同地域和人群的吸烟疾病效应和健康影响的评估研究是十分重要和必要的。随着世界卫生组织制定的第一部专门重点解决一个公共卫生问题的国际多边公约——《烟草控制框架公约》的正式通过,以及我国政府的签署和批准,有必要科学地评估人类健康影响的重要危险因素——吸烟对区域人群疾病效应和健康的影响程度,探索从“研究到行动”的决策情景和框架体系,从而进一步完善和有效执行我国控烟策略和措施。政策循环分析法是一种科学的、系统的分析方法,帮助确定问题、诊断原因、及政策发展和政治决策。本研究受国际发展研究中心资助,定量与定性调查研究于2006年在上海市徐汇区开展。
研究目的
全面分析区域人群健康状况、疾病流行特点和趋势,监测不同性别、年龄人群吸烟和戒烟行为,估算人群吸烟归因分值,从而定量评估吸烟危险因素的疾病效应。同时,深入研究大众人群吸烟行为、对烟草及控烟环境、控烟政策和措施的认知和反应,分析我国控烟环境、存在的问题和障碍,探询其中的根源,从而为进一步完善和有效执行综合控烟策略和措施提供科学数据和决策依据。
研究方法
本研究以吸烟归因效应评价和政策循环分析作为研究的基础,开展定量和定性调查研究,主要研究方法应用如下;
(1)死因分析和评价:通过研究现场5年人群全死因的系统监测和分析,掌握人群疾病死亡流行病学特征和变化趋势,评价人群健康状况及主要卫生问题。
(2)人群吸烟归因效应评价:估算区域不同性别、年龄人群吸烟归因分值,进一步评估人群吸烟归因死亡和潜在寿命损失年,综合评价吸烟的疾病效应。
(3)定性调查研究:采用焦点小组讨论和知情人深入访谈二种研究方法开展定性调查,共完成由9名学生和7名卫生人员组成的二组焦点小组讨论,以及6名知情人的深入访谈,访谈对象选择卫生行政、教育、烟草、街道的管理者、非政府控烟机构和杂志媒体负责人等代表人物。
(4)定量问卷调查:分别采用累计概率比例抽样法和固定样本量调查方法完成721份18岁以上社区成年人群和初中一、高中一年级及职校一年级480名在校青少年学生的二组研究样本人群的问卷调查。
主要发现
1.吸烟归因疾病效应和健康影响
吸烟对区域居民健康影响和疾病效应是严重的和明显的。2006年徐汇区≥35岁户籍人群中,因吸烟导致各种归因疾病死亡931人,占≥35岁人群总死亡的24.5%,占全人群总死亡的15.2%,男、女性人群疾病总死亡中,分别有26.1%和2.6%是吸烟导致的。在全人群疾病死因中,52.9%的呼吸系统疾病、20.8%的恶性肿瘤和8.8%的心脑血管疾病死亡的真正根本原因是吸烟。恶性肿瘤是人群吸烟归因死亡数最多的疾病,占全部吸烟归因死亡的44.0%。吸烟归因死亡数最多的前三位疾病死因分别是气管肺癌、慢性阻塞性肺病和支气管炎、肺气肿,吸烟归因潜在减寿年数损失最大的前三位疾病死因分别是气管肺癌、慢性阻塞性肺病和脑血管疾病。
2.影响居民健康的主要卫生问题
由于人口学效应、相对和绝对流行病学效应的综合作用,居民的疾病死亡率维持在较低水平。循环系病、肿瘤和呼吸系病成为影响居民健康的前三位主要疾病死因,这三者死亡人数占总死亡数的75.74%,人群寿命损失严重的前三位疾病死因分别是肿瘤、循环系统和损伤中毒,三者占全部疾病潜在寿命损失年数的78.02%。居民以与吸烟危险因素密切相关的慢性非传染性疾病为特点的疾病死亡模式,这已成为影响区域居民健康的主要卫生问题。
3.青少年学生吸烟状况、认知和行为的影响因素
青少年学生吸烟率为2.91%,尝试吸烟率为16.01%,不同性别、年龄和身份学生的吸烟率和尝试吸烟率差异具有统计学意义。吸烟率和尝试吸烟率均随年龄增长而上升,其中男生,尤其是职校男生和高中男生吸烟和尝试吸烟率较高。青少年尝试初始吸烟的主要原因是好奇和受别人影响,尝试初始吸烟获得途径最主要是来自朋友,青少年的认知和行为很容易受外界环境和周围人群行为的影响。青少年吸烟行为指标虽然处于低水平,但他们的吸烟行为和健康影响不容忽视,必须引起学校、家长、卫生部门和全社会的高度重视。
4.成年人群的吸烟状况和认知反应
大众人群吸烟现象仍然严重,重度吸烟比例较高,戒烟率仍然很低。吸烟危害健康的观念已被大多数人所认识和知晓,但对健康危害的严重程度的认识仍不足,对吸烟可导致心血管系统疾病如中风和冠心病的认知率相对较低,非吸烟者也缺乏强烈的自我保护健康的意识和环境健康的责任。成年人群的吸烟状况和认知反应不容乐观。
5.吸烟者的戒烟状况和戒烟信心
人群戒烟和打算戒烟的比例仍然较低,大部分吸烟者对戒烟信心不确定或缺乏。近一半吸烟者中不愿意戒烟和没有想过戒烟,38.5%吸烟者对自己能否戒烟不清楚,24.6%吸烟者对戒烟没有信心。约75%的调查对象认为政府应该提供规范的戒烟服务。
6.吸烟状况和控烟环境不容乐观的三个层面因素
造成目前我国吸烟状况和控烟环境不容乐观局面的主要原因是控制烟草的种植和生产领域(供应层面),控制烟草的市场流通、贸易领域(流通层面)和控制烟草的消费者使用领域(需求层面)三个层面的能力、技术、资源、组织等严重不足。
政策建议
1.准确识别、系统监测和全面评估人群疾病死亡的真正根本原因
加强对影响区域人群健康的重要疾病及致病危险因素流行状况和变化趋势的准确识别、系统监测和科学分析,全面评价人群健康水平,同时,充分认识到这些主要致病危险因素的严重性、危害性和可预防性,针对人群疾病模式变化特点,结合致病危险因素的健康影响,确定疾病预防控制的优先领域,加强NCD及其吸烟等重要致病危险因素的预防、干预和控制策略和措施。
2.以吸烟归因疾病效应评估为依据,完善和有效执行控烟策略和措施
加强区域人群吸烟危险因素的疾病死亡效应和健康影响的综合识别和评估体系,明确吸烟这一重要的致病危险因素对健康的危害性和干预的必要性,以吸烟归因疾病效应评估为依据,进一步完善和有效执行控烟策略和措施,为FCTC提供可靠策略依据,并支持烟草控制策略、行动和决策,推动烟草控制工作的进展。
3.烟草控制工作是一项政策性很强的社会行动
烟草的疾病效应和社会影响是灾难性的,但是却是可预防的。必须建立强大、相互协作、支持的联盟,在综合性国家控烟策略中,要求政府把制定、完善有效的控烟法规、政策和措施置于优先位置。
4.加强青少年吸烟预防和干预,积极营造良好的无烟支持性环境
青少年吸烟预防和控制应作为全社会维护和促进青少年身心健康的重点和优先工作,针对各年龄段青少年的身心特点,开展形式多样的主题教育和同伴教育活动,强调学生主动接受正规的健康教育,以获得一系列与终身健康有关的知识和技能,同时全社会应该为青少年培养健康行为习惯提供一个良好的支持环境和积极向上的人文氛围,努力创造人人参与和共同行动的无烟环境。
5.采取综合、有效的控烟策略和措施是政府的责任和义务
综合烟草控制策略措施应同时从烟草的供应、流通和需求三个层面着手,依靠多部门的合作,采取综合治理,由政府组织发动、全社会的积极支持和参与,从组织上、规制上、经济上、行为上、技术能力上和国际合作上解决这个复杂的健康问题。
Background
Smoking is considered as the leading preventable cause of premature death and illness in China and worldwide.Smoking causes the adverse health effects,disease burdens and social economic lost which have arisen the great attentions of governments and international health organizations worldwide.It has inspired the global tobacco control strategies and prompt actions to count the epidemic,to reduce the disease burdens and promote the health of populations.It is crucial and necessary that assessment research of smoking attributable disease impacts and health effects among the different regions and populations be taken.With the Framework Conventions of Tobacco Control adopted by WHO which is an historic international treaty to deal with one health issue,ratified and passed by Chinese government,it is necessary to assess the regional smoking attributable disease impacts and health effects,to explore the decision-making situation and framework system of "research to actions",to promote the implementation and enforcement of evidence-based tobacco control policies and interventions.The Political Policy Circle Analysis is a scientific and systemic analysis tool to guide the problem definition,causes diagnosis, policy development and political decision.The research program was funded by the IDRC.The quantity and quality investigations were conducted at Xuhui District, Shanghai,in 2006.
