SINGAPORE: Singapore ratcheted up the heat against tobacco in 2018, to the delight of many in the country.
With a slew of measures making it harder for one to light up or start smoking, Singapore appears to be systematically de-normalising tobacco use as a habit, and painting it as a socially unacceptable and undesirable activity.
THE TIDE TURNS
A series of moves undertaken in 2018 have turned the tide as the nation made huge strides in its campaign against tobacco.
Apart from hiking up excise taxes on all tobacco products in February 2018 to make smoking more financially costly, the Smoking Act was amended to make it more difficult to smoke in public spaces.
The passed amendments additionally bans smoking in reservoirs and parks, compounds of autonomous universities and private education institutions, and more recently, public areas within the Orchard Road precinct, with the latter to be implemented come Jan 1, 2019.
Authorities also moved swiftly to make smoking less pleasurable and accessible.
A proposed enhancement to the Tobacco Act that mandates graphic health warning labels on tobacco product packaging was announced last October. Authorities intend to slap on mandatory standardised packaging on all tobacco products with enlarged graphic health warning labels.
Changes to the same Act had earlier banned point-of-sale display of tobacco products in August 2017, which strengthened Singapore’s comprehensive ban on tobacco advertisements, promotion and sponsorship implemented since 1971.
A ban on the possession, purchase and use of imitation and alternative tobacco products kicked in in February 2018. This comes on top of earlier legislation prohibiting the import and sale of imitation tobacco products such as electronic nicotine delivery systems.
Most significantly, the minimum legal age for the purchase of tobacco products will be progressively raised from 18 to 21, over 2019 to 2021.
A CLEAR, CONSISTENT MESSAGE
The suite of tobacco control measures sends a clear, consistent simple message: Smoking harms. After all, tobacco use remains the leading cause of preventable death worldwide.
If this is the case, why is the introduction of any new measure often met with criticisms that it is ineffective or politically motivated? Singapore is also not the only country to have introduced a range of aggressive measures to tackle smoking.
The World Health Organisation (WHO) in 2017 published a guideline on the “best buy” interventions for the prevention and control of non-communicable diseases such as diabetes, cardiovascular diseases and cancer. A “best buy” is a policy action that has been evaluated to be cost-effective and ought to be implemented.
These “best buys” include increasing excise taxes and prices of tobacco products; eliminating exposure to second-hand tobacco smoke in indoor workplaces, public places, public transport; and the implementation of plain or standardised packaging and large graphic health warnings on all tobacco packages.
They also involve the enactment and enforcement of comprehensive bans on tobacco advertising, promotion and sponsorship, and the use of mass media campaigns that educate the public about the harms of smoking, tobacco use and second-hand smoke.
Sounds familiar? Singapore’s stance against tobacco is very much aligned to international recommendations and best practices.
TARGETING THREE GROUPS
These measures, as well as those implemented in Singapore, are meant to work as a package to target different segments in the population, specifically, non-smokers, smokers who aim to kick the habit, and smokers who presently have no intention to quit.
Anti-tobacco policies that are relevant to non-smokers, including standardised packaging and the raising of the minimum legal age, are aimed at discouraging experimentation and initiation, and minimising harm from second-hand and third-hand smoke.
One can even argue that the entire suite of tobacco control measures seeks to uncompromisingly de-normalise the image of smoking, to deter smoking initiation.
For smokers aiming to kick the habit, point-of-sale display bans and comprehensive prohibitions on advertising also minimise visual triggers to nicotine addiction, in addition to eliminating the promotion of tobacco.
The smoking ban in public areas creates additional barriers to one seeking to light up, which can be a much-needed psychological disincentive to this group of smokers.
Any criticism levelled at the futility of these measures on smokers with no intention to quit is misguided, as they were never formulated with the primary intention of targeting this group in the first place.
No doubt this group now faces huge inconveniences as a result of new measures, but the majority of these policies are to prevent people from joining, as well as to facilitate exiting, this group of smokers.
CURBS ON SMOKING CAN STILL BE BOOSTED
There certainly is a lot more we can do to drive down the smoking rate in Singapore.
First, we can consider a ban on all flavoured cigarettes, including those with menthol. The cooling effect from menthol additives masks the harshness from cigarette smoke, thereby decreasing irritation and actually makes smoking initiation more likely, especially among adolescent youths.
Numerous governments worldwide, including the United States and the European Parliament, have either seriously considered or have made firm commitments to outlaw flavoured cigarettes.
The Canadian province of Ontario banned menthol cigarettes in 2017 and early data suggests this has influenced smokers to kick the smoking habit. In a study of 1,000 smokers in Ontario, 1 in ten said they would quit smoking, but 4 in 10 attempted to quit smoking after the ban was implemented.
A public consultation on banning the sale of menthol and other flavoured cigarettes was conducted in December 2015. Perhaps it is timely to review and consider this move seriously.
One other concept previously discussed is the establishment of a smoke-free generation. Presently, the minimum legal age to smoke has been raised year-on-year from 18 to 21 from 2019 to 2021.
If this is allowed to proceed indefinitely, there will come a point in time when smoking in Singapore is no longer legally allowed, effectively outlawing smoking altogether while recognising and respecting the choices faced by existing smokers.
This strategy is easy to pen down in a commentary but operationally challenging to implement and enforce when the minimum legal age is a rolling number and in managing the social supply of cigarettes from older friends, relatives or even foreigners. The authorities and public will have to be open-minded enough to endure decades of enforcement chaos to achieve a longer-term vision.
A compromise is to continue the increase of the minimum legal age until 25. After all, there is a wealth of scientific evidence to suggest that smoking initiation rates drops considerably at that age.
RAISE THE PRICE OF CIGARETTES
A less harsh lever is the appropriate use of aggressive taxation to drive up the price and decrease the affordability of tobacco products, as was recommended as a WHO “best buy”.
After all, the retail price for a pack of 20 cigarettes in Singapore is the highest in Asia, but still below countries such as Australia, New Zealand, Norway, and the United Kingdom, countries with the lowest smoking prevalence, according to a WHO benchmark survey performed in 2016.
Raising the price of tobacco products reduces smoking initiation among adolescents and youths, and exerts a strong, tangible disincentive for existing smokers to continue the habit. Even for the persistent smoker, price increases can have the effect of reducing consumption.
Opponents to policies such as banning specific tobacco products, aggressive taxation, or the enactment of a tobacco-free society have been quick to state that these measures drive up smuggling and illicit trade on contraband cigarettes. No doubt stiff penalties for buyers, sellers, and importers of contraband cigarettes are needed as strong deterrents.
But let us be clear, cigarette smuggling exists in almost every country worldwide regardless of the tax levied, given the opportunity for high profits.
THE STEADY ANNIHILATION OF SMOKING
Will we be able to deter all cigarette trafficking activities even with the harshest penalties? We know the answer from looking at drug trafficking in Singapore.
The Government of Singapore possesses an international reputation for setting policies with long-term objectives in mind that do not pander to populist sentiments.
This is best reflected in our tobacco control policies, with the adoption of evidence-based approaches that stride gradually but steadily towards the annihilation of smoking as an acceptable social practice.
Dr Teo Yik Ying is dean of the Saw Swee Hock School of Public Health at the National University of Singapore.