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Who Still Smokes? Designing the Tobacco Endgame

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Addressing the tobacco industry vector

The tobacco industry’s escalating attacks on public health are replicated across the world, as is the harm caused by its products.

http://www.jpost.com/Opinion/Addressing-the-tobacco-industry-vector-482330

‘THE TOBACCO industry attempts to impede tobacco regulation have changed over the years, but have not abated – they have instead mutated, and on a global scale.’

I was privileged recently to deliver the keynote address to the annual meeting of the Israel Society for Smoking Cessation and Prevention. The title was “Advocacy efforts in countering tobacco industry tactics.”

In the address I quoted Dr. Margaret Chan, director- general of the World Health Organization, who in 2008 said, “I want to remind governments in every country of the range and force of counter-tactics used by the tobacco industry – an industry that has much money and no qualms about using it in the most devious ways imaginable.”

Just as the primary vector for malaria is the mosquito, the primary vector for the tobacco epidemic is the tobacco industry. The industry attempts to impede tobacco regulation have changed over the years, but have not abated – they have instead mutated, and on a global scale.

When the WHO’s first and only internationally binding treaty – the Framework Convention on Tobacco Control (WHO FCTC) – entered into force (Israel became a signatory in 2005), there was a dramatic increase in the number of countries implementing tobacco control policies. The industry determined to adapt to the new situation.

According to WHO, the tobacco industry has continued to use advertising, promotion and sponsorship to undermine tobacco control efforts. In addition, it has sought to interfere with tobacco control on a global scale using a variety of tactics. For example, it lobbies and funds politicians and political parties to hijack the political and legislative process. It exaggerates the economic importance of the industry, while remaining silent on the massive health and economic costs of tobacco use. It manipulates public opinion to gain the appearance of respectability, often under the guise of corporate social responsibility, while irresponsibly playing down or denying the real harms its products.

It fabricates support by developing and resourcing front groups who advocate on the industry’s behalf. It continues to attempt to discredit proven scientific and economic evidence – often erroneously claiming that evidence from one country isn’t applicable in another.

And, increasingly, it intimidates governments with litigation or the threat of litigation, or trade threats.

Tobacco companies have recently launched a spate of international legal challenges to oppose the implementation of legitimate and robust tobacco control measures. Bilateral investment treaties have been used as the premise for international commercial arbitration challenges against Uruguay and Australia. This typifies the tobacco industry’s response to countries exercising their regulatory autonomy in the tobacco space: one of untenable intimidation.

This intimidation of governments is important because only governments can ratify and implement UN treaties, such as the WHO FCTC, mandate public health legislation and implement taxation policies that increase the price and reduce the affordability of tobacco products – the single most effective way of reducing tobacco use.

Legal and trade challenges typically have a delaying effect upon the country concerned – the implementation of tobacco control measures is paused until the case is resolved, they are expensive for governments (typically costing millions of US dollars) and have a regulatory chill effect on other countries that might be contemplating similar measures. However, these challenges have been repeatedly dismissed by high courts, constitutional courts and courts of justice in jurisdictions including Australia, the UK, Kenya, France, the European Union, South Africa, Thailand and Uruguay.

In addition, more and more countries are dismissing tobacco industry opposition, and introducing plain packaging. Responding to the industry’s increased use of trade law, Bloomberg Philanthropies and the Gates Foundation announced an $ 4 million fund to support countries against such threats – but we need to adopt other strategies too.

For example, research is often directed toward establishing the rates of smoking prevalence, health and mortality, and the economic impact of tobacco. This research is invaluable, but more effort also should be directed at tracking tobacco industry behavior so we can more efficiently monitor and resist the tobacco industry vector. Many advocates do not even know whether the tobacco industry donates to front groups or politicians in their country; whether the International Tax and Investment Center (funded by the tobacco industry) has visited their Finance Ministry with the mantra of not raising tobacco taxes; or whether the industry has met with government (and under WHO FCTC Article 5.3, the tobacco industry should have no part in formulating tobacco control policy).

This is perhaps why recent allegations regarding tobacco industry bribes to the Israeli government came as such a shock.

The tobacco industry’s escalating attacks on public health are replicated across the world, as is the harm caused by its products. The global tobacco epidemic, which will kill six million people this year, cannot be addressed unless we are equipped to counter all the industry’s tactics and all governments – including Israel’s – stand firm in stopping the tobacco industry from influencing health policy development and implementation.

