Can Asia Kick the Habit?

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In the Tondo Slum, a 30-minute drive from downtown Manila, thousands of Filipinos live in sordid shacks beside the ironically named Aroma dump site. Destitute, they make a living by scavenging amid the trash that stretches into the middle distance—for this is where much of the capital's garbage ends up. The smell is the first thing that leaves you speechless: from the toxic singe of burning plastic to the reek of scattered sewage. The second is the sight of Aroma's enthusiastic smokers. Not of the skeletal granddads or of the work gangs, cigarettes permanently dangling from their lower lips. No, the genuinely startling sight is that of Aroma's child smokers, and they're everywhere. "It's not as if I'm not used to the stink," says 13-year-old Michael Rivera, explaining why he has smoked since age 5. "But today is especially stinky, and we know something inside the cigarette takes away the stink." Smoking also eases their hunger, says Michael's 16-year-old brother Eduardo, drawing hard on a cigarette. "What can we do?" he asks. "It's so much cheaper to smoke than eat."

Asia has long been the home of inveterate smokers. To millions of them, cigarettes are the stuff of daily social intercourse. Nothing is done without them—no task unrewarded, no meal concluded. Everybody knows that Asia is supposed to be the last great frontier of the tobacco industry, a place where vast numbers continue to expose themselves to the risks of lung cancer, cardiovascular disease, emphysema and other smoking-related illnesses. And yet, across the region, an Asian antismoking movement is quietly but inexorably gathering strength. It isn't large yet, but it is starting to have a dramatic impact—from fresh legal wins in unlikely quarters to tough bans on smoking in public places.

Just last week, the University of Hong Kong announced the results of a government-funded study estimating that smoking costs the territory's economy $640 million a year, providing fresh ammunition for politicians and activists pushing to secure the passage of impending legislation to ban smoking in restaurants and bars. Back in December, Thai smokers likewise found themselves under siege: after King Bhumibol Adulyadej expressed fears for the health of his nation's youth, the government decided to impose new measures that will limit the sale of cigarettes to 10 hours a day. Most significantly, the Framework Convention on Tobacco Control (FCTC)—a treaty sponsored by the World Health Organization (WHO)—became binding law on Feb. 27 in the first 40 countries to ratify it. A third of these countries are in Asia, and more Asian nations are expected to adopt the treaty's tough antismoking provisions over the coming months. The tobacco industry's last great frontier is suddenly starting to resemble the front line in a losing battle as a gathering legion determines to combat Asia's most preventable cause of death.

The magnitude of the challenge and the stakes involved are almost overwhelming. Of the five countries that consume the most tobacco globally, three—China, Japan and Indonesia—are in Asia (the other two are the U.S. and Russia). About 50,000 teenagers across Asia take up smoking every day, according to the WHO. China alone accounts for one in every three cigarettes smoked worldwide, and as many as 1.2 million Chinese die from smoking-related diseases annually, according to WHO statistics—as do some 30,000-40,000 Vietnamese, 52,000 Thais, 57,000 Indonesians and 90,000 Japanese. If present trends continue, about 4.2 million Asians can be expected to perish each year from smoking by 2020. Beyond the human toll, the numbers stand for extraordinary economic wastage—in wealth that will never be generated, professional expertise lost, and huge sums spent caring for the victims of tobacco—in Japan, 5% of all health-care spending goes to treating smoking-related illnesses. No wonder Asians and their governments are beginning to recognize that the situation must be addressed.



 

One measure of the extent to which regional attitudes to tobacco have changed has been the readiness of Asian countries to adopt the FCTC. Since May 2003, the treaty has been ratified by 57 nations across the region, making it one of the most rapidly embraced covenants in the U.N.'s history. The FCTC requires participating states to outlaw tobacco advertising and sponsorship, to demand that tobacco firms cover at least 30% of every cigarette pack with health warnings, and to ban the use of euphemistic adjectives like "light" or "mild" to describe cigarettes. It's the first legal initiative that attempts to control the use of tobacco on a global scale, and Asian countries are among its keenest supporters, including Japan, India, Pakistan, Thailand, Vietnam, Bangladesh, Singapore and Sri Lanka. China and Cambodia have yet to ratify the treaty, but they are signatories. To paraphrase the old Virginia Slims slogan, Asia's come a long way, baby.

