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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.”

What will it take to get China’s 350 million smokers to quit? Public bans, tax hikes on the cards

Promised smoking ban welcome but Margaret Chan urges city mayors to also curb tobacco marketing

China has not done enough to control smoking even though the mainland authorities plan to put a smoking ban into effect within this year, said World Health Organisation Director-General Margaret Chan.

“Tobacco control is very close to my heart and a very important subject for the World Health Organisation,” Chan said at a meeting on the sidelines of the 9th Global Conference on Health Promotion in Shanghai. “The WHO’s member states have developed and adopted the WHO framework convention on tobacco control.”

The world’s largest tobacco market, with 350 million smokers, China has not yet passed a national law to ban smoking in public places. Of more than 600 cities across the country, only 18 have passed their own smoking control regulations.

“I used to say to Chinese officials that you have done well but not enough and there is room for further improvement,” Chan said. “I look forward to seeing the progress of China’s national tobacco control law.”

Mao Qunan, spokesman for the National Health and Family Planning Commission, China’s health authority, said a national law is expected to go into effect within this year.

Chan said she encouraged dozens of mainland city mayors who were attending the conference to introduce regulatory or fiscal measures to prevent the marketing of tobacco products and to stop tobacco sponsorships of sports events.

Mao said the biggest obstacle in the legislation was that the public did not have adequate awareness of the dangers from smoking.

“The Chinese government is beefing up an awareness campaign on smoking control, making laws and reforming the tobacco tax and price system to honour our commitment to the WHO’s framework convention on smoking control,” he said.

The mainland’s tax reform on tobacco products, which began seven years ago, has met strong resistance from tobacco producers and cigarettes sold on the mainland are still among the cheapest in the world, Wu Yiqun, a Beijing-based smoking control campaigner, told the Economic Observer.

The official said that health promotion work, such as smoking control, needed multisector collaboration. “Without support and involvement from other departments, many of our tasks can’t be achieved,” he said.

A Shanghai Declaration on Health Promotion was released at the conference, urging governments across the world to integrate health into their sustainable development agenda.

For a long time, the mainland has been lacklustre in global health rankings for allocating only 5-6 per cent of its gross domestic product to health services. Premier Li Keqiang, in his keynote speech at the conference on Monday, said China’s spending on health services has been increasing year by year over the past few years. He did not give specific figures.

“We will put health in a strategic position and regard it as a priority task. In our development mindset, we should prioritise health and emphasise health goals in our economic and social planning,” Li said. “Public policies should favour health goals and fiscal spending should guarantee the development of health-related causes.”

Nationwide public smoking ban expected by year’s end

A nationwide ban on smoking in public places circulated as a draft two years ago and building upon curbs in nearly 20 Chinese cities is expected to become law by the end of 2016, the Shanghai Daily reported.

Smoking would be prohibited at indoor public venues, on public transportation and outdoors in areas where schools and youth facilities are present, the newspaper said, citing a draft. Smoking in stadiums also would be banned. Mao Qun’an, a senior spokesperson with the National Health and Family Planning Commission, reportedly said the regulation was making its way through the legislative process and would be issued by the end of the year.

WHO Chief Calls for Multisectoral Collaboration in Global Health Advocacy

“Tobacco use kills around 6 million people each year. That’s a fact. Health literacy must extend from the personal to the political and policy levels,” said Margaret Chan, the director-general of WHO, in her keynote address at the 9th Global Conference on Health Promotion.

From November 21 to 24, World Health Organization officials, health ministers and health city mayors, totaling more than 1,180 health sector personnel from 126 countries and regions, will gather in Shanghai to discuss global health promotion and equity.

The conference, led by WHO, rotates host cities every three to four years. This year’s event is the first one to be held in China, the country with the world’s biggest population and thus the toughest challenge when it comes to health.

Describing the combination of legislative and fiscal measures as “among the most effective interventions,” Chan called for intersectional efforts at both the national and municipal levels to reshape people’s environments and lifestyle choices.

