IN FOCUS: Singapore wants fewer people to smoke. How can it make this happen?
In 1986, the Government launched the National Smoking Control Programme with the theme, Towards a Nation of Non-Smokers. More than three decades and many anti-smoking measures later, the goal remains to convince fewer people to light up.
SINGAPORE: About a year ago, Mr Muhammad Adli Jumat, 27, tried quitting smoking for the third time.
His previous attempts had involved switching tobacco flavours, then gradually cutting down on the number of cigarettes he smoked each day. The initial weeks progressed well, but after a few months, he lost motivation and relapsed.
This time, the marketing executive decided to go cold turkey. He also kept himself more occupied by working harder and going to the gym, with the goal of getting fit for the holidays.
But about three to four months in, he started smoking again as his go-to for dealing with stress.
"There were stupid people at work, and I have no willpower to entertain all of those," he told CNA. "People can be super motivated like every new year, but three months in it's gone."
Mr Adli, who smokes five to six sticks a day, said it would help if authorities gave more incentives to quit, like grocery vouchers or health insurance premium discounts.
"Outreach programs to adult smokers are a lost cause," he said. "By the time these people reach their 20s, it's too late for any real behavioural change."
Nevertheless, Singapore's anti-smoking measures have seen some success.
From as early as the 1970s, the Government has introduced measures to promote a smoke-free lifestyle in Singapore, the National Environment Agency (NEA) told CNA.
"In the early days of Singapore’s independence, smoking was allowed indoors but it was not long before the Smoking (Prohibition in Certain Places) Act was introduced in October 1970 to prohibit smoking in omnibuses, cinemas and theatres," a spokesperson said.
The country's smoking rate has shrunk from 18.3 per cent in 1992 to 10.6 per cent in 2019, through a combination of legislative and public education efforts.
Authorities have regulated tobacco advertising and conducted multiple anti-smoking campaigns, mindful of its allure with the young.
They have also raised the minimum legal age, made tobacco products more expensive with higher taxes, and prohibited smoking in even more places.
"The inaugural ban in 1970 has since been progressively extended to many other public places," NEA said, noting that smoking is now prohibited in more than 32,000 places, including sheltered walkways and common residential areas.
"NEA has been gradually expanding the list of smoking prohibited places covered under the Act in consultation with the public and relevant stakeholders."
READ: Nearly 700 fines issued for smoking in prohibited areas in a month since start of circuit breaker: NEA
Still, the Government wants to reduce the smoking rate even further, to below 10 per cent of the population by this year.
Then-Senior Parliamentary Secretary for Health Amrin Amin called this goal "ambitious", after announcing it in 2018. According to the Health Promotion Board (HPB), Singapore's smoking rate is already one of the lowest in the world.
To further bring down the rate, a range of options could be considered, according to experts and stakeholders that CNA spoke to.
For instance, a public health expert said the Government could consider offering better protection from secondhand smoke, further increasing the tobacco tax and regulating tobacco flavours.
And Member of Parliament (MP) Louis Ng, who heads the Government Parliamentary Committee for Sustainability and the Environment, said authorities could also give more subsidies for quitting programmes, and roll out campaigns that focus on the benefits of quitting rather than the harms of smoking.
CURBING SECONDHAND SMOKE
The issue was thrust further into the spotlight when Mr Ng, who is MP for Nee Soon GRC, raised a motion in Parliament on Oct 5, calling for a ban on smoking near windows or balconies at home to reduce exposure to secondhand smoke.
It was a controversial suggestion that generated debate, with comments on social media showing non-smokers generally supported such a move.
READ: Secondhand smoke a 'public health concern', says Louis Ng, proposing ban on smoking near home balconies, windows
"The debate is important so that both sides can share their views and their voices are heard," Mr Ng told CNA, calling the reaction to his suggestions "positive".
"We are tackling hard to bring down the smoking rate because we know it’s bad," he added. "On the other end of the spectrum, we really need to protect those who are not smoking but could then suffer the same harmful effects. And it’s a lot of people."
A public health expert from the National University of Singapore (NUS) told CNA that roughly 300 people in Singapore die from secondhand smoke exposure each year.
Dr Yvette van der Eijk of the Saw Swee Hock School of Public Health said tackling secondhand smoke in outdoor areas like hawker centres and residential estates is one way of further reducing the smoking rate.
“Although Singapore has comprehensive smoking bans covering most indoor areas, people are not protected from secondhand smoke in many outdoor areas," she said.
"In some other countries, smoking is regulated in outdoor areas and housing units where people are often crowded together.
"This is an issue that needs to be addressed in Singapore, especially given the high population density and high volume of complaints related to secondhand smoke."
