The World’s Largest Smoking Ban: China’s Upcoming Smoking Ban and its effect on Particulate Matter in China’s Restaurants and Cafés

By Kyle Wong

[box]Absract[/box]

In China, an estimated 560 million suffer from constant secondhand smoke exposure putting almost half of the population at a greater risk of heart disease and lung cancer. In 2003 the Chinese government ratified the World Health Organization Framework Convention on Tobacco Control and promised to protect its people from secondhand smoke exposure. Since then the Ministry of Health has passed a law effective January 1, 2011 that will ban smoking in indoor public places. However, many people are skeptical whether this law will be effective.

This paper is an empirical study aimed to help the Chinese government make more informed decisions while enforcing this smoking ban. It consists of several indoor air quality tests measuring PM2.5 levels in restaurants, and a survey to gauge the public’s knowledge and attitudes toward the law. Based on this study an effective smoking ban would significantly improve indoor air quality in regards to PM2.5 concentrations in restaurants and cafes. Our survey also suggests that improved marketing of the smoking ban could increase the likelihood of the laws implementation and reduce the health effects related to secondhand smoke.

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Writer’s note: The smoking ban described in this paper has been delayed to a further date.

The stereotype that Chinese people like to smoke might be an understatement. There are about 350 million smokers in China that consume a third of the world’s cigarettes[i]. This smoking culture has tremendous economic benefits for policy makers, as in 2007 the state-owned tobacco monopoly accounted for almost US $2billion in government profit[ii].

This financial gain is not without consequence as high smoking rates have lead to significant smoking related illnesses. 670,000 deaths each year can be contributed to smoking related illnesses[iii] and this figure is expected to rise to 2 million deaths each year by 2020[iv].
If smoking is considered a threat to your personal health, then secondhand smoke (SHS) should be seen as a threat to the health of the general public. Unlike smoking, exposure to secondhand smoke is not a personal choice as exposure occurs in indoor public places. 90% of the population is exposed to secondhand smoke in restaurants and 58.4% of the population has been exposed in government buildings[v].

Secondhand smoke is a known human carcinogen and contains 250 chemicals that are known to be toxic[vi]. One harmful pollutant emitted by smoking is Particular Matter 2.5 (PM2.5), which leads to decreased lung function, aggravated asthma, chronic bronchitis, and other dangerous health effects. The medical journal The Lancet estimates that 600,000 people worldwide die yearly from secondhand smoke related illnesses, with children and elderly being the most vulnerable[vii]. In China, an estimated 560 million suffer from constant secondhand smoke exposure putting almost half of the population at a greater risk of heart disease and lung cancer.

The Chinese government has taken measures to protect its people against the adverse effects of smoking and exposure to secondhand smoke by ratifying the World Health Organization Framework Convention on Tobacco Control. Since then the Ministry of Health has passed a law effective January 1, 2011 that will ban smoking in indoor public places. However, with a deeply-rooted smoking culture many people are skeptical whether this law will be effective.

This paper is an empirical study aimed to help the Chinese government make more informed decisions while enforcing this smoking ban. It consists of several indoor air quality tests measuring PM2.5 levels in restaurants, and a survey to gauge the public’s knowledge and attitudes toward the law.

[box]Methodology[/box]

The present study is an analysis of secondhand smoke exposure in 18 randomly selected restaurant and cafes throughout China. Secondhand smoke exposure was assessed by measuring levels of PM 2.5 using a laser aerosol monitor called a Sidepak (Model AM510).  The data collected was grouped into two main categories: venues that had smoking patrons and venues without smoking patrons. The purpose is to measure the difference in air quality and to extrapolate air quality improvements if a smoking ban became effective.

A common protocol was applied to assess the levels of PM 2.5, which was based off of the Global Air Monitoring Study Indoor Air Monitoring Protocol and the protocol used in J. Lee et al.’s article Secondhand smoke exposures in indoor public places in seven Asian countries. Prior to each measure, the Sidepak was zero-calibrated with a filter to ensure more consistent readings. The air flow rate was set to an industry standard 1.7L/min and PM 2.5 levels were recorded each minute.

In addition to recording PM 2.5 concentration levels, control variables that affected concentration levels were also monitored. These control variables included: whether smoking was permitted, number of smokers, size of restaurant, and if there was central air present. Restaurant size was approximated based on the number of tables; restaurants with less than 10 tables were classified as small, 11 to 20 tables were classified as medium, and greater than 20 tables were classified as large.

