Economic evaluation of population‐level dementia prevention strategies in China: informing policy and public health action

Abstract

INTRODUCTION

While it has been postulated that population‐based strategies targeting modifiable dementia risk factors are cost effective in high‐income settings, their health and economic impact in China remains unclear.

METHODS

A Markov model evaluated five interventions: salt substitution, smoke‐free legislation, increased tobacco tax, sugar‐sweetened beverage tax, and alcohol tax. Outcomes included dementia cases, deaths averted, life years gained, and lifetime cost‐savings, assessed from a societal perspective over an infinite time horizon. Subgroup and sensitivity analyses were performed.

RESULTS

All interventions were assessed to be cost‐saving. Salt substitution was modeled to have the greatest impact, resulting in 1,940,000 quality‐adjusted life years gained and lifetime cost savings of US$65 to US$70 billion. Smoke‐free policies and tobacco taxes also showed significant benefits. Beverage and alcohol taxes had smaller but meaningful effects. Males generally benefited more.

DISCUSSION

We estimated that population‐level interventions would reduce costs in China, with the largest gains from targeting hypertension and smoking. Prioritizing such strategies may generate substantial health gains while reducing long‐term societal costs.

Highlights

• This study evaluated five population‐level interventions targeting modifiable dementia risk factors in China using a lifetime Markov model.

• Salt substitution produced the greatest health and economic benefits, followed by smoke‐free legislation and tobacco taxation.

• Fiscal policies on sugar‐sweetened beverages and alcohol showed smaller but meaningful impacts.

• Population‐level prevention strategies, particularly targeting hypertension and smoking, offer substantial potential to reduce dementia burden in China.

1. BACKGROUND

Dementia is an acquired decline in cognition involving one or more cognitive domains (e.g., learning and memory, language), accompanied by functional decline. ¹ As the population ages, the overall burden of dementia is increasing worldwide. China had 190.64 million people aged 65 and above in 2020, ² accounting for 13.5% of the total population, an increase of 4.6 percentage points compared with 2010. With this aging trend, the incidence, prevalence, and mortality of dementia are rising, leading to a growing socioeconomic burden and making dementia a major health and societal challenge in China. Between 2019 and 2021, the number of cases of Alzheimer's disease and related dementias (ADRD) in China rose from 14.54 to 16.99 million, while ADRD‐related deaths increased from 429,606 to 491,774, highlighting the rapid escalation of the disease burden. ³

Despite decades of research, no curative or disease‐modifying treatments for dementia exist. Only four cholinesterase inhibitors and memantine are approved worldwide, providing modest symptomatic relief without altering disease progression. ⁴ Consequently, preventing or delaying onset through modification of key risk factors has become the most promising and potentially cost‐effective public health strategy to mitigate the growing burden of dementia. The 2024 update of the Lancet Commission on dementia prevention, intervention, and care estimated that up to 45% of dementia cases could be prevented or delayed by addressing 14 modifiable risk factors across the life course, including less education, hearing loss, traumatic brain injury, hypertension, excessive alcohol use, obesity, smoking, depression, social isolation, physical inactivity, air pollution, diabetes, vision loss, and high cholesterol. ⁵ Beyond identifying risks, the commission underscored actionable strategies for dementia prevention, such as controlling midlife blood pressure, promoting hearing aid use, limiting alcohol intake, reducing exposure to tobacco smoke and air pollution, and supporting smoking cessation. This framework highlights the potential for both policy and individual‐level interventions to substantially mitigate dementia risk through sustained prevention efforts.

Previous economic evaluations indicated that certain individual‐level interventions, such as smoking cessation, hearing aid provision, and hypertension treatment, could be cost‐effective. ⁶ However, these approaches rely heavily on individual motivation and resource availability, which may limit their reach and potentially widen health disparities. In contrast, population‐level strategies, which act on broader social and environmental determinants, offer the potential for more equitable and scalable impact. A recent modeling study in England suggested that such approaches, particularly those targeting smoking, alcohol, and food reformulation to address obesity and hypertension, could reduce costs. ⁷

Although evidence from high‐income countries has demonstrated the potential feasibility and economic value of population‐level dementia prevention strategies, no comparable evaluations have been undertaken in China. This gap is particularly concerning given China's rapidly aging population, its substantial dementia burden, and the escalating health and economic costs associated with the disease. Assessing the cost‐effectiveness of population‐based interventions in this context is therefore urgent, both to guide national policy and to contribute to the broader global agenda on equitable and sustainable dementia prevention.

