Nearly every day in China, women go to work in smoke-filled offices, exposed to the fumes of cigarettes smoked mainly by male colleagues. After work is over, many go home to breathe secondhand smoke created by husbands or other family members.
China is known as the Smoking Dragon, but its addiction to tobacco isn’t shared between the sexes. According to the most recent national survey, 288 million men smoked regularly in China in 2010, compared with 13 million women.
Lately, the women are striking back. Last fall, China’s State Council proposed the nation’s toughest restrictions yet on indoor smoking and the marketing of tobacco. The announcement was a major victory for China’s tobacco-control movement, which includes several women who’ve been on the front lines for decades.
“This is a very important step,” said Yang Gonghuan, an epidemiologist who’s been documenting tobacco’s toll on Chinese public health since the 1980s. “It is very difficult to push for these kinds of changes on a national level. . . . It has taken many, many years.”
Although China is known for its smog and other environment problems, no public health issue poses more of a threat than tobacco. An estimated 1 million Chinese die each year from lung cancer and other smoking-related diseases.
China’s anti-smoking movement includes many prominent men. Former NBA center Yao Ming and other celebrities have lent their names to the cause. An activist named Li Enze filed a lawsuit in 2013 against China’s tobacco monopoly, alleging that it had fraudulently marketed a low-tar cigarette brand called Black Tiger.
Yet in government and among tobacco-control groups, women are leading the charge. China’s health commissioner, Li Bin, has been outspoken in seeking a national indoor-smoking ban. Li sits on the State Council, a top-level panel that drafted the restrictions unveiled in November. Two of her key deputies are women.
Among academics, Yang is known for her extensive research into tobacco use and disease trends. Brookings Institution researcher Cheng Li said Yang “has played a crucial rule in China’s anti-smoking campaign,” particularly by co-authoring an influential 2011 report that documented the health effects.
Other top anti-smoking advocates include Wu Yiqun, the founder of the Thinktank Research Center for Health Development, and Xu Guihua, vice chair and secretary-general of the Chinese Association on Tobacco Control.
Angela Pratt, who leads the World Health Organization’s anti-smoking efforts in China, said Yang, Wu and Xu had played crucial roles in elevating the issue.
“These people have been the driving force of tobacco control for a long time,” she said.
As Pratt noted, the battle is far from won. Although smoking rates have declined in recent years, more than half of Chinese men smoke regularly, according to the WHO. Some 700 million Chinese – twice the population of the United States – are routinely exposed to secondhand smoke, which kills an estimated 100,000 people annually.
It isn’t entirely clear why so many women are driving China’s tobacco-control movement, but cloud-filled rooms may be a factor. “The issue of secondhand exposure is a big issue for women,” Pratt said. Many are increasingly aware of the potential health impacts on children.
Chinese have smoked tobacco for centuries, and up until the early 1900s women regularly could be seen with men puffing on pipes. But with the advent of cigarettes, Chinese intellectuals and foreign missionaries started frowning on women who smoked. According to Carol Benedict’s book, “Golden-Silk Smoke: A History of Tobacco in China, 1550-2010,” society started to describe female smokers as “modern women,” a label also given to the promiscuous and unpatriotic.
As a result, women quit smoking, even as Chinese leaders such Mao Zedong and Deng Xiaoping smoked openly in public, encouraging the habit among men.
Today, China is the world’s biggest consumer of tobacco. It’s also the largest manufacturer, producing more than 2.3 trillion cigarettes yearly, nearly half the world’s total. Unlike in the United States, private companies such as Philip Morris do not dominate the market. Instead, the China National Tobacco Corp. – an arm of the State Tobacco Monopoly Administration – controls nearly all the cigarette brands sold.
That puts the Chinese government in an unusual dual role: One arm of the government, the Health Ministry, tries to restrict tobacco use and warn of its dangers, while other government agencies benefit from tobacco’s profits and tax revenues, which totaled nearly $120 billion in 2012, about 6 percent of government revenues.
