Smoking Environments in China: Challenges for Tobacco Control (Global Perspectives on Health Geography)

This book fills a major gap in research into smoking and tobacco control in China. In recent decades, few studies have explored the significance of geographical factors and the role they have played either in affecting the prevalence of smoking or in tobacco control responses to the smoking epidemic in China. In light of this, the book investigates the importance of national, regional and local environmental factors affecting smoking in China. It shows how geographical, social and institutional contexts have influenced the implementation and success of tobacco control initiatives, and situates smoking trends in China in a broader global context. The authors synthesize Chinese and western research on the smoking epidemic and uniquely focus on the importance of environmental factors and Chinese cultural perspectives in understanding smoking behaviour and the ineffectiveness of many tobacco control initiatives, especially how these conflict with Chinese economic policy. The book is aimed at academic and policy audiences both internationally and inside China, and will be of interest to a wide audience, not only geographers, but also epidemiologists, sociologists and others working in public health. Acknowledgements Contents About the Contributors Chapter 1: Introduction 1.1 Introduction 1.1.1 Three Vignettes 1.1.1.1 Platform Smokers: Arrival in Xuzhou 1.1.1.2 Tobacco Advertising Still Matters: Friday Night on Nanjing East Road, Shanghai 1.1.1.3 Retailing and Smoking Norms in a Hangzhou Neighbourhood 1.1.2 Smoking as a Global Issue 1.1.3 Western Geographical Approaches to Smoking Research 1.1.3.1 Places and Health 1.1.3.2 Places and Health Behaviour 1.1.3.3 Places and Tobacco Control 1.1.3.4 Critique of Past Geographical Smoking Research 1.1.4 Smoking and Tobacco Control in China 1.1.4.1 Why China? 1.1.4.2 Past Smoking and Tobacco Control Research in China 1.1.4.3 Critique of Chinese Research 1.1.5 Key Objectives of This Book 1.1.6 Structure of the Book 1.1.6.1 Theoretical Perspectives 1.1.6.2 Chinese Smoking Geographies References Chapter 2: Epidemiological Transition of Smoking in China 2.1 Introduction 2.2 Smoking in China: Data Scorecard, 2015 2.3 Smoking Transition Models 2.4 Demographic Differences in Smoking Prevalence in Post-Reform China 2.4.1 Age and Gender Differences 2.4.2 Cohort Analysis of Changes in Smoking Prevalence by Gender 2.4.2.1 Age and Cohort Effects 2.4.2.2 Period Effects 2.4.3 Synopsis 2.5 Socioeconomic Status and Smoking 2.5.1 Research on SES Differences in China 2.5.2 Class in China, if It Exists 2.5.3 An Economic Class Analysis of Smoking 2.5.3.1 Defining Classes 2.5.3.2 Class Gradients in Smoking? 2.5.4 Synopsis 2.6 Ethnicity and Smoking 2.6.1 Race and Ethnicity in China 2.6.2 Ethnicity and Smoking Behaviour in China 2.6.3 Synopsis 2.7 Geographical Variations in Smoking Transitions 2.8 Conclusion References Chapter 3: The Rise of China Tobacco: From Local to Global Player 3.1 Introduction 3.2 Emergence of the Chinese Tobacco Industry: 1902–1982 3.2.1 Opening Up China: British American Tobacco and the Emergence of a Capitalist Monopoly (1902–1949) 3.2.2 From Capitalist to State Monopoly (1949–1982) 3.3 Structure of the Tobacco Industry (1982–2003) 3.3.1 Institutional Structures 3.3.2 Subnational Stakeholders: Provincial Governments and the Industry 3.3.3 Changing Geographies of Production: The Case of Yunnan 3.3.4 The Illicit Cigarette Market 3.3.5 Tobacco Growers 3.4 State Restructuring: Recentralisation of Control and Improving Productivity (2003–) 3.4.1 Regaining Central