Comment
Tobacco in China: taming the smoking dragon
www.thelancet.com Vol 385 May 30, 2015
Beijing smoke-free, the Beijing law includes strong and enforceable penalty provisions. For instance, owners or managers of premises, and not just individual smokers, will be liable for fines if they do not comply with the new law. China is home to more than 300 million smokers, about 4 million of whom live in Beijing.5,6 Today, more than one in every three cigarettes smoked in the world is smoked in China—most of those by Chinese men.7 The 2010 Global Adult Tobacco Survey reported that the prevalence of current smoking in China was 52·9% among men and 28·1% among the population overall.5 Although the prevalence of current smoking in women remains low at 2·4%, rates of exposure to second-hand smoke in Chinese women are among the highest in the world.8 In this context, the decision to adopt such a strong smoke-free law in Beijing is important, and it is hoped that other cities across China will emulate this example. Beijing has now set the benchmark in smoke-free policy for China, and we hope that similar national legislation will follow. Indeed, a draft national tobacco control regulation, which includes provision for smoke-free public places, is currently before China’s State Council. The adoption of the Beijing law is a major advance in tobacco control, but its effectiveness in reducing exposure to second-hand smoke—and improving indoor air quality in public places across the city—will only be as good as the city’s enforcement effort in the lead-up to the law and after its introduction on June 1.
See Editorial page 2122
Imaginechina/Corbis
Beijing’s air pollution makes news headlines around the world: hazy images of people’s faces shrouded in masks and iconic monuments obscured by smog are now as synonymous with the city as the monuments themselves. As expatriate residents of Beijing, our friends and family from home often ask us: “But living in Beijing, how do you breathe?” We hope the answer is more easily after June 1, 2015, when Beijing’s new smoke-free law will take effect.1 Although Beijing’s outdoor ambient air pollution routinely makes the news, indoor air pollution in the city—and across China—is often worse than outdoor air pollution.2 One of the main causes of China’s indoor air pollution is second-hand tobacco smoke.3 At times in Beijing, the level of particulate matter with a diameter of less than 2·5 μg per m³ (PM2.5) can reach 500 μg/m³ or more. To put this into context, WHO’s guidelines on air quality recommend that mean PM2.5 exposure should not exceed 25 μg/m³ over 24 h.4 However, the smoke from just three cigarettes burning in a restaurant can result in a PM2.5 level of about 600 μg/m³ which will increase to about 1200 μg/m³ with the smoke from five cigarettes.2 The smoke from 20 or more smokers, which is not unfeasible in a crowded bar or restaurant, will result in a PM2.5 level that will be off the chart. For Beijing’s population of some 23 million residents and its many visitors, the Beijing Smoking Control Ordinance, passed by the Beijing Municipal People’s Congress in November, 2014, is set to change indoor air pollution in the city.1 Although China does not yet have a national smoke-free law, the new Beijing law is the strongest subnational tobacco control regulation adopted in the country to date, and complies with the requirements of Article 8 of the WHO Framework Convention on Tobacco Control. The Beijing Smoking Control Ordinance requires all indoor public places, including workplaces, restaurants and bars, hotels, airports, and public transport facilities, to be totally smoke-free. Many outdoor public places, such as nursery schools and some hospital campuses, will also be required to be smoke-free. In addition, the law bans tobacco advertising in mass media, public places, outdoors, and on public transport. Importantly, unlike previous attempts to make public places in
2123
Comment
Smoke-free regulations that are not actively enforced do not reduce exposure to second-hand smoke. Effective enforcement of a smoke-free law in a city the size of Beijing will be a colossal task. It will require a visible and ongoing enforcement effort, rigorous application of penalties for breach of the law, as well as substantial investment in resources for public education and awareness about the new law and the importance of protecting against exposure to secondhand smoke. Tobacco control in China is a difficult undertaking.9 In a country where the world’s biggest tobacco company, the China National Tobacco Corporation, is a powerful state-owned enterprise with a seat at the tobacco control policy table, and cigarettes have an important social currency, victories are few and far between.9 In this context, Beijing’s smoke-free law deserves to be regarded as a major step forward in the battle against the smoking dragon. And the people of Beijing should be able to breathe a little easier for that.
