Professor aids China’s nascent anti-smoking efforts

L.A. Cicero

Assistant Professor Matthew Kohrman with some of the cigarette packages he collected in southern China. The medical anthropologist has applied his academic expertise in China to help address its smoking epidemic.

In late 2005, Kohrman and a group of colleagues published the first smoking-cessation manual in China based on anthropological research.

Tobacco is big business in China, which is home to roughly 360 million smokers—more than in any other country. It’s also a leading cause of death. This year, smoking-related diseases will take an estimated 1 million lives in China and be responsible for one of every eight deaths among Chinese men, said Matthew Kohrman, assistant professor of cultural and social anthropology. By 2050, if current trends continue, the figure is expected to jump to one-in-three male deaths.

In China's traditionally patriarchal society, smoking is an activity almost exclusive to men, Kohrman said. Seventy percent of men over 15 years old smoke, compared to less than 4 percent of women. Smoking is regarded as socially unacceptable for women, although slight upticks have been recorded among young female urbanites who regard it as cool and glamorous. Among men, the habit is equated with success, strength and sociability. Alongside the country's emerging market economy, cigarettes have been used to facilitate and seal business deals. A common Chinese expression today goes, "Men who don't smoke will work in vain to ascend to the top of the world."

Organizing a campaign to stem China's looming health crisis is further complicated because tobacco has been the single-largest contributor to its national tax system in recent years, Kohrman said. The country grows one-third of the world's tobacco crop and manufactures one-third of its cigarettes. Although oil and petroleum have gained in importance, tobacco remains a significant contributor to the economy, particularly in southwestern Yunnan province—China's "tobacco kingdom"—where 70 percent of taxes come from cigarette production.

In comparison to efforts to stem AIDS, which has received a lot of media attention, government support and significant international funding to establish disease-prevention organizations, tobacco control languishes. According to the United Nations, fewer than 1 million people have AIDS in China, but more than this number will die this year from smoking-related diseases. "Tobacco is much more sensitive because it's such a big part of the economy," Kohrman said. "And even with the epidemiological tidal wave that is about to hit the country, it's not seen as that pressing."

Despite such obstacles, Kohrman has witnessed some positive developments as China vies to be accepted as a modern state. Last October, China ratified the World Health Organization's Framework Convention on Tobacco Control, an international treaty aiming to reduce global demand for tobacco products by encouraging countries to adopt anti-smoking measures. In recognition of that milestone, China again will mark "World No Tobacco Day" on May 31.

Kohrman, a medical anthropologist interested in "biopolitics"—how health and the human body relates to the formation of political life—has applied his academic expertise in China to help address the nation's smoking epidemic. Kohrman is the author of Bodies of Difference: Experiences of Disability and Institutional Advocacy in the Making of Modern China, a book examining disability in relation to modernity and state building. In late 2005, Kohrman and a group of Chinese colleagues published Striding Along the Road to Health: A Handbook for Giving Up Smoking. It is the first smoking-cessation manual ever published in China based on anthropological research.

"This is a health project, but deeply informed by my ethnographic work," Kohrman said. "I feel strongly that while doing ethnographic study, anthropologists can't just sit back and be flies on the wall and write papers about suffering. They have to do things to mitigate that suffering." Kohrman said his anthropological research benefits from his policy work and vice versa. "As a result of this project, I have credibility throughout the Chinese public health system," he said. Leading up to this year's "World No Tobacco Day," the manual was featured on Chinese state television in a national broadcast on May 29.

The slim paperback is based on research supported by grants Kohrman received from the U.S. National Institutes of Health and the American Cancer Society. Developed in collaboration with the China Centers for Disease Control and Prevention and the School of Public Health in Kunming, the capital of Yunnan province, the self-help manual offers a set of behavioral and conceptual tools attuned to Chinese social mores.

"There's nothing like this," Kohrman said. "There are other smoking-cessation manuals, but they are usually direct translations of foreign texts that make no effort at developing something more related to every day social and economic life."

In a trial run, 3,000 copies have been published and are being circulated nationwide. This fall, Kohrman will begin a pilot test in Kunming involving 400 smokers who want to quit. Half of the group will receive the book and will be monitored to see if the book helps them kick the habit.

The colorful handbook is loosely based on an English-language manual that was revised and adapted according to input from Chinese focus groups and tobacco control experts. A Kunming advertising agency created hip graphics, many in the style of Japanese anime, geared to the interests of the manual's largely male target audience. The book is endorsed by Hong Zhaoguang, China's leading popular health guru, and other prominent Chinese professionals. Colorful stickers printed with sayings such as "Smoking can cause bad breath" and "No Smoking" are included in the book. Actor Jackie Chan, an ardent anti-smoking advocate, is featured on the back cover crushing a giant cigarette over his knee. In an unusual collaboration between mainland China and Taiwan, Kohrman worked with a Taipei health foundation to secure copyright permission to use Chan's image.

Kohrman said the book is different from its predecessors because instead of merely listing tobacco-related health problems, it contextualizes the risks within broader issues of concern to society. "There are anxieties about rising health-care costs and the decline in health-care financing," Kohrman said. "Most families are not insured, the old state is gone and people have to bear the burden of health-care costs." For example, a 30-year-old smoker might already be struggling under the burden of covering health-care costs for his parents. "One can say, 'Hey, you're 30 right now and you can smoke for another 20 years, but then you'll get a disease and it will be very expensive,'" Kohrman said. "You can speak to issues they're already attentive to."

The manual also discusses how cigarette smoking incubates disease, Kohrman said. "Alas, people are much more attentive to communicable diseases; they really worry about pathogens moving from person to person." It also tries to dispel misconceptions, such as if someone has smoked for a number of years and then quits, his body experiences changes that could actually induce disease.

Kohrman knows the anti-smoking lobby faces a tough battle ahead. Tobacco replacement therapy and smoking-cessation clinics are in short supply across China. More people are quitting, he said, but then fall back: "There's a very fraught sense of self forming around quitting." Men think, "I'm a manly man because I can quit," and "I am weak and lacking willpower" if they fail, Kohrman said. "So there's a lot of self-loathing that's starting to occur."

The 2008 Summer Olympics in Beijing is expected to boost the anti-smoking lobby, Kohrman said. "There's been a lot of ongoing struggles within China's polity about creating the healthy modern individual," he said. The late Communist leader Mao Zedong, a heavy smoker, wrote essays in the 1920s about the importance of the healthy, athletic individual.

"The spirit of strong physicality has grown over time, and the Olympics is the most recent iteration of that: the importance of being internationally recognized as a strong, healthy state made up of strong, healthy individuals," Kohrman said. "This is the conflation of health and modernity. It's a foundational piece of nationalism."