Taken together, we conducted an economic evaluation using a Markov model to assess population‐level interventions targeting major modifiable dementia risk factors in China. Specific objectives were to estimate (1) the potential reductions in dementia cases and (2) the corresponding cost savings from a societal perspective under each intervention scenario.

2. METHODS

2.1. Risk factors and interventions

RESEARCH IN CONTEXT

1. Systematic review: A PubMed search (to April 24, 2026) identified 19 studies; only two modeled dementia prevention in China, and none conducted economic evaluation of population‐level interventions.

2. Interpretation: This is the first study estimating cost‐effectiveness of such strategies in China. All five interventions reduced costs, with salt substitution yielding the greatest benefits, followed by tobacco control measures.

3. Future directions: Population‐level prevention – especially targeting hypertension and smoking – offers an effective, equitable approach. Integrating dementia outcomes into economic evaluations can support evidence‐based policy and broader healthy aging strategies in China and similar settings.

In this economic modeling study, the risk factors considered included tobacco smoking, excessive alcohol consumption, hypertension, and obesity. We focused on interventions identified in a previously published article restricting our analysis to those not yet implemented in China or existing measures that could be further scaled (e.g., smoke‐free legislation). ⁸ As described in the statistical analysis plan (Supplementary Method 1), the interventions assessed were (1) promotion of salt substitution strategies to reduce sodium intake through partial replacement with potassium salt (salt substitution strategies) ⁹ ; (2) implementation of comprehensive smoke‐free legislation covering all indoor public places, workplaces, and public transport (smoke‐free legislation) ¹⁰ ; (3) an increase in tobacco excise tax from 11.0% to 24.2% ¹¹ ; (4) a sugar‐sweetened beverage tax set at 10% of the retail price (taxation of sugar‐sweetened beverages) ¹² ; and (5) a 10% increase in alcohol taxation (increases in alcohol taxation). ¹³ These are all interventions assessed in China for their impact on the relevant risk factors. Relative risks (RRs) and prevalence estimates for hypertension, smoking, obesity, and excessive alcohol use were obtained from published evidence syntheses and nationally representative survey data. Intervention effects were derived from previously published studies evaluating the impact of population‐level policies on the corresponding risk factors. Specifically, the salt substitution strategy was modeled through its effect on blood pressure and subsequent hypertension prevalence, smoke‐free legislation and tobacco taxation were modeled through their effects on smoking prevalence and tobacco consumption, taxation of sugar‐sweetened beverages was modeled through its effect on obesity prevalence, and alcohol taxation was modeled through its effect on alcohol consumption. For interventions affecting consumption rather than prevalence directly, reductions in exposure prevalence were estimated using published assumptions and elasticity‐based approaches. Detailed parameter values, data sources, and modeling assumptions are provided in Tables 1 and 2 and Supplementary Method 2.

TABLE 1.

Risk factor prevalences, relative risks, and mortality.

Measure	Hypertension	Smoking	Obesity	Alcohol use
Relative risk of dementia for risk factor	1.2	1.3	1.3	1.2
Prevalence of risk factor in key age group, %	33.9	23.4	14.4	13.0
Risk of dementia relative to population mean
With the risk factor	1.12	1.21	1.25	1.17
Without the risk factor	0.94	0.93	0.96	0.97
Benefits per person with risk factor removed
Life years gained	0.01617	0.02392	0.02436	0.01664
Life years without dementia gained	0.10229	0.15161	0.15459	0.10548
Life years with dementia gained	−0.08612	−0.12769	−0.13023	−0.08883
Quality‐adjusted life years gained	0.05062	0.07500	0.07646	0.05218
Cost savings (US$)	1713.84	2541.04	2591.56	1767.81

TABLE 2.