Objectives
This research study is to analyze the characteristics and trends of health status and diseases patterns in the district,to monitor the smoking behaviors among different age and gender,to assess the population smoking attributable fraction and the disease impact from smoking.The research is to investigate and assess the general public's opinions and perceptions toward smoking and tobacco control strategy,to analyze the national tobacco control situation,and conduct policy diagnosis and analysis to map out barriers and obstacles for policy development in order to provide the evidence and stimulate decision-making around implementation and enforcement of tobacco control.
Research Methods
Quantity and quality research methods were applied based on the smoking attributable disease impact and political policy circle analysis.The main research methods are as follows:
(1) Disease surveillance and analysis:monitor and analyze five-year mortality of population,master the epidemiological characteristics and trends,evaluate the health status of the target population.
(2) Population attributable risk assessment:considering the risk relatives and smoking prevalence,the population smoking attributable fraction was estimated to analyze the smoking attributable mortality and potential years of life lost,to assess the population smoking attributable impact.
(3) Qualitative research:focus group interviews and key informants interviews were conducted.The two focus groups consist of 9 students and 7 health professionals. 6 key informants were selected as a health administrator,an education supervisor,a representative of tobacco business,a local government official,NGO representative and a journalist and Editor in chief of Magazine.
(4) Quantitative research:a multistage-sampling questionnaire survey with PPS method and sample investigation were undertaken respectively.A total of 721 residents and 480 students from grade one of primary school,high school and professional school were surveyed.
Main Findings
1.Smoking attributable disease impacts and health effects
The smoking attributable disease impacts and health effects to local people are severe and evident.During year 2006,the smoking attributable mortality is 931, accounting for 24.5%of total deaths of population over 35 years old,15.2%of total deaths of whole population.Among the total deaths of whole population,26.1%of male deaths and 2.6%of female deaths were caused by smoking.The actual cause of death from 52.9%respiratory diseases,20.8%malignant neoplasms and 8.8% cardiovascular diseases is smoking.Malignant neoplasm is the most popular smoking attributable disease,accounting for 44.0%of total smoking attributable mortality.The three leading SAM are lung cancer,COPD and bronchitis & emphysema.The three leading smoking attributable PYLL are lung cancer,COPD and cerebrovascular disease.
2.Main health issues that affect the health status of local population
Due to the impacts of demography,relative and absolute epidemiology disease effects,the mortality of local population remains the lower lever during recent five years.The cardiovascular diseases,malignant neoplasms and respiratory diseases become three main causes of deaths,accounting for 78.74%of total deaths.The leading three causes of deaths from potential years of life lost are malignant neoplasms,Cardiovascular Diseases and injuries,accounting for 78.02%The NCDs and injury become the main issues that affect the health of population.
3.The smoking of the adolescents and influencing factors of their cognition and behavior
The smoking prevalence of the adolescents is 2.91%,16.01%for experimental smoking.The smoking prevalence has significant difference among gender,age and grade.The smoking and experimental smoking prevalence rise with the development of the grade.For male students from high school and technical school,their smoking and experimental smoking prevalence are much higher.The main reasons for their initial smoking are curious and influenced by the others.The primary way for getting their initial cigarettes is from their peers.The cognition and behavior of the adolescent smoking are more easily influenced by the environmental factors and others behaviors. Although their smoking prevalence is not so high,the smoking behaviours for the adolescents and the health effects should not be ignored.It should arise the great emphasis from the school,parents,health departments and the whole society.
4.The smoking status and perception of the adults
The smoking is still epidemic among the public.The proportion of heavy smoking is much higher and quit rate is still low.The perception of adverse effects of smoking has been accepted by most adults.But the severity of the harmful effects of smoking is not clearly understood.Especially,the knowledge for smoking attributable disease,such as stroke and coronary heart diseases is low.Non-smokers are lack of responsibility of self-protection for their health and environment.The smoking status and perception of the adults are not optimistic.
5.Quitting status and confidence of the smokers
The proportions of quitting smoking and contemplation to quit are still low.Most of the smokers have no much confidence and confirmation to quit.Nearly half of them are unwilling to quit and thinking about quitting.38.5%of smokers are not sure their ability for quitting.24.6%of smokers have no confidence to quit.About 75%of respondents consider it government responsibility for providing the smoking-quitting service.
6.Three primary areas for baring the tobacco control strategies
The primary reasons that cause the situation of smoking and tobacco control strategies not optimistic were diagnosed and classified as three areas:1) the deficiency of tobacco controlling in supply area-tobacco planting and production;2) the deficiency of tobacco control in circulation area-tobacco marketing circulation, distribution and trade;3) the deficiency of tobacco control in consumption area—tobacco consumers' demand.
Recommendations
1.Accurate identification,systemic surveillance and comprehensive assessment of the actual causes of deaths
Accurate identification,systemic surveillance and comprehensive analysis about the patterns and trends of diseases and risk factors that affect the population health and quality of life in the district should be strengthened in order to evaluate the health status of target population.Meanwhile,it is crucial to fully recognize the significance, severity and prevention of the important risk factors,to determine the priority of disease prevention and controlling according to health effects of the risk factors,to strengthen the preventive strategies to NCDs and risk factors,such as smoking.