NEA said the Smoking (Prohibition in Certain Places) Act is one strategy used to protect non-smokers from secondhand smoke.
"In identifying the places where smoking should be prohibited, NEA adopts a pragmatic approach and takes into consideration whether the public places are air-conditioned or enclosed, or are places frequented by families and vulnerable groups," the spokesperson said.
"For example, NEA has stopped accepting applications for new smoking corners at food establishments islandwide since Jun 30, 2017."
Homemaker Ms Carole Ogawa, who lives on the seventh floor of an HDB block in Queenstown, said she closes the seven windows in her living room every day to stop cigarette smoke from wafting in.
The 31-year-old said her neighbour downstairs would smoke near the window once in the early morning and once more in the evening, every weekday. The frequency goes up during the weekends.
“Sometimes we have to shut the window during mealtimes when we are right by it, and the house becomes stuffy,” she said. “Sometimes when I open my toilet door, it smells like someone was squatting inside smoking.”
READ: Commentary: Smoking near windows dismissed as neighbourly nuisance but has public health costs
Ms Ogawa said she has visited her neighbour to request that he only smokes at the kitchen window at a fixed time each day, so she has fewer windows to close and knows when to do it.
“The minute his door opened, it was just a strong smoke smell,” she said of the visit, adding that the neighbour was “indifferent” to what she said. “We tried to negotiate, but he didn’t keep to it.”
Ms Ogawa, who has three children aged four, two and one-and-a-half, said this episode has left her “super frustrated”.
“It’s not just the smell, but the worry that it may cause health problems to my very young children,” she said, adding that she has tried getting help from her MP to no avail.
“COVID made everything worse, the children had no school and had to be kept indoors, and my guess is the neighbour had to work from home because his frequency of smoking increased.
“The most we can do to protect ourselves is shut the windows, but it makes us resent the neighbour for being so selfish.”
TO BAN OR NOT TO BAN
Mr Ng had suggested that NEA enforce the partial ban in homes using surveillance cameras, similar to how it detects high-rise littering.
But Senior Minister of State for Sustainability and the Environment Amy Khor had warned that such methods could be “highly intrusive”, although Mr Ng noted that the cameras could be calibrated to maintain privacy.
READ: NEA asks Bedok resident to assist in investigations after thermal camera captures smoker outside unit
The smoker Mr Adli said he was against such a ban, pointing out that it represented yet another stick in a heavily skewed carrot and stick approach.
“It would blur the line even more on privacy,” he said. “It might just end up making people point fingers at each other.”
Another smoker, Mr Mohamed Khaidzir, said he understood the need for such legislation. However, the aircraft lead technician said it might open a can of worms, noting that the burning of incense could be considered in the same category.
“Everyone has their fair share of air pollutants,” said the 29-year-old, who smokes an average of six sticks a day but never at home.
However, a fellow smoker who only wanted to be known as Tom said the ban would be “good”.
“I feel like you can do whatever you want at home, but when you affect other people, it’s a no go,” said the 28-year-old content writer, who smokes three sticks each day.
NEA said it has adopted a balanced and pragmatic approach, by working with relevant agencies and stakeholders to encourage smokers to be considerate to their neighbours and smoke away from the windows.
It is also aware that some local grassroots members are trying out different methods to address secondhand smoke in their areas.
For example in Nee Soon South, members have set up designated smoking points and put up advisories at smoking hotspots to remind smokers to be considerate, given the effects of secondhand smoke on vulnerable groups.
But NUS’ Dr van der Eijk said encouraging smokers to be considerate is unlikely to be enough, noting that people have a right to breathe smoke-free air, especially in their own homes.
“Back in the 1990s, when countries considered full smoking bans in public places, the tobacco lobby fought hard and invented the concept of 'mutual accommodation' – the idea that, instead of regulation, non-smokers and smokers should just try to cooperate on the matter,” she added.
“This did not work and a lot of people were still exposed to secondhand smoke. It was not until the smoking bans were implemented and properly enforced that people were finally protected from secondhand smoke.”
NEA acknowledged there have been calls from the community to ban smoking at windows or balconies in homes.
"While there have been suggestions for enforcement against smoking acts at home, there are technological and privacy limitations to gathering evidence required to prove such smoking acts," the spokesperson reiterated.
"The current technology does not allow us to enforce against smoking acts at home without expanding inordinate expenses and infringing privacy of ordinary people in their homes.
"Implementing stronger, more draconian measures could come across as being overly intrusive, as the home is ultimately a private space."
Rather than an outright ban, NEA said it works together with agencies like the Housing and Development Board, HPB and relevant Town Councils to reach out to smokers in homes.
