CLOSING SPEECH BY MR AMRIN AMIN, PARLIAMENTARY SECRETARY FOR HEALTH, ON THE TOBACCO (CONTROL OF ADVERTISEMENTS AND SALE) (AMENDMENT) BILL, 7 NOVEMBER 2017
Mr Speaker, I thank Members for speaking up in support of the Bill. I will now address Members’ queries on the Bill.
Effectiveness of smoking measures
2. Mr Gan Thiam Poh and Ms Joan Pereira asked how effective our current measures are in reducing the prevalence of smoking, including in our youths. MOH has been strengthening our tobacco control measures over the years. Our measures are based on proven, best practices recommended by the World Health Organization and are designed to work at multiple levels. However, no single measure operates on its own. Collectively, the measures work together to reduce smoking prevalence in the longer term. As tobacco use is an addiction, we also do not expect to see significant drops in prevalence immediately after new measures are introduced.
3. Our smoking rates have fallen from 18% in 1992 but they have remained at about 12-14% for the last decade. We see that progress has been made but we need to do more.
Raising of Minimum Legal Age (MLA)
Phased implementation
4. Dr Chia Shi Lu, Mr Alex Yam and Ms Joan Pereira suggested to raise the MLA to 21 with immediate effect. I understand their concerns. However, we are mindful of the impact on current smokers between the ages of 18 and 21. Smoking is an addiction, and even as we encourage smokers to stop smoking, they will need some time. The phased implementation provides a realistic timeframe.
5. Raising the MLA alone will not eliminate youth smoking. We will continue to send a strong message to young people to stay away from cigarettes.
6. Educational efforts and support for youth smokers to quit must complement legislative measures. I agree with what Dr Intan has shared. We must encourage our youths to devote their time, effort, mind and energy to useful and meaningful activities and stay away from tobacco products. This is indeed the holistic approach we have adopted.
7. The Health Promotion Board’s (HPB) smoking cessation programmes for youths adopt a strengths-based approach to build confidence for behaviour change. In response to Dr Lee Bee Wah’s question, there are Student Health Advisors (SHAs) trained in smoking cessation who are stationed full-time in 50 schools and Institutes of Higher Learning (“IHLs”). Dr Lee Bee Wah will be happy to know that there are SHAs stationed in schools in Yishun. Since 2015, HPB’s smoking cessation programmes have reached out to more than 4,400 youths.
8. We also work closely with the Ministry of Education and IHLs to incorporate anti-tobacco messages into the curriculum. HPB conducts additional educational programmes in schools, and in 2016, we reached out close to 50,000 youths. Youths are also taught skills to refuse cigarette offers in social settings.
Prohibition on ENDS
Clarification on harm reduction
9. In response to Mr Louis Ng, we have looked into Prof Linda Bauld’s study in detail. It was a cross-sectional study that looked at the situation at one point in time. This study design is not suitable for studying the gateway effect. There had been studies in the US, UK and Canada, which followed up on more than 40,000 youths over time, and found that e-cigarette users had a greater risk of becoming cigarette users. All these studies have found evidence to support the gateway effect.
10. On Mr Leon Perera’s question regarding standardised tobacco packaging, we are still studying this. Our final decision on whether to proceed with the measure will be made only after the upcoming public consultation. The decision whether to proceed to standardise tobacco packaging will be based on several considerations, including public health, intellectual property and international law perspectives. We will ensure that any measure, if introduced, is consistent with our domestic law and international obligations.
11. Mr Leon Perera has asked if e-cigarettes are as harmful or more harmful than conventional cigarettes. That is the wrong question to ask. The correct question should be whether e-cigarettes are harmful to health. The answer is yes. E-cigarettes expose users to chemicals and substances that cost adverse health effects.
12. Mr Louis Ng and Mr Leon Perera have sought clarification on MOH’s stance on tobacco harm reduction. We are aiming for a high and precautionary level of public health protection. While there are studies that claim that there is no gateway effect, there are as many, more authoritative, studies which point to a gateway effect.
13. In response to Mr Louis Ng and Mr Leon Perera’s comment on how other countries are allowing ENDS, I would like to highlight that there is no consensus among public health authorities that ENDS should be allowed. While the UK has advocated for e-cigarettes to have a central role in smoking cessation, the US is pushing for tighter regulation of ENDS, andin other countries, the sale of ENDS remains banned.
