Challenges for philanthropy and tobacco control in China (1986-2012).

OBJECTIVE: To identify the international philanthropies that have invested in tobacco control in China, describe their role and strategies in changing the social norms of tobacco use, and define the outcomes achieved.
METHODS: Information on the international philanthropic donor China projects, including activities and outcomes, was gathered from multiple sources including organisational websites, key informant interviews and emails with project officers, and published research papers and reports.
RESULTS: Philanthropic donations to China's tobacco control efforts began in 1986. The donors provided funds to national, city, provincial government organisations, non-government organisations, universities, and healthcare organisations throughout China to establish a tobacco control workforce and effective programmes to reduce the burden of tobacco use.
CONCLUSIONS: International engagement has been an important dimension of tobacco control in China. Recognising the large burden of illness and capitalising on proven effective control measures, philanthropic organisations understandably seized the opportunity to achieve major health gains. Much of the international philanthropic investment has been directed at public information, policy change and building the Chinese research knowledge base. Documenting research and evaluation findings will continue to be important to ensure that promising practices and lessons learned are identified and shared with the China tobacco control practitioners. The ultimate question is whether foreign philanthropy is making a difference in tobacco control and changing social norms in China? The answer is plainly and simply that we do not know; the evidence is not yet available.

China confronts a daunting tobacco challenge. The country grows more tobacco, produces more cigarettes, makes more profits, and has more smokers than any other country in the world.

According to the Global Adult Tobacco Survey conducted in 2010, there are over 300 million smokers in China and 53% of men smoke.1 By 2020, it is projected that China will suffer 2 million deaths annually due to tobacco use.2

But the tobacco problem in China is not the same as in any other country, developed or developing, for at least five major reasons. First is the sheer scale and complexity of tobacco use and control in China. The scale is reflected by the statistics and complexities are demonstrated by the uniquely Chinese cultural use of cigarettes as gifts of social reciprocity and exchange. Second is the powerful role the Chinese government plays as the monopolistic corporate marketer of tobacco as well as the public body responsible for protecting the health of the Chinese people. Third, tobacco is a major source of revenue for the Chinese government through the entire chain of production, marketing, sales and excise taxes. The government's China National Tobacco Corporation (CNTC) is the largest for-profit tobacco company in the world.3 Yet, because of its still mostly fee-based healthcare system, the financial burden of sickness due to tobacco is mostly borne by individual families, not the government. Fourth, China does not have a diverse and pluralistic civil society or many non-governmental advocacy organisations in tobacco or any other field. Social movements are not encouraged and are difficult to mount in China. And finally, in China as elsewhere, information and data are extremely limited and very hard to access. This paucity of information appears to be especially true in the case in tobacco.

Despite this daunting and complex picture, China has recently taken some important steps to curb tobacco use. The Ministry of Health issued a smoke-free (SF) hospital policy in 2009, with guidelines for healthcare facilities to be smoke-free by 2011,4 and the Ministry of Health and the Ministry of Education issued a policy with guidelines for creating SF schools.5 The Ministry of Health also authorised a policy prohibiting smoking in indoor public places starting 1 May 2011,6 and the National People's Congress included a statement of commitment to tobacco control in the 12th 5-year Plan.7 In additional to national efforts, cities have adopted SF policies and released media campaigns and health education programmes aimed at changing social norms.8

International engagement has been an important dimension of tobacco control in China. In 2006 China ratified the WHO Framework Convention on Tobacco Control (FCTC) that includes a commitment to implement the obligations contained in FCTC.9 Despite China's ratification to the treaty there remain considerable gaps between the FCTC requirements and the treaty implementation. The lack of government responsibility and the fact that the China Tobacco Monopoly is responsible for the implementation of the FCTC has been blamed for the gap.10 International and academic organisations have also worked with Chinese partners in highlighting the threat that tobacco poses to health. This has included important epidemiological studies with Oxford11 and the National institutes of Health (NIH) Fogarty Center.12–15

