Stanford anthropologist and APARC-affiliated faculty Matthew Kohrman talks about his latest book that sheds light on the world’s greatest cause of preventable death in the context of the world’s most populous country.
A common mythology is that cigarette smoking is yesterday’s problem. But as Stanford Associate Professor of Anthropology Matthew Kohrman shows, the cigarette epidemic is today’s greatest health calamity. In a recent book he edited and co-authored, Poisonous Pandas: Chinese Cigarette Manufacturing in Critical Historical Perspectives, Kohrman assembles leading scholars from a variety of disciplines who examine sources of the world’s greatest cause of preventable death and who open up a new area of research: critical historical studies of China’s cigarette industry.
China today is the world’s largest manufacturer and consumer of cigarettes and is, therefore, the most important setting in which to investigate the proliferation of cigarette production amidst the public health condemnation of smoking. Poisonous Pandas, part of Shorenstein APARC’s series with Stanford University Press, focuses on that thinly-studied phenomenon. The book's co-editors include Robert Proctor, professor of the history of science at Stanford; Gan Quan, director of tobacco control at the International Union Against Tuberculosis and Lung Disease; and Liu Wennan, editor for the Institute of Modern History at the Chinese Academy of Social Sciences. I recently sat down with Kohrman to discuss the book and its findings.
How did you get involved in studying China’s cigarette industry?
Before I arrived at Stanford I had studied disability-rights organizations in China. I was interested in biopolitics, and particularly in the intersection between state and gender. My first book explored what happens in a patriarchal environment when the patriarch's body breaks down and it focused on the rise of disability discourse in China. When it was time to consider my next project I started thinking about the people I was interacting with during my years of community research—men mostly. These men were smokers, many of them very joyous smokers, who found cigarettes to be indispensable for building relationships and getting through the complexities of their adult lives. And in addition to sharing with me their joys of smoking, they also shared with me personal stories of heartbreak, of how they and their family members who were smokers had fallen ill and were dying from tobacco-related diseases.
As a medical anthropologist, thinking about cigarettes in China allowed me to extend the study of what social scientists call biopolitics. Cigarettes allowed me to move the study of biopolitics from something focused on life making to something also centered on death making. After all, cigarettes have long been heavily marketed as life promoting and they have long generated huge amounts of taxes, which countries use for providing government services. At the same time cigarettes have become the single greatest cause of preventable death in the world today. No less interesting is that this is a story long grounded in a close synergy between governments and corporations, in China and pretty much everywhere else in the world.
When I began my ethnographic fieldwork on tobacco in China I initially studied mostly consumer behavior—which is what the rhetoric of global health emphasizes and what researchers are often disciplined to investigate. But I quickly realized that focusing solely on cigarette consumption, without considering the relationship between supply and demand, was like studying obesity while ignoring food; it was like studying nuclear proliferation while ignoring the mining, refinement, and sale of uranium. So, I shifted focus and began looking more and more at the cigarette industry, especially as managed in China, and started asking questions about why public health had been designed in ways that conceal the role of the industry.
Your book dispels the prevalent notion that public health interventions have succeeded in making the cigarette epidemic a thing of the past. What, in fact, has been happening worldwide, and particularly in China?
It’s true that there have been declines in smoking usage in a number of countries, particularly among the well educated. Yet, three times more cigarettes are produced and consumed today worldwide than in the 1960s, when the scientific community reached a consensus about the health risks of cigarette smoking. Cigarettes are the cause of an estimated six million deaths worldwide. In the United States today half a million deaths a year are attributed to cigarettes.
Other important global trends we see are the outsourcing of cigarette consumption and the consolidation of the tobacco industry worldwide around a set of big players (outside of China those are most notably Philip Morris/Altria, BAT, Imperial Tobacco, and Japan Tobacco). Following a carefully choreographed playbook, the industry has ramped up marketing and sales of cigarettes in lower- and middle-income countries. Driving that trend have been several companies carrying out a massive mergers-and-an-acquisition game, buying up smaller companies around the world at a frenzied pace, closing cigarette factories in high-income countries, and building more efficient new ones elsewhere, especially in places like Eastern Europe, Russia, Africa, and across Asia. So, instead of declining as we would expect based on our impressions living here in California, the number of daily cigarette smokers around the world is projected to continue climbing, with new smokers coming on board in low- and middle-income countries that often have relatively high birth rates, while in high-income countries, which often have declining birth rates, the number of smokers continues to fall. The net result is an escalating global health catastrophe, much of it unfolding outside the purview of the academy.
