The Possibilities for the Greatest Transformation in Health May be Emerging in China
Tobacco in China
China continues to be a critically important player in global public health. It is home to more than 300 million smokers, and the health impacts are profound. Tobacco harm reduction and smoking cessation are two sides of the same coin, providing solutions to smokers that exercise empathy and respect for their choices. China is well positioned to assume leadership in tobacco industry transformation and the development of reduced-harm products to replace combustible cigarettes across its vast monopoly – through this very same principle of empathy. The Foundation for a Smoke-Free World is founded also on the principle of empathy for the smoker, as well as for the tobacco farmer.
These are times of dynamic action in China. First, China National Tobacco Corporation (CNTC) launched its first heated tobacco product in South Korea. Second, reports indicate that CNTC plans to list its international unit on the Hong Kong stock exchange. Third, China Tobacco Anhui Industry Corporation, a subsidiary of CNTC, announced that a new product will be available for consumer experience activities in Shenzhen and Hefei. The non-combustible heated tobacco product, from the Toop generation of products, uses magnetic induction heating technology. Fourth, reports indicate that CNTC is battling the smuggling trade, which brought millions of dollars of heated tobacco products into China illegally last year. This is occurring while the administration is potentially considering regulatory frameworks for e-cigarettes and heated tobacco products. We believe these events indicate that the time is ripe to engage for positive long-term health outcomes in China.
The nicotine ecosystem in China is large and complex
We estimate that CNTC has approximately 43% of the global cigarette market share, based on retail volume for 2017. CNTC produced approximately 2.3 trillion cigarette sticks in 2017. The scale, scope, and economic implications of the tobacco industry in China are massive:
- In 2016, the total industrial and commercial tax revenue generated by CNTC was approximately 1.1 trillion yuan (about $160 billion USD).
- According to CNTC, the Chinese tobacco industry employs 550,000 people.
- Company reports, industry sources, and estimates indicate that China has more than 1 million farms growing tobacco, with more than 5 million growers involved.
- More than 80% of tobacco production and more than 50% of cigarette production in China are concentrated in poor areas.
At first glance, the economic dependence on tobacco in China and the health-related costs appear to be in conflict. Tax revenue associated with cigarettes contributes to funding school programs, social security, infrastructure, and other development needs. However, the apparent conflicts could be diminished if China embraces a smoke-free world. In our view, making progress toward a smoke-free China will help it achieve the bold health goals outlined in The 13th Five-Year Plan. The key to accomplishing China’s health goals may depend on whether the innovations aimed at ending the internal combustion engine can be as vigorously applied to ending combustible cigarettes.
Tobacco and The 13th Five-Year Plan
The 13th Five-Year Plan for Economic and Social Development of The People’s Republic of China (2016-2020) identifies key goals related to health and innovation, which are compatible with the objectives of the Foundation for a Smoke-Free World.
As stated in Chapter 60, Promote a Healthy China; Section 3, Major Disease Prevention and Treatment and Basic Public Healthcare Services: “We will implement a comprehensive strategy for the effective prevention and control of chronic diseases such as cardiovascular, brain, and vascular diseases as well as diabetes, malignant tumors, respiratory disease, and mental illness.” The purpose of the Foundation for a Smoke-Free World – to improve global health by ending smoking in this generation – is compatible with a Healthy China by working to reduce smoking-related morbidities and mortality.
Part II, Innovation-Driven Development states, “With innovation as the basis from which to pursue development, we will give a central role to innovation in science and technology. . . .” In fact, innovation in harm reduction is already being led by China. Today, most of the world’s e-cigarette manufacturers are in China, specifically Shenzhen. The Foundation believes that innovation, properly harnessed, could reduce future harm from smoking. For example, tools on smartphones and consumer-oriented sensors and apps can help smokers measure and change their behavior, understand health impacts, and receive customized feedback and intervention to help them quit or smoke less.
That said, the results of a large study raise serious questions about China’s health goals. Specifically, the study, which recruited more than 170,000 Chinese adults in 2013-2014, found that, among men, 60.7% were ever smokers. The prevalence of ever smoking in men was higher in rural than urban areas and varied from 39.5% to 67.4% across 31 provinces. Results associated with adult men regarding heavy smoking, mean age at first starting to smoke regularly, and knowledge about smoking hazards are troubling – although smoking prevalence remained extremely low among women in China (2.8% had ever smoked). The study is one of the largest nationally representative surveys of smoking ever conducted in China in recent decades.
With this background, transformation into products that reduce harm can promote China’s health goals and be implemented in a manner that also ensures the long-term preservation of government revenue needed for various social security programs. Revenue streams can be transitioned to higher value products, compared to the primitive and deadly combustible cigarette. A comprehensive approach safeguards employment and agriculture, while reducing overall health costs to the Chinese population.
China is well positioned to assume leadership in the areas of health and innovation, as reflected in The 13th Five-Year Plan. Indeed, we believe this direction is inevitable. In January 2017, President Xi, addressing the World Economic Forum in Davos, made a powerful commitment to expand the use of technologies in the service of humankind. With about 2.3 trillion cigarettes produced in China annually, and almost all e-cigarette device manufacturing occurring within the country, the signals are mixed. However, if the Chinese choose to embrace harm reduction across the vast monopoly, the global impact would be massive. Hence, we call upon China to build on the President Xi’s Davos statement by implementing strategies to address the world’s greatest cause of premature death and disease – smoking – in a display of far-sighted leadership that has set China apart for centuries.