P—protect people from tobacco smoke

At the time of writing this article, there has still been no national ban on tobacco use in public places in China. Some relevant judgments have merely appeared as specific items in other national laws and regulations enacted in the early years.8–12 Mainland China administers 31 province-level divisions, including 22 provinces, 5 autonomous regions and 4 municipalities. Based on CCDC data,13 legislation to ban smoking is in force in all four municipalities. There is no province-level legislation in any province or autonomous region. Thirty out of the 31 provincial capitals and 154 out of the 337 prefecture-level cities (45.7%) have legislation that bans smoking. The public places where smoking is prohibited are stipulated by the local government. Some additional no-smoking areas were identified on the basis of the principles in the national laws and regulations at that time. Although most of the smoking bans entered into force in the 1990s, smoking in public places, including places where smoking is prohibited, remains a serious problem, and the enforcement of the smoking ban is poor.14–22

In the past 3 years, to support major international and domestic events, and to build healthy cities, some cities including Beijing,23 Shenyang,24 Yinchuan,25 Hangzhou,26 Shanghai27 and Guangzhou28 have amended their local smoking bans or issued governmental circulars. The areas where smoking is prohibited and where smoking rooms are allowed to be set up still vary from city to city. The public places where smoking is totally prohibited are: (1) indoor medical institutions; (2) inside and outside nurseries and kindergartens; (3) short-distance public vehicles and (4) indoor public places for science, education, culture and art, as well as indoors at cultural relic sites. The public places where smoking bans in different cities show slight differences are: (1) primary and middle schools, colleges and universities; (2) stadiums and gyms; (3) waiting areas and areas selling tickets for short-distance public transportation and (4) indoor business halls for public utilities, finance and commerce. The public places where smoking areas or smoking rooms are allowed to be set up are waiting rooms for long-distance public transportation and hotels where smoke-free rooms or floors are designated. The public places where the lack of smoking rules results in large differences across the country are workplaces, restaurants, places for entertainment and recreation and business premises for internet access services. In the newly amended local regulations on smoking, which have been enacted over the last 3 years, the highest fines appear in Shanghai; they range from 10 000 to 30 000 RMB for corporate bodies and 50–200 RMB for individuals. The fines in other cities range from 1000 to 5000 RMB for corporate bodies and 5–50 RMB for individuals. On the whole, the punishment for violation is generally regarded as being too light for both corporate bodies and individuals.

Lacking the clear leadership for national legislation, local legislation on smoking is quite varied. In general, smoking is banned in a limited number of public places in China, which is far from what is required in the FCTC,1 especially considering that ‘engineering approaches, such as ventilation, air exchange and the use of designated smoking areas, do not protect against exposure to tobacco smoke’.2 There are difficulties in violation reporting, law enforcement and monitoring. Because the national tobacco control legislation has not yet been brought into the legislative agenda of the National People's Congress and the State Council, it will be hard to achieve large strides towards providing universal public protection from tobacco smoke in the near future. In 2009, the NHSLG issued Resolutions on Achieving 100% Smoke-free around National Healthcare System in 2011,7 which requires a total smoking ban in departments of health administration and medical institutions in 2011. However, no specific funding has yet assigned for these antismoking efforts. These efforts also lack professional guidance, monitoring and external evaluation.

O—offer help to quit tobacco use

In 2008, Yang et al surveyed 39 248 first-line doctors from 977 hospitals in 96 Chinese cities.29 30 The results showed that 86.8% of the doctors erroneously believe that ‘nicotine in cigarettes is the chemical substance that causes cancer’, 50.3% believe that ‘filters reduce the harm of smoking’ and 38.9% believe that ‘lower tar and nicotine cigarettes are less harmful’. These misperceptions31 may have an important impact on doctors' knowledge concerning smoking cessation treatments, especially nicotine replacement therapy (NRT), and their willingness and ability to provide smoking cessation advice. Also, in this survey, 17.4% of the doctors reported that they never or seldom asked their patients about smoking, 37.4% checked smoking status only when patients' diseases were associated with smoking and 45.2% checked smoking status most of the time. Only 2.4% of the doctors had ever prescribed a smoking cessation medicine to their patients. Between 2007 and 2009, several surveys found similar results, suggesting that the tobacco control capabilities of Chinese medical staff are weak.32–42 Furthermore, the high prevalence of smoking among medical staff in China (ie, 38.7% of men, 1.1% of women and 20.4% in total are current smokers) is also a barrier to their ability to offer effective help to other smokers.30