The second major component of this study was a survey of Beijing residents to forecast the effectiveness of the smoking ban. The purpose of the survey was to poll people’s knowledge of the smoking ban and the likelihood of them helping to enforce the ban. Basic demographic questions were asked to record sex, income, age, occupation, hometown and education level. Altogether 107 people completed our survey in its entirety. All of our surveys and air quality tests were conducted before the smoking ban came into effect from October 2010 until December 2010.

[box]Results[/box]

The US EPA created The US National Ambient Air Quality Standard (NAAQS) to protect the general population from contaminants believed to be the most harmful to humans and the environment. The NAAQS for PM 2.5 for 24 hours is 35µg/m3. Of the 18 venues surveyed, the average concentration of PM 2.5was approximately 81µg/m3, which is about 2.3 times the acceptable level. These findings are consistent with Lee’s research which found average PM2.5 levels in China to be 98 µg/m3 and average concentrations in restaurants in seven Asian countries to be 92µg/m3[i].

Two thirds of the venues we observed had visible smokers (12/18). These locations had an average concentration of103µg/m3, which is about 3 times higher than the NAAQS level. The venues without smokers (6/18) had air quality levels on par with the NAAQS at 37µg/m3.

Thus there was a significant air quality difference between restaurants with and without smokers; restaurants with smokers had PM 2.5concentration levels about 2.8 times greater than those without smokers.The US EPA created The US National Ambient Air Quality Standard (NAAQS) to protect the general population from contaminants believed to be the most harmful to humans and the environment. The NAAQS for PM 2.5 for 24 hours is 35µg/m3. Of the 18 venues surveyed, the average concentration of PM 2.5was approximately 81µg/m3, which is about 2.3 times the acceptable level. These findings are consistent with Lee’s research which found average PM2.5 levels in China to be 98 µg/m3 and average concentrations in restaurants in seven Asian countries to be 92µg/m3[viii].

The survey administered was moderately representative of Beijing’s population demographic. Of the 107 people surveyed the gender breakdown was 56% male and 44% female; 69% had income levels between RMB 0-5,000 Yuan per month, 21 % between RMB 5,000 and 10,000 Yuan per month, and 10% had incomes above RMB 10,000 Yuan per month; 28 % had only middle school diplomas, 24% had high school diplomas, 36% attended university, and 12% attended graduate school.Of the surveyed participants 62%  (66/107) have been exposed to secondhand smoke in restaurants in the past 30 days. This rate is below the 88.5% exposure rate in restaurants claimed by the 2010 Global Adult Tobacco Survey which interviewed 13,354 participants throughout China.

Awareness of the smoking ban is an important factor to the law’s enforcement. According to the survey results, only 27% (29/107) of our participants have heard of the law to be enforced January 1, 2011. While the law has appeared in Chinese media, there is still a misperception over its details. Part of the confusion—and major challenge—regarding the law is related to China’s socially acceptable smoking culture. 38% (3/8) of the non-smoking restaurants observed had smokers despite noticeable “No Smoking” signs.

To better enforce the no smoking ban, one of the most important components is a hotline to report smoking violations. From the survey 40% (42/107) of the participants said they would consider reporting smoking violations and 64% (69/107) would consider asking people to stop smoking.

[box]Discussion[/box]

There are a number of factors that contribute to PM2.5 concentration levels in restaurants and cafes throughout China—cooking, heating, and outdoor PM2.5 being a few. However, studies have found that the presence of smokers is one of the strongest correlations to indoor PM2.5 concentration levels. As seen in equation one, factors such as number of smokers (source emission rate, S) is positively correlated with concentration levels where as air flow (number of air changes per hour, n) and size of the room (Volume, V) are negatively correlated.


Source: Masters, 2008[ix]

Since smoking is often seen as a social activity at venues such as restaurants, it is common to see multiple smokers at the same table. One reason for high smoking levels in China is the affordability of cigarettes. Since 1990 disposable income has risen much faster than the price of cigarettes; currently cigarettes can be purchased for only RMB 5 Yuan a pack[x].

In addition to high smoking levels and poor quality tobacco, the building codes in China are less strict than the building codes in the United States leading to worse air circulation. This circulation is an important factor in reducing PM2.5 concentrations caused by secondhand smoke. Of the venues that we surveyed, one third of them (6/18) did not have evidence of central air. The air quality in these levels in these venues was noticeably poor, with PM2.5 concentrations averaging 129µg/m3.

