Singapore

The Big Read: After raising legal smoking age, what next? Iceland may offer answer

The Big Read: A more holistic approach to curb smoking?
Published: 12:10 AM, March 18, 2017
Updated: 10:54 AM, March 19, 2017

SINGAPORE — Under his friends’ influence, he had his first puff when he was 15, and has been hooked since.

Much as Mr Haiqal Sari, 22, had tried to quit smoking several times over the last few years, he only saw himself lighting up more. He now smokes up to a pack a day — up from a few sticks when he first started — and burns a third of his allowance as a full-time national serviceman (NSF) on cigarettes.

He still hopes to wean himself off tobacco one day — as all smokers would, he says — and he knows that it is all about willpower. But he argues that the legislative measures in place, including bans and steep taxes, do little in helping him kick the habit.

Smoking bans are “not effective at all” without active enforcement, and habitual smokers willingly accept any hikes in cigarette prices, he said.

A fellow smoker, who wanted to remain anonymous, said that while bans on where he can smoke have inconvenienced him, they have not reduced the amount of cigarettes he smokes each day. “Unless there are personal or health reasons, I think it probably won’t stop a person entirely,” said the 28-year-old media practitioner, who 
 is also hoping to quit one day.

Earlier this month, the Ministry of Health (MOH) announced that the legal age for smoking will be raised from 18 to 21 — the latest in a series of legislative measures undertaken over the decades to bring down the smoking rate in Singapore and guard against the harmful effects of passive smoking.

The proposed laws will be tabled in Parliament within a year, and the change will be phased in over a few years. Given that many pick up the habit in their teens, smokers, non-smokers, experts and youth counsellors interviewed believe the move will be decisive, although some pointed out that it would not be in line with age restrictions on other vices, such as drinking. Still, they urged authorities to relook their efforts to get rid of smoking, including tailoring the message to youths for whom the unhealthy aspect of smoking is not an immediate concern.

“A lot of what we have now centres on ‘scare tactics’, and they are very top-down… some people don’t take too kindly to that, especially youths…The more you tell them not to do it, the more they want to try,” said the smoker who did not want to be named. Former smoker Chrystine Wong, 23, stressed the importance of pointing youths to “healthier coping mechanisms”, noting that many resort to smoking due to stress and peer pressure, among other things. She was motivated by the desire to improve her body image, and turned to exercise. Smoking usually points to “deeper issues” that need to be addressed. “And often, they are not tackled through legislation,” said Ms Wong.

While deterrence is key, more can also be done for those looking to quit smoking, given that it is a familiar refrain among smokers that they regret picking up the habit and want to stub it out.

Some smokers feel that the current approach stigmatises smoking and discourages smokers from seeking help. The focus should instead be on the attractiveness of a smoke-free lifestyle, they said.

Criminal lawyer Josephus Tan successfully quit smoking in January after 25 years. “I decided to quit because I thought I deserved something better… Without smoking, you have the possibility of doing much more,” he said.

As the experiences of some other countries, most notably Iceland, have shown, the final push to eradicate smoking here could require a more holistic approach - going beyond legislation and public education - as well as a frank national discussion where the voices of smokers can be heard, observers said.

TOWARDS A ‘SMOKE FREE’ NATION

Singapore has a declared aim to become a smoke-free nation. Its anti-smoking efforts date all the way back to 1970, when smoking was first prohibited in buses, cinemas and theatres. A year later, the Republic became the first country in the world to ban tobacco advertising.

Over the past dozen years, the list of places where smoking is outlawed has expanded quickly, as the authorities worktowards the long term goal - no timeline has been specified - of banning smoking in all public places, except designated areas.

Currently, smoking in banned in all indoor public spaces and most outdoor areas, except for beaches, open spaces and uncovered walkways.

In 2014, excise duties for tobacco were also increased by 10 per cent, with then-Finance Minister Tharman Shanmugaratnam noting that smoking prevalence was on the rise among those aged 18 to 29.

Now, of the S$12 charged for a pack of some brands of cigarettes sold here, for example, S$8.50 (71 per cent) goes to the Government as tax.

These efforts appear to have borne fruit: The smoking rate among those between 18 to 69 years old has fallen from 18.3 per cent in 1992 to around 13 per cent in 2014, but this decline has bottomed out in recent years. The prevalence of smoking among young men is still high, while the smoking rates of young women are creeping up.

In other Asian countries such as China, Malaysia, Japan and South Korea, the smoking rate ranges between 18 and 26 per cent, according to a 2015 World Health Organization report. The study also ranked Singapore among the “highest achieving countries” in tobacco dependence treatment, monitoring tobacco use and raising awareness of its harms, among other things.

Recognising that 95 per cent of the smokers here had their first puff before they reach 21, and almost half (45 per cent) became habitual smokers between 18 and 20 years old, the Government is looking towards more measures to deter youths from lighting up. For example, point-of-sale display of tobacco products will be banned from August.

