Tobacco Control in China

This book comprehensively covers the science and policy issues relevant to one of the major public health issues in China. It pulls together the prevalence pattern of tobacco use in different population and burden of the myriad of tobacco-related diseases. The book pays more attention to review the successes and failures of tobacco control policies in China, including the protect peoples from second-hand smoke, comprehensive banning tobacco advertisement promotion and sponsor, regulation of the contents of tobacco products and low tar cigarettes, warn about the dangers of tobacco, support for smokers to quit, and increasing tobacco taxation and price, as well as monitor and assessment on tobacco use and implement of prevention policy under the international background of tobacco control.

The book analyse and explain the influence factors, especially interference from tobacco industry with public management theory frame for promoting tobacco control policies and looks at lessons learnt to help set health policy for reducing the burden of tobacco-related diseases. It is a helpful reference for experts in public health and epidemiologists in tobacco control, advocators and policy maker.

• Language: English
• Publisher: Springer
• Release date: May 21, 2018
• ISBN: 9789811083150

Book preview

© Springer Nature Singapore Pte Ltd. 2018

Gonghuan Yang (ed.)Tobacco Control in Chinahttps://doi.org/10.1007/978-981-10-8315-0_1

1. Introduction: China and the Negotiation of WHO FCTC

Gonghuan Yang¹  

(1)

Institute of Basic Medical Science Chinese Academy of Medical Sciences, School of Basic Medicine Peking Union Medical College, Beijing, China

Gonghuan Yang

Abstract

This chapter, as the introduction of the book "Tobacco Control in China", described the response to the tobacco use pandemic from international public health community so as to understand the tobacco control in China by the international perspective. Tobacco use pandemic is a global problem and must be solved at the global level. It cannot be solved by traditional public health strategy, but should be solved based on the international law at the legal level! WHO Framework Convention on Tobacco Control (WHO FCTC) is the important weapon responding the tobacco pandemic under the Globalization. However, the attitudes and actions of the Chinese government during the negotiations on the WHO FCTC have shown that China’s more pursuit of international recognition beyond pursuit of public health and safety, has presaged the setback of the implementation of WHO FCTC in China. Thirdly, the brief review of the tremendous progress made by the most Parties of WHO FCTC over the last 10 years reflects the status of China’s tobacco control described in the following chapters as a mirror.

Keywords

WHO Framework Convention on tobacco controlGlobalizationNegotiationImplementationChina

1.1 Tobacco Use: A Serious Public Health Problem at a Global Level

In 1951, a cohort study of British physicians on tobacco and health was initiated by Richard Doll and Bradford Hill. The study proved that physicians who were mild smokers were seven times more likely to die of lung cancer than non-smokers, while for ‘moderate’ smokers, the risk was 24 times higher.¹ By the late 1950s and early 1960s, the mounting evidences on the health effects of smoking were formally reviewed and evaluated by government committees. In the United Kingdom, the 1962 report of the Royal College of Physicians concluded that smoking was a cause of lung cancer and bronchitis and a contributing factor to coronary heart disease.² In 1981, Professor Takeshi Hirayama published a prospective cohort study of 91,540 non-smoking Japanese women with smoking spouse.³ The non-smoking wives were followed up for mortality, including mortality due to lung cancer, for 14 years. The risk of lung cancer was examined in relation to the level of smoking by the spouse, resulting in the finding of a statistically significant exposure-response relationship. This was the first study to assess the possible importance of passive smoking as one of the causal factors for lung cancer.⁴

Since 1964 a series of the Surgeon General’s reports as a government scientific reports pointed out that cigarette smoking has been causally linked to diseases of nearly all organs of the body, to a poorer health status, and to harm to the fetus. Even 50 years after the first Surgeon General’s report, research continues to find links between diseases and smoking, including such common diseases as diabetes mellitus, rheumatoid arthritis, and colorectal cancer.⁵ Exposure to SHS has also been causally linked to cancer, respiratory, and cardiovascular diseases, and the adverse impact on the health of infants and children.⁴

By the 1990s, the tobacco epidemic was a severely public health problem and a leading cause of premature deaths. WHO reported The escalation of smoking and other forms of tobacco use worldwide had resulted in the loss of at least 3.5 million human lives in 1998 and was expected at that time to cause at least 10 million deaths a year by 2030 if the pandemic was not controlled, with 70% of these deaths occurring in developing countries.⁶ Tobacco use not only leads to a significant increases in morbidity and mortality, but also reduce productive powers and increase avoidable health expenditure.

