Understanding the Tobacco Epidemic and Control Measures in China

1. The Big Picture

2. Module 1: The Big Picture Introductions • Name • Reason for being involved with tobacco control • What you hope to get out of this training

3. Module 1: The Big Picture About This Module • Defines the scope of the tobacco epidemic worldwide and in China • Describes the reach and influence of the tobacco industry • Describes the harms caused by tobacco • Introduces the Framework Convention on Tobacco Control (FCTC) and describes its role in international tobacco control • Describes the current strengths and challenges of tobacco control in China • Provides guidance on how the articles from the FCTC can be implemented for local and city-wide tobacco control in China

4. Module 1: The Big Picture Learning Objectives At the end of this module, you will be able to: • Describe the current and projected impact of tobacco use in China • Describe the harms caused by tobacco to active smokers, people exposed to secondhand smoke, and the economy • List the 3 goals of tobacco control • Explain the role of the Framework Convention on Tobacco Control (FCTC) in international tobacco control • Describe the guidelines put forth by the FCTC • Explain the current strengths and weaknesses of tobacco control in China • Define social norm change and its implications for tobacco control in China • Describe ways to operationalize FCTC guidelines in cities in China

5. Module 1: The Big Picture Module Sections Section 1: The Tobacco Epidemic: Worldwide and China Section 2: International Tobacco Control and Best Practices Section 3: Tobacco Control in China

6. Module 1: The Big Picture Agenda

7. Module 1: The Big Picture Logistics and Housekeeping • Parking, bathrooms, schedule • Participation • Group rules • Participant Guide

8. Module 1: The Big Picture Section 1:The Tobacco Use Epidemic – Worldwide and China

9. Section 1: The Tobacco Use Epidemic Tobacco History: Worldwide 1960s: Major health hazards of smoking were reported 15th Century 1 BC 19th Century 16th Century 20th Century 1 BC: Use in the Americas, including smoking, chewing, and tobacco enemas 1492: “Discovered” by Columbus in the Americas 1881: Invention of the cigarette rolling machine 16th Century: Tobacco imported from the Americas and introduced to East Asia and China by European traders Source: Tobacco Atlas 4th edition, tobaccoatlas.org

10. Section 1: The Tobacco Use Epidemic Tobacco History: China 16th Century 17th Century • Tobacco introduced to China via Japan and the Philippines • Tobacco becomes a commercial crop along South China seaboard • Tobacco widely cultivated and consumed in Ming China and Qing Manchuria • Tobacco becomes an important commercial crop; provides a livelihood for millions, becomes a revenue source for the government • Fully appropriated by Chinese local cultures of production and consumption, enjoyed by both men and women

11. Section 1: The Tobacco Use Epidemic The 20th Century Tobacco Epidemic • British-American Tobacco (BAT) Company marketing and factories in China • Aggressive countrywide marketing • Peasant farmers taught to grow tobacco from American seeds • 1950s: China-State Tobacco Monopoly Administration founded and foreign companies had to leave • Nationalized cigarette industry became major part of Chinese economy • Aggressive advertisement, promotion, and sponsorship campaigns have continued Photo Credit: AP Photo in 18 Aug 2010 Telegraph 11

12. Section 1: The Tobacco Use Epidemic Current Cigarette Consumption: Worldwide Number of cigarettes consumed, counted in billions 5000b 4000b Global Cigarette Consumption in one century increased over 100 times. 3000b 2000b 1000b 1880 1900 1920 1940 1960 1980 2000 2009 Source: Tobacco Atlas 4th edition, tobaccoatlas.org

13. Current Cigarette Consumption: Top 5 Countries Section 1: The Tobacco Use Epidemic These five countries consume more than half of the world’s cigarettes Source: Tobacco Atlas 4th edition, tobaccoatlas.org

14. Section 1: The Tobacco Use Epidemic Smoking Patterns: Worldwide • Historically, high-income countries had highest rates • Low and mid-income countries increasing rates • Increased marketing • Increased social acceptability • Economic development • Population growth Source: Tobacco Atlas 4th edition, tobaccoatlas.org

15. Section 1: The Tobacco Use Epidemic Four Stages of the Tobacco Epidemic

16. Section 1: The Tobacco Use Epidemic Tobacco’s Grip on China: Today • 301 million smokers in China • 53% of adult males smoke • ½ of all smokers are killed by smoking and many more disabled by the disease • 3.5 million people will die by 2030 if trends continue • China is the world’s largest producer and consumer of tobacco

