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www.thelancet.com Vol 382 December 14, 2013 1959

China tackles the health eff ects of air pollutionWith fast economic growth over the past three decades, China became the world’s second largest economy in terms of gross domestic product (GDP) in 2010 and was the world’s biggest energy consumer in 2009. In 2012, China’s total energy consumption reached 2·43 billion tonnes oil equivalent, and its per-capita GDP energy consumption was 1·4 times higher than the world average. Coal is the main source of energy in China and accounts for 67% of the country’s total energy consumption; in 2012, consumption of coal reached as high as 1·63 billion tonnes oil equivalent, accounting for 50% of the world’s total coal consumption. The number of on-road civilian vehicles in China increased from 16·09 million in 2000 to 93·56 million in 2011. China’s heavy chemical and petrochemical industries have been growing robustly over the past 10 years. The country’s current cement and crude steel production capacity total 1·7 billion tonnes and more than 1 billion tonnes, respectively.

China’s extensive industrial development, substantial coal-dependent energy consumption, and increasing number of vehicles have led to a rise in emissions of air pollutants and carbon dioxide. The country now produces the largest number of major pollutants in the world, which cause serious air pollution and substantially reduced visibility. The heavy haze in January, 2013, which lasted for almost a month and aff ected a large area, led to severe pollution and was a cause for concern both at home and abroad.

Air pollution has serious direct eff ects on public health in China. The Global Burden of Disease Study 2010 found that particulate matter with an aerodynamic diameter of less than 2·5 μm (PM2·5) has become the fourth biggest threat to the health of the Chinese people.1 In addition, the death rate from lung cancer has soared since 1970, and is now the leading cause of death from malignant tumours in the country.2 The death rate from lung cancer increased to 30·84 deaths per 100 000 population in 2004–05.2 Compared with 1973–75, the death rate and age-adjusted death rate from lung cancer in 2004–05 increased by 464·8% and 261·4%, respectively.2

Studies by the World Bank, WHO, and the Chinese Academy for Environmental Planning on the eff ect of air pollution on health concluded that between 350 000 and 500 000 people die prematurely each year as a result of

outdoor air pollution in China.3–5 According to the Global Burden of Disease Study 2010, about 1·2 million people in China died prematurely and 25 million disability-adjusted life-years (DALY) were lost in 2010 as a result of air pollution.1 These fi ndings are a maximum international estimation, however, and might overestimate the health eff ects of outdoor air pollution in China. Research from the World Bank, the Chinese Academy for Environmental Planning, and Fudan University that used a revised exposure–response relation coeffi cient to long-term air pollution and real-time air monitoring data in cities produced results that better refl ect the real situation in the country.6,7

Prevention and control of environmental pollution in China is diffi cult because there are multiple pollution sources and pollutants across cities and regions, along-side the existing eff ects of regular pollution and cli-mate change. China is faced with an arduous task in addressing the challenges of environmental pollution. In a move to improve air quality, protect the climate, and reduce the health burden of air pollution, the Chinese Government is taking tough measures to prevent and control air pollution.

In 2012, the Chinese Government launched a National Plan on Air Pollution Control in Key Regions during the 12th Five-Year Plan (2011–15) that set out for the fi rst time strict targets and measures to prevent and control air pollution in 13 key regions nationwide. To further

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1960 www.thelancet.com Vol 382 December 14, 2013

Worldwide, many patients undergo percutaneous coro-nary intervention (PCI), with almost a million pro cedures in the past year in the USA alone.1 In patients with ST-segment elevation myocardial infarction (STEMI) or high-risk acute coronary syndromes, PCI reduces mortality2 and major cardiovascular events,3 as part of an invasive manage ment strategy. Clopidogrel, when added to aspirin, reduces events in patients undergoing PCI and has been the standard antiplatelet therapy for more than a decade. Recently, prasugrel (a thienopyridine) and ticagrelor (a direct-acting, non-thienopyridine

adenosine diphosphate [ADP] receptor antagonist) have been found to be more eff ective than clopidogrel.4,5 Both agents reduce non-fatal myocardial infarction and stent thrombosis, but ticagrelor is unique in that it also reduces mortality compared with clopidogrel.5