2.Reinforce the enacting and implementation of tobacco control policy based on the assessment of smoking attributable disease impacts.
The identification and assessment of population smoking attributable mortality and health effects in the district should be enhanced.It should be recognized that severity of smoking to the health and need of prevention.Based on the smoking attributable disease impacts,the tobacco control strategies and interventions should be enacted and implemented.It provides the evidence to the FCTC,support tobacco control strategies,actions and decisions,to promote the process of tobacco control.
3.Social action acquiring more political policy to tobacco control
The tobacco epidemic of disease impacts and social effects is devastating,but preventable.The powerful,cooperative and supportive union should be built.It is imperative to put enacting and implementation of tobacco control policy and regulations priority from the government among comprehensive national tobacco control strategies.
4.Strengthen smoking prevention and interventions among the adolescents to create the supportive,tobacco-free environment
Smoking prevention and interventions among the adolescents should be integrated to important priority program that requires the whole society to promote their health. According to the physical and psychological characteristics of different age,the theme education and peer activities should be conducted in order to acquire the health related knowledge and skills of life-lasting,which emphasize the positive participation to the formal health education.Meanwhile the supportive environment and positive cultural surrounding should be created for the adolescents to promote their healthy behaviors and habits.It is vital to build the tobacco-free environment for everyone participation and actions.
5.The responsibility and obligation of the government to adopt the comprehensive tobacco control strategies
The comprehensive tobacco control strategy should focus on the three areas: tobacco supply,circulation and consumption areas.Depending on the cooperation of multi-departments,government organization and the whole society support and participation,the effective implementation and enforcement of tobacco control policy lie on organization,regulation,financing,behaviour,capacity and international cooperation to counter the epidemic.
引文
[1]李立明.流行病学,第五版。北京:人民卫生出版社,2003:192-197.
[2]World Health Organization.The World Health Report 2002:Reducing risks,promoting healthy life.WHO,Geneva,2002:81-92.
[3]Mokdad,Ali H,Marks,James S,Stroup,Donna F.Actual causes of death in the United States,2000.JAMA.2004;291:1238-1246.
[4]World Health Organization.World Health Report 2003.WHO,Geneva,2003.
[5]US Department of Health and Human Services.Reducing the health consequences of smoking:25 years of progress.A report of the Surgeon General,1989.Rockville,Maryland:Public Health Service,Centers for Disease Control,Office on Smoking and Health,1989,(DHHS Publication No(CDC)89-8411).
[6]Zaridze D,Peto R,et al.Tobacco:a major international health hazard.IARC Scientific Publication No.74.Lyon,France:International Agency for Research on Cancer,1986.
[7]International Agency for Research on Cancer(IARC).Tobacco smoke and involuntary smoking(IARC monographs programme on the evaluation of carcinogenic risks to humans,volume 83.Lyon,France:International Agency for Research on Cancer(IARC),2002.
[8]郑富钢,赵百东,程永照.FCTC履约前基本情况调查报告好履约思路的思考.中国烟草学报2005;1.
[9]Murray CJL,Lopez AD.Alternative projections of mortality and disability by cause 1990-2020:Global burden of disease study.Lancet,1997,349(9064):1498-1504.
[10]Jha P,Ranson MK,Nguyen SN,Yach D.Estimates of global and regional smoking prevalence in 1995,by age and sex.Am J Public Health 2002;92:1002-06.
[11]World health statistics 2007.WHO Library Cataloguing-in-Publication Data http://www.who.int/statistics.
[12]杨功焕,马杰民,刘娜,等.中国人群2002年吸烟和被动吸烟的现状调查.中华流行病学杂志,2005,26(2):77-83.
[13]Yang GH,Fan LX,Tan J,et al.Smoking in China:findings of the 1996 National Prevalence Survey.JAMA.1999 Oct 6;282(13):1247-1253.
[14]CDC.The health consequences of smoking:a report of the Surgeon General.Atlanta,GA:US Department of Health and Human Services,CDC;2004.
[15]World Health Orgnization.Report on the global tobacco epidemic:The MPOWER package.Geneva,World Health Organization 2008.
[16]Mathers CD,Loncar D.Projections of global mortality and burden of disease from 2002 to 2030.PLoS Medicine,2006,3(11):e442.
[17]World Health Organization.Tobacco alert.Geneva:WHO,1996.
[18]World Health Organization.Tobacco epidemic:health dimensions.Geneva:WHO,1997.
[19]Jha P,Chaloupka FJ.Curbing the epidemic:governments and the economics of tobacco control.Washington,DC:World Bank,1999.
[20]US Department of Health and Human Services.The Health Consequences of Involuntary Exposure to Tobacco Smoke.A Report of the Surgeon General:2006.Washington DC:US Government Printing Office,2006.
[21]Doll R,Hill AB.Smoking and carcinoma of the lung.BMJ.1950;2:739-748.
[22]US Department of Health Education and Welfare.The Health Consequences of Smoking.A Report of the Surgeon General:1971.Washington DC:US Government Printing Office,1971.
[23]Hirayama T.Non-smoking wives of heavy smokers have a higher risk of lung cancer:a study from Japan.Br Med J,1981,282(6259):183-185.
[24]Hirayama T.Life-style and mortality:a large-scale census-based cohort study in Japan.Basel,New York:Karger,1990.
[25]Majid Ezzati,Alan D Lopez.Estimates of global mortality attributable to smoking in 2000.Lancet 2003;362:847-852
[26]Guindon GE et al.The cost attributable to tobacco use:a critical review of the literature.Geneva,World Health Organization,2006.
[27]H-Y Sung,L Wang,S Jin,T-W Hu,Economic burden of smoking in China,2000. Tobacco Control 2006;15(SupplⅠ):i5-i11
[28]United States.Surgeon General's Advisory Committee on Smoking and Health,"Smoking and Health." United States.Public Health Service.Office of the Surgeon General,1964.Official Report.
[29]US Department of Health and Human Services.The health consequences of smoking:nicotine addiction.A Report of the Surgeon General.Washington DC:US Government Printing Office;1988.
[30]World Health Organization(WHO).Framework Convention on Tobacco Control,Geneva World Health Organization,2005.
[31]World Health Orgnization.Report on the global tobacco epidemic:The MPOWER package.Geneva,World Health Organization 2008.
[32]Gao YT,Zheng W,Gao RN,et al.Tobacco smoking and its effect on health in China.Lyon:IARC,No.105.1991.62-67.
[33]Doll R.Tobacco:an overview of health effects.L yon:IARC,No.74.1986.11-22.
[34]Peto R.Influence of dose and duration of smoking on lung cancer rates.Lyon,France:International Agency for Research on Cancer,1986.
[35]Peto R et al.Mortality from smoking worldwide.British Medical Bulletin,1996,52(1):12-21。
[36]Niu SR,Yang GH,Chen ZM,et al.Emerging tobacco hazards in China:2Early mortality results from a prospective study.BMJ 1998;317:1423-1424.
[37]Majid Ezzati,Alan D Lopez,Anthony Rodgers,et al.Selected major risk factors and global and regional burden of disease.Lancet 2002;360:1347-60.