1.2 Response to the Challenge of the Global Tobacco Pandemic: WHO FCTC

The international community recognizes that past efforts to stem the global tobacco pandemic have proven in effective. The epidemic of tobacco use spread rapidly from the developed to the developing world, owing to driving force from the multinational industry and the addictiveness of nicotine. Globalization undermined the efforts of individual countries to control tobacco use. The traditional public health approach to reducing tobacco use were not match for the tobacco industry’s power, transnational reach and economic strength. International experts have suggested that the WHO should use its unused constitutional authority to change the rules of tobacco control, by developing an international framework convention covering key aspects of tobacco control with cross-border. Dr. Brundtland, as Director General of the WHO from 1998 to 2003, allocated sufficient resources to support the protracted, complex work of preparing Member States for the WHO’s first foray into treaty making.

Dr. Gro Harlem Brundtland (former WHO Director-General) point out The tobacco habit is extensively communicated! It is communicated through the media, the entertainment industry, and most directly through the marketing and promotion of specific products. Global trade in tobacco has increased markedly over the last few years. Direct foreign investment by multinationals in developing countries has also increased. New joint ventures are announced every few months between multinationals based in a few developed countries and the governments from emerging markets. Also she continued Tobacco control cannot succeed solely through the efforts of individual governments, national nongovernmental organizations and media advocates. We need an international framework convention that will cover key aspects of tobacco control that cross national boundaries. The framework convention will seek to address key areas of tobacco control such as: harmonization of taxes on tobacco products, smuggling, tax-free tobacco products, advertising and sponsorship, international trade, package design and labeling and agricultural diversification.⁷ That is to say, tobacco epidemic is a global problem and must be solved at the global level. It cannot be solved by traditional public health strategy, but should be solved based on the international law at the legal level!

After six rounds of negotiations, WHO FCTC was developed, in 2003. On 21st May 2003, the 56th World Health Assembly unanimously adopted the WHO FCTC.⁸ It took only 7 years to start negotiations to the Convention into force. The WHO FCTC is one of the fastest treaties to be negotiated, adopted and concluded, with unanimous adoption by the convention by the World Health Assembly, acceptance by the signatories, and rapid entry into force in February 2005, which means the Governments committed to creating a healthy, tobacco-free New World for future generations. As the preamble to the Convention, "The Parties to this Convention, Determined to give priority to their right to protect public health, Recognizing that the spread of the tobacco epidemic is a global problem with serious consequences for public health that calls for the widest possible international cooperation and the participation of all countries in an effective, appropriate and comprehensive international response; Reflecting the concern of the international community about the devastating worldwide health, social, economic and environmental consequences of tobacco consumption and exposure to tobacco smoke. When the treaty was closed to new signatories, on 29 June 2004, it had 168 signatories, making it one of the most widely embraced treaties in United Nations history. This suggests that governments agree to curb tobacco consumption is one of the priorities to protect people’s health and health concern of the people is the basic part of the development goal of people-oriented. The governments have recognized the people-oriented" social development goals. The WHO FCTC covers the key strategies of tobacco control. The core provisions for reducing demand are contained in Articles 6–14, which address both price and tax measures, and non-price measures to reduce the demand for tobacco, including protection from exposure to tobacco smoke; regulation of the contents of tobacco products, regulation of tobacco product disclosures, education, communication, training and public awareness, comprehensive banning of tobacco advertising, promotion and sponsorship, and measures to reduce tobacco dependence and help people to give up smoking. The core provisions for reducing supply are contained in Articles 15–17 and cover illicit trade in tobacco products, sales to and by minors, and support for economically viable alternative activities. The Framework Convention also covers other important areas, such as liability, and protection of public health policies from the interests of the tobacco industry with respect to tobacco control, protection of the environment, national coordinating mechanisms, international cooperation, reporting and exchange of information, and institutional arrangements (Article 5 and 18–26).⁹

1.3 China and the Negotiation of WHO FCTC

China’s attitude and performance in the WHO FCTC negotiations were the result of the game between the health departments and the tobacco industry, but ultimately reflect the basic position of the Chinese government in international affairs.