The current prevalence of smoking in Israel is about 20%. Israel’s next step could be, as many countries have already done, to announce a target of 5% prevalence rate by 2028, and work annually to achieve this target. This is an ambitious target, but challenging rather than impossible.

Designing the Tobacco End Game

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Hong Kong Department of Health Tobacco Control Zero Efforts

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Vapers beware: 10 things to know about e-cigarettes

With catchy names like Smurf Cake and Unicorn Puke and sweet flavors like bubble gum and strawberry, electronic cigarettes may have special appeal to young people, but that doesn’t mean they are safe.

https://www.universityofcalifornia.edu/news/vapers-beware-ten-things-know-about-e-cigarettes

Evidence is mounting that e-cigarettes are exposing a new generation to nicotine addiction and may be leading users toward a cigarette habit. As a result, the U.S. surgeon general last month issued a report declaring youth e-cigarette use “a major public health concern.”

“All Americans need to know that e-cigarettes are dangerous to youth and young adults,” said Surgeon General Vivek Murthy, in releasing the report. “Any tobacco use, including e-cigarettes, is a health threat, particularly to young people.”

The battery-powered devices heat a liquid typically containing nicotine mixed with the chemicals propylene glycol and glycerin as well as flavorings to deliver an aerosol inhaled by the user. While e-cigarettes deliver nicotine without the tar and smoke of traditional tobacco cigarettes, they still are considered tobacco products.

But their healthy halo has helped propel their popularity: E-cigarettes are now so popular that more American youth vape than smoke cigarettes. In just a decade, e-cigarettes have become a multibillion-dollar business led by multinational tobacco companies with outlets not just online but everywhere from vape shops to convenience stores and retail giants like Wal-Mart.

Ads tout them as a cool, harmless alternative to cigarettes. E-cigarette users, or vapers, have contests to see who can blow the largest cloud of vapor.

But there’s more to e-cigarettes than meets the eye. The surgeon general’s report aligns with increasing scrutiny of e-cigarettes, from new regulations to a growing body of research into health effects.

Here are 10 things to know about e-cigarettes:

E-cigarettes contain nicotine

E-cigarettes contain nicotine, which is addictive and can harm the developing adolescent brain, said UC San Francisco professor of medicine Stanton Glantz.

A lot of the kids who take up vaping are at low risk for smoking, but once they start using e-cigarettes, they are three to four times more likely to start using cigarettes, Glantz said.

“The biggest health concern with e-cigarettes is they are prolonging and expanding the tobacco industry,” Glantz said.

Glantz, director of UCSF’s Center for Tobacco Control Research and Education, said he was initially neutral on e-cigarettes, but now finds them concerning. Among other hazards, e-cigarettes produce ultrafine particles than can trigger inflammatory problems and lead to heart and lung disease.

“The data is just becoming overwhelming,” Glantz said.

E-cigarettes expose people to more than ‘harmless water vapor’

E-cigarettes are billed as producing “harmless water vapor,” but, strictly speaking, the vapor produced when users exhale is actually an aerosol that contains a mixture of nicotine, flavorings and other ingredients that can be toxic.

Stanford University pediatrics professor Bonnie Halpern-Felsher has studied young people’s perceptions of e-cigarettes. In September, she launched a free, downloadable youth tobacco prevention toolkit with an e-cigarette module, funded by the UC Tobacco-Related Disease Research Program (TRDRP) and the California Department of Education.

“Youth are definitely using e-cigarettes because they think they are cool,” Halpern-Felsher said. “Adolescents and young adults don’t know a lot about e-cigarettes. They think it’s just water or water vapor. They don’t understand it’s an aerosol. They don’t understand that e-cigarettes can have nicotine. They don’t understand that flavorants themselves can be harmful.”

The flavors can be toxic

More than 7,000 varieties of flavored e-cigarettes are on the market.

UC Riverside professor of cell biology Prue Talbot screened the cytotoxicity (quality of being toxic to cells) of 36 refill fluids and found that some were highly toxic. The most cytotoxic flavor, Cinnamon Ceylon, contained a chemical called cinnamaldehyde, which gives cinnamon its flavor and whose side effects may include coughing and sore throats. Talbot has been studying more flavors and is building a database to help determine the most dangerous ones.

“Flavors are something that could be potentially regulated,” Talbot said.

Vaping has secondhand and thirdhand effects

Unlike cigarettes, which emit smoke from the lit end, e-cigarettes don’t produce sidestream emissions between puffs, but they still generate secondhand and thirdhand effects when users exhale the mainstream vapor.

