Smoking is the world's No. 1 cause of avoidable death. The 2018 edition of Tobacco Atlas, a publication of the American Cancer Society and Vital Strategies, reports that tobacco use kills about seven million people each year and that this figure is expected to increase with a population that is growing and ageing.
In Singapore, more than 2,200 people die from tobacco-related diseases every year, making tobacco use one of the top risk factors for death and disability.
Singapore is known for tough tobacco-control measures, including comprehensive bans on advertising, promotion and sponsorship; high taxation; designation of smoke-free areas; measures to reduce illicit trade; and support for smoking cessation.
These measures were recently toughened with the prohibitions on the marketing, sale, use and possession of e-cigarettes and emerging tobacco products.
Current global policies on e-cigarettes range from outright prohibition in countries such as Brazil, Thailand, Turkey and United Arab Emirates, to largely unregulated market access in the United States. In between these extremes are places that allow prescription-based use (such as Canada, France, Japan and New Zealand), those that regulate the contents of e-cigarettes and their components (Britain, France, Germany, the Netherlands, the Philippines and Sweden) and those that regulate the marketing of nicotine-containing e-cigarettes and medical products (Canada, Japan, Mexico and New Zealand). While these policy approaches are diverse, there are important points of consensus.
First, e-cigarettes are many times less harmful than traditional cigarettes, at least in the short term. Second, children and youth have to be protected from e-cigarettes as much as from conventional cigarettes. Third, a regulatory framework on the safety and marketing of e-cigarettes needs to be put in place. Finally, the focus on comprehensive tobacco control must not be compromised, and e-cigarettes should not become a smokescreen that distracts policymakers from this broader goal.
The current ban runs the risk of keeping public health officials in the dark on the likely impact of these products on public health. Meanwhile, the risks of smuggling and illegal (and, therefore, unreported) use are not insignificant. In short, the current prohibition not only prevents Singapore from realising the potential public health benefits of e-cigarettes, but it also limits the ability of the authorities to manage their costs.
Given the above set of considerations, one can then examine what kind of policy response might be apt when it comes to dealing with e-cigarettes.
Here, it is worth noting that when dealing with vices or public "bads", Singapore usually takes a pragmatic view that embraces the strategy of reducing harm. For instance, with gambling, alcohol and commercial sex, risks to the public and to consumers are mitigated through a combination of legal and regulatory measures to promote less harmful alternatives.
But, in the case of e-cigarettes and emerging tobacco products, Singapore has adopted the extreme measure of prohibition.
Singapore has not only banned the sale and import of e-cigarettes and emerging tobacco products, but it has also criminalised the use and possession of these products. Cambodia, Nepal, Thailand, Vietnam and some states in Malaysia (Kedah, Johor, Negeri Sembilan and Kelantan) also ban the use and possession of e-cigarettes.
Singapore's measures are rather restrictive, especially if one considers that conventional cigarettes - the most harmful tobacco product which kills one in two of its users - can be legally and easily purchased.
Those who support a ban on smoking alternatives - even though they are less harmful than smoking - say that it is justified partly because their long-term effects are unknown. Also, the evidence on their effectiveness as tools to help people give up smoking is not conclusive. A larger concern is the potential for "gateway effects" - or the possibility that people experimenting with e-cigarettes and emerging tobacco products may take up smoking.
This is especially pertinent among youth-within this group, smoking has become more prevalent in recent years. There is also the fear that e-cigarettes would lead to a renormalisation of smoking in Singapore, reversing the significant progress made over the decades in making it less socially accepted and expected.
While it is clear that e-cigarettes introduce risks for certain populations, it is equally critical to consider that they bring potential benefits to many - especially smokers who want to quit and are not able to without the aid of less harmful alternatives.
Whether the costs of e-cigarettes for future users outweigh the benefits to current and would-be smokers switching to something less harmful, it is entirely an empirical question - not an ideological one. There is also no global consensus on whether, in practice, e-cigarettes crowd out or crowd in cigarette use.
Whether e-cigarettes result in a gateway effect, the size of that effect and its impact on youth, in particular, will depend on a number of factors, including individual preferences and social norms, relative pricing and the appeal of the products that are allowed into the market.
In the face of such uncertainty, the right policy response is surely not an outright ban. Rather, the uncertainty underlines the importance of establishing a regulatory framework that is appropriate to context and ensures that these lower harm products are targeted at, and marketed to, smokers.
Anticipating the likely public health impact to the population also requires more country-specific research. This is much harder to undertake as long as the complete prohibition on the use of lower harm products remains in place.
Indeed, the current ban runs the risk of keeping public health officials in the dark on the likely impact of these products on public health. Meanwhile, the risks of smuggling and illegal (and, therefore, unreported) use are not insignificant.
In short, the current prohibition not only prevents Singapore from realising the potential public health benefits of e-cigarettes, but it also limits the ability of the authorities to manage their costs.
Clearly, while there are trade-offs and risks, decisions still have to be made. Some independent and credible public health bodies, such as Public Health England, have found sufficient evidence of net benefits to justify promoting e-cigarettes to existing smokers. Others have concluded differently or have yet to make up their minds. It is important that, in the face of uncertainty, governments should keep an open mind and make policy only on the basis of evidence and cost-benefit calculations.
- Tikki Pang and Gayle Amul are visiting professor and research associate, respectively, at the Lee Kuan Yew School of Public Policy, National University of Singapore.