“Today’s complex health challenges can no longer be addressed by the health sector acting alone. Curbing the rise of antimicrobial resistance requires policy support from agriculture. Access to clean energy fuels economic growth, but it also reduces millions of deaths from respiratory and cardiovascular disease associated with air pollution,” Chan said.

Citing success in Australia, the U.K. and France, the director-general called on more countries to carry out Plain Packaging, a tobacco control measure headed by the WHO Framework Convention on Tobacco Control.

“In October, WHO urged governments to introduce taxes on sugar-sweetened beverages to reduce their significant contribution to obesity, diabetes and dental decay,” she added.

Chan also urged governments to accept responsibility for protecting children from obesity, and for assisting the poor in accessing healthy foods.

No butts about it: the noose tightens on smoking

CHINA, with almost as many smokers as the US has people, is stepping up its campaign to curtail tobacco use. Starting in March, Shanghai is introducing a ban on smoking in all indoor public venues, workplaces and public transport.

The restriction will cover hotels, restaurants, offices, airports, railway stations and entertainment venues. The ban was approved by the Shanghai People’s Congress Standing Committee on November 11, after months of intense debate and deliberation.

“We are delighted with the adoption of this new law,” said Dr Bernhard Schwartländer, World Health Organization representative in China. “Shanghai will be protecting non-smokers from the deadly harm of second-hand smoke.”

Under the new regulation, hotels cannot even offer rooms designated for smoking, and restaurants and entertainment venues will not be allowed to set aside smoking areas. Smoking will also be banned in government offices, public meeting rooms and canteens. Airports, railway stations, ferry ports and bus stations will have to close their smoking-designated rooms, said Ding Wei, a deputy director delegate with the Legislative Affairs Commission of the Shanghai Congress.

Indoor smoking rooms have already been closed at Shanghai’s two airports and railway stations.

The new regulation also extends the smoking ban to outdoor areas frequented by children, such as training institutes, historic sites and stadiums.

Persons violating the regulation will be subject to fines of up to 200 yuan (US$29), and companies that breach the rule are liable for fines of up to 30,000 yuan.

Stamping out cigarette smoking in China has always been a difficult task. Smoking traditionally has been considered sociable and a symbol of friendship among men. It’s not uncommon for hosts to put packs of cigarettes on a table, alongside liquor and sweets, for guests.

Compared with many Western countries, cigarettes in China are relatively cheap and widely available. Then, too, governments reap a lot of revenue from taxes on tobacco.

The Chinese Association on Tobacco Control estimates there are about 316 million smokers in this country, and about 1.5 million Chinese die every year from tobacco-related diseases.

The new crackdown on smoking has been widely lauded.

“This is a major milestone in the decades-long efforts to control smoking in public areas in Shanghai,” said Ding, who has at the forefront of anti-smoking legislation since 1994.

In that year, Shanghai was the first city in China to adopt some restrictions on smoking in public areas. Ahead of the 2010 World Expo, the restrictions were extended to ban smoking in and around primary schools, kindergartens and hospitals. Restaurants with 75 seats or more and businesses of more than 150 square meters were permitted to designate smoking and non-smoking sections.

In the past five years under the existing regulations, local authorities have collected about 1.8 million yuan in fines from 971 companies and 482 individuals.

Ding said the current regulation doesn’t completely address rising anti-smoking public sentiment. Two surveys earlier this year, by the city’s health commission and legislative body, found more than 90 percent of people support a complete ban on all smoking indoors.

Moreover, a study released by Fudan University earlier this year showed that smoking-designated rooms in airports, railway stations, hotels and other public areas don’t adequately protect non-smokers from passive exposure to smoke.

Fine particle pollution, as measured by PM2.5, was as high as 900 micrograms per cubic meter near the entrances of such rooms, said Professor Zheng Pinpin, head of the Smoking Control Research Center at Fudan. The national safety standard is 75 micrograms, and the World Health Organization considers anything higher than 25 to be unsafe for human health.

The new ban does acknowledge the existence of people who don’t want to quit the habit. It allows outdoor smoking areas to be set up near public venues, workplaces and transport hubs. However, those areas must be away from public passageways and erect signs warning that smoking is harmful to health. The areas will also need approval from the city’s fire prevention authority.

