Protecting People from Tobacco Smoke in China: Current Status and Challenges

Introduction

Over the past two years, many people have encountered difficulties due to the advent of coronavirus disease 2019 (COVID-19). The COVID-19 pandemic has unleashed many concerns, such as social isolation and loneliness, drastic lifestyle changes, uncertainty about the future, and financial pressure. Some people reported smoking more than usual to reduce stress or loneliness, which has made more individuals vulnerable to exposure to second-hand tobacco smoke (SHS). As we know, there is no safe level of exposure to SHS, and even brief exposure can cause harm. Under these circumstances, it is crucial to reiterate the topic of protecting people from the harms of SHS.

To help countries fulfill the promise of the World Health Organization (WHO) Framework Convention on Tobacco Control (FCTC), WHO has established MPOWER, a package of the six most important and effective tobacco control policies: Monitoring Tobacco Use and Prevention Policies (M), Protecting People from Tobacco Smoke (P), Offering Help to Quit Tobacco Use (O), Warning about the Dangers of Tobacco (W), Enforcing Bans on Tobacco Advertising, Promotion and Sponsorship (E), and Raising Taxes on Tobacco (R). China ratified the WHO FCTC in 2005. It has been more than 16 years since the FCTC came into force in 2006. However, China still has a significant population exposed to SHS, with an estimation of 702 million people based on the 68.1% SHS prevalence in 2018. According to the WHO report of 2021, in China, the “Protecting People from Tobacco Smoke” (P) received the lowest grade compared to the other five strategies. Therefore, this article will analyze the current status and challenges for P in China.

SHS: A Serious Issue in China

The WHO FCTC requires each Party to provide a completely smoke-free environment in indoor workplaces, public transport, indoor public places, and other public areas. However, the indoor environment in China remains a serious issue.

In 2010, 740 million (72.4%) non-smokers were exposed to SHS in public places in China. By 2018, the prevalence decreased slightly to 68.1%, but the total exposed population was still more than 700 million. In 2018, 50.9% reported exposure to SHS occurring at indoor workplaces and 44.9% at home. The worst exposures in indoor public places were in internet cafes (89.3%), nightclubs & bars (87.5%), and restaurants (73.3%).

Health Problems Caused by SHS

The scientific evidence of the harm of SHS has been conclusively established since 1986, following the US Surgeon General’s report. Numerous studies have shown that exposure to SHS contributes to various serious and often fatal diseases in non-smokers, including lung cancer, cardiovascular and other chronic diseases, and sudden infant death syndrome. The WHO report of 2009 estimated that SHS caused about 600,000 premature deaths annually worldwide. The Global Burden of Diseases (GBD) 2019 study estimated this number had doubled, reaching 1.304 million. Most deaths attributable to SHS occurred among children and women.

In China, the vast population exposed to SHS leads to a significant burden of disease. Research has indicated that SHS caused around 22,200 deaths from lung cancer and 33,800 deaths from ischemic heart disease (IHD) in 2002. According to GBD 2019 results, the largest number of deaths attributed to SHS was observed in China, increasing from 382,000 in 2010 to 416,000 in 2019. In 2019, deaths attributable to SHS in China accounted for 31.9% of the world’s total.

Fortunately, smoke-free laws can reduce exposure to SHS. A 100% smoke-free environment is the only proven way to adequately protect health from the harmful effects of SHS. Smoke-free policies have been shown to decrease SHS exposure by 80%–90% in high-exposure settings. Additionally, scientific evidence establishes that an immediate reduction in heart attacks and respiratory problems results from implementing a 100% smoke-free policy, with acute myocardial infarction (AMI) being the most sensitive disease to these policies.

Milestones in Controlling SHS in China

Tobacco control in China has been ongoing for more than 40 years, dating back to the late 1970s. In 1979, the Ministry of Health (MOH) and other ministries jointly issued a notice on health education regarding the harm caused by smoking and control measures. Between 1988 and 1998, various campaigns for smoke-free hospitals, schools, and public transport were conducted, supported by international organizations like WHO and the World Bank.

In 1997, China hosted the 10th World Conference on Tobacco or Health, which was significant for tobacco control efforts. Notably, prior to this conference, China implemented a national policy banning smoking in public transport and waiting areas.

In 2003, China actively joined the WHO FCTC as the 77th party member, and the FCTC came into force in China in 2006. In 2007, the State Council approved establishing the WHO FCTC implementation coordination mechanism, with the State Tobacco Monopoly Administration (STMA) as the leading group, which violated Article 5.3 of the WHO FCTC. In 2018, the implementation coordination mechanism was reorganized with the National Health Commission (NHC) as the chair, marking significant progress.