Since reform and opening to the outside world in 1979, China began really to integrate into the international community, posing as a co-operator. China claimed to be an international responsible nation and to assume international responsibility.

Meanwhile, the health community of China very actively supported the idea that the WHO should take the lead in the development of an international convention to curb the prevalence of tobacco at the tenth conference of smoking or health held in Beijing in 1997.¹⁰ The Ministry of Health (MOH) of China also actively responded to the negotiation of the first global public health treaty. However, as a country with a large state-owned tobacco production and consumption, the Chinese government has been concerned that a decline in tobacco consumption would affect China’s economy. In summer 2000, the MOH organized a workshop, inviting officers from various ministries of the State Council.¹¹ At this workshop, several key points on tobacco control were clarified:

Firstly, the epidemic of tobacco use in China was so severe that it would be bound to cause serious health hazards. The serious health risk caused by the epidemic of tobacco use in China will inevitably lead to rising medical costs, exacerbating poverty and social instability. In addition, one of the important measures of tobacco control is increasing taxes and prices of tobacco products, which will be beneficial to the health of the people and increase the country’s fiscal revenue. The 1999 report of the World Bank concluded that tobacco control is not only beneficial to people’s health, but also valuable for the development of the national economy.¹² Secondly, based on international experience, even if effective tobacco control measures are implemented, the prevalence of smoking in the population can only drop by around 1% per year. Meanwhile, 1% of Chinese population is projected to increase annually from 2000 to 2020.¹³ That means the number of smokers will not be reduced in the short term. Chinese tobacco companies therefore have 20–30 years to complete the transformation of their enterprises. China is also adjusting its industrial structure, and tobacco companies, as an industry that represents a health hazard, should fall into disuse or be transformed, in line with the State policy of industrial structure adjustment. The National Development and Reform Committee (NDRC) calls the tobacco industry a Sunset industry¹⁴ to visually express its understanding for tobacco industry.

As has been claimed by China’s Ministry of Foreign Affairs, the Chinese delegation (to the WHO FCTC negotiation) not only safeguards China’s rights and interests as a major power for tobacco production and consumption, but also establishes its image as a responsible major power.¹⁵

Before going to Geneva, the Chinese delegation received clear instructions from the State Council to make efforts to actively contribute to the WHO FCTC, and not to quibble on the WHO FCTC text. The instruction, in essence, determined the direction of the efforts of Chinese delegation and criticized the officials of the STMA for their stubborn opposition towards the Convention. The head of China’s delegation at the first session of the negotiating conference said that the Chinese Government supported the formulation of the proposed framework for the convention on tobacco control, and had elaborated its views at the two working group meetings. Anti-tobacco initiatives had already been introduced into the Chinese legislation. … China gave its full commitment to being involved in that process for the forthcoming 3 years.¹⁶

China’s delegate repeatedly expressed the notion that China devotedly supports the WHO’s efforts to control tobacco, appreciating the great significance of the WHO FCTC, and presenting itself as a responsible power with a completely cooperative attitude towards the negotiation.¹⁷

However, the China National Tobacco Corporation (CNTC) did not want an international Convention on tobacco control. The CNTC is a state-owned monopoly over the tobacco industry, and also a government department: the State Tobacco Monopoly Administration (STMA). The CNTC and STMA are a unified organization, in charge of the management and production of tobacco. In October 2000, at the WHO hearing on the Framework Convention, the CNTC explicitly expressed its opposition: "Firstly, as a legal product should have its existence in the market place and should not be ‘eliminated’; … Secondly, individual countries are different in many aspects and can have their own choices and therefore tobacco control should respect these differences and should not violent their country sovereignty." The CNTC also described its other strategies and opinions, which are discussed later. Thus, the CNTC’s intention was that the form, scope and scale of any tobacco controls should respect the different circumstances of each country, and that the choices made should not interfere with national sovereignty.