The authorities are also taking steps towards standardising tobacco packaging, which has been implemented in countries such as Australia, France and the United Kingdom. Such countries have seen “significant value in (the move)... to reduce the appeal of tobacco products, particularly to youths, and raise the visibility and effectiveness of health warnings”, MOH said.

Despite the existing minimum legal age, MOH noted that two in three smokers below 18 obtain their cigarettes from friends and schoolmates. In the last five years, an average of about 4,500 underage smokers were caught annually. Underage smokers are referred to the Health Promotion Board (HPB) to help them quit smoking.

Since 2013, the National Environment Agency has stepped up its enforcement hours against littering and smoking by about 50 per cent to 35,000 man-hours per month. The number of tickets issued to individuals – including non-residents – caught smoking in prohibited areas is on the rise: 19,000 last year, compared to about 17,000 in 2015, and 4,800 in 2011.

SOCIETAL COST OF SMOKING

Tobacco is a leading cause of diseases and ill-health in Singapore: About six residents died prematurely from smoking-related diseases each day in 2015, MOH said.

Public health experts agree that smoking exerts an enormous cost on society. However, there is a lack of localised research on this topic, with the most recent study published in 2002 in the Singapore Medical Journal.

Led by economist Euston Quah from the Nanyang Technological University, the study estimated the social costs of smoking for Singapore in 1997 to be between S$673 million and S$839 million. These direct costs include the cost of hospital care for the main diseases related to smoking, as well as the amount spent on hospital, physician and nursing home care for current and former smokers.

The indirect cost of smoking, which takes into account the value of income lost, was estimated to be S$614m for a single year. However, the study acknowledged that its findings might underestimate the effects, given that data on physician visits and nursing home care were not available.

Dr Tan Khay Boon, senior lecturer at SIM Global Education, pointed out that indirect costs could be higher when taking into account fire hazards, litter caused by smoking, discomfort imposed on non-smokers and the cost of monitoring non-smoking zones.

On the global front, a study of 152 countries accounting for 97 per cent of the world’s smoking population found that the direct healthcare cost of diseases attributable to smoking in 2012 was US$422 billion – or 5.7 per cent of the world’s total health expenditure, said Professor Chia Kee Seng, dean of the Saw Swee Hock School of Public Health. The same study estimated economic losses due to sickness and death from diseases linked to smoking in 2012 at more than US$1 trillion.

Prof Chia also highlighted the adverse impact the tobacco industry poses to the natural environment, such as through high deposits of toxic substances from pesticides, growth regulators and chemical fertilisers, which deplete soil of nutrients and deforestation. Cigarette butts, which poison aquatic life, also form the largest bulk of waste collected along the world’s coasts,, he said.

The industry also exploits tobacco farmers in low-income nations. “Even though Singapore does not have tobacco cultivation, our demand for cigarettes directly contributes to these tobacco-related issues in the world,” he said.

But more than just a question of dollars and cents, several experts – including Prof Lee Hin Peng of the Saw Swee Hock School of Public Health – stressed the need to “de-normalise” smoking as a social habit, so that people no longer pick it up.

ALTERNATIVE TOBACCO PRODUCTS: A CONTENTIOUS DEBATE

Alternatives to cigarettes which are banned here — such as electronic cigarettes, e-pipes and heated tobacco products — remain a contentious topic that has divided policy watchers and smokers.

While supporters of these products argue that they offer a lower-risk substitute that can help people quit smoking, opponents — such as the Singapore Cancer Society (SCS) — back the health authorities’ position that studies have not conclusively established their usefulness.

Noting that such products are relatively new to the scene, SCS chief executive Albert Ching said: “E-cigarettes and alternative products are not a way to help smokers quit smoking because there has been little research on whether they are safe and effective.”

Prof Chia cautioned that they may serve as a “gateway” to smoking. “Youths who would not otherwise have smoked would try out ENDS (electronic nicotine delivery systems) and move on to regular cigarettes for the more intense nicotine experience,” he pointed out.

Agreeing, Prof Lee argued that “touted alternatives” are, in fact, equally hazardous. “We have to ‘de-normalise’ smoking. Smoking is not chic,” he said.

Behavioural economist Donald Low countered that if such alternatives are indeed safer, legalising them would allow “new, less harmful substitutes” into the market.

“When you try to get people to change their bad habits, replacement is more effective than elimination… This is why e-cigs and alternative tobacco products, which seek to mimic the experience of smoking, may be a promising strategy,” said Mr Low.

To the argument that vaping products may be a “gateway drug”, he said: “Based on the evidence out there, it is just as likely, if not even more so, that these products are a gateway out of smoking… Those (he added quote marks: ‘gains’) have to be stacked against the ‘losses’ of people who wouldn’t have otherwise picked up smoking using these alternative products”

Mr Low urged the Government to consider studies by international health authorities, citing as example the Royal College of Physicians in Britain, which found that e-cigarette users were made up almost entirely of existing and former smokers.

