As the world’s largest producer and consumer of cigarettes, China has struggled to cope with the myriad health hazards that plague its more than 300 million smokers. But in late November, the State Council released a draft of a proposed nationwide ban on smoking in indoor public areas for public consultation—a move which was promptly criticized by the state director of the country’s tobacco monopoly administration.
China Economic Review sat down late last week with the World Health Organization’s representative in China, Angela Pratt, to discuss the prospects of a nationwide smoking ban, regulatory conflicts of interest, smoking rates among Chinese youth and the latest trends in tobacco use throughout greater China.
The State Council recently released the latest draft of a proposed ban on smoking in indoor public spaces for public consultation. What is the World Health Organization’s initial take on the content of the regulations?
We were really very happy to see the draft released last week for a number of reasons, not least of all because it’s actually a very comprehensive set of tobacco control policies. The draft law includes a provision to make all indoor public places in China smoke free, and a number of outdoor public places smoke free. It includes a proposal to ban all tobacco advertising promotion and sponsorship. It would introduce graphic warnings on tobacco packets for the first time, and include a strong emphasis on public education and awareness support to smokers who need help with cessation services. And it includes a particularly strong focus on protecting young people, and various restrictions on sales to minors—on retail outlets near schools, among other things.
So we were delighted to see the draft law released, and delighted to see such a comprehensive range of policies included. And if it’s passed in its current form and then implemented, it will really be a giant step forward for tobacco control in China.
What is the likelihood of it being passed and implemented?
I think the fact that the draft law has been released in its current form – that we have the draft law on the table – is a very good sign. I can’t predict exactly what is going to happen as the State Council has its deliberations on the draft. We can anticipate that the tobacco industry will oppose some parts of the draft law, they’ve been quite open about that. In fact you’ve written on that in the last few days.
We will be arguing very hard that the law should be adopted in its current form, that the provisions in there shouldn’t be watered down or weakened or any of the existing provisions removed. And the reasons for that are that China needs all of these measures if it’s going to effectively tackle the public health crisis that is tobacco use in this country, and watering down any of them will significantly diminish the capacity of the draft law to be able to do that. So that’s the answer to the first question.
In terms of enforcement, there is no question that the enforcement is absolutely critical. I mean, the best law in the world, the most perfectly drafted law, won’t help anybody if it’s not well-enforced. And it’s well documented that there have been attempts in China in the past to make public places smoke free, for example, and those have not been well-enforced.
I guess there are a couple points to make in relation to this. The first is that it is true that previous attempts at enforcement have been lackluster. But it’s difficult to enforce weak laws, and in the past a lot– city-level laws, for example – have been quite weak. You know, loads of exemptions and loopholes, and it’s really hard for enforcers to actually enforce properly a law where the legal basis is weak. The enforcement provisions in this law are very strong.
Let me give you one very specific example of this. With banning smoking in public places, one of the things that we’ve learnt from around the world that’s very important is that you make the business manager or the owner of the bar or restaurant or hotel responsible for making his or her premises smoke free. If you just fine the individual smoker there’s no incentive for the owner or the manager to make the whole place smoke free. But the penalty provisions in this law would apply to both the individual and the owner of the premises. Quite significant fines, up to 30,000 RMB for premises owners or managers that don’t comply, and the possibility of their business being shut down if they continue to fail to comply.
So we’re optimistic about enforcement because there clearly has been a lot of thought going into the drafting of the law and there are very strong provisions in the law for it to be enforced, but absolutely it will require a huge effort from national authorities—local and city level authorities—to actually really put their shoulders to the wheel and make that happen if the law is adopted as we hope it will be.
As you mentioned briefly, and as we’ve written about (also briefly), the director of the state tobacco monopoly administration recently criticized the idea of tobacco controls, stating that, “smoking has hundreds of years of history and objectively a market demand for cigarettes still exists”. Including the tobacco monopoly administration, what are some of the largest institutional barriers to curtailing the popularity of smoking in China?
The power of the tobacco industry is chief amongst the barriers, and it’s not just the fact of it being a state-owned monopoly. The real problem is the conflict of interest which exists whereby the industry for the State Tobacco Monopoly Administration (STMA) has a seat at the tobacco control policy table. So the Ministry of Industry and Information Technology, which is the ministry that the STMA sits within, it’s the lead ministry responsible for implementation of the Framework Convention on Tobacco control – the global tobacco treaty in China.
So the analogy I’d use – I’m from Australia – is it’s like the health minister turning up to the cabinet for a tobacco control proposal to strengthen tobacco control policy and the tobacco industry, Phillip Morris, is not just sitting on the other side of the table—they’re chairing the meeting. So that’s the kind of quite fundamental conflict of interest that exists within China currently. And ultimately that is going to have to be resolved. I also stress that that’s in contravention of the Framework Convention, so there’s a clear provision within the Framework Convention that the tobacco industry, whether that’s private industry or it’s state owned, should not have a role in making tobacco control policies. That absolutely is a big problem.
But another really big problem in China is that public awareness is still very low about the harm of tobacco use. Most people in China don’t have a great awareness of the range of health problems that smoking tobacco can cause. In particular people don’t have strong awareness about the harm of second hand smoke or being exposed to other people’s smoke, and that is a bit of a drag on more progressive tobacco control policies as well.
The experience the world over is that the more people know about how bad tobacco is for them, the less likely they are to want to smoke it, or to use it. So that’s something that also needs to be addressed. It’s something that we at WHO work very hard on. It’s something we know that the national health and family planning commission, the National Health Mini
stry is also working very hard on, and we’re very pleased to see that there’s strong recognition of that in the draft law that was released—that, for example, smoke free public places, all of those kinds of policies need to be accompanied by strong public awareness campaigns.