The World Bank in an early health loan included tobacco control as a significant public health measure. More recent significant international engagement has been the recent entry into China of major American foundations. For the past century, such distinguished philanthropies as the Rockefeller, Ford and Gates foundations have pioneered many fields in China. Rockefeller, in particular, focused on health philanthropy, and through the Rockefeller-endowed China Medical Board built the famous Peking Union Medical College in the first half of the century and has worked collaboratively with a dozen medical universities since returning to China in 1980.16 Ford Foundation focused on women's reproductive health in China,17 while Gates Foundation has been a strong supporter of high priority diseases like HIV/AIDS.18

What has been distinctive, however, are American philanthropies, especially Bloomberg and Gates Foundations, that are investing significantly in tobacco control in China. Why have these foundations launched tobacco control work in China? What are they doing? What has been their impact? These questions are the focus of this paper which presents for the first time difficult-to-obtain data on their activities. While definitive evidence is lacking, the data raises key issues associated with foreign philanthropic engagement in tobacco control in China.

Methods

Information on the international philanthropic donor China projects, including organisation, strategies, timing and activities were compiled from multiple sources which are summarised in tables 1 and 2. Organisational websites were initially searched. To obtain more indepth understanding, interviews were conducted with senior staff of the Bloomberg and Gates foundations. These data were followed and supplemented with email exchanges. Budgetary data were especially difficult to obtain and are not presented, although quantitative aspects of foundation-supported activities are provided to the extent feasible. To the best knowledge of the authors, the information presented in this paper, however incomplete, are not available in any other source. Yet, they shed some light into some of the fundamental strategic issues surrounding philanthropic support for tobacco control in China.

Table 1

Four international organisations’ early tobacco control work in China

Year	Philanthropic organisation	Key projects/Outcomes
1986—Present	WHO19 20 (D Xiao, personal communication, 2012)	▸ Established the WHO Collaborating Center for Tobacco or Health in China (1986)▸ Conducted prevalence surveys (1989–1998)▸ Established quit lines and cessation clinics (1996–2010) (D Xiao, personal communication, 2012)▸ Participated in mass education activities and conducted a wide range of tobacco control research projects (1986—present) (D Xiao, personal communication, 2012)▸ Established partnerships to develop the China Tobacco Control Action Plan (2009), to organise the second National Symposium on Smoking and Health(1991) and the first WHO FCTC Expert Forum of China (2004) (D Xiao, personal communication, 2012), and to develop a white paper on harms of smoking and secondhand smoke (SHS) (2011)▸ Supported100% SF policy in Chinese Traditional Medicine hospitals (2011) (S England, personal communication, 2011)
1996–2004	World Bank21 22(Y Jiang, personal communication, 2012)	▸ Funded seven China cities to create model tobacco control projects—Beijing, Chengdu, Liuzhou, Luoyang, Shanghai, Tianjin and Weihai. – Decrease in overall smoking rate 80000 people participated in Quit2Win competitions – Increase in knowledge of harms of tobacco use – Provided training in health promotion – Adopted SF public policies in all cities; banned outdoor advertising and cigarette sales to minors in most cities
2003–2007	Fogarty International Center23 24	▸ Supported efforts to increase tobacco control capacity in three provinces: Jiangxi, Henan and Sichuan resulting in: – Provincial and local-level Centers for Disease Control and Prevention (CDC) staff conducted surveys and measure air nicotine (Center of Excellence) – Developed and implemented SF policies and education campaigns – Developed/implemented community based interventions (rural schools, homes, hospitals and communities)▸ Developed the US-based Global Tobacco Control Leadership Program
2005–2008	American Cancer Society25	▸ Established a representative office in Beijing (2005)▸ Trained cessation counsellors and established cessation clinics (2007–2008)▸ Sponsored the first Cross Strait Tobacco Control Conference in Taiwan▸ Cosponsored a SF worksite campaign▸ Codeveloped the ‘Cessation Clinic Operations Manual’

FCTC, Framework Convention on Tobacco Control; SF, smoke-free.

