| Objectives:The aim of this study was to compare and analyze the prevalence of tobacco exposure(including active smoking and secondhand smoking exposure)and five smoking related chronic diseases(hypertension,coronary heart disease,stroke,chronic obstructive pulmonary disease and asthma)among three ethnic groups(Han,Naxi and Bai)in Yunnan Province,measure the burden of five smoking related chronic diseases and the population attributable risk(PAR)of chronic diseases attributed to tobacco exposure and to analyze the harm of tobacco exposure and five kinds of smoking related chronic diseases on the health of the population in rural and ethnic minority areas of Yunnan Province,and its impacts on family and social economy.Some suggestions for improving the management and control of chronic diseases were put forward.Methods:This study employed a cross-sectional survey design.7534 Han,Bai and Naxi villagers aged 35 and above were selected from three counties of Yunnan Province for on-site questionnaire survey and physical examination.Through face-to-face questionnaire survey,the basic demographic information,family economic status(family population,annual total family income,annual total expenditure,annual food expenditure,etc.),active smoking(hereinafter referred to as smoking)and secondhand smoking(SHS)exposure behavior(age of first smoking and regular smoking,type of smoking,smoking mode,smoking quantity,nicotine dependence,willingness to quit smoking,smoking and SHS exposure places,etc),life and behavior,the prevalence of five kinds of smoking related chronic diseases,and family history,medical expenses incurred due to chronic diseases(hospitalization expenses,outpatient expenses,drug expenses,transportation expenses,nutrition expenses,accommodation expenses,and lost work expenses,etc.)incurred by patients and caregivers for seeing a doctor.The height,weight,waist circumference,hip circumference,blood pressure and lung function were measured by physical examination.Disability adjusted life year(DALY)was used to measure the burden of five kinds of smoking related chronic diseases;the family catastrophic health expenditure and poverty due to illness were used to evaluate the impact of five kinds of smoking related chronic diseases on family economy;the direct economic burden of five kinds of chronic diseases was calculated by two-step model method,and the human capital method combined with DALY method was used to measure the indirect economic burden of five chronic diseases,combined with PAR,the social and economic burden of five chronic diseases attributed to tobacco exposure was calculated.Multivariate logistic regression was used to analyze the relationship between tobacco exposure and five chronic diseases,as well as the influencing factors of catastrophic health expenditure and poverty due to illness.Results1.A total of 7830 questionnaires were distributed and 7534 valid questionnaires were obtained,with an response rate of 96.2%,including 2502 Han people(33.2%),2531 Naxi people(33.6%)and 2501 Bai people(33.2%).The overall prevalence of smoking,current smoking,nicotine dependence and SHS exposure among current smokers were 38.9%,30.4%,37.5%and 30.3%,respectively;the prevalence rates of smoking among Han nationality,Naxi ethnic minority and Bai ethnic minority were 37.3%,40.6%and 38.7%,respectively,of which males was 74.8%,78.2%and 81.2%,and females was 1.8%,4.1%and 2.8%,respectively;The prevalence of current smoking was 28.5%,32.2%and 30.5%respectively,of which 57.9%,63.2%and 65.3%for men and 0.8%,2.2%and 1.0%for women;the prevalence of nicotine dependence of current smokers was 35.0%,42.3%and 34.8%,respectively,of which men were 35.1%,42.5%and 34.9%,and women were 30.0%,36.7%and 28.6%;prevalence of SHS exposure was 22.5%,38.4%and 30.3%,respectively,of which males was 18.4%,30.1%and 25.9%,and that of females was 24.2%,41.4%and 31.7%,respectively.Prevalence of both smoking and current smoking of males were significantly higher than that of females(Chi-square test,P<0.01),while prevalence of SHS exposure of females was higher than that of males(Chi-square test,P<0.01);prevalence of smoking and current smoking among people with educational level of primary school and above were higher than those of illiterate people(P<0.01 by Chi-square