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BZ24 RZ128 04ev, ~= JAMA-J AM MED ASSOC 95 r,~3A Brief Report ® (C)AMER MEDICAL ASSOC IL THIS ARTICLE IS FOR INDIVIDUAL USE ONLY STOREDYELECTRONICALLYRWI7HO~D~WRDT~EN PERMISSION FROM THE COPYRIGHT HOLDER UNAUTHORIZED REP RODUCTION M. TNAY RESULT FTNANr~ra~ Cigarette Smoking in China °"° °r"FR PFN"'TrFS. Prevalence, Characteristics, and Attitudes in Minhang District You Long Gong, MD; Jeffrey P. Koplan, MD, MPH; Wei Feng, MD; Charles H. C. Chen, PhD; Ping Zheng, MD; Jeffrey R. Harris, MD, MPH Objective.-To determine the prevalence, pattern, and financial implications of cigarette smoking and the attitudes toward and knowledge of the health effects of tobacco use in a population in China. Design.-A two-stage, stratified cluster survey using door-to-door interviews. Setting.-Minhang District, China (near Shanghai), with a population of 506 000. Participants.-A total of 3423 males and 3593 females aged 15 years and older. Main Outcome Measures.-Smoking prevalence, age of initiation of smoking, reasons for smoking, knowledge of tobacco hazards, and costs of smoking. Results.-A total of 2279 males (67%) but only 72 females (2%) smoke. Many males initiate smoking in adulthood. A total of 1156 males (50.7%) began smoking between 20 and 24 years of age, and 666 (29.2%) began between 25 and 39 years of age. Among all respondents, 6202 (88.4%) believe smoking is harmful for both the smoker and those exposed passively to the smoke. Only 332 (14.1 %) of all male smokers reported a desire to quit smoking. Current smokers spent an average of 3.65 yuan daily on cigarettes or 1332 yuan yearly (8.5 yuan per US dollar), which represents 60% of personal income and 17% of household income. Conclusions.-The survey reveals a dangerous health situation that in all like- lihood will worsen. More than two thirds of men smoke, and people in successive age cohorts start smoking at earlier ages. Smokers spend a substantial proportion of their income on cigarettes. There is a low rate of quitting and a low desire to quit despite high awareness of the health hazards. Tobacco control measures need to be implemented urgently in China. (JAMA. 1995;274:1232-1234) I now give you my assurance that we mean to cut off this harmful drug forever. What it is forbidden to consume, your dependencies must be forbidden to manufacture. Commissioner Liu Tse-hsu, Governor-General of Hupei and Hunan, to Queen Victoria, regard- ing opium, March 1839' TOBACCO use is a growing health con- cern in the developing world, particu- larly in places where disposable income is increasing and cigarette smoking is promoted by national agricultural inter- ests and multinational manufacturers? China has a huge existing market for tobacco products and also is the world's leading grower of tobacco 3•' China is in the midst of significant and substantial economic reform. Changes are From the Shanghai Medical University (Drs Gong and Feng) and Minhang District Bureau of Health (DrZheng), Shanghai, People's Republic of China, and The Pruden- tial Center for Health Care Research (Dr Koplan) and National Center for Chronic Disease Preventionn and Health Promotion, Centers for Disease Control and Pre- vention (Drs Chen and Harris), Atlanta, Ga. Reprints requests to National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control and Prevention, Mailstop K-40, At- lanta, GA 30333 (Dr Harris). occurring that could prove influential in determining the future directions of to- bacco use and health outcomes: the local establishment by transnational tobacco companies of large-scale cigarette pro- duction facilities with state-of-the-art equipment5; the restructuring and up- -grading of Chinese-owned cigarette pro- duction facilities; a proliferation of adver- tising as a means of promoting product sales in general and cigarettes in particu- lar (Philip Moiris w-ith its Marlboro