Table 2

Tobacco control work of Bloomberg and Gates foundations in China

Year	Philanthropic organisation	Key Projects/Outcomes
2007—Present	Bloomberg Initiative—Campaign for Tobacco Free Kids26 27 (Y Xi, S England, and E Yin, personal communication, 2012)	▸ Increased media coverage of tobacco control issues by 27% between 2008–2010▸ Trained journalist to promote tobacco control issues▸ Provided media advocacy training and legal workshops for government policy makers and lawyers▸ Raised awareness of health risks of smoking with a multi-city pack warning campaign ‘I want to tell you because I love you’ (2011)▸ Partnered with other international organisations to support the adoption of SF public place policies in China cities▸ Support advocacy efforts that led to the Shanghai World Expo's organisation decision to return tobacco company donation▸ Prevented a tobacco company-sponsored sports event
2007—Present	Bloomberg Initiative—Johns Hopkins School of Public Health28 (S Tamplin and E Yin, personal communication, 2012)	▸ Promoted the adoption and implementation of policies to ban smoking in public places, and to improve tobacco control capacity in 40 cities and 20 provinces▸ Offered the US-based Global Tobacco Control Leadership Program
2007—Present	Bloomberg Initiative—International Union Against Tuberculosis and Lung Disease26 (Y Lin, Q Gan, N Dong, H Liu, personal communication, 2012)	▸ Supported public sector efforts to pass and enforce key policies Established SF policy in tuberculosis (TB) centres and supported SF families initiative in Hunan Province (2007–2009) Supported the establishment of SF public places in Olympic cities (2007–2009) Supported the establishment of SF universities with public health facilities (2012–2014) Established SF Traditional Chinese Medicine hospitals (2011–2013) Supported the advocacy efforts for SF workplaces and public places in Shanghai (2008–2011), Guangdong (2011–2013), and Chongqing (2009–2012), Lanzhou (2009–2012), Nanchang (2009–2012), Shenyang (2009–2012), and Jinan (2012–2014) Supported the advocacy efforts for SF workplaces and public places in Guangzhou (2009–2013), Harbin (2010–2014), Shenzhen (2010–2014), and Tianjin (2010–2014) ▸ Established tobacco control training programmes in selected universities
2008—Present	Bloomberg Initiative— WHO (D Xiao, personal communication, 2012)	▸ Created a SF hospital model for China and piloted the model in 40 hospitals▸ Promoted a national effort to establish SF hospitals throughout China
2007—Present	Bloomberg Initiative—World Lung Foundation(Y Chang and W Chen, personal communication, 2012)	▸ Created eight mass media campaigns for China and partnered with organisations in China to promote the campaigns in various locations▸ Launched a national media campaign (2012)
2009—Present	Bloomberg Initiative—US CDC Foundation29 (S Asma, personal communication, 2012)	▸ Partnered with China CDC to implement the Global Adult Tobacco Survey (GATS) (2010) and collected data on tobacco use and key tobacco control measures
2008—Present	Bill and Melinda Gates Foundation—China Medical Board (J Koplan and L Chen, personal communication, 2012)	▸ Promoted antitobacco control activities in its associated academic health science centre grantees Established SF campuses Developed curricula on hazards of smoking and SHS Increased cessation among physicians ▸ Conducted research on economics and epidemiology of tobacco use▸ Cosponsored an academic conference on tobacco control (2011)▸ Supported a supplemental issue of Tobacco Control (2012–2013)
2008—Present	Bill and Melinda Gates Foundation—Emory University Global Health Institute30 (J Koplan and P Redmon, personal communication, 2012)	▸ Provided grant funds/training and technical assistance to 17 cities (Anshan, Bayannouer, Changchun, Changsha, Dalian, Hangzhou, Kelamayi, Luoyang, Nanjing, Nanning, Ningbo, Shanghai, Suzhou, Shanghai, Tangshan, Wuxi and Yinchuan to change tobacco use social norms Established SF hospitals, schools, businesses, airports, businesses, restaurants, hotels, airports, mega events and families Advocated for city-wide SF public place policies Increased TV and news media on tobacco control issues Launched mass media campaigns Delivered community interventions to promote cessation, prevent initiation, and protect non-smoker from SHS ▸ Provided grant funds/technical support to 5 universities to conduct tobacco control research (Kunming University School of Public Health, Shandong University, Shanghai Jiao Tong University School of Public Health, Tsinghua University Law School, Yunnan Agricultural University College of Economics and Management/ Pioneers of Health Consultancy Center▸ Cosponsored academic conference on tobacco control (2011)▸ Sponsored development of web-based China Tobacco Control Resource Center (2011)▸ Published monthly electronic tobacco control newsletter
2011—Present	Bill and Melinda Gates Foundation—China Red Cross	▸ Provided support to universities, government and non-government organisations, and cities to change tobacco use social norms and ensure long-term political support for tobacco control in China