test).Prevalence of SHS exposure among people with poor access to medical services was higher than those with good access to medical services(Chi-square test t,P<0.05).Among the three ethnic groups,prevalence of smoking,current smoking and SHS exposure among Naxi ethnic minority were the highest,and those of Han nationality were the lowest(Chi-square test,P<0.05),whereas prevalence of nicotine dependence of current smokersamong Naxi nationality was the highest,and that of Bai ethnic minority was the lowest(Chi-square test,P<0.05).2.The results showed that the current epidemic situation of smoking SHS exposure behaviors in three ethnic groups in the survey areas were as follows:Naxi people's daily smoking amount(21±13 cigarettes)and monthly smoking expenditure(403±439 yuan)were the highest,while the Han nationality were the lowest(17±11 cigarettes and 293±226 yuan,rank sum test,P<0.01).Age of initiating smoking among Naxi nationality was the lowest(19±6 years),and that of Han nationality was the highest(21±5 years old,P<0.01);.Age of regular smoking was the lowest in Naxi nationality(20±6 years),and the highest in Bai nationality(24±10 years,analysis of variance P<0.01).The most popular form of smoking tobacco in the three ethnic groups was filter cigarettes(>77%),while prevalence of female smokers in Naxi ethnic minority(28.6%)was significantly higher than that of Han and Bai nationality(P<0.01).The highest proportion of smoking reasons was a craving for tobacco(>50%),and the highest proportion of smoking cessation reasons was suffering from illness(>30%);The proportion of Naxi people who smoked in public places and never tried to quit smoking(52.3%and 77.7%)was the highest,while that of Han nationality was the lowest(32.6%and 68.2%,P<0.01).Naxi people had the highest proportion of exposure to SHS places in public places,and the proportion of persons who did not care about smoking was the highest(Chi-square test,P<0.01),while the proportion of Han smokers smoking in front of children and pregnant women was the highest in the past week(Chi-square test,P<0.05).3.The prevalence of 5 kinds of smoking related chronic diseases in three ethnic groups in the survey area was compared.The overall prevalence rates of hypertension,coronary heart disease(CHD),stroke,chronic obstructive pulmonary disease(COPD)and asthma were 41.1%,2.6%,4.1%,14.1%and 1.3%,respectively.Among them,the prevalence rates of Han nationality were 45.2%,2.5%,4.2%,11.5%and 0.8%,respectively;those of Naxi ethnic minority were 38.0%,2.9%,1.8%,17.7%and 1.7%,respectively;those of Bai ethnic minority were 40.2%,2.3%,6.2%,13.2%and 1.4%,respectively.Prevalence of COPD and stroke was significantly higher in men than in women(Chi-square test,P<0.01)in these three nationalities.Prevalence of COPD and stroke was significantly higher in men than in women(Chi-square test,P<0.01).Prevalence of hypertension in Han nationality was higher than that in Naxi and Bai nationality(P<0.01 by chi-square test),and incidence of stroke in Bai nationality was significantly higher than that in Han nationality and Naxi nationality(P<0.01 by chi-square test),and COPD in Naxi nationality was significantly higher than that in Han and Bai nationality(P<0.01).Tthere was no significant difference in the prevalence of CHD among the three nationalities(chi-square test,P<0.01).4.Burden of 5 kinds of smoking related chronic diseases among three nationalities in the survey area was compared:the DALY per 1000 population of hypertension,CHD,stroke,COPD and asthma were 1.23,21.65,27.94,54.37 and 0.95 in Han nationality,3.34,26.43,29.39,85.93 and 1.42 in Naxi nationality,and 1.00,19.71,27.79,59.44 and 1.15 in Bai nationality,respectively.The DALY per thousand population rate of male patients with CHD,stroke and COPD was higher than that of women.The DALY per thousand population rate of hypertension,CHD,stroke and COPD was the highest in Naxi nationality and the lowest in Bai nationality,whereas the burden of asthma was the highest in Bai nationality and the lowest in Han nationality.5.Multivariate logistic regression analysis showed that the risk of suffering from hypertension,CHD,stroke,COPD and asthma among smokers in the survey area was 1.50 times,7.82 times,4.31 times,2.24 times and 3.95 times higher than those of non-smoking