Officers hand out advisories to remind smokers to be considerate to their neighbours, as well as helplines to help them quit smoking, the spokesperson said.
"To complement these existing efforts, we are also continuing to improve the process for resolving community disputes, as well as to step up public education efforts," the spokesperson added.
RAISING TOBACCO TAXES
Beyond that, Dr van der Eijk said Singapore could further reduce its smoking rate by adopting a "more comprehensive stance" on tobacco taxes, which she said are currently low compared to other developed countries.
For instance in Australia, a pack of cigarettes could cost more than S$30, compared to less than S$20 in Singapore.
Studies have shown that increasing tobacco taxes and the price of tobacco products is the single most consistently effective tool for reducing tobacco use.
In 2018, the Singapore Government raised the excise duty for all tobacco products by 10 per cent to discourage consumption. This followed another 10 per cent increase four years earlier.
One smoker, who only gave his name as James, said he would consider quitting more seriously if the price of a cigarette pack hits S$20.
“That would deter me from indulging in it so frequently,” said the 28-year-old airline analyst, who smokes three to five sticks a day.
Mr Khaidzir said even the slightest of price hikes would make him reconsider his habit. “The old-timers will find the cheapest sources, down to the cent,” he added.
While the MP Mr Ng is a proponent of the partial smoking ban in homes, he acknowledged that authorities could try a more incentive-based approach to reducing the smoking rate.
"We have been using the stick approach, how about we try the carrot?" Mr Ng said, suggesting setting aside more funding to subsidise cessation programmes.
"When I speak to many smokers, they try to quit, but they just can’t. After a while, they pick up the habit again. If we can help people to quit using a more carrot approach, I think that might have a longer-term result."
READ: Vaccination and smoking cessation subsidies among task force’s recommendations for healthier Singapore
This seems to be an approach which is being looked at. In March, the Government announced that eligible smokers enrolled in new smoking cessation pilot programmes could get full subsidies for nicotine replacement therapy to help them quit.
These would take place in public healthcare institutions like hospitals, polyclinics and national specialty centres after they resume normal operations pending the COVID-19 situation.
Mr Ng also suggested "more positive" campaigns that highlight the benefits of quitting smoking, possibly told through real-life stories.
The HPB's recent campaign, a video series launched in 2018 titled I Should Have Said, featured ex-smokers sharing regrets about their habit. One of them, after getting throat surgery, struggles to speak to his family during a visit in hospital.
"Being a smoker for 17 years, we are all aware of the harmful effects. So, (health warnings on cigarette packaging) don't work because we already know it," Mr Ng said.
"That’s why we should try the carrot approach for those who are really trying to quit, so we can help more. And that might then bring the smoking rate down to below 10 per cent."
Ms Ogawa, the resident affected by secondhand smoke, said anti-smoking campaigns should also encourage families to find hobbies and spend quality time together, especially as many parents work long hours.
“Because of that, parents have less time to spend with their kids, or less ‘me time’ to unwind,” she said, concerned that she still sees students in uniform smoking on the rooftop of an adjacent car park.
“Often, teenagers are left on their own and find bad company. I feel that smoking is a very social thing that many people find to connect.”
According to the Ministry of Health, smoking prevalence among students in secondary schools, the Institute of Technical Education and polytechnics decreased from 8 per cent in the period from 2011 to 2013, to 4 per cent in the period from 2014 to 2016.
In 2017, the average age of those who started smoking daily was 18 years.
The smoking minimum legal age will be raised to 21 years from the start of next year. Authorities have also banned the point-of-sale display of tobacco products, which must now come in standardised packaging.
READ: Mandatory standardised packaging, bigger graphic health warnings on all tobacco products from Jul 1
To further deter youth smoking, NUS’ Dr van der Eijk said authorities should consider regulating tobacco flavours, especially menthol.
Over half of the cigarettes sold in Singapore are flavoured with menthol, she said, making Singapore's menthol cigarette market share one of the largest in the world.
"Tobacco companies use menthol-flavoured cigarettes to target youth, and the menthol makes cigarettes more addictive," she added.
"Although Canada, the European Union and other countries have banned tobacco flavours, there is currently no regulation on tobacco flavours in Singapore."
Still, Dr van der Eijk said there are challenges to implementing smoke-free legislation, mainly resistance from the tobacco lobby.
They often work through third parties like hospitality associations, retailers and advocacy groups, and typically “spread a lot of misinformation” to build resistance to smoking bans, she said.
For instance, the US-ASEAN Business Council had “strongly lobbied” against plain tobacco packaging in Singapore, arguing that it “would violate Singapore’s obligations to protect intellectual property rights” and “serve as unnecessary obstacles to trade”.
