The devastation caused by smoking in China is monumental. According to the Global Burden of Disease Study (1), in 2017, smoking caused 2.2 million deaths among smokers and an additional 0.4 million deaths among non-smokers due to secondhand smoke, with the total of 2.6 million deaths establishing smoking as the leading cause of death in China. The magnitude of the death and disease caused by smoking in China far exceeds China’s position as the most populated country in the world: although China represents 18.5% of the global population, it suffers one-third of annual global deaths from smoking (7.1 million) and secondhand smoke (1.2 million) (2). The economic cost of smoking is also extraordinary, estimated to be as high as 368 billion CNY (3).
The goal of Healthy China 2030 is to reduce non-communicable diseases (NCD) deaths by 30%. But this cannot be achieved without great reductions in smoking. China has taken the critically important step of incorporating tobacco control into the Healthy China 2030 plan, but it is important to take strong action to achieve these dramatic reductions in smoking. Fully implementing the key demand reduction measures of the World Health Organization (WHO) Framework Convention on Tobacco Control (FCTC) — higher taxes; comprehensive national smoke-free laws; large pictorial warnings on cigarette packs; strongly enforced comprehensive bans on tobacco advertising, promotion, and sponsorship; and support for cessation (demand-reduction strategies that correspond to the WHO’s MPOWER① measures) (4) — is strongly associated with reductions in smoking prevalence (5). It is estimated that if China were to achieve this full implementation, smoking prevalence would decrease from 26.6% in 2018 (6) to 20%, and this would lead to the achievement of the Healthy China 2030 goal (7).
The theme for the 2021 WHO World No Tobacco Day is “Commit to Quit”, which is a year-long campaign launched in December 2020 designed to promote smoking cessation (8) — a key component of the FCTC. The FCTC obligates 181 countries, including China, to implement strong tobacco control measures to promote cessation and to prevent tobacco uptake. Article 14 of the FCTC focuses on measures to encourage cessation and treatment for tobacco dependence. Reviews have found that Article 14 implementation has been poor (9-10). In 2018, only 23 countries had implemented comprehensive cessation services (11), which include implementing effective cessation programs, including diagnosis and treatment of tobacco dependence in health care settings, involving medical and health care professionals, and in taking steps to make evidence-based cessation treatments (e.g., stop smoking medications) available and affordable.
The International Tobacco Control (ITC) Policy Evaluation Project examined indicators of progress on cessation in China in comparison with two other ITC East Asian countries — the Republic of Korea and Japan — based on data from the most recent ITC cohort surveys of smokers [China (2013–2015); Republic of Korea and Japan (2020)]. Extensive information about the methods of the ITC cohort surveys are available elsewhere (12-15). Briefly, the ITC China Survey was conducted among 7,817 adult smokers selected using a multistage probability sample in 10 locations in China: 5 cities (Beijing, Shanghai, Guangzhou, Kunming, Shenyang) and 5 rural areas (Changzhi, Huzhou, Tongren, Xining, Yichun). The Republic of Korea web-administered cohort survey was conducted among 3,766 adult smokers from a national survey panel. The Japan web-administered cohort survey was conducted among 2,757 adult smokers from a national survey panel. Table 1 presents the smoking prevalence of the three countries over time.
Country 2010 2015 2018 China 28.1% 27.7% 26.6% Japan 19.5% 18.2% 17.8%* The Republic of Korea 27.5% 22.6% 22.4% Note: Smoking prevalences in China are from the 2010 and 2018 Global Adult Tobacco Survey (6,16) and from the 2015 China Adults Tobacco Survey (17). Smoking prevalences in Japan are from the National Health and Nutrition Survey (NHNS) Japan (18). Smoking prevalences in the Republic of Korea are from the Republic of Korea National Health and Nutrition Examination Survey (KNHANES) (19).
* The smoking prevalence in Japan for 2018 may also include users of heated tobacco products (HTPs), since the NHNS asked about “smoking”, thus not making a clear distinction between cigarettes and HTPs.
Table 1. Smoking prevalence in China, Japan, and the Republic of Korea over time.
|①||MPOWER：Monitor tobacco use and prevention policies; Protect people from tobacco smoke; Offer help to quit tobacco use; Warn about the dangers of tobacco; Enforce bans on tobacco advertising, promotion and sponsorship; Raise taxes on tobacco.|