people respectively,and the risk of suffering from hypertension,CHD,stroke,COPD and asthma in persons exposed to SHS were 1.42,8.71,3.10,2.31 and 3.08 times higher than those of non-exposure to SHS persons,respectively.If smoking and exposure to SHS were eliminated,prevalence of hypertension,CHD,stroke,COPD and asthma would decrease by 16.20%,72.61%,56.29%,32.5%,53.44%and 11.29%,70.01%,38.85%,28.4%and 38.66%respectively.The prevalence of five smoking related chronic diseases in men was significantly higher than that in exposure to SHS,and prevalenceof five smoking related chronic diseases attributed to SHS exposure was significantly higher than that of smoking in women.6.Among 5812 families surveyed,the incidence of catastrophic health expenditure caused by hypertension,CHD,stroke,COPD and asthma before reimbursement of medical insurance was 14.93%,28.04%,27.21%,14.45%and 24.21%,respectively,and the incidence of poverty due to illness was 18.82%,26.98%,24.26%,17.28%and 17.89%,respectively.The incidence of catastrophic health expenditure after reimbursement of medical insurance was 13.42%,24.34%,24.26%,11.73%and 18.95%respectively,and the incidence of poverty due to illness was 5.44%,10.05%,11.80%,5.86%and 8.42%,respectively.The incidence rates of catastrophic health expenditure caused by five kinds of chronic diseases in three nationalities were 13.81%,21.67%,32.08%,12.68%and 14.29%for Han,18.26%,37.5%,22.73%,13.49%and 22.50%for Naxi,and 14.10%,22.81%,25.16%,17.63%and 32.35%for Bai,respectively;The incidence of disease-related poverty was 19.00%,26.67%,33.96%,18.31%and 14.29%in Han nationality,27.81%,33.33%,20.45%,18.58%and 20.00%in Naxi nationality,and 13.25%,19.30%,18.71%,15.11%and 17.65%in Bai nationality,respectively.Among them,the incidence of family disease-related poverty was the highest in Han nationality patients with stroke(33.96%)and the lowest in Han nationality patients with asthma(14.29%);the incidence of family disease-related poverty was the highest in Naxi nationality patients with coronary heart disease(33.33%),and the lowest in Naxi nationality patients with COPD was the lowest(18.58%);the incidence of poverty caused by disease in Bai nationality patients with CHD was the highest(19.30%)and hypertension was the lowest(13.25%).In the three ethnic groups,the incidence of disease-related poverty in the families of Naxi people with hypertension was higher than that of Han and Bai families with hypertension(chi square test,P<0.05).Incidence of poverty caused by illness in families of Han nationality patients with stroke was higher than that of the Naxi and Bai families with stroke(chi-square test,P<0.05).Multivariate logistic regression analysis showed that suffering from hypertension,CHD,stroke,COPD and asthma were risk factors of catastrophic health expenditure,while high annual per capita income was the protective factor of catastrophic health expenditure.Poor households,hypertension,coronary heart disease and stroke were risk factors of disease-related poverty,while annual per capita income of family was the risk factor of catastrophic health expenditure,high annual per-capita household income and good access to medical services were protective factors for poverty caused by illness.7.The per capita economic burden of hypertension,CHD,stroke,COPD and asthma were 3422.2 yuan,11377.4 yuan,10592.4 yuan,10548.3 yuan and 5580.9 yuan respectively,of which the per capita direct economic burden was 3295.4 yuan,9902.3 yuan,8688.3 yuan,5672.7 yuan and 5499,7 yuan,and the per capita indirect economic burden was 126.8 yuan,1475.1 yuan,1904.1 yuan,respectively 6 yuan and 81.2 yuan.The total economic burden of disease was 788.3 million yuan,49.8 million yuan,78.6 million yuan,270.4 million yuan and 24.9 million yuan respectively.The direct disease economic burden and per capita total disease economic burden of coronary heart disease were the highest,followed by stroke,and hypertension;however,the per capita indirect disease economic burden was the highest in chronic obstructive pulmonary disease,followed by stroke and asthma was the lowest.Among coronary heart disease,stroke,chronic obstructive pulmonary disease and asthma,the largest proportion of the direct diseases economic burden was the hospitalization expenses,while the proportion of