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Smoking in China: Can or Should China Kick the Habit?

Tsung O. Cheng

PII: S0167-5273(14)00973-5DOI: doi: 10.1016/j.ijcard.2014.05.005Reference: IJCA 18177

To appear in: International Journal of Cardiology

Received date: 25 April 2014Accepted date: 5 May 2014

Please cite this article as: Cheng Tsung O., Smoking in China: Can or Should China Kickthe Habit?, International Journal of Cardiology (2014), doi: 10.1016/j.ijcard.2014.05.005

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Editorial

Smoking in China: Can or Should China Kick the Habit?

Tsung O. Cheng, M.D.

From the Department of Medicine, the George Washington University,

Washington, D.C.

For correspondence: Tsung O. Cheng, M.D., Department of Medicine, The George

Washington University Medical Center, 2150 Pennsylvania Avenue, N.W.,

Washington, D.C. 20037, U.S.A. Telephone: 202-741-2426 FAX: 202-741-2324

e-mail: tcheng@mfa.gwu.edu

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China is the largest tobacco producer and consumer of cigarettes in the

world [1, 2, 3, 4, 5]. One of every three cigarettes manufactured in the world is

consumed in China [1, 2, 3, 4, 5]. The Chinese continue to smoke all the time and

everywhere (Figures 1, A and B). Even more alarming is the prevalence of

teenage smoking in China [6, 7, 8]; three of every 5 Chinese smokers begin

smoking at the age of 15-20 years [6]. Foreign tobacco companies deliberately

target youth in China [9]. The Chinese government should stop the deceptive and

misleading advertisement by the tobacco industry to counter tobacco control in

China by marketing the so-called ‘less harmful, low-tar’ cigarettes [10]. The

recent introduction of electronic cigarettes – these battery-operated nicotine

inhalers - in an attempt to discourage adolescents from smoking has proven to be a

failure; the just completed National Youth Tobacco Survey showed that the use of

e-cigarettes actually encourages conventional cigarette use among US adolescents

[11]. On November 19, 2013, former New York City Mayor Michael Bloomberg

signed into law the “Tobacco 21” bill, imposing the strictest age restriction on

tobacco sales of any major U.S. city [12]. Beginning in May 2014, it will be

illegal to sell tobacco products and electronic cigarettes to persons younger than 21

years of age. The law “Tobacco 21” is, indeed, an idea whose time has come [13].

China has over 350 million smokers – a number exceeding the entire U.S.

population – which accounts for 35% of the world’s total [14]. They are being

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targeted by the tobacco industry as stricter control on tobacco began to bite in the

United States. The young smokers in China not only like to smoke foreign brands

of cigarettes but also name brands. Next to Coca Cola and Mickey Mouse,

Marlboro is the third most well-known American name in China [1]. As a matter

of fact, in China today a carton of Marlboro cigarettes is the commonest and most

sought-after gift item people give to their friends. Giving cigarettes as gifts is a

common practice in China, the incidence being 3.5% according to findings from

the International Tobacco Control Survey [15]. Tobacco control interventions in

China may need to de-normalize the practice of giving cigarettes as gifts in order

to decrease the social acceptability of smoking.

In spite of health hazard warnings on the cigarette packs as required by the

Ministry of Health [16] and incontrovertible evidence that cigarette smoking is a

major cause of death in China [17], a direct cause of coronary artery disease in

China [18], an indirect cause of coronary artery disease by causing hypertension

[19] and CYP2A6 genotype moderated association with diabetes [20] in China,

many Chinese continue to smoke, including the medical profession. Nearly half of

male physicians in China are current smokers [21], thus adding to the difficulty of

smoking control. Therefore, physicians in China should lead the way by not

smoking themselves. 2011 was declared the “Year of Total Smoking Cessation by

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Health Care Professionals” to pave the way for a healthy China by 2020 [22].

Unfortunately such a prediction was never realized.

Despite the unanimous approval of the global anti-tobacco treaty by all 192

countries in the World Health Organization (WHO), with ratification by China in

2005, China has failed to genuinely pursue the WHO’s Framework Convention on

Tobacco Control (FCTC) because of domestic political and social factors [23].

China is one of the few countries in the world that has state-owned monopolies

running tobacco production and trade [14]. China’s Premier Li Keqiang’s brother,

Li Keming, has served as Deputy Director of the State Tobacco Monopoly

Administration since 2003, and Li Keming has worked in the tobacco industry for

the past three decades [24]. This is particularly ironic, as Li Keqiang has been in

charge of China’s public health since 2008 and Chinese president’s wife, Peng

Liyuan, has served as an “Anti-Smoking Ambassador” for the Chinese Association

on Tobacco Control since 2009 [24].