In a TRDRP-funded study, Berkeley Lab researcher Hugo Destaillats led a team that found 31 chemicals that include several toxicants at significant levels in e-cigarette vapor. The most toxic chemicals included acrolein, a severe eye and respiratory irritant; and formaldehyde, an irritant and probable carcinogen.

Emissions varied by type of device and voltage.

“The way you heat the liquid drastically determines if you produce a lot of compounds or just a few,” Destaillats said. “As you increase the voltage, toxic byproduct concentrations increase exponentially.”

The batteries can explode

There were 134 reports of e-cigarette batteries overheating, catching fire or exploding between 2009 and January 2016, according to the Food and Drug Administration, which will host a public workshop in April to gather information about e-cigarette battery safety concerns.

E-cigarette batteries “can explode without notice,” Talbot said. “People can be quite severely injured.”

E-liquids are poisonous if swallowed

Calls to poison control centers about e-cigarette exposure in young children have skyrocketed nationally in recent years. In California, the number of calls involving e-cigarettes increased from 19 in 2012 to 243 in 2014, according to the UC-administered California Poison Control System. More than 60 percent of those e-cigarette calls were related to nicotine poisoning in children 5 and under.

E-cigarettes show mixed results in helping smokers quit

While some people have quit smoking with e-cigarettes, on average, adult smokers who use e-cigarettes are about 30 percent less likely to stop smoking cigarettes, Glantz said. Also, e-cigarettes are associated with more, not less, cigarette smoking among adolescents.

“If you are a middle-aged person who has been smoking for 20 years, maybe it is good to switch to e-cigarettes,” Destaillats said. “But if you are a teenager and never have smoked, then it is not a good idea to use e-cigarettes.”

The minimum age has risen

In June, California became the nation’s second state, following Hawaii, to raise the minimum age for tobacco sales to 21, and for the first time added e-cigarettes to the definition of tobacco products. In August, the FDA extended its tobacco oversight to e-cigarettes, banning sales to those under 18.

“It sends a message to youth that e-cigarettes are in the same category of all tobacco products,” Halpern-Felsher said.

E-cigarettes will be taxed

Under Proposition 56, the tobacco tax passed by California voters in November, the state will tax e-cigarettes for the first time, starting April 1. It’s estimated that the price of a typical 30-milliliter bottle of e-liquid could increase to about $30 from $20.

“Anytime you increase the price, people buy less,” Glantz said.

The tax revenue will enhance education efforts by boosting funding for the state Tobacco Control Program. The surgeon general’s report also will make it easier for states to integrate e-cigarettes into tobacco education campaigns and could lead to more regulations, Glantz said.

E-cigarettes may be safer than cigarettes, but unknown risks remain

Expect more information to emerge about e-cigarettes as studies examine long-term effects.

“It’s often assumed that e-cigarettes are safer than cigarettes, but that could be an incorrect assumption,” Talbot said. “We don’t yet know the long-term health effects of e-cigarettes.”

Decades of research have helped scientists determine that cigarette smoke creates more than 7,000 chemicals, at least 69 of which are known to cause cancer and many of which are poisonous.

So, while e-cigarettes deliver fewer cancer-causing chemicals than cigarettes, research has yet to reveal how e-cigarettes fully impact heart and lung health and their cancer-causing potential, Glantz said.

He estimates that e-cigarettes are about one-third to one-half as dangerous as cigarettes.

In other words, they are still plenty dangerous.

“Regular cigarettes are super unhealthy,” Destaillats said. “E-cigarettes are just unhealthy.”

COSH urges the Government to take full account of public opinions Enact Enlargement of Pictorial Health Warnings Promptly

http://smokefree.hk/en/content/web.do?page=news20170116

Hong Kong Council on Smoking and Health (“COSH”) urges the Government and Legislative Council to enact the enlargement of pictorial health warnings promptly in order to reduce the attractiveness of tobacco, motivate more smokers to quit and deter youth from trying the first cigarette. Mr Antonio KWONG, COSH Chairman remarked, “Results from survey conducted by COSH and two rounds of public consultations organized by the Legislative Council showed that majority of citizens and organizations supported the enlargement of pictorial health warnings to 85%. The Government and Legislative Council should take full account of public opinions and enact the proposed tobacco control measure as soon as possible.”

The Government briefed the legislative proposals to strengthen tobacco control on 18 May 2015, including enlarging the size of pictorial health warnings to at least 85% of the two largest surfaces of the packet, increasing the number of forms of health warning from six to twelve and adding the quitline 1833 183. The date of enactment is yet to be scheduled after more than one and a half years.

