• Advertising and Promotion
• Advocacy
• Economics
• Public policy
• Taxation and Price

Long viewed by tobacco companies as a ‘prize’ market because of its huge population,1 China trails most other countries in implementing strong, effective tobacco control policies. Advertising still proliferates, workplaces are not widely smoke-free, and cigarette taxes, while increased modestly, remain ineffectively designed for tobacco control purposes. Meanwhile, some one million Chinese people die yearly from tobacco-caused diseases.2

Yet with its giant state-owned tobacco industry and very limited competition, the Chinese government could relatively easily make China the global leader in public health rather than the global leader in profiting from its own people's disease and death. One way to do this would be to raise taxes at the consumer level to an amount significant enough to reduce consumption, as suggested by a paper in this issue of Tobacco Control, 3 and to dedicate those taxes to programmes that change social norms about tobacco and help people to quit.

China's chances of doing so, however, depend on shifting the perspectives of those leaders who still view cigarette smoking as an accepted everyday practice, many of whom are most probably cigarette smokers themselves. In a country that permits China Tobacco Company to fund elementary schools, wherein banners are displayed reading “Tobacco can help you become an achiever,”4 change will take sustained effort from within and international support from without. As with tobacco companies everywhere, the Chinese tobacco industry has worked hard to convey the idea that inhaling toxic gases from a paper tube some 20 times a day is normal. In a country that consumes more than 37% of the world's cigarettes, where almost 60% of men smoke,5 it is not surprising that tobacco use is ubiquitous and widely accepted. What is perhaps still surprising to many in the global tobacco control community is that China ratified the World Health Organization Framework Convention on Tobacco Control (FCTC), marking a commitment to implement stronger measures to stem the tobacco epidemic.

As with tobacco companies everywhere, the Chinese tobacco industry has also linked its deadly products with meaningful imagery to make it seem impossible that cigarettes could be regarded as other than normal, everyday consumer items.6 At the WHO FCTC Third Conference of the Parties (COP-3) in Durban in late 2008, I heard the Chinese delegation argue forcefully and passionately during discussion of guidelines for implementing Article 11 (which deals with packaging and labelling of tobacco products) that their country could not possibly institute graphic warnings on cigarette packs because those packs featured revered cultural icons. To cover them with graphic warnings, they explained, would convey a terrible disrespect. Perhaps the Chinese delegates really believed this. But I also heard the ripples of laughter that followed this assertion, recognition by the rest of the world's delegates that the exploitation of revered cultural images to sell death is itself disrespectful. The provision in question was not weakened.

Unfortunately, while China's costs of tobacco use in disease and death are estimated at $US5 billion yearly and growing,7 profits and taxes from its tobacco corporation top 10 times that amount.8 However, the effects of tobacco are cumulative, and unless they are addressed, tobacco-related disease and death will begin to hurt China's booming economy in the coming years. Also, despite its profitability, cigarette production is of declining importance to the economy, contributing less than 1% to the total value of industrial production in 2002.2

‘Face’ is an important notion in China, on both the level of individuals and that of the state. One does not want to act in a way that may result in ‘losing face’—that is, one wants to act in the socially correct way. This means that tobacco control advocates must work to change norms around tobacco's meaning in society, as in the television campaign ‘Giving cigarettes is giving harm’, illustrated on this issue's cover. This campaign, which is helping to change the meaning of tobacco's symbolic associations in China with gift-giving and special occasions, shows the hapless giver of cigarettes losing face as the recipients shrink back in horror at the real consequences the ‘gift’ represents. The wonderful video is well worth a look (http://www.worldlungfoundation.org/ht/d/sp/i/7217/pid/7217).

Perhaps the desire to not lose face at the level of the state accounted for the fact that the 2008 Olympics inspired stronger smoke-free policies in Bejing: on display before the world, China sought to emphasise its commitment to health. In general, China is showing a new and encouraging openness to addressing global public health threats more aggressively, as seen in its response to the swine flu outbreaks last year. Tobacco control education is being provided for the first time in schools of public health.9 Xu Guihua, vice president of the China Tobacco Control Association, has asserted that China will indeed meet its FCTC obligation and ban tobacco advertising by 2011.10 These and many other current developments there are all signs of hope.

In the end, the choices China makes will determine, in important ways, its chances—its chances for a healthy population and workforce and its chances for saving face in the global public health community by leading the world in implementing the treaty it has ratified, rather than trying to weaken it.