[38]M Ezzati,A D Lopez.Regional,disease specific patterns of smcking-attributable mortality in 2000.Tobacco Control 2004;13:388-395.
[39]Flagship Course on Health Sector Reform and Sustainable Financing.Harvard School of Public Health and The World Bank Institute.http://www.hsph.harvard.edu/ihsg/Flagship.
[40]陈英耀,唐智柳,钱序,等.用诊断树的方法论证我国产前诊断技术发展的障碍.中国卫生质量管理.2004,11(3):14-15.
[41]王声涌.死因分析与评价方法的进展.中华流行病学杂志,1996,17(4): 239-241.
[42]北京协和医院世界卫生组织疾病分类合作中心.疾病和有关健康问题的国际统计分类(第一卷).北京:人民卫生出版社,1996.
[43]Levin ML.The occurrence of lung cancer in man.Acta Union International Contra Cancrum.1953;9:531-541.
[44]Bruzzi P,Green SB,Byar DP,et al.Estimating the population attributable risk for multiple risk factors using case-control data.Am J Epidemiol.1985;122:904 - 914.
[45]Greenland S,Robins JM.Conceptual problems in the definition and interpretation of attributable fractions.Am J Epidemiol.1988;128:1185-1197.
[46]Kahn HA,Sempos CT.Attributable risk.In:Statistical methods in epidemiology.New York:Oxford University Press,1989:73-84.
[47]Northridge ME.Public health methods-attributable risk as a link between causality and public health action.Am J Public Health 1995;85:1202-1204.
[48]Walter SD.Attributable risk in practice.Am J Epidemiol 1998;148:411-413.
[49]Office on Smoking and Health National Center for Chronic Disease Prevention and Health Promotion,Centers for Disease Control and Prevention(CDC):Smoking-Attributable Mortality,Morbidity,and Economic Cost(SAMMEC),version 3.0[Software and Documentation.]US Department of Health and Human Services,Agosto,1996.
[50]Romeder JM,Mc Whinnie JR.Potential years of life lost between ages 1 and 70:an indicador of premature mortality for health planning.Int J Epidemiol.1977;6:143-57,151.
[51]Thun MJ,Day-Lally C,Myers DG,et al.Trends in tobacco smoking and mortality from cigarette use in Cancer Prevention Studies Ⅰ(1959 through 1965)and Ⅱ(1982 through 1988).In:Changes in Cigarette-Related Disease Risks and Their Implication for Prevention and Control:Smoking and Tobacco Control Monograph.
[52]Centers for Diseases Control and Prevention.Cigarette-smoking attributable mortality and years of potential life lost-US,1990.Morbidity and Mortality Weekly Report 1993;Vol.42:645-9.)
[53]Jenny Kitzinger.Qualitative Research:Introducing focus groups.BMJ,1995,311:292-302
[54]李哲,冯学山.专题小组讨论.上海预防医学,2003,15(11):538-539.
[55]Matthew B.Miles,A.Michael Huberman.Qualitative Data Analysis(Second Edition).SAGE Publications.1994.
[56]费小兢.2005年吴中区居民主要死因减寿年数分析.中国慢性病预防与控制,2006,14(6):453.
[57]周天枢,郑弘,陈崇帼.平均减寿年数及其标准化方法探讨,中国卫生统计,1998,15(2):42.
[58]Centers for Disease Control and Prevention.Smoking-attributable mortality,morbidity,and economic costs.Available at:http://www.cdc.gov/tobacco/sammec.Accessibility verified February 10,2004.
[59]杨功焕等.行为危险因素监测--方法与应用.北京医科大学:中国协和医科大学联合出版,1998.
[60]2006年上海市死亡监测报告,上海市疾病预防控制中心专业报告(内部资料).
[61]金怌焕主编.医用统计方法.上海医科大学出版社.1998,上海:494.
[62]Kenneth J.Rothman,Sander Greenland.Morden Epidemiology.Lippomcott-Raven Publishers.1998.
[63]张文彤.SPSS统计分析教程.北京:希望电子出版社.2002.
[64]上海市徐汇区年鉴编撰委员会编.徐汇年鉴2006.上海:汉语大词典出版社,2006
[65]上海市徐汇区统计局编.徐汇区统计年鉴.2006(内部资料).
[66]杨功焕、黄正京、谭健,等.中国人群主要卫生问题--全国疾病监测死亡资料分析.中华流行病学杂志,1996,17(4):199-202.
[67]Liu BQ,Peto R,Chen ZM,Boreham J,Wu YP,Li JY,et al.Emerging tobacco hazards in China:1.Retrospective proportional mortality study of one million deaths.BJM 1998;317:1411-1422.
[68]姜垣,金水高.1998年我国居民吸烟归因社会经济负担.中国卫生经济,2000;19(10):55-57.
[69]Majid Ezzati,S.Jane Henley,Michael J.Thun,et al.Role of Smoking in Global and Regional Cardiovascular Mortality.Circulation.2005;112:489-497.
[70]Makomaski M,Kaiserman J.Mortality attributable to tobacco use in Canada and its Regions,1991.Can J Public Health 1995:257-65.
[71]Lopez AD,Collishaw NE,Piha T.A descriptive model of the cigarette epidemic in developed countries.Tobacco Control 1994;3:242-247.
[72]卫生部.2006年中国“吸烟与健康”报告.北京:2006.
[73]李爱兰,黄悦勤,王燕玲,等.我国青少年学生吸烟行为及其影响因素的初步分析.中国公共卫生,2001.17(1):75-77.
[74]王燕玲,黄悦勤,李爱兰,等.中国四省市少年吸烟及烟草知识调查及其影响因素分析.中国学校卫生,2002,21(6):456-457.
[75]许小频,郝瑞丰,聂少萍,等.广州青少年吸烟现状研究,中国学校卫生,2001,22(1):13-15.
[76]黎江,李新建,彭宁宁.上海市部分城区青少年学生吸烟行为,中国校医,2005,19(2):111-114.
[77]冯育基,杨功焕.青少年吸烟行为形成的影响因素.疾病监测.2002,17(3):112.
[78]Chassin L,Presson CC,Rose JS,et al.The natural history of cigarette smoking from adolescence to adulthood:demographic predictors of continuity and change.Health Psychology,1996;15(6):478-484.
[79]CDC.Preventing tobacco use among young people:A report of the surgeon general.Atalanta.US Dept.of Health and Human Service,1994.
[80]1996年全国吸烟行为的流行病学调查课题组.1996年全国吸烟行为的流行病学调查,北京:中国科学技术出版社,1997.1-5.
[81]Philip L Rice著.胡佩诚,等译.健康心理学.北京:中国轻工业出版社,2002.75-77.
[82]傅华,李锋,主编.现代健康促进理论与实践.上海:复旦大学出版社,2003,103.
[83]姜垣.控烟政策--成功与挫折.北京:中国协和医科大学出版社,2005,81-87.
[84]周瑞增,程永照,主编.WHO《烟草控制框架公约》对案及对中国烟草影响对策研究.北京:经济科学出版社,2006.