Policy interventions and their estimated effectiveness.

Measure	Salt substitution	Smoke‐free legislation	Increases in tobacco taxation	Taxation of sugar‐sweetened beverages	Increases in alcohol taxation
Reduction in prevalence of risk factor, %	22.3	8.4	4.6	4.4	2.3
People aged 45 years shedding risk, n	1,724,974	449,617	243,542	145,148	68,201
Total lifetime benefits in age cohort
Life years gained	27,893	10,756	5826	3536	1135
Life years without dementia gained	176,451	68,167	36,924	22,439	7194
Life years with dementia gained	−148,557	−57,411	−31,098	−18,902	−6059
Quality‐adjusted life years gained	87,316	33,720	18,265	11,097	3559
Cost savings (US$ million)	2956.33	1142.49	618.85	376.16	120.57
Benefits summed over indefinite succession of age cohort
Life years gained	619,854	239,022	129,470	78,587	25,226
Life years without dementia gained	3,921,127	1,514,821	820,528	498,636	159,861
Life years with dementia gained	−3,301,273	−1,275,799	−691,058	−420,050	−134,635
Quality‐adjusted life years gained	1,940,363	749,342	405,894	246,607	79,080
Cost savings (US$ million)	65,696.13	25,388.71	13,752.22	8359.09	2679.27

2.2. Markov model

We constructed a state‐transition Markov model to evaluate the effectiveness and cost‐effectiveness of each intervention in preventing dementia. The model comprised three mutually exclusive health states: (1) healthy (without dementia), (2) dementia, and (3) death (Figure 1). Individuals could transition between states on an annual cycle, reflecting the natural history of dementia and age‐specific mortality.

FIGURE 1.

Conceptual framework of the model.

The model simulated a closed cohort of the adult Chinese population at risk of developing dementia and followed them over their remaining lifetime. Age‐specific incidence rates determined the probability of transition from healthy to dementia. Mortality was incorporated through both all‐cause age‐specific death rates and excess mortality associated with dementia.

For each intervention scenario, the model adjusted incidence probabilities based on RRs associated with reductions in exposure to the targeted risk factors (e.g., smoking or hypertension). Intervention effects were assumed to persist throughout the life course unless otherwise indicated by the published evidence. For each intervention, we estimated health outcomes and year‐by‐year dementia‐related costs for individuals with and without the risk factors and then aggregated these outcomes across the lifetime horizon.

2.3. Model parameters

We used China as our setting, applying risk effects to the appropriate adult Chinese population, based on good pre‐existing data on risk factor prevalence in this setting. The key inputs of the Markov model, including demographic parameters, epidemiological parameters, parameters related to the risk factors and interventions, and costs parameters, were all from published sources.

Demographic parameters included age‐specific population numbers and deaths from the China Population Census Yearbook 2020. ² Epidemiological parameters comprised age‐specific incidences, prevalences, and mortalities of dementia, which were derived from the 2021Global Burden of Disease study. ³ We used prevalence calculated based on the 2020 wave data of the China Health And Retirement Longitudinal Study (CHARLS) ¹⁴ and previously published RRs ⁵ of modifiable risk factors on dementia, to derive RRs relative to the general population for each risk factor. Risk factor prevalences were used for the time of life to which the risk applies, for example, as hypertension is considered to be a risk factor for dementia in midlife (age 45 to 64 years), prevalence is given for all people with hypertension in midlife. We treated risk factors as binary (i.e., a person either has the risk factor or does not). Based on pooled evidence in the Lancet Commission on dementia prevention, ⁵ hypertension, smoking, obesity, and alcohol use were associated with increased risk of dementia, with relative risks ranging from 1.2 to 1.3. The corresponding prevalence of these risk factors in midlife (aged 45 to 64 years) was 33.9% for hypertension, 23.4% for smoking, 14.4% for obesity, and 13.0% for alcohol use. ¹⁴ We assumed intervention effects would apply equally to everyone and would continue to maintain their effectiveness throughout the life course. For each intervention, we applied published effect sizes to estimate the proportion of individuals with the relevant risk factor who would benefit. Evidence was identified through PubMed searches combining terms for each risk factor and potential interventions, and only studies reporting effect estimates for risk‐factor reduction were included. In all cases, the comparator was the current situation in China. Health utility parameters were derived from a previous modeling study of dementia in China. Consistent with published estimates, dementia was assumed to be associated with a utility decrement of 0.40 compared with the age‐specific general population. ¹⁵ Cost parameters considered direct medical costs, direct non‐medical costs, and indirect costs, which were derived from nationwide research conducted in China. ¹⁶ All costs were estimated in Chinese renminbi (RMB), converted to 2024 US dollars using country‐specific consumer price indices and official exchange rates (US dollar 1≈RMB 7.1). All data were from previously published work, and no ethical approval was needed to complete this work.

