HONG KONG - China's first anti- tobacco law went into effect on January 1, 1992. It has the potential to save more lives in a single country than any other health law in history.
The law mandates the reduction of tar in tobacco products, bans or restricts smoking in public transport and in public places, bans smoking by elementary and high school students, requires the printing of tar levels and health warnings on local and imported cigarette packets and bans tobacco advertising on TV and radio and in newspapers and magazines. The law also mandates improved education about the health effects of smoking, with particular emphasis on young people.
The law promises to have a substantial impact on both health and economics in China. It should also serve as an example for other developing countries, demonstrating that a developing country can grasp the political nettle of tobacco control.
The casualties
Anti-tobacco legislation is desperately needed in China, which houses the world's largest population of smokers by far. There are more smokers in China than the entire population of the United States. Dr. Weng Xin Zhi, the executive vice president of the Chinese Association on Smoking and Health, reports that his 1984 National Prevalence Survey of 519,000 people showed "that 61 percent of males and 7 percent of females over 15 years of age smoked, with over 56 percent of male doctors smoking." This represents between 250 and 300 million smokers.
Oxford epidemiologist Richard Peto predicts that "of all the children alive today in China under the age of 20 years, 50 million of them will eventually die from tobacco."
Peto and Tom Novotny, an epidemiologist at the U.S. Centers for Disease Control, believe that the figures will inevitably worsen. China's rising population means there will be more people who smoke, even if the percentage rates of smokers in the population remain the same. Additionally, smoking is on the increase in China, and the female market represents an as-yet-untapped source for future expansion. "Peak exposure of the market probably has not occurred, and peak mortality will not occur until well into the next century," contend Peto and Novotny. Recent studies in Beijing indicate that smoking is rising rapidly among Chinese adolescents.
Nor does the problem lie only in China's future. Already the most common causes of death are tobacco-related: heart disease, cancer, stroke and respiratory diseases.
Smoking also affects large numbers of non-smokers in China. Dr. Weng's 1984 survey showed that 40 percent of non-smokers interviewed were "passive-smokers," meaning that they regularly inhale the environmental tobacco smoke of smokers. Like their Western counterparts, Chinese children have been shown to be affected by their parents' smoking.
Tobacco affects the environment as well as people. In 1989, the China Daily reported that "most of the forest fires that broke out this year were caused by human factors such as smoking." In a fire that swept the whole northeast part of China in 1987, five forestry workers were arrested for starting the fire by throwing cigarette ends onto grass, spilling oil and producing sparks from a chain saw. In this, the country's worst-ever forest fire, 3 million acres of land were ravaged, 300 people were killed, and 5,000 people were made homeless. On December 24, 1983, a fire caused by a passenger's cigarette led to the crash landing of a Chinese plane at Guangzhou, killing 23 people. China immediately banned smoking on all internal flights, becoming the first country in the world to do so.
Tobacco drains the economy with costs of medical and health care, premature death, lost productivity, the use of land which could grow nutritious crops, fires, clearing up smokers' litter and in other ways. The Chinese Academy of Preventive Medicine notes that "the health-related economic costs caused by smoking in 1989 were estimated at US$5 billion," about the same figure earned from tobacco taxes.
The cost to the individual is also substantial. A pack of local cigarettes costs less than US$0.20 whereas imported cigarettes cost more than US$2.00 for a pack of 20 cigarettes. Even a pack of 20 local cigarettes costs between 14-19 percent of the daily median household income, whereas a daily pack of imported cigarettes costs twice the daily median income.
The domestic tobacco lobby
China is the largest producer of tobacco in the world. The government monopoly, the China National Tobacco Corporation (CNTC), dominates the Chinese market with an approximately 99 percent share.
Traditionally, the Chinese government has highly valued the tobacco industry. Jin Maoxian, vice president of the CNTC, says that "because the tobacco industry generated so much revenue, its development received a great deal of attention from all tiers of government and was given special consideration when it came to investment and the use of foreign exchange." Today, China collects more than US$5 billion annually in tobacco taxes, making tobacco the largest industrial tax source. Export earnings are steadily increasing and currently stand at US$120 million per year.