17. Current Smoking Rates: China Section 1: The Tobacco Use Epidemic 301 Million Current Smokers . Source: GATS China 2010

18. 375 million “ever” smokers • 25 million have quit smoking (7%) • 350 million continue to smoke (93%) • Smokers who attempted to quit • Previously: 36% • In the past 12 months: 36% • Smokers advised to quit by a health care provider in the past 12 months • 34% Section 1: The Tobacco Use Epidemic Smoking Cessation: China Tobacco Control Office, Department of Health, The Government of the Hong Kong Special Administrative Region

19. Section 1: The Tobacco Use Epidemic Trend in Tobacco Production (1965-2009): Worldwide Source: Tobacco Atlas 4th edition, tobaccoatlas.org

20. Section 1: The Tobacco Use Epidemic Five Largest Tobacco Companies: Worldwide （2008）

21. Tobacco Industry in China Section 1: The Tobacco Use Epidemic Tobacco industry is large part of economy • 33 province companies • 57 enterprises of cigarette industry • More than 1000 commerce agencies • 510,000 staff • 16,530 retail shops Output and sale of cigarettes • Estimated 2 trillion cigarettes sold per year • Over 400 brands available Tobacco industry represents an estimated 8% of yearly national income

22. Section 1: The Tobacco Use Epidemic Break

23. Active smokers • Secondhand smoke (SHS) • The economy Section 1: The Tobacco Use Epidemic Harm Caused by Tobacco Use

24. Section 1: The Tobacco Use Epidemic Activity: What are the harms that tobacco can cause to: • Active smokers? • People exposed to secondhand smoke? • The economy?

25. Tobacco smoke contains a mix of more than 7,000 chemicals Toxic metals Includes chromium, arsenic, lead, and cadmium Cancer-causing chemicals Includes formaldehyde, benzene, polonium, and vinyl chloride Poison gases Carbon monoxide, hydrogen cyanide, ammonia, butane Section 1: The Tobacco Use Epidemic Chemicals in Tobacco Smoke: Active Smokers Source: Surgeon General’s Report, 2004

26. Cancer Cardiovascular diseases Heart attack Stroke Respiratory diseases Lung cancer COPD Diabetes Tuberculosis Section 1: The Tobacco Use Epidemic Cancer and Diseases in Active Smokers

27. Lung Trachea Bronchus Esophagus Oral Cavity Lip Nasopharynx Nasal Cavity Larynx Paranasal Sinuses Stomach Bladder Kidney Pancreas Uterine Cervix Acute Myeloid Leukemia Section 1: The Tobacco Use Epidemic Most Common Cancers in Active Smokers

28. What is secondhand smoke? Section 1: The Tobacco Use Epidemic • Secondhand smoke is mixture of smoke released by the cigarette, cigar, or pipe AND exhaled smoke by the smoker • Secondhand smoke contains over 2,000 chemicals produced when tobacco products burn 2 hours of secondhand smoke = approximately 4 cigarettes

29. Toxins in SHS include: • Ammonia • Arsenic • Benzene • Carbon monoxide • DDT • Formaldehyde • Hydrogen cyanide • Lead • Chromium VI Section 1: The Tobacco Use Epidemic Chemicals in Secondhand Smoke

30. Secondhand smoke causes: Lung cancer Heart disease Asthma Pneumonia Bronchitis Low birth weight babies Section 1: The Tobacco Use Epidemic Dangers of Secondhand Smoke Scientific evidence shows that there is no safe level of exposure to secondhand smoke. SHS increases risk of: Sudden Infant Death Syndrome (SIDS) Respiratory infections Ear problems

31. Section 1: The Tobacco Use Epidemic Dangers of Secondhand Smoke SHS endangers everyone Certain groups are at special risk • Children • Pregnant women • People with asthma or cardiovascular disease

32. Smoking is the leading preventable cause of death in the world • In 2011, almost 6 million people died from smoking • 1.2 million deaths in China • 80% of deaths occurred in low- and middle-income countries • By 2030, 8 million annual tobacco-related deaths expected • 3.5 in China • It is estimated that one billion people worldwide will die from smoking during the 21st century Section 1: The Tobacco Use Epidemic Deaths from Smoking and Secondhand Smoke: Worldwide and China

