How did it all come to this? That is the typical response of anti-tobacco campaigners, when asked about their crusade to rid Hong Kong of a highly addictive but legal product that has been linked time and again to everything from obesity and diabetes to stroke and cancer. Anthony Hedley, chair professor of community medicine at the University of Hong Kong, has been campaigning for tougher anti-smoking laws since he arrived here 21 years ago. He believes that 'we are losing an enormous amount of ground'. 'From a public health point of view, it's very serious,' he said. 'Hong Kong is beginning to stand out among economically developed nations as a place which is losing progress in terms of the gains which it made in advocacy and legislation, and it will eventually lose ground in terms of health protection.' Such concerns are not without foundation. Research by the university has estimated that 7,000 Hongkongers die from active or passive smoking each year. The total cost to the community, taking into account pain, suffering and lives lost, is put in excess of HK$70 billion per year. Smoking is considered one of the biggest health concerns in developed countries, right up there with high blood pressure, alcohol misuse and high cholesterol. However, despite the tireless efforts of people such as Professor Hedley and a strong community of tobacco-control activists and public health officials, there is a growing consensus that the city is losing its war against cigarette consumption. This may not be readily apparent to the average man or woman. According to figures from the Department of Health's Tobacco Control Office, the percentage of Hongkongers who smoked daily has fallen from 14.9 per cent in 1993 to 11.8 per cent in 2007-08. A cursory glance down a typical Hong Kong street may lead many to believe that fewer people are lighting up, compared with a decade ago. That is thanks, in part, to the smoking ban implemented in 2007 at all indoor public places that succeeded in ridding the city's restaurants of cigarette smoke. Hong Kong is also one of fewer than 20 countries or regions around the world where all cigarette packets feature graphic warning labels that convey on an emotive level the dangers of smoking. Finally, the passing of a sweeping set of legislative amendments to the city's smoking laws in 2006 generated substantial media interest. Yet, despite these measures, the anti-smoking lobby remains frustrated. Activists centre on how the city, once considered a trailblazer in the field of tobacco control, has been surpassed by more progressive jurisdictions. Consider that, in the late 1990s, Hong Kong was seen as a model of tobacco-control policies following the passage in 1997 of sweeping reforms that virtually eliminated all but the smallest forms of tobacco advertising in the city. At the time, such a ban was not even in place in Britain, of which Hong Kong was still a part. Fast forward a decade, and the situation is reversed. Four years after New York banned smoking from all enclosed workspaces, the so-called ban on smoking in 'all' indoor public venues, implemented with much pomp and circumstance, was rife with extensions - for bars, bathhouses and mahjong parlours. Critics belittle the ban, and say it is continuing to fail in one of its chief aims: to protect catering and hospitality workers from second-hand smoke. Against this backdrop, the reality - despite what some may perceive - is that the consumption of tobacco has risen steadily over the years. Latest Customs and Excise Department figures show that 3.79 billion cigarettes were sold last year, compared with 3.33 billion in 2006. In 2007, 3.49 billion cigarettes were consumed. 'Up until 1997, we were, arguably, the second best in Asia after Singapore, but after that, all the way up to 2007, we did almost absolutely nothing during that period,' said Judith Mackay, a senior policy adviser to the World Health Organisation. 'We did have legislation that went through and came into effect in 2007 which brought us a little bit more up to speed, but then we had all these ridiculous extensions,' she added, referring to the grace periods given to some businesses and the delaying of a ban on point of sale cigarette advertising until later this year. 'Both of those had extensions in the law and it made it less than perfect.' But where Hong Kong really fell behind was in its failure to increase tobacco duty, despite the fact that it wais widely considered to be the best measure to cut consumption, she said. Before yesterday's 50 per cent rise, the last time the government put up the duty was in 2001. In the 1990s, some of the highest tobacco tax increases were recorded. Year after year, anti-smoking lobbyists called on the government to raise the tobacco duty, only to have their pleas ignored. Most recently, the publicly funded Council on Smoking and Health (Cosh) sent a petition, with around 4,000 signatures from people around the world, to Financial Secretary John Tsang Chun-wah urging him to raise the tobacco duty. Hong Kong is bound, under the WHO Framework Convention on Tobacco Control - a global anti-smoking treaty which has been signed by Beijing - to implement tax or price measures. Dr Mackay noted that even the mainland, the largest producer and consumer of cigarettes in the world, is considering using taxation to curb consumption. She said that Hong Kong had been 'shockingly, critically and embarrassingly backwards' on raising the duty. 'It's really shameful.' Aside from the bold step of a tobacco duty increase, Dr Mackay said that it was also important that the extensions, which will expire in June, be ended without further delay. Furthermore, the government needed to hold out against putting smoking rooms in bars in Hong Kong, which had already spent HK$2.5 million of taxpayers' money to study, she said. While there has been some debate over the plan's merits, putting a ventilated smoking room in every bar in Hong Kong was simply too expensive, and it would still fail to protect the health of the people who work at these places, Dr Mackay said. 'Somebody's got to clean it, work in it, so it's still not without risk.' Finally, Hong Kong should consider plain packaging for cigarette packets, which would be a world first, and set prevalence targets, a measure not uncommon in other jurisdictions. Dr Mackay challenged the government to reduce smoking prevalence to 11 per cent for daily smokers by the end of 2010. A spokesman for the Food and Health Bureau said the government agreed that taxation was one of the many effective measures to reduce smoking. He said the financial secretary considered all factors before making a decision. And he was adamant that the administration would make no exemptions in its planned implementation of the amendments to anti-smoking laws passed in 2006, including its plans to end the grace periods for bars and other places under the indoor smoking ban, and to eliminate point of sale advertising for cigarettes. However, he said the government was still continuing its study on smoking rooms. No decision had yet been made, he said, and the government would report to the Legislative Council when it was ready. At a conference on managing tobacco dependence, held by the Tobacco Control Office in Hong Kong last week, Secretary for Food and Health York Chow Yat-ngok acknowledged that, while Hong Kong had made progress in fighting smoking, more needed to be done. He made the comments shortly after the government unveiled an extension to its community-based smoking cessation programme, to include after-office hours and weekends. Meanwhile, there have also been calls for the government to commit more resources to fighting smoking. James Middleton, the anti-tobacco committee chairman for lobby group Clear the Air, believes that the current resources allocated by the government to fight smoking are inadequate. In the 2008-09 fiscal year, the government budgeted HK$47 million for the Tobacco Control Office to carry out its duties. The office employs 124 people, including 85 tobacco-control inspectors, to carry out enforcement, seven police officers, and various medical and clerical professionals. Meanwhile, each year, Cosh receives a dwindling subvention that stood at HK$11.3 million in the previous budget, down from HK$14.8 million in 2005-2006. 'The Tobacco Control Office has  inspectors to cover the whole of Hong Kong on two shifts. It's totally inadequate. How can you do that?' Mr Middleton said.