CDC, Centers for Disease Control and Prevention; GATS, Global Adult Tobacco Survey; NGO, Non-governmental organisation; NIH, National Institutes of Health; SHS, secondhand smoke; SF, smoke-free; TB, tuberculosis.

Results

Table 1 shows the earlier foreign funding towards China's tobacco control by the WHO, the World Bank, NIH's Fogarty Center and the American Cancer Society. These organisations collaborated in surveys, research, pilot projects, interventions and policies, all of which helped to elevate tobacco control as an important national public health issue.

Added impetus to these tobacco control efforts were achieved by the recent significant philanthropic work of the Bloomberg Initiative, The Bill and Melinda Gates Foundation and the China Medical Board (table 2). As of 2012, the Bloomberg Initiative functions in China through an impressive array of intermediary organisations including the WHO, the International Union Against Tuberculosis and Lung Disease, Johns Hopkins Bloomberg School of Public Health, World Lung Association, the Centers for Disease Prevention and Control Foundation, and Campaign for Tobacco Free Kids. In parallel fashion, the Bill and Melinda Gates Foundation continues to provide support for tobacco control in China through direct operations as well as grants to the Emory Global Health Institute, the China Red Cross and Campaign for Tobacco Free Kids. The China Medical Board has received some funding from Gates but also invests its own funds independently, especially in tobacco control research.

These philanthropies have provided funds to national, city, provincial government organisations, non-government organisations, universities and healthcare organisations throughout China. The funds have been used to build up a tobacco control workforce and increase their capacity to develop and deliver effective tobacco control interventions, support national and local governments to adopt and enforce SF policies, provide cessation services, deliver effective media campaigns, and conduct important tobacco control research. The funding support has also been used to establish centres and organisations devoted to promoting tobacco control, support conferences and workshops, and create educational products and tools.

Discussion

A natural first question is why have American philanthropies, especially Bloomberg and Gates, selected tobacco control in China as a high priority programme in their foundations? The answer in some ways is obvious. Many studies have underscored that tobacco use in China stands out as among the largest preventable cause of death in the world.31 Proactive interventions would seem timely given lessons learned from successful tobacco control in other countries. Recognising the large burden of illness and capitalising on proven effective control measures, these philanthropic organisations understandably seized the opportunity to achieve major health gains.

The intrusion of foreign foundations has not been without counter-attack in China. Pro-tobacco interest groups in China may accuse these foundations as meddling in Chinese priorities or indeed the foreign work may even have ulterior motives. For example, it has been questioned why American foundations invest in tobacco control in China, when the USA remains one of the world's largest tobacco producers? The charge of foreign interference may also serve to weaken Chinese partner groups who can be accused of being aligned with foreigners. On the other hand, many Chinese public leaders have exercised public health leadership in advocating for tobacco control, and many Chinese may admire the foreign foundation work as valid and legitimate because of their genuine public health commitment.