Cangrelor diff ers from all currently available ADP receptor antagonists in that it is intravenously adminis tered, produces rapid (almost immediate) platelet inhibition, and has a short biological half-life of 3–6 min, with normalisation of platelet func tion within 1 h. Similar to ticagrelor, it is a

Cangrelor: a new CHAMPION for percutaneous coronary intervention

improve air quality in cities, the Chinese Government released, in September, 2013, the fi rst National Action Plan on Air Pollution Prevention and Control (2013–17), which requires that, by 2017, particulate matter with an aerodynamic diameter of less than 10 μm (PM10) in cities at or above the prefecture level be reduced by over 10% compared with the 2012 level, and that the number of blue sky days should grow year on year. This plan also requires that annual PM2·5 in the Beijing-Tianjin-Hebei Area, Yangtze River Delta, and Pearl River Delta should be reduced by over 25%, 20%, and 15%, respectively, by 2017 compared with 2012, and that the annual PM2·5 in Beijing should be controlled at 60 μg/m³ in 2017. Setting out the principle of breathing the same air and working hard together, the National Action Plan requires that US$277·5 billion be invested over the next 5 years in the prevention and control of air pollution. The National Health and Family Planning Commission of the People’s Republic of China initiated the development of an air pollution and health eff ects monitoring system in October, 2013.

These tough measures should lead to an improvement in China’s air quality and remarkable public health benefi ts. According to research results from the Chinese Academy for Environmental Planning, 200 000 people will be prevented from dying prematurely each year if the annual level of PM10 in Chinese cities reaches the fi rst level standard of 40 μg/m³, as set out in the newly revised China National Ambient Air Quality Standards.8 In the course of implementing a range of plans, laws,

regulations, and policies, China will prioritise public health improvement, strengthen analyses of health eff ects, and make policy for environmental and health intervention more targeted and eff ective.

Zhu Chen, *Jin-Nan Wang, Guo-Xia Ma, Yan-Shen ZhangChinese Medical Association and Chinese Academy of Sciences, Beijing, China (ZC); Chinese Academy for Environmental Planning, Chaoyang District, Beijing 100012, China (J-NW); and Center for Environmental Risk and Damage Assessment, Chinese Academy for Environmental Planning, Beijing, China (G-XM, Y-SZ)wangjn@caep.org.cn

We declare that we have no confl icts of interest. ZC is President of the Chinese Medical Association and Academician of the Chinese Academy of Sciences, Beijing, China; J-NW is Vice President and Professor of the Chinese Academy for Environmental Planning, Beijing, China. The authors alone are responsible for the views expressed in this publication, and they do not necessarily represent the views or policies of the Chinese Government.

1 Yang GH, Wang Y, Zeng YX, et al. Rapid health transition in China, 1990–2010: fi ndings from the Global Burden of Disease Study 2010. Lancet 2013; 381: 1987–2015.

2 National Offi ce for Cancer Prevention and Control, National Center for Cancer Registries, Bureau of Disease Prevention and Control, Ministry of Health. Cancer death report in China: the third national retrospective sampling death survey. Beijing: People’s Medical Publishing House, 2008.

3 The World Bank. Cost of pollution in China: economic estimates of physical damages. Washington, DC: The World Bank, 2007.

4 WHO. Country profi le of environmental burden of disease: China. 2009. http://www.who.int/entity/quantifying_ehimpacts/national/countryprofi le/china.pdf (accessed Sept 1, 2013).

5 Yu F, Ma GX, Qi J, Wang JN. Report of China’s environmental-economic accounting in 2007–2008. Beijing: China Environmental Science Press, 2012.

6 Yu F, Ma GX, Zhang YS, Cao D, Gao F, Wang JN. Several issues on health impact assessment of air pollution in China. Nat Med J China 2013; 93: 2695–98.

7 Chen RJ, Chen BH, Kan HD. A health-based economic assessment of particulate air pollution in 113 Chinese cities. China Environ Sci 2010; 30: 410–15.

8 Wang JN, Ma GX, Yu F, et al. An evaluation of potential health benefi ts by PM10 of the new ambient air quality standard for China. Chinese Environ Policy 2012; 8: 1–26.

Published OnlineSeptember 3, 2013

http://dx.doi.org/10.1016/S0140-6736(13)61840-1

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