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Introduction. This study investigated the intensity of cigarette consumption and its correlates in China among urban male factory workers, a cohort especially vulnerable to tobacco exposure, one that appears to have benefitted little from recent public health efforts to reduce smoking rates.

Methods. Data were collected from men working in factories of Kunming city, Yunnan, China, who are current daily smokers (N = 490). A multinomial logistic regression was conducted to examine the factors in association with smoking intensity in light, moderate, and heavy levels.

Results. Light smoking correlated with social smoking, smoking the first cigarette later in the day, self-reported health condition, and quit intention. Heavy smoking was associated with purchase of lower priced cigarettes, difficulty refraining from smoking, and prehypertensive blood pressure.

Conclusion. Even in regions where smoking is highly prevalent, even among cohorts who smoke heavily, variation exists in how cigarettes are consumed. Analyses of this consumption, with special consideration given to smoking intensity and its correlates, can help guide tobacco-control strategists in developing more effective interventions.

 

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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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Premium Chinese cigarette brand Panda for sale in a duty-free shop at Dubai's airport.
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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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Packages of cigarettes for sale in China.
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Tobacco is the single greatest cause of preventable death in the world today, including in China where cigarette smoking is a popular pastime. "The [tobacco] industry in China is run by the Tobacco Monopoly Administration, a central government administrative body created in the 1980s, also known as China Tobacco Corp.," said Matthew Kohrman in a February 2011 interview with NPR's Morning Edition. China nonetheless issued a nationwide indoor smoking ban on May 1. Speaking with Al Jazeera English on the first day of the ban, Kohrman predicted that Chinese citizens will increasingly comply with the ban even if in fits and starts initially. "It all has to do with implementation," he suggested. "It all has to do with changing the culture of smoking and people’s thinking about it—that takes time."



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In the past year, AHPP faculty affiliate Matthew Kohrman published in the Asia-Pacific Journal of Public Health a critical assessment of international anti-tobacco interventions. He has also been quoted in Science, Harvard Global Health Review, and Stanford University News regarding tobacco-control efforts in China and around the world.
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On December 18, tobacco control was the theme of the 2009 Kunming Health and Development Conference, co-convened by the Yunnan Health and Development Research Association, Pioneers for Health, and ThinkTank Research Center for Health Development. “Pioneers for Health” is a health policy non-governmental organization (NGO) founded in China a year ago with help from AHPP faculty affiliate Matthew Kohrman, Associate Professor of Anthropology. Pioneers for Health also received the good news that Tobacco-Free Kids/Bloomberg Initiative to Reduce Tobacco Use has renewed it for another two-year grant to cover all operational and health advocacy costs.

Article in Translation (Source:  The Economic Daily 经济日报):

More than sixty specialists and academicians from the fields of medicine, economy and sociology convened in Kunming (YunnanProvince) on December 18 for the 2009 Kunming Health and Development Conference, jointly hosted by the Yunnan Health and Development Research Association, Pioneers for Health, and ThinkTank Research Center for Health Development. The theme of the conference was "Tobacco Control for the Creation of a Healthy Lifestyle".  The conference was divided into three parts. For the first part a short film was shown. Titled "Tobacco: From Global Epidemic to Global Control", the film detailed the history of the global tobacco epidemic and its development up to the current day. It looked at the background and significance of the Framework Convention on Tobacco Control. The specialists and academicians present all agreed that a global consensus has been reached regarding the need for tobacco control. As a signatory of the FCTC and as a large nation, China is now responsible for carrying out a huge task. Tobacco control in Yunnan Province will be especially arduous. The second part -- Tobacco Control in Yunnan; Taking the First Step -- focused on the tobacco control effort in Yunnan Province. Topics for discussion included an analysis of ideas and methods to prevent youth from smoking. In the third part -- The Challenges and Opportunities for Tobacco Control in Yunnan Province; a Multi-disciplinary Perspective -- economists, sociologists and health experts engaged in a discussion of issues regarding tobacco control. During the discussion the participants stressed that tobacco control concerns not only public health, but also community development, the domestic economy, the people's livelihood, and the government's image. The most popular topics in this segment were "Tobacco and the Economy", "Tobacco and Health", and "The Influence of Popular Culture on the Behavior of Smoking". A multi-disciplinary approach was used when delving into the issues surrounding tobacco control.

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AHPP faculty affiliate, Matthew Kohrman, was interviewed by China Radio International (CRI) on August 13th, 2009 about tobacco control in China. As CRI reports, "tobacco control is always a difficult subject for law makers... Still, there appears to be a growing movement -- including in China -- to control tobacco sales."
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Susan V. Lawrence is Head of China Programs at the Campaign for Tobacco-free Kids, a Washington, DC-based non-governmental organization that works to reduce tobacco use and its devastating health and economic consequences in the United States and around the world. She divides her time between Washington, DC and China.