The Legislative Council collected views of the public and held special meetings on the enlargement of pictorial health warnings twice. Among the hundred submissions received in July 2015 regarding the increase in the size of pictorial health warnings, more than 80% supported. Besides, over 100 submissions were received for the special meeting of Legislative Council Panel on Health Services to be held tomorrow (17 January 2017), in which around 70% agreed the proposed measure.

The School of Public Health of The University of Hong Kong was commissioned by COSH to carry out the Tobacco Control Policy-related Survey 2016. It was found that public support on enhancing the pictorial health warnings was overwhelming, 79.5% of all respondents agreed to display more threatening messages about the health risks of smoking. About 72.5% of all respondents supported to increase the coverage of the health warnings to 85% while about half of the current smokers also supported. Majority of respondents opted for plain packaging* of cigarettes as well. In addition, COSH has collected over 26,500 signatures from citizens and organizations through street counters and online platform supporting the enlargement of pictorial health warnings since May 2015.

In recent years, many countries have successfully introduced more stringent measures to regulate tobacco packaging. Prof Judith MACKAY, Director of Asian Consultancy on Tobacco Control and Senior Policy Advisor of World Health Organization claimed, “Hong Kong ranked the 72nd in the world regarding the implementation of pictorial health warning and behind many developing countries like Laos, Myanmar and Sri Lanka. Hong Kong should enlarge and strengthen the pictorial warnings promptly in order to reduce the use of tobacco.” World Health Organization called for more countries to enlarge pictorial warnings covering more than 85% and implement plain packaging. “Get ready for plain packaging” was designated as the theme of World No Tobacco Day 2016.

Recently, some organizations opposed the proposed enlargement of warnings in the pretext that it would lead to a surge in cigarette smuggling activities. A recent study also claimed that illicit cigarettes composed for around 30% of cigarette consumption in Hong Kong. Prof LAM Tai-hing, Chair Professor of Community Medicine cum Sir Robert Kotewall Professor in Public Health, School of Public Health, The University of Hong Kong said, “the public should express reservation on the results of this tobacco industry-funded study. The data collection methods and calculations of the study were unclear using dubious methods.” The tobacco industry and its allies always express strong opposition against tobacco control measures proposed by the Government under the pretext that it will lead to a surge in cigarette smuggling activities. As recommended by the World Health Organization, the most effective measure against smuggling is tight control and aggressive enforcement.

With the Government’s multi-pronged tobacco control policies over the years, the smoking prevalence in Hong Kong has gradually reduced from 23% in early 80s to 10.5% in 2015. In view of the tobacco epidemic in Hong Kong and the international tobacco control trend, we urge the Government and Legislative Councilors to take account of public opinions and implement the enlargement of pictorial health warnings as soon as possible to safeguard public health. The Government should also actively consider adopting plain packaging within 2 to 3 years and develop long-term and comprehensive tobacco control policies including regulating the emerging tobacco products and e-cigarettes, raising tobacco tax substantially, expanding no-smoking areas, increasing resources on education, publicity, smoking cessation services and enforcement to further reduce the smoking prevalence in Hong Kong and protect people from the harms of smoking and secondhand smoke.

*Remarks: Plain packaging standardizes and simplifies the packaging of tobacco products. The pictorial health warnings on the main sides of cigarette pack are expanded. All forms of tobacco branding should be labeled according to the government prescriptions and with simple and plain format. This means that trademarks, graphics and logos are not allowed on cigarette packs, except for the brand name that is displayed in a standard font size, colour and location on the package. The packaging should not contain other colours and should include only the content and consumer information, such as toxic constituents and health warnings required by law. The quitline number should also be displayed at a prominent position. Australia was the first country to introduce plain packaging in 2012. The measure was also implemented in the United Kingdom, France and Hungary in 2016 and will be implemented in Ireland in 2017.

Bigger graphic health warnings on Hong Kong cigarette packs needed, anti-smoking group says

Survey finds most in favour of move, which advocates say can protect public health and encourage more to quit habit

http://www.scmp.com/news/hong-kong/health-environment/article/2062577/more-graphic-health-warnings-hong-kong-cigarette

An anti-smoking body has pressed the government to speed up legislation on cigarette pack health warnings after a survey revealed almost 80 per cent of people desired sterner messages on smoking risks.

