In 2005, China ratified the WHO Framework Convention on Tobacco Control (FCTC). To meet the conditions set out by the FCTC, the Chinese Ministry of Health issued a formal decision in 2009 to completely ban smoking in all health administration offices and medical facilities by the end of 2011. This initiative is a landmark event in the increasing commitment by the Chinese government to tobacco control. Many hospitals are now “smoke-free”, but only nominally, since the Ministry of Health does not have the authority to issue/implement laws. The regulation is a policy in nature. Patients, visitors, as well as physicians, continue to puff within the hospital premises, and even within the offices and wards.

China is the largest producer and consumer of tobacco in the world. Conservative estimate of the smoking population in China is 350 million (1). Based on a large-scale survey, two thirds of adult men in China are smokers. Consistent with this finding, newly diagnosed cases of lung cancer are estimated at >600,000 per year. Chinese physicians are not immune to tobacco despite of their knowledge (or lack of it as described below).

A number of factors contribute to the high tobacco use in Chinese physicians: some are common to the general population; the remaining may be unique to the profession. First, smoking is still perceived by many as a male embodiment. It promotes acceptance within the “circle of brothers”. Lighting up a cigarette without offering to others is considered impolite. Refusing an offer is insulting in many occasions. Second, smoking is an important mechanism to deal with the daily stress due to heavy workload: it is not rare for a Chinese physician to see >100 patients per day. Third, it is a common practice for patients to “bribe” the doctors, particularly in the event of a serious condition. Lack of knowledge is also a significant factor. Nearly all physicians know the cause-effect relationship between smoking and lung cancer, but only 60% know smoking could also cause ischemic heart diseases. Less than 1/4 of Chinese physicians are aware of the association between passive smoking and sudden infant death syndrome (2).

An analysis of historical data hinted light at the end of the tunnel. For example, smoking rate in Chinese physicians was 23% in 2004 (2), and 20.4% in 2009 (3). Also, the physicians in large metropolitan areas (e.g., Shanghai and Beijing, where anti-tobacco laws are now in place) are much less likely to smoke during their shift. Last but not least, physicians could take the lead in the battle against tobacco use, but winning the war requires much more efforts. Here, a particular concern is the dependence of government budget on tobacco tax (now at 8%-9% of the overall government expenditure). The “Big Tobacco” will not fade out voluntarily. Until the government finds an alternative to tobacco tax income, the war will drag on.

The author thanks Dr. Kehong Zhang at the Ivy Editing & Consulting (Shanghai, China; E-mail: kz@theivyediting.com) for extensive editing of this letter.