World No Tobacco Day: Tobacco Control Offers Proven Public Health Benefits -- Will China Seize the Opportunity?

China can be a model for other countries trying to navigate the very troubling relationship between the economic gains and detrimental effects of smoking.
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By Jeffrey L. Sturchio and Ambassador Sally G. Cowal

We've known about the dangers of smoking for decades, but tobacco use continues to be the leading cause of preventable death in the world, killing more than six million people each year. If current trends continue, 80 percent of all tobacco-related deaths are expected to occur in low-and middle-income nations by 2030. China alone has an estimated 300 million smokers -- nearly as many people as the entire population of the United States. Despite the fact that smoking is a major risk factor for disease, tobacco is also a significant contributor to China's economy, which begs the question, is China doing as much as it can to reduce the prevalence of smoking?

China is home to the greatest number of smokers, and more than half of Chinese men use tobacco. What's more disconcerting is that up to 60 percent of Chinese physicians smoke. Unless the government ramps up interventions to reduce smoking, the current number of tobacco-related deaths (1.2 million) is predicted to nearly triple by 2030. But smokers aren't the only ones at risk. Exposure to secondhand smoke is also a significant problem, affecting 70 percent of adults and contributing to more than 100,000 deaths each year. More than half of both men and women report secondhand smoke exposure in the workplace and at home. About 63 percent of Chinese adults have observed smoking in the workplace, compared to about 24 percent in Brazil, 30 percent in India, 35 percent in Russia and 8.6 percent in the U.S. Indeed, smoking is engrained in the workplace and cigarettes are frequently used as business gifts or to foster relationships among colleagues.

Another challenge is that multinational tobacco companies are increasing efforts to market to women, particularly young women. From introducing cigarettes for women, to glamorizing tobacco use in advertising, the aggressive marketing tactics of tobacco companies make smoking seem attractive. While fewer than two percent of all women in China smoke, a recent study indicates that more than 20 percent of female high school and college-aged Chinese students have tried cigarette smoking. This is particularly worrisome, considering that most smokers adopt the habit before they are 21 years old. An increase in the low proportion of women smokers would have an extremely negative effect on health outcomes, particularly among those of reproductive age.

The smoking-associated health costs to China amounted to $28.9 billion in 2008 alone, including decreased or lost worker productivity, and direct medical expenses. However, the reality is that China gains $95 billion each year from tobacco taxes - more than twice its annual health budget of $42.5 billion. Moreover, the state-run China National Tobacco Corporation is the biggest tobacco company in the world. This dynamic creates an even greater disincentive for instituting and enforcing a robust tobacco control plan.

To be fair, the government of China, under the leadership of President Xi, has begun to implement some regulations to restrict smoking in hospitals, schools and other public venues. However, a comprehensive ban on tobacco use in all public spaces is still needed. The Ministry of Health has also been working diligently behind the scenes to implement policies and develop effective strategies to address the smoking epidemic. And the government needs to follow through on the enforcement of these anti-smoking policies. This may pose a challenge, considering the number of government officials who smoke and the pervasive culture of smoking in the workplace.

One promising initiative is the China-U.S. Smoke-free Worksite initiative (CUSW), a collaboration between the Chinese Ministry of Health and the U.S. Department of Health and Human Services. Launched in September 2012, this public-private partnership to combat tobacco use helps employers decrease workplace secondhand smoke exposure, raise awareness about smoking-related health risks and support smokers' efforts to quit. Outcomes from the CUSW have been positive so far, with a growing number of local and multinational companies joining the effort. The CUSW and other related initiatives represent an opportunity to create a framework for healthier workplaces by engaging business leaders in national tobacco control efforts. The Chinese government may want to consider a similar model for making the workplace a healthier environment for its own employees.

However, much more can be done to establish and better leverage national policies. On this World No Tobacco Day (May 31), the World Health Organization is calling for all countries, including the United States, to increase taxes on tobacco to reduce smoking and save lives. Currently, China doesn't rely heavily on specific excise taxes for tobacco, leading to the widespread availability of low-cost cigarettes. Recent estimates indicate imposing a cigarette tax that amounts to 75 percent of the price of a pack may reduce smoking among men and women in China by 10 percent in 2015.

While the challenge of tobacco in China is immense, it's not insurmountable. Many other countries have successfully implemented policies that have reduced the prevalence of smoking dramatically despite the considerable influence of the tobacco industry. China can be a model for other countries trying to navigate the very troubling relationship between the economic gains and detrimental effects of smoking. It's time for China to put the health of its people first and lead the way in implementing sustainable, effective tobacco control policies.

Ambassador Sally G. Cowal is Senior Vice President, Global Health at the American Cancer Society. She leads the Society's efforts to reduce the global burden of cancer primarily through advocacy for effective tobacco control measures; improvement of access to cancer screening, treatment and pain relief; and collaborations with other cancer control organizations, advocates and governments. Cowal has been a key contributor to the public health and nonprofit arenas, having helped found the Joint United Nations Program on HIV/AIDS (UNAIDS), as well as serving as Founder, President and CEO of the Cuba Policy Foundation. Cowal served as U.S. Ambassador to the Republic of Trinidad and Tobago, appointed by former Presidents George H.W. Bush and William J. Clinton. Cowal has also served as U.S. Deputy Assistant Secretary of State, Minister Counselor for Public Affairs at the U.S. Embassy in Mexico, and Counselor for Political Affairs at the U.S. Mission to the United Nations. Other foreign service assignments have taken her from India to Colombia to Israel. She comes to the American Cancer Society most recently from Population Services International (PSI).

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