Smoking ban in China

On May 20, 2009, the Ministry of Health of the People's Republic of China issued a formal decision to completely ban smoking in all health administration offices and medical facilities by the year 2011. With an ever-increasing Chinese smoking population of over 350 million, the enactment of the May 20 initiative represents 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 populational health impacts of smoking within the last decade.

Impact of the 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 work places, public areas, and public transportation vehicles.

Despite China's own widespread and complex smoking issue, the ratification of the FTCC 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.

Chinese Ministry of Health Report

Prior to enacting the nationwide smoking ban, the Chinese 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 on the basis of 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

Although China still lags behind many countries in implementing tobacco control policy, the Ministry of Health's May 20 initiative represents a tremendous positive step in helping to establish more unified smoking controls and codify public health authority at broad administrative levels. The Ministry's "Decision" formally requests localities 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 in order to "actively promote the importance of implementing a total smoking ban in military and civil health administration offices and medical and health institutions."

Popular 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, the fourth lowest rate of 14 ITC countries surveyed."

Dissent, Skepticism, 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 populational impact of de jure national smoking bans. In practice, it is often the case that only government offices, schools, museums, 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 Heath, “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 the rural countryside, 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 plantation 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:

• In addition to "strong social pressure placed upon Chinese men to smoke", it is also expected that female smoking will become "more socially acceptable as the tobacco industry increasingly targets female smokers."

Current tobacco control legislation in China does not explicitly address gendered or social bases for smoking.

• Smoking cessation is "relatively uncommon in China, and most smokers quit cigarette smoking because of chronic illness." Indeed, "awareness of the health risks of smoking is low in China. Only 68% of smokers believe that smoking causes lung cancer in smokers (compared to well over 90% in Western countries) and 54% believe that smoking causes lung cancer in non-smokers. Only 37% of smokers are aware that smoking causes coronary heart disease and only 17% are aware that smoking causes strokes."

In order to maintain a robust, sustainable effort in tobacco control, China will particularly need to focus upon the role of public health education in smoking prevention and health promotion.

• "Taxation is a very effective method of reducing tobacco use. However, very few smokers (5%) in the ITC China Survey reported thinking about price as a reason to quit smoking—a sign that prices are too low."

Current tax regulations in Chinese tobacco control policy are limited, inconsistent, and tied to the structural intricacies of domestic ownership and control of tobacco production and distribution.

Regional and City-Wide Initiatives

Shanghai

In light of its preparations to host the 2010 World Expo, the city of Shanghai has recently heightened its anti-smoking legislation. The Shanghai People's Congress issued the city's first smoking control law in March 2010. The law bans smoking in 12 types of public places including indoor smoking at schools, hospitals, sport stadiums, public transport vehicles and Internet cafes. Anyone caught smoking would first be given a warning and then face a fine of 50 to 200 yuan if they resist. According to Li Zhongyang, the deputy head of the Shanghai Health Promotion Committee, the smoking ban was enacted to protect citizens’ health and also promote Shanghai’s image as a cosmopolitan city.

According to a report by the Fudan University Media and Public Opinion Research Center, 93.5% of the 509 people they interviewed supported a smoking ban at all Shanghai Expo 2010 pavilions and also felt that smoking should not be allowed in restaurants or shopping centers near the Expo area. Another survey done by public health experts from Fudan University which involved 800 hotel guests and around 4,000 patrons and employees of restaurants, shops and entertainment venues in Shanghai found that about 73 percent of the hotel guests said Shanghai should adopt a smoking ban in public areas, 84 percent of restaurant guests reported exposure to second-hand smoke, and 74 percent of them were annoyed by the fumes and support smoking controls. While many interviewers found second-hand smoke itself toxic and damaging to citizen’s health, a main reason behind popular support for the smoking ban relates to the citizen’s concern for Shanghai’s image. According to one citizen that the public health experts from Fudan interviewed, "Smoking has been banned in public places in several countries. We should do the same, at least during the Expo, since it is a cosmopolitan event. And of course, for the sake of the public who would be visiting." For organizers of the Expo, there was also the issue of hypocrisy if they did not deal with China’s severe smoking problem as part of their “Healthy Expo.”

Despite the popular support for the Shanghai smoking ban, many also feel skeptical about the actual implementation of the law. Shanghai residents point out that despite the fact many shopping malls and all subways and subway stations actually already banned smoking prior to this law, there is low compliance and people often smoke directly in front of NO SMOKING signs. One most basic concern Shanghai residents have regarding the ban is the lack of clarity regarding who will do the fining and who will report the offenses. Public health experts agree that it will be difficult to enforce a strict ban with the large amount of smokers present in Shanghai.

In addition to passing the smoking ban, Shanghai legislators have designed a Chinese website Smoke Free China to raise anti-smoking awareness. Also, the most concrete measure that has been taken is that Expo organizers refused a 200 million yuan ($29.3 million) donation from the Shanghai Tobacco Company last year to maintain their "healthy Expo" stance.

Beijing

In light of the passage of national tobacco initiatives and international publicity for the 2008 Summer Olympics, the Beijing city government extended a public smoking ban on May 1, 2008 to include sports venues and all indoor areas of government offices, transport stations, schools and hospitals. The ban had a generally strong impact, with poll results suggesting that a majority of Chinese residents (69% out of over 10000 respondents) are "not only aware of a smoking ban in Beijing, but [95% of respondents] also hope that the authorities promote the move nationwide."

According to China Daily News,

"The survey also showed that 81.6 percent of respondents were eager to stop smoking, or had heard of family members and friends who were considering kicking the habit. 'I am delighted by such encouraging support from the public, it will help to promote legislation to control tobacco use,' [said] Jiang Yuan, vice-head of the tobacco control office under the Chinese Center for Disease Control and Prevention."

The Beijing government has also adopted a policy of persuasion, combined with a fine of up to 5,000 yuan ($730) for violating the ban, in an attempt to further encourage citizens to curtail public smoking.

Interestingly, a direct positive public health impact of the Beijing smoking ban has manifested in the arena of fire prevention. According to People's Daily,

"The smoking ban has cut the number of fires in the city sparked by cigarette butts by more than half ... In the first week of this month, the Beijing fire brigade put out eight cigarette-related fires, an average of 1.14 per day ... The new daily average [after the extended smoking ban] was less than half of what was reported in the first four months of this year, when the city's firefighters had to put out 325 fires caused by cigarette butts, or 2.7 per day."

Guangdong Province

In 2007, Guangzhou and Jiangmen became Guangdong's first two cities for experimental enforcement of total smoking ban at some public places. The public places for smoking ban included restaurants, entertainment outlets, schools, supermarkets, and governmental offices. However, by March 2010, the Guangzhou Municipal People's Congress prepared to lift the smoking ban in work places, including offices, conference rooms and auditoriums.