Following 2016, in the Post-FCTC era, China launched more tobacco control initiatives, including creating a nationwide smoke-free medical and health system, holding the “Smoke-Free Olympics” in 2008, and enacting local legislations for smoke-free indoor public places. The China Tobacco Control Action Plan (2012–2015) was released in 2012 to meet Article 5.1 of WHO FCTC requirements, but unfortunately, by the end of 2015, its goals were not achieved. Currently, the plan remains a national tobacco control plan without follow-up. One encouraging step is the inclusion of tobacco control in the Healthy China 2030 Strategy, set by the Political Bureau of the Central Committee of the Chinese Communist Party in 2016. The Healthy China Action Plan (2019–2030) includes two targets: 1) reducing smoking prevalence among people aged over 15 to lower than 24.5% by 2022 and 20% by 2030, and 2) achieving 30% and 80% of the population protected by 100% smoking bans by 2022 and 2030, respectively.

Absence of Comprehensive National Smoke-Free Law

According to Article 8 of the WHO FCTC, each Party must enact a comprehensive national smoke-free law. The WHO report of 2021 indicated that 67 countries received Grade I for P, where smoking bans were at best-practice level. Among them, 72% were middle- or low-income countries. However, China received the lowest grade (Grade IV) for this strategy, indicating a complete absence of a national ban or only two public places completely smoke-free across the country.

After 16 years of implementing the WHO FCTC, China still has not met its obligations and lacks a comprehensive national smoke-free law. On November 24, 2014, a long-awaited draft national tobacco control guideline was released by China’s State Council, aiming to reduce tobacco smoke harms and protect public health. This draft was meant to gather public feedback by the end of 2014, but it has not progressed since then.

The Chinese population is eager for 100% national smoke-free regulations. A national survey in 2018 showed high support for a smoke-free ban in public places, with over 90% supporting a ban in indoor workplaces and public spaces. Support for restaurants and bars/nightclubs was slightly lower, at 80% and 60%, respectively. Even smokers showed considerable support.

Smoke-Free Legislation at the Subnational Level

Currently, approximately 1.8 billion people (a quarter of the world’s population) live in 67 countries (34%) covered by the best-practice smoke-free laws worldwide.

In China, although there is no comprehensive national smoke-free law, momentum continues to grow at the subnational level. More than 20 cities have taken promising steps to enact laws or regulations that meet WHO FCTC requirements, including Beijing, Shanghai, Shenzhen, and others. Notably, in 2021, Beijing upgraded its comprehensive smoke-free law in line with the amended Minors Protection Law, emphasizing youth protection from SHS. As for the Healthy China Action Plan target—30% of the population protected by complete smoking bans by 2022—some provinces have achieved success, including Beijing (100%), Shanghai (100%), and Henan (69.6%).

Some cities have enacted bans on smoking in public places, but they cannot be regarded as smoke-free cities due to unclear requirements for complete smoke-free indoor public spaces, workplaces, and public transport. An example is Chongqing, which allows smoking areas in restaurants, hotels, and places of amusement, setting a negative precedent for tobacco control in China.

In brief, only 195 million people (13.8% of the population) are protected from a smoke-free environment, indicating a significant gap from the Healthy China Action Plan targets.

Current Status of Policy Enforcement in China

Smoking prevalence is declining in cities with comprehensive smoke-free laws. Beijing and Shanghai began enforcing comprehensive smoke-free laws in 2015 and 2017, respectively, leading to a decline in smoking prevalence rates. In 2014, one year after enforcing a 100% smoke-free policy in public places, Beijing reported a drop in smoking prevalence rates from 29.6% to 22.9%. Additionally, according to the China Tobacco Control Survey (CTCS) conducted in 2019, the smoking prevalence in Beijing dropped to 21.7%. Shanghai witnessed a decline in smoking prevalence from 25% in 2013 to 22% in 2019.

In contrast, while smoking prevalence is declining in cities with comprehensive smoke-free laws, in cities with weaker enforcement, the prevalence of smoking is stable or increasing. The 2020 CTCS revealed that smoking prevalence in Guangzhou remained stable at 23.2%, and the prevalence rate of SHS exposure in public places in Guangdong province increased from 55.7% in 2018 to 67.4% in 2020.

