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Chinese man smoking

A study led by researchers from Oxford Population Health has described the long-term impact of cigarette consumption in China and assessed the implementation of five key tobacco control strategies advocated by the World Health Organization (WHO). The review is published in The Lancet Public Health.

Worldwide, smoking is responsible for more deaths than any other external cause. If current patterns persist, smoking will cause around one billion deaths this century, mainly in low- and middle-income countries, such as China.

Chinese men consume around 40% of the world’s cigarettes which is causing an increase in smoking-related diseases and deaths. It is estimated that three million people per year in China could die from smoking-related causes by 2050 unless a substantial number of current smokers stop smoking permanently.

To assess tobacco control progress, obstacles, and opportunities in China the researchers collected data from 19 surveys. They found that while there has been a reduction in the number of people who smoke since the 1990s, there has been an increase in higher risk smoking behaviours such as a younger starting age, which can significantly increase risks of disease later in life, and an increase in the number of cigarettes smoked each day.

The proportion of deaths in China from smoking-related causes has increased from 12% reported in the 1990s to 20% in the 2010s, particularly in men who live in urban areas and start smoking at an earlier age.

The review also assessed five tobacco control strategies: taxation; package warnings; bans on advertising, sponsorship, and promotion; public smoking bans; and smoking cessation services.

The wide variation in retail prices for different tobacco brands in China could weaken the effect of tax increases. However, evidence from France and many other countries suggests that a substantial increase in taxes on tobacco products could reduce consumption and increase government income to help tackle the growing burden of smoking-related diseases.

Effective health warnings on cigarette packages, together with plain packaging, could inform smokers about the hazards of smoking and the benefits of stopping while counteracting the effect of appealing packaging. Currently, China only mandates small, text-based warnings and allows manufacturers to use appealing designs and branding. National surveys have shown that the majority of the public (70%), including smokers (65%), support the use of graphic warnings on tobacco packaging.

The WHO Framework Convention on Tobacco Control (FCTC) mandates a comprehensive ban on all forms of tobacco advertising, promotion, or sponsorship to weaken marketing strategies, but loopholes in China’s advertising laws remain, including allowing advertisements at the point of sale and in other public spaces. The researchers also note that, with a few exceptions such as flights, nationwide restrictions on smoking have not been implemented.

Dr Peter Ka Hung Chan, lead author of the review, said ‘Our review has identified many opportunities for reducing cigarette consumption in China. This can be achieved, as in many other countries, through more comprehensive and effective implementation of the measures set out by the WHO FCTC, especially increased taxation and stronger package warnings.’

The health benefits associated with stopping smoking are well-known, but cessation services are under-used in China with just 3-5% of smokers having used helplines, medications to help them stop smoking, or attended a cessation clinic. In 2016, the Chinese government’s Healthy China 2030 agenda set out a target to reduce overall smoking prevalence to 20% by 2030.

Professor Zhengming Chen, Richard Peto Professor of Epidemiology at Oxford Population Health and a senior author of the review, said ‘To achieve the goals set out by the Chinese government, we need to encourage more people to stop smoking and prevent young people from taking up smoking. This will require political will and a framework of legal restrictions, supported by continuous advocacy and interdisciplinary research evidence.’