Unlikely as it sounds, the remote Himalayan kingdom of Bhutan is the region's pacesetter. Never mind tweaking regulations on tobacco advertising—the Bhutanese government has banned the sale of tobacco altogether (as well as, from last week, smoking in all public places). Tobacco has been gradually withdrawn from retail outlets in 18 of the country's 20 administrative districts since 1994. As of December 2004, it became illegal to sell tobacco in the remaining two districts, including the capital, Thimphu. While the short-term beneficiaries of the new policy will be black-market traders—now able to charge up to $2.60 for a packet of Marlboro, up from an under-the-counter price of $1.30 before the ban—in the long term, all Bhutanese will gain.

Granted, smoking has never been an important part of the culture. A survey in the early 1990s found that just 1% of Bhutanese smoked, thanks to their isolation from the modern world and their devotion to a saint of the Mahayana tradition of Buddhism, who told devotees that the tobacco plant sprang from the menstrual blood of a she-devil. But it's the symbolic value of the ban that's important. In the past, a total outlawing of tobacco has been nothing more than a heady fantasy to antismoking activists. The fact that it has become reality—even if in a sparsely populated, postmedieval mountain kingdom—is an extraordinary development.

Though Buddhism never stopped the monks of Thailand from lighting up, ecclesiastical discipline is forcing them to quit. In a 2002 survey, more than half of the country's monks revealed they smoked—compared with 22% of the regular population. So associated were monks with smoking that worshippers commonly left packets of cigarettes in begging bowls and the baskets presented to monks as offerings—all well and good, until Thailand's Ministry of Health reported in 2002 that 35% of monks admitted to hospital were suffering from smoking-related illnesses. That year, the government launched an antismoking campaign targeting Thai-land's divines: signs were posted at temples to remind monks that the Buddha's teachings on detachment from earthly things applied to cigarettes, too, and 9,000 temples have since declared themselves smoke-free. A recent study by two Thai universities found the prevalence of smoking among monks has dropped to 24%—a halving in just two years. Health officials view this figure with some skepticism, saying monks have become more reticent toward medical researchers, yet the sanctum has indisputably been breached.

Tobacco's opponents have also struck in Japan, once the spiritual homeland of unfettered smoking. Here, an estimated 30 million smokers are enticed by some of the developed world's cheapest cigarettes—selling at an average of $2.60 a pack, versus about $8 in the U.K. Many are dispensed from the 626,000 cigarette-vending machines that clutter the urban streetscape.

For generations of Japanese, sumo wrestling and smoking have been inseparable. But no longer. In an announcement that left traditionalists aghast, the Japan Sumo Association recently declared that Tokyo's Ryogoku Kokugikan (national sumo arena) will become entirely smoke-free from this month. Similar bans are taking place in six other stadiums across the country. The initiatives stem from a high-profile legal action launched last May by Junichi Noda, a 56-year-old court stenographer and sumo fan who says he has never smoked. Noda claimed passive smoking ruined his enjoyment of the 2004 May Grand Sumo Tournament final, and sued the Japan Sumo Association for nominal compensation of about $50. "If I didn't speak up, the world wouldn't get any better," says Noda, who welcomed the ban by settling his suit without compensation.





 

With the number of smokers steadily declining (to fewer than 30% of the adult population, according to a Japan Tobacco Inc. survey), social tolerance of the habit is waning. Since 2002, authorities in Tokyo's prestigious Chiyoda ward—the heart of the Japanese capital—have been introducing outdoor smoking bans, and smoking on the street is now prohibited in more than half the district. Meanwhile, Kobe's popular Takenohama Beach became, last summer, Japan's first beach to restrict smoking, which can now take place only in designated areas. "We were hesitant to enforce the smoking ban too strictly, but it turned out that people were quite cooperative," says Ritsuko Morigami, spokeswoman for the local tourism association. Likewise in Osaka, a pachinko parlor, the Shikairo, has become smoke-free in an effort to attract female clients. "People often remark how fresh the air is," says manager Maya Ihara. "We get pregnant customers, and I believe they come here because there's no tobacco smoke."

In India, an act of Parliament has banned tobacco advertising, the sale of cigarettes within 90 m of schools, and smoking in many public places (although it is poorly enforced). In the Philippines, new rules applying to Manila's business district, Makati, ban smoking in all enclosed public places, including shopping malls and offices. Larger restaurants and bars can offer a smoking section—but only if it's fully enclosed and occupies no more than 25% of the total floor area. The new mood has even reached Vietnam. Here, Dr. Trinh Tre Hung of the Co Nhue Commune (or ward) in Hanoi is striving to create the country's first smoke-free neighborhood. "I don't think we can get everyone to quit," he concedes, "but we have to try to encourage them." People no longer smoke at commune meetings, and all members of the commune's Farmers' Union claim to have stubbed out their cigarettes for good. While compliance remains spotty beyond official gaze (at an open-air noodle stand across the road from the medical center, one resident of the commune says he's never even heard of the initiative), Dr. Trinh and others like him may prevail. Vietnam is one of the latest Asian countries to have ratified the FCTC, putting its name to the document in December.