A related issue is why Chinese domestic philanthropy does not sufficiently recognise the tobacco challenge and continues to remain on the sideline of tobacco control. Given the accumulation of new wealth, Chinese philanthropy has emerged in recent years, albeit tobacco has not yet attracted Chinese foundation support. Some domestic health investments involve building hospitals or medical schools, especially donations from Hong Kong. For whatever reason, tobacco has not yet attracted the growing Chinese philanthropic community. But it should be noted that there are several extremely active antitobacco groups that are fiercely combating the epidemic of tobacco use, like Think Tank, a non governmental organisation (NGO) headed by retired public health officials. The Ministry of Health has also established a government-organised NGO called the China Tobacco Control Association that has strengthened the ministry's antitobacco work.

Much of the international philanthropic investment has been directed at public information, policy change and building the Chinese research knowledge base. Research by the Chinese scientists themselves is especially important because of the common argument that international findings on the consequences of smoking are not applicable to Chinese people, for various reasons. Philanthropic efforts have resulted in research papers related to topics such as prevalence and exposure to secondhand smoke among the general population as well as target groups, knowledge, attitudes and belief studies, disease and economic burdens of tobacco use and secondhand smoke, smoking patterns and socioeconomic influences, smoking experimentation and initiation, cessation, roles and outcomes of taxes and SF policies. Documenting research and evaluation findings will continue to be important to ensure that promising practices and lessons learned are identified and shared with the China tobacco control practitioners.

The path to changing social norms on tobacco in China is not easy given the complex position of the government. Health is only one of many ministries involved in tobacco. There are powerful voices in governmental leadership at all levels of the system that are supportive of tobacco as a crop, manufactured product, personal habit, source of employment and source of government revenue. Also, China's tobacco industry has a strong influence in perpetuating the social norm of tobacco use. It employs many tactics to demonstrate social responsibility under the guise of corporate philanthropy efforts, all to market tobacco products. Even though the FCTC includes a ‘comprehensive ban on all tobacco advertising, promotion, and sponsorship,’32 the China tobacco industry continues to promote their products.

The CNTC also offers ‘philanthropy’ to reduce poverty, investing in environmental sustainability, donating to education and providing funding for disaster relief.33 34 The CNTC and subsidiary companies have made significant contributions aimed at targeting the youth in an effort to attract new smokers. The contributions target the youth by providing funding support for schools and educational services as well as youth events and activities.35 36 A number of the funded schools even bear the name of the tobacco company. One of the schools, Sichuan Tobacco Hope School has a school slogan that reads ‘Talent comes from hard work—Tobacco helps you become talented.’36

Internationally, the British American Tobacco company has also engaged in philanthropic donations in China. In an attempt to divert attention away from secondhand smoke, they funded the Beijing Health Promotion Society (initially named the Beijing Liver Foundation) in 1997. They also used the society to foster relationships with the CNTC and State Tobacco Monopoly Association to help them undermine China's SF legislation.37

The ultimate question in this struggle between antitobacco and pro-tobacco forces in China is whether foreign philanthropy is making a difference in tobacco control in China? The answer is plainly and simply that we do not know; the evidence is not yet available. And in this regard, it should be recognised that tobacco control in China is not the same as in other countries, either developed or developing. Changes in social norms—in China and elsewhere—are hard to understand, predict or energise. Public information and education, ultimately, will be important legacies of the foundations’ work. Government's policies, it should be underscored, will likely be a critical factor.

When and how will the government's health imperative ultimately overcome the commercial governmental interest? Some of the answer may depend upon how the Chinese public perceives the role of those who control the government in protecting the people's health. The current public perception is that smoking is mostly a private individual matter and non-interference by government is acceptable. In other words, government is not held accountable for lack of public action. If public outcry over the health damages of tobacco were to grow, as has happened in other countries and as has happened in Chinese healthcare reform, Chinese decision-makers may shift its tobacco policies dramatically to protect its reputation which is foundational to its legitimacy and power.