In China at present, over 300 million people are daily cigarette smokers, over half of the population is regularly exposed to cigarette smoke, and more than a million deaths per year can be attributed to cigarette smoke exposure. Predictions are that, by 2030, morbidity will triple to 3.5 million annual deaths and that, by 2050, one out of three male deaths will be tobacco-related. Chinese hospitals are already filled with patients suffering from tobacco-induced illnesses. Death due to lung cancer alone has soared in China during the past three decades. It’s mostly men who are dying from these ailments, families are struggling to care for them, and are spending their savings on invasive treatments which, even in the richest of countries, often have poor outcomes.
And the industrial source of all this devastation? China’s State Tobacco Monopoly Administration (STMA, also known as the China National Tobacco Corporation, or China Tobacco) is responsible for two out of every five cigarettes rolled, packed, and shipped worldwide today. Catering mostly to a domestic market, China Tobacco produces more cigarettes now than the world’s next four largest tobacco companies combined.
In that regard, it is important to re-emphasize that this story isn't unique to China and must not be interpreted as only a matter of one country poisoning its people with cigarettes. Rather what happens in China is a piece of a global story about the worldwide tripling of tobacco production and consumption.
...those who die from using cigarettes don't make good victims in the sense of mobilizing politics. - Matthew Kohrman
Why isn’t more attention being paid to this global cigarette epidemic? Why doesn’t it make headlines?
One answer is that those who die from using cigarettes don't make good victims in the sense of mobilizing politics. There are several reasons for that. First, typically there is a long delay from the start of cigarette use to death, meaning there is no sudden “crash” or “outbreak” event associated with tobacco, as opposed to, say, Ebola or other types of infectious diseases that, as we know, can trigger media and security attention. At the same time, survival rates among the paradigmatic cigarette victim, the lung cancer patient, are very low, so there is no strong survivor community like with other types of cancer. In the United States today far more women die of lung cancer than of breast cancer, but there is no critical lung cancer victimology as there is around breast cancer.
Second, prodded by industry rhetoric, cigarette smoking in much of the world is strongly tied up with the notions of consumer choice and freedom, and therefore cigarettes create victims who are largely blamed for their own behavior. This rhetoric is supported by weak warning labels: consumers are alerted that smoking is “harmful” to their health and told that they are taking on that risk at their own discretion. This has much to do with the prevalent tobacco-control approach: we push out knowledge that says that you're smarter if you don't smoke and that people who do smoke cannot control themselves. This is why the tobacco industry actually loves warning labels (to a certain degree): warning labels protect the industry by creating a short-circuiting of the victimology that is needed to develop a critical political and social action. More to the point, whenever someone gets sick from a “tobacco-related disease,” there is a lot of intimate blaming that crops up (of self as well as one’s smoking compatriots), such that few people are inclined to talk about their or their family member’s tobacco-induced disease. Cigarettes, therefore, remain a well-known killer on the scale of demographics and epidemiology, but very much a silent killer at the level of social action.
Third, the global cigarette epidemic is a gendered story: far more men worldwide smoke than women. In China today only two to three percent of women are daily cigarette smokers, compared with well over half of men ages 25 to 64. Now for various reasons, men—particularly older men—don't make as sympathetic a victim as women or children do.
Finally, the epidemiology of tobacco is increasingly understood as class-based: with more and more of the people killed by tobacco-induced illnesses being people in less-educated and in lower- and middle-income contexts. Whether that is actually true is an open question. But because cigarette smoking has become increasingly associated with the poor, its resultant morbidity is increasingly associated in people’s minds with the poor. And as we well know, rarely is caring for the poor a political priority around the world.
All this means that, overall, the cigarette epidemic isn’t an attractive or generative story for political mobilization.
Your book prioritizes several themes, the first of which is cigarette normalization, that is, not just how the behavior of cigarette smoking has become perceived as normal, but also how the cigarette’s widespread availability as a consumer product has come to be viewed as unremarkable, expected, and commonplace. What has shaped this process of normalization, particularly in China?