Antismoking fervor has even reached such unlikely spots as Hong Kong's Dublin Jack bar. With U2 songs blaring from the speakers and an unpretentious, Guinness-guzzling crowd, this may be the territory's most authentic Irish pub—so authentic that it has followed the example of pubs in Ireland, where smoking in such establishments was outlawed in 2004. Since last August, a discreet sign in the window has read: DUBLIN JACK KICKS ASH. Although many smokers have drifted away, the policy has lured new customers like investment banker Rickie Wong. "So often, I need to leave bars because it's too smoky," he says. "I started coming here because it's simply more comfortable." Other operators are monitoring Dublin Jack's experience as a bill to outlaw smoking in all workplaces—including bars and restaurants—is expected to be tabled in Hong Kong's legislature in the next few months. Many expect it to pass without difficulty.

To gauge how taut the net around Asian smokers may eventually become, look at Singapore, which has been famously tough on cigarettes since 1970 when legislation was first introduced banning smoking in cinemas and buses. Today, all air-conditioned areas except bars are smoke-free, and last November the country introduced mandatory counseling for smokers under 18 (they are nabbed by antismoking police attached to the Health Sciences Authority). Since August, cigarette packets have had to carry dreadful color photos of the damage smoking can wreak, including images of a cancerous lung, a young man on life support, and a brain oozing blood after a stroke.

Singaporean café worker Polin Hadnin is already reduced to taking hurried smoke breaks beside a bleak rear entrance to her workplace. Cigarette butts are jammed in the lone ashtray and there's no place to sit. There are probably few people more socially scorned than the Singaporean smoker. But Polin's mental defenses are shored up with comforting thoughts—about the aged relative who has smoked all his life and is still going strong, about the fitness fanatic who never touched a cigarette but keeled over one day, and so on. "If it's really so bad for you," she asks, "why don't they just ban it?"

Poor Polin. If the Bhutanese example is anything to go by, they just might.





 

Asia's antismoking activists, slightly stunned by their own progress, are allowing themselves a moment of gratification. Hong Kong-based Dr. Judith Mackay gave up her job in hospital medicine for antismoking work in 1984, and today is the WHO's senior consultant on tobacco and author of the book The Tobacco Atlas. "When I first started in tobacco control," she says, "it was a lonely existence. Only Singapore, and to a much lesser extent Hong Kong, had taken any action on tobacco. I think the transnational tobacco companies thought Asia was theirs for the taking. But most countries in Asia now have health-education programs, laws, and many have tax policies, even litigation. There are now local movements in all the countries—either government, ngo or academic, and public opinion has swung around."

Veteran Japanese campaigner Fumisato Watanabe measures the changes by the relative ease with which nonsmokers are now able to obtain concessions. "We tried to get smoking restrictions passed in stadiums 10 years ago," says the Tokyo-based director of the Tobacco Problem Information Center (TOPIC). "But there just wasn't the same level of support then." This time, TOPIC persuaded like-minded Japanese to send e-mails, letters and faxes to the authorities in support of Junichi Noda's sumo suit.

Yet none of this—no number of smoke-free pubs or e-mail campaigns—will have a dramatic impact on regional statistics unless headway can be made in China, where the problem is now of stupefying dimensions. The WHO estimates that China has 350 million smokers, and that if the current trend continues, a third of today's young male population will ultimately die from smoking-related illnesses. While there has been no official nationwide study of Chinese smoking published since 1996, advance findings of a new survey by the Chinese Academy of Medical Sciences were shown to TIME by Professor Yang Gonghuan, the research leader. These put the smoking rate in 2002 at 36% of the general population. That's a 1.2% fall since 1996, but worrying trends are emerging. Smoking rates are actually rising among young men aged 15-19 and women aged 15-24, while lung-cancer rates are soaring. From 1991-2000, the rate of lung-cancer deaths in China nearly doubled, and it's now the country's leading cause of cancer deaths.

