In the coursework for our master’s degree, we frequently have used terms such as “community engagement,” “stakeholder buy-in” and “resource mobilization” when we talk about effecting change in target communities. We have studied different approaches for policy implementation (top-down and bottom-up), frameworks for political prioritization and how to recognize specific windows in which action has the highest likelihood for success. However, one central concept always recurs: change in a community must come from the community.
This core tenet of change is what I have learned to appreciate from my capstone research on tobacco control. Unlike other issues that my classmates are researching, such as HIV, cancer and malaria, tobacco use involves a playing field made uneven by competing sociocultural factors and commercial interests. Sometimes these two are combined, as in the case of my capstone research location in China.
China currently has one-third of the world’s smokers—an astounding 300 million smokers consuming an estimated 2.3 trillion cigarettes in 2017. The figure makes more sense, however, when we understand that the tobacco industry is operated by the Chinese government and contributes between 7% and 11% of the annual tax revenue. There is evidence to suggest that government leadership used the tobacco industry to rapidly expand the economy at the cost of the population’s health.
China adopted the WHO’s Framework Convention on Tobacco Control in 2003, which reflects a commitment to controlling tobacco use. Though progress was initially slow, more recently cities have made strong commitments to reduce the culture of smoking with hopes of creating smoke-free cities. From my internship with the Beijing Tobacco Control Association (BJTCA), I have begun to see how these commitments become policy and how policy is then implemented.
In 2014, Beijing passed the Smoking Control Ordinance, the strongest tobacco control measure adopted in China, which completely restricted smoking in all indoor places, as well as many public outdoor venues. These regulations included heavy fines, but penalties are hard to levy without proper surveillance, and this surveillance is nearly impossible without the support of local communities.
violations within the city. Photo by Pei Hao
To address this need, the BJTCA created the Beijing Tobacco Control Map to provide a platform to monitor tobacco-use violations. The general public could report violations via phone or WeChat (a rough Chinese equivalent of Facebook), and a marker would appear on the map. Volunteers would then visit the violating site and either update the marker as “Resolved” or “Repeat Violator.”
While generally successful as a proof-of-concept tool, the Tobacco Control Map needed to be further developed to improve adherence rates. My participation with the BJTCA involved developing an index based on the map to publicly pressure city sub-districts into increasing their own enforcement. Pairs of volunteers are trained, given uniforms and certificates, and provided small reimbursements for bus/subway rides to check their local sub-districts for violations. The index requires them to visit office buildings, supermarkets, restaurants, malls, government buildings, etc., and to score these venues based on violations (e.g., people smoking unaddressed by staff, ashtrays in the venue, smell of smoke, cigarette litter, etc.). The scores are reported and compiled into the system and the final index is reported through media outlets such as television, radio and periodicals. The BJTCA then heavily publicizes the city sub-districts with the worst index scores, and this negative publicity is intended to drive local community leaders to promote enforcement efforts.
The strategy hinges on having a huge volume of volunteers that help publicize the BJTCA’s efforts through social media campaigns, tobacco-control marches and even flash mobs. One Saturday morning, I had the opportunity to meet several of the volunteers at a training session and learned that most of them were retirees who had joined the volunteer corps of the city. While they previously acted as civilian guides at bus stops and tourist destinations, many began seeing tobacco control work as a necessity and were recruited into the BJTCA through anti-smoking advertisements.
In a city whose urban borders span 1,600 square miles and almost 22 million people, Beijing’s public health campaigns would be virtually impossible without the strong commitment of the community and its leaders. My internship mentor told me that the BJTCA utilizes more than 15,000 volunteers from every city sub-district to carry out its work, and that every contribution is invaluable to the cause.
For the frequent disappointments we hear about making change sustainable in global health, my time working on tobacco control in Beijing shines brightly in my memory. Not only is there an emerging political will for fixing the problem, the community and its leaders are showing the same strong commitment. After graduation, I am hoping to return to Beijing to continue working with the BJTCA in this fight against smoking.