“Apart from the stricter regulations, we also have to take into account the feasibility of the rules,” Ding admitted.

Indoor smoking rooms will be allowed under “special circumstances” and with prior approval. They may include factories where outdoor smoking is hazardous or restricted places where there are security concerns.

“We hope that this clause in the law is never invoked,” said Schwartländer, adding that emphasis should be on ensuring that the new law is strictly enforced without any exceptions.

Law enforcement officers can fine individuals and companies on the spot if anyone is caught smoking in a no-smoking area. The new rule also encourages the public to send in photos of offending behavior to the 12345 hotline. Of course, cleaning up Shanghai’s often foul air is not only a matter of curbing smoking. Efforts are underway to promote the use of clean-burning vehicles, and fireworks restriction within the Outer Ring Road.

Smoking banned in all indoor public sites, workplaces from March as city passes law

SHANGHAI will extend its smoking ban to all indoor public venues, indoor workplaces and public transport sites from March 2017, the city’s top legislative body said today.

That means the ban on smoking would be imposed at all the hotels, restaurants, offices, airports and railway stations and even entertainment venues, according to the city’s new smoking control regulation which was approved by the standing committee of Shanghai People’s Congress today.

Hotels cannot categorize smoking or non-smoking rooms, while restaurants and entertainment venues cannot set up smoking areas. The meeting rooms, canteens and offices of government agencies will also ban smoking. The airports, railway stations, ferry ports and bus stations will shut down all the smoking rooms, according to the regulation.

The new regulation also extend the smoking ban on outdoor areas to public venues for minors, such as primary schools, kindergartens and training institutes, children’s hospitals, historic venues, stadiums and public transport waiting areas. Performance areas like stages and audience areas will also be smoke-free.

“The regulation aims to take a stricter control on smoking and extend the smoking ban areas to protect the public from second-hand smoking,” said Ding Wei, deputy director of the congress’s legislation department.

The current regulation, which was introduced in 2009 ahead of the World Expo 2010 Shanghai, stipulates that star-rated hotels, restaurants, airports, railway stations and ferry terminals could set up smoking areas or smoking rooms. Hotels were allowed to categorize their rooms into smoking or non-smoking.

Considering the feasibility of the new regulation and avoiding the “walking smokers” on streets, the regulation has added that outdoor smoking spots can be set up near the public venues, workplaces and transportation hubs, Ding said.

However, the outdoor smoking areas must be away from the public and major passageways and have signs saying “Smoking is harmful to health.” Facilities to collect cigarette ash and butt must be arranged. They will also have to be approved by the city’s fire prevention authority, the regulation says.

Fines for breaking the new laws are unchanged at 50-200 yuan (US$7.34-US$29.4) for individuals and up to 30,000 yuan for companies.

WHO commends Shanghai’s move to strengthen smoke-free law; urges strict enforcement as way forward

The World Health Organization (WHO) warmly welcomes the strengthening of Shanghai’s existing tobacco control law with respect to smoke-free public places and work places. The Shanghai Regulations on Control of Smoking in Public Places was amended today after months of intense debate and deliberation.

“We are delighted that with the adoption of this new law, Shanghai will be protecting non-smokers from the deadly harms of second-hand smoke. The amended law clearly prohibits smoking in all indoor public places, work places, and public transport as well as in many outdoor public areas. We look forward to Shanghai’s continuous effort to fully implement and enforce the 100% indoor smoking ban without exceptions,” said Dr Bernhard Schwartländer, WHO Representative in China.

The WHO Framework Convention on Tobacco Control (WHO FCTC) – the global tobacco control treaty which China ratified in 2005 – requires all indoor public places and work places to be 100% smoke-free. This is because exposure to second-hand smoke kills – and there is no safe level of exposure. Governments, including in cities like Shanghai, have an obligation to protect non-smokers from toxic, carcinogenic second-hand smoke. Exposure to second-hand smoke causes around 100,000 deaths in China each year.