[1]World Health Organization.World Health Report 2003.WHO,Geneva,2003.
[2]US Department of Health and Human Services.Reducing the health consequences of smoking:25 years of progress.A report of the Surgeon General,1989.Rockville,Maryland:Public Health Service,Centers for Disease Control,Office on Smoking and Health,1989,(DHHS Publication No(CDC)89-8411).
[3]Zaridze D,Peto R,et al.Tobacco:a major international health hazard.IARC Scientific Publication No.74.Lyon,France:International Agency for Research on Cancer,1986.
[4]World Health Orgnization.Report on the global tobacco epidemic:The MPOWER package.Geneva,World Health Organization 2008.
[5]黄敬亨.健康教育学.复旦大学出版社.2006.
[6]CDC.The health consequences of smoking:a report of the Surgeon General.Atlanta,GA:US Department of Health and Human Services,CDC;2004.
[7]张开镐.吸烟对健康的危害.中国药物依赖性杂志,2001,10(3):171-172.
[8]US Department of Health and Human Services.The Health Consequences of Involuntary Exposure to Tobacco Smoke.A Report of the Surgeon General:2006.Washington DC:US Government Printing Office,2006.
[9]International Agency for Research on Cancer(IARC).Tobacco smoke and involuntary smoking(IARC monographs programme on the evaluation of carcinogenic risks to humans,volume 83).Lyon,France:International Agency for Research on Cancer(IARC),2002.
[10]Levin MI,Goldstein H,Gerhardt PR.Cancer and tobacco smoking.JAMA 1950;143:336-38.
[11]Doll R.Tobacco:an overview of health effects.Lyon:IARC,No.74.1986,11-22.
[12]高玉堂,邓杰,顶永兵,等.上海市居民吸烟玉癌症及有关疾病十年前瞻性研究.中华预防医学杂志,1999,33(1):5-8.
[13]World Health Organization.Tobacco alert.Geneva:WHO,1996.
[14]朱振岗.吸烟对健康的主要危害.中国公共卫生,1997,13(6):323-324.
[15]Jha P,Ranson MK,Nguyen SN,Yach D.Estimates of global and regional smoking prevalence in 1995,by age and sex.Am J Public Health 2002;92:1002-06.
[16]World Health Organization.Tobacco epidemic:health dimensions.Geneva:WHO,1997.
[17]Doll R,Hill AB.Smoking and carcinoma of the lung.BMJ.1950;221(2):739-748.
[18]Royal College of Physicians of London.Smoking and Health:summary of a report of the Royal College of Physicians of London on smoking in relation to cancer of the lung and other diseases.Publication No.S2-70.London,UK:Pitman Medical Publishing,LTD,1962
[19]US Department of Health Education,and Welfare(DHEW).Smoking and health:report of the Advisory Committee to the Surgeon General.DHEW-Public Health Service Publication No.1103.Washington,DC:US Government Printing Office,1964.
[20]US Department of Health and Human Services.The Health Consequences of Involuntary Smoking.A Report of the Surgeon General:1986.Washington DC:US Government Printing Office,1986.
[21]National Research Council and Committee on Passive Smoking.Environmental Tobacco Smoke:Measuring Exposures and Assessing Health Effects.Washington DC:National Academy Press,1986.
[22]US Department of Health Education and Welfare.The Health Consequences of Smoking:A Report of the Surgeon General,1971.Washington DC:US Government Printing Office,1971.
[23]Hirayama T.Non-smoking wives of heavy smokers have a higher risk of lung cancer:a study from Japan.Br Med J,1981,282(6259):183-185.
[24]Hirayama T.Life-style and mortality:a large-scale census-based cohort study in Japan.Basel,New York:Karger,1990.
[25]National Institutes of Health.Health Effects of Exposure to Environmental Tobacco Smoke.Smoking and Tobacco Control Monograph No.10.Bethesda, MD:NIH Pub,1999.
[26]US Environmental Protection Agency.Respiratory Health Effects of Passive Smoking:Lung Cancer and Other Disorders.Washington DC:US Government Printing Office,1992.
[27]California Environmental Protection Agency.Health Effects of Exposure to Environmental Tobacco Smoke,Final Report,September 1997.
[28]California Environmental Protection Agency.Proposed identification of environmental tobacco smoke as a toxic air contaminant:executive summary.Sacramento,California Environmental Protection Agency,June,2005.
[29]Bruzzi P,Green SB,Byar DP,Brinton LA,Schairer C.Estimating the population attributable risk for multiple risk factors using case control data.Am J Epidemiol.1985;122:904-914.
[30]Levin ML.The occurrence of lung cancer in man.Acta Union International Contra Cancrum.1953;9:531-541.
[31]Greenland,S.,Robins,J.M.Conceptual problems in the definition and interpretation of attributable fractions.American Journal of Epidemiology,1988;128(6):1185-1197.
[32]Beverly Rockhill,Beth Newman,Clarice Weinberg.Use and misuse of population attributable fractions.American Journal of Public Health.1998;88(1):15-20.
[33]施侣元.人群归因危险度百分比及其在药物流行病学中的应用。药物流行病学杂志,2001:10(4):209-210.
[34]Northridge ME.Public health methods--attributablerisk as a link between causality and public health action.Am J Public Health 1995;85:1202-1204.
[35]Bruzzi P,Green SB,Byar DP,et al.Estimating the population attributable risk for multiple risk factors using ease - control data[J].Am J Epidemiol,1985,122:904 - 914.
[36]Northridge ME.Public health methods-attributable risk as a link between causality and public health action.Am J Public Health 1995;85:1202-1204.
[37]Walter SD.Attributable risk in practice.Am J Epidemiol 1998;148:411-413.
[38]王天爵.病例-对照研究调整人群归因危险度的估计.中国卫生统计,1992,9(1):60.
[39]Shultz JM.SAMMEC:smoking attributable mortality,morbidity,and economic costs-computer software and documentation. Center for Nonsmoking and Health, Minnesota Department of Health, Minneapolies, August 1986.
[40] Shultz JM, Novotny TE, Rice DP. Quantfying the disease impact of cigarette smoking with SAMMEC II software. Public Health Rep 1991;106:326-33.
[41]Thun MJ, Day-Lally C, Myers DG, et al. Trends in tobacco smoking and mortality from cigarette use in Cancer Prevention Studies I (1959 through 1965) and II (1982 through 1988). In: Changes in Cigarette-Related Disease Risks and Their Implication for Prevention and Control: Smoking and Tobacco Control Monograph.
[42] Robert Welte, HansHelmut Konig, Reiner Leidl. The costs of health damage and productiveity losses attributable to cigarette smoking in Germany. EuropeanJournal of Public Health, 2000; 10(1):31-38.
[43]Zorrilla-Torras, Beten; Garcia-Marin, Natividad; Galan-Labaca, et al. Smoking attributable mortality in the community of Madrid: 1992-1998. European Journal of Public Health, 2005; 15 (1): 43-50.
[44]Majid Ezzati, Alan D Lopez. Estimates of global mortality attributable to smoking in 2000. Lancet 2003; 362: 847-52.