So what are the smoking trends among different age groups in China today? Are younger people now as likely to smoke as their parents?
I’m sure you’re aware there’s a big difference between men and women. 53% of men smoke, only 2.5% of women smoke, so there’s a big gender differential among the adult population. The latest data that we have on youth smoking rates, 13-15 year olds, suggests – I don’t have the numbers in front of me – but it’s a similarly small number of girls, like 2% of girls, and I think it’s around 14% of boys. So women and girls are similar, but boys and men show quite a big difference. We know that in China boys tend to take up smoking later in their teens, so that latest use data isn’t necessarily instructive about whether that age group will go on to replicate the current proportion of smoking amongst men.
Then there are two other things: There was a survey released last year done by some colleagues of ours at Johns Hopkins University in the U.S. So they surveyed five and six-year-old schoolchildren in China, and 22% of those kids say that they expect to become smokers when they grow up. To me that’s actually almost the single most startling statistic of all in the sort of ocean of data that’s available about how big a problem this is in China—that five and six-year-old kids see a future for themselves as smokers. 22% of them, that’s a big proportion. And while there’s no data yet to show that this is happening, I do fear that more young women are starting to smoke in China.
What do you think is behind that?
I think that it’s tobacco marketing creating an impression of tobacco smoking as being associated with independence, beauty, glamor, freedom. We can see a very clear correlation over time in other countries between economic development and an increase in the female smoking rate. That’s basically what I think we’re seeing in China, that the tobacco marketing really tapped into that. So that’s personally my biggest fear, that smoking rates among young women are increasing. There are a range of things that are really important to address that, but comprehensively banning tobacco marketing is one of the really important things.
Speaking of economic development, there was a study from the Brookings Institute in 2012 that estimated taxes on the industry contributed 7-10% of government revenue annually. Is it also possible to estimate the yearly economic damage caused by smoking to China?
Yes, most estimates put tobacco taxes and profits at between 7-10% as a proportion of total government revenue. We are working on a project at the moment jointly with the United Nations Development Program on updating the current social and economic cost of tobacco use, and predicting those costs into the future if current smoking rates stay as they are.
I am very confident that the costs of tobacco use far outweigh the economic benefits – the overall costs in terms of loss of productivity, people dying prematurely while they’re in the prime of their working lives. There’s evidence from around the world that costs always outweigh economic benefits. We would be very happy to talk more on this when we have the results from our research project ready next year.
China is also both the biggest consumer and producer of cigarettes worldwide. How did it become such a heavyweight in production and such a massive consumer?
That’s a good question. It’s partly sheer numbers, but not entirely. Partly I think it can be attributed to the fact that it is a government-owned enterprise and you know, the government has encouraged the industry to grow. It’s partly the result of very entrenched social norms around smoking, especially for men. I don’t completely agree with the description of smoking in China, as it being inherently part of Chinese culture to smoke cigarettes. It is a very strong social norm currently in China to smoke cigarettes. But culture and social norms are two slightly different things.
But yes, it is a social norm that has developed or become more entrenched over time. And the development of that social norm can also be attributed to the fact that cigarettes are incredibly cheap in China. It’s a very cheap social currency, if you like. So I think there’s a range of reasons for why that’s the case.
Speaking of culture, do we know how smoking rates on the mainland compare to those in greater China – in Taiwan, Hong Kong and Macau? Do those line up?
“No,” is the short answer. I don’t know off the top of my head the figures for Taiwan and Macao, but the smoking rate is much, much lower than in mainland China. In Hong Kong the overall smoking rate is about 12%, in China the overall smoking rate amongst the adult population is 28%, and the trajectory in Hong Kong is downwards. That’s the result of all the kinds of policies that we argue are really important, and Hong Kong’s a great example which shows they can have an effect—things like smoke-free public places, taxes on tobacco, marketing bans, etcetera. So there is quite a big difference between Hong Kong and the mainland.
How effective have previous anti-smoking efforts been in China, either by the government or by the private sector?
Mixed success, for some of the reasons I talked about earlier—there’s never been a comprehensive smoke-free law in China. There have also been attempts at public awareness campaigns in different cities, again, with mixed success. There haven’t been enough of those when you compare it to places like Australia or the US or the UK, where there have been really long-running, sustained awareness campaigns about the harm of tobacco. That’s not something that we’ve seen in China really, so I guess you can describe the overall history of tobacco control in China to date as fairly patchy. That’s why we’re so excited about the draft law that was released, because it really will be a very, very big step forward.
What is the WHO doing in China to promote awareness of the dangers of smoking, and to what extent is it working with local institutes—private or public, or NGOs?
The most important thing probably is that we’re increasingly working a lot on social media, and we do that for two reasons. One is very pragmatic: We don’t have the budget to run big TV advertising campaigns ourselves. But more importantly, we know that Chinese people get their information and news online, and from social media platforms rather than the traditional media, so that’s something we have started to engage more with.
We also work with a lot of other partner organizations and directly with the government to support their efforts to improve public awareness—we give advice to the government on their campaigns and how they might be able to be made more effective, and similarly work with other national and international partner organizations to support their efforts. We do a lot of media outreach as well. Some of that is about advocating for the kinds of policies we’ve been discussing, but some of that also is with the objective of trying to generate discussion and raise awareness. ♦
rviewer: Hudson Lockett (@KangHexin)