Tobacco is the largest source of income for the Chinese government and

millions of its citizens [6, 25]. According to the Ministry of Health, China’s state-

run tobacco monopoly employs more than half a million workers in factories, 10

million in farming and 13 million in retail trade. Tobacco taxes are the major

source of revenue for the government and amounted to 513.11 billion yuan ($75.13

billion), a year-on-year increase of 12.2% [26], which is about 10% of all revenues,

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constituting the biggest source of tax revenues in China. In addition, according to

the Chinese Association on Tobacco Control, 52 tobacco companies donated to or

sponsored 79 welfare activities in 40 cities and counties during the last 4 months of

2009 [27]. In 2011, more than 100 primary schools in China were sponsored by

tobacco companies on the hunt for the next generation of smokers; the schools

often bear the names of Chinese cigarette brands, such as Zhongnanhai or Liqun,

over their gates and in some cases have slogans in the playground [28].

Thus the government that needs money to raise living standards in China is

as addicted to tobacco revenue as smokers are to nicotine [29]. It is a dilemma

China has to face: wealth first or health first. There is an apparent contradiction

that exists in modern China: the state wants to have the revenue from tobacco,

while the Ministry of Health wants to stop people from smoking in order to protect

their health [5]. The recent report by the Chinese Association on Tobacco Control

pointed out that the social costs of smoking in China greatly outweighs the benefits

and that balancing health care and lost-labor costs against the industry’s social and

salary contributions ends up with a net loss to society of more than $9 billion a

year [5, 27].

According to the China Report on the Health Hazards of Smoking, released

in 2012 by the Chinese Ministry of Health [30], more than one million Chinese die

from smoking-related diseases each year. If this epidemic continues, smoking will

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kill three million Chinese people each year by 2050, and China will suffer greatly

from both the medical and economic cost of tobacco-related diseases [30].

It is not too late to reverse this trend. The recent report from the United

Kingdom demonstrated that smoking cessation improves lung function in not only

patients with chronic obstructive lung disease but also in subjects with normal

spirometric readings [31]. Another report from Rome that the Italian smoking ban

of 2005 resulted in a statistically significant reduction in acute coronary events in

the adult Italian population [32] should be a further incentive. A 30-year follow-up

study from the Netherlands reported a life expectancy gain of 3 years following

smoking cessation after coronary bypass surgery [33]. In the MyHealthCheckup

survey reported in 2011 from Canada [34], the average increased life expectancy or

life-years gained associated with making appropriate life style changes included

2.2 to 4.7 years from smoking cessation, as compared to 0.7 to 1.1 years from

exercise, and 0.4 to 0.7 years from weight reduction. Another systematic review

and meta-analysis by investigators from England published in 2011 concluded that

even stopping smoking shortly before surgery can reduce postoperative

complications [35]. The health benefit of smoking cessation has been repeatedly

reported even more recently from nearly every country around the world, including

England [36], France [37], Ireland [38], Italy [39,40], Japan [41], Netherlands [42],

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New Zealand [43], Panama [44], Scotland [45], Switzerland [46], United Kingdom

[47], United States [48,49], and the CONFIRM Registry [50].

That air pollution is associated with adverse cardiovascular consequences

[51] was highlighted by a 2004 scientific statement from the American Heart

Association [52]. China has been called the air pollution capital of the world [53].

Next to industrial development, environmental tobacco smoke is the second major

cause of air pollution in China. In 2010, there were 740 million people who were

passive smokers in China, as compared with 540 million in 2007 [54]. In 2013,

exposure to second-hand smoke was as high as 72.4% [55].

It was most encouraging to read in the February 5, 2010 issue of Chinese

Medical Journal that seven major Chinese cities launched smoke-free programs

[56]. The seven cities were Shanghai, Wuxi, Ningbo, Changsha, Luoyang,

Tangshan and Qingdao. Surprisingly, Beijing was not included. Beijing, as the

seat of China’s central government, must set an example by joining the other seven

cities in launching the ambitious but urgently needed smoke-free program. If

Shanghai had the courage to turn down a 200-million yuan (29.3 million US

dollars) sponsorship deal from a tobacco company in July 2009 for the 2010 World

Expo, Beijing certainly can, and should, do better [57].

Conclusion

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China is changing and is changing rapidly. Economically China is getting

richer. Politically China is getting stronger and more powerful internationally.

