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The critical role of China in global tobacco control

Many might think that the best way to reduce the global tobacco epidemic is by health education and banning sales to minors – policies well-liked by teachers, parents, and governments. But these are ineffective means of reducing smoking prevalence. Surprisingly, it is a fiscal measure that is the critical and easily the most important means of improving public health, as by raising the price, cigarettes become less affordable, especially to the young.

In a 41 country study by David Levy et al, tobacco taxation headed the list as the best way of reducing the numbers of smokers and hence reduction of smoking deaths. Second was the creation of smoke-free areas, third: pack warnings, fourth: offering help to quit tobacco, and fifth: bans on tobacco advertising, promotion, and sponsorship.

Effect of meeting targets 2007-2010 on smokers & smoking-attributable deaths, by policy table
‘Effect of meeting targets 2007-2010 on smokers & smoking-attributable deaths, by policy table’. Used with Author’s permission.

This is confirmed by the tobacco industry ‘Scream Test’: the industry will ‘scream’ by undermining, attacking, obstructing, and intimidating governments with legal and trade threats for any measure likely to be effective (such as tax, smoke-free, plain packaging, large graphic warnings). It is telling that they positively support schools education and a ban on sales to minors – indicating that these are indeed the least effective measures.

How does this knowledge apply to tobacco control in China, the world’s largest producer and consumer of tobacco? It is staggering to think that one in every three cigarettes smoked in the world today is smoked in China. Certainly no improvement in the global tobacco epidemic can ignore what is happening in China.

Although knowledge and action on tobacco began in the 1980s with the first national prevalence survey and a conference on tobacco held in Tianjin, followed by dozens of research papers, conferences, and exhortations to action from both within and outside China, the key action areas of tax, smoke-free areas, and warnings have not been implemented in any effective way. Tobacco tax remains extremely low; there is no national smoke-free law (a draft is still languishing between various government bodies, although promised in 2017), and China is extraordinarily reluctant to introduce any graphic pack warnings, claiming these would be insulting to the beautiful pictures of China that appear on many of the packs!

This is in spite of the fact that over a decade ago, China ratified the World Health Organization Framework Convention on Tobacco Control (WHO FCTC), and is therefore under international obligation to introduce tobacco control measures.

HKsmoking5000fine. Own work. CC BY 3.0 via Wikimedia Commons.

Given the enormity of the epidemic, the ill-health, the more than one million annual deaths caused by tobacco already evident in China, and tobacco being a huge economic burden on the economy, why is this?

The biggest tobacco company in the world is the Chinese government, and the state-owned tobacco industry remains a major obstacle to tobacco control. It is not only responsible for the tobacco industry, but the WHO FCTC mechanism in China is still led by the Ministry of Industry and Information Technology, which also oversees the China Tobacco Monopoly Administration. This represents a major conflict of interest within the Ministry, which thus far has been extremely detrimental to tobacco control.

The monopoly has increasingly adopted a more aggressive stance on obstructing tobacco control, much like the tactics of the transnational tobacco companies, as shown by the World Health Organization in 2012.

However, there are glimmerings of hope. In the last few years, tobacco control efforts have begun to accelerate beyond expectations. The triggering event was the publication on tobacco by the Chinese Central Party School, the ideological think tank of the Communist Party, followed by a spate of activity: directives to government officials; regulations issued by the Ministry of Education, the People’s Liberation Army, and the Healthy City Standards; tobacco clauses in national advertising and philanthropy laws; the creation of a Smoke-free Beijing (and Shanghai in March 2017); a modest increase in tobacco taxation; and the national smoke-free law currently in draft.

To contribute to the global movement in tobacco control, there is a crucial need for China to build upon these recent developments in accepting the economic research evidence of the debit of tobacco to the economy. China should recognize the studies that show farmers can earn more by switching to other crops. The central government must implement robust, comprehensive legislation as well as increasing cigarette price through taxation. Most challenging of all, China must work to tackle the power and influence of the state tobacco monopoly over tobacco control.

Featured image credit: ‘Smoking’ by Олег Жилко. CC0 Public Domain via Unsplash.

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