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Newly printed “no smoking” signs went up across China when the government rolled out a nationwide public indoor smoking ban in May 2011. A sticky gray layer of smoke residue now coats many signs, representing the challenges China’s growing tobacco-control movement faces against a multibillion-dollar government-run industry and deeply embedded social practices.

How has the cigarette become so integrated into the fabric of everyday life across the People’s Republic of China (PRC)?

To get to the heart of this question, historians, health policy specialists, sociologists, anthropologists, business scholars, and other experts met Mar. 26 and 27 in Beijing for a conference organized by Stanford’s Asia Health Policy Program. They examined connections intricately woven over the past 60 years between marketing and cigarette gifting, production and consumer demand, government policy and economic profit, and many other dimensions of China’s cigarette culture.

Anthropologist Matthew Kohrman, a specialist on tobacco in China, led the conference, which was held at the new Stanford Center at Peking University. In an interview, he spoke about the history of China’s cigarette industry, cigarettes and society, and the tobacco-control movement.

The early years

Tobacco first entered China through missionary contact in the 1600s, says Kohrman, but it was not until the early 20th century when cigarettes began gaining popularity. The first cigarette advertising was a “confused tapestry” of messages as marketers figured out what spoke to the public. “There were just as many images of neo-Confucian filial piety as there were of cosmopolitan ‘modern women,’” says Kohrman.

Through improved marketing and aggressive factory building, British American Tobacco and Nanyang Brothers, China’s two largest pre-war firms, helped increase the demand for cigarettes. The Sino-Japanese War (1937–1945) disrupted the cigarette supply, but their popularity had taken hold. Some cigarette firms shifted during the war to the relative safety of southwest China, where tobacco production has remained concentrated ever since.

Post-1949

After the founding of the PRC in 1949, the tobacco industry was nationalized and strong relationships between the central government and cigarette manufacturers in the provinces were formed. Cigarettes also began to be viewed as a part of everyday life. “Ration coupons for cigarettes were issued alongside grain, sugar, and bicycle coupons,” says Kohman. “The Maoist regime legitimized cigarettes as the right of every citizen."

During the Deng Xiaoping era (1978–1997), China’s cigarette industry really took off as manufacturers competed with one another for foreign currency to purchase cutting-edge European equipment and newer varieties of tobacco seed stock. Increased production and the return of full-scale advertising fueled greater consumer demand, and manufacturers began producing more and more varieties of cigarette. Vendors displayed glass cases filled with a colorful patchwork of cigarette packs bearing names like Panda, Double Happiness, and Red Pagoda.

The tobacco industry remained under government control as other industries privatized in the 1980s and 1990s. Party-state management of the cigarette became even more centralized in the early 1980s with the creation of the China Tobacco Monopoly Administration and its parallel external counterpart, the China Tobacco Corporation.

Since 1949, provincial protectionism has marked the cigarette market. It is now possible to purchase Beijing cigarettes in Kunming, Chengdu brands in Shanghai, and so on, but to distribute cigarettes in another province, a manufacturer must cut a deal with provincial government officials. Provincial administrations are loath to cut such deals because central government policy dictates that the portion of cigarette sales tax which does not go to the central government always is channeled to the finance bureau of the province of original production. China’s 2001 entry into the World Trade Organization opened the market ever so slightly to international brands like Marlboro and Kent, but domestic brands continue to dominate because of fierce protectionism.

...If it chooses to do so, China is in a position to lead and change the landscape in a very profound way.
-Matthew Kohrman, Professor of Anthropology, Stanford

A new era

In 2003, the World Health Organization established the first global health treaty, the Framework Convention on Tobacco Control (FCTC). Although the United States still has not yet ratified the FCTC, China signed the treaty in 2003 and ratified it in 2005. Kohrman says China’s tobacco industry giants fear competition from international cigarette brands more than they worry about tobacco-control measures related to the FCTC.

Nonetheless, the FCTC ushered in a new era of public health research about tobacco and has helped increase public awareness about the dangers of smoking. New restrictions have been imposed on print and television advertising for cigarettes, and international organizations, such as the Bloomberg Family Foundation, have begun funding anti-tobacco work in China.

A big challenge to tobacco-control campaigns, says Kohrman, is the sheer amount of money that tobacco companies have available for marketing. “In 2010, China’s tobacco industry posted profits in excess of U.S. $90 billion—that’s huge. Tobacco control research and advocacy now annually receive a few million dollars, and much of that is coming through outside funders, which have very specific projects in mind.”