BS is WHO Representative in China. AP is Technical Officer for the Tobacco Free Initiative at World Health Organization China Representative Office. Bloomberg Philanthropies provides funding support to WHO to support WHO’s tobacco control work in China. We have no competing interests. © 2015. World Health Organization. Published by Elsevier Ltd/Inc/BV. All rights reserved. 1 2
3
4
5
6
7 8
9
Bernhard Schwartländer, *Angela Pratt
Beijing Municipal People’s Congress. Beijing Smoking Control Ordinance. Nov 27, 2014. Beijing: Beijing Municipal People’s Congress, 2014. Liu RL, Yang Y, Travers MJ, et al. A cross-sectional study on levels of second-hand smoke in restaurants and bars in five cities in China. Tob Control 2010; 19 (suppl 2): i24–29. Campaign for Tobacco Free Kids. Study: secondhand smoke greatest source of indoor air pollution in Beijing. Sept 28, 2012. http://www. tobaccofreekids.org/tobacco_unfiltered/post/2012_09_28_china (accessed May 21, 2015). WHO. WHO air quality guidelines for particulate matter, ozone, nitrogen dioxide and sulfur dioxide—global update 2005. Geneva: World Health Organization, 2006. Chinese Center for Disease Control and Prevention. Global Adult Tobacco Survey (GATS) China 2010 Country Report. 2010. http://www.who.int/ tobacco/surveillance/survey/gats/en_gats_china_report.pdf (accessed May 19, 2015). Wang X. Proportion of smokers has fallen, survey finds. China Daily May 21, 2015. http://usa.chinadaily.com.cn/epaper/2015-05/21/ content_20783662.htm (accessed May 21, 2015). Eriksen M, Mackay J, Schluger N, Islami F, Drope J. The tobacco atlas, fifth edition. Atlanta, GA: American Cancer Society Inc, 2015. Centers for Disease Control and Prevention. Current tobacco use and secondhand smoke exposure among women of reproductive age— 14 countries, 2008–2010. MMWR Morb Mortal Wkly Rep 2012; 61: 877–82. Yang G, Wang Y, Wu Y, Yang J, Wan X. The road to effective tobacco control in China. Lancet 2015; 385: 1019–28.
World Health Organization China Representative Office, Chaoyang District, Beijing 100600, China [email protected]
Anacetrapib in familial hypercholesterolaemia: pros and cons Published Online March 3, 2015 http://dx.doi.org/10.1016/ S0140-6736(14)62315-1 See Articles page 2153
2124
Cholesterol ester transfer protein (CETP) promotes transfer of cholesterol esters from HDL, in exchange for triglycerides from proatherogenic apolipoprotein B-containing lipoproteins. Genetic deficiency or pharmacological inhibition of CETP is associated with cholesterol enrichment of HDL and reduction of LDL cholesterol (LDL-C) concentrations. In the REALIZE study reported by John Kastelein and colleagues1 in The Lancet, the potent CETP inhibitor anacetrapib reduced LDL-C by nearly 40%, and increased HDL cholesterol (HDL-C) by more than 100%, compared with placebo, in 306 patients with heterozygous familial hypercholesterolaemia. Patients were randomly allocated in a 2:1 ratio to 52 weeks of treatment with either anacetrapib 100 mg daily, or placebo. Most patients were already receiving intensive statin treatment, and more than 70% were also receiving ezetimibe. Although the REALIZE study was
neither designed nor powered to assess cardiovascular outcomes, a concerning but statistically non-significant excess of cardiovascular events in the anacetrapib group (4 of 203 [2%] vs 0 of 102 [0%]) was seen, in addition to a higher rate of cutaneous adverse events in the treatment group as compared with the placebo group. Despite high-dose statin treatment, even in combination with other lipid-lowering drugs such as ezetimibe, most familial hypercholesterolaemia patients are unable to achieve recommended LDL-C targets. Additional treatment strategies are thus needed that not only reduce LDL-C concentrations further, but also, and more importantly, reduce cardiovascular events. Are CETP inhibitors the way to go? Several factors make anacetrapib attractive. It is an oral drug and its lipid-modifying effects are impressive. In REALIZE,1 the addition of anacetrapib 100 mg daily resulted in an absolute reduction of LDL-C of 1·2 mmol/L in www.thelancet.com Vol 385 May 30, 2015
Tobacco in China: taming the smoking dragon
www.thelancet.com Vol 385 May 30, 2015
