The queues outside the Tianjin Medical University Cancer Institute and Hospital begin to form as early as 4am – come much later, and you risk not getting face time with a doctor.

China's public hospitals may ostensibly work on an appointment and referral system, but in practice, the crush of people means it's generally first come, first serve. Many at the front of the queue each morning are "number hawkers", opportunists who sell their spot in line for a fee.

"In big hospitals, clinics are as crowded as vegetable markets in the morning," says Wang Changli, the hospital's head of lung cancer, and one of the country's top lung cancer experts. Wang's day is an endless procession of ward checks, examinations and lung cancer operations – at least five or six a day just to keep the waiting list from spiralling out of control. He sees so many patients he never remembers their names – but says he can tell each patient apart from their chest X-ray.

Wang's team of surgeons operate on more than 2000 patients a year, but has to turn away thousands more who are inoperable, having discovered their illness too late.

"There is no solution and there is no end," he says. "Lung cancer is the leading form of cancer [in China], there are too many people, high mortality rates, and endless treatment. After all these years … you can't help but feel dispirited at times."

For all the alarming reports that China's toxic air pollution levels are contributing to a spike in cancer rates, most incidences of lung cancer are still far and away attributable to smoking; and like with most statistics associated with China, the numbers are staggering.

China is home to more than 350 million smokers – about one-third of the world's total. More than 1 million die of tobacco-related disease each year – about one every 30 seconds. That number is expected to double by 2025. The economic burden of tobacco-related illness has run into the tens of billions of dollars.

China's biggest obstacle in fighting its tobacco addiction has traditionally been itself. The all-powerful tobacco monopoly is government-owned, and turned over 600 billion yuan (more than $100 billion) in revenue to the state, according to a 2012 Brookings Institution report. Li Keming, the brother of Premier Li Keqiang, is a senior administrator at the State Tobacco Monopoly Administration.

"The tobacco lobby, or the tobacco industry, is the government. It's like turning up to the cabinet table in Australia to debate tobacco control policy and having Phillip Morris sitting on the other side," says Dr Angela Pratt, who saw Australia's unprecedented plain-packaging laws introduced while serving a five-year stint as then health minister Nicola Roxon's chief of staff.

She is now leading the World Health Organisation's Tobacco Free Initiative in Beijing.

China ratified the WHO's framework convention on tobacco control in 2005, which meant it should have banned smoking in indoor public areas completely by 2011. But existing laws are loophole-ridden, often poorly enforced, and inconsistent from city to city.

But China's 12th five-year plan, endorsed by the National People's Congress in March 2011, has an ambitious goal of improving the average life expectancy for the Chinese population by one year within the next five years. For the first time, tobacco control – particularly the banning of smoking in indoor areas – was highlighted.

A directive from President Xi Jinping last year has seen officials banned from being seen smoking in public, and prohibited from giving tobacco as gifts. Xi's glamorous wife, singer Peng Liyuan, is also an official anti-smoking ambassador.

"There has been a change in attitude at the most senior levels of the Chinese government," Pratt says.

The push is now on for an unprecedented nationwide ban on smoking in indoor public areas, to be considered by the State Council next year.

A similar law in Beijing set to take effect next year is expected to provide momentum for the nationwide ban, and provide a crucial test as to whether smoke-free laws can be effectively enforced in a country where smoking culture is entrenched, especially among men and in rural areas.

While smoking prevalence is higher in a number of eastern European countries including Estonia and Russia, China stands out for its skew in gender. More than 53 per cent of Chinese men smoke, compared to about 2 per cent of women.

Smoking in China, like other parts of Asia, is still associated with "masculinity" and retains significant social currency, often passed on as gifts including for weddings and birthdays.

And critics of China's tobacco controls say only raising the price of cigarettes, through increased taxes, can effectively curb smoking rates, particularly in rural areas where a pack of cigarettes can sell for less than $1.

But many Chinese like Tian Jinpu are forced to give up smoking the hard way. Tian, whose two-pack-a-day habit has finally caught up with him after 40 years, was due for urgent surgery, having discovered a malignant tumour in his lungs, fortuitously caught during a health check just days earlier.

"I never thought I would have such a disease. I knew the dangers of smoking for a long time, but it was hard to give up and I didn't want to," Tian, 57, says from his hospital room in Tianjin. "My family also didn't dare ask me to give up."