E-cigarettes are allowed but regulated in the UK, with a study by England’s public health authority finding it to be “around 95 per cent safer for users than (traditional) smoking”. Mr Low said: “We can’t control which scenario will materialise, (but) the right policy response when dealing with uncertainty is to go and find out more. And we keep our minds open, so that if it is shown to work elsewhere, we should produce those results here, rather than say ‘never’.”

Smokers whom TODAY spoke to, however, were skeptical about the alternatives. “They do not have the same effect as cigarettes. Most people use them for a while and end up going back to real cigarettes,” said Mr Haiqal.

‘HOLISTIC APPROACH NEEDED’

Singapore is not the only country that is determined to stamp out smoking. Philippines President Rodrigo Duterte, for example, is mulling over signing an executive order to ban smoking nationwide, while Canada recently unveiled plans to reduce its smoking rate from 13 per cent currently to less than 5 per cent by 2035, by prohibiting smoking in apartments and condominiums and raising the minimum legal age to 21.

In Europe, Iceland, which has drastically reduced teenage smoking, drinking and drug use, has been hailed as a model for other countries to emulate. Some observers here also see merits in the Icelandic way: Apart from restricting tabacco sales to youths, curfews were introduced and teenagers were offered classes in music, dance, hip hop, art or martial arts, for example. The idea was to provide “natural-high alternatives” through a variety of alterations in the youths’ brain chemistry, and provide them with better coping mechanisms. Between 1998 and last year, the percentage of 15- and 16-year-olds in Iceland smoking cigarettes every day fell from 23 per cent to just 3 per cent.

American psychology professor Harvey Milkman, who helped to develop the Icelandic model, told UK magazine Mosaic Science: “People can get addicted to drink, cars, money, sex, calories, cocaine – whatever... Why not orchestrate a social movement around natural highs: around people getting high on their own brain chemistry – because it seems obvious to me that people want to change their consciousness – without the deleterious effects of drugs?”

Social workers in Singapore felt the Government’s focus should shift radically towards understanding the root causes and motivations behind why youths turn to smoking.

For many at-risk youths, smoking is a coping mechanism or a manifestation of bigger, underlying problems that they grapple with, including relationship failure, rejection, exam stress and other family issues, said Ms Lena Teo, deputy director of therapy and mental wellness services at the Children-at-Risk Empowerment Association (Care Singapore).

Ms Iris Lin, head of youth services at Fei Yue Community Services, said that while laws would force young people to re-evaluate their choices, they would ultimately have little impact on youths who are already hooked on smoking from as young as 13.

Anti-smoking campaigns must go beyond the overt “scare tactics and statements”, which might not work on teenagers who feel like they “do not have much to lose,” said Ms Lin. Instead, use targeted messages to “speak their lingo”, such as telling boys that smoking can affect their stamina in sports, or pointing out to girls that smoking affects their image, she suggested. Tapping on their aspirations is another way. “We ask, ‘If you continue to smoke, is it stopping you from achieving your dreams?’ When you put such questions to them, it causes them to pause and think about a larger thing in life, rather than the instant pleasure they get from smoking,” said Ms Lin.

Ms Sheena Jebal, chief executive of NuLife Care and Counselling Services, said that when counselling youth smokers, she would focus her message on how smoking can affect boy-girl relationships, as well as “image, looks and hygiene” - things which are very important to teenagers.

Mass outreach programmes in schools may not capture students’ attention, said Mr Wilson Tan, executive Director of Youth Guidance Outreach Services (YGOS). He said: “The face-to-face personal touch is very important.. (someone) who is there to advise them, give them ideas of how to stand against negative pressure and say no to something which might cause them more trouble.”

Ms Gwen Ho, senior social worker from Students Care Service, stressed that role models and parental values are important, as adult figures play a significant role in shaping the youths’ perceptions of smoking.

MOH said it recognises that smoking is a “social issue that requires the effort of everyone in the community to tackle”. “Positive role modelling and positive social support from parents, family members and peers are also critical in encouraging our young to lead a tobacco-free and healthy lifestyle for the long term,” the ministry said.

HPB works with the Ministry of Education and institutes of higher learning to include anti-tobacco messages in the school curricula and co-curricular activities. For instance, under the Student Health Advisor (SHA) programme, 40 per cent of youth smokers who received counselling have cut down on smoking, while 16 per cent quit successfully after three months, said HPB.

Last year, the SCS also roped in more than 1,000 National Cadet Corps leaders and 700 Girl Guides as Smoke-Free Ambassadors in 30 secondary schools.

As for those who need help kicking the habit, HPB runs a cessation programme which has garnered strong interest from the public. Since 2014, 10,000 smokers have been signing up for the “I Quit 28-Day Countdown” each year - an increase of almost seven times since the inaugural edition in 2011. The cessation programme has a success rate of 10 per cent each year, HPB said.

For many smokers like Mr Haiqal, the hope is that their voices can be heard as the country seeks to bring down the smoking rate further. They want to be part of the solution - instead of being seen as the problem.

Mr Haiqal said he would like to see a “real” national discussion on smoking to find out the root causes and how to address them. “If you create a stigma... you make people more reluctant to talk about it,” he said.