Control: An End to Localism 3.4.2 Changes in the Geography of Cigarette Production 3.4.3 Changes in Tobacco Growing 3.5 A Globalising Industry 3.5.1 International Competitiveness 3.5.2 Trade Liberalisation and the Tobacco Industry 3.5.3 Globalisation of the Chinese Tobacco Industry 3.6 Conclusion References Chapter 4: The Tobacco Industry: Marketing Strategies and Consumption 4.1 Introduction 4.2 Marketing Tactics 4.3 Economic Reliance on Tobacco and Smoking Prevalence 4.3.1 Price Variations 4.3.2 Enforcement of Tobacco Control 4.3.3 Advertising and Marketing 4.3.4 Corporate Community Involvement and Pro-smoking Cultures 4.4 Tobacco Retailing and Consumption 4.4.1 Distribution Arrangements: Wholesalers and Retailers 4.4.2 Tobacco Outlet Density and Smoking 4.4.3 Relevance to China 4.4.4 Point of Sale Advertising 4.4.5 Point of Sale Advertising and Consumption 4.5 Social Media Marketing Strategies 4.6 Conclusion References Chapter 5: Geographical Context and Cultural Practices Affecting Smoking 5.1 Introduction 5.2 Smoking and the Chinese Cultural Context 5.2.1 Smoking as an Extension of Confucian Culture 5.2.2 Adoption of Smoking and Cultural Resistance 5.2.3 Cultural Processes in Contemporary China 5.2.3.1 The Role of Gender and Patriarchy 5.2.3.2 Sharing and Gifting Cigarettes 5.2.3.3 Self-Exempting Beliefs 5.2.3.4 Shanghuo as a Self-Exempting Belief 5.2.3.5 Patriotism and Smoking 5.2.3.6 Regional Cultural Influences 5.3 Cultures of Rural Smoking 5.3.1 Rural Smoking Prevalence 5.3.2 Why Smoking Is Higher in the Countryside 5.3.2.1 Gender Norms 5.3.2.2 Cigarette Sharing and Gifting 5.3.2.3 Poverty and Income Gaps 5.3.2.4 Stress 5.3.2.5 Differential Access to Health Services 5.3.2.6 Rural Ageing 5.3.2.7 Institutional Causes 5.4 Culture as Institutionalised Discrimination: Rural-Urban Migration and the Hukou System 5.4.1 Rural-Urban Migration and Smoking 5.4.2 Migration and the Hukou System 5.4.3 Hukou Status and Smoking 5.5 Conclusions References Chapter 6: Income Inequality, Urban Development and Smoking 6.1 Introduction 6.2 A General Framework on Urban Income Inequality, Urban Change and Health Outcomes 6.3 The Growth of Income Inequality 6.3.1 Global Trends 6.3.2 The Growth of Income Inequality in China 6.4 Income Inequality and Health in China 6.4.1 Impacts of Income Inequality on Smoking 6.4.2 How Relevant Are Western Explanations of the Health Effects of Income Inequality? 6.4.2.1 Social Comparisons 6.4.2.2 Social Capital 6.4.2.3 Lack of Institutional Resources 6.5 Chinese Urban Development and Its Implications for Smoking 6.5.1 Patterns of Urban Development 6.5.1.1 A New Urban Poverty 6.5.1.2 The Social Polarisation of Urban Space 6.5.1.3 Housing Booms and Increased Inequality 6.5.1.4 Landscapes of Change 6.6 Urbanisation and the Social Distribution of Smoking 6.7 Conclusions References Chapter 7: Policy Environments for Tobacco Control 7.1 Policy Processes in China 7.1.1 Post-war Instability and the ‘Open-Door’ Policy (1949–2012) 7.1.2 The Perfect Storm: Policy Process Under Pressure 7.1.3 Steering and ‘Top-Level Design’ 7.1.4 Policy Actors in Tobacco Control 7.1.4.1 The Party and the Legislature 7.1.4.2 Government Bureaucracies 7.1.4.3 Local Governments 7.1.4.4 The State-Owned Tobacco Monopoly 7.1.4.5 Intergovernmental Agencies 7.1.4.6 Non-government Organisations (NGOs) and Expert Advocates 7.2 Challenges to Policy Action for Tobacco Control 7.2.1 Community Knowledge and Smoking Norms 7.2.1.1 Community Understanding of Smoking 7.2.1.2 Community Smoking Norms 7.2.2 Political Leadership in Tobacco Control Policy 7.2.3 Institutional Challenges to Tobacco Control 7.2.3.1 National Policy and