The emergence of “harm-reduction” products raises questions about the government’s moral responsibility to allow instead of banning them
The Singapore government has a goal of reducing the country’s smoking rate to “below 10 per cent by 2020”. It is a laudable target but it has run into problems – the smoking rate has not budged for the last 10 years, and it has imposed a blanket ban on all electronic nicotine delivery system products.
Singapore’s smoking rate has stubbornly remained at between 13 and 14 per cent.
1984 – 19.0 per cent
1992 – 18.3 per cent
2004 – 12.6 per cent
2007 – 13.6 per cent
2010 – 14.3 per cent
2013 – 13.3 per cent
2016 – About 14.0 per cent
In the last 32 years, the smoking rate has decreased by about only 5 per cent. And to make things worse, smokers may be picking up the habit at a younger age too.
The Straits Times said in April, “The average age at which they first lit up was 16 years old in 2013, down from 17 in 2001.” (Straits Times, 20 April 2017.)
With just 21/2 years for the government to achieve its 2020 goal, it seems unlikely that it will succeed, given the situation.
It is therefore reasonable to ask: is there a better way to discourage smoking? And does Singapore have a moral obligation, for health reasons, to consider or allow alternative electronic nicotine delivery systems (ENDs) for existing smokers?
Singapore’s campaign against smoking is extensive. This include initiatives such as I Quit, the National Tobacco Control programme, and smoking cessation touchpoints where smokers can get help to quit. These will be increased from 150 in 2014 to 600 by 2020.
The government has tightened the regulatory regime over the years, including the increase in tobacco taxes, restricting smoking in public places, and a ban on tobacco advertising.
The smoking age will be raised from 18 to 21 in the next few years; and the ban on electronic nicotine delivery systems (ENDS) and vaporisers will also be extended to include the purchase, use and possession of these. Presently, only the importation, distribution, sale and offer of sale of these products are illegal.
This leads us to the question: should we not allow new products which may be less harmful to current smokers, and which may even help them quit smoking altogether, without becoming a gateway for never-smokers to pick up the habit?
In the last few years, what are described as “harm-reduction”, or “less-risk”, products such as electronic cigarettes and heated cigarettes, have come onto the market in some countries.
Briefly, e-cigarettes are battery-operated, electronic devices that heat a nicotine-laced liquid and emit it as a vapour. This liquid contains no tobacco and is thus not burned.
Heated, or heat-not-burn, cigarettes are tobacco sticks inserted into an electronic holder which heats up the cigarette without burning it.
In both, smokers inhale a vapour or aerosol instead of smoke, hence the term “vaping”, used to describe this new way of smoking.
Both kinds of products seek to reduce the amount of harmful chemicals which arise from tobacco combustion, ie tobacco smoke. It is the smoke from cigarette being burned that when inhaled is lethal.
Do note that these new products are not touted as harm-free, but less-harm, or less-risk. Nicotine, after all, is a poison and addictive, and is harmful to the adolescent brain, for example, and to pregnant women and others.
But according to several studies, the harm from these new products pales in comparison to that from traditional or burned cigarettes.
The World Health Organisation (WHO), in a 2016 report, said that ENDs does not help smokers quit smoking. It also recommended that countries should ban nicotine delivery devices from all public places where smoking is not allowed.
Although it said that e-cigarettes are “likely to be less toxic than conventional cigarettes”, the WHO recommended that regulations be put in place to address health concerns. (See here.)
Its report, however, has been criticised by experts in the industry.
Singapore welcomed the WHO report, and said that “ENDS, including e-cigarettes, that claim to be smoking cessation products to help smokers quit tobacco use should demonstrate their safety and effectiveness with the same level of scientific rigour required for approved Nicotine-Replacement Therapies under the Medicines Act.” (See here.)
The US Surgeon General also cautioned that “although e-cigarettes generally emit fewer toxicants than combustible tobacco products, we know that aerosol from e-cigarettes is not harmless.”
Other countries, such as the United Kingdom, however, take a slightly different view.
“Although it is not possible to estimate the long-term health risks associated with e-cigarettes precisely, the available data suggest that they are unlikely to exceed 5 per cent of those associated with smoked tobacco products, and may well be substantially lower than this figure.”
And on its website, the RCP says:
“It shows that, for all the potential risks involved, harm reduction has huge potential to prevent death and disability from tobacco use, and to hasten our progress to a tobacco-free society.”
It recommends that “in the interests of public health it is important to promote the use of e-cigarettes, NRT [nicotine replacement therapy] and other non-tobacco nicotine products as widely as possible as a substitute for smoking in the UK.”
“Our review of the evidence found e-cigarette use carries a fraction of the risk of smoking, a conclusion reiterated by the Royal College of Physicians earlier this year,” said Kevin Fenton, national director of health and wellbeing at PHE, in September last year.
“No new evidence has been published to contradict this,” Fenton said.
Tobacco companies’ position
Tobacco companies have also recognised that harm-reduction is the way to go.
Andre Calantzopoulos, CEO of Philip Morris International (PMI), the world’s largest international tobacco company, has said PMI’s long term aim is to move away from tobacco products.
“I believe there will come a moment in time where I would say we have sufficient adoption of these alternative products … to start envisaging, together with governments, a phase-out period for cigarettes… I hope this time will come soon,” he said earlier this year.
“We certainly see a future where Philip Morris no longer will be selling cigarettes in the market,” Martin Inkster, managing director of Philip Morris UK and Ireland, told Reuters last year.
Traditional tobacco companies have been spending huge amount of money on developing new ENDs products.
