Singapore should aim to be smoke-free, not just smoke-lite

Over the last 30 years, Singapore has rolled out a host of tobacco control measures. These include heavy taxation, control of tobacco sales and advertising, smoking prohibition in public places, smoking cessation services, point-of-sale display ban of tobacco products, and public education.

Singapore’s smoking prevalence fell dramatically from 20 per cent in 1984 to 13.3 per cent in 2013. However, the decline in the proportion of smokers had plateaued over the last 10 years, hovering around 23 to 24 per cent in males, and 3.5 to 4 per cent in females, and has not budged since.

This means that the proportion of new smokers has gone up to equal or “replace” that of those who have died from or quit the habit, suggesting more aggressive efforts are needed to stop people from picking up smoking.

Furthermore, smoking prevalence among youths age 18 to 29 has risen between 2004 and 2010, from 18.2 per cent to 25.3 per cent among males, and 6.6 per cent to 7.3 per cent among females.

Eighty per cent of smokers in Singapore are addicted before the age of 21. In a 2000 Health Promotion Board survey of secondary one to four students, about 11 per cent had smoked at least one day in the preceding month and about 25 per cent had tried smoking.

Early this week, a Bill to raise the minimum legal age for smoking from 18 to 21 years old was tabled in Parliament. This is a strategically correct move and underscores a recognition that more needs to be done to curb youth smoking initiation.

One is more likely to pick up smoking if there are smokers in his social circle. Raising the minimum legal age makes it harder for underage smokers to get cigarettes from their social network. It also contributes toward de-normalising smoking.

Raising the minimum legal age reduces youths’ exposure to cigarettes in a crucial time window. Adolescence is a period of greatest peer affiliation and susceptibility to peer influence. The parts of the brain associated with psychosocial maturity, future perspective taking, and managing sensation seeking and impulsivity, continue to develop until about age 25. The younger the adolescent is when he starts smoking, the higher the level of nicotine dependence and, the greater the intensity and persistence of his smoking habit.

Emerging tobacco products such as e-cigarettes and heat-not-burn cigarettes have become popular in other countries. These are no less harmful than cigarettes and the proposal to prohibit the possession of such products in Singapore is a right move.

Standardised packaging has been shown to decrease the appeal of tobacco products, enhance the effectiveness of graphic health warnings and reduce misperceptions about the relative harmlessness of cigarettes.

Australia, the first country to adopt the measure, has already experienced positive results. France, Ireland and the United Kingdom have also recently implemented standardised packaging and Singapore will do well to follow suit.

Yet government policies alone are insufficient to combat the tobacco scourge. The community plays a vital role in preventing youths from adopting the habit and helping smokers quit.

It begins with the family, where parents and older siblings model healthy behaviour and choices, including a smoke-free lifestyle. Those in the social circles of smokers can serve as support networks to encourage smoking cessation.

Two-thirds of Singaporeans work. Hence, the workplace is a key setting for reaching smokers and providing the supportive social environment conducive for quitting smoking. Employers can support smoke-free environments at workplaces. They can also participate in the HPB’s Come Together Quit Together programme to encourage non-smokers, as friends and supporters, to help smokers at their workplaces quit smoking.

DE-NORMALISING TOBACCO USE

Singapore aims to reduce its smoking prevalence further to 12 per cent by 2020. It is heartening to learn of the authorities’ efforts in adapting newer, improved strategies in tobacco control. But looking at Finland, which has set a deadline to bring the smoking rate to 2 per cent by 2040, and New Zealand, to less than 5 per cent by 2025, are the current and proposed measures sufficient to achieve Singapore’s desired goal? And have we underset the country’s smoking prevalence target for 2020?

Tobacco products, unlike other regulated consumer products such as alcohol, is deliberately designed to be addictive. There is no level of “safe” or “harmless’ consumption, and the harmful effects affect others, and not just the smokers themselves.

To eradicate the tobacco epidemic and create a smoke-free Singapore for future generations, perhaps we must consider the need to gravitate from prevailing discussions on tobacco control toward incorporating more innovative strategies, particularly those based on the “Tobacco Endgame” concept that has started gaining attention in academic literature in recent years.

“Endgame” solutions share a common focus on phasing out commercial tobacco products by placing significant restrictions on their use and availability.

The objective is to de-normalise tobacco use, rather than merely controlling the tobacco epidemic, and eventually completely phase out tobacco smoking.

The “Endgame” concept is still developing. Understandably, its discourse has been met with its share of scepticism and criticisms ranging from being extreme, to being ambiguous about its goals.

While not all “Endgame” strategies will apply to Singapore’s context, it is critical for us to start adopting a progressive vision and game-plan using the best of existing control, as well as bold and progressive “Endgame” strategies.

We should move toward the aim of being a smoke-free nation, not compromise and settle for a smoke-lite nation.

ABOUT THE AUTHOR:

Dr Chia Kee Seng is professor and dean of Saw Swee Hock School of Public Health, National University of Singapore.