【作者】 周雷；

【导师】 傅华；

【作者基本信息】 复旦大学 ， 劳动卫生与环境卫生学， 2008， 博士

【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。更多还原

【Abstract】 BackgroundSmoking 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.ObjectivesThis 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 MethodsQuantity 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 Findings1.Smoking attributable disease impacts and health effectsThe 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 populationDue 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 behaviorThe 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 adultsThe 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 smokersThe 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 strategiesThe 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.Recommendations1.Accurate identification,systemic surveillance and comprehensive assessment of the actual causes of deathsAccurate 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 controlThe 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 environmentSmoking 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 strategiesThe 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.更多还原