Beijing smoke-free, the Beijing law includes strong and enforceable penalty provisions. For instance, owners or managers of premises, and not just individual smokers, will be liable for fines if they do not comply with the new law. China is home to more than 300 million smokers, about 4 million of whom live in Beijing.5,6 Today, more than one in every three cigarettes smoked in the world is smoked in China—most of those by Chinese men.7 The 2010 Global Adult Tobacco Survey reported that the prevalence of current smoking in China was 52·9% among men and 28·1% among the population overall.5 Although the prevalence of current smoking in women remains low at 2·4%, rates of exposure to second-hand smoke in Chinese women are among the highest in the world.8 In this context, the decision to adopt such a strong smoke-free law in Beijing is important, and it is hoped that other cities across China will emulate this example. Beijing has now set the benchmark in smoke-free policy for China, and we hope that similar national legislation will follow. Indeed, a draft national tobacco control regulation, which includes provision for smoke-free public places, is currently before China’s State Council. The adoption of the Beijing law is a major advance in tobacco control, but its effectiveness in reducing exposure to second-hand smoke—and improving indoor air quality in public places across the city—will only be as good as the city’s enforcement effort in the lead-up to the law and after its introduction on June 1.
See Editorial page 2122
Imaginechina/Corbis
Beijing’s air pollution makes news headlines around the world: hazy images of people’s faces shrouded in masks and iconic monuments obscured by smog are now as synonymous with the city as the monuments themselves. As expatriate residents of Beijing, our friends and family from home often ask us: “But living in Beijing, how do you breathe?” We hope the answer is more easily after June 1, 2015, when Beijing’s new smoke-free law will take effect.1 Although Beijing’s outdoor ambient air pollution routinely makes the news, indoor air pollution in the city—and across China—is often worse than outdoor air pollution.2 One of the main causes of China’s indoor air pollution is second-hand tobacco smoke.3 At times in Beijing, the level of particulate matter with a diameter of less than 2·5 μg per m³ (PM2.5) can reach 500 μg/m³ or more. To put this into context, WHO’s guidelines on air quality recommend that mean PM2.5 exposure should not exceed 25 μg/m³ over 24 h.4 However, the smoke from just three cigarettes burning in a restaurant can result in a PM2.5 level of about 600 μg/m³ which will increase to about 1200 μg/m³ with the smoke from five cigarettes.2 The smoke from 20 or more smokers, which is not unfeasible in a crowded bar or restaurant, will result in a PM2.5 level that will be off the chart. For Beijing’s population of some 23 million residents and its many visitors, the Beijing Smoking Control Ordinance, passed by the Beijing Municipal People’s Congress in November, 2014, is set to change indoor air pollution in the city.1 Although China does not yet have a national smoke-free law, the new Beijing law is the strongest subnational tobacco control regulation adopted in the country to date, and complies with the requirements of Article 8 of the WHO Framework Convention on Tobacco Control. The Beijing Smoking Control Ordinance requires all indoor public places, including workplaces, restaurants and bars, hotels, airports, and public transport facilities, to be totally smoke-free. Many outdoor public places, such as nursery schools and some hospital campuses, will also be required to be smoke-free. In addition, the law bans tobacco advertising in mass media, public places, outdoors, and on public transport. Importantly, unlike previous attempts to make public places in
2123
Comment
Smoke-free regulations that are not actively enforced do not reduce exposure to second-hand smoke. Effective enforcement of a smoke-free law in a city the size of Beijing will be a colossal task. It will require a visible and ongoing enforcement effort, rigorous application of penalties for breach of the law, as well as substantial investment in resources for public education and awareness about the new law and the importance of protecting against exposure to secondhand smoke. Tobacco control in China is a difficult undertaking.9 In a country where the world’s biggest tobacco company, the China National Tobacco Corporation, is a powerful state-owned enterprise with a seat at the tobacco control policy table, and cigarettes have an important social currency, victories are few and far between.9 In this context, Beijing’s smoke-free law deserves to be regarded as a major step forward in the battle against the smoking dragon. And the people of Beijing should be able to breathe a little easier for that.