brand is the leading source of advertising rev- enue in China)6; a desire among the young to emulate the West and appear "sophis- ticated" by adopting perceived Western styles'; and collapse of many components of the cooperative health care system, leaving many individuals with financial responsibility for their own health care $ Shanghai Medical University, the Min- hang District (formerly Shanghai County) Bureau of Health, the People's Republic of China, and the Centers for Disease Con- trol and Prevention (CDC) have collabo- rated since 1980 in studying health care delivery, health outcomes, and health be- haviors in the population of Minhang Dis- trict,1,10 a suburban area with a population of approximately 506 000 near Shanghai Municipality. In this study, we describe the prevalence, pattern, and familial finan- cial implications of smoking and the atti- tudes toward and knowledge of the health effects of tobacco use in Minhang in 1993. Methods Door-to-door interviews were con- ducted from October through December 1993 by 60 staff members of the Minhang District Health Bureau and students of Shanghai Medical University. The inter- viewers received 3 days of training. Su- pervisors oversaw conduct of the survey and reviewed completed responses. Data entry of each questionnaire was per- formed separately by two persons. We used a two-stage, stratified cluster method. First, 20 sample villages/urban units were randomly selected from the 280 villages in Minhang. Second, 52 sample neighborhoods were randomly selected from the 208 neighborhoods in those vil- lages/urban units. The further random se- lection process gave every household and resident in Miuihang an opportunity of be- ing sampled. The overall sample size was 1.8% (1/56) of the population. All house- hold members aged 15 years or older were interviewed. Parents provided informa- tion on children younger than 15 years. Information was obtained from the in- terviewees using open-ended questions on smoking status (current, former, or nonsmoker), age of initiation, use of do- mestic vs imported cigarettes, reasons for smoking, the effect of advertising, beliefs about tobacco and health, attitude toward quitting smoking, and individual expen- ditures on tobacco. Current smokers were persons who had smoked more than 100 cigarettes in their lifetimes and who were still smoking daily at the time of the in- terview. Former smokers were persons who had smoked more than 100 cigarettes in their lifetimes but were not smoking at the time of the interview. Never smokers were persons who had never smoked or had smoked no more than 100 cigarettes in their lifetimes. All estimations in this survey were per- formed using a survey statistical analysis 1232 JAMA, October 18, 1995-Vol 274, No. 15 Cigarette Smoking in China-Gong et al

in India. AIDS. 1991;5:117-118. 7. Friedman SR, Des Jarlais DC. HIV among drug injectors: the epidemic and the response. AIDS Care. 1991;3:239-250. S. Lamothe F, Bruneau J, Soto J. Progression of prevalence of HI V-1 infection among injection drug users in Montreal, Quebec. Can Commun Dis Rep. 1992;18:98-101. 9. Lampinen TM, Joo E, Seweryn S, Hershow RC, Weibel W. HIV seropositivity in community-re- cruited and drug treatment samples of injecting drug users. AIDS. 1992;6:123-126. 10. Lurie P, Reingold AL, Bowser B, et al. The Public Health Impact of Needle-Exchange Pro- grams in the United States and Abroad, Volume 1. Atlanta, Ga: Centers for Disease Control and Pre- vention; September 1993. 11. Stimson GV. The prevention of HIV infection in injecting drug users: recent advances and re- maining obstacles. In: Program and abstracts of the Sixth International Conference on AIDS; June 20- 24, 1990; San Francisco, Calif. 12. Frischer M, Green S, Goldberg D, et al. Esti- mates of HIV infection among injecting drug users in Glasgow from 1985-1990. AIDS.1992;6:1371-1375. 