Public health in China: time to invest in prevention

China has the world’s largest and fastest-growing ageing population. Paired with a now record low fertility rate of 1·09, China is facing ongoing unique challenges in addressing population health. We dedicate this issue of  The Lancet Public Health to the best research from China, offering an opportunity to take stock on progress and future challenges.

Ahead of Universal Health Coverage day on Dec 12 - a day to reflect on progress towards health for all and raise awareness on the need for strong and resilient health systems-Winnie Yip and colleagues summarise the remarkable progress China has made towards universal health coverage in the past two decades. They identified improvements in reproductive, maternal, newborn, and child health, infectious diseases, and service capacity and access. For instance, the numbers of medical practitioners and health-care facility beds per 1000 people have more than doubled from 2003 to 2021. However, Yip and colleagues also identified key gaps, such as stagnation in improving risk factors for non-communicable diseases

Ka Hung Chan and colleagues summarise the status of China’s cigarette consumption, related disease burden, and tobacco control strategies in 2023. Although smoking prevalence is gradually declining in China, it remains high, with 50% of adult men currently smoking. Smoking was estimated to account for a fifth of all adult deaths in men in China in the 2010s. This disproportionate exposure to adverse health behaviours and consequences in men in China is also evident for alcohol intake. Iona Millwood and colleagues investigated the effects of alcohol consumption on mortality in the China Kadoorie Biobank cohort, in which 92% of current drinkers were men. On the basis of the positive associations observed, the authors estimate that alcohol drinking accounted for approximately 7-8% of male deaths in China. This increased risk is further supported by Jinlei Qi and colleagues’ data on estimated burden of cancerrelated death. Using data from the National Mortality Surveillance system that covers a quarter of the Chinese population, they found that the total number of cancer-related deaths had increased by 21·6% from 2005 to 2020, with 65% of cancer deaths occurring in men. The leading causes of cancer mortality were tracheal, bronchus, and lung and liver cancer-which are potentially modifiable through reducing tobacco and alcohol exposure. To improve health behaviours, Chan and colleagues recommend leveraging the power of increased taxation and stronger package warnings to encourage smoking cessation. Improving health behaviours now, especially in men, will be crucial to enable prevention.

Moreover, the ageing of the population poses new challenges. In their modelling study, Ruhai Bai and colleagues predict that China’s life expectancy could reach 81·3 years by 2035, driven by gains in survival for people aged 65 years and older. Although this increase is a win for China’s public health strategy, it indicates a further increase in the population of older people and calls for consideration of their specific health risks and needs. According to the2023 China report of the Lancet Countdown on health and climate change, 2022 was record-breaking in terms of heat and droughts and associated with a 342% increase in heat-related mortality, which is a key concern for the elderly population, who are particularly prone to temperature-associated health impacts. A larger number of people living longer will require new considerations for long-term care and support. In Zhihui Li and colleagues’ quasi-experimental study on the effect of disabilitytargeted cash transfers in 2·7 million eligible individuals with disabilities who are registered in the administrative system, participants receiving cash transfers were less likely to develop new disabilities and to report financial hardship, and more likely to use rehabilitation and medical services. These findings highlight the power of supporting those with chronic diseases to improve health trajectories in the long term.

The expected increases in longevity evidence the improvements China has made and is making in population health. While managing an ageing population that suffers from chronic disease will be a challenge to the health and social system, it is key to improve the health of younger generations now. It is time to unambiguously tackle smoking and alcohol intake as major contributors of morbidity and mortality in China and invest in a future healthy population.