Co-Ordination 7.2.3.2 Provincial and Local Institutions and Tobacco Control 7.2.3.3 The Institutionalisation of ‘Big Tobacco’ 7.2.4 Tobacco Industry Resistance to Regulation 7.2.4.1 Maintaining a Positive ‘Patriotic’ Image 7.2.4.2 Research and Marketing Misinformation About Tobacco Harms 7.2.4.3 Targeting Vulnerable Segments in the Market 7.2.4.4 Corporate Social Responsibility 7.2.5 Advocacy and Policy Networks: Barriers to Achievement 7.3 The Progress of Tobacco Control (1979–2012) 7.3.1 Tobacco Control During the Reform Period 1979–1999 7.3.2 Negotiating the Framework Convention on Tobacco Control (1999–2006) 7.3.3 Implementing the Framework Convention on Tobacco Control 2006–2012 7.3.3.1 Failure of Policy Transfer 7.3.3.2 Alternative Action on Tobacco Control 7.3.3.3 Research and Monitoring 7.4 The Turning Tide? Action on Tobacco Control (2013–2019) 7.5 Conclusion References Chapter 8: Evaluating China’s Record of Tobacco Control 8.1 Introduction 8.2 Taxation and Pricing Interventions 8.2.1 The 2009 and 2015 Tax Increases 8.2.2 Impacts on Consumption 8.2.3 Explaining Behavioural Responses to Increased Cigarette Prices 8.2.4 Summary 8.3 Smokefree Policies 8.3.1 National Policy Developments 8.3.2 Assessing Gains 8.3.3 Summary 8.4 Banning Tobacco Advertising, Promotion and Sponsorship 8.4.1 Early Policy Changes 8.4.2 Policy Changes Since 2015 8.4.3 Tobacco Packaging 8.4.4 Summary 8.5 Health System Interventions 8.5.1 Smoking Cessation Services; Patterns of Provision 8.5.2 Healthcare Professionals: Adequate Role Models? 8.5.3 Current Smoking Behaviour Among Medical Students 8.5.4 Tobacco Control Advocacy 8.5.4.1 Local Innovation: The FCTC Tobacco Control Advocacy Programme 8.5.4.2 Programme Implementation and Results 8.5.5 Summary 8.6 Conclusions 8.6.1 The Scope and Effectiveness of Current Policy 8.6.2 Policy Implementation and Place References Chapter 9: Case Study: Smoking Bans and Secondhand Smoke 9.1 Introduction 9.2 Individual and Environmental Correlates of SHS Exposure 9.2.1 The Need for Smokefree Policies 9.3 Geographies of Implementation: Sub-national Smokefree Initiatives 9.3.1 Smokefree Initiatives in Major Cities 9.4 Smokefree Policy Enforcement: Comprehensiveness and Compliance 9.4.1 Factors Influencing Variations in Enforcement 9.4.2 Strength of Smokefree Policies and SHS Exposure 9.5 Health Outcomes 9.5.1 Smokefree Policies and Changes in Exposure 9.5.2 Smoking Bans and Smoking Cessation 9.5.3 Smoking Bans and Health Inequalities 9.6 Social Outcomes 9.6.1 Smokefree Policies and Denormalisation 9.6.2 Smokefree Policies and Smoking in the Home 9.6.2.1 Extent of Home Smoking Restrictions 9.6.2.2 Individual and Household Characteristics Associated with HSRs 9.6.2.3 Impact of Smokefree Legislation on Smoking in the Home 9.7 Conclusion References Chapter 10: Conclusions: Environments and Smoking in China 10.1 Introduction 10.2 The Economic Environment and Its Impacts 10.3 Cultural Environments and Smoking 10.4 The Social Environment: Urbanisation and Smoking 10.5 Environments of Smoking Cessation and Tobacco Control 10.6 Challenges for Future Research in China 10.6.1 The Big Picture: Resource Challenges and the Academic Role of Public Health 10.6.2 Conceptual Challenges 10.6.3 Methodological Issues 10.7 Research Priorities: A Guiding Framework, Erickson’s Model 10.7.1 Geographic Variations in the Policy Process 10.7.2 Neighbourhoods and Pro-smoking Cultures 10.7.3 Better Understanding of Cultural Practices Limiting Smoking Cessation 10.7.4 Geographic Variations in Smoking Transitions 10.7.5 Monitoring Tobacco Control: Developing Better Information Systems 10.8 Conclusion References Index