China’s tobacco advertisers have adapted to the new restrictions that prevent them from openly promoting cigarettes in the media. They have instead moved to point-of-sale and soft-marketing tactics, including misinformation campaigns about the “dangers” of quitting smoking. “The actual expenditure on marketing probably hasn’t dropped very much,” says Kohrman.

Cigarettes and society

Strong marketing and the legitimization of cigarettes as a part of everyday life have led to the deep integration of cigarettes into Chinese society. While only 3 to 4 percent of women in China smoke, cigarettes are an important part of male identity and social mobility. The wide range of cigarette brands has led to the growth of high-end varieties favored by businessmen and politicians, with some brands costing as much as $50 a pack. The custom of cigarette gifting has existed in China for decades, and it is difficult for a young man to turn down a package of cigarettes from a senior colleague or supervisor.

There is also the fact that nicotine is highly addictive, and quitting is difficult in an environment where smoking cigarettes is socially sanctioned. Kohrman says, “When you take an incredibly addictive substance like nicotine and throw it into the mix of all of these norms and customs, it creates a pretty toxic brew.”

The future?

Tobacco control presents a formidable challenge in China, one that requires understanding the historical context and complex dimensions of the cigarette industry. “Cigarettes have been insinuated into so many aspects of daily life across China, and the market for this product has now become so closely enmeshed with matters of government finance and operations,” says Kohrman.

What happens in China could have implications for the entire world. “There’s a tobacco-induced human annihilation unfolding right now in almost every country and questions about how society and Big Tobacco are enmeshed, and how cigarette culture and government finance have become mutually supportive are pivotal,” says Kohrman. “Every country except Bhutan has legalized cigarette sales and is subject to many of the same general issues as China—only in China they’re on a much larger scale. But if it chooses to do so, China is in a position to lead and change the landscape in a very profound way.”   

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Venue Changed to the Philippines Conference Room

China has recently reformed its health care system with the intent of providing universal coverage for basic health care to every Chinese citizen. Three separate health insurance plans have recently been launched to achieve this objective: the rural newly cooperative medical scheme, urban resident health insurance, and urban employee-based health insurance. Each plan differs substantially in terms of insurers, insured population, premiums, and benefits packages. Using data from the 2009 China Health and Nutrition Survey, Hai Fang will discuss a study that investigates whether and to what extend different health insurance plans have created disparities in health care utilization and expenditure.

Hai Fang is an assistant professor in the Department of Health Systems, Management, and Policy at the University of Colorado Denver, and a research associate in the Kennedy School of Government at Harvard University. He earned his doctorate in economics and master of public health from the State University of New York at Stony Brook in 2006. Before joining the University of Colorado Denver, he taught at the University of California, Davis, and the University of Miami. His research interests include health economics, labor economics, and public health.

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Hai Fang Associate Professor, Department of Health Systems, Management, and Policy Speaker University of Colorado Denver
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This colloquium will discuss the state of evidence, challenges, and research agenda regarding the growth of private hospitals and public-private hospital partnerships in developing Asia.

Dominic Montagu is an assistant professor of epidemiology and biostatistics and lead of the Health Systems Initiative at the Global Health Group of the University of California, San Francisco (UCSF). His work is focused on private delivery of health services in developing countries and on market function for health services and health commodities. He has active field research projects ongoing in Nigeria and Myanmar. Montagu holds masters degrees in business administration and public health, as well as a doctorate in public health, from the University of California, Berkeley (UC Berkeley). He has worked extensively in Africa and Asia, and teaches on the private sector in developing countries, and on the regulation of private hospitals and public-private-partnerships at UCSF, UC Berkeley, and on behalf of the World Bank Institute.

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Dominic Montagu Speaker University of California, San Francisco
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The global health community has been aiming at ensuring health coverage for all. To achieve universal health care coverage, the German Social Health Insurance model is one solution. However, one major disadvantage of Social Health Insurance is the fragmented insurance plans, exemplified by 3,500 insurance plans in Japan’s public universal health insurance system. To improve the financial sustainability of Japan’s public universal health insurance, policy options include consolidating fragmented plans as already implemented in Germany and South Korea.

This presentation has two major goals. One is to evaluate the optimal health insurance size in consolidating 3,500 insurance plans in Japan through a simulation analysis using the best available micro data in Japan. The other goal is to discuss the global policy implications based on the experiences of Japan's public universal health insurance.

