China wrestles with tobacco control
Around one-third of the world's smokers live in China, which has some of the largest tobacco companies. Weiyuan Cui interviews DrÂ Yang Gonghuan about the formidable forces of opposition to tobacco control in a country estimated in 2002 to have 350 million smokers.
Q: Has there been progress in tobacco control in China?
A: Before 2006, attempts at tobacco control were mainly research by health experts and basic health education. Since China joined the WHO Framework Convention on Tobacco Control (WHO FCTC), the Government, media, research institutions and the public have acknowledged the need for tobacco control. The Ministry of Health has published an annual tobacco control report and there have been campaigns to increase tobacco tax and warnings added to packaging. However, tobacco control faces great opposition. Tobacco control is not mentioned at all as a priority in the health reform plan, and the budget we have only accounts for 0.5% of the total budget for disease control and prevention.
Q: Which authorities in China are responsible for tobacco control?
A: The Ministry of Industry and Information Technology was appointed to lead the implementation of the WHO FCTC in China, a role that includes many ministries including the Ministry of Health. The State Tobacco Monopoly Administration controls the China National Tobacco Corporation, which is a state-owned monopoly and the largest single manufacturer of tobacco products in the world. The administration is responsible for policy and enforcing regulations, such as those governing warnings on packaging. It does not involve health departments in policy-making, keeping that role for itself and the government departments it nominates.
Q: How does this work in practice?
A: The State Tobacco Monopoly Administration (which sits in the Ministry of Industry and Information Technology) issued regulations on cigarette package labelling that took effect in January 2009. These warnings on packaging fall well short of the requirements. According to the legally binding Article 11 of the WHO FCTC endorsed by China, warning signs should cover 50% of the display area; Chinese regulations require only 30%, and the warnings are in tiny characters. The WHO FCTC requires health warnings to describe the harm tobacco can cause, but Chinese warnings merely state: "smoking harms your health" and "quitting smoking early helps reduce the risk". By issuing domestic regulations on cigarette package labelling that flaunted Article 11, the State Tobacco Monopoly Administration hampered the best way for the public to learn about the harm caused by tobacco. The Administration's strategy of dodging price increases also blunts the effect of tobacco tax increases by the Ministry of Finance. Meanwhile, the tobacco companies target young people. For instance, a primary school rebuilt after the Sichuan earthquake with funds from a tobacco company is named "Sichuan Tobacco Hope Primary School". On the school walls is inscribed: "Talents are brewed by intelligence; tobacco helps you grow up and become accomplished."
Q: What can be done to resolve this conflict of interest on tobacco control?
A: Tobacco control concerns quite a few ministries. At the very least, the ministry in charge of tobacco production should not be in charge of tobacco control as well. The Ministry of Health must take charge of implementing the WHO FCTC and the administration of tobacco control should be separate. If an entity can behave as both a private company and part of government, it will always have the economic leverage and policy-making power to thwart tobacco control efforts. We need to close the gaps between domestic laws and the WHO FCTC's provisions. In fact, since 1992, the central government has made the separation of government and enterprise functions a goal. At each of China's legislative conferences, delegates have proposed the separation of the State Tobacco Monopoly Administration and tobacco corporations. As our report Healthy China 2020 has pointed out, to achieve our health goals a consensus must be reached not just within the health administration system, but at the national level, to solve the essential obstacles. We suggest a National Committee on People's Health be established to deal with health issues that are the responsibility of many ministries.
Q: Do you have difficulty getting public support?
A: Generating the political will to support tobacco control is crucial, but engaging the public is equally important. In October 2008, China's Centre for Disease Control invited more than 2000 artists to take part in the Public Tobacco Control Campaign. Our online survey to gauge support for China's implementation of the WHO FCTC generated 1.4 million "yes" votes within three weeks. We lobbied hard for the separation of government and the tobacco industry, the use of pictorial warnings on packaging, tax increases and legislation to control secondary smoking. Yet the tobacco forces remain all-powerful. They once accused us of acting against the national interest by threatening economic growth; now they just ignore us. But I remain optimistic of progress, given the support we have had from central and regional government, the media and the public.