2.4. Model outcomes

The primary outcomes were life years, life years with dementia, life years without dementia, and quality‐adjusted life years (QALYs) gained under each intervention scenario. All benefits were summed to represent the lifetime effect of the target age cohorts using a period life table. We established when in the life course each intervention would be delivered and discounted future dementia‐associated savings back to present value. Costs were calculated over the lifetime of an infinite succession of age cohorts who would benefit from the policy to give the final result with all current and future cohorts discounted. The cost‐effectiveness analysis was done from a societal perspective, capturing direct medical costs, direct non‐medical costs, and informal care costs. Both current and future costs and benefits were discounted at 4.5% per year to yield net present values, as recommended by China Guidelines for Pharmacoeconomic Evaluations 2025. ¹⁷

2.5. Sensitivity analysis

We conducted subgroup analyses by sex (male and female), by urban–rural residence, and across geographic regions (Eastern, Central, Western, and Northeast China). We additionally used the prevalence of modifiable dementia risk factors derived from the 2015 wave of the CHARLS to examine whether the results remain robust when accounting for temporal changes in exposure patterns.

To evaluate the impacts of different taxation levels on health and economic outcomes, a one‐way scenario sensitivity analysis was conducted by varying tobacco and alcohol taxation levels. For tobacco taxation, three absolute tax rate scenarios were modeled: 17.6%, 24.2% (base case), and 30.8%. For alcohol taxation, three relative increase scenarios were considered, corresponding to 5%, 10%, and 15% increases above the baseline taxation level (base case: 10% increase).

In the univariate sensitivity analysis, we considered the uncertainty of the following parameters: (1) prevalence of risk factors, (2) incidence of dementia, (3) case fatality of dementia, (4) all‐cause mortality, (5) risk ratio of risk factors, and (6) annual costs of dementia. We changed the values of parameters by ±10% and modeled the preventable dementia cases and all‐cause deaths. We used tornado diagrams to reflect the impact of parameters on the results.

We performed probabilistic sensitivity analysis (PSA) to examine the robustness of our results. By drawing 1,000 sets of model parameter values from their distributions, we presented the results in the form of an incremental cost‐effectiveness ratio scatter plot for each risk factor. Our study followed the updated Consolidated Health Economic Evaluation Reporting Standards 2022 (CHEERS 2022) checklist (Supplementary Method 3). ¹⁸ All analysis were conducted using R version 4.3.2.

2.6. Role of funding sources

The funding sources of this study did not influence or participate in the study design, data collection, data analysis, data interpretation, or writing of the paper.

3. RESULTS

3.1. Main findings

On an individual level, over a lifetime horizon, removal of each risk factor was estimated to gain about 0.02 life years and between 0.05 and 0.08 QALYs, resulting in per‐person cost savings ranging from US$1714 to US$2592 (Table 1). At the cohort level, across all scenarios, the interventions produced reductions in the prevalence of their respective risk factors ranging from 2.3% to 22.3%. When applied to the key age cohorts, the number of individuals shedding each risk factor ranged from 68,201 to 1,724,974 (Table 2).

The salt substitution strategy generated the greatest health and economic benefits among all interventions evaluated. If the strategy were introduced over an indefinite succession of age cohorts, there would be 620,000 life years gained, 1,940,000 QALYs gained, and cost‐savings of US$65.7 billion.