But there are differences between the CNTC monopoly and Western commercial tobacco companies. The monopoly sees its role as the organizer and controller of a state industry, carrying out government directives, and not as an apologist for tobacco. It acknowledges that smoking is harmful, is working to reduce the tar and nicotine in cigarettes, is cooperating with the Ministry of Public Health on health warnings on cigarette packets and even participates in the World Health Organization's annual "World No Tobacco Day" by not selling cigarettes and urging people not to smoke on that day. How long this cooperation will be maintained is difficult to say.
Foreign tobacco companies: then and now
According to a story told by executives of British American Tobacco (BAT), when the cigarette rolling machine was first invented, James Duke, the U.S. founder of BAT, said, "Bring me the atlas." When he turned the pages, looking not at maps, but at population figures, he stopped when he came to the figure: Pop: 430,000,000. "That," he said, "is where we are going to sell cigarettes." And "that" was China.
By the end of the nineteenth century, Duke had achieved his goal, penetrating almost the whole of China with sophisticated manufacturing and advertising techniques the country had never before seen. In his book, Big Business in China: Sino-Foreign Rivalry in the Cigarette Industry, 1890-1930, Sherman Cochran reports that "BAT resorted to illegal as well as legal distributing techniques to circumvent government opposition."
BAT effectively demolished the local Chinese tobacco companies with legal writs, price wars, fierce competition, political pressures and a range of other activities to put the local companies out of action. After a turn-of-the-century boycott petered out, "BAT drove almost all 20 existing Chinese cigarette firms out of business or out of the market," according to Cochran.
Now, history is repeating itself. The foreign tobacco companies have identified China as their golden goose for the twenty-first century. In a September 1986 article in the industry journal World Tobacco, Rene Scull, then-vice president of Philip Morris Asia, stated: "No discussion of the tobacco industry in the year 2000 would be complete without addressing what may be the most important feature on the landscape, the China market. In every respect, China confounds the imagination." Rather than defending China's people from predatory attacks, CNTC's Jin Maoxian's response was to tell the foreign companies: "China's door is open to you all."
R.J. Reynolds Tobacco International took the CNTC at its word. RJR established a joint-venture cigarette company which commenced production at its Xiamen factory in 1988. U.S. health advocates have vigorously protested against this exportation of disease, disability and death to China. Assistant U.S. Surgeon General Dr. Jeffrey P. Koplan has estimated that the 2.5 billion cigarettes produced annually at this new factory "will eventually lead to 75,000 deaths yearly" in China.
One of the most immediate concerns of anti-smoking advocates in China and elsewhere in the world is that the United States may threaten to impose unilateral trade sanctions under section 301 of the U.S. Trade Act if China does not open its market to foreign tobacco companies and loosen its restrictions on tobacco advertising. In recent years, the U.S. Trade Representative (USTR) has pried open the markets of Japan, South Korea, Taiwan and Thailand with these threats. An October 31, 1991 letter to the director of China's National Health Education Institute, Dr. Chen Bing Zhong, from Joseph A. Massey, the assistant U.S. Trade Representative for Japan and China, states ominously: "Because of discriminatory Chinese government import controls, the volume of cigarettes exported from the United States into Chinese markets is the lowest that it has been for several years."
Health activists are urging the USTR to not interfere with China's anti-smoking program. A November 13, 1991 letter from this writer to the U.S. Trade Representative Carla Hills remains unanswered at the time of publication. The letter states: "China needs vital encouragement and support from countries with a long track record of recognition of the problems of smoking and proven effective action to protect their citizens. I would suggest that the U.S. would be better served, especially on a long-term basis in China, by extending health expertise rather than by supporting the tobacco companies. While I respect the need for fair trade practices, I would most earnestly urge you not to include tobacco products in these negotiations."