China's economic success over the past three decades has been blamed for fueling humankind's biggest smoking epidemic. Though there are no records of the prevalence of smoking before 1984, the availability of cigarettes was restricted to ordinary Chinese until at least the late 1970s. Smoking was largely a privilege for Communist Party cadres, and cigarettes could only be acquired in exchange for ration coupons so valuable that they were often treated as cash. But today China is a cigarette cornucopia. In 1978, the country produced 550 billion cigarettes. In 2003, China's factories turned out 1.75 trillion cigarettes, of which only 1% were exported, leaving the rest for domestic consumption—a terrible harbinger for the future. Dr. Wu Yanwei, the China program officer for the who's Tobacco Free Initiative, says smoking rates may have peaked but illness rates have not, because diseases like lung cancer might not manifest themselves until years after a person has stopped smoking. "What we're seeing now isn't the worst of it," warns Wu. "Wait for about 10 years."

In the meantime, this remains a country where polite warnings ("Smoking harms health") occupy a sheepish 10% of the packet, while tar content is often printed quite prominently. A Beijing cabbie explains: "We Chinese feel that if a cigarette doesn't contain at least 8 mg of tar, then it doesn't have any jin [vigor]." When asked about cancer, Jenny Zhu, a 22-year-old electronics trader smoking in a bar in Shanghai's trendy Xintiandi quarter, says, "I can't worry about that ... You don't need to live too long, just long enough."





 

Across town, the world's largest tobacco museum opened last July at a cost of $22 million. Built with donations from local branches of the government's tobacco monopoly, this 96,000-sq-m facility unabashedly promotes the joys of smoking. "There are a lot of limitations on advertising," says Wang Chuanqing, the museum's vice curator and an official of the Shanghai Tobacco Monopoly Administration. "So we use the museum format to showcase tobacco." Inside, displays feature everything from cigarette-making machinery to an edict from Chairman Mao, instructing cadres to forgo foreign brands and smoke only cigarettes made by Chinese state-owned factories. "Everyone knows smoking is bad for your health," Wang concedes. "But tobacco is legal and has been for nearly 400 years."

Against this sort of entrenchment, the country's antitobacco movement has mar-shaled only meager forces. There's no nationwide smoking-cessation program, and China's participation in Quit and Win, an annual, worldwide drive, has been halfhearted: only 6,000 Chinese signed up in 2004 and the vast majority have continued to smoke. Grassroots initiatives, meanwhile, have failed amid a climate of apathy. Chaoyang Hos-pital's quit-smoking clinic, which dispensed advice as well as medication to smokers, shut down a year ago. "Not many people in China want to quit," says a nurse who worked there. Even if they did, nicotine patches, gum and other cessation aids are hard to find in China. "We got rid of the stuff," shrugs a clerk in a pharmacy opposite Beijing's National Tobacco Control Office. "It was useless, nobody ever bought any."

It's too soon, however, for the tobacco-control movement to give up on the world's most populous nation. China's expected ratification of the FCTC could pave the way for a top-down revolution in the social tolerance of smoking. No one denies that certain aspects of the FCTC, such as the establishment of smoke-free areas, will encounter enforcement problems in a country the size of China, but a start will have been made. And if new regulations are supported by more punitive tax policies, the possibilities become tantalizing. A 2002 study co-sponsored by the World Bank estimated that by raising taxes by 5% on cigarettes that currently sell for 50¢ a pack, the Chinese government could save up to 2.2 million lives as many smokers would try to cut back.

It wouldn't be the first time that a tobacco basket case has radically changed. Four decades ago, the U.K. had the world's worst rate of death from smoking. But from 1965-95, growing awareness of the physical and social costs of smoking saw cigarette sales slump from 150 billion a year to 80 billion, and tobacco-related deaths of people aged 35-69 halved to around 40,000 a year.

It's the kind of volte-face made, on a micro level, by smokers every day. High-profile Taiwan TV host Hu Gua smoked more than a pack a day for 15 years before quitting last May. His increasingly pallid complexion onscreen is what spurred him to action. "It isn't difficult to do," he says, "if you bear the health of your loved ones in mind." Says Hideshi Miura, a 45-year-old computer engineer from Tokyo who stopped smoking more than six years ago: "The best thing about quitting was the self-confidence it gave me. It also freed my mind: 10-20% of my mind was always taken up with thoughts about smoking, like whether I had any cigarettes left. I don't have to worry about that anymore." Veena Serippanich, a 21-year-old arts student at Bangkok's Chulalongkorn University who still smokes when she goes on a night out, is one of millions of Asians likely to follow their lead. "I don't want to suffer from lung cancer," says Serippanich. "I need to stop before it's too late."