China’ Delegation to WHO FCTC Negotiation was only the Delegation including representatives of the tobacco industry,¹⁸ which roused suspicious over the real position of China’s delegation to the WHO FCTC. The delegate from the STMA, in particular, professed¹⁹ that the words including a picture or pictogram illustrating the harmful consequences of tobacco consumption should be deleted from text of WHO FCTC. They also said that as the health warning covering 10% of the area of packaging in China, we must respect domestic laws and practices and cannot agree to the requirements of the Framework Convention. Due to the speech on the pictorial health warning, China’s delegate was offered the Dirty Ashtray Award.

The head of the Chinese delegation, however, interpreted the opposition to the pictorial health warning as an attempt to get more member states to accept the Framework Convention. So Convention should be general and flexible enough to allow tobacco control measures to be implemented in accordance with the individual situation and economic conditions prevailing in different countries.²⁰ The explanation is logically absurd and the expresses was similar to the views of the CNPC at the WHO hearing.

On one hand, the Chinese government actively participated in the negotiations on the WHO FCTC as a result of the strong advocacy from the professional health community, and effort from the Ministry of Health, with the Chinese government hoping to be praised as a responsible great power in dealing with international affairs. On the other hand, the Chinese government was reluctant to embrace a treaty with the strict tobacco control measures, as it regards its tobacco industry as a good source of government revenue. In other words, China views tobacco control as an internal economic issue rather than a public health issue.

Regardless of the debate or compromise in the negotiation process, the Chinese government signed the treaty in November 2003. While signing the WHO FCTC on behalf of China, Wang Gunagya, China’s UN ambassador, stated that China has played an active and constructive role in the negotiation of the WHO FCTC. By endorsing the international convention, China is once again demonstrating to the world its commitment to supporting the WHO and the government’s strong determination to control tobacco.²¹ The convention was ratified by the standing Committee of the National People’s Congress of China, China’s top legislative body, in 2005,²² indicating that China should fulfill its legal obligation in accordance with the WHO FCTC.

Nevertheless, it remains to be seen how far the tobacco control strategies covered in WHO FCTC to be internalized into China’ policies. As Sebastian Heilmann and Nicole Schulte-Kulkmann note, in effect, Chinese policymakers try to utilize policy diffusion as an instrument for negotiating and promoting the nation’s global rise. Yet, when it comes to implementation, global regulatory standards are weakened or even neutralized through discretionary enforcement. The depth and robustness of normative assimilation therefore remain uncertain.²³ It has been proved that the fear is well founded based on the implementation of the Convention after its entry into force in China.

1.4 Implementation of the WHO FCTC

Significant progress has been made since WHO FCTC came into force in February 2005. With 180 party member states in March 2015, covering 90% of the World’s population, the WHO FCTC has been among the most popularly and rapidly embraced global health norms in the history of the United Nations.²⁴ Meanwhile, the principal treaty bodies, the Conference of the Parties and the Permanent Secretariat, were established and are fully functional. The six sessions of the Conference of Parties (COP) have adopted the first protocol and several guidelines covering more than ten substantial Articles of the Convention, including the guideline of Article 6 adopted in the sixth Session of the COP. Eighty percent of the Parties have submitted their implement report of WHO FCTC to the reporting system of the treaty, the analyzed results were in the progress reports by the secretariat of WHO FCTC. The implementation of the Convention is on the track.

To expand the fight against the tobacco epidemic, the WHO has introduced the MPOWER package of six proven policies, which comprise the key Article of the WHO FCTC: 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, and Raise taxes on tobacco.²⁵

In the decade since the WHO FCTC came into force, and 7 years after the introduction of MPOWER, there has been great progress in global tobacco control. Today, the number of countries that have implemented at least one MPOWER measure (not including Monitoring and Mass media measures) at the highest level has reached 103 countries, covering 2.8 billion people, or 40% of the world’s population.²⁶ This proven that most countries worldwide, large and small, rich and poor, could combat the global tobacco epidemic and protect the health of their people.