33. Section 1: The Tobacco Use Epidemic Projected Tobacco-Related Deaths: China

34. Section 1: The Tobacco Use Epidemic Male Deaths from Tobacco: Worldwide and China • Tobacco causes more than 15% of deaths among men worldwide • In China, between 10 and 14.9% of men die from tobacco-related causes Source: Tobacco Atlas 4th edition, tobaccoatlas.org

35. Section 1: The Tobacco Use Epidemic Female Deaths from Tobacco: Worldwide and China • Tobacco causes 7% of deaths among women worldwide • In China, 10-15% of women die from tobacco-related causes • Smoking rates are increasing among women in many countries Source: Tobacco Atlas 4th edition, tobaccoatlas.org

36. Section 1: The Tobacco Use Epidemic Deaths Caused by Secondhand Smoke in Nonsmokers: Worldwide • In 2011 approximately 600,000 nonsmokers died from secondhand smoke exposure • 75% of secondhand smoke deaths occur among women and children • In China it is estimated that more women die from exposure to passive smoking than from active smoking

37. Smoking harms the economy through: • Health care costs for smokers and nonsmokers • Productivity lost among workers who smoke • Premature death and disability among smokers • Increasing or deepening poverty Section 1: The Tobacco Use Epidemic Harm to the Economy

38. According to a 2008 survey, the total smoking costs were 200.7 billion RMB (0.7% of GDP) • Direct medical costs of smoking: 43.1 billion RMB (3% of total health expenditures) • Indirect costs of smoking: 157.6 billion RMB • The economic burden of cigarette smoking has increased substantially during the past decade • Compared to 2000, the direct costs of smoking rose by 72% in 2003 and 154% in 2008, while the indirect costs of smoking rose by 170% in 2003 and 376% in 2008. Section 1: The Tobacco Use Epidemic Harm to the Economy: China

39. Smoking rates often higher within lower socioeconomic groups • Resources spent on tobacco instead of food and other essential needs. • One half of tobacco-related deaths in the developing world occur in middle age, depriving many households of years of potential income. • Medical care costs for treating chronic diseases further impoverish poor families. Section 1: The Tobacco Use Epidemic Tobacco Use and Poverty In China, an average of 17% of household income is spent on tobacco

40. Section 1: The Tobacco Use Epidemic Knowledge Competition! 40

41. Section 1: The Tobacco Use Epidemic Knowledge Competition! Question 1: In China, of the 375 million “ever” smokers, what percentage have quit? • 3% • 7% • 15% • 53%

42. Section 1: The Tobacco Use Epidemic Knowledge Competition! Question 2: Chinese men currently smoke what portion of the world’s cigarettes? • One-tenth • One-fifth • One-third • One-half

43. Section 1: The Tobacco Use Epidemic Knowledge Competition! Question 3: TRUE or FALSE: China National Tobacco Corporation produces more cigarettes than any other company in the world.

44. Section 1: The Tobacco Use Epidemic Knowledge Competition! Question 4: Which of the following is NOT a stage of the tobacco epidemic? • Stage 1: The onset of cigarette smoking in men • Stage 2: A dramatic increase in smoking in men and onset of smoking in women • Stage 3: A dramatic decrease in smoking in men and women • Stage 4: An increase in smoking-related illnesses and death

45. Section 1: The Tobacco Use Epidemic Knowledge Competition! Question 5: By 2030 if current patterns continue, smoking is predicted to cause approximately what percentage of all deaths among middle-aged Chinese individuals? • 13% • 33% • 46% • 73%

46. Section 1: The Tobacco Use Epidemic Congratulations!!! The winner is…

47. Smoking became a solidified part of Chinese culture beginning in the early 1900s • China is in Stage 2 of the tobacco epidemic – meaning that it is experiencing a sharp increase in men smoking and the onset of smoking in women • Smoking can cause dire consequences for smokers, non-smokers who are exposed to secondhand smoke, and to the economy Section 1: The Tobacco Use Epidemic Summary

48. Module 1: The Big Picture Lunch

49. Module 1: The Big Picture Section 2:International Tobacco Control and Best Practices

50. Section 2: International Tobacco Control Question: What are the goals of tobacco control?