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Singapore’s calibrated approach to e-cigarettes and raising legal age for smoking

The recent Parliamentary debate regarding the smoking Bill raised two interesting issues. First, why is Singapore opting to progressively roll out the minimum legal 21-year age limit for smoking over the next three years instead of immediate implementation?

Singapore’s calibrated approach to e-cigarettes and raising legal age for smoking

there can be a place for e-cigarettes as a nicotine replacement therapy for smoking cessation and be made available only to confirmed smokers, provided there is rigorous evidence from randomised controlled trials on the effectiveness and safety, says the author. Photo: Reuters

The recent Parliamentary debate regarding the smoking Bill raised two interesting issues. First, why is Singapore opting to progressively roll out the minimum legal 21-year age limit for smoking over the next three years instead of immediate implementation?

Next, should we consider offering electronic nicotine delivery systems options, such as e-cigarettes, as cessation aids to current smokers?

There is clear, documented evidence for raising the minimum legal age above 18. Research has shown that parts of the brain responsible for decision making, impulse control, sensation seeking, future perspective taking, and peer susceptibility continue to develop through young adulthood.

The younger the youths when they first try smoking, the greater the levels of nicotine addiction, intensity of smoking and likelihood of continuing to smoke into adulthood.

The young may be more susceptible than adults to the harmful effects of tobacco smoke, as their internal organs and tissue are still maturing during childhood and adolescence.

The Institute of Medicine compared estimates of decreased smoking prevalence in the US, which may have resulted from raising the minimum legal age to 19, 21 and 25.

The estimates showed that raising it to 19 might reduce smoking prevalence by about 3 per cent from 2015 to 2100, whereas an increase to 21 or 25 might drive prevalence down to 11-12 per cent in the same period.

In particular, they also found that the gradual increase of the legal age did not significantly change the long-term effect of the measure on smoking prevalence.

A staggered roll-out of the minimum legal age gives our target group, the 18-20 year old smokers, sufficient time to quit the addiction.

Data from the Ontario Tobacco Survey, drawn from observation of 1,277 smokers over three years, found that it could take between six and 30 quit attempts before success.

The ease and time it takes to quit smoking can vary widely among individuals. Many factors influence how easily or quickly one can quit smoking, including:

• physiology (e.g. level of nicotine dependence);

• behaviour (e.g. slip-ups);

• environment (e.g. smoke-free home or workplace);

• psycho-emotional (e.g. anxiety, depression);

• cognitive (e.g. motivation, knowledge about related harms);

• access to cessation assistance; and

• social context that can make quitting a lower priority (e.g. social norms).

The 18-20 year olds who smoke today are legally allowed to do so. Removing that permission with the force of law may be perceived as harsh and unsympathetic.

The perception of such "deprivation" might ironically drive them to intensify their habit in response. Progressively raising the minimum legal age may help mitigate this potential unintended consequence.

Also raised in Parliament: The benefits of allowing smokers controlled access to e-cigarettes as part of cessation programmes.

In 2016, the US Surgeon General published a report highlighting the worrying trend of increasing e-cigarettes use amongst young adults 18-24 years of age, and provided a distinct recommendation of preventing access to e-cigarettes by youths.

The report clearly outlined that, as with regular cigarettes, e-cigarettes contain nicotine that can lead to addiction, and risk harming brain development in youths.

And just like regular cigarettes, the use of e-cigarettes unnecessarily exposes the users to volatile chemical compounds, and we simply do not know enough at this point in time about the long-term health impact from aerosolising these compounds.

More worryingly, evidence from the United Kingdom, US and Canada this year suggests a possible "gateway effect" of e-cigarettes, where one invariably moves on to regular cigarette use after developing a nicotine addiction through e-cigarettes.

Previously, a small number of studies have dismissed the gateway effect, but what makes the 2017 studies more compelling is that these studies involved a larger number of adolescents, and for a longer period of time.

For example, one of these studies is a systematic review of more than 17,000 youths led by Samir Soneji from the Dartmouth Institute for Health Policy and Clinical Practice. It reported that e-cigarette users were 3.6 times more likely to move on to initiate regular cigarette use, which is a tremendous gateway effect.

There is evidence to suggest that e-cigarettes cause less harm to health with less potential for addiction than regular cigarettes.

As such, there can be a place for e-cigarettes as a nicotine replacement therapy for smoking cessation and be made available only to confirmed smokers, provided there is rigorous evidence from randomised controlled trials on effectiveness and safety.

In fact, the Ministry of Health takes a nuanced position on this issue, that e-cigarettes are no different to nicotine patches, gums and inhalers, and can qualify to be registered as a therapeutic product by the Health Sciences Authority under the Health Products Act, and therefore be exempted from the ban under the Tobacco Control Act.

But this can only happen when the evidence for e-cigarettes as an effective nicotine replacement therapy tool is clear and reproducible.

It is never easy or straightforward to formulate public policies targeting problems of addiction. Thoughtful calibrations are imperative to avoid unintended consequences, especially where risks of developing or driving irresponsible behaviour exist.

What is clear from the parliamentary discussion, though, is the unified vision towards reducing the harm caused by smoking. Perhaps we should be asking whether Singapore has the ultimate vision of becoming a smoke-free country like Bhutan or Finland, and what steps should we take to achieve this?

Raising the minimum legal age progressively is a good start, but why stop there? Imagine a Singapore with a "Millennium Effect", where anyone born after year 2000 will never need to face the risk of addiction to tobacco products, that is, if we continue to raise the minimum legal age every year over the next few decades.

While we are at that, we have to ensure that products such as e-cigarettes should never be made available to non-smokers, and to never cease in our efforts to encourage and enable current smokers to quit the habit completely.

ABOUT THE AUTHOR:

Professor Teo Yik Ying is Dean-designate, NUS Saw Swee Hock School of Public Health.

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