The 2010, 2012, 2014 and 2016 global progress reports on the implementation of the WHO FCTC indicated that the Parties themselves have been taking extraordinary steps to implement the WHO FCTC. Most Parties have now reached the requirement of the Convention within the prescribed time limit of execution, particularly, Articles relating to the protection of people from SHS, the pictorial health warnings and comprehensive banning tobacco advertising, promotion and sponsorship. However, a third of Parties have not yet achieved full implementation of the related Articles since ratifying the WHO FCTC.²⁷

Overall, the average rate of implementation of the treaty, when calculated by indicators comparable across all reporting cycles, increased steadily, from 52% in 2010 to 56% in 2012, 59% in 2014 and 65% in 2016. However, progress of the different Articles has been uneven, ranging from 15% to 88% varying, implement rate of two-thirds of Articles were over 50%, the highest is Article 8 (Protection from exposure to tobacco smoke), next is the Article 11 (Packaging and labeling of tobacco products) (76%).²⁸ Implementation rates are also very different among Parties.

1.4.1 General Obligations (Article 5)

Strengthening national capacity and legislation for tobacco control is one of the general obligations under the Convention; it is the first step of the WHO FCTC that the Party is legally obliged to internalize. The success or failure of tobacco control depends on how the WHO FCTC is explained and implemented at national and community levels.

Article 5 of the treaty requires Parties to develop, implement, periodically update and review comprehensive multi-sector national tobacco control strategies, plans and programmes in accordance with the Convention and the protocols; Towards this end, each Party shall, in accordance with its capabilities: (a) establish or reinforce and finance a national coordinating mechanism or focal points for tobacco control; and (b) adopt and implement effective legislative, executive, administrative and/or other measures and cooperate, as appropriate, with other Parties in developing appropriate policies for preventing and reducing tobacco consumption, nicotine addiction and exposure to tobacco smoke.

Based on a series of the Global progress report of the WHO FCTC, the proportion of Parties reporting the development and implementation of comprehensive multi-sector national strategies, plans and programmes (Article 5.1) has increased consistently from 49% in 2010 to 59% in 2012, 65% in 2014 and in 73% in 2016.²⁹ Sixty one percent of the Parties have strengthened their existing tobacco control legislation, or approved new legislation, since ratifying the Convention, but 39% Parties have still not put in place legislative measures in accordance with the requirements of the Convention in 2014.³⁰

Appointing a national tobacco control focal point, strengthening the national coordination mechanism and international cooperation, are the basic national obligations with overarching impact. Most Parties have completed these aspects of their infrastructure.

1.4.2 Protect Tobacco Control Policies from the Tobacco Industry

Parties to the WHO FCTC have understood the tobacco industry as the main pusher of the tobacco epidemic. The preamble of the WHO FCTC emphasizes the need for Parties to be vigilant of any efforts by the tobacco industry to impede or undermine tobacco control efforts, and to grasp any activities of the tobacco industry that have a negative impact on tobacco control efforts. Article 5.3 of the WHO FCTC states that in setting and implementing their public health policies with respect to tobacco control, Parties shall act to protect these policies from commercial and other vested interests of the tobacco industry in accordance with national law.

In November 2008, the third session of COP adopted guidelines of Article 5.3, emphasizing the fundamental and irreconcilable conflict between the tobacco industry’s interests and public health policy. The guidelines recommend that Parties establish measures to limit interactions with the tobacco industry and reject partnerships and non-binding or non-enforceable agreements with the tobacco industry and so on, especially treat State-owned tobacco industry in the same way as any other tobacco industry.

In addition, Article 12.C stresses the importance of public education and awareness of the activities of the tobacco industry, and the Parties agree to promote public access, in accordance with national law, to a wide range of information on the tobacco industry as relevant to the objective of this Convention. Article 12.E reiterates the importance of the participation of public and private agencies and nongovernmental organizations not affiliated with the tobacco industry in developing and implementing inter-section programmes and strategies for tobacco control. Furthermore, Article 20.4C also mentioned to cooperate with competent international organizations to progressively establish and maintain a global system to regularly collect and disseminate information on tobacco production, manufacture and the activities of the tobacco industry which have an impact on the Convention or national tobacco controlactivities.

In brief, the Parties should have a sense of closely monitoring the activities of the tobacco industry to interfere with public health policy-making, preventing the tobacco industry from interference with tobacco control policies, and regulating activities described as socially responsible by the tobacco industry, and so on.

