Studies have found links between density of tobacco sellers and teens picking up the habit
Singapore's latest move to deter youths from taking their first puff is to raise the minimum legal age for smoking from 18 to 21, a measure to be phased in over a few years.
The Government can go further by doing what recent research suggests could be effective, especially in targeting the young: Restrict the number of sales points for cigarettes.
Now, cigarettes are sold at many types of shops and in every neighbourhood. Smokers can take their pick from more than 4,700 tobacco retail outlets, ranging from petrol stations to supermarkets, convenience stores, kopitiams, mom-and-pop shops, and even some money changers. That is about 40 times the number of McDonald's restaurants islandwide.
There is currently no cap on the number of such outlets - it is time to consider one.
DOUBTS OVER COHORT, TOTAL BAN
Singapore's multi-faceted strategy to tackle smoking includes lowering tar and nicotine limits in 2013, banning misleading terms on cigarette packs like "mild" or "light", and introducing graphic warnings. In 2014, tobacco taxes went up by 10 per cent, the following year e-cigarettes were banned. Last year, restrictions on public smoking were extended to reservoirs and over 400 parks, on top of those at coffee shops, entertainment nightspots, covered walkways and multi-storey carparks.
As for public education and cessation efforts, the Health Promotion Board in 2011 started I Quit, a national anti-smoking movement. Smokers who pledge to quit are given support. Among the 10,000 smokers who signed up for I Quit every year since 2014, 10 per cent managed to quit.
Smoking among adults fell from 18.3 per cent in 1992 to 13.3 per cent in 2013 but the rate has since stagnated at that level. Also, smokers are starting younger. The average age at which they first lit up was 16 years old in 2013, down from 17 in 2001. Professor Chia Kee Seng, dean of the Saw Swee Hock School of Public Health, warned that "the younger a person is when he starts smoking, the higher the level of nicotine dependence, and the greater the intensity and persistence of his habit".
A movement called "Tobacco Free Generation" was started in 2010, backed by doctors. It proposes to outlaw smoking for everyone born after 2000. But it is unclear if that would work. Senior Minister of State for Health Amy Khor told Parliament last year that there were "significant practical difficulties and risks in implementing and enforcing such a ban", which would be "easy to circumvent".
Tasmania drafted legislation in 2014 to ban tobacco sales to anyone born after 2000 but that is up against roadblocks in Parliament. The island state's health minister questioned how the ban would be enforced and whether people could be treated differently, based on age.
Another option is a total ban. Bhutan, the only country to have tried it, banned the cultivation, manufacture, distribution and sale of tobacco in 2004. But a nationwide survey found that tobacco use among Bhutanese students aged 13 to 15 shot up, from 18.8 per cent in 2006 to 30.3 per cent in 2013.
RELOOK THE RETAIL SCENE
A new frontier in tobacco control has emerged recently and it is to limit "tobacco retailer density". The premise is that the concentration and proximity of tobacco shops in a given area affects one's likelihood of lighting up. Therefore, restricting their number and locations, such as near homes and schools, could reduce smoking prevalence. It mainly targets youth smoking.
Studies between 2004 and 2014 overseas found that tobacco retailer density and proximity correlates to adolescent lifetime smoking. The density of tobacco sellers has also been linked to experimental smoking among teenagers.
A 2011 study in Canada of more than 36,000 secondary school students found that the number of tobacco retailers around a school was linked to higher chances of male students who never smoked being susceptible to the habit in the future. A similar observation was made in Scotland. A study published in 2014 said teenagers who lived in areas of highest density of retailers had about 50 per cent higher odds of having tried smoking before, as well as of being current smokers.
The impact also extends to adults, who are found to be more likely to puff if they live in neighbourhoods with higher concentrations of convenience stores that sell cigarettes. This finding stems from a United States study of 82 neighbourhoods published in 2005, which also reported that the distance between a person's home and the nearest tobacco retail outlet matters.
In the US, three states - Hawaii, Indiana and Utah - had crafted laws requiring a minimum distance between retailers and places that youth frequent. Six states had planned or proposed to cap the number of tobacco sellers in a specific area, said a policy report published in June last year.
This suggestion has its limits, of course. Professor Augustine Tee of Changi General Hospital said proximity to tobacco outlets may not impact die-hard addicts, who will find ways to get their fix. But the inaccessibility may help some smokers stub out for good, said the senior consultant respiratory physician.
Limiting the number of tobacco shops will also send a broader message on social norms regarding smoking. Retailer restriction can be done in several ways. Licensing is one obvious avenue. The good thing is that Singapore already has a framework for issuing licences to tobacco sellers. The next step would be to adjust the parameters to, for example, cap the number of retailers by geographical area - at most 20 retail outlets per neighbourhood - or by population size, such as by having one tobacco shop per 5,000 residents.
Another policy solution proposed by CounterTobacco.org is to have a minimum distance between shops, and to bar tobacco sellers from being near schools and playgrounds.
Toa Payoh, with a resident population of about 123,000, has at least 160 tobacco shops. A larger estate like Tampines, which has some 259,000 residents, has at least 220. The figures are derived from official data of tobacco retailers' locations as of June last year, which are available online, by grouping them into postal sectors.
While there is no magic number to work towards, reducing these retail points by a third, or even half, will still leave each neighbourhood with a reasonable number of places to buy tobacco from.
A NOT-FOR-PROFIT MODEL
Yet a bolder overhaul of the retail scene should not be ruled out further down the road.
The way alcohol sales are managed in Nordic nations like Sweden and Iceland shows that the retail set-up can influence habits. In Sweden, one cannot find beer and wine at grocery or convenience stores. A government-owned chain called Systembolaget is the only retailer that sells beverages with more than 3.5 per cent alcohol by volume. Its website states: "Systembolaget exists for one reason - to minimise alcohol-related problems by selling alcohol in a responsible way, without a profit motive."
These alcohol shops close at 6pm on weekdays, 1pm on Saturdays and are shut on Sundays. Buyers have to be above 20, and underage kids cannot be in the vicinity of the shop. Those lingering outside may get questioned by the authorities.
In Iceland, only government-run stores called Vinbudin sell alcohol, and most close at 6pm.
Alcohol consumption rates in Sweden, although high in the past, have declined markedly, as have Iceland's.
A not-for-profit system for tobacco products could be another way to keep smokers in check here.
Such retail-targeted moves could, compared to an all-out ban or raising tobacco taxes, mitigate the problem of cheap contraband cigarettes being driven deeper underground. A primary motivation that pushes smokers to deal in smuggled cigarettes is price. In Singapore, a pack of legal cigarettes sells for an average of $13, but contraband ones can cost as little as $6.
A 2006 public health study in Taiwan reported that every NT$1 (S$0.05) increase in the price of legal cigarettes raised the probability of smokers - who previously did not use smuggled cigarettes - switching to contraband by 26.1 per cent.
With the number of tobacco shops in Singapore now at a record low - last year's figures are the lowest since licensing was introduced in 1998 - it is timely to take a deeper review of the retail environment.
Shrinking the pool of tobacco outlets, coupled with the raising of smoking legal age and the upcoming product display ban in August, can work in tandem to deliver a knockout punch to youth smoking.
Other initiatives, including public education, should be beefed up too, with the ultimate aim of resetting social norms on this age-old habit.
Tobacco should not only be put out of sight, but also out of reach and out of favour among the young.
A version of this article appeared in the print edition of The Straits Times on April 20, 2017, with the headline 'Curb tobacco access to fight youth smoking'. Print Edition | Subscribe
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