Smoking in China is prevalent, as the People’s Republic of China is the world’s largest consumer and producer of tobacco. As of 2022, there are around 300 million Chinese smokers, and 2.4 trillion cigarettes are sold there every year, accounting for 46% of the world total.

Tobacco Industry

The China National Tobacco Corporation is, by sales, the largest single manufacturer of tobacco products in the world and boasts a monopoly in mainland China, generating nearly $213 billion in revenue in 2022. Within the Chinese guanxi system, tobacco is still a ubiquitous gift acceptable on any occasion, particularly outside urban areas. Tobacco control exists as smoking bans, but public enforcement is rare outside the largest cities, such as Shanghai and Beijing. Furthermore, outside the largest cities in China, smoking is considered socially acceptable anywhere at any time, even if it is technically illegal. Smoking is a social custom in the PRC, and giving cigarettes at any social interaction is a sign of respect and friendliness.

Tobacco Control Organizations

The Chinese Association on Tobacco Control (中国控制吸烟协会; Zhōngguó kòngzhì xīyān xiéhuì) is engaged in tobacco control by members of the voluntary sector, including academic, social, and mass organizations, as strong enforcement of existing tobacco control laws is not supported by the Chinese Government.

Tobacco Control Legislation

Overview of Regulations

On May 20, 2009, the Ministry of Health of China issued a formal decision to completely ban smoking in all health administration offices and medical facilities by the year 2011. The enactment of the May 20 initiative represented an important landmark in China’s commitment to tobacco control. However, due to the Chinese government’s complex relationship with tobacco policy (for instance, many localities rely upon tobacco tax revenue as a substantial source of income), there have been many concerns about the practicality of the national policy’s enforcement.

In addition to the May 20 measure, numerous provincial and city-level administrations in China have also enacted policies to control the prevalence and health impacts of smoking within the last decade.

WHO Framework Convention on Tobacco Control

On October 11, 2005, China became the 78th country in the world to ratify the WHO Framework Convention on Tobacco Control (FCTC), an international treaty intended to reduce tobacco-related disease and death. Under the conditions of the FCTC, China is required to completely ban “promotion and sponsorship on radio, television, print media, and the Internet within five years,” as well as to prohibit tobacco companies from sponsoring international events or activities. China has also resolved to ban all tobacco vending machines, as well as smoking in indoor workplaces, public areas, and public transportation vehicles.

Despite China’s own widespread and complex smoking issue, the ratification of the FCTC in China represents a significant commitment to tobacco control in international public health policy. According to Dr. Shigeru Omi, the WHO Regional Director for the Western Pacific region, “implementing the Convention will not be easy, as smoking is an ingrained habit in China … but the Government has made clear its commitment to take action.” In light of the FCTC, concerns about international image, and strong support from both citizens and domestic health authorities, the Chinese government has become increasingly involved in tobacco prevention and tobacco-related health promotion programs.

Ministry of Health Report

The Ministry of Health had already maintained active involvement in decrying the negative effects of smoking and striving toward decreased prevalence of tobacco use. On May 29, 2007, the Ministry released a report (2007 年中国控制吸烟报告—The 2007 China Smoking Control Report) detailing alarming levels of secondhand smoke exposure (affecting over 540 million Chinese citizens), recommendations for legislation to reduce harm from secondhand smoke, and the feasibility of implementing public smoking bans based upon polling data. Notably, the report agreed with international scientific consensus about secondhand smoke, citing numerous findings from public health authorities in other countries to assert the conclusion that “there is no safe level of exposure to second-hand smoke,” that ventilation equipment is ineffective in reducing the harm from exposure to second-hand smoke, and that the most effective protective public health measure against smoking is a legislative ban of smoking in public places. With an explicitly stated objective of “building smoke-free environments for the sake of enjoying healthy life,” the report has received strong support and praise from the Campaign for Tobacco-Free Kids, a U.S. health advocacy group based in Washington, D.C.

In addition, the report suggested a strong likelihood of success for the implementation of complete public smoking bans in seven major urban areas based on demonstrated widespread popular support for such measures. According to an analysis by the Campaign for Tobacco-Free Kids, polling data in the Ministry of Health report revealed:

“Overwhelming public support for the enactment of totally smoke-free public spaces … support for total smoking bans exceeds support for partial smoking bans … Among smokers, the polls found that 93.5% support a total ban on smoking in all schools, 75.5% support a total ban in hospitals, and 94.3% support a total ban in all public transport. Among non-smokers, 95.1% support a total ban in all schools, 78.1% support a total ban in hospitals, and over 93.8% support a ban in public transport. Some 70.6% of non-smokers support some type of smoking ban in bars and restaurants.