[45]Majid Ezzati, Alan D Lopez. Regional, disease specific patterns of smoking-attributable mortality in 2000.Tobacco Control 2004;13:388-395.
[46]McGinnis J. Michael, Foege William H. Actual causes of death in the United States. JAMA, 1993; 270 (18): 2207-2212.
[47]Mokdad, Ali H, Marks, James S, Stroup, Donna F. Actual causes of death in the United States, 2000. JAMA. 2004; 291: 1238-1246.
[48]Liu BQ, Peto R, Chen ZM, Boreham J, Wu YP, Li JY, et al. Emerging tobacco hazards in China: 1. Retrospective proportional mortality study of one million deaths. BJM 1998; 317:1411-1422.
[49]Niu SR, Yang GH, Chen ZM, et al. Emerging tobacco hazards in China: 2. Early mortality results from a prospective study. BMJ 1998; 317:1423-1424.
[2]World Health Organization.The World Health Report 2002:Reducing risks,promoting healthy life.WHO,Geneva,2002:81-92.
[3]Mokdad,Ali H,Marks,James S,Stroup,Donna F.Actual causes of death in the United States,2000.JAMA.2004;291:1238-1246.
[4]World Health Organization.World Health Report 2003.WHO,Geneva,2003.
[5]US Department of Health and Human Services.Reducing the health consequences of smoking:25 years of progress.A report of the Surgeon General,1989.Rockville,Maryland:Public Health Service,Centers for Disease Control,Office on Smoking and Health,1989,(DHHS Publication No(CDC)89-8411).
[6]Zaridze D,Peto R,et al.Tobacco:a major international health hazard.IARC Scientific Publication No.74.Lyon,France:International Agency for Research on Cancer,1986.
[7]International Agency for Research on Cancer(IARC).Tobacco smoke and involuntary smoking(IARC monographs programme on the evaluation of carcinogenic risks to humans,volume 83.Lyon,France:International Agency for Research on Cancer(IARC),2002.
[8]郑富钢,赵百东,程永照.FCTC履约前基本情况调查报告好履约思路的思考.中国烟草学报2005;1.
[9]Murray CJL,Lopez AD.Alternative projections of mortality and disability by cause 1990-2020:Global burden of disease study.Lancet,1997,349(9064):1498-1504.
[10]Jha P,Ranson MK,Nguyen SN,Yach D.Estimates of global and regional smoking prevalence in 1995,by age and sex.Am J Public Health 2002;92:1002-06.
[11]World health statistics 2007.WHO Library Cataloguing-in-Publication Data http://www.who.int/statistics.
[12]杨功焕,马杰民,刘娜,等.中国人群2002年吸烟和被动吸烟的现状调查.中华流行病学杂志,2005,26(2):77-83.
[13]Yang GH,Fan LX,Tan J,et al.Smoking in China:findings of the 1996 National Prevalence Survey.JAMA.1999 Oct 6;282(13):1247-1253.
[14]CDC.The health consequences of smoking:a report of the Surgeon General.Atlanta,GA:US Department of Health and Human Services,CDC;2004.
[15]World Health Orgnization.Report on the global tobacco epidemic:The MPOWER package.Geneva,World Health Organization 2008.
[16]Mathers CD,Loncar D.Projections of global mortality and burden of disease from 2002 to 2030.PLoS Medicine,2006,3(11):e442.
[17]World Health Organization.Tobacco alert.Geneva:WHO,1996.
[18]World Health Organization.Tobacco epidemic:health dimensions.Geneva:WHO,1997.
[19]Jha P,Chaloupka FJ.Curbing the epidemic:governments and the economics of tobacco control.Washington,DC:World Bank,1999.
[20]US Department of Health and Human Services.The Health Consequences of Involuntary Exposure to Tobacco Smoke.A Report of the Surgeon General:2006.Washington DC:US Government Printing Office,2006.
[21]Doll R,Hill AB.Smoking and carcinoma of the lung.BMJ.1950;2:739-748.
[22]US Department of Health Education and Welfare.The Health Consequences of Smoking.A Report of the Surgeon General:1971.Washington DC:US Government Printing Office,1971.
[23]Hirayama T.Non-smoking wives of heavy smokers have a higher risk of lung cancer:a study from Japan.Br Med J,1981,282(6259):183-185.
[24]Hirayama T.Life-style and mortality:a large-scale census-based cohort study in Japan.Basel,New York:Karger,1990.
[25]Majid Ezzati,Alan D Lopez.Estimates of global mortality attributable to smoking in 2000.Lancet 2003;362:847-852
[26]Guindon GE et al.The cost attributable to tobacco use:a critical review of the literature.Geneva,World Health Organization,2006.
[27]H-Y Sung,L Wang,S Jin,T-W Hu,Economic burden of smoking in China,2000. Tobacco Control 2006;15(SupplⅠ):i5-i11
[28]United States.Surgeon General's Advisory Committee on Smoking and Health,"Smoking and Health." United States.Public Health Service.Office of the Surgeon General,1964.Official Report.
[29]US Department of Health and Human Services.The health consequences of smoking:nicotine addiction.A Report of the Surgeon General.Washington DC:US Government Printing Office;1988.
[30]World Health Organization(WHO).Framework Convention on Tobacco Control,Geneva World Health Organization,2005.
[31]World Health Orgnization.Report on the global tobacco epidemic:The MPOWER package.Geneva,World Health Organization 2008.
[32]Gao YT,Zheng W,Gao RN,et al.Tobacco smoking and its effect on health in China.Lyon:IARC,No.105.1991.62-67.
[33]Doll R.Tobacco:an overview of health effects.L yon:IARC,No.74.1986.11-22.
[34]Peto R.Influence of dose and duration of smoking on lung cancer rates.Lyon,France:International Agency for Research on Cancer,1986.
[35]Peto R et al.Mortality from smoking worldwide.British Medical Bulletin,1996,52(1):12-21。
[36]Niu SR,Yang GH,Chen ZM,et al.Emerging tobacco hazards in China:2Early mortality results from a prospective study.BMJ 1998;317:1423-1424.
[37]Majid Ezzati,Alan D Lopez,Anthony Rodgers,et al.Selected major risk factors and global and regional burden of disease.Lancet 2002;360:1347-60.
[38]M Ezzati,A D Lopez.Regional,disease specific patterns of smcking-attributable mortality in 2000.Tobacco Control 2004;13:388-395.
[39]Flagship Course on Health Sector Reform and Sustainable Financing.Harvard School of Public Health and The World Bank Institute.http://www.hsph.harvard.edu/ihsg/Flagship.
[40]陈英耀,唐智柳,钱序,等.用诊断树的方法论证我国产前诊断技术发展的障碍.中国卫生质量管理.2004,11(3):14-15.
[41]王声涌.死因分析与评价方法的进展.中华流行病学杂志,1996,17(4): 239-241.
[42]北京协和医院世界卫生组织疾病分类合作中心.疾病和有关健康问题的国际统计分类(第一卷).北京:人民卫生出版社,1996.
[43]Levin ML.The occurrence of lung cancer in man.Acta Union International Contra Cancrum.1953;9:531-541.