Tobacco giant Philip Morris International, whose Singapore arm made up almost half of the country’s tobacco market share in 2017, actively participates in the US-ASEAN Business Council.
Philip Morris had also opposed the tobacco retail display ban on grounds that it “imposes unnecessary impediments to the operation of the legitimate tobacco market”.
These examples were included in a 2018 research paper on tobacco control in Singapore, which was published in the journal Asia & the Pacific Policy Studies. It was co-authored by Ms Gianna Gayle Amul, who was a research associate at NUS’ Lee Kuan Yew School of Public Policy.
Furthermore, Singapore’s global role as a tobacco distribution hub presents a “key challenge” for tobacco control, the paper said.
According to data from market research firm Euromonitor, Singapore's cigarette exports have increased from 21 billion sticks in 2002 to 27 billion sticks in 2016.
“Despite having some of the toughest tobacco control measures in place, the operations of transnational tobacco companies based in Singapore create economic, mainly trade, complexities for tobacco control not only in Singapore but also for the region,” the paper said.
In response to queries from CNA, Philip Morris Singapore said that it supported "evidence-based, pragmatic policies" that prevent people from picking up smoking and encourage current smokers to quit.
"Phasing out flavoured cigarettes is possible only when smokers have a less harmful alternative to switch to," said Mr Jeremy Rabani, head of external affairs at Philip Morris Singapore.
While Mr Rabani suggested e-cigarettes as an alternative, Singapore has banned the purchase, use and possession of these devices since 2017. Officials have said they contain nicotine and cancer-causing chemicals, and produce vapour that could cause respiratory diseases.
Despite the challenges, the tobacco control research paper said Singapore can bank on strong policies and strict enforcement to consider moving towards a “tobacco endgame”, including an eventual total ban of cigarettes for individuals born in or after the year 2000.
This is detailed in a separate 2010 research paper on phasing out tobacco, which argued that a fixed minimum age ban is likely to have “limited success” due to difficulties in enforcement and the range of cigarette sources available to youths.
The paper, published in the medical journal BMJ, was co-authored by Dr Deborah Khoo, who was at the Department of Surgical Oncology in the National Cancer Centre Singapore.
“Ultimately, this proposal will lead to the phasing out of tobacco provision, without the short-term disruption that makes a sudden ban impracticable,” the paper said, adding that more than 70 per cent of respondents in a survey supported the proposal.
“It is a simple, at-a-stroke initiative that removes the risk of being hostage to future changes in political or economic climate.”
READ: 'Not intended to be a magic bullet': Health professionals weigh in on proposed changes to tobacco packaging
On a policy level, the tobacco control research paper said Singapore can further reduce its smoking rate target to 5 per cent by 2035, closer to its long‐term goal of being a “nation of non‐smokers”.
This is similar to targets set by a handful of developed countries, including Canada (by 2035), New Zealand (by 2025) and Finland, which set the target lower at less than 2 per cent by 2040.
“Notably, these countries have similar or higher smoking prevalence rates than Singapore, which makes the push for Singapore to adopt a similar tobacco endgame target not only possible but also desirable,” the paper said.
NO MAGIC BULLET
Nevertheless, Dr van der Eijk said bringing down the smoking rate requires a multi-faceted response that includes addressing youth smoking, helping smokers quit, protecting against secondhand smoke, and dealing with the tobacco lobby.
“As such, there is no magic bullet and authorities need to adopt a range of comprehensive measures that, together, will bring down smoking rates over time,” she added.
Even if there was a magic bullet, the MP Mr Ng believes it would not be a blanket ban on smoking.
“We’re all adults now,” he said. “As 21-year-olds, you have the right to choose whether you want to smoke. Those rights should be preserved, but again it cannot affect others.”
NEA said it is mindful that there are smokers who may have been smoking for years, and inevitably find it tough to quit smoking overnight.
"Whether a smoker is smoking in a public place that is non-prohibited, or at home, we urge both smokers and the wider community to practise social graciousness and good neighbourliness," the spokesperson said.
NEA said everyone has a part to play in upholding high standards of public health and maintaining a liveable environment in Singapore.
"We urge the community to take ownership and collective responsibility for our environment and cultivate positive social norms among fellow residents," the spokesperson added.
"For example, if you see someone smoking in a prohibited place, step forward and remind him or her to observe the laws and be considerate."
Ultimately, Tom the smoker feels any decision about his habit would come from within. “I feel like this is a personal choice, not based on any Government policy whatsoever,” he said. “If I quit, it’s for my own reasons.”
Editor's note: This article was updated on Nov 30 to add comments from Philip Morris.