Reducing tobacco use in China

china building

By Robin Tricoles

A new partnership targets the nation's 400 million smokers.

When it comes to smoking, the United States of yesteryear looks remarkably similar to China today. A mere 40 years ago, smoking not only was a ubiquitous, socially acceptable behavior here, it was encouraged — even glamorized. At work and at play, cigarettes held sway over millions of Americans. The same is true in China today.


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Using lessons learned in this country, the Emory Global Health Institute and the Tobacco Technical Assistance Consortium(TTAC) are collaborating with Chinese public health leaders to reduce smoking. Funded by a five-year $14 million grant from the Bill & Melinda Gates Foundation, the Emory Global Health Institute–China Tobacco Partnership (GHI–CTP) builds on TTAC's success in helping U.S. states and communities develop strategies and training to protect the public from smoking. 

TTAC was formed in 2001 with support from the American Cancer Society, the Robert Wood Johnson Foundation, and the American Legacy Foundation to aid tobacco control organizations in effectively using the funds that states received from the 1998 landmark Master Settlement Agreement to curb tobacco use by establishing comprehensive tobacco programs.

Based in the RSPH, TTAC started with seed money and a staff of three. Last year, revenue totaled more than $4 million, excluding the Gates grant, says executive director Pam Redmon, one of 16 TTAC staff members.

TTAC's ability to grow its funding has made it possible to expand its reach locally, statewide, nationally, and internationally. Among its clients is the CDC, for which TTAC provides training and manages the Tobacco Control Network, a group of experts from all 50 states, the District of Columbia, and U.S. territories. TTAC also offers clients expertise in coalition building and strategic planning and provides on-line courses aimed at curbing and preventing smoking. "Communities of Excellence Plus" has proven to be its most popular program.

"A Community of Excellence is one in which no tobacco use is the norm," says Redmon, a former cardiac nurse and graduate of the RSPH. "You're involving people in the communities where they live, work, and play — in schools, hospitals, and work places, for example — in changing the social norm of tobacco use so that tobacco is less desirable, less acceptable, and less accessible. The program focuses on the factors that make up a healthy community to protect its citizens from the harms of second-hand smoke and tobacco use."

  Pam Redmon and Kathleen Miner

Pam Redmon (left) and Kathleen Miner are looking to change how people view smoking in China to curb tobacco use. Using lessons learned in this country, the Emory Global Health Institute and the Tobacco Technical Assistance Consortium (TTAC) are collaborating with Chinese public health leaders to reduce smoking. 


TTAC's mission is a strong draw for RSPH students, who help extend the consortium's reach. "By providing service opportunities for students, we've helped Rollins build a national reputation in tobacco prevention and control through TTAC projects all over the United States," says Kathleen Miner, associate dean of applied public health and TTAC principal investigator. "And now with the new funding from the Gates Foundation, Rollins has the potential of developing a global name in tobacco prevention and control."

The reason TTAC's services are so needed is sobering: Tobacco use remains a leading cause of death, domestically and globally. And its use is growing.

China's smoldering health threat

The 1.3 billion people who live in China are not immune to this health threat. While only 5% to 10% of women there smoke, 60% of men do, most likely around their wives and children. Some anecdotal evidence suggests that women may be smoking more, says GHI director Jeffrey Koplan.

"You would not have seen young women smoking a few years ago," says Koplan. "This is an early sign, which we've seen in other countries when cigarettes are being marketed heavily to women. Smoking is equated with being sophisticated, modern, cosmopolitan."

"China is a particularly important place to begin to control smoking because it has 400 million smokers — more smokers than there are people in the United States," he adds. "Smoking plays such a pivotal role for many countries that see it as a harbinger of change and development. So it would be good to have a model of change and development for positive health practices."

It was Koplan who first asked TTAC to consider taking its tobacco control efforts global. Ultimately, the Gates Foundation recommended zeroing in on China.

"Smoking is a new area for the Gates Foundation," he says. "It has largely focused on infectious diseases and maternal and child health issues. So this is a big jump."

  jeffrey koplan  

Jeffrey Koplan first asked TTAC to work globally, which ultimately led to the new partnership between Emory and China.


In February, Koplan, Redmon, and Michael Erikson, a Gates grant partner from Georgia State University, met with public health officials in China. Talks focused on where to launch programs, forming a tobacco-control advisory committee, and creating an academic tobacco-control center of excellence.

"We plan to start small, targeting four to six cities and tailoring strategies to fit each site's circumstances," says Redmon. "Then we'll see what practices look promising and fund more cities during the remaining years of the grant. The center of excellence will provide grantees with technical assistance and support as they strive to develop comprehensive and sustainable tobacco programs."

Working at the local level, GHI–CTP will help cities develop programs and policies aimed at changing the social norm: specifically how people view tobacco use.

One proven method of altering the social norm is appealing to adults to protect their children. "For example," notes Koplan, "we'll encourage adults to improve the health of their children by not smoking at home."

Equally important is tailoring smoking interventions and policies — such as clean indoor-air laws or cigarette taxes — to suit the needs of a city or country. "What may work in one city may not in another," says Miner. "In some cases, policy intervention may be the way to go — interventions that educate children in school, place warning labels on cigarette packages, or raise taxes on how much cigarettes cost."

Emory experts have yet to know if pricing influences cigarettes' popularity in China. Although China's tobacco industry is nationalized, cigarette pricing varies greatly. High-end cigarettes with elaborate packaging are highly prized as gifts.

"There's a real status around cigarettes," says Redmon. "The price of cigarettes varies from very cheap to very, very expensive. Raising cost has been shown to decrease cigarette use in many other countries. If China were to increase the cost of cigarettes through an excise tax, smoking prevalence would be expected to decrease."

While attitudes about smoking differ in the United States and China, both nations share similarities regarding the tobacco industry and government.

"China's National Tobacco Corporation is the largest tobacco producer and finished cigarette maker in the world," says Koplan. "The government has a monopoly on tobacco and runs the regulatory entity on tobacco. Yet the government also does health promotion and health education. The U.S. tobacco industry is overseen by the Department of Agriculture, so it's the same scenario. We share the same problem and so can bring our experience to this issue."

As Emory experts work with Chinese public health officials, they must do so in concert with China's needs, culture, and government to grow its tobacco control movement. 

"The Gates funding will allow China to assess the situation and ensure that strategies with the greatest potential for eliminating tobacco use and sustaining anti-tobacco norms are implemented," says Redmon. "We hope to see a healthier, tobacco-free China as a result."

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