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 After decades of decline, the prevalence of smoking in China has held steady in recent years. Coupled with population growth, this means there are now more smokers in China than ever, according to a new study on global smoking prevalence published this month in the Journal of the American Medical Association. 
 
 China gained almost 100 million smokers between 1980 and 2012, despite an overall decrease in smoking prevalence in the same period from 30.4 percent to 24.2 percent. But prevalence has plateaued, remaining nearly unchanged since 2006. Prevalence is defined as the percentage of the population that smokes every day, adjusted for age. 
 
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 Using a wide range of sources, including in-country surveys, government statistics and World Health Organization data, researchers also found that China had the highest number of smokers in the world in 2012 with 281 million, about one-third of the world’s smoking population. A report late last year by the state-run broadcaster CCTV put the number of smokers in China around 350 million. 
 
 The study, titled “Smoking Prevalence and Cigarette Consumption in 187 Countries, 1980-2012,” was conducted by researchers at the Seattle-based Institute for Health Metrics and Evaluation. The paper is among the first to produce a comprehensive global time series on smoking prevalence. 
 
 The findings are significant, said Judith Mackay, senior adviser to the World Lung Foundation, because they highlight the “absolute need for China to awake and really grasp the political nettle of tobacco control.” 
 
 “The study shows that the tobacco epidemic is going to be a whole lot worse before it gets better, particularly in lower income countries,” Dr. Mackay said in a telephone interview. “If they do nothing at all there are going to be massive costs for China in terms of premature deaths, health care costs, environmental costs, economic costs, family costs — there are all manners of costs.” 
 
 Substantial population growth and unchanging smoking prevalence in populous countries such as China, Bangladesh and Indonesia help explain why since 2006 the global decline in daily tobacco smoking has decelerated. 
 
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 The leveling off of smoking prevalence in China and globally can also be attributed in part to varying degrees of addictiveness. 
 
 “Change in tobacco prevalence typically has been slow, underscoring what a hard habit it is to break,” said Emmanuela Gakidou, professor of global health and director of education and training at the Institute for Health Metrics and Evaluation, in a news release. 
 
 The average number of cigarettes consumed daily per smoker in China has increased as well. According to the study, whereas the average smoker consumed about 15 cigarettes a day in 1980, by 2012 that number had risen to 22. 
 
 By contrast, four countries — Canada, Iceland, Mexico and Norway — reduced their smoking prevalence by more than half in the same period. Globally, the average number of cigarettes consumed per smoker per day declined from about 18 to about 17 in 2012. 
 
 The increase in number of smokers in China has taken place in spite of a number of measures enacted by the government in recent years to restrict smoking, which researchers say is among the leading risk factors for death in China. 
 
 These efforts have included a ban on smoking in restaurants and other public places as well as a directive issued in December urging Communist Party officials to quit altogether. But with no penalty for noncompliance, these measures are rarely enforced. 
 
 But while the overall number of smokers in China has increased, the skewed gender ratio of China’s smoking population has only become more pronounced. Only about 4 percent of smokers in China in 2012 were female, down from about 8 percent in 1980. That greater independence and improved economic conditions have not led to an increase in smoking among Chinese women — and Asian women more generally — is “puzzling,” said Dr. Mackay of the World Lung Foundation, considering that these factors have been associated with a rise in smoking among women in the West. 
 
 “It’s been surprising,” said Dr. Mackay. “But we are very thankful for that surprise.” ||||| Story highlights China moves to ban public indoor smoking by end of 2014 
 
 Half of Chinese men smoke, according to survey 
 
 China is largest consumer and producer of tobacco 
 
 China, the world's largest tobacco consumer, is aiming to ban indoor smoking in public areas by the end of the year. 
 
 About one in three cigarettes smoked in the world is in China, according to the World Health Organization. And more than half of Chinese men smoke, according to the Global Adult Tobacco Survey in 2010. 
 
 Although the nation's health ministry issued guidelines in 2011 to ban smoking in places like hotels and restaurants, they haven't been "strictly enforced," according to Xinhua, China's state-run news agency. 
 
 The China's National Health and Family Commission is now working on a tobacco control law with clear punishments, according to Xinhua. 
 
 The country's health authorities estimate over a million deaths from tobacco-related diseases every year. The WHO warns that if tobacco use is not decreased in China, these deaths will increase to 3 million by 2050. 
 
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 Last month, Chinese government officials were told not to smoke in public places such as hospitals, public transport or schools to set a good example for the public. 
 
 The latest moves by the Chinese government on tobacco are "hopeful," said Dr. Judith Mackay, the senior adviser at the World Lung Foundation, who examines tobacco issues in China. 
 
 About 32 Chinese cities have passed their own rules to restrict public smoking, she added. 
 
 "China stands on its own in the magnitude of the problem," said Mackay. "Unless there is change in China, we won't proceed further in reducing the tobacco epidemic in the world." 
 
 Tobacco use in China has far-reaching consequences, she said. 
 
 "This isn't a health problem. It's a huge economic problem. There's all these things ranging from medical and health care costs, the costs to the families and there's the cost of secondhand smoke."
– The world's biggest cigarette consumer is taking steps to stamp out smoking in indoor public spaces—and unlike earlier anti-smoking measures in China, officials say this one will be strictly enforced with clear penalties put in place, CNN reports. A third of all smoking worldwide takes place in the country, and "unless there is change in China, we won't proceed further in reducing the tobacco epidemic in the world," a senior adviser at the World Lung Foundation says. Smoking rates in China have dipped a little over the last few decades, but population growth means there are now more smokers in the country than even before, the New York Times finds. The average number of cigarettes smoked daily per smoker has actually risen since 1980, from 15 to 22. Unlike in other countries, however, greater independence has not caused an increase in smoking among Chinese women: Only around 4% of the country's smokers are female, down from 8% in 1980.