The Campaign is a partner organization in the Bloomberg Initiative to Reduce Tobacco Use, launched in 2005 with funding from New York Mayor and philanthropist Michael Bloomberg. The initiative’s work is focused on low- and medium-income countries that together account for two thirds of the world’s smokers. Other partners in the initiative are the Centers for Disease Control Foundation, the Johns Hopkins University Bloomberg School of Public Health, the International Union Against Tuberculosis and Lung Disease, the World Health Organization, and the World Lung Foundation.

Before joining the Campaign for Tobacco-free Kids, Ms. Lawrence worked for 16 years as a journalist, including a cumulative 11 years between 1990 and 2003 as a staff correspondent in China. She served as China bureau chief and later Washington correspondent for the Hong Kong-based newsweekly Far Eastern Economic Review, as a Beijing-based staff correspondent for The Wall Street Journal, and as China bureau chief for the newsmagazine US News & World Report. A fluent Mandarin Chinese speaker, she holds Bachelor’s and Master’s degrees in East Asian Studies from Harvard University and was a Harvard-Yenching Institute Scholar in the History Department at Peking University from 1985-87. 

Her talk is the third in the colloquium series on tobacco control in East Asia, sponsored by the Asia Health Policy Program at the Shorenstein Asia-Pacific Research Center, in coordination with FSI’s Global Tobacco Prevention Research Initiative.

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Susan V. Lawrence Head of China Programs Speaker Campaign for Tobacco-Free Kids
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The stated purpose of the Trade Act of 1974 was to promote free trade. Section 301 authorized the U.S. President to impose retaliatory trade sanctions if negotiations were unsuccessful in reducing unreasonable limits on trade. The Act was reinforced in 1984, became known as “Super 301”, and made annual assessment and retaliatory measures mandatory.

Because of trade imbalances, four emerging Asian countries gave the US firms access to cigarette markets: Japan (1987), Taiwan (1987), South Korea (1989) and Thailand (1990). These forced market opennings were called the “Second Opium War” by local protestors in these countries, challenging U.S. export of unwelcome and unhealthy products.

A sea change occurred in the decades that followed the cigarette market opening in Taiwan. Of particular interest are changes in areas marketing skills and market share; lower cigarette prices; paradoxical increased smuggling; increased youth consumption; evolution of the powerful tobacco industry lobby; and a sharp increase in tobacco-related cancer deaths. Accompanying the increased cigarette consumption, a special, unusual habit of chewing betel quid started and grew into a mainstream practice among adult males (nearly one out of four). Oral and esophageal cancer increased sharply soon after the market opened. At the same time, the patriotic protectionists, NGOs, and government galvanized an anti-smoking movement, which gradually transformed Taiwan's culture so that smoking in public is no longer socially acceptable. A new term, “de-normalization,” was coined about the favorable effect of market opening.

 The ironic outcome of Super 301 is that while the market was forced open solely by the US, in only ten years, US market share, once leading, shrunk to a distant fifth, after Japan, UK, Germany and domestic producers. The trade imbalance was little affected by the opening of the cigarette market.

Dr. Wen's colloquium continues the colloquium series on tobacco control in East Asia, sponsored by the Asia Health Policy Program at the Shorenstein Asia-Pacific Research Center, in coordination with FSI’s Global Tobacco Prevention Research Initiative.

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Chi Pang Wen Speaker National Health Research Institutes, Taiwan
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Why do community-based education and social persuasion programs for promoting healthy lifestyle and preventing chronic disease sometimes fall short of our expectations? Why are population effects so difficult to engineer and why are they so ephemeral? This research carried out at USC, the Claremont Graduate University, and collaborating institutions in China integrates across social, behavioral, and neurocognitive sciences to address those questions.

We conclude tentatively that the answer to each of the questions may lie in individual and context variability relative to program response, and that in order to more fully address the question of prevention program response variability requires engagement and integration across several levels of science to consider the roles of social groupings, environmental selection and design, social influence processes, and brain biology. What works in one social, cultural or organizational setting may not be so effective in another. What works for persons with certain genetic and experiential backgrounds may be totally ineffective for persons with different dispositional or personality characteristics. In a series of community/school based prevention trials carried out in markedly different southern California and central China settings, we have uncovered domains of consistent response, and other domains of substantial environment- and disposition-based response variability. A social influences based smoking prevention program framed in collectivist values and objectives worked to prevent smoking in one cultural setting but not another. And an individualist framed social influences program worked in the setting where the collectivist program did not. But the characteristics of the particular settings which defined program success or failure were different from what conventional (e.g., cultural psychology) wisdom would have led us to expect. Furthermore, both within and across cultural settings, the same individual dispositional characteristics moderated or determined program effectiveness, again in ways not predicted by the common cultural and behavioral science wisdom. In recent studies carried out both in China and the U.S. we have found affective decision deficits, with known neural underpinnings, to account for rapid progression to regular smoking and binge drinking. These deficits are akin to the dispositional characteristics found earlier to moderate prevention program effects. Subsequent brain imaging studies confirm the hypothesized regions of neural involvement. Together these findings hold promise for more effective – situation and phenotype specific – approaches to engendering and sustaining more optimal individual and population health behavior.

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Carl Anderson Johnson Dean & Professor Speaker School of Community & Global Health, Claremont Graduate School
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