But the Chinese cardiovascular health is deteriorating, and is threatening China’s

future. Cigarette smoking and air pollution, of which second-hand smoking is one

of the major culprits, play a major role in this regard. Cigarette smoking is

responsible for an annual excess of nearly one million deaths in China [58]. China

had 200 million more people suffering from the effects of secondhand smoke over

a three-year period from 2008 to 2011 [59]. Multigenerational co-residence is a

widespread phenomenon in China; thus passive smoking is an inevitable and

uncontrollable health hazard.

Never in the history of China have children been likely to have a shorter life

expectancy than their parents. Complete implementation of WHO FCTC

recommended policies would prevent more than 12.8 million smoking attributable

deaths in China by 2050 [60]. So the question is not “Can China kick the habit of

smoking?”, but “Should China kick the habit of smoking?” The answer is an

emphatic Yes! More than a year has passed since China installed a new president

Xi Jin-ping. He has reformed forcefully in several areas but many challenges

remain. It is my sincere hope that he will move rapidly to rid China from this

ignominious national scourge once for all and not let China kill its own people..

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REFERENCES

1. Cheng TO: The current state of cardiology in China. Int J Cardiol 2004;

96:425-439.

2. Cheng TO: The deteriorating cardiovascular health in China in the past

decade. Int J Cardiol 2007; 114:129.

3. Cheng TO: Cardiology in contemporary China. An update. Int J Cardiol

2008;126:147-159.

4. Cheng TO: Prevention of cardiovascular disease in modern China: Utile or

futile? CVD Prevention and Control 2009; 4:1-7.

5. Cheng TO: Cardiovascular health, risks and diseases in contemporary China.

Int J Cardiol 2012; 154: 233-42.

6. Cheng TO: Teenage smoking in China. J Adolescence 1999;22:607-620.

7. Cheng TO: Adolescent smoking in China. Int J Cardiol, 2008;126:1-2.

8. Zhang X, Li Y, Zhang Q, Lu F, Wang Y: Smoking and its risk factors in

Chinese elementary and middle school students: a nationally representative

sample study. Addic Behav 2014;39:837-41.

9. Cheng TO: Foreign tobacco companies deliberately target youth, not only in

Taiwan but also in China. BMJ 2005 online

http://bmj.bmjjournals.com/cgi/eletters/331/7507/10-b

ACC

EPTE

D M

ANU

SCR

IPT

ACCEPTED MANUSCRIPT

10

10. Yang G: Marketing ‘less harmful, low-tar’ cigarettes is a key strategy of the

industry to counter tobacco control in China. Tob Control 2014; 23:167-72.

11. Dutra LM, Glantz SA: Electronic cigarettes and conventional cigarette use

among US adolescents: a cross-sectional study. JAMA Pediatr 2014 Mar 6.

doi: 10.1001/jamapediatrics.2013.5488 [Epub ahead of print]

12. A local law to amend the administrative code of the city of New York, in

relation to raising the sales age from eighteen to twenty-one years for

cigarettes and tobacco products and establishing a sale age of twenty-one

years for electronic cigarettes. Int. No. 250-A, Local Law 94. November 19,

2013

(http://countertobacco.org/sites/default/files/NYC_RaisingMinimumSalesAg

e_FullTextandDetails.pdf)

13. Winickoff JP, Gottlieb M, Mello MM: Tobacco 21 – an idea whose time has

come. N Engl J Med 2014; 370:295-7.

14. Yin P: Harnessing the beast. As the country fights a high smoking rate,

tobacco firms have found new ways to advertise. Beijing Review 2013;

56(26):28-9.

15. Huang LL, Thrasher JF, Jiang Y, Li Q, Fong GT, Quah AC: Incidence and

correlates of receiving cigarettes as gifts and selecting preferred brand

ACC

EPTE

D M

ANU

SCR

IPT

ACCEPTED MANUSCRIPT

11

because it was gifted: Findings from the ITC China Survey. BMC Public

Health 2012; 12:996.

16. Cheng TO: Smoking in China. BMJ 1995; 310:61.

17. Lam TH, He Y, Li LS, Li LS, He SF, Liang BQ: Mortality attributable to

cigarette smoking in China. JAMA 1997;278:1505-1508.

18. He Y, Lam TH: A review on studies of smoking and coronary heart disease

in China and Hong Kong. Chin Med J 1999;112:3-8.

