China, with 20% of the world’s population, produces and consumes about 30% of the world’s cigarettes, and already suffers about a million deaths a year from tobacco. This is more than in any other country, and the hazards are expected to increase substantially during the next few decades, over and above the effects of demographic changes, as a delayed effect of the large increase in cigarette use between the 1950s and 1990s and of a further sharp increase in cigarette consumption since 1999.
In developed countries cigarette smoking became popular during the first half of the twentieth century, but the main increase in tobacco deaths was not seen until several decades later, during the second half of the century. In the US, mean cigarette consumption per adult in 1910, 1930 and 1950 was 1, 4 and 10 a day, respectively, after which it remained fairly constant for a few decades. As a delayed result of this increase in cigarette smoking, the proportion of all US deaths at ages 35–69 attributed to tobacco rose over the next few decades from ‘‘only’’ about 12% in 1950 to 33% in 1990.
In Chinese men, the pattern of increase in cigarette smoking that had been seen between 1910 and 1950 in the US was repeated 40 years later between 1952 and 1992. In most parts of China women now smoke far less than men. Mean cigarette consumption per Chinese man in 1952, 1972 and 1992 was 1, 4 and 10 per day, respectively, after which it leveled off for a few years, then continued to rise. Nationwide retrospective and prospective studies in China indicate that by 1990 tobacco already caused about 12% of all male deaths at ages 35–69, and by 2030 it will probably cause about one third of them, unless there is widespread cessation among those who already smoke. Although the overall hazard per cigarette smoker may be about the same in China as elsewhere, the chief diseases by which tobacco caused death in the 1990s were very different in China, with about half of the tobacco deaths involving emphysema rather than cardiovascular disease. The patterns of tobacco death also differed between one region and another, and may change substantially over time as a result of changes in diet and other factors. Large prospective epidemiological studies are now in place to monitor the evolution of the growing tobacco epidemic in China and elsewhere over the next few decades.