13. Frischer M, Floor M, Green S, et al. Reduction in needle sharing among community-wide samples of drug injectors. Int J STD AIDS. 1992;3:288-290. 14. Frischer M, Haw S, Bloor M, et al. Modelling the behaviour and attributes of injecting drug us- ers: a new approach to identifying HIV risk prac- tices. Int J Addict. 1993;28:129-152. 15. Hagan H, Hale CB. HIV-1 Seroprevalence Sur- veys in Pierce County, June 1988 to December 1992. Tacoma, Wash: Tacoma-Pierce County Health De- partment; 1993. 16. Millson P, Myers T, Rankin J, Major C, Fearon M, RigbyJ. Trends in HIV seroprevalence and risk behaviour in IDUs in Toronto, Canada. In: Pro- gram and abstracts of the Ninth International Con- ference on AIDS; June 6-11,1993; Berlin, Germany. Abstract PO-C15-2936. 17. Kaldor J, Elford J, Wodak A, Crofts JN, Kidd S. HIV prevalence among IDUs in Australia: a methodological review. Drug Alcohol Rev. 1993;12: 175-184. 18. Ljungberg B, Christensson B, Tunving K, et al. HIV prevention among injecting drug users: three years of experience from a syringe exchange pro- gram in Sweden. J AIDS: 1991;4:890-895. 19. Tunving K, Nyholm K, Andersson B. Two suc- cessful syringe- and needle-exchange programs in Lund/Mahno, Sweden: their effects on the help- seeking drug-using communities and the surround- ing drug treatment facilities. In: Program and ab- stracts of the Eighth International Conference on AIDS; July 19-24, 1992; Amsterdam, the Nether- lands. Abstract PuC 8231. 20. Papaevangelou G, Ancelle-Park R, Seyrer Y. HIV prevalence and risk factors for infection among intravenous drug users in the European Commu- nity. In: Program and abstracts of the Seventh International Conference on AIDS; June 16-21,1991; Florence, Italy. Abstract MD 4074. 21. Hagan H, Des Jarlais DC, Purchase D, et al. An interview study ofparticipants in the Tacoma, Wash- ington syringe exchange. Addiction. 1993;88:1691- 1697. 22. Ross MW, Wodak A, Gold J, Miller ME. Dif- ferences across sexual orientation on HIV risk be- haviours in injecting drug users. AIDS Care. 1992; 4:139-148. 23. Ross MW, Stowe A, Wodak A, Miller ME, Gold J. Predictors of HIV status among injecting drug users, and health promotion. J R Soc Health. In press. 24. btillson P, Myers T, Rankin J, et al. Descriptive epidemiology of injection drug users in Toronto. Presented at the Second Annual Canadian National Conference on HIV/AIDS; May 28-29, 1992; Van- couver, British Columbia. 25. Hagan H, Des Jarlais DC, Purchase D, Reid T, Friedman SR. The Tacoma syringe exchange. J Addict Dis. 1991;10:81-88. 26. Frischer M, Elliot L. Discriminating needle- exchange attenders from non-attenders. Br J Ad- dict. 1993;88:681-687. 27. Friedman SR, de Jong W, Wodak A. Commu- nity development as a response to HI V among drug injectors. AIDS. 1993;7(suppl 1):S263-S269. 28. Des Jarlais DC, Friedman SR. AIDS prevention programs for injecting drug users. In: Wormser GP, ed. AIDS and Other Manifestations of HIV Infec- tion. 2nd ed. New York, NY: Raven Press Ltd; 1992: 645-658. 29. Millson P, Coates R, RankinJ, et al. Evaluation of a Programme to Prevent Human Immunodefi- ciency Virus Transmission in Injection Drug Us- ers in Toronto: Final Report to the National Health Research and Development Programme, Health and Welfare Canada. Ottawa, Ontario: National Health Research and Develoment Programme; De- cember 1991. NHRDP grant 6606-4333-AIDS. 30. Taylor A, Frischer M, McKeganey N, Platt S, Goldberg D, Green S. HIV risk behaviours among female prostitute drug injectors in Glasgow. Ad- diction. In press. 31. Carr S, Green S, Goldberg D, et al. HIV preva- lence among female street prostitutes attending a health care drop-in centre in Glasgow. AIDS. 1992; 6:1553-1554. 32. Christensson B, Ljungberg B. Syringe exchange for prevention of HIV infection in Sweden: prac- tical experiences and community reactions. Int J Addict. 1991;26:1293-1302. 