“This is why tobacco control in China happens so slowly,” said Yang, a professor of medicine who directs the Burden of Disease Research and Dissemination Center in Beijing. “The tobacco industry is very powerful.”
Yang, who formerly worked in China’s version of the U.S. Centers for Disease Control and Prevention, became interested in smoking-related diseases and other preventable illnesses while attending medical school in Chengdu in the early 1980s. Early in her career, she studied at Harvard School of Public Health and worked on health projects for the World Bank and the World Health Organization. Because of her WHO experience, she became part of the Chinese delegation that worked on the Framework Convention on Tobacco Control, which China ratified in 2005.
China’s signing of that treaty was a triumph for the global tobacco-control movement, but expectations quickly diminished. Smoking has remained common in public places across the country, particularly in rural areas, where half of the population lives. Large numbers of doctors in China smoke. It wasn’t until 2010 that the Health Ministry banned smoking in its own building.
In recent years, attitudes toward smoking have started to shift. Top leaders of China’s Communist Party are either nonsmokers or are careful not to be spotted lighting up in public. Late in 2013, the party banned government officials from smoking in public or giving cigarettes as gifts. Individual cities have enacted their own restrictions on tobacco.
The draft regulations unveiled in November, if enacted and enforced, would take China into another realm. The proposed rules would ban indoor smoking and make private businesses responsible for enforcing the ban, subject to fines if they don’t. It would further limit the marketing of tobacco in China and require larger warning labels on cigarette packs.
Xu Guihua, of the Chinese Association on Tobacco Control, said enforcement of the rules would be crucial, and would require a cultural shift in China. Average citizens will need to get involved, since police can’t be everywhere.
“In the past several hundred years, people have cultivated the habit of smoking wherever they want,” she said. “Changing this will take some time.”
Even so, Xu said the proposal would save lives and help China comply with the WHO’s tobacco treaty. She credited a broad coalition for the breakthrough.
“Many people involved with tobacco control have been active on this issue for years, calling for new regulations,” said Xu. “New leaders in China, including Xi Jinping, see this as important.”
Xi, who became Communist Party secretary in 2012 and president the following year, is often described as the strongest Chinese leader since Deng Xiaoping. One of his top priorities: cracking down on corruption and changing the image of government officials, widely viewed as fat cats who like to wine and dine in smoke-filled banquet halls.
For that reason, you’ll never see a photo of Xi with a cigarette in his fingers.
But there’s another reason as well. Xi’s clean-living ways are thought to be influenced by his wife, Peng Liyuan, a former celebrity singer long active on public health issues. Since 2009, Peng has served as an “ambassador for tobacco control” for the Chinese Association on Tobacco Control.
Still, anti-smoking advocates remain wary of the clout of the cigarette industry. It also has friends at the top. Since 2003, Li Keming, the brother of China’s premier, Li Keqiang, has served as deputy director of the State Tobacco Monopoly Administration.
In an interview published Dec. 1 by a Shanghai newspaper, Li Keming’s boss, Ling Chengxing, made clear that he and his agency oppose the proposed regulations.
“We should avoid the inclination of being lopsided and absolute,” he was quoted as saying, and “promote the work of smoking control in a healthy, orderly, effective and solid manner.”
The fate of tobacco control in China might come to a head in the months to come. The Health Ministry has urged the State Council to make the proposed tobacco restrictions a “tier one” priority, which would facilitate their enactment in 2015. If it remains a lower tier priority, enactment of new rules might be delayed, giving the tobacco industry more time to derail them.
Yang remains optimistic. She said concerns over rising health care costs were getting the government’s attention. One study has estimated that, as of 2010, the medical and lost-labor costs of tobacco-related diseases totaled $253 million yearly in China, far more than the revenues and taxes generated by tobacco.
“Twenty years ago, I think, the Chinese government cared mainly about economic development,” she said. “Now there is more and more awareness about chronic diseases. The government is being forced to consider the (economic) burden.”