We estimated that the smoke‐free legislation would result in 239,000 life years gained, 749,000 QALYs gained, and cost savings of US$25.4 billion across indefinite successive age cohorts.

The tobacco excise tax reform would be expected to gain 129,000 life years and 406,000 QALYs, resulting in an estimated cost saving of US$13.8 billion across indefinite successive age cohorts.

The taxation of sugar‐sweetened beverages would be expected to gain 79,000 life years and 247,000 QALYs, resulting in an estimated cost saving of US$8.4 billion across indefinite successive age cohorts.

The alcohol taxation increase would be expected to gain 25,000 life years and 79,000 QALYs, resulting in an estimated cost saving of US$2.7 billion across indefinite successive age cohorts.

3.2. Subgroup analyses

The patterns of benefits were broadly consistent across subpopulations, although the magnitude of effectiveness varied (Figure 2). Males generally experienced greater absolute benefits compared with females across most interventions, except for the sugar‐sweetened beverage tax. Urban populations showed greater benefits than rural populations, particularly for salt substitution and smoke‐free legislation. The eastern and urban regions exhibited the greatest health gains and economic savings, while the Northeast and Western regions showed comparatively smaller effects.

FIGURE 2.

Estimated impacts of each intervention on dementia cases, deaths, life years, and costs across subgroups defined by sex, urban–rural residence, and geographic region.

3.3. Sensitivity analyses

The sensitivity analysis using risk factor prevalences from the 2015 CHARLS wave (Tables S1 and S2) showed that the overall ranking of intervention effectiveness and the qualitative conclusions remained unchanged. Differences in total effectiveness were driven primarily by changes in prevalence, most notably the lower prevalence of hypertension and higher prevalence of smoking in the 2015 dataset.

In addition, one‐way scenario sensitivity analyses demonstrated a consistent monotonic increase in health and economic benefits with higher taxation levels for both tobacco and alcohol policies. For tobacco taxation, risk factor prevalence reduction increased from 2.3% (17.6% tax scenario) to 6.9% (30.8% tax scenario), with the number of individuals aged 45 years shedding risk increasing from 121,771 to 365,313. Correspondingly, QALYs gained increased from 202,947 to 608,840 and cost savings from US$6876.11 million to US$20,628.32 million across indefinite successive age cohorts. A similar pattern was observed for alcohol taxation, where relative increases in taxation of 5%, 10% (base case), and 15% above the baseline level led to risk factor prevalence reductions from 1.2% to 3.5%, QALYs gained from 39,540 to 118,620, and cost savings from US$1339.64 million to US$4018.91 million across indefinite successive age cohorts (Tables S3 and S4).

Tornado diagrams and probabilistic sensitivity analyses found that all interventions delivered lower cost, averted more dementia cases and deaths, and gained more life years in each scenario (Figures S1–S4). The leading influencing variables were cost, case fatality, incidence, and all‐cause mortality.

4. DISCUSSION

To our knowledge, this is the first study to estimate the cost‐effectiveness of population‐level interventions targeting dementia risk factors in China. The study adopted a lifetime horizon with an infinite time frame to evaluate long‐term effectiveness and societal costs. Without exception, all the interventions examined were found to avert excess dementia cases and deaths while generating net cost savings. When applied to the whole eligible Chinese population, the scale of benefits is substantial. Importantly, our model explicitly incorporated all‐cause mortality and state‐specific mortality differentials between health states, thereby accounting for the higher mortality risk associated with dementia. In this framework, individuals in the dementia state experience elevated mortality compared with those in the healthy state. Consequently, reductions in dementia incidence through risk factor modification also indirectly reduce mortality by increasing the proportion of individuals remaining in the lower‐mortality healthy state. Given the strong age dependence of dementia incidence, these effects become more pronounced at older ages, where both baseline incidence and excess mortality associated with dementia are higher.