The WHO has been trying to monitor and counterattack the activities of the tobacco industry to interfere with public health policymaking though setting up the database and publishing reports.

In 2000, the WHO committee of experts on tobacco industry documents published Tobacco industry strategies to undermine tobacco control activities at the World Health Organization.³¹ The committee found that the evidence shows that tobacco companies have operated for many years with the deliberate purpose of subverting the efforts of WHO to address tobacco issues.

The WHO report " Tobacco industry interference in tobacco control "³² describes the spectrum of tobacco industry practices that interfere with tobacco control. Other reports, based on internal industry documents and companies’ public pronouncements, give many examples of how the multinational tobacco companies interfere in tobacco control.³³ , ³⁴ , ³⁵

The WHO provided the technical resource to support the implementation of the Article 5.3 Guidelines by sharing practical actions and best practices, and giving examples applicable to the implementation of Article 5.3 of the WHO FCTC.³⁶

Almost two thirds of the Parties have provided additional information on their progress in implementing Article 5.3, including promoting and raising awareness of the need to implement Article 5.3 within governments, the development of codes of conduct, ethical guidelines and administrative policies for civil servants, and so on.³⁷

There have been a few examples of litigation to promote tobacco control. A recent case was the successful legislation to prohibit tobacco industry logos, brand imagery, colors and promotional texts in Australia following the dismissal, by the highest court of Australia, of a challenge from transnational tobacco companies on Aug. 15, 2012.³⁸ Since December 1, 2012, cigarettes and tobacco products in Australia have been sold in plain olive green packets bearing graphic health warnings, such as pictures of mouth cancer and other smoking-related illnesses.

The global public health community has recently recognized the scope and intensity of interference from the tobacco industry and began to take protective action. The guideline of Article 5.3 of the WHO FCTC points out that Treats State-owned tobacco industry in the same way as any other tobacco industry, which hit the mark in the countries with the state-owned tobacco industry, such as China. The STMA is a member of the Inter-Ministry Coordination and Steering Committee for the Implementation of the WHO Framework Convention on Tobacco Control in China in charge of tobacco control policies, including Articles 9, 10, 11 and 15 of the WHO FCTC,³⁹ which is the main reason why China falls behind the majority of countries around the world in relation to tobacco control. Nonetheless, Parties with state-owned tobacco companies should find a way to separate the interests of the tobacco industry from tobacco control and health interests, and governments with state-owned tobacco companies must still give priority to protecting public health, through the effective implementation of the WHO FCTC, protecting the tobacco control policies from interference by tobacco industry interests.

1.4.3 The Reduction in Demand for Tobacco

Articles 6–14 are measures of reducing tobacco use, corresponding to five policies of WHO MPOWER package.

1.4.3.1 Price and Tax Measures to Reduce the Demand for Tobacco

Article 6 encourages price and tax measures as effective means to reduce the demand for tobacco. These include tax increases that result in an increase in the sale price of tobacco products; and prohibiting or restricting sales of tax- and duty-free tobacco products. Guidelines for the implementation of Article 6 were adopted at the COP 6 in October 2014.

First, the proportion of countries levying excise taxes has further increased (to 92% in 2014 and 2016, up from 67% in 2010 and 85% in 2012). Second, a combination of specific and ad valorem type taxes has become more widely used. Finally, the average proportion of all taxes in the retail price of tobacco products has further increased (to 67% in 2014, compared with 57% in 2012).⁴⁰ The worldwide simple average of total tax share on cigarette prices is 58% in 2016. This average is lower than in 2014. However, there are still significant differences between the Parties and regions in terms of levels of taxation and prices of tobacco products (minimum tax burden 5%; maximum tax burden 90%). Since 2012, seven countries (Bangladesh, Bosnia and Herzegovina, Croatia, Kiribati, New Zealand, Romania and the Seychelles) have raised taxes on cigarettes to more than 75% of the retail price; as up 2015, it is in a total of 33 countries covering 1/10 of world’s population that levy taxes of tobacco products were over more than 75% of the cigarette retail price.⁴¹