33. Neaigus A, Friedman SR, Curtis R, et al. The relevance of drug injectors' social networks and risk networks for understanding and preventing HIV infection. Soc Sci Med. 1994;38:67-78. 34. Stall R, Ekstrand ML, Pollack L, McKusick L, Coates TJ. Relapse from safer sex: the next chal- lenge for AIDS prevention efforts. J Acquir Irrr,- mune Defic Syndr. 1990;3:1181-1187. 35. Ekstrand ML, Coates TJ. Mainte:,ance of safer sexual behaviors and predictors of risky sex: the San Francisco Men's Health Study. Am J Pu`olic Health. 1990;80:973-977. 36. Osmond DH, Page K, Wiley J, et al. Human immunodeficiency virus infection in homosexual/ bisexual men, ages 18-29: the San Francisco Young Men's Health Study. In: Program and abstracts of the Ninth International Conference on AIDS; June 6-11, 1993; Berlin, Germany. Abstract WS-C07-3. 37. Office of National Drug Control Policy (ONDCP). Needle Exchange Programs: Are They Effective? Washington, DC: Executive Office of the President, Office of National Drug Control Policy; July 1992. ONDCP Bulletin No. 7. 38. Stimson GV. AIDS and injecting drug use in the United Kingdom, 1988 to 1993: the policy re- sponse and the prevention of the epidemic. Soc Sci Med. In press. 39. Dolan KA, Stimson GV, Donoghoe MC. Reduc- tions in HIV risk behaviour and stable HIV preva- lence in syringe-exchange clients and other injec- tors in England. Drug Alcohol Rev. 1993;12:133- 142. 40. Baker M, Tobias M, Brady H. Detection of HIV antibodies in used syringes in New Zealand. In: Program and abstracts of the Seventh Interna- tional Conference on AIDS; July 16-21, 1991; Florence, Italy. Abstract WC 3364. 41. Brown BS, Beschner GM, eds. Handbook on Risk of AIDS. Westport, Conn: Greenwood Press; 1993. 42. DiClemente R, Peterson J, eds. Preventing AIDS: Theories and Methods of Behavioral Inter- ventions. New York, NY: Plenum Press; 1994. 43. Anderson RM, May RM, Boily MC, Garnett GP, Rowley JT. The spread of HIV-1 in Africa: sexual contact and the predicted demographic im- pact of AIDS. Nature. 1991;352:581-589. 44. Cordray DS. Quasi-experimental analysis: a mix- ture of methods and judgment. New Dir Prog Eval. 1986;31:9-28. 45. Des Jarlais DC, Choopanya K, Vanichseni S, et al. AIDS risk reduction and reduced HIV serocon- version among injecting drug users in Bangkok. Am J Public Health. 1994;84:452-455. 46. Chitwood DD. HIV risk and injection drug us- ers: evidence for behavioral change. Am J Public Health. 1994;84:350. 47. Des Jarlais DC, Hagan H, Friedman SR, et al. Biological validation of self-reported behavior change among IDUs. In: Program and abstracts of the 10th International Conference on AIDS; Au- gust 7-12,1994; Yokohama, Japan. Abstract PD0495. 48. Des Jarlais DC, Friedman SR, Choopanya K, et al. 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pacKage, SUDAAN, to account for intra- class correlations within the primary sam- pling units (households)." The X2 test was used to determine the significance of dif- ferences in proportions. Statistical signifi- cance was defined by a two-sided cx level less than or equal to .05. Results A total of 2821 households were se- lected for study, and of these, 2716 house- holds participated (96.3% rate of house- hold participation). The 2716 households were inhabited by 8876 individuals of whom 8552 participated in the survey and provided a completed survey instru- ment (96.3% rate of individual partici- pation). Among the 8552 persons who completed the questionnaire, 7016 were 15 years of age or older and were in- terviewed for the risk factor section of the questionnaire. Of the 7016 partici- pants, there were 3423 males (48.8%) and 3593 females (51.2%). For males, the mean age was 41.9 years (range, 15 to 90 years), and for females, the mean age was 43.2 years (range, 15 to 93 years). A total of 2279 males (67%) but only 72 females (2%) smoke cigarettes currently, yielding a population prevalence of 33%. Smoking prevalence peaked at 81% for