[44]Bruzzi P,Green SB,Byar DP,et al.Estimating the population attributable risk for multiple risk factors using case-control data.Am J Epidemiol.1985;122:904 - 914.
[45]Greenland S,Robins JM.Conceptual problems in the definition and interpretation of attributable fractions.Am J Epidemiol.1988;128:1185-1197.
[46]Kahn HA,Sempos CT.Attributable risk.In:Statistical methods in epidemiology.New York:Oxford University Press,1989:73-84.
[47]Northridge ME.Public health methods-attributable risk as a link between causality and public health action.Am J Public Health 1995;85:1202-1204.
[48]Walter SD.Attributable risk in practice.Am J Epidemiol 1998;148:411-413.
[49]Office on Smoking and Health National Center for Chronic Disease Prevention and Health Promotion,Centers for Disease Control and Prevention(CDC):Smoking-Attributable Mortality,Morbidity,and Economic Cost(SAMMEC),version 3.0[Software and Documentation.]US Department of Health and Human Services,Agosto,1996.
[50]Romeder JM,Mc Whinnie JR.Potential years of life lost between ages 1 and 70:an indicador of premature mortality for health planning.Int J Epidemiol.1977;6:143-57,151.
[51]Thun MJ,Day-Lally C,Myers DG,et al.Trends in tobacco smoking and mortality from cigarette use in Cancer Prevention Studies Ⅰ(1959 through 1965)and Ⅱ(1982 through 1988).In:Changes in Cigarette-Related Disease Risks and Their Implication for Prevention and Control:Smoking and Tobacco Control Monograph.
[52]Centers for Diseases Control and Prevention.Cigarette-smoking attributable mortality and years of potential life lost-US,1990.Morbidity and Mortality Weekly Report 1993;Vol.42:645-9.)
[53]Jenny Kitzinger.Qualitative Research:Introducing focus groups.BMJ,1995,311:292-302
[54]李哲,冯学山.专题小组讨论.上海预防医学,2003,15(11):538-539.
[55]Matthew B.Miles,A.Michael Huberman.Qualitative Data Analysis(Second Edition).SAGE Publications.1994.
[56]费小兢.2005年吴中区居民主要死因减寿年数分析.中国慢性病预防与控制,2006,14(6):453.
[57]周天枢,郑弘,陈崇帼.平均减寿年数及其标准化方法探讨,中国卫生统计,1998,15(2):42.
[58]Centers for Disease Control and Prevention.Smoking-attributable mortality,morbidity,and economic costs.Available at:http://www.cdc.gov/tobacco/sammec.Accessibility verified February 10,2004.
[59]杨功焕等.行为危险因素监测--方法与应用.北京医科大学:中国协和医科大学联合出版,1998.
[60]2006年上海市死亡监测报告,上海市疾病预防控制中心专业报告(内部资料).
[61]金怌焕主编.医用统计方法.上海医科大学出版社.1998,上海:494.
[62]Kenneth J.Rothman,Sander Greenland.Morden Epidemiology.Lippomcott-Raven Publishers.1998.
[63]张文彤.SPSS统计分析教程.北京:希望电子出版社.2002.
[64]上海市徐汇区年鉴编撰委员会编.徐汇年鉴2006.上海:汉语大词典出版社,2006
[65]上海市徐汇区统计局编.徐汇区统计年鉴.2006(内部资料).
[66]杨功焕、黄正京、谭健,等.中国人群主要卫生问题--全国疾病监测死亡资料分析.中华流行病学杂志,1996,17(4):199-202.
[67]Liu BQ,Peto R,Chen ZM,Boreham J,Wu YP,Li JY,et al.Emerging tobacco hazards in China:1.Retrospective proportional mortality study of one million deaths.BJM 1998;317:1411-1422.
[68]姜垣,金水高.1998年我国居民吸烟归因社会经济负担.中国卫生经济,2000;19(10):55-57.
[69]Majid Ezzati,S.Jane Henley,Michael J.Thun,et al.Role of Smoking in Global and Regional Cardiovascular Mortality.Circulation.2005;112:489-497.
[70]Makomaski M,Kaiserman J.Mortality attributable to tobacco use in Canada and its Regions,1991.Can J Public Health 1995:257-65.
[71]Lopez AD,Collishaw NE,Piha T.A descriptive model of the cigarette epidemic in developed countries.Tobacco Control 1994;3:242-247.
[72]卫生部.2006年中国“吸烟与健康”报告.北京:2006.
[73]李爱兰,黄悦勤,王燕玲,等.我国青少年学生吸烟行为及其影响因素的初步分析.中国公共卫生,2001.17(1):75-77.
[74]王燕玲,黄悦勤,李爱兰,等.中国四省市少年吸烟及烟草知识调查及其影响因素分析.中国学校卫生,2002,21(6):456-457.
[75]许小频,郝瑞丰,聂少萍,等.广州青少年吸烟现状研究,中国学校卫生,2001,22(1):13-15.
[76]黎江,李新建,彭宁宁.上海市部分城区青少年学生吸烟行为,中国校医,2005,19(2):111-114.
[77]冯育基,杨功焕.青少年吸烟行为形成的影响因素.疾病监测.2002,17(3):112.
[78]Chassin L,Presson CC,Rose JS,et al.The natural history of cigarette smoking from adolescence to adulthood:demographic predictors of continuity and change.Health Psychology,1996;15(6):478-484.
[79]CDC.Preventing tobacco use among young people:A report of the surgeon general.Atalanta.US Dept.of Health and Human Service,1994.
[80]1996年全国吸烟行为的流行病学调查课题组.1996年全国吸烟行为的流行病学调查,北京:中国科学技术出版社,1997.1-5.
[81]Philip L Rice著.胡佩诚,等译.健康心理学.北京:中国轻工业出版社,2002.75-77.
[82]傅华,李锋,主编.现代健康促进理论与实践.上海:复旦大学出版社,2003,103.
[83]姜垣.控烟政策--成功与挫折.北京:中国协和医科大学出版社,2005,81-87.
[84]周瑞增,程永照,主编.WHO《烟草控制框架公约》对案及对中国烟草影响对策研究.北京:经济科学出版社,2006.
[1]World Health Organization.World Health Report 2003.WHO,Geneva,2003.
[2]US Department of Health and Human Services.Reducing the health consequences of smoking:25 years of progress.A report of the Surgeon General,1989.Rockville,Maryland:Public Health Service,Centers for Disease Control,Office on Smoking and Health,1989,(DHHS Publication No(CDC)89-8411).
[3]Zaridze D,Peto R,et al.Tobacco:a major international health hazard.IARC Scientific Publication No.74.Lyon,France:International Agency for Research on Cancer,1986.
[4]World Health Orgnization.Report on the global tobacco epidemic:The MPOWER package.Geneva,World Health Organization 2008.
[5]黄敬亨.健康教育学.复旦大学出版社.2006.
[6]CDC.The health consequences of smoking:a report of the Surgeon General.Atlanta,GA:US Department of Health and Human Services,CDC;2004.