The globalization of tobacco started in a colonial context, in the late 1400s, but the ability to inhale tobacco smoke is a relatively new phenomenon that began in the late 1800s, with the discovery of flue-cured tobacco, something which made tobacco smoke far more addictive. With the discovery of flue-curing and the advent of the cigarette rolling machine in the late 1800s, cigarettes become commodities: consumer goods increasingly visible and understood to be as normal to the retail experience as gum, wrapped candy, or razor blades—part of the average store of daily use items. Not long after the first cigarette rolling machine was patented, there were more cigarettes available than existing cigarette consumers desired. That is, companies found that it was much easier to produce cigarettes than to sell them. The remedy for the industry quickly became advertising. The birth of the U.S. advertising business is closely tied to the cigarette industry.
The same also applies to China. Tobacco had been part of governance and part of everyday life there since the end of the Ming dynasty when Beijing first began taxing tobacco, but cigarettes only became normalized in China during the early twentieth century, helped along by the tobacco industry building the country’s early advertising apparatuses.
Communism nurtured this normalization. Mao and other Communist forbearers viewed tobacco and cigarette taxes in particular as vital to state-building. As a consequence, in the Communist pre-1949 Base Areas, the Red Army blocked people’s access to exogenous cigarettes and set up cigarette factories of their own. In that context, locally produced cigarettes came to be viewed as integral to life for an emergent party-state. This view was intensified in the 1950s with the nationalization of the industries and the state’s promotion of cigarette manufacturing not just in traditional venues like Shanghai but in most provinces. In the 1960s cigarette ration coupons were issued, thereby furthering the normalization of cigarettes as items to which a citizen should have some guaranteed access, on par with grain and meat.
Regulatory localization has also been crucial to cigarette normalization in China. In the early 1950s the Chinese Communist leadership granted significant autonomy over the tobacco industry at the province level, such that a state-run monopoly turned into a set of regionalized public cartels that allowed manufacturers controlled by local party bosses to sell their cigarettes only within their boundaries. With the rise of regional state-owned factories pumping out cigarettes, regional governments issuing cigarette ration coupons for those cigarettes and blocking access to product from other parts of the country, it was not just that cigarette brands became highly localized. Cigarettes themselves became an index of residency and locality—part of one’s identity as a resident of Hunan, Yunnan, Shandong, etc.
Another aspect of cigarette normalization in Communist China has been party careerism: success at helping sell local cigarette brands has been a way for local cadres to prove their political worth to the party. This became especially the case after Mao's death. In the Deng Xiaoping era, promotion within the party came to be closely tied to raising local GDP. This sparked an immense increase in regional cigarette production and marketing because cigarette sales are an easy way to spike GDP.
Eventually, after the State Tobacco Monopoly Administration took over many of the reins of China’s cigarette businesses from local party authorities in the 1980s, that Beijing-based bureaucracy began consolidating and closing smaller cigarette factories in order to engineer economies of scale. STMA’s organizational mandate has been to increase efficiencies and make cigarettes the centerpiece of a new consumerist era.
China has accelerated its tobacco-control efforts over the past few years. What is your view of these efforts?
In 2003, the Chinese government signed the World Health Organization’s Framework Convention on Tobacco Control, which enacts a set of universal standards aimed at limiting tobacco use worldwide, and we’ve seen Hu Jintao’s and Xi Jinping’s administrations taking various measures towards tobacco control. These include directives to government officials, restricting tobacco advertising and smoking in public places, as well as at least one experiment in raising the rates of cigarette taxes. But the road towards comprehensive tobacco prevention in China is going to be a long one, especially given the power and influence of the industry and its State Tobacco Monopoly Administration. Public opinion in China regarding the cigarette epidemic is yet to be mobilized in any notable way.
That does not mean we should despair, my Chinese colleagues working on this topic tell me. It just means that there is that much more work to do. And that brings us back to the Poisonous Pandas volume. A central aim of this book is to help nurture a new area of historical research in China, critical industry studies of tobacco. But the purpose of the book does not stop there. The authors contributing to Poisonous Pandas hope that, in time, this area of study will serve as a fertile ground for a vibrant critical consciousness regarding the tobacco industry to emerge, one that extends well beyond the academy. Qiānlǐ zhī xíng, shǐyú zú xià. A journey of a thousand miles begins with a single step.