China’s cigarette smoking epidemic

The global tobacco epidemic kills an estimated 8 million people every year. The proven health risks of tobacco use have led to the World Health Organization (WHO) Framework Convention for Tobacco Control and other commitments from health ministries around the globe. Even though China is nominally on board with the anti-cigarette agenda, tobacco use in China is still widespread and is tightly tied to the culture.Nearly one in three smokers in the world is Chinese. Over 300 million people in the People’s Republic regularly puff on cigarettes, and Chinese people as a whole buy an estimated 2.3 trillion cigarettes every year.

Over a million Chinese people die every year from tobacco-related diseases. The most important one is lung cancer, which was newly diagnosed in nearly 800,000 patients in China in 2018. Mortality rates for lung cancer are disproportionately high in China, and over 75 percent of lung cancer deaths in Chinese men are attributable to smoking. In fact, men are particularly at risk because cigarette use is highly gendered in China: One study estimated the rate of smoking to be 52.9 percent in Chinese men and 2.4 percent in Chinese women. As cancer rates rise, the overall economic burden of cigarette smoking on the Chinese economy is growing rapidly — $3.3 billion in 1989, $5.0 billion in 2000, and $28.9 billion in 2008.

Why does the Chinese government allow such massive tobacco use?

The answer is not complicated: Despite the growing cost of smoking to China’s economy, the tobacco industry in China contributes between 7 percent and 11 percent of the Chinese government’s annual tax revenues. In fact, the profits of the Chinese National Tobacco Company (CNTC) — a state-owned enterprise — exceed the combined profits of three comparable British and American companies: Altria, Philip Morris International, and British American Tobacco.

To learn more about the history of the tobacco industry in China, listen to this Sinica Podcast with Matthew Kohrman, associate professor of anthropology at Stanford University.

Smoking and Chinese culture

While smoking in the U.S. has become stigmatized, smoking is an ingrained part of socializing in mainland China and remains ubiquitous — on the street, in the stairwells of buildings that have banned smoking, and even in restaurants despite smoking bans in many cities.

The normalization of smoking in China has made it difficult to reduce smoking rates, even amongst doctors. One study found that 45.2 percent of surgeons surveyed in China were smokers, and 42.5 percent of those surgeons reported having smoked in front of patients.

In the wider society, cigarettes are often used as gifts for building relationships — including between doctors and the families of patients — as well as to display generosity during festivals and weddings and as business favors. CNTC has tried capitalizing on this social phenomenon by employing a “premiumization” strategy, which involves the production of cigarettes that can cost up to several hundred U.S. dollars a carton — a high-status gift.

Smoking has also become associated with masculinity. Early strategies of Chinese tobacco advertising included portraying smoking as being healthy for men, and as an activity that promotes fraternization in social groups. In contrast, smoking for women was historically portrayed negatively, often associated with prostitution. These gender divisions are reflected in differences in smoking rates mentioned above — 52.9 percent in Chinese men and 2.4 percent in Chinese women.

In 1953, when the Communist Party of China closed foreign sales of tobacco, efforts were made to increase smoking consumption by including cigarettes in military kits, offering citizens cigarette rations, and packaging cigarettes to represent male performativity and vocational success.

Cigarette branding

A key difference in cigarette marketing between China and the U.S. is the use of brands. Where the U.S. is dominated by iconic brands such as Marlboro and Camel, China has significantly more brand variety. In 1990, CNTC’s various local subsidiaries were together producing an estimated 2,000 brands. By 2013, however, the number was reduced to 90 brands as provincial tobacco companies consolidated.

Brands are often targeted toward local consumers and bear names that evoke local landmarks, icons, or even cities themselves. Many smokers use cigarette brands as symbols of their home regions and remain loyal to their local brands even when they move away. In some cases, the effect of branding may be applied more broadly to the Chinese identity, as in the case of the brand Chunghwa (中华 zhōnghuá), which simply means “China,” or “Chinese.” Before advertising was restricted in China in 1994, Chunghwa used a slogan, “Love our China” (爱我中华 ài wǒ zhōnghuá), appealing directly to the nationalistic sentiments of Chinese smokers.

In research I conducted at the University of California San Francisco, these local brands were found to be associated with more addictive smoking behaviors. Though further research is required, existing evidence suggests that the social activity of smoking with others may strongly impact smokers’ willingness to quit or the cigarettes they consume per day, and connecting cigarette brands with smokers’ identities may be an important factor in building nicotine addiction. Imagine, for instance, if you grew up in the San Francisco Bay Area or New York City and were offered a Golden Gate Bridge or Empire State Building cigarette, respectively. If all your peers were smoking these cigarettes, you might have a higher chance of becoming a smoker.

China’s fight against tobacco

China ratified the WHO Framework Convention for Tobacco Control (FCTC), the first international treaty to promote tobacco control, in October 2005 and started implementation in January 2006. The FCTC includes several recommendations and strategies for tobacco control, including restricting sales to minors, restricting advertising, tax strategies, and educating the public on the dangers of tobacco. China was one of the first signatories to the FCTC, but as of 2010, WHO ranked China in the bottom 20 percent of success in tobacco control and FCTC compliance.

China committed to tobacco control in its 12th Five-Year Plan in December 2013 by restricting government officials from smoking in public places, and then banning smoking in schools, colleges, and universities in January 2014. Since 2008, more than 12 cities have passed legislation to control tobacco, and these public commitments represent the beginning of a national effort to protect the Chinese people from smoking and smoke exposure.

For example, Beijing adopted the Beijing Smoking Control Ordinance in November 2014, which was the strongest tobacco control measure adopted anywhere in China. The rules completely restricted smoking in all indoor places as well as many outdoor places. The Beijing Tobacco Control Association (BJTCA) has developed the Beijing Tobacco Control Map, including a Complaint Map, to consolidate the efforts of the general population and government through linking social media, mass media, and government enforcement. The Complaint Map allows the general populace to report violations of the Smoking Control Ordinance in public venues through WeChat. These violations include allowing ashtrays, displaying tobacco advertisements, and failing to stop customers from smoking in a venue. The complaints are compiled into an index and sent to media outlets in the hope that negative publicity will drive local community leaders to promote enforcement efforts.

The strategy is being disseminated to other Chinese cities and hinges on having a large number of volunteers who help publicize tobacco control efforts through social media, tobacco control marches, and other public events like flash mobs.

Future of tobacco control in China

Considering the political support for tobacco control, China may at last be on the road to a tobacco-free future. But it has a long way to go. Despite the public health costs and global stigmatization of tobacco use, it will be very hard for the Chinese government to wean itself off tobacco tax revenue. In 2007, one official at CNTC said that restricting smoking would cause social instability. As long as officials continue to take such positions on tobacco use, China will remain a smoker’s paradise with staggering rates of lung disease.