14. We have looked at the claim that ENDS are “95% safer than cigarettes” as cited in a 2015 report by Public Health England and repeated by the Royal College of Physicians. A number of studies used by the report were of limited quality. In fact, an editorial in the Lancet, a leading medical journal, has criticised the report for using weak evidence.
15. Mr Leon Perera cited the Cochrane review that e-cigarettes can help smokers to quit. We have studied the report; I have read the report. What he did not emphasise was the overall quality of evidence that ENDS can help smokers to quit is low. The report mentioned about the small number of trials, low event rates, and wide confidence intervals. The study concluded that the long-term safety of the use of ENDS was unknown. I’m sure Mr Leon Perera does not want to put our smokers who are trying very hard to quit at risk.
16. Of note too is that e-cigarettes are still not available through the UK National Health Service. Why? No e- cigarettes have been licensed by the UK Medicine and Healthcare Regulatory Agency. The WHO does not recognise ENDS as a legitimate smoking cessation aid. There is no conclusive scientific evidence proving the product’s safety and efficacy. Australia does not support ENDS until there is more evidence on its safety and effectiveness in smoking cessation.
17. Some tobacco companies are pivoting from smoke-producing cigarettes to smoke-free but nicotine-containing products such as e-cigarettes and heat-not-burn tobacco products. They hired researchers and lobbyists to help them with this pivot. The form of nicotine delivery differs, but the revenue-generating base product is still nicotine. ENDS are marketed as “healthier” alternatives and youths are targeted. I think the danger of many more youths becoming addicted to nicotine is clear. We must not let down our guard. We must protect our young.
18. Our goal is not just a smoke-free future, but a nicotine-free one. So-called lesser-harm tobacco products still expose the user to toxic and addictive substances that are harmful to health. In response to Mr Leon Perera, we are open to evidence proving that ENDS are safe and effective for smoking cessation. ENDS manufacturers can submit evidence for us to evaluate their products for registration as smoking cessation therapy under the Health Products Act. So far, none has done so.
Enforcement on online sales
19. A number of members have raised concerns on the online sales and smuggling for ENDS. MOH is similarly concerned. The Health Sciences Authority (HSA) enlists the help of e-commerce sites to shut down listings for prohibited products such as ENDS and their refill liquids and cartridges. ICA and Singapore Post also assist to conduct regular checks for prohibited products.
20. Mr Gan Thiam Poh asked if we can take action if sellers are not within our jurisdiction. This is a challenge because we have limited powers to act against parties located outside Singapore. We are doing what we can. Persons who purchase prohibited products from overseas will be liable for an offence even if the seller is based outside of Singapore. We also take action against Singapore-based sellers. Since 2012, HSA has prosecuted 14 sellers of e-cigarettes and other types of vaporisers.
Impact on retailers
21. Dr Chia highlighted the impact of MLA increase on retailers. In particular, employees under the age of 21 will not be allowed to handle tobacco sales. We have met with retailers and have heard their concerns. I would like to clarify that businesses can still continue to hire persons under 21, but they cannot sell tobacco. Current employees between 18 and 21 will not be affected. We have also conducted a survey among tobacco retailers. We found that 5% of retailers currently employ workers who are aged 18 to 21 to sell tobacco products. Thus, a small number of businesses will face challenges after the MLA has been implemented. We seek the support of the industry in supporting the MLA policy. This is to ensure that we achieve our wider public health objectives. We will continue to work with tobacco retailers to ensure the smooth implementation of the MLA increase.
Additional enforcement via logistic companies
22. Mr Chia and Ms Perera suggested that we place greater onus on logistic companies to curb the importation of prohibited products. We have been reaching out to major logistic companies as well as the Singapore Aircargo Agents Association (SAAA) to educate and remind the industry of the ban.
Penalties for sale or importation of ENDS
23. Mr Chia also asked if we can remove the ceilings for fines for sale, distribution and import of ENDS, and to base the penalties on the quantity and value of the products seized. Fines that are meted out for such offences will generally take into account the volume and potential profit that could be made. We note