A letter from the Washington, D.C.-based Coalition on Smoking OR Health, representing the American Cancer Society, the American Lung Association and the American Heart Association, similarly asked the USTR to not press China to open its cigarette market. It stated, "health concerns [must] take precedence over trade concerns where uniquely harmful products such as cigarettes are involved." This letter, too, remains unanswered.
The current example of Taiwan bodes ill for China. In response to a threat of unilateral trade sanctions under the 301 Trade Agreement, Taiwan signed an agreement regarding tobacco in 1986 with the USTR. Six years later, Taiwan is now attempting to pass a national tobacco control law, which includes a provision banning advertising. The USTR claims that this law "reveals potential inconsistencies" with the 301 trade agreement and held a meeting in Washington, D.C. on January 23, 1992 to discuss the matter, only to postpone any decision and to schedule another meeting later in the year. In a letter to the Taiwan government, the USTR pointedly refers to the importance of cooperation "at a time when Taiwan is seeking active consideration of its GATT [General Agreement on Tariffs and Trade] application." The letter further states: "The Taiwan authorities should also take note of the importance of cigarette exports to U.S. trade interests. Cigarette exports have made a significant contribution to reducing the global U.S. trade deficit."
U.S. Senators Jesse Helms, R-North Carolina, and Mitch McConnell, R-Kentucky, and the tobacco companies have added their weight in letters to the Taiwan government.
Whether the Chinese (in China or Taiwan) smoke Western or Chinese cigarettes has significant public health consequences. Foreign tobacco companies may now only have a small market share in China, but their behavior is different from the national monopoly.
The foreign companies market and promote cigarettes in ways unknown to the national monopoly, with expensive advertisements portraying healthy, attractive, macho, wealthy, sporty and emancipated Western images. These are especially powerful images for China's youth.
By 1987, a Media and Marketing article entitled "Great Leap into the PRC," reported that Philip Morris's Marlboro was the fourth top foreign advertiser in China, behind only Toshiba, Hitachi and NEC. Many of the tobacco advertisements violate the restrictions China had in place at the time. For example, the South China Morning Post detailed in 1986 how a Hong Kong advertising agency places advertisements on clocks and lighted panels in railway stations and on trains, skirting the law by claiming that these are decorations, not advertisements.
The foreign companies also sponsor sports, arts and health organizations. Philip Morris contributes thousands of dollars to help the disabled in China, which some liken to the Colombian cocaine cartel establishing drug rehabilitation centers.
"The cigarette companies are very cunning," says Chinese Minister of Health Dr. Chen Min Zhang in the 1989 British documentary "The Fragrant Smoke." "Since they know they can't have direct advertising, they use deceit to get their commercials placed before the viewing audience. Sport should really be a means of healthy enjoyment and recreation for the public. But [promotion] for smoking does precisely the opposite."
A journey of 10,000 miles begins with a single step
More than three centuries ago, a Chinese philosopher, Fang Yizhi, discussed the dangers of smoking, pointing out that long years of smoking "scorches one's lung." But the anti-smoking campaign in China began only in 1979, with the issuing, with the approval of the state council, of a Joint Circular on the harmful effects of smoking by the ministries of Public Health, Education, Finance and Agriculture. In 1984, the then- Minister of Health made the strongest official public statement to that date that smoking was harmful to health.
Since 1984, China has conducted numerous health education campaigns on smoking, including an ongoing major campaign to help peasant farmers in remote areas quit smoking. The country held its first "No-Smoking Day" in Shanghai in April 1987, and, since 1988, it has held a national "No-Tobacco Day" coinciding with the World Health Organization's World No-Tobacco Day. In 1990, Chinese health advocates established the Chinese Association on Smoking and Health to coordinate tobacco-control activity throughout China. The Chinese Academies of Preventive Medicine and Medical Sciences and the National Institute of Health Education have been the principle movers in tobacco-control activities.
The January 1 law represents a great leap forward in tobacco control in China. There is an ancient Chinese saying: "A journey of 10,000 miles begins with a single step." The first steps in tobacco control have now been taken in China, but there are still many miles ahead.