Tobacco-related deaths are a commercially propagated epidemic. Each year, smoking kills more than six million people, a tenth of them the innocent victims of second-hand smoke. This death toll persists despite a slew of tobacco control measures adopted by many countries worldwide, such as taxation, control of sales and advertising, smoking cessation services and public education.
Singapore has been very successful with relatively stricter measures such as restricting public smoking areas, a point-of-sale display ban, and banning shisha and e-cigarettes. The proportion of smokers among Singaporeans aged 18 and above decreased from 20 per cent in 1984 to 14.3 per cent in 2010, and per capita consumption of tobacco has decreased from 2.36kg to 0.77kg in just 30 years.
However, 25 per cent of our male population are still smokers. This does not compare well with other developed countries such as Canada (17 per cent), the United States (17 per cent), Australia (15 per cent) and Sweden (9 per cent). More worrying is that our young continue to pick up smoking. From 2010 to 2014, approximately 7,000 young people under the age of 18 were caught smoking. And in a study involving 13,000 below-18 youth, a quarter had already tried smoking.
It is no secret that tobacco companies deliberately target those aged 18 to 21 with aggressive marketing to promote a lifetime of dependence on highly addictive tobacco products.
Research shows that people who do not start smoking before age 21 are unlikely to ever begin, and the younger children are when they first start smoking, the more likely they are to become habitual smokers.
The current legal age for the purchase, possession and use of tobacco in Singapore is 18. This should be raised to 21 or even higher. There is evidence that brain development continues till 25 years of age, and the areas responsible for decision-making, impulse control, sensation seeking and future perspective taking continue to develop later on into adulthood. Some argue that an age restriction may backfire, making smoking an enticing "forbidden fruit" or a rite of passage to adulthood, and thus more desirable to youth. However, there is no sufficient evidence for this hypothesis. Indeed, places that raised age restrictions have witnessed a decline in smoking prevalence among their youth. Needham, Massachusetts, in the US reduced smoking among youth by 46 per cent after raising the minimum legal age from 16 to 21 years.
There is evidence that increasing the size of the graphic health warnings prevents youth smoking initiation, boosts motivation to quit, reduces smoking among adults and sustains smoking cessation.
To the uninitiated, tobacco smoking is unpalatable and aversive. In a bid to lure the young, tobacco companies add flavouring and advertise them as attractive products. To counter this, many countries have already banned or will be banning the sale of flavoured tobacco products, including menthol cigarettes. No doubt the tobacco industry will continue its never-ending efforts to circumvent such control measures with other types of ingredients. In the long run, all non-tobacco ingredients should be restricted, leaving tobacco manufacturers free to mix only different styles of tobacco leaves or stems.
Like for all consumer products, packaging plays a key role in marketing. Graphic health warnings on cigarette packs have successfully limited tobacco companies from using them for advertising and promotion. There is evidence that increasing the size of the graphic health warnings prevents youth smoking initiation, boosts motivation to quit, reduces smoking among adults and sustains smoking cessation. According to a 2016 international status report on cigarette-package health warnings by the Canadian Cancer Society, Nepal has the largest warning label, covering 90 per cent on both the front and back of the cigarette pack. This is followed by India and Thailand at 85 per cent. Most countries, like Singapore, are at 50 per cent. Expanding the size of graphic health warnings is a highly cost-effective control measure we should consider implementing.
Several countries, including Australia, France, Britain, Ireland and New Zealand, have gone a step further to augment enhanced graphic health warnings with standardised packaging. Also known as "plain packaging", this requirement removes all branding elements (colour, image, trademarks, logos and text) and allows only the brand name in a standardised font, size and location on the pack. This reduces the appeal of the pack and strengthens the impact of the graphic health warning. As expected, the tobacco industry fought vigorously against this. Philip Morris took out an international lawsuit against the Australian government and lost.
Many have disputed the success of plain packaging as a control measure. However, in tobacco control, it is key to recognise that no single element works in isolation to reduce smoking prevalence. Rather, it is the combined effect of multiple tobacco measures that will curb smoking habits and, more importantly, prevent the younger generation from ever picking up the habit.
Internationally, there is a movement to go beyond conventional tobacco control strategies and adopt new, bold and fundamentally different strategies that aim to eliminate smoking altogether. These are broadly classified as "endgame strategies". Perhaps Singapore should begin this journey towards eliminating smoking completely. We would not be the first country to endorse and adopt this approach. New Zealand, Finland, Canada, Sweden and France have all endorsed the goal of achieving a smoke-free society in the next eight to 23 years.
The World Health Organisation summed it all up when it stated, in its 2015 global report on trends in prevalence of tobacco smoking: "Tobacco is the only legal drug that kills its users when used exactly as intended by its manufacturers."
Let's all work together to end this scourge. There is no other option.
Dr Chia Kee Seng is professor and dean at the Saw Swee Hock School of Public Health, National University of Singapore, and Dr Kenneth Warner is Avedis Donabedian Distinguished University Professor of Public Health at the Michigan School of Public Health, University of Michigan.