Among the five interventions evaluated, the salt substitution strategy to reduce sodium intake emerged as the most effective and economically advantageous measure. This finding underscores the central role of midlife hypertension management in preventing dementia, aligning with evidence that elevated blood pressure during midlife is a key modifiable risk factor for cognitive decline. Tobacco control measures, including both comprehensive smoke‐free legislation and excise tax increases, also demonstrated substantial and sustained health and economic gains. These results highlight the potential of regulatory policies to deliver broad population‐level benefits that extend beyond traditional tobacco‐related diseases. In contrast, fiscal measures targeting sugar‐sweetened beverages and alcohol consumption produced smaller but still meaningful effectiveness, reflecting their lower baseline prevalence in midlife populations. Nonetheless, their cost‐saving nature and potential co‐benefits for metabolic and vascular health strengthen their relevance as part of a comprehensive prevention package. Taken together, these results underscore that multifaceted population‐level interventions acting on key modifiable risk factors could generate substantial long‐term reductions in dementia burden and health expenditures. Our subgroup analysis showed that males derived greater benefits across most interventions except for the sugar‐sweetened beverage tax, consistent with evidence on the impact of lifestyle and behavioral risk reduction: Men benefit more from reductions in smoking and alcohol use, whereas women gain more from improvements in diet and physical activity. ¹⁹ While there were distinct regional disparities in the total health gains and economic savings achieved, per‐capita reductions in disease burden were largely comparable across Eastern, Northeast, Central, and Western regions (Figure S5). This pattern indicates that the observed differences in aggregate benefits are primarily driven by variations in population size across regions, rather than differences in baseline risk factor exposure or intervention effectiveness at the individual level. In line with this, urban populations yielded more pronounced aggregate intervention effects than rural counterparts, particularly for population‐wide measures such as salt substitution and smoke‐free legislation.

Our findings are consistent with evidence from recent international studies that supports the economic value of population‐level and multidomain dementia prevention strategies. A modeling study in England demonstrated that all population‐based interventions aimed at reducing dementia risk factors reduced costs and yielded long‐term QALY gains over an infinite time horizon. ⁷ Complementing this, a systematic review of 45 economic evaluations concluded that community‐ and population‐level interventions – particularly those addressing smoking, educational attainment, and physical inactivity – were highly cost‐effective and often cost saving across diverse settings, from high‐income countries such as the USA and the UK to low‐ and middle‐income countries like Mexico, Tanzania, and Thailand. ²⁰ More recently, a scoping review further strengthened the economic rationale for dementia prevention, reporting that multidomain programs targeting at‐risk populations achieved an average gain of 0.08 QALYs per participant at a mean cost of US$497, with incremental cost‐effectiveness ratios ranging from cost saving to moderately cost‐effective. ²¹ Collectively, these findings indicate that both population‐wide and targeted preventive approaches can deliver substantial health and economic returns, providing convergent evidence that large‐scale policy action on modifiable risk factors is an efficient and equitable strategy to reduce the global dementia burden.

Despite the growing recognition of dementia as a public health priority, China's current policies for dementia prevention remain limited in scope and implementation. Only seven national policy documents have addressed dementia‐related risk factors, and just one of them specifically targets Alzheimer's disease. Most existing measures are embedded within broader initiatives for chronic disease control or tobacco education, where dementia is mentioned merely as a secondary outcome. Furthermore, these policies are largely programmatic in nature and lack detailed implementation guidelines or robust evaluation frameworks. Moreover, although national targets aim to raise public awareness of dementia prevention to 80%, recent surveys indicate that only about 63% of adults can correctly identify risk factors, with markedly lower awareness among older, less educated, and rural populations. ²² Against this background, our study provides timely and policy‐relevant evidence by quantifying the potential cost‐effectiveness and population‐level benefits of specific preventive interventions, thereby offering an empirical foundation for translating high‐level strategic goals into actionable, evidence‐informed public health policies.