PMI, for example, invested US$3 billion in coming up with IQOS, its brand name for its heated cigarettes. The company says the vapor produced has less than 10 per cent of the amount of harmful chemicals found in normal cigarette smoke.
Other companies like Japan Tobacco International, Reynolds American and British American Tobacco, are also testing and developing their own less-risk products.
Caution, of course, is always advised.
Despite the claims by the tobacco companies, and research results such as those from the UK, the bottomline is that there is no universal agreement that less-risk products are what they claim to be.
“If smokers switch to electronic cigarettes or other products that can be shown to cut the risks to their health, this could lead to a big improvement in public health,” said Deborah Arnott, chief executive of Action on Smoking and Health (ASH), a UK-based health charity. “But we need independent evidence to support any claims made by the tobacco industry.”
A moral responsibility to consider benefits of less-risk products?
In Singapore, despite the ongoing debate, the fundamental questions are:
Should the government ban something which could in fact benefit existing or current smokers? Do not our health authorities have a moral responsibility and obligation to make available alternatives, or at the very least, be open to the possibility or potential that these new products can be beneficial to existing smokers?
According to the government’s Healthhub website, “about 7 Singaporeans die prematurely from smoking–related diseases each day.”
That’s 2,555 Singaporeans a year.
“Smoking–related diseases… are the nation’s top killers,” the website says.
The health risks of smoking are a long list, as you can see from the National Registry of Diseases Office.
Yet, smoking is the most preventable cause of death globally.
The most desirable thing for anyone to do, especially the young, is not to pick up smoking at all or to quit completely if one is a smoker. But this is often an ideal, evidenced by the fact that despite Singapore’s tough anti-smoking regime targeted at preventing youth smoking, for example, the number of young smokers has in fact increased in recent years.
In 2013, the Ministry of Health said there were “significant increases in smoking among young adults, aged 18 to 39.”
Gateway to smoking?
One of the concerns among authorities is that these less-risk products will be a gateway for young people and never-smokers (those who have never smoked) to become smokers.
A study by the University of Michigan found that “teenagers who used e-cigarettes were four times more likely to start smoking tobacco within a year.” Researchers said that “vaping may desensitise youngsters to the dangers of smoking, even when they were initially aware of the harms.” (See here.)
But even in the United States, these studies have produced different results.
Elsewhere, research has shown that these products do not much interest non-smokers. It is existing or current smokers who are more likely to switch to these new less-risk cigarettes.
Moreover, the authorities can restrict access to these products, as what Canada and the UK have done.
“The British health authorities regulate strictly the marketing of new products and monitor their sale and use patterns,” said Donald Low, economist and Associate Dean at the Lee Kuan Yew School of Public Policy, in an article in the Business Times in February.
“They have found that e-cigarettes have been a significant gateway out of smoking for millions of adults without causing youths to experiment with nicotine,” he said.
The RCP also reported that “the available evidence to date indicates that e-cigarettes are being used… by confirmed smokers who are trying to reduce harm to themselves or others from smoking, or to quit smoking completely.”
An expert independent evidence review was published in 2015 by PHE and it concluded that “e-cigarettes are significantly less harmful to health than tobacco and have the potential to help smokers quit smoking”. It also found that “there is no evidence so far that e-cigarettes are acting as a route into smoking for children or non-smokers.”
The Singapore regulatory authorities, however, take a zero-sum attitude towards smoking.
“[This] policy stance forces smokers to choose between two unpalatable options: quit or risk premature death,” said Low.
“Reduced risk products offer a third, more palatable option: switch to something much less harmful,” he added.
Colin Mendelsohn, a tobacco treatment specialist and a conjoint associate professor in the School of Public Health and Community Medicine at the University of New South Wales in Australia, would agree.
“Banning e-cigarettes is counterproductive to good public health outcomes,” he wrote in an article in the Sydney Morning Herald in June.
“Vaping products are consumer goods designed to replace an existing, far more harmful, consumer product,” he said. “As such, they can be effectively managed by existing consumer laws, which would regulate quality and safety, advertising, sales to minors and restrictions on use.”
He noted that smoking rates in Australia have stalled the last 3 years, as it has in Singapore, while continuing to decline in other countries where e-cigarettes are widely available.
“Innovative solutions like e-cigarettes are now required to kick start progress once again,” he said.
Public policy, Low argues, must be evidence-based:
“It is time that tobacco policy in Singapore consider the growing evidence of the potential usefulness of lower-risk products,” he said. “Banning them is lazy policymaking; regulating them in a way that reflects their potential benefits and risks is far more prudent.”
Mendelsohn says: “Policy should be based on evidence, not fear mongering, exaggeration, misrepresentation of evidence and rhetoric. Most importantly, any assessment of vaping should be compared with the risks of smoking, which vaping is designed to replace.”
The WHO said, in another report in 2016, that “if the great majority of tobacco smokers… switch without delay to using an alternative source of nicotine with lower health risks, and eventually stop using it, this would represent a significant contemporary public health achievement.”
“This would only be the case if the recruitment of minors and non-smokers into the nicotine-dependent population is no higher than it is for smoking, and eventually decreases to zero,” the global health authority said.
It added, however, that whether the new nicotine delivery systems can do this job is still a subject of debate.
Nonetheless, given the differences in research outcomes from different organisations and countries, Singapore’s policy stand should be one of keeping an open mind, instead of one which closes the door shut on new inventions.
A quit-or-die policy on smoking is an outdated way of dealing with the issue. It is doubtful that such an attitude will help us achieve our goal in 2020 of bringing the smoking rate to below 10 per cent.
We need to be opened to alternative possibilities.
The writer was himself a smoker for 27 years and believes that any product which are less harmful or which can help smokers quit should be seriously considered by the authorities.