The urban-rural divide hampering China’s efforts to cut smoking

The tyranny of distance and the yawning social divide in China are seriously hampering attempts to control an “epidemic” of diseases such as lung cancer, despite billions being spent on healthcare, experts have warned.

Health and social outcomes vary greatly between urban and rural areas, between rich and poor, causing such alarm in Beijing that President Xi Jinping has made raising “common prosperity” the watchword of his bid to rule for an unprecedented third term.

Xi Chen, associate professor of health policy and economics at Yale, says the healthcare system favours profit-driven hospitals rather than local family doctors, and a skewed private health insurance system penalises those living in the regions, trapping many families in poverty.

“Healthcare is a major burden,” Xi Chen says. “One third of people face catastrophic healthcare expenditure in their lives, defined as spending more than 10% of their income on healthcare. Insurance typically only covers 66% of costs. Then people have a major problem.

“There is a big disparity. If you are in an urban area, insurance will cover much of the cost. People in rural areas, much less so. Because insurance policies are skewed towards paying for in-patient care, doctors tend to register patients for hospital care when it might not be necessary, raising the burden on the system.”

This approach lands society with a huge healthcare bill that feeds the growing social divide. China has massively expanded its hospitals, but more than half are private, meaning doctors are often paid according to profits so are more interested in promoting treatment-based care than a preventative or early-intervention approach.

The focus on hospitals instead of local family doctors means that people with developing health issues don’t get seen early enough and then end up presenting at hospital when their illnesses are much worse, incurring more costs and fuelling inequalities.

Decades for the smoke to clear

No issue better illustrates China’s double-edged sword of rising levels of disease and inequality than smoking-related diseases such as lung cancer, stroke, emphysema and other respiratory problems.

Mark Parascandola, an epidemiologist at the US National Cancer Institute, says China is experiencing “a lung cancer epidemic on an unprecedented scale”, and the government in Beijing is acutely aware of the health dangers that poses. Smoking-related diseases already account for at least 1.4 million Chinese lives every year.

The government has started to make a concerted effort to encourage people to kick the habit by banning smoking in many public areas of larger cities and in workplaces and on public transport. Its Healthy China action plan, launched in 2019, mapped out a comprehensive list of such regulatory measures as well as promoting better education about the dangers.

However, regional disparities, differences between large and small cities and differing attitudes mean the impact on smoking remains patchy. Smoking is banned on the nation’s prestigious high-speed train services, but the habit is still allowed on many non-high-speed trains and other modes of public transport. It is also banned in restaurants and bars, although many in smaller cities may have exemptions, but is not yet banned in government facilities.

Equally, workplace bans have been unpopular in smaller cities, emphasising the increasing social divide between China’s more advanced urbanised areas and its vast rural population of 600 million people. According to the most recent global adult tobacco survey, 51% of Chinese adults were exposed to secondhand smoking at work and 45% had the same problem at home.

Professor Bernard Stewart, an expert on cancer causation at the University of New South Wales in Sydney, says the message about the danger of cancer may not have penetrated throughout China.

“Cancer is the most feared disease [in the west]. But I don’t know if that’s true in China,” he says. “The cancer link to smoking is definitely established there and perhaps known to all middle-class Chinese. But it may not have the impact it has here.”

Regardless of the strategy China uses, the health impacts of its high rates of smoking will play out over the course of decades.

“Health consequences of tobacco smoking can develop over a long time,” Parascandola says. “Even if they succeed in reducing smoking, the high prevalence means millions of people are at high risk from outcomes like lung cancer.

“Look at the US, the UK, Australia … smoking prevalence reduced in the 70s and 80s. But we don’t see the impact until much more recently in terms of reduced lung cancer deaths. Even with measures in place in China, it will take time before we see impact for lung cancer deaths.”

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