outpatient expenses was the largest in hypertension.8.The results of the study on the social and economic effects of tobacco exposure on the investigated areas showed that:the social and economic burden of hypertension,coronary heart disease,stroke,chronic obstructive pulmonary disease and asthma attributed to smoking were 127.7 million yuan,44.2 million yuan,87.9 million yuan,13.3 million yuan and 36.2 million yuan,respectively,and the social and economic burden attributed to exposure to SHS was 89.0 million yuan,30.5 million yuan,76.8 million yuan,9.6 million yuan and 34.9 million yuan respectively.The social and economic burden of hypertension attributed to smoking and exposure to SHS was the largest,while chronic obstructive pulmonary disease was the lowest.For the five chronic diseases,smoking contributes more socioeconomic burden of illness than exposure to SHS in men,whereas exposure to SHS contributes more socioeconomic burden of illness than smoking in women.Conclusions1.The overall prevalence of smoking of the population in the surveyed areas was higher than the national average level,and the nicotine dependence rate among current smokers was also at a high level,but the willingness to quit smoking was significantly lower than the national level.There were gender and ethnic differences in prevalence of smoking and exposure to SHS smoking among the investigated population,and men had significantly higher prevalence of smoking than that of women.Women were more likely to suffer from exposure to SHS than men,and ethnic minorities had higher prevalence of both smoking and exposure to SHS than Han nationality,particularly in the Naxi people.2.There were obvious ethnic differences in smoking habits,the use of smoking utensils,smoking behaviors,smoking knowledge and attitude among different ethnic groups in the surveyed areas.Among them,Naxi villagers are particularly weak in tobacco control awareness and related knowledge,which should be paid attention to.In the future,the formulation of tobacco control policies should take into account the ethnic heterogeneity such as different customs and habits,so as to take targeted health education and tobacco control measures.3.The prevalence and burden of five kinds of smoking related chronic diseases were significantly different among different nationalities.The prevalence of hypertension in Han nationality was the highest,which was higher than the national level.The DALY per thousand population rates of hypertension,CHD,stroke and COPD of Naxi nationality were the highest,while that of asthma was the highest in Bai nationality.The harm of five kinds of smoking related chronic diseases on the health of ethnic minorities can not be ignored.4.The incidence of catastrophic health expenditure and disease-related poverty of five kinds of smoking related chronic diseases in the surveyed areas was significantly higher than that of the general level in China.The incidence of catastrophic health expenditure and disease-related poverty in families with five kinds of smoking related chronic diseases was significantly higher than that of non sick families,which brought heavy economic burden of disease to family.To a certain extent,the new rural cooperative medical care system can reduce the catastrophic health expenditure of families and the incidence of poverty caused by illness,which has a positive effect on reducing the economic burden of disease of local residents.5.Smoking and exposure to SHS significantly increased the prevalence of hypertension,coronary heart disease,stroke,chronic obstructive pulmonary disease and asthma in the survey population,which not only caused harm to the health of residents,but also consumed a lot of medical resources,resulting in a huge social and economic burden.In addition,among the five chronic diseases,smoking contributes more socioeconomic burden of illness than exposure to SHS in men,whereas exposure to SHS contributes more socioeconomic burden of illness than smoking in women.Strengthening health education on the hazards of smoking and passive smoking among local villagers will help to reduce prevalence of five kinds of smoking related chronic diseases,and also reduce the social and economic burden of these diseases. |
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