1.4.3.2 Protection from Exposure to Tobacco Smoke

Article 8 addresses the adoption and implementation of effective measures to provide protection from exposure to tobacco smoke in indoor workplaces, public transport, indoor public places and, as appropriate, other public places. In 2008, the COP 3 adopted guidelines for the implementation of Article 8, requiring that each Party should strive to provide universal protection within 5 years of the WHO FCTC’s entry into force for that Party.⁴²

Based on the 2016 progress report of the WHO FCTC, Article 8 has the highest average implementation rate by all substantive articles of WHO FCTC, and increasing from 78% by 126 Parties in 2012, 84% by 130 Parties in 2014 and 88% in 133 Parties in 2016. A noteworthy trend is the extension of ban on smoking in public places, such as beaches, transport stops, public parks, outdoor cafes, sheltered walkways and hospital compounds, outdoor markets and even some streets, prisons, and private vehicles when carrying children, as in Australia, Canada Singapore, New Zealand, South Africa, Fiji and other countries. The hospitality sector is still one of the least regulated sectors in relation to smoke-free policies. Although the hotel industry is the least smoke-free sector, nearly 50% countries still make bars and restaurants completely smoke-free since 2014.

By 2014, 55 countries had implemented a comprehensive smoke-free legislation, covering 1.5 billion people, or 20% of the world’s population.⁴³

1.4.3.3 Tobacco Product Regulation

Article 9 deals with the testing and measuring of the contents and emissions of tobacco products, Article 10 deals with the disclosure of information on such contents and emissions to governmental authorities and the public. Based on the 2016 progress report of WHO FCTC, only about half of the reporting Parties regulate the contents and the emissions of tobacco products, fewer than half of the Parties require the testing of contents and measurement of emissions of tobacco products. Over 60% of the reporting Parties required manufacturers or importers of tobacco products to disclose information on the contents and emissions of tobacco products to governmental authorities, and around half of the Parties required such disclosures to be made publicly available.⁴⁴

1.4.3.4 Packaging and Labeling of Tobacco Products

In general, most Parties are very active to implement Article 11 on package health warnings, with increasing warning size, more requiring pictorial warnings. And more and more countries consider for implementation of plain packaging. Also from the 2016 WHO FCTC progress report, the average of implementation of Article 11 of the Convention in 2016 reached 76%. In the 3-years deadline, close to 90% the Parties have health warning required with clear, visible and legible approved by authority, over three-quarter Parties’ health warning in package are over 30% of areas, the percentage of Parties requiring health warnings covering 50% or more of the principal display area has increased since 2014. Fifty eight percent Parties (74 countries) require pictorial health warnings on tobacco product packaging in 2016.

1.4.3.5 Comprehensive Banning Tobacco Advertising, Promotion and Sponsorship

Tobacco Advertising Promotion and Sponsor briefly call TAPS. Article 13 of the WHO FCTC requires Parties to the treaty to implement and enforce a comprehensive ban on tobacco advertising, promotion and sponsorship, within 5 years of FCTC ratification.

According to the WHO Secretariat of the WHO FCTC 2016 global progress report, the average of the implementation rates for Article 13 was increasing year by year, from 59% in 2012, 63% in 2014, and 71% in 2016. In the 2016 reporting period, 96 Parties reported to have a comprehensive TAPS ban in place, but in fact, only 34 countries banned TAPS in global internet,⁴⁵ which is matched with finding of WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2017: only 25% (34 countries or regions) do a comprehensive ban of TAPS.⁴⁶ Except for this, there have been obvious progress on banning TAPS in 2016. One hundred and eight Parties (accounting for 83% of reports) has banned tobacco sponsorship of tobacco products. It is a more difficult to prohibit display at point of tobacco product sale, but 75 Parties (56% of reports) have banned tobacco product display at sale point.