Dr. Byung-Kwang Yoo is an associate professor in health policy in the Department of Public Health Sciences at the UC Davis School of Medicine. Yoo’s unique career includes clinical medicine (MD) in Japan and research experience as a health services researcher/health economist in the United States. He obtained an MS in health policy and management from Harvard University, and a PhD in health policy and management (concentration on health economics) from Johns Hopkins University. Yoo used to work as a research associate at the Center for Health Policy at Stanford University, as a health economist at the Centers for Disease Control and Prevention in Atlanta, and as an assistant professor in the Division of Health Policy at the University of Rochester School of Medicine in New York State. He has published his work in leading journals such as Lancet, Health Economics, Health Services Research, the American Journal of Public Health, and the American Journal of Preventive Medicine.

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Byung Kwang Yoo Associate Professor in Health Policy in the Department of Public Health Sciences, School of Medicine Speaker UC Davis
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2011-12 Developing Asia Health Policy Fellow
YiSiyan_Profile.jpg MD, PhD

Dr. Siyan Yi joined the Walter H. Shorenstein Asia-Pacific Research Center (Shorenstein APARC) as a 2011-12 Developing Asia Health Policy Postdoctoral Fellow from the National Center of Global Health and Medicine and the University of Tokyo, Japan, where he jointly served as a research fellow and lecturer. He also served as an adjunct faculty member at Cambodia’s School of Public Health, the National Institute of Public Health, and the School of International Studies at the Royal University of Phnom Penh. He is currently an Associate Professor and UHS-SPH Integrated Research Programme Leader at NUS Saw Swee Hock School of Public Health (profile page here).

Yi’s research has centered largely on epidemiological methods. This has included, for example, work on surveys in Cambodia on adolescent risky sexual behaviors, substance abuse, and depression; a health promotion project in primary schools; sexual behaviors among people living with HIV/AIDS; and HIV risky behaviors among tuberculosis patients. Currently, he is involved in hospital- and community-based research projects in several developing countries as well as in Japan. He has published several papers in these research areas in international journals. His selected publications include:

  • Siyan Yi, Akiko Nanri, Kalpana Poudel, Daisuke Nonaka, Hori Ai, Tetsuya Mizoue. “Association between serum ferritin and depressive symptoms in Japanese municipal employees.” Psychiatry Research, 2011. 189: 368-372.
  • Siyan Yi, Daisuke Nonaka, Marino Nomoto, Jun Kobayashi, and Tetsuya Mizoue. “Predictors of the uptake of A (H1N1) influenza vaccine: Findings from a population-based longitudinal study in Tokyo.” PLoS One, 2011. 6: e18893.
  • Siyan Yi, Krishna C. Poudel, Junko Yasuoka, Paula H. Palmer, Songky Yi, and Masamine Jimba. “Risk vs. protective factors for substance use among adolescent students in Cambodia.” Journal of Substance Use, 2011. 16:14-26.
  • Siyan Yi, Krishna C. Poudel, Junko Yasuoka, Paula H. Palmer, Songky Yi, and Masamine Jimba. “Role of risk and protective factors for risky sexual behaviors among high school students in Cambodia.” BMC Public Health, 2010. 10: 477.
  • Siyan Yi, Krishna C. Poudel, Junko Yasuoka, Masao Ichikawa, Vutha Tan, and Masamine Jimba. “Influencing factors for seeking HIV voluntary counseling and testing among tuberculosis patients in Cambodia.” AIDS Care, 2009. 21: 529-534.

Yi holds an MHSc (2007) and a PhD (2010) in international health sciences from the School of International Health at the University of Tokyo’s Graduate School of Medicine. He also earned an MD in general medicine from the University of Health Sciences, Cambodia (2001). Yi has won research awards, including: the Young Investigator Award from the Asia Pacific Academic Consortium for Public Health (2008), the Montreux Prize from the Swiss Association for Adolescent Health and the International Association for Adolescent Health (2009), and the Scientific Research Award from the University of Tokyo (2009).

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What influence might graphic warning labels have on cigarette sales? Matthew Kohrman is studying that question with experimental methods in Southwest China. Kohrman’s research is generating much-needed data in support of the expansion of China’s warning label system. Among the countries increasingly adopting graphic labels, the United States will require visual warnings on all cigarette packages by next fall.

Stanford Cancer Center News: Smoking cessation in a land of two trillion cigarettes
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