“When this new law comes into force from March next year, the people of Shanghai will be able to breathe smoke-free indoor air. This is a huge step forward for the health of Shanghai’s more than 20 million residents: deaths caused by involuntary exposure to second-hand smoke are entirely preventable, and from a public health perspective that is simply unacceptable,” Dr Schwartländer said.

WHO notes with concern the clause in the new law which states that the city government may issue specifications regarding indoor smoking rooms under special circumstances.

“We hope that this clause in the law is never invoked. Allowing indoor smoking rooms – in any circumstances – would be in clear contravention of the WHO FCTC. The emphasis should now be on ensuring that the new law is strictly enforced, without any exceptions. Shanghai can count on WHO’s full support in this regard,” Dr Schwartländer said.

“Cities like Beijing, Moscow and others around the world have clearly shown that a comprehensive law that is fully WHO FCTC compliant coupled with rigorous enforcement, public education, and strong political leadership is a sure-win formula for success. 100% smoke-free public places do work. And they are incredibly popular with the public,” said Dr Schwartländer.

As Shanghai plays host to the 9th Global Conference on Health Promotion in just 10 days’ time, all eyes will be on the city and its best practices in promoting public health.

“By fully implementing and enforcing the comprehensive indoor smoking ban without exceptions, Shanghai will once again be able to position itself as a leader in tobacco control and the Healthy City movement in China.” Dr Schwartländer concluded.

About the World Health Organization (WHO):

WHO is the directing and coordinating authority for health within the United Nations system. It is responsible for providing leadership on global health matters, shaping the health research agenda, setting norms and standards, articulating evidence-based policy options, providing technical support to countries and monitoring and assessing health trends.

For more information, please contact:
Ms WU Linlin WHO China Office E-mail: Office Tel: +86 10 6532 7191

China’s 2015 tobacco tax adjustment: a step in the right direction

In August 2016, the Chinese public health community got a much-needed boost. The President of the People’s Republic of China, Xi Jinping, said at the National Meeting on Health attended by members of the Standing Committee of the Political Bureau of the Communist Party Central Committee, “An all-around moderately prosperous society cannot be achieved without the people’s all-around health.” He stressed that “Prevention should be more important than treatment” and “If these issues are not addressed effectively, the people’s health may be seriously undermined, and economic development and social stability will be compromised.”

Given China’s size and importance in the world, the emphasis placed by President Xi on health promotion and disease prevention is nothing but revolutionary. Indeed, in an era where the organization and delivery of specialized, high-cost medical care dominates global health practice, the words of President Xi signals the emergence of a more balanced health paradigm in China, where public health and medical care reinforce and complement each other as part of a continuum of multi-sectoral actions to deal with both the causes and consequences of social, environmental, and behavioural drivers of ill health, premature mortality, and disability.

China has the highest number of tobacco users in the world (>300 million) and smoking is a major killer. Approximately 1 million deaths every year are caused by tobacco, despite improved access to medical care thanks to the expansion in recent years of national health insurance coverage.

In the face of this dire reality, what to do? Wait to treat people when they develop lung cancer and other tobacco-related diseases, or adopt measures to prevent the onset of disease in the first place? Governments have an obligation and the means to protect their population’s wellbeing by adopting effective fiscal and regulatory measures, in addition to providing medical care to those persons who fall ill. In that sense, 2015 may prove to be a landmark year for tobacco control in China, as the Government adopted a national tax reform on cigarettes as well as a ban on smoking in public places in Beijing—a ban that is proposed to be expanded across the country.

Initial assessments done by a team from WHO’s Collaborating Center for Tobacco and Economics at Beijing’s University of International Business and Economics (UIBE), show that the 2015 tobacco tax reform is proving to be a win-win for both fiscal and public health in China. The evidence thus far:

• Impact on price and market structure. The weighted average wholesale price increased by 8.9% from 10.27RMB per pack in 2014 to 11.18RMB per pack in 2015. The average retail price increased by 10.29%, from 11.61RMB per pack to 12.81RMB per pack. However, from a global perspective, the weighted average cigarette price in China is still cheap: less than US$2 per pack on average. As the low-end price categories increased more than middle and premium price categories of cigarettes, the price gaps between tiers have been reduced. This encourages smokers up-shifting from the low end categories (Class V and Class IV) to the middle and upper price categories (Class III and Class II).

