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At a typical Chinese wedding ceremony, instead of handing out candy, the bride will go from table to table offering each male guest a "wedding" cigarette, often an expensive brand to light up as a mark of the new couple's hospitality. Even non-smokers are expected to not turn down the gesture.

It is a simple example of how smoking is ingrained in modern-day Chinese culture. The World Health Organization (WHO) estimates that China has 350 million smokers, accounting for more than a quarter of the world's 1.3 billion total.

In China, smoking claims one million lives every year. According to WHO estimates, if the rate of smoking remains unchanged, the death toll is likely to climb to 2.2 million a year by 2020, with cancer, cardiovascular and respiratory diseases the big killers.

According to a study published in the 2005 Chinese Journal of Epidemiology, more than 460 million Chinese are regularly exposed to secondhand smoke, the majority being women and children.

Research in Shanghai showed that in families where one partner smokes, the risk of a child contracting cancer is 50 percent higher than for one whose parents don't smoke, a figure the WHO calls "substantial".

A report released this week by the Ministry of Health said 100,000 Chinese people die every year from tobacco-related illnesses caused by passive smoking.

Though estimates vary, it is clear that far more men smoke than women. The smoking rate among men (aged over 15) is about 57 per cent, compared to only 3.1 per cent for women.

Experts believe a shift in male attitudes will be key to reducing smoking rates.

"Controlling smoking among males is 100 times more difficult than the AIDS prevention work I was involved with six years ago," Jing Jun, a sociology professor at Tsinghua University and a heavy smoker, said.

He said he had tried to quit several times but always failed.

"It tortures my mind when I am not smoking. More importantly, a smoking culture makes it difficult for smokers like me to be completely isolated from tobacco," he said.

Jing seldom buys cigarettes as many people send him tobacco as gifts. At many social functions, offering cigarettes is considered a goodwill gesture and a conversation starter.

Fang Yuting, a family medical practitioner at Hemujia Hospital in Beijng, said many of her foreign patients who quit smoking before coming to China, picked up the habit again.

"It is difficult for my patients to find a smoke-free place to conduct business discussions," Fang said.

"Particularly, Chinese businessmen tend to offer cigarettes to them as a courtesy most of time, and it is difficult to refuse."

Fang believes that having a smoke-free working and living environment is particularly important for one to quit smoking. She has compiled a list of smoke-free restaurants in Beijing, and gives it to her patients.

According to Xu Guihua, deputy director of the Chinese Association on Smoking Control, the smoking rate is commonly in "reverse ratio" to the education level of social groups. Smoking is much more prevalent among poor people in China.

However, interestingly, the smoking rate among male doctors is very high compared to other countries, about 60 percent.

Xia Yang, a doctor at Beijing Shijitan Hospital, a non-smoker, said many of his colleagues smoke.

"I think it is quite normal," he said. "Although they have more health knowledge, doctors are no different from anyone else."

Many doctors start to smoke when they are medical students, Xia said.

According to Xu, the smoking rate among young women, particularly white-collar workers, and adolescents has climbed in recent years.

The WHO estimates that because of the growing population and the increase in smoking among 15-24-year-olds, the total number of smokers in China rose by 30 million between 2002 and 2006.

Cigarette stores are ubiquitous and the choice of brands is huge. Stores even sell candy and fruit-flavored cigarettes, perhaps to lure kids and young women into smoking.

Also, most cigarettes stores have ice cream and soft drinks on sale either in the window or directly outside the shop.

Despite an official ban on cigarette sales to anyone under 18, children can still easily buy them.

Cigarettes in China are relatively inexpensive - the cheapest ones selling for 2 per pack - compared to in Western countries, which often levy high taxes on the tobacco industry, in some cases as much as 66 percent of the retail price.

Xu said the tobacco industry sells pro-smoking images to kids via movies - that it is cool, grownup and sexy. The WHO believes tobacco advertising has become "sneakier" and more subtle.

Comparatively, the rising smoking rate among white-collar young women is largely contributed to a desire to be more fashionable, Xu said.

One company employee surnamed Wang said she believed smoking rates among women was underestimated.

"I started smoking out of curiosity. Besides a comfortable feeling from smoking, I feel it is cool and sexy."

She said she preferred cigarettes with a slight mint flavor, and that she would never smoke in front of men or in public. Smoking she reserves for when she's alone, or with female friends, she said.

Although the government has said it wants to make the 2008 Summer Olympics in Bejiing smoke-free, getting just some of the country's smokers to kick the habit will be a huge challenge.

In 2003, the government signed the WHO Framework Convention on Tobacco Control, which formally came into effect in January last year.

The convention states that China must undertake steps to implement effective legislative or administrative measures to reduce smoking in indoor workplaces, public transport, indoor public places and other places, where appropriate.

Ministry of Health spokesman Mao Qun'an said revised regulations on health management in public areas with a new clause on smoking control had been submitted to the central government for examination and approval.

The new regulation states that "Smoking Forbidden" signs should be posted in public spaces and anyone who breaks the law should be fined.

The WHO signaled the urgent need for countries to make all indoor public places and workplaces 100 percent smoke-free with the release of its new policy recommendations, ahead of World No Tobacco Day, today.

Henk Bekedam, the WHO representative in China is pleased with progress so far, yet frustrated at its lack of speed.

"If I reflect on the past five years I've been here, I'm very excited about China signing and ratifying the Framework Convention on Tobacco Control," Bekedam said.

"We are at this very moment quite concerned in the sense that we had hoped for more progress."

The WHO wants more progress in a number of areas including stronger health warnings on cigarette packs, a complete ban on tobacco advertising and for the government to raise taxes on tobacco products.

China's tobacco industry is government-owned and operated.

"One of the concerns for the government is the potential loss of revenue from increased tobacco taxation - based on the assumption that reduced demand will mean less revenue," Bekedam said.

"This is not the case," he said.

"We know globally and also within China that if you raise taxation by 10 percent, then normally what happens is that demand (for cigarettes) will go down by 4-6 percent."

Bekedam called this a win-win situation, as revenue gains will still outstrip losses in cigarette sales. Lives will also be saved, and therefore lower public health expenditures.

Despite the WHO's relatively simple formula for success, more public education is needed to get the anti-smoking message across.

"We do not yet have enough change in behavior as a society. We need to do an awful lot more in order to get there," Bekedam said.

With such a large smoking population, a smoke-free China seems a long way off, but for many anti-smokers, the Olympics could be a positive catalyst for change.

Yang Yan, a research fellow with the smoking control office of the Chinese center for disease control and prevention, said all Olympic stadiums, the Olympic village and all restaurants with BOCOG contracts should be smoke-free.

Also, other restaurants in Beijing should have at least 75 percent of their area designated as non-smoking, which Yang believes will be the most difficult part to achieve.

In February, the Beijing municipal bureau of health sent a notice to the owners of 40,000 restaurants in the capital of its new smoking-control campaign.

However, few took notice as they believed banning smoking would be bad for business.

"The smoking and drinking culture in restaurants is too deep to change for Chinese people," Li Deyi, owner of Lilaodie Hotpot Restaurant, said.

"Offering cigarettes to others when having meals is as common as shaking hands. Unless there is a law to ban smoking in restaurants, I would not forbid my visitors from smoking."

Yang said that they would continue to educate and negotiate with restaurant owners on the smoking issue.

"The Olympics is a really good opportunity to change foreigners' impressions of the Chinese smoking culture," she said.

"After the Olympics, we hope all smoking control policies will be maintained."

(China Daily May 31, 2007)