The Council on Smoking and Health made the call ahead of another public hearing held on Tuesday in the Legislative Council to collect views on whether to implement the law.

The legislation will expand the size of health warnings on cigarette packs from the current 50 per cent to 85 per cent of the packaging surface.

The proposal was first submitted by the government in May 2015, and the first hearing was held in July in the same year.

According to a survey commissioned by the council and done between February and September last year, 79.5 per cent of 2,058 respondents – comprising smokers, non-smokers and ex-smokers – want cigarette packs to show clearer and more graphic warnings.

Another 72.5 per cent of them also want to see the graphic warnings enlarged to cover 85 per cent of the packaging surface, a move also supported by almost half of the smokers in the survey.

“The implementation work has dragged on for one and a half years. This measure can protect public health and help more people quit smoking.

“We hope that Legco will not procrastinate on the legislation any further,” council chairman Antonio Kwong Cho-shing said.

He said that Australia recorded a drop of 2.2 percentage points in average smoking rate after introducing plain cigarette packaging in 2012.

Of this amount, 0.55 percentage points, or 108,000 fewer smokers, were due directly to the new measure which only allowed brand names to be displayed in a standard font size, colour and position on the packaging, thereby making them less conspicuous and seemingly less desirable.

Professor Judith Mackay, a veteran tobacco control advocate and senior policy advisor for the World Health Organisation, said a larger graphic warning would have an even bigger visual impact and induce more smokers to quit.

According to a Canadian Cancer Society survey which studied the effectiveness of health warnings on cigarette packs worldwide, Hong Kong ranked 72nd out of 205 places.

“We used to be among the top 12 jurisdictions [in cigarette pack warnings] … now we are lagging very far behind from the international experience,” Mackay said. She has been working on tobacco control advocacy in the city for more than 30 years.

The survey done by the Canadian group looked at various factors, including whether graphic warnings existed on the packaging design, the sizes of the images and when the warnings were introduced.

Mackay attributed the city’s poor ranking partly to outdated warnings, which were first introduced in 2007, and the lack of information on helpline numbers for those seeking to quit the habit.

She said in the long run the government should also further increase tobacco tax to make cigarettes less affordable.

Kwong from the Council on Smoking and Health said it submitted a letter to the financial secretary late last year to suggest increasing tobacco tax to 100 per cent.

Graphic Pack Warnings in Hong Kong

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Next chief executive should back annual tobacco tax hike in Hong Kong

Your editorial (“Preventive health care is an investment, not a burden [1]”, January 1) has hit the nail on the head regarding the importance of, and investment in, prevention versus cure in Hong Kong.

We all need the “ambulance and curative services” to rescue us when we are taken ill, but unless the whole of government – particularly the finance, trade and economic branches, as well as the Independent Commission Against Corruption and the Ombudsman – grasps the political nettle of issues such as tobacco control, health will never improve, nor will the many thousands of annual deaths from tobacco be reduced.

Indeed, the entire Hong Kong government is under an international obligation to do so, being a party to the World Health Organisation Framework Convention on Tobacco Control.

One of the most important platforms of any incoming chief executive is their future preventive health plan for Hong Kong citizens.

Let us call upon each of the potential chief executive candidates to outline their health platforms. We should discard all those who see these platforms in terms of more hospital beds, which will never solve the problem of improving Hong Kong’s health. And the current health paradigm is such that improvements will only come about by addressing the vested interests of big business – the tobacco, alcohol, food, and even salt industry –including their often unrecognised front groups.

With tobacco control, we have known for decades what works, and how very cost-effective these measures are. Yet governments around the world hesitate to act.

Increasing tobacco tax heads the list of the best single measure to reduce smoking. It may be surprising to many that a fiscal measure is more important than health education in schools or banning sales to youth, for example, but it is the single best action governments can take to reduce consumption among the young.

Why can Hong Kong not follow Australia and New Zealand and commit to an annual tobacco tax increase of, say, 10 per cent per annum to the year 2025?

Any chief executive candidate who would endorse this would get my (hypothetical) vote.

It would give us an orderly and planned route to follow, and avoid the incredible waste of time and energy lobbying annually for tobacco tax increases. And it would have a massive effect in saving young and middle-aged lives, and in what is termed “frailty avoidance” in the elderly.

Dr Judith Mackay, Clear Water Bay

Hong Kong leads mainland in war to cut smoking

http://www.ejinsight.com/20161209-hong-kong-leads-mainland-in-war-to-cut-smoking/

When a person goes to buy a packet of cigarettes in Hong Kong, he or she faces two obstacles. One is the price — Double Happiness at HK$43 and Marlboro at HK$57 — the result of a tobacco tax up to 68 per cent of the price.