Q: What is China's attitude to the WHO Framework Convention on Tobacco Control?
A: At the Durban session of the WHO FCTC in November 2008, I was one of the Ministry of Health's representatives on China's delegation, which was led by the Ministry of Industry and Information Technology. But as the director of the State Tobacco Monopoly Administration also sits on the party committee of the ministry, it was like having the Administration lead the delegation. The attitude towards tobacco control shown by the delegation was terrible. One speaker argued that Chinese tobacco packaging featured mountains, rivers and monuments, and placing "ugly" pictures besides such scenes would "humiliate the Chinese people". But I don't think these behaviours represent the essential attitude of China's government. As we know, tobacco control can reduce the burden of chronic diseases, help resolve the problem of limited medical resources and lead to economic development. The delegation's behaviour at the Durban session was merely a manifesto of the opposition from vested interest groups.
Q: What else needs to be done?
A: Tobacco control is by no means just the business of the Ministry of Health. Many parties need to promote advocacy and policies such as banning smoking in public venues, promoting tobacco tax increases, etc. There needs to be more research on the harmful impact of tobacco; precise monitoring of the prevalence of tobacco use; and criteria need to be developed for evaluating tobacco control.
Q: Is there support for tobacco control across government departments?
A: Most government departments support control measures. In December 2008, the Ministry of Civil Affairs was to award six tobacco companies with China's National Charity Award. These firms had financed schools named after their brand, which in some cases was printed on student uniforms. We convinced the ministry to drop the companies from its award list; the Shanghai Municipal Government declined a 200 million yuan sponsorship from Shanghai Tobacco Co. for the World Expo; and a project sponsored by the Bloomberg Foundation has reached 40 cities in 20 provinces, affecting 64 million people. All the mayors of participating cities have banned smoking in public indoor venues and 16 cities have passed regulations banning smoking in offices, schools, restaurants and hospitals.
Q: What is the profile of smokers in China?
A: Smoking rates among Chinese men have been consistently high in recent history, comparable to those in Poland, the Republic of Korea and the Russian Federation a few decades ago. Other countries have achieved more in tobacco control while China out-puffs the western countries. We found that in 2007, 57% of males smoked, although that was a decrease of 2% on 2002. This was attributed to smokers aged over 45 heeding doctors' warnings to quit. In theory, it will take a generation to reduce the rate as youngsters are educated not to smoke throughout their lifetime. As for Chinese women, a strong prejudice against female smoking developed between the 1950s and the 1970s, resulting in low rates [3.7% prevalence]. Today, while more female students and educated career women tend to smoke, the overall rate remains low. We believe rates have hit an historical low and will likely increase.
Q: Which group is the most difficult to educate on tobacco control?
A: The rural population, because they receive the least health education and resources. The most important groups to reach, however, are the doctors and governmental officials at the local level. The officials in particular are given information about the effects of smoking but turn a deaf ear to it as they receive cigarettes as gifts, as part of a social trend. That is why it is difficult to control tobacco smoking in China; it often goes beyond public health boundaries.
Q: Why is there such high exposure to secondary smoking in China?
A: About 53% of non-smokers are exposed to second-hand smoking in China. Several social factors contribute to this. Gender inequality makes many women powerless to stop men smoking at social gatherings. The National Tobacco Control Office has urged people not to provide cigarettes to guests or give them as gifts. Generally, smoking is far from being considered socially unfavourable.
Q: What was the reaction to a 2005 Beijing University study that found the health costs of tobacco far exceeded the profits from the tobacco industry?
A: No government department is discussing this research even though the study and its conclusions are robust. Medical costs definitely exceed tobacco revenue, but it does not make sense for the government to compromise its revenue to reduce medical costs, which are mostly shouldered by the public due to inadequate health insurance. The workforce loss indicated by the study is a long-term problem, but most local governmental officials are focused on today's issues.