men aged 30 through 39 years (Table 1). Only 62 men (1.8%) were former smokers. Differences in rates of smoking by edu- cation, income, and location of residence were not statistically significant (Table 2). Most of the subsequent results are given for male smokers only, who constitute 96% of smokers in the study group. Men in Minhang continue to initiate smoking well into adulthood (Table 3). For example, 228 men (10%) began smoking between 30 and 39 years of age. Men in Minhang have initiated smoking in suc- cessively earlier age cohorts. The propor- tion who initiated smoking between 20 and 24 years of age was 55.1% for those who were aged 25 through 29 years, 44.6% for those aged 30 through 39 years, 31.1% for those aged 40 through 59 years, and 20.3% for those aged 60 years and older. Although "the expectation of enjoyment" was the most common reason for initiat- ing smoking among 1460 (64.1%) of 2279 male smokers, 157 (39.7%) of 395 males in the younger age groups (15 through 29 years) listed "social asset" as a reason. More younger males, 217 (28.4%) of the 763 males aged 15 through 29 years, than older males, 279 (10.5%) of 2660 aged 30 years and older, stated a preference for imported cigarettes. Among male smokers, 74 (18.7%) of 395 younger smok- ers (aged 15 through 29 years) and 158 (8.4%) of 1884 older smokers (aged 30 years and older) smoked imported ciga- rettes. Males were more likely to smoke imported brands if they were more edu- Table 1.-Smoking Prevalence by Sex and Age for All Adult Residents, Minhang District, China" Proportion of Current Smokers, No. (%) Age Group, y Males Females Total Total 3423 (66.6) 3593 (1.7) 7016 (33.3) 15-19 192 (7.8) 189(0.0)_ 381 (3.9) 20-24 219 (49.8) 278(1.1) 497(22.5) 25-29 352 (77.0) 362 (0.8) 714 (38.4) 30-39 996 (81.1) 898 (0.8) -- - 1894 (43.0) 40-49 635 (74.8) 647 (1.2) 1282(37.7) 50-59 472 (64.6) 543(l.8) _ 1015 (31.0) 60-69 385 (56.6) 395 (4.3) 780 (30.1) ?70 172 (45.3) 281 (4.3) 453 (19.9) * For males, P=.05; for females, P=.10; for total, P=.01. P values are derived from x2 tests of the association between smoking prevalence and age among males, females, and the total population. Figures not in parentheses are the number of residents on which the proportion is based. Table 2.-Distribution of Current Smokers, Former Smokers, and Never Smokers for Males 15 Years of Age and Older by Selected Socioeconomic Variables, Minhang District, China* - Characteristic Total No. Current Smokers, No. (%) Former Smokers, No. (%) Never Smokers, No. (%) Total 3423 2279 (66.6) 61 (1.8) 1083 (31.6) Education Illiterate 210 119 (56.7) 15(7.1) 76 (36.2) Primary 837 606 (72.4) 26(3.1) 205 (24.5) Middle school 1758 1234 (70.2) 19(1.1) 505 (28.7) Junior college 380 220 (57.9) 0 (0.0) 160 (42.1) College and higher 238 100 (42.0) -1 (0.4) 137 (57.6) Household income, yuan per yeart <5000 563 359 (63.8) 18 (3.2) -- 186 (33.0) 5000-6999 722 505 (69.9) -15 (2.1) 202 (28.0) 7000-9999 . . . 949 655 (69.0) 16(1.7) 278 (29.3) 10 000-14 999 738 .466 (63.1) 6 (0.8) 266 (36.0) ? 15 000 451 294 (65.2) 6 (1.3) 151 (33.5) Place of residence Rural 2314 1636 (70.7) 51 (2.2) 627 (27.1) Suburban 1109 643 (57.9) 10(1.0) 456 (41.1) *For education, P=.08; for household income, P=.23; for place of residence, P=.10. P values are derived from the X2 tests of the association between education, income, and place of residence vs smoking status. tThe currency exchange rate is approximately 8.5 yuan per US dollar. cated, had higher incomes, and were ur- ban residents. For the 2279 current male smokers, the choice of brands was based on cost (45.5%), taste (27.3%), social sta- tus (18.0%), brand reputation (6.3%), and other reasons (3.0%). Among 2046 male smokers who usually smoked domestic brands, cost (48.7%) and taste (26.4%) were the most common reasons for brand selection, whereas for 119 male smokers of impar-ted brands, taste (38.7%), social status (23.5%), and cost (23.5%) were the most common reasons. Of all 7016 male and female respon- dents, 6202 (88.4%) believed that smok- ing is harmful for the smoker and 6195 (88.3%) believed smoking is also harm- ful to those passively exposed to ciga- rette smoke. Among 2279 current male smokers, 1869 (82%) believed that ciga- rette smoking was a health hazard. Almost half (48.6%) of 2279 male smok- ers acknowledge their awareness of ciga- rette advertisements. The rates of this awareness were directly correlated with educational level: 25.2% of 119 illiterate males were aware of cigarette adver- tising compared with 75.0% of the 100 college-educated males. Of those 1108 male current smokers who were aware of advertising, television was the most common source at 80.6% A total of 332 (14.1%) of all 2279 male current smokers wished to quit smoking. However, of those 322, only 26 (8%) ac- tually had quit smoking for 1 day or longer in the previous 12 months. The most com- mon reasons for wanting to quit were concern about their own health (72.4%), economic considerations (27.6%), objec- tions of family members (12.9%), and con- cerns about the health of others (9.6%). Health concerns increased with age. The average number of cigarettes smoked daily was 16.5 (range, one to 60; 16.6 for males and 13.4 for females). Smok- ers younger than 20 years smoked be- tween 5.5 (those aged 15 years) and 9.8 (those aged 19 years) cigarettes per day. Average daily cigarette consumption did not vary by income. Current smokers spent an average of 3.65 yuan (range, 0.25 JAMA, October 18, 1995-Vol 274, No. 15 2050235676 Cigarette Smoking in China-Gong et al 1233

Table 3.-Proportion of Current Male Smokers by Age of Initiation of Smoking, Minhang District, China Age, y No. % 10-14 15 0.7 15-19 378 16.6 20-24 1156 50.7 25-29 438 19.2 30-39 228 10.0 40-49 41 1.8 50-59 19 0.8 ? 60 4 0.2 Total 2279 100.0 to 15.00 yuan) daily on cigarettes, or ap- proximately 1332 yuan yearly. (The ex- change rate has been approximately 8.5 yuan per US dollar from 1993 through 1995.) This expenditure represents an av- erage of 60% of personal income and 17% of household income. The proportion of individual and household income consumed by cigarette expenditures increased with successively lower income levels. Comment This survey reveals a dangerous health situation that in all likelihood will worsen. More than two thirds of males in Minhang District smoke, a rate comparable with those found in other parts of China (57% to 80%) 4,12-1' People in successive age co- horts seem to start smoking at earlier ages. Younger smokers prefer and more often smoke imported brands. Smokers are willing to spend a substantial propor- tion of their income on supporting their habit. There is a low rate of quitting smok- ing and a low desir e to quit despite high awareness of the detrimental health con- sequences of tobacco use. In addition, ciga- rettes sold in China have higher tar con- tent and are more likely to be unfiltered than those sold in the United Statesls and thus present a greater health risk. Future prospects could be even grim- mer. Females, most of whom generate their own income, represent an untapped market for tobacco interests. Only 2% of females smoke in Minhang. Other studies from China show similarly low prevalence rates for smoking among females (7% to 14%):', tz,13 The lower smoking prevalence in Minhang compared with other Chinese areas studied may be due to the more lu- ral nature of Minhang. Rural society is as- sociated with more traditional values such as lower acceptability of smoking by fe- males. The higher rate of smoking (4%) re- ported by the older females may reflect the initiation of smoking in preliberation China, when social norms were different. The emulation of the West, particularly in perceived style and fashion, creates a fer- tile background for the advertising of transnational