19. Luo L, Luan RS, Yuan P: Meta-analysis of risk factors on hypertension in

China. Chin J Epidemiol 2003;24:50-3.

20. Liu T, Chen WQ, David SP, et al: Interaction between heavy smoking and

CYP2A6 genotypes on type 2 diabetes and its possible pathways. Eur J

Endocrinol 2011; 165:961-7.

21. Xiao D, Zhong N, Bai C, et al: Nicotine gum or patch treatment for smoking

cessation and smoking reduction: a multi-centre study in Chinese physicians.

Front Med 2014; 8:84-90.

22. Hu D: Play the key role in medical reform and take action to lead to a healthy

China. Chin J Cardiol 2011;39:1-2.

23. Jin J: Why FCTC policies haven’t been transferred in China: domestic

dynamics and tobacco governance. J Health Polit Policy Law 2014 Mar 6

[Epub ahead of print].

ACC

EPTE

D M

ANU

SCR

IPT

ACCEPTED MANUSCRIPT

12

24. Li C: The Political Mapping of China’s Tobacco Industry and Anti-Smoking

Campaign. Washington, D.C.: John L. Thornton China Center at Brookings;

John L. Thornton China Center Monograph Series, Number 5, August 2012,

p. xvii.

25. Cheng TO: Why does the Chinese government allow BAT to open factory in

China after it signed up to the WHO convention on tobacco control? BMJ

http://bmj.bmjjournals.com/cgi/eletters/329/7459/188

26. Lan X: Tobacco dilemma. Beijing Review 2010;53(4):44-45.

27. VOA Report: Annual tobacco deaths in China could top 3.5 million by 2030.

http://www,voanews.com/english/news/asia/Report-Predicts-Annual-Tobacco-

Deaths-in-China-Topping-35-Million-by-2030-113000814.html

28. Glucroft B: Smoking in China, from restaurants to primary schools.

http://www.isidorsfugue.com/2012/12/smoking-in-china-from-restaurants-

to.html

29. Cheng TO: China’s addiction to tobacco revenue. Financial Times, May 23,

2001, p.14.

30. China Report on the Health Hazards of Smoking: Executive Summary.

Ministry of Health of the People’s Republic of China December 2012.

31. Dhariwal J, Tennant RC, Hansell DM, et al: Smoking cessation in COPD

causes a transient improvement in spirometry and decreases micronodules

ACC

EPTE

D M

ANU

SCR

IPT

ACCEPTED MANUSCRIPT

13

on HRCT. Chest 2014 Feb 13. Doi: 10.1378/chest. 13-2220 [Epub ahead of

print].

32. Cesaroni G, Forastiere F, Agabiti N, Valente P, Zuccaro P, Perucci CA: Effect

of the Italian smoking ban on population rates of acute coronary events.

Circulation 2008;117:1183-8.

33. van Domburg RT, Reimer WSO, Hoeks SE, Kappetein AP, Bogers AJJC:

Three life-years gained from smoking cessation after coronary artery bypass

surgery: A 30-year follow-up study. Am Heart J 2008;156:473-6.

34. Grover S, Coupal L, Kouache M, Lowensteyn I, Marchand S, Campbell N:

Estimating the benefits of patient and physician adherence to cardiovascular

prevention guidelines: the MyHealthCheckup Survey. Can J Cardiol

2011;27(2):159-66.

35. Myers K, Hajek P, Hinds C, McRobbie H: Stopping smoking shortly before

surgery and postoperative complications: a systematic review and meta-

analysis. Arch Intern Med 2011; 171:983-9.

36. Sims M, Maxwell R, Bauld L, Gilmore A: Short term impact of smoke-free

legislation in England: retrospective analysis of hospital admissions for

myocardial infarction. BMJ 2010; 340:c2161.

37. Séguret F, Ferreira C, Cambou JP, Carrière I, Thomas D: Changes in

hospitalization rates for acute coronary syndrome after a two-phase

ACC

EPTE

D M

ANU

SCR

IPT

ACCEPTED MANUSCRIPT

14

comprehensive smoking ban. Eur J Prev Cardiol 2013 Aug 5 [Epub ahead

of print].

38. Stallings-Smith S, Zeka A, Goodman P, Kabir Z, Clancy L: Reductions in

cardiovascular, cerebrovascular, and respiratory mortality following the

national Irish smoking ban: interrupted time-series analysis. PLoS One 2013;

8:e62063.

39. Barone-Adesi F, Vizzini L, Merletti F, Richiardi L: Short-term effects of

Italian smoking regulation on rates of hospital admission for acute

myocardial infarction. Eur Heart J 2006; 27:2468-72.

