Question: What do you get when you put the world’s biggest smokers in the world’s most polluted cities – and then wait for +20 years?

Answer: You get approximately 20M super-smoking Chinese men. A unique population that has likely inhaled more carcinogens than any other human beings alive. And as they are almost all men, I call this group China’s “puff daddies”.

Here’s my little back-of-the-envelope calculation on this.

• China is a huge smoking country. There are 350M smokers and China produces over 40% of the world’s cigarettes.
• But if you take the top 20% of these smokers (by consumption), you get about 60-70M really heavily smoking people. These are the really high-powered, 1-2 packs a day smokers.
• And if you take the 20% of those that live in the most polluted cities (assuming an even geographic distribution), that gets you about 15-20M Chinese super-smokers.
• And as only 4% of Chinese smokers are women, these +20M “super-smoking meets super pollution-inhaling Chinese” are almost all guys.

These +20M Chinese “puff daddies” are an important demographic to watch. They will inhale more pollutants in their lifetimes than probably any other group alive. And it is a pretty large group. It is as if the entire population of Australia was replaced by super-smoking men. And, unfortunately, as time goes by their medical conditions are going to become more and more apparent.

I think China’s puff daddies are really five factors playing out in combination:

Factor 1: China has very high prevalence of smoking in a very large population.

The China smoking numbers are well-known: 300-350M smokers consuming 130 billion packs of cigarettes per year. This is about a third of the world’s cigarettes annually. It results in 1.3M deaths per year (about 10% of all deaths in China).

It is very unusual to have such a big population with such a high smoking prevalence. Greece is actually #1 for smoking per capita. But China is far and away #1 in the aggregate.

Factor 2: China’s air quality is a major health threat – and this is likely synergistic with smoking.

Air pollution is more of a Northern China phenomenon, as that’s where a lot of the polluting factories are. In Beijing, where I live, the air quality index (AQI) typically goes between 50 and 250. At 100, I usually start to wear a mask. At 200 (described as “very unhealthy” on my phone app), school kids are kept indoors. And on the “airmageddon” days (300-400 and above), things start to shut down. It’s like walking in fog.

Most studies argue that pollution is now the 4th biggest health threat in China, behind heart disease, dietary risk and, yes, smoking. And smoking, unfortunately, can have a synergistic effect when combined with other inhaled carcinogens (i.e., the cancer rates go up more in combination with some pollutants).

Factor 3: Second-hand smoke is a problem in a dense country with a smoking culture.

Second-hand smoke is also a big deal in China. Lots of people smoking impacts other people. Volume, density and social acceptability matter. According to PRC researchers, over 700 million Chinese are affected by secondhand smoking.

And unfortunately, this has a particularly cumulative effect when it happens indoors – such as in restaurants, offices, bars and homes. According to the WHO, the air in a restaurant with three smokers reaches a 600 AQI level. And it increases to 1,200 with five smokers.

The irony here is that when the pollution is really bad outside, everyone tends to stay inside, where they then smoke in close quarters.

Factor 4: Lung cancer survival rates are low.

The 5 year lung cancer survival rate is very low. This depends on the type and the stage of the cancer, but even Stage 1 non-small cell cancer (arguably the best kind) has only a 50% five-year survival rate. According to the American Lung Association, the five year survival rate for lung cancer overall is about 17%.

This is not a disease that most people survive long-term. China’s puff daddies are looking like a very high mortality demographic.

Factor 5: Smoking is not really decreasing much in China.

The percentage of the Chinese population that smokes has been holding steady at about 24% – but the population itself is still growing. So the total number of Chinese smokers is still increasing overall. Although smoking by Chinese women is decreasing.

Additionally, the average number of cigarettes consumed daily per smoker has actually increased (according to JAMA). The average Chinese smoker consumed about 15 cigarettes a day in 1980. In 2012, it had risen to 22. So this is increasing as well.

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Overall, China’s puff daddies are the result of a unique combination of China factors. And unfortunately, in the next decade, we can probably expect to see a bow wave of lung cancer from this. China’s puff daddies, arguably the world’s biggest smokers, will be riding the top of this wave.

Thanks to Vijay Vaitheeswaran for suggesting the name puff daddies.

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I write and speak about “how rising Chinese consumers are disrupting global markets – with a special focus on digital China”.

Photo by Alan, Creative Commons license with link here.