Why Haven’t Chinese Leaders Acted Decisively to Reduce Tobacco Use?

In mid-October, Russian Prime Minister Dmitri Medvedev voiced support for a proposed ban on smoking in public places by 2015. “The government is not at war with smokers,” he said, “but we are making a stand against smoking.”

Compared to Russia, where about a third of the population smokes, China has “the biggest tobacco problem in the world.” As Cheng Li pointed out in a recent publication, China is “the world’s biggest tobacco producer, largest cigarette consumer, and gravest victim of the smoking-related health crisis.” About 350 million people smoke (which is approximately thirty percent of the world’s total smoking population), with 740 million people regularly exposed to second-hand smoke (including 180 million under the age of fifteen). Each year, more than 1.2 million people die of smoking related illness, which is twelve percent of the country’s total annual deaths. The numbers speak for themselves: the global anti-tobacco campaign cannot be successful without effective tobacco control in China.

Unfortunately, China’s anti-tobacco policies are among the least effective in the world. The government did ratify the Framework Convention on Tobacco Control (FCTC) in 2005, pledging to ban smoking in workplaces and indoor public spaces by January 9, 2011. But this deadline passed without any significant change made in these areas. Worse, there has been an increase in cigarette production in China, as well as a continuing rise in the size of both the smoking population and those victimized by second-hand smoke. At issue is not just poor enforcement, but also blatant violation of an international treaty that it pledges to comply with. Indeed, so far China has not met the FCTC requirements in terms of displaying the graphic health warnings on cigarette packaging and disclosing tobacco ingredients to the public.

As demonstrated by the experiences of curtailing tobacco use in other countries, political commitment on the part of top leadership is “one of the most essential ingredients in successful tobacco control.” Despite the scope and seriousness of the tobacco epidemic in China, thus far we haven’t seen any decisive government action on this issue. None of the Politburo Standing Committee members (all of them nonsmokers) have made any public statements against tobacco production and consumption. This is in sharp contrast to their attitudes toward other public health problems, including HIV/AIDS and pandemic flu, even though tobacco today kills ninety times more Chinese citizens annually than HIV/AIDS.

According to University of Michigan professor John Kingdon, whether an issue is up for an active and authoritative decision depends on: 1) how a given condition gets defined as a problem; 2) whether a viable, agreed upon policy proposal to address the problem is available; and 3) whether the political climate is right for effective government action. Alas, none of the above conditions are being met by China’s anti-tobacco campaign.

First, while scientific evidence and epidemiological data categorically point to the negative consequences of tobacco use, there is still a lack of consensus on whether it should be reclassified as a problem. Research conducted by Peking University’s China Center for Economic Research shows that the total economic cost of smoking in 2005 (about $37 billion) is far more than the fiscal revenue drawn from the tobacco industry (nearly $30 billion). But many government officials—especially those in China’s tobacco bureaucracy or in provinces where tobacco production is considered a “pillar industry”—still believe that the tobacco industry is crucial for China’s economic growth. Also, unlike an acute “outbreak event” like SARS, which can quickly raise the eyebrows of national leaders, smoke-related illness is an “attrition epidemic” that is less likely to generate immediate and strong esprit de corps among key leaders and strengthen state autonomy from special interests in decision making. Indeed, Chinese leaders believe the health consequences of tobacco will take about ten to twenty years to develop.

Second, while the discourse on tobacco control—thanks to a bottom-up public health movement—has to some extent softened up the policy environment, China has yet to find a viable and agreed upon policy proposal to address its tobacco epidemic. In absence of strong government support, the movement against tobacco use is not enough to coalesce around consensus for the need for significant change. According to one survey, thirty-seven percent of the Chinese asked do not know that lung cancer could be caused by smoking, and even fewer knew that heart disease could be caused by smoking. Some cost-effective, “best buy” solutions are technically feasible, but these measures (e.g., cigarette tax increases, product labeling, advertising bans, and smoking restriction) are not congruent with the dominant values of the policy community: Chinese political elites fear that a strong tobacco control policy would undermine economic growth, upon which the regime’s legitimacy hinges.

Finally, the politics so far have not been receptive to effective government action. At present, the Ministry of Health (MOH) is the primary central agency supporting strong tobacco control, but it is bureaucratically weak and has to deal with the powerful Ministry of Industry and Information Technology (MIIT), the lead agency for tobacco control. On top of this, the MIIT has an administrative relationship with the State Tobacco Monopoly Administration (STMA), which shares senior management staff with China National Tobacco Cooperation (CNTC), the world’s largest cigarette maker. This institutional arrangement is like having the representative of Philip Morris appointed to the U.S. Federal Drug Administration to make tobacco regulation decisions. It came as no surprise that those few anti-tobacco activists (Yang Gonghuan, Wu Yiqun, and Xu Guihua) often feel like Don Quixote challenging a ferocious giant. A compromise between MOH and STMA/CNTC is unlikely not only because they pursue totally different objectives (MOH: reduced tobacco use and better public health; tobacco industry: expanded production and higher profit), but also because MOH does not have much to offer in the bargaining process. During the FCTC negotiations, a STMA official allegedly accused an MOH official of being “traitorous” and claimed that “1/10 of your salary comes from us!” While government leaders in 2003 threw their support behind the MOH in the negotiation process, since then tobacco control has not been a major issue at the highest levels of politics. Ironically, Li Keming, the brother of soon-to-be premier Li Keqiang (whose portfolio includes the health sector), has been the deputy head of STMA since 2003. As the 18^th Party Congress draws near, the leaders have been so preoccupied with the game of power distribution and writing Bo Xilai’s political obituary, that tobacco control has been placed on the backburner. One can only hope that the policy window will open after the dust of power jockeying settles. A silver lining in the cloud: the wife of soon-to-be CCP Party Secretary Xi Jinping is a supporter of tobacco control.