40. Barone-Adesi F, Gasparrini A, VizziniL, Merletti F, Richiardi L: Effects of

Italian smoking regulation on rates of hospital admission for acute coronary

events: a country-wide study. PLoS One 2011; 6(3):e17419.

41. Sato Y, Minatoguchi S, Nishigaki K, et al, for the SHYOGI study

investigators: Design of prospective study of acute coronary syndrome

hospitalization after smoking ban in public places in Hyogo prefecture:

Comparison with Gifu, a prefecture without a public smoking ban. Int J

Cardiol 2014; 63: 165-8.

42. de Boer SPM, Serruys PWJC, Valstar G, et al, on behalf of the

interventional cardiologists of the Thoraxcentre 1980-1985. Am J Cardiol

2013; 112:1311-4.

ACC

EPTE

D M

ANU

SCR

IPT

ACCEPTED MANUSCRIPT

15

43. Barnett R, Pearce J, Moon G, Elliott J, Barnett P: Assessing the effects of

the introduction of the New Zealand Smokefree Environment Act 2003 on

acute myocardial infarction hospital admissions in Christchurch, New

Zealand. Aust N Z J Public Health 2009; 33:515-20.

44. Jan C, Lee M, Roa R, Herrera V, Politis M, Motta J: The associatin of

tobacco control policies and the risk of acute myocardial infarction using

hospital admissions data. PLoS ONE 2014; 9 (2): e88784

45. Mackay DF, Haw S, Newby DE, et al: Impact of Scotland’s comprehensive,

smoke-free legislation on stroke. PLoS One 2013; 8(5):e62597.

46. Humair JP, Garin N, Gerstel E, et al: Acute respiratory and cardiovascular

admissions after a public smoking ban in Geneva, Switzerland. PLoS One

2014; 9(3):e90417.

47. Pirie K, Peto R, Reeves GK, Green J, Beral V, Million Women Study

Collaborators: The 21st century hazards of smoking and benefits of stopping:

a prospective study of one million women in the UK. Lancet 2013;

381:133-41.

48. Jha P, Ramasundarahettige C, Landsman V, et al: 21st-century hazards of

smoking and benefits of cessation in the United States. N Engl J Med 2013;

368:341-50.

ACC

EPTE

D M

ANU

SCR

IPT

ACCEPTED MANUSCRIPT

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49. Glantz SA, Gibbs E: Changes in ambulance calls after implementation of a

smoke-free law and its extension to casinos. Circulation 2013; 128:811-3.

50. Miller NS: CT says it all: Quit smoking, cut heart risk. Chest Physician

November 2013; 8(11): 1,18.

51. Mittleman MA: Air pollution, exercise, and cardiovascular risk. N Engl J

Med 2007;357:1147-1149.

52. Brook RD, Franklin B, Cascio W, et al: Air pollution and cardiovascular

disease: a statement for healthcare professionals from the Expert Panel on

Population and Prevention Science of the American Heart Association.

Circulation 2004;109:2655-2671.

53. Watts J: China: the air pollution capital of the world. Lancet

2005;366:1761-1762.

54. Xinhua Daily Telegraph: Smoking burdens. Beijing Review December 30,

2010; 53(52):4.

55. Yang G, Wang Y, Zeng Y, et al: Rapid health transition in China, 1990-2010:

findings from the Global Burden of Disease Study 2010. Lancet 2013;

381:1987-2015.

56. Xinhuanet: Seven Chinese cities launch smoke-free program. Chin Med J

2010;123:368

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ACCEPTED MANUSCRIPT

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57. Cheng TO: Is China going to ban cigarette smoking? Int J Cardiol 2010;

145:1-2.

58. Thomas GN, Wang MP, Ho SY, Mak KH, Cheng KK, Lam TH: Adverse

lifestyle leads to an annual excess of 2 million deaths in China. PLoS One

2014; 9(2):e89650.

59. Anti-smoking in China. http://www.chinadaily.com.cn/china/2011-

01/07/content_11808366.htm Accessed March 10, 2014.

60. Levy D, Rodriguez-Buño RL, Hu TW, Moran AE: The potential effects of

tobacco control in China: projections from the China SimSmoke simulation

model. BMJ 2014; 348:g1134.

FIGURE LEGENDS

Figure 1. Smoking in China in front of a nonsmoking sign in an airport terminal

(A) and at a bus depot (B, credit: Imaginechina via AP Images)

Figure 1

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