The implications of our findings extend beyond dementia prevention. Empirical evidence indicates that interventions aimed at dementia prevention can generate substantial co‐benefits across other major non‐communicable diseases (NCDs). Lifestyle and clinical strategies targeting shared risk factors, such as hypertension, smoking, obesity, and diabetes, have been shown to delay or reduce the incidence of dementia, including Alzheimer's disease, while simultaneously lowering the risks of cardiovascular and metabolic disorders. The Rotterdam Study showed that avoiding smoking, hypertension, and overweight delayed NCD onset by 9 years and extended life expectancy by 6, highlighting broader health gains from dementia risk reduction. ²³ Evidence from younger populations similarly indicates that early, population‐level control of modifiable risks reduces neurodegenerative and cardiometabolic diseases across the life course. ²⁴ Consequently, incorporating dementia‐related outcomes into the economic evaluation of NCD prevention policies captures not only the primary neurological benefits but also the secondary cardiovascular and metabolic advantages, leading to a more comprehensive and favorable assessment of cost‐effectiveness. This underscores the importance of adopting an integrated, life‐course framework in evaluating NCD prevention policies.

Our study's strengths include a robust, transparent Markov modeling framework that integrates health and economic evidence using nationally representative Chinese data and meta‐analytic relative risks. By evaluating five intervention scenarios, the model yields empirically grounded, policy‐relevant results. Conservative assumptions, such as higher intervention costs and exclusion of secondary health benefits, minimize overestimation of cost‐effectiveness, meaning true long‐term gains may be greater. Extensive one‐way and probabilistic sensitivity analyses confirmed the model's robustness and consistent cost‐saving outcomes, underscoring its methodological reliability.

Nevertheless, several limitations should be acknowledged. First, we assumed constant prevalence and relative risks of modifiable dementia factors over time. Although this static approach may not capture behavioral changes, evidence from 2011 to 2018 shows no significant shifts in China's dementia risk profile, supporting its validity for medium‐term projections. ²⁵ Consistently, the sensitivity analysis using the prevalence of modifiable risk factors derived from the 2015 CHARLS wave produced results that were highly comparable to the main analysis, further confirming the robustness of our estimates. Second, our analysis did not explicitly consider the implementation costs of the proposed strategies. However, existing evidence suggests that many of these measures are low‐cost or cost‐neutral. For example, evidence from Latin American countries shows that taxes on tobacco, alcohol, and sugar‐sweetened beverages effectively reduce consumption and increase fiscal revenue without adverse macroeconomic effects, while also contributing to improved population health. ²⁶

Additional evidence from China further indicates that higher tax rates generate proportionally greater health, economic, and equity benefits. Importantly, fiscal revenue does not decline until taxes reach very high levels – approximately 72% of the retail price for tobacco, 59% for alcohol, and 40% for sugar‐sweetened beverages – beyond which total revenue begins to fall. ²⁷ Finally, the implementation and enforcement of population‐level policies require substantial time and resources. As Walsh et al. note, ²⁸ such interventions are often difficult to justify, implement, and evaluate, with policymakers perceiving them as complex and politically risky despite potential long‐term benefits. Commercial actors – particularly powerful transnational corporations – shape policy environments in ways that hinder the adoption and implementation of interventions targeting key health risk factors, contributing to persistent policy inertia despite the availability of effective public health measures. ²⁹ Consequently, while modeled analyses may project significant effectiveness, real‐world effectiveness is frequently limited by practical, financial, and political constraints.

Overall, our analysis provides strong evidence that population‐level strategies to reduce exposure to key modifiable dementia risk factors would yield substantial long‐term health and economic benefits in China. Although the full benefits of such interventions may take years to become apparent, their sustained impact on reducing dementia incidence and delaying disease onset is likely to translate into meaningful public health gains over time. Taken together, these findings strengthen the case for embedding effective, scalable, and equitable population‐level dementia prevention policies as part of a broader national public health strategy in China, which also carry important implications for other developing countries confronting the challenge of “getting old before getting rich.”

CONFLICT OF INTEREST STATEMENT

The authors have no conflicts of interest to declare. Author disclosures are available in the Supporting Information.

CONSENT STATEMENT

This study did not involve human participants or identifiable personal data. Therefore, informed consent was not required.

Supporting information

Supporting Information: alz71762‐sup‐0001‐SuppMat.docx

Supporting Information: alz71762‐sup‐0002‐SuppMat.pdf