• Impact on tax incidence. The sales weighted tax share as % of retail price increased from 52% in 2014 to 56% in 2015, which is still lower than WHO recommended standard of 75%. The sales weighted average excise tax as % of retail price increased by 4% from 31% in 2014 to 35% in 2015.

• Impact on consumption. For the first time since 2001, as confirmed by the State Tobacco Monopoly Administration (STMA), the volume of cigarette sales decreased by 2.36% in 2015 compared to 2014. After the 2015 tax adjustment, sales continued to decrease by 4.61% over May 2015-April 2016 compared with May 2014-April 2015, and by 5.36% between October 2015-September 2016 compared with October 2014-September 2015.

• Impact on government’s revenue. According to STMA data, the tobacco industry in China contributed 840.4 billion RMB (about US$129.29 billion) tax revenue from tobacco products in 2015, an increase of 9% over the 2014 level. As a state-owned enterprise, it also contributed an additional 190.97 billion RMB (US$29.38 billion) profit to the central government, plus 63.6 billion RMB (US$9.79 billion) enterprise income tax to the central government. The 2015 tax increase was applied at the wholesale level, which generated an additional 57.8billion RMB (US$8.89 billion) in excise tax at the wholesale level.

• Impact on public health. A preliminary estimation suggests that within 12 months followed by the 2015 tax increase, the total number of smokers would decrease by about 5 million.

While the impact of the 2015 tobacco tax increase is generating measurable benefits, the price of cigarettes in China continues to be low and increasingly affordable for a population that enjoys rapid wage increases. If the ultimate goal is to help smokers quit and prevent the next generation from getting addicted to smoking cigarettes, then additional tobacco tax policy reforms are needed in China, especially for re-orienting the excise tax structure towards specific excise taxes at the retail level in the medium-term and towards a uniform tax system at the retail level in the long-term. A recent study* estimated that a 50% increase in tobacco price through excise tax would lead over 10 years to 5.3 million years of life gained, and reduce expenditures on tobacco-related disease treatment by US$2.4 billion.

Looking into the future, as evidenced in a World Bank study “Toward a Healthy and Harmonious Life in China: Stemming the Rising Tide of Non-Communicable Diseases”, with stronger tobacco control measures including steeper tobacco tax increases, the rapid rise in China’s non-communicable diseases can be halted, resulting in major gains for people’s health and the country’s social and economic development.

Smokers shanghaied

The two airports serving Shanghai, China, will ban smoking inside terminal buildings from Sunday, when all indoor smoking rooms are set to be closed, according to a story in the Shanghai Daily citing a statement by the airport authority.

But the authority has set up new smoking areas outside the terminal buildings at the Pudong and Hongqiao international airports.

Two outdoor smoking areas have been set up at Pudong airport’s T1 terminal, and three have been set up at the airport’s T2 terminal. Hongqiao airport has two outdoor smoking areas at each of its two terminal buildings.

The outdoor smoking areas are said to be located at the ‘remote bays waiting areas’ for domestic and international flights at both airports.

The new ban was in accord with the recommendations of the World Health Organization’s Framework Convention on Tobacco Control as well as with the city’s new smoking control regulation, an official with the airport authority was quoted as saying.

Shanghai’s railway stations have also shut down all indoor smoking rooms.

Meanwhile, the city’s legislative body is evaluating stricter rules that would extend smoking bans to all indoor public venues, including hotels, restaurants, offices and transport facilities. The new rules have to be further evaluated and revised but are expected to come into force by the end of this year.