1.4.3.6 Treatment of Tobacco Dependence

Average implementation of articles 14 of the Convention in 2016 was 50% based on 18 indicators,⁴⁷ which of these indicators are highly implemented. Besides the majority (over three quarters) of the Parties (133) utilized the opportunities provided by events, such as the World No Tobacco Day or had run media campaigns, to promote tobacco cessation, 69% of the reporting Parties included tobacco dependence diagnosis and treatment and counseling services in their national tobacco-control strategies, plans and programmes, as well as had integrated diagnosis and treatment into their health-care systems. Seventy eight percent Parties covered the costs of services and treatment in primary health care fully or partially through public funding or reimbursement schemes. Seventy nine (59%) Parties offered assistance to improve the accessibility and affordability of pharmaceutical tobacco dependence products, including nicotine replacement therapy (NRT), bupropion and varenicline available in their jurisdiction.

1.5 Closing Remark

WHO FCTC has been developed in order to cope with the global epidemic of tobacco use, saving the huge loss of health around the world from the tobacco epidemic. The formulating process of WHO FCTC fully embodied the concern of the international community and governments for the health of the people, also showed determination and wisdom with using international law to cope with the negative effect of globalization. The Convention being into effect on February 27, 2005, quickly became international regulations with the most widely accepted in the history of the United Nations. Now, WHO FCTC as a powerful weapon to deal with the global tobacco epidemic, is playing a great role.

Today, following the WHO FCTC, the difficulties are not longer insurmountable. Numerous countries have passed, or are renewing and strengthening, their national legislations and policies to conform to the evidence-based interventions set forth in the Framework Convention. Tobacco control is now almost universally acknowledged as a significant public health priority, tobacco control policies and strategies are popularizing in the world and donor support is growing. The global tobacco control community has expanded, and tobacco control capacity continues to improve at various levels.

Now, WHO FCTC have set up the new rules, and the commitment of all the players will make a difference to change the world with tobacco epidemic.

However, the global public health community cannot relax its vigilance. The tobacco industry continues to thrive, and fuel the conflict between profit and health. The addictiveness of nicotine continues to enslave over a third of the world’s adult population, and globalization continues to facilitate the spread of the tobacco epidemic, through trade, travel and communication.

Tobacco control is a marathon effort in public health, and the entry into force of the WHO FCTC is just one milestone in a long, ongoing struggle to address the tobacco epidemic effectively. It is the challenge to ensure that obligations and commitments under the treaty are successfully translated into effective national and Community actions.

China is the world’s largest producer and consumer of tobacco. There are 360 million smokers among more than 1.3 billion population in China; about one-third of all smokers in the world are in China. A staggering 44% of the world’s cigarettes are smoked in China. China is the epicenter of this epidemic, and thus lies at the heart of global efforts to stop it. However, The attitudes and actions of the Chinese government in the negotiations on the WHO FCTC described in the second section of this chapter, have shown that China focused on the pursuit of international recognition rather than public health and safety, which has presaged the setback of the implementation of WHO FCTC in China. The 10-year implementation process of the WHO FCTC in China will be described in this book confirms the above prediction. The focus of this book is how to promote tobacco control in China, let China make progress together with the whole World using the new rules of universal health coverage. It is useful for tobacco control, also inspiring for the other public affairs globally.

Footnotes

1

Doll R, Hill AB. The mortality of doctors in relation to their smoking habits: a preliminary report. British Medical Journal 1954; 1:1451–1455.

2

Royal College of Physicians of London. Smoking and Health. 1962. London: Pitman Medical.

3

Hirayama T. Cancer mortality in nonsmoking women with smoking husbands based on a large scale cohort study in Japan. Preventive Medicine 1984;13(6):680–90.

4

Hirayama T. Non-smoking wives of heavy smokers have a higher risk of lung cancer: a study from Japan. British Medical Journal (Clinical Research Edition) 1981 January 17; 282:183–185.

5

U.S. Department of Health and Human Services. How Tobacco Smoke Causes Disease: The Biology and Behavioral Basis for Smoking-Attributable Disease: A Report of the Surgeon General. Atlanta, GA: U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, National Center for Chronic Disease Prevention and Health Promotion, Office on Smoking and Health, 2010.

6

Resolution WHA52.18. Towards a WHO framework convention on tobacco control. In: Fifth-second World Health Assembly: 22–27 May 1999. Volume 1. Resolution and decisions. Geneva, World Health Organization, 1999 (WHA52/1999/REC/1). Available at http://www/who.int/tobacco/framework/wha52_18/en/index.htm1. Last accessed on 09 December 2009.

7

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