BS is WHO Representative in China. AP is Technical Officer for the Tobacco Free Initiative at World Health Organization China Representative Office. Bloomberg Philanthropies provides funding support to WHO to support WHO’s tobacco control work in China. We have no competing interests. © 2015. World Health Organization. Published by Elsevier Ltd/Inc/BV. All rights reserved. 1 2
3
4
5
6
7 8
9
Bernhard Schwartländer, *Angela Pratt
Beijing Municipal People’s Congress. Beijing Smoking Control Ordinance. Nov 27, 2014. Beijing: Beijing Municipal People’s Congress, 2014. Liu RL, Yang Y, Travers MJ, et al. A cross-sectional study on levels of second-hand smoke in restaurants and bars in five cities in China. Tob Control 2010; 19 (suppl 2): i24–29. Campaign for Tobacco Free Kids. Study: secondhand smoke greatest source of indoor air pollution in Beijing. Sept 28, 2012. http://www. tobaccofreekids.org/tobacco_unfiltered/post/2012_09_28_china (accessed May 21, 2015). WHO. WHO air quality guidelines for particulate matter, ozone, nitrogen dioxide and sulfur dioxide—global update 2005. Geneva: World Health Organization, 2006. Chinese Center for Disease Control and Prevention. Global Adult Tobacco Survey (GATS) China 2010 Country Report. 2010. http://www.who.int/ tobacco/surveillance/survey/gats/en_gats_china_report.pdf (accessed May 19, 2015). Wang X. Proportion of smokers has fallen, survey finds. China Daily May 21, 2015. http://usa.chinadaily.com.cn/epaper/2015-05/21/ content_20783662.htm (accessed May 21, 2015). Eriksen M, Mackay J, Schluger N, Islami F, Drope J. The tobacco atlas, fifth edition. Atlanta, GA: American Cancer Society Inc, 2015. Centers for Disease Control and Prevention. Current tobacco use and secondhand smoke exposure among women of reproductive age— 14 countries, 2008–2010. MMWR Morb Mortal Wkly Rep 2012; 61: 877–82. Yang G, Wang Y, Wu Y, Yang J, Wan X. The road to effective tobacco control in China. Lancet 2015; 385: 1019–28.
World Health Organization China Representative Office, Chaoyang District, Beijing 100600, China [email protected]
Anacetrapib in familial hypercholesterolaemia: pros and cons Published Online March 3, 2015 http://dx.doi.org/10.1016/ S0140-6736(14)62315-1 See Articles page 2153
2124
Cholesterol ester transfer protein (CETP) promotes transfer of cholesterol esters from HDL, in exchange for triglycerides from proatherogenic apolipoprotein B-containing lipoproteins. Genetic deficiency or pharmacological inhibition of CETP is associated with cholesterol enrichment of HDL and reduction of LDL cholesterol (LDL-C) concentrations. In the REALIZE study reported by John Kastelein and colleagues1 in The Lancet, the potent CETP inhibitor anacetrapib reduced LDL-C by nearly 40%, and increased HDL cholesterol (HDL-C) by more than 100%, compared with placebo, in 306 patients with heterozygous familial hypercholesterolaemia. Patients were randomly allocated in a 2:1 ratio to 52 weeks of treatment with either anacetrapib 100 mg daily, or placebo. Most patients were already receiving intensive statin treatment, and more than 70% were also receiving ezetimibe. Although the REALIZE study was
neither designed nor powered to assess cardiovascular outcomes, a concerning but statistically non-significant excess of cardiovascular events in the anacetrapib group (4 of 203 [2%] vs 0 of 102 [0%]) was seen, in addition to a higher rate of cutaneous adverse events in the treatment group as compared with the placebo group. Despite high-dose statin treatment, even in combination with other lipid-lowering drugs such as ezetimibe, most familial hypercholesterolaemia patients are unable to achieve recommended LDL-C targets. Additional treatment strategies are thus needed that not only reduce LDL-C concentrations further, but also, and more importantly, reduce cardiovascular events. Are CETP inhibitors the way to go? Several factors make anacetrapib attractive. It is an oral drug and its lipid-modifying effects are impressive. In REALIZE,1 the addition of anacetrapib 100 mg daily resulted in an absolute reduction of LDL-C of 1·2 mmol/L in www.thelancet.com Vol 385 May 30, 2015