This study shows that the absence of smoking significantly improves indoor air quality in regards to PM2.5. Based on the air quality tests conducted in this research and the health effects of secondhand smoke studied by medical communities, the health effects of consistent secondhand smoke exposure in restaurants in China can lead to significant health problems. The cardiovascular effects of secondhand smoke are found to be nearly as large as smoking, thus putting the general public at a greater risk of heart disease[xi]. According to a report produced by the American Heart Association secondhand smoke increases the risk of coronary heart disease by about 30%[xii]. Other effects of secondhand smoke include lung cancer, respiratory disease[xiii], and pulmonary disease.

The upcoming smoking ban in indoor public places is significant because secondhand smoke affects millions of innocent bystanders in restaurants and cafes throughout China. Its successful implementation can improve indoor air quality and prevent negative health effects related to secondhand smoke such as cardiovascular disease and lung cancer. It can also reduce the economic costs associated with secondhand smoke such as medical costs (direct cost) and decreases in productivity (indirect cost)[xiv]. This law and its effects could become a catalyst for other smoking bans throughout Asia.

The enforcement of this ban will depend greatly on the support of the Communist Party. The successful enforcement of the smoking ban will also depend upon the Chinese consumers to report smoking violations and abide by the law. The government cannot depend solely on venue owners to enforce this ban because they have an economic incentive to allow smoking because it appeases customers. 38% (3/8) of the no smoking restaurants observed did not enforce their own policy; some of these restaurants even sold cigarettes on their menu and had ashtrays readily available.

Based on the survey results we cannot decisively conclude that the Chinese population will play an active role in enforcing the law. However, the findings are promising as 64% of the participants stated that they would consider asking people to stop smoking and 40% would consider reporting smoking violations. These figures can be perceived as high considering only only 27% (29/107) of our participants have heard of the smoking ban. With greater knowledge of the smoking ban, average consumer enforcement is expected to increase. These figures suggest that the Chinese population—particularly non-smokers—support the smoking ban.

[box]Conclusion[/box]

Based on this study an effective smoking ban would significantly improve indoor air quality in regards to PM2.5 concentrations in restaurants and cafes. Our survey results show that Chinese citizens generally support this smoking ban and may help with its enforcement. To improve the smoking ban’s effectiveness the Communist Party should increase awareness of the ban. By sending a clear message through the media, the Chinese government could increase the likelihood of the laws implementation and reduce the health effects related to secondhand smoke.


[i] World Health Organization. Cigarette Consumption. Available at:

http://www.who.int/tobacco/en/atlas8.pdf. Accessed on November 12, 2010.

[ii] Liu T, Xiong B. Tobacco economy and tobacco control (in Chinese). Economic Science Press;

2004.

[iii] Gu D, Kelly T, Wu X, et al. Mortality attribution to smoking in China. N Engl J Med 2009;360:150-159

[iv] Liu BQ, Peto R, Chen ZM, et al. Emerging tobacco hazards in China: BMB 1998;317:1411—22

[v] Global Tobacco Surveillance System (GTSS), Global Adult Tobacco Survey (GATS): Fact Sheet China: 2010

[vi] National Toxicology Program.9th Report on Carcinogens 2000. Research Triangle Park, NC: U.S. Department of Health and Human Services, National Institute of Environmental Health Sciences; 2000

[vii] Öberg M, Jaakkola M, Woodward A, et al. Worldwide burden of disease from exposure to second-hand smoke: a retrospective analysis of data from 192 countries. The Lancet – 26 November 2010

[viii] Lee, J., et al., Secondhand smoke exposures in indoor public places in seven Asian countries. Int. J. Hyg. Environ. Health. 2010; 10:10-16

[ix] Masters, Gil. Air Pollution. In: Introduction to Environmental Science. Third ed. Upper Saddle River: Pearson Education, 2008.

[x] Hu, TW. The Role of Taxation in Tobacco Control and Its Potential Economic Impact in China. Tobacco Control 2010; 19:58-64.

[xi] Barnoya, Joaquin, and Stanton A. Glantz. Cardiovascular Effects of Secondhand Smoke: Nearly as Large as Smoking. Circulation 2005; 111:2684-698.

[xii] Barnoya, Joaquin, and Stanton A. Glantz. Cardiovascular Effects of Secondhand Smoke: Nearly as Large as Smoking. Circulation 111 (2005): 2684-698.

[xiii] Gu D, Kelly T, Wu X, et al. Mortality attribution to smoking in China. N Engl J Med 2009;360:150-159

[xiv] Hu, TW. The Role of Taxation in Tobacco Control and Its Potential Economic Impact in

China. Tobacco Control 2010; 19:58-64.