[7]张开镐.吸烟对健康的危害.中国药物依赖性杂志,2001,10(3):171-172.
[8]US Department of Health and Human Services.The Health Consequences of Involuntary Exposure to Tobacco Smoke.A Report of the Surgeon General:2006.Washington DC:US Government Printing Office,2006.
[9]International Agency for Research on Cancer(IARC).Tobacco smoke and involuntary smoking(IARC monographs programme on the evaluation of carcinogenic risks to humans,volume 83).Lyon,France:International Agency for Research on Cancer(IARC),2002.
[10]Levin MI,Goldstein H,Gerhardt PR.Cancer and tobacco smoking.JAMA 1950;143:336-38.
[11]Doll R.Tobacco:an overview of health effects.Lyon:IARC,No.74.1986,11-22.
[12]高玉堂,邓杰,顶永兵,等.上海市居民吸烟玉癌症及有关疾病十年前瞻性研究.中华预防医学杂志,1999,33(1):5-8.
[13]World Health Organization.Tobacco alert.Geneva:WHO,1996.
[14]朱振岗.吸烟对健康的主要危害.中国公共卫生,1997,13(6):323-324.
[15]Jha P,Ranson MK,Nguyen SN,Yach D.Estimates of global and regional smoking prevalence in 1995,by age and sex.Am J Public Health 2002;92:1002-06.
[16]World Health Organization.Tobacco epidemic:health dimensions.Geneva:WHO,1997.
[17]Doll R,Hill AB.Smoking and carcinoma of the lung.BMJ.1950;221(2):739-748.
[18]Royal College of Physicians of London.Smoking and Health:summary of a report of the Royal College of Physicians of London on smoking in relation to cancer of the lung and other diseases.Publication No.S2-70.London,UK:Pitman Medical Publishing,LTD,1962
[19]US Department of Health Education,and Welfare(DHEW).Smoking and health:report of the Advisory Committee to the Surgeon General.DHEW-Public Health Service Publication No.1103.Washington,DC:US Government Printing Office,1964.
[20]US Department of Health and Human Services.The Health Consequences of Involuntary Smoking.A Report of the Surgeon General:1986.Washington DC:US Government Printing Office,1986.
[21]National Research Council and Committee on Passive Smoking.Environmental Tobacco Smoke:Measuring Exposures and Assessing Health Effects.Washington DC:National Academy Press,1986.
[22]US Department of Health Education and Welfare.The Health Consequences of Smoking:A Report of the Surgeon General,1971.Washington DC:US Government Printing Office,1971.
[23]Hirayama T.Non-smoking wives of heavy smokers have a higher risk of lung cancer:a study from Japan.Br Med J,1981,282(6259):183-185.
[24]Hirayama T.Life-style and mortality:a large-scale census-based cohort study in Japan.Basel,New York:Karger,1990.
[25]National Institutes of Health.Health Effects of Exposure to Environmental Tobacco Smoke.Smoking and Tobacco Control Monograph No.10.Bethesda, MD:NIH Pub,1999.
[26]US Environmental Protection Agency.Respiratory Health Effects of Passive Smoking:Lung Cancer and Other Disorders.Washington DC:US Government Printing Office,1992.
[27]California Environmental Protection Agency.Health Effects of Exposure to Environmental Tobacco Smoke,Final Report,September 1997.
[28]California Environmental Protection Agency.Proposed identification of environmental tobacco smoke as a toxic air contaminant:executive summary.Sacramento,California Environmental Protection Agency,June,2005.
[29]Bruzzi P,Green SB,Byar DP,Brinton LA,Schairer C.Estimating the population attributable risk for multiple risk factors using case control data.Am J Epidemiol.1985;122:904-914.
[30]Levin ML.The occurrence of lung cancer in man.Acta Union International Contra Cancrum.1953;9:531-541.
[31]Greenland,S.,Robins,J.M.Conceptual problems in the definition and interpretation of attributable fractions.American Journal of Epidemiology,1988;128(6):1185-1197.
[32]Beverly Rockhill,Beth Newman,Clarice Weinberg.Use and misuse of population attributable fractions.American Journal of Public Health.1998;88(1):15-20.
[33]施侣元.人群归因危险度百分比及其在药物流行病学中的应用。药物流行病学杂志,2001:10(4):209-210.
[34]Northridge ME.Public health methods--attributablerisk as a link between causality and public health action.Am J Public Health 1995;85:1202-1204.
[35]Bruzzi P,Green SB,Byar DP,et al.Estimating the population attributable risk for multiple risk factors using ease - control data[J].Am J Epidemiol,1985,122:904 - 914.
[36]Northridge ME.Public health methods-attributable risk as a link between causality and public health action.Am J Public Health 1995;85:1202-1204.
[37]Walter SD.Attributable risk in practice.Am J Epidemiol 1998;148:411-413.
[38]王天爵.病例-对照研究调整人群归因危险度的估计.中国卫生统计,1992,9(1):60.
[39]Shultz JM.SAMMEC:smoking attributable mortality,morbidity,and economic costs-computer software and documentation. Center for Nonsmoking and Health, Minnesota Department of Health, Minneapolies, August 1986.
[40] Shultz JM, Novotny TE, Rice DP. Quantfying the disease impact of cigarette smoking with SAMMEC II software. Public Health Rep 1991;106:326-33.
[41]Thun MJ, Day-Lally C, Myers DG, et al. Trends in tobacco smoking and mortality from cigarette use in Cancer Prevention Studies I (1959 through 1965) and II (1982 through 1988). In: Changes in Cigarette-Related Disease Risks and Their Implication for Prevention and Control: Smoking and Tobacco Control Monograph.
[42] Robert Welte, HansHelmut Konig, Reiner Leidl. The costs of health damage and productiveity losses attributable to cigarette smoking in Germany. EuropeanJournal of Public Health, 2000; 10(1):31-38.
[43]Zorrilla-Torras, Beten; Garcia-Marin, Natividad; Galan-Labaca, et al. Smoking attributable mortality in the community of Madrid: 1992-1998. European Journal of Public Health, 2005; 15 (1): 43-50.
[44]Majid Ezzati, Alan D Lopez. Estimates of global mortality attributable to smoking in 2000. Lancet 2003; 362: 847-52.
[45]Majid Ezzati, Alan D Lopez. Regional, disease specific patterns of smoking-attributable mortality in 2000.Tobacco Control 2004;13:388-395.
[46]McGinnis J. Michael, Foege William H. Actual causes of death in the United States. JAMA, 1993; 270 (18): 2207-2212.
[47]Mokdad, Ali H, Marks, James S, Stroup, Donna F. Actual causes of death in the United States, 2000. JAMA. 2004; 291: 1238-1246.
[48]Liu BQ, Peto R, Chen ZM, Boreham J, Wu YP, Li JY, et al. Emerging tobacco hazards in China: 1. Retrospective proportional mortality study of one million deaths. BJM 1998; 317:1411-1422.
[49]Niu SR, Yang GH, Chen ZM, et al. Emerging tobacco hazards in China: 2. Early mortality results from a prospective study. BMJ 1998; 317:1423-1424.