The debate on regulation of e-cigarettes in China

China manufactures 80% of the world’s e-cigarettes.1

The domestic Chinese e-cigarette market has expanded since 2014, with a 33% increase in sales in 2015 alone.2 The 2014 China Global Youth Tobacco Survey, which studied 155 117 students aged 13–15 years, showed that 45·0% of them had heard about—and 1·2% had used—e-cigarettes.3 Some members of the global public health community are calling for regulation of e-cigarettes, but, owing to inconclusive evidence on their impact,4 no simple and unified guidelines exist to assist countries in such regulation. In China, a regulatory framework has been debated between the public health community and government agencies since 2005. We aim to analyse the development of a regulatory system for e-cigarettes and the interests and strategies of policy makers in China, and hope that this Comment might assist other countries undergoing similar debates on the regulation of e-cigarettes.

There have been dramatic changes in the way that e-cigarettes are marketed in China since they first emerged in 2005. Back then, e-cigarette companies promoted their products as a cigarette-like but healthier alternative to tobacco, as a tool to help quit smoking, and as gifts,5 which attracted attention from tobacco control advocates and government agencies.

However, with little evidence on the health effects of e-cigarettes, and little international experience in their regulation, government agencies were initially hesitant to take over regulatory responsibility. The ensuing debate centred on whether to categorise e-cigarettes as tobacco, medicinal, general, or harmful products—each coming under different agencies with different regulatory mechanisms.

Over a decade later, this issue is still unresolved.

The China Food and Drug Administration expressed its position in 2006 that “Electronic Nicotine Delivery Systems (ENDS) should not be managed as medical equipment.”6 The State Tobacco Monopoly Administration (STMA) refused to classify e-cigarettes as tobacco products but rather as potentially harmful chemical products, recommending regulation under State Administration of Work Safety.

Nonetheless, the e-cigarette industry was challenged by the media and public health advocates for its marketing ploys. The industry then changed its strategy to promote e-cigarettes as fashionable, innovative, leisure consumer goods, and built a fan base, both online and offline. Many e-cigarette centres, clubs, and bars were established in major cities to help disseminate and portray the culture of vaping, and to increase sales of e-cigarettes.

As the e-cigarette industry developed, the Chinese tobacco monopoly decided to include e-cigarette development in its own strategy. It established a task force led by the STMA’s leaders to coordinate issues related to all new tobacco products. Its local branches, an affiliated research centre, and two e-cigarette companies agreed to cooperate in development of e-cigarettes co-branded with the key existing cigarette brands.7

The trajectory of e-cigarette regulatory development has also been affected by the changing policy context in China. First, many tobacco control measures have been implemented, such as increases in tobacco tax, revision of advertising laws, non-smoking directives to government officials, and a national smoke-free law under process.

Second, as China’s economy has begun to slow down since 2009, a core strategy of the Chinese administration to stimulate economic vitality is through deregulation of industries. The government also encourages industries to form associations for improved self-regulation. With more than 1000 brands, 6000 products, and over 1800 companies in the industry, leading e-cigarette companies echoed this central policy by establishing the first National Association of Electronic Cigarettes in 2015.8

The Ministry of Industry and Information Technology (MIIT)—the supervising ministry for STMA—seems to support the self-regulation of the e-cigarette industry. By encouraging small and medium e-cigarette companies to form into associations, MIIT might be able to manage the industry more easily.

However, MIIT suggested that the STMA should seriously consider and push forward the regulation of e-cigarettes and other tobacco products.9 At the time of writing, the central government has yet to make a decision on how to regulate e-cigarettes.

Whether e-cigarettes end up being regulated by the STMA or through self-regulation by the e-cigarette industry, we call upon the central government to include e-cigarettes in all future tobacco surveys, and establish a regulatory system as soon as possible to at least ban sales to children, prevent e-cigarette marketing towards youth and non-smokers, and require disclosure of ingredients and labelling—as a first step until the science is clear.

Xiaoxin Xu, *Xinsong Wang, Xiulan Zhang, Yanli Liu, Huan He, Judith Mackay

School of Social Development and Public Policy, Beijing Normal University, Beijing 100875, China (XX, XW, XZ, YL); School of Public Administration, Southwestern University of Finance and Economics, Chengdu, Sichuan, China (HH); and Vital Strategies, Kowloon, Hong Kong Special Administrative Region, China (JM)
We declare no competing interests.

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