Nationwide Ban Initiatives

Although China still lags behind many countries in implementing tobacco control policy, the Ministry of Health’s May 20 initiative helped to establish more unified smoking controls and codify public health authority at broad administrative levels. From 2009, Projects sponsored by the Bloomberg Initiative and directed by Yang Tingzhong were designed as the first program to prohibit all forms of smoking in university campuses in China. The Ministry’s “Decision” formally requests local governmental units to “set up multi-agency FCTC Implementation Leading Small Groups” to assist with regional strategies of enforcement, with the explicit goal that:

“by the year 2010, all health administration offices, both military and non-military, and at least 50% of all medical and health institutions should become smoke-free units, so that the goal of a total smoking ban in all health administration offices and medical and health institutions can be fulfilled by 2011.”

The “Decision” also encourages health administration offices to utilize mass media resources and draw upon large-scale publicity campaigns such as World No Tobacco Day to “actively promote the importance of implementing a total smoking ban in military and civil health administration offices and medical and health institutions.”

Public Opinion

As polls from the 2007 Ministry of Health report showed, there is widespread public approval of smoking bans among residents of urban areas. Various health experts, activists, and public advocacy groups regard the Chinese government’s escalating efforts toward tobacco policy as “surely good news for the country’s smoking control progress.” Notable support also exists within the sphere of representative politics; allegedly, political advisors of the CPPCC have even gone so far as to call for smoke-free legislative sessions.

However, widespread apathy and tacit acceptance toward smoking policy are likely to predominate within large portions of the Chinese population. China has a relatively low social disapproval rate of smoking—according to the International Tobacco Control Policy Evaluation Project (ITC), “only 59% of smokers think that Chinese society disapproves of smoking,” which is the fourth lowest rate of 14 ITC countries surveyed.

Dissent and Unresolved Issues

Given the complex and multifaceted nature of political agendas in China, governmental public-health-related interests often clash with economic interests. Because tobacco remains a significant source of both health risks and revenue for municipal and national governing entities, specific Chinese tobacco control policies in different contexts may betray an overall position of ambivalence or inconsistency. For instance, local exemptions to public indoor smoking bans are often made for small businesses, particularly in the restaurant and entertainment industries. Such indeterminate enforcements of supposedly well-defined public health regulations in practice may limit the impact of de jure national smoking bans. In practice, it is often the case that only some government offices, schools, museums, some hospitals, and sports venues effectively function as smoke-free areas. In addition, the cultural basis of smoking in China presents a significant barrier to de facto acceptance and integration of smoking control policies. According to Li Xinhua, an expert on tobacco-control publicity and education in the Ministry of Health, “about 60 percent of medical workers and professors are smokers [and thus in violation of the law calling for a complete public smoking ban]. Some of them even smoke boldly in hospitals or schools.” This is problematic because, regardless of whether these professionals continue to smoke out of habit, social custom, or “apparent disregard” for evidence of smoking risk, they are still expected to “behave themselves and set a good example for others in tobacco control,” Li says.

Also, enforcement of national tobacco-control policies is still largely sparse in rural areas, where the state-owned China National Tobacco Corporation exerts much of its influence in tobacco production and marketing. As a response to FCTC recommendations for reduction of access and supply-side tobacco regulation, the Ministry of Health is now targeting farmers to give up tobacco plantations and trying to “convince them that the tobacco industry can be replaced by other industries that are more healthy, sustainable, and profitable.”

Another potential obstacle is the Chinese tobacco industry’s lack of complete compliance with nationally defined policies regarding the correct presentation of warning labels on cigarette packages, which must be readily visible and cover at least 30% of the visible area of the packaging. Wu Yiqun, vice executive director with the Beijing-based Thinktank Research Center for Health Development, criticized China’s tobacco industry supervisory administration for “[failing] to oversee Chinese tobacco producers” in this aspect.

Furthermore, the International Tobacco Control Policy Evaluation Project brings up the following persistent smoking issues in its 2009 report focused on China:

• Infrequent enforcement of smoking bans across various sectors of society.
• Limited efforts in public outreach to encourage cessation of smoking.
• Lack of assistance available for smokers who wish to quit, including stop-smoking programs or quitlines, especially in rural areas.
• The presence of passive smoking as a leading public health threat, especially for women and children.
• Weak implementation of the smoke-free legislation.

Conclusion

In conclusion, while tobacco control measures in China have made progress over the past few decades, enforcement and compliance remain inconsistent. Public attitudes toward smoking are complex and varied, and the tobacco industry continues to hold significant power in the country’s economy. Comprehensive strategies combining regulation, public health advocacy, and social attitudes will be essential for reducing smoking prevalence and addressing the associated health risks in the future.