Background China is the world's largest consumer of tobacco and has a large smoking-related chronic disease burden. In this nationwide study, we aimed to evaluate smoking prevalence and its implication on chronic diseases in the Chinese population. Methods We collected data from serial cross-sectional National Health Service Surveys done in China in 2003, 2008, and 2013. These surveys cover all 31 provinces, autonomous regions, and municipalities in mainland China, and use multistage stratified cluster sampling. We divided mainland China into east, central, and west regions and then sampled counties from each region stratified by urban and rural areas. All respondents aged 15 years or older in the selected households were eligible. We analysed the variation in smoking prevalence from 2003 to 2013, further identified risk factors for smoking, and assessed the association between smoking and chronic diseases by using multiple logistic regression. Findings The number of individuals interviewed and involved in the study was 153 450 in 2003, 145 223 in 2008, and 229 676 in 2013. The standardised smoking prevalence in China was consistently high, with a proportion of current smokers of 26.0% (95% CI 25.8-26.2) in 2003, 24.9% (24.8-25.1) in 2008, and 25.2% (25.1-25.4) in 2013 (p value for trend 0.5062). For men, prevalence was 48.4% (48.1-48.7) in 2003, 47.0% (46.6-47.4) in 2008, and 47.2% (46.9-47.5) in 2013. For women, prevalence was 3.1% (3.0-3.2) in 2003, 2.3% (2.2-2.5) in 2008, and 2.7% (2.6-2.8) in 2013. Smoking prevalence varied in different regions, and we identified four major patterns. While a consistently high proportion of Chinese men smoked, the standardised smoking prevalence in women younger than 40 years increased from 1.0% in 2003 to 1.6% in 2013. Moreover, the smoking prevalence among adolescent smokers aged 15-24 years increased from 8.3% in 2003 to 12.5% in 2013. Alcohol consumption was closely linked to smoking in adolescents (odds ratio 7.5, 95% CI 6.9-8.1). Risk factors for adolescent smoking were having older family members who smoke (1.9, 1.8-1.9) and low level education (1.3, 1.2-1.4). Increased risks of chronic diseases were related to smoking (1.1, 1.0-1.1), with higher risks related to early smoking initiation (1.1, 1.0-1.1) and long-term smoking (1.2, 1.2-1.3). Interpretation The implementation of tobacco control policies in China since the signing of the WHO Framework Convention on Tobacco Control in 2003 has not been effective in reducing smoking prevalence. Smoking prevalence among adolescents of both genders has increased substantially and there has been a steady increase among young women. More practical and effective policies targeting adolescents and women are urgently needed. Action is needed to prevent the large and growing smoking-related chronic disease burden further increasing as China's population ages. Copyright (c) 2018 Elsevier Ltd. All rights reserved.