The MOH and the Office of the National Patriotic Health Campaign Committee (PHCC) state that ‘healthcare providers should have the knowledge and skills to provide smoking-cessation services and at least give brief advice routinely to all smokers’ and that ‘healthcare providers who are specialists in smoking-cessation counseling and quitlines should be available in the hospital’ are two of the requirements for a smoke-free hospital.43 All hospitals around the country are encouraged to meet these two requirements for a smoke-free hospital in 2011.7

W—warn about the dangers of tobacco

The STMA and the GAQSIQ jointly enacted the Provision on Cigarette Packaging and Labelling Selling within the Territory of the People's Republic of China, which came into effect on 1 January 2009.44 However, there is still a considerable gap between the provisions and the FCTC requirements.2 These gaps include:

1. Location: The FCTC requires the health warnings to be positioned at the top of the principal display areas on both the front and the back of each unit packet and package, but the Chinese provision requires them to be positioned at the bottom.

2. Size: The FCTC specifies that the area of the health warning should be 50% or more, but no less than 30%, of the principal display area, and the text should be in bold print in an easily legible font size. The provision takes the minimum requirement of no less than 30% of the principal display area. The height of Chinese characters is required to be not less than 2.0 mm and the text does not need to be in bold print.

3. Use of pictorials: Pictorial health warnings are not required in the provision.

4. Colour: The provision states that the background colour of the health warning area can be the same as that of other areas in the package, but it should be in a different colour class from the text of the health warning. By not requiring contrasting colours for the background of the text as required by the FCTC, this provision fails to enhance noticeability and maximise the legibility of text-based elements of health warnings and messages.

5. Message content: Two sets of health warnings are mandated. The first set states ‘Smoking is harmful to your health’ and ‘Quit smoking reduces health risk’, whereas the second set states ‘Smoking is harmful to your health’ and ‘Quit smoking early is good for your health’. The warnings and messages do not fully address the specific health effects and the impact of exposure to tobacco smoke.

6. Language: The provision requires Chinese characters to be used on the front side, while English words are to be used on the back.

7. Information on constituents and emissions: Quantitative statements on cigarette packages about tobacco constituents and emissions are required in the provision, such as the amount of tar, nicotine and carbon monoxide. This is contrary to the FCTC standards.

In January 2009, Jiang et al developed prototypes of 10 sets of health warnings using the packaging of ChungHwa brand cigarettes as the background, including two sets of small, text-only health warnings used in mainland China (one old version before 2009 and one new version since 2009), four sets of larger warnings with pictures used in other countries (translated into Chinese) and the same four sets of larger, text-only warnings used in other countries (translated into Chinese).45 A survey of these health warnings in four Chinese cities indicated that larger warnings with pictures were more likely to encourage tobacco users to quit smoking and to discourage smoking among youth than larger text-only warnings, although both these types of warnings were better than the small text-only warnings used in China. The new health warnings, which meet the requirements of the provision in 2009, have had a very limited impact compared with the old health warnings. This survey also showed that health warnings in English printed on the back of the package played little role in warning consumers. The percentage of smokers who could not correctly translate ‘Smoking is harmful to your health’ and ‘Quit smoking early is good for your health’ into Chinese was 73.2% and 89.9%, respectively.

In response to these weaknesses in the new Chinese health warnings on tobacco packages, in 2008 the Framework Convention Alliance (FCA) presented China a ‘Dirty Ashtray Award’ for attempting to mock the Article 11 guidelines by citing its preference for beautiful cigarette packaging over the health of its citizens.46

E—enforce bans on tobacco advertising, promotion and sponsorship

The Advertising Law of the People's Republic of China enacted in 199547 and its Provision on Tobacco Advertising,48 prohibits: tobacco advertisements on radio, television, movies, newspapers and magazines; tobacco advertisements in public places, including all types of waiting rooms, cinemas, theatres, conference halls, stadiums and gyms and advertisements for tournaments and shows named after the tobacco industry or tobacco products in the media mentioned above. In settings where tobacco advertising is not banned, the warning ‘Smoking is harmful to your health’ must be included in the advertisement. The departments of administration for industry and commerce are responsible for monitoring advertisements. According to the Ban on Smoking in Public Transport and Waiting Rooms enacted in 1997,9 tobacco advertising inside and outside public vehicles and in the waiting rooms for long-distance public transportation are prohibited. In the Requirements for Ratification of National Tobacco Advertising-Free Cities49 issued by the MOH and the SAIC in February 2003, the requirements for tobacco advertising were extended. However, the application and ratification processes to be designated a National Tobacco Advertising-Free City were based on the principles of self-assessment and voluntary application; that is, this procedure was not audited by any independent third party to assess whether these standards were complied with.

An ITC survey in six Chinese cities in 2006 showed that, overall, 40.3% of Chinese smokers reported noticing messages designed to encourage smoking at least once in the last 6 months.50 A total of 27.9% of respondents noticed tobacco sponsorships for sports and arts events, whereas 38.5% noticed tobacco promotion of various forms. In 2007, Li observed 73 outdoor tobacco advertisements in 19 administrative districts and counties of Shanghai, which were mainly promoting tobacco companies or tobacco products.51 Most of these outdoor tobacco advertisements stood on both sides of major roads or on buildings along key streets.

The tobacco industry continually takes advantage of loopholes in the laws and plays ‘edge ball’ games. In addition to corporate image advertisements, brand extension advertisements and related sports events, film and TV programmes with tobacco brands through sponsorship or title sponsorship, tobacco companies frequently appear in the mass media by way of donating to the public welfare, thus gaining increasing influence. The first choice of these tobacco companies is to donate money to support schools, especially primary and middle schools. For instance, there are 17 Hope Primary Schools named after tobacco brands in China.52 According to a report from the CATC, between September and December of 2009, there were 79 major public welfare, sports and entertainment events receiving donations from tobacco companies. Of these, 63 were public welfare donations that occurred in 40 cities and counties in 15 provinces, and 8 were sports and entertainment donations.53 Moreover, eight tobacco companies were even praised by local governments in recognition of their public welfare donations.

Of the 140 most charitable domestic corporations that won the China Charity Award in 2008 as announced by the Ministry of Civil Affairs (MOCA), 6 were tobacco companies, and the China National Tobacco Corporation (CNTC) ranked first, as it had donated the most money of all of the companies considered.54 Fortunately, the six tobacco companies were removed from the list of award winners thanks to the strong opposition from various circles.55 In addition, there were no tobacco companies in the nomination list for the China Charity Award in 2009.56 In May 2009, the Shanghai Tobacco (Group) Corporation donated 200 million RMB to the China Pavilion of the Shanghai 2010 World Expo. Twenty professionals wrote a letter to the Bureau of the Shanghai World Expo Coordination appealing for the return of the money to the donor. After the letter was disclosed to the public, the Bureau terminated the donation contract 74 days later.

R—raise taxes on tobacco products

The MOF and the State Administration of Taxation (SAT) jointly issued the Notice on Adjusting Consumption Tax of Tobacco Products, which came into force on 1 May 2009.57 58 According to the statement, the purpose of this consumption tax adjustment was to ‘increase government revenue from tobacco products and improve the consumption-based tax system’. Tobacco control was not taken into consideration.

All adjustments were levied on the producer price. After the adjustment, the consumption tax rate for Grade A cigarettes rose from 45% to 56%, Grade B cigarettes from 30% to 36% and cigars from 25% to 36%. Meanwhile, the price point that separates Grade A from Grade B cigarettes also rose from 50 RMB to 70 RMB. In addition, a 5% ad valorem tax was added to the wholesale price of cigarettes. According to a calculation by Hu et al,58 the new tax rate on the retail sale of the product was 43.4%, which is 3.4% higher than the previous rate, but still much lower than the median tax rate (65–70%) in other countries.59

For the purposes of tobacco control, the tax rate on lower-priced cigarettes should have been increased by substantially raising the unit tax. However, the unit tax rate during this period of adjustment remained unchanged until the time of writing this article. Based on this new policy, the ad valorem tax on cigarettes with a production price below 7 RMB and 5 RMB increased by 11% and 6%, respectively, while the ad valorem tax on cigarettes at 5–7 RMB reduced by 9% instead.58 Thus, it is obvious that this wave of adjustment mainly influences smokers who consume middle-priced or high-priced cigarettes above 7 RMB, and it has little influence on smokers who consume low-priced cigarettes.

Theoretically, increasing the tax rate on production should directly raise the sales price. However, both the wholesale and the retail prices of cigarettes have remained stable since the adjustment of the tobacco tax in May 2009. This indicates that tobacco companies have absorbed the tax adjustment, bearing the burden of the increased tax. The increased tax rate has little impact on the retail price of cigarettes and thus has no impact on consumers.60