Global research into the medical mortality associated with smoking shows conclusively that it is a time delayed phenomenon, which means that over a third of today’s Chinese smokers are likely to be dead or suffering from smoking-related medical conditions by 2030¹. With a reputed 350 million smokers (The US population is 300 million), China accounts for over a quarter of the world’s smokers and consumes almost one third of the world’s cigarettes. In terms of smoking patterns the habit is very much biased towards men with over 66% of men smoking compared to around 3.1% of women (2002 China CDC study), though there is a pronounced shift in the demographic for the younger age group with around 33% of male teenagers compared to 8% of female teenagers smoking. In China there have been two major studies into smoking prevalence conducted in in1996 and 2002. In both studies the average consumption was around 15 cigarettes per day though with higher income smokers, they were smoking higher priced brands and almost twice the number of cigarettes compared to lower income smokers. 

 

Second hand smoke is believed to affect a further 450 million persons, whilst the total number of deaths associated with primary smoking and second hand smoking is estimated at 1.1 million people per year or just over 3,000 per day.  This is calculated to rise to over 2 million per year by 2020.

 

Work published in The New England Journal of Medicine in September 2005 by Jiang He² and colleagues further confirmed the impact of smoking on the ill health of China. The study entitled “The major causes of death in China” looked at a nationally representative cohort of 169,871 men and women. They were first evaluated in 1991 and followed up in 1999 and 2000. In addition to the leading causes of death the study was able to show the leading risk factors associated with death. Whilst hypertension and its control/prevention would result in an 11.7% reduction in overall mortality, smoking, if controlled, would result in a 10% reduction in mortality in men and a 3.5% reduction in women. Interestingly, these figures were for active smokers only.

 

The problem is compounded by the total tacit acceptance of smoking throughout the population.  In work conducted by Synovate Healthcare in 1998, over 55% of doctors and 61% of teachers smoked. In research published by Xinhua in May 2005，12% of doctors claimed to smoke in front of their patients. Further findings from the Xinhua report showed that whilst 95% of doctors knew of the link between lung cancer and smoking, only 60% knew that it was linked to TB, 50% that it was a major cause of ED and only 75% that it was a risk factor in coronary heart disease. With respect to smoking cessation aids fewer than 50% of doctors were aware they existed whilst 97% of doctor never spoke with their “smoking patients” about the need to quit. Both Pfizer (Pharmacia as was) and GSK (SB as was) can testify to the abject failure they had when attempting to launch smoking cessation products NiQuitin and NicoDerm in the China market in early 2000. It is only in the past twelve months that multinational companies have once again started to show an interest in the smoking cessation market. The nicotine replacement therapies exist in a variety of forms – patch, gum, inhaler, nasal spray, lozenges etc. Bupropion hydrochloride, available with the brand names Zyban, Wellbutrin SR, and Wellbutrin XL is marketed by GlaxoSmithKline. Originally developed as an anti-depressant drug it also works well as a smoking cessation aid. Clinical data has shown it to have dramatic effects on controlling withdrawal symptoms associated with stopping smoking.

 

Varenicline tartrate was discovered and developed by Pfizer and is marketed under the trade mark of Chantix. It was approved by the FDA in May of 2006 and has the ability to partially activate nicotine receptors in the brain so reducing a person's craving for nicotine when they quit smoking.  A further benefit is that if a person smokes whilst taking varenicline treatment, the drug impedes smoking satisfaction by blocking nicotine from binding with these same receptors.

 

Synovate Healthcare’s research in the smoking cessation field also showed that consumers were even less aware of the associations between smoking and medical conditions with few being aware of the association with COPD, asthma, bronchitis or heart disease. Further compounding any interest in smoking cessation aids was their mind set related to stopping smoking – which was that they were completely in control of their smoking and that should they ever want to stop it was simply a matter of setting their mind to it. Addiction was something they could not comprehend.

 

Whilst the government officials at the Ministry of Health have recognized the negative impact smoking has on well being and has introduced public health campaigns, one can argue that the central government could be doing even more. Globally it has been shown time and again that an increase in direct taxation on cigarettes both reduces the amount of cigarettes smoked and number of people smoking whilst at the same time increasing revenue for investment in central government investment. Tobacco farming in China contributes around 30% of the global tobacco leaf production, which is all under the control of the State Tobacco Monopoly Association (STMA). The STMA is responsible for setting production quotas, procurement prices, manufacturing and marketing. The Ministry of Agriculture has no jurisdiction over anything. Whilst the central government collects tax on cigarette products (from smokers) the local and provincial government collect taxes on tobacco leaf production – and in provinces such as Yunnan, Guizhou, Henan, Sichuan and Hunan, this revenue makes up a substantial portion of the provincial tax revenue. The STMA in association with its affiliated organization the China National Tobacco Company (CNTC) has branches in each province all the way down to district/county level. The CNTC employs around half a million people and in 2003 generated around US $ 2 billion in tax for the central government. In 2003, that amounted to around 7.4% of central government tax revenue which had been declining and has continued to decline as a percentage of total tax revenue year on year, as automobiles, petroleum, telecommunications and other high tech industries grow in significance.

 

The fact remains that in China there is considerable room for increased taxation on cigarettes. In countries such as the UK, Australia, France and Canada around 66% of the cost of cigarettes is government tax. In China it is around 40%. Research conducted by Te Wei Hu³ and colleagues suggested that a 10% increase on tax to the smoker would result in a reduction in cigarette consumption of just over 1.5% whilst the increase in tax revenue would amount to US $ 3.6 billion.

 

As to what will happen in the future with respect to smoking there is uncertainty.  However the winds of change felt in Europe and the USA with respect to smoking in public places is slowly becoming evident in China. Further application of these new ideas together with an increase in direct taxation on smoking together with a harder line on smoking by the medical profession could well result in significant changes to the well being of China’s non-smokers.

 

[1] BMJ via South China Morning Post August 2001

2 New England Journal of Medicine; 15th September 2005; Dr Jiang He et al

3 “Effects of cigarette tax on cigarette consumption and the China economy.” Tobacco Control 2002