tobacco companies. In some areas of China, increased rates of smoking among females are already being seen. For the entire population of China, lung cancer rates are increasing by 4.5% per year.'7 It is estimated that there will be a huge increase in lung cancer deaths, esti- mated to reach 900 000 annually by 2025.11 The proportion of individual and fam- ily income spent on tobacco is striking. Even if our survey underestimates in- comes by 50%, the amount spent on smok- ing would still be substantial. Beyond the personal economic costs of smoking, in China as well as the United States, tobacco as a profitable crop and com- modity creates a conflict of interest for a government also responsible for improv- ing its people's health. Nonetheless, the economic costs of smoking to both the individual and society appear to outweigh its perceived benefits.t9,2o Warnings have been issued previously in the medical literature on the health crisis in China due to tobacco use;21 and some reassurance has been found in regulations imposing controls and re- strictions on the tobacco industly.' How- ever, the warnings have provoked little organized local governmental or inter- national action, and the regulations have been inconsistently enforced. Control measures that have been ef- fective in many parts of the world should be effective in China as well?1 Regular and routine surveillance of behavioral risk factors, including smoking, on a represen- tative sample of the Chinese population would provide a baseline for prevention and control efforts and permit program evaluation. While taxation is beyond the responsibility of the Ministry of Health, increases in cigarette prices have been shown to decrease use.' Thus, an increase in taxes would be expected to further tobacco control efforts.19 The ban on ciga- rette sales to schoolchildren should be en- forced. There needs to be a massive in- crease in investment in and application of health education, particularly in schools for all age levels. Particular effort is nec- essary to make health care workers and teachers community models of a nonsmok- ing lifestyle. The ban on cigarette adver- tising needs to be rigorously enforced by prohibiting the depiction of brand names and the use of logos, not just the act of smoking itself. Tobacco companies should not be allowed to sponsor sports events. The 10th World Conference on To- bacco and Health to be held in Beijing in 1997 will provide a highly visible forum for a broader discussion of the hazards of tobacco use in-China and the oppor- tunities for prevention and control. Because cigarette smoking in China is a public health emergency, immediate control measures are needed to reduce what could become a health disaster. Per- sistent international interest in the prob- lem of tobacco use in China is needed, and steps must be taken to control and pre- vent tobacco use. In a country that em- braced the doctrine of "prevention first" for many conditions and health risks to im- prove the health and longevity of its popu- lation, there is an urgent need to maintain this approach to do away with a current "pest" and continue to "serve the people." We thank Judith Mackay, FRCP, Asian Consul- tancy on Tobacco or Health; Howard Barnum, PhD, The World Bank; and Michael Eriksen, ScD,Office of Smoking and Health, Centers for Disease Con- trol and Prevention, for their helpful reviews of the manuscript. References 1. Hibbert C. The Dragon Wakes. 1793-19TZ. Mid- dlesex, England: Penguin Books; 1984:111. 2. World Bank. World Development Report 1993. NNew York, NY: Oxford University Press; 1993. 3. MacKenzie TD, Bartecchi CE, Schrier RW. The human costs of tobacco use. N Engl J Med. 1994; 330:975-990. 4. Weng XZ, Hong ZG, Chen DY. Smoking preva- lence in Chinese aged 15 and above. Chin Med J (Engl). 1987;100:886-892. 5. Cai GY, Liu L, Jin F. 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