The other is the hideous image on the packet of the worst consequences of smoking.

A survey by the Economic Intelligence Unit earlier this year ranked Hong Kong as the eighth most expensive city in the world for a packet of branded cigarettes, at US$7.48.

Top was London with US$14.30, followed by New York with US$13.67 and Singapore with US$9.15.

These two measures, along with the creation of smoke-free areas in public and work places, have been effective in cutting the number of smokers.

According to government figures, the percentage of daily cigarette smokers aged 15 and above in Hong Kong in 2015 was 10.5 percent, down from 10.7 percent in 2012 and 23.3 per cent in the early 1980s.

The mainland, the world’s largest tobacco market with 316 million smokers in 2015, has only recently started to learn the lessons of Hong Kong.

Since 2010, the number of smokers has increased by 15 million and cigarette production risen by 35 per cent.

The health warnings are written, not visual, and appear modestly at the bottom of the packet. They would not frighten any first-time user.

In 2015, China increased the tobacco tax to 40 per cent. Consumption tax from tobacco in 2015 was 536 billion yuan, an increase of 60 billion from a year earlier. The recommendation of the World Health Organisation (WHO) is that the tax should be 70 per cent of the retail price.

“There is certainly room for future tobacco tax increase,” said Jian Shi, director of the information office of the Taxation Research Institute at the State Administration of Taxation in Beijing.

“In some western countries, the tobacco tax rate has reached 70-80 per cent. The room for the increase needs to be considered based on the development goal of the industry and the condition of national revenue.”

Health professionals argue that increasing the tobacco tax is the quickest and most effective way to cut smoking — by both preventing young people from starting and encouraging smokers to quit.

According to WHO figures, each increase of 10 per cent in the price will cause 3.7 per cent of adults and 9.3 per cent of teenagers to stop smoking.

Antonio Kwong Cho-shing, chairman of the Hong Kong Council on Smoking and Public Health, said that selective or modest hikes would not make much of an impression on smoker numbers in Hong Kong.

“Only a 100 per cent increase in tobacco tax would induce people to quit smoking,” he said. If the government accepted this proposal, an average pack would cost HK$119.

The Department of Health has proposed an enlargement of the health warning.

It said on Nov. 23 that the area of the graphic health warning shall be of a size that covers at least 85 percent of the two largest surfaces of the packet or the retail container and that the number of forms of health warning should be increased from six to 12.

The situation in the mainland is years behind. The biggest obstacle is that the State Tobacco Monopoly Administration (STMA), the world’s biggest manufacturer of cigarettes, is also the industry regulator.

This is despite years of lobbying by China’s health professionals, the WHO and the norms practised around the world. They argue that the two must be separate institutions.

According to WHO figures, 1.2 million die each year in China from smoking-related diseases; this number will double by 2025.

Jian Shi put it succinctly. “The major difficulty lies in that the related departments have quite different views on this matter, and it is difficult for them to reach agreement on this matter. That will cause obstruction to policy making and implementation.”

The STMA opposes graphic health warnings and higher taxes because they would hurt its sales and profits. Yet, simply due to global population expansion, there will be more smokers in 2040 than there are today, so it is difficult to believe that this concern is genuine.

The health lobby has had some success, in the modest increase in tobacco tax and restrictions on smoking in indoor public areas and workplaces and some outdoor areas introduced in Beijing in June 2015. Other mainland cities have taken similar measures at different times.

On Dec. 6, the Beijing Commission of Health and Family Planning said that more than 2,700 people had been fined for violating these restrictions, with total fines of 142,500 yuan, as of Nov. 30 this year.

Professor Dr Judith Mackay, based in Hong Kong and Asia’s leading anti-tobacco campaigner, said that the price of cigarettes in China is still extremely low.

“The latest small tobacco tax increase, while laudable, will not have a serious, sustained effect on reducing smoking. It is time to review the whole tobacco tax structure in China, significantly increase the price of cigarettes and thus protect the health of the Chinese people.

“In Australia, there is a regular increase of 12.5 per cent tobacco excise tax every year. The cost of a packet could soon rise to A$40 (HK$230). Hong Kong and China should both consider long-term tobacco tax planning in this way, so that tobacco control proceeds in an orderly form, and immense energy and time is not wasted year by year in campaigning for a tax increase. Otherwise, thousands will die.”