However, the effective implementation of smoke-free laws has faced significant challenges. Enforcement of local regulations has been weak, with violations often unpunished. For example, during a survey conducted by Beijing University and the National Health Commission in 2018, 29.7% of smokers reported being able to smoke indoors in public places. Smoking was particularly prevalent in internet cafes, bars, and restaurants, where enforcement was often lacking. In contrast, the self-regulation of bars and nightclubs failed to meet expectations, leading to inadequate protection against SHS for non-smokers. Public places like schools, hospitals, and other organizations often lack comprehensive smoking policies.

Tobacco Industry Interference

According to Article 5.3 of the WHO FCTC, the tobacco industry has a clear conflict of interest in promoting tobacco products, and Parties should adopt measures to protect public health policies from commercial and other vested interests of the tobacco industry.

The tobacco industry has a long history in China, dating back to the late 19th century. The country has the largest tobacco industry in the world, producing around 2.5 trillion cigarettes annually. Consequently, the industry has exerted significant influence over tobacco control measures in China, obstructing the development of comprehensive national smoke-free laws.

Government regulations must balance tobacco control and economic interests. However, the dominance of the tobacco industry has hindered tobacco control efforts. For example, although China’s State Tobacco Monopoly Administration (STMA) has implemented measures to control tobacco sales, its dual role as both regulator and promoter of the industry raises serious conflicts of interest. Tobacco companies continue to exert influence over local governments, which has hampered the enforcement of local smoke-free laws and the promotion of public health policies.

Conclusion

In summary, protecting people from tobacco smoke in China faces significant challenges. The lack of a comprehensive national smoke-free law continues to expose a substantial population to SHS. Despite progress at the subnational level, enforcement of existing laws remains weak. Continued efforts to strengthen tobacco control policies, promote public awareness, and protect against tobacco industry interference are essential to improve public health outcomes in China. To protect the health of non-smokers, especially children, it is critical for China to fully implement its commitments to the WHO FCTC and strive toward a smoke-free environment for all.

Current Status

In recent years, China has made strides in tobacco control and protecting public health from the harmful effects of tobacco smoke. As the world’s largest consumer of tobacco, the country faces significant health challenges due to high smoking rates and widespread exposure to secondhand smoke.

1. Legislation and Policies:
   • The WHO Framework Convention on Tobacco Control (FCTC) has influenced China’s tobacco policies, prompting the government to implement stricter regulations on tobacco advertising, promotion, and sponsorship.
   • Local regulations have been enacted in several cities to create smoke-free environments in public spaces such as restaurants, workplaces, and public transportation.
2. Public Awareness Campaigns:
   • Government and non-governmental organizations (NGOs) have launched campaigns to educate the public about the dangers of smoking and secondhand smoke.
   • Campaigns target various demographics, including youth and women, to discourage tobacco use and promote healthier lifestyles.
3. Health Initiatives:
   • The Chinese government has recognized the need for tobacco control as part of its broader public health agenda, aiming to reduce smoking prevalence and improve overall health outcomes.
   • Smoking cessation programs and resources have been introduced to support individuals seeking to quit smoking.

Challenges

Despite these efforts, several challenges remain in effectively protecting the public from tobacco smoke:

1. High Smoking Prevalence:
   • China has one of the highest smoking rates in the world, with millions of smokers and a culture that often normalizes tobacco use.
   • Rural areas tend to have higher smoking rates, and awareness of the risks associated with smoking may be lower in these communities.
2. Weak Enforcement of Regulations:
   • While regulations exist, enforcement is often inconsistent, and violations of smoke-free laws can occur without repercussions.
   • Local authorities may lack the resources or motivation to effectively enforce existing regulations.
3. Influence of the Tobacco Industry:
   • The China National Tobacco Corporation holds significant economic power and influence, which can hinder comprehensive tobacco control efforts.
   • The industry’s lobbying efforts and marketing strategies continue to promote tobacco use, undermining public health initiatives.
4. Cultural Attitudes:
   • Social norms surrounding smoking can complicate efforts to change attitudes towards tobacco use.
   • Tobacco is often associated with social interactions, and quitting can be challenging for many individuals due to peer pressure and cultural expectations.
5. Limited Access to Cessation Resources:
   • Although cessation programs exist, access to resources and support for quitting smoking is still limited in many areas, particularly rural regions.
   • Health care providers may not always receive training to effectively support patients in quitting smoking.

Conclusion

Protecting people from tobacco smoke in China requires ongoing efforts to strengthen legislation, improve enforcement, and increase public awareness. While significant progress has been made, addressing the challenges posed by high smoking prevalence, cultural attitudes, and industry influence is essential for creating a healthier environment and reducing the burden of tobacco-related diseases in the country. Enhanced collaboration between government, NGOs, and health professionals can lead to more effective tobacco control strategies and ultimately protect the health of the population.