Objective To assess excess all cause and cause specific mortality during the three months (1 January to 31 March 2020) of the coronavirus disease 2019 (covid-19) outbreak in Wuhan city and other parts of China. Design Nationwide mortality registries. Setting 605 urban districts and rural counties in China’s nationally representative Disease Surveillance Point (DSP) system. Participants More than 300 million people of all ages. Main outcome measures Observed overall and weekly mortality rates from all cause and cause specific diseases for three months (1 January to 31 March 2020) of the covid-19 outbreak compared with the predicted (or mean rates for 2015-19) in different areas to yield rate ratio. Results The DSP system recorded 580 819 deaths from January to March 2020. In Wuhan DSP districts (n=3), the observed total mortality rate was 56% (rate ratio 1.56, 95% confidence interval 1.33 to 1.87) higher than the predicted rate (1147 v 735 per 100 000), chiefly as a result of an eightfold increase in deaths from pneumonia (n=1682; 275 v 33 per 100 000; 8.32, 5.19 to 17.02), mainly covid-19 related, but a more modest increase in deaths from certain other diseases, including cardiovascular disease (n=2347; 408 v 316 per 100 000; 1.29, 1.05 to 1.65) and diabetes (n=262; 46 v 25 per 100 000; 1.83, 1.08 to 4.37). In Wuhan city (n=13 districts), 5954 additional (4573 pneumonia) deaths occurred in 2020 compared with 2019, with excess risks greater in central than in suburban districts (50% v 15%). In other parts of Hubei province (n=19 DSP areas), the observed mortality rates from pneumonia and chronic respiratory diseases were non-significantly 28% and 23% lower than the predicted rates, despite excess deaths from covid-19 related pneumonia. Outside Hubei (n=583 DSP areas), the observed total mortality rate was non-significantly lower than the predicted rate (675 v 715 per 100 000), with significantly lower death rates from pneumonia (0.53, 0.46 to 0.63), chronic respiratory diseases (0.82, 0.71 to 0.96), and road traffic incidents (0.77, 0.68 to 0.88). Conclusions Except in Wuhan, no increase in overall mortality was found during the three months of the covid-19 outbreak in other parts of China. The lower death rates from certain non-covid-19 related diseases might be attributable to the associated behaviour changes during lockdown.

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Background The use of e-cigarettes among adults is increasing globally. Since 2018, policies in China have restricted e-cigarette use; however, little information is available on the national trend in e-cigarette use before regulations were implemented. Therefore, we sought to estimate the trend in e-cigarette use in China before policy implementation and explored associated factors. MethodsWe assessed two nationally representative cross-sectional datasets from the China Chronic Disease and Nutrition Surveillance (CCDNS) surveys initiated in 2015 (June, 2015, to May, 2016) and 2018 (August, 2018, to June, 2019). The surveys were done at 298 national disease surveillance points in 31 provinces in mainland China, and used a multistage, stratified, cluster-randomised sampling design, recruiting community-based Chinese adults aged 18 years and older. Within the standard CCDNS survey, face-to-face questionnaire interviews were used to collect selfreport data on e-cigarette use in the preceding 30 days. E-cigarette users were those who self-reported e-cigarette use on 1 day or more in the past 30 days. Prevalence estimates of past 30-day e-cigarette use were weighted to represent the Chinese adult population accounting for the complex sampling design. Populations for the years 2015-16 and 2018-19 were standardised with the 2010 population census to gain comparable estimates. Multivariable logistic regression models adjusted for age, sex, urban or rural residence, household income, occupation, and education level were applied to identify factors associated with the likelihood of e-cigarette use among the total population, ever smokers (current and former), and never smokers across both surveys. Findings Our study included 189 306 Chinese adults from the 2015 survey (100 405 [53•0%] women; mean age 43•6 years [SD 14•6]) and 184 475 Chinese adults from the 2018 survey (102 373 [55•5%] women; mean age 43•4 years [13•9]). The weighted prevalence of past 30-day e-cigarette use among Chinese adults increased from 1•3% (95% CI 1•1-1•5%) in 2015-16 to 1•6% (95% CI 1•4-1•8%) in 2018-19 (an increase of 0•3% [95% CI 0•1-0•6]; Rao-Scott χ² p=0•0086). Based on weighted proportion data, e-cigarette users were predominantly men (97•4% [95% CI 96•7-98•1] in 2015-16 and 97•0% [95•4-98•6] in 2018-19) and current conventional smokers (93•0% [90•7-95•2] in 2015-16 and 96•2% [95•1-97•3] in 2018-19). Across both surveys, the odds of e-cigarette use were significantly associated with obesity (odds ratio 1•6 [95% CI 1•3-2•1]; p=0•0007), awareness of smoking hazards (1•2 [1•0-1•4]; p=0•022), and smoking status (in current smokers, 135•2 [87•7-208•6]; and in former smokers, 33•5 [21•3-52•7]; p<0•0001). Among current smokers, the odds were increased with daily cigarette consumption (2•1 [1•5-2•8]; p<0•0001), smoking more than 20 cigarettes per day (1•8 [1•5-2•3]; p<0•0001), and an attempt to quit smoking (within the past 12 months, 1•9 [1•5-2•4]; and before the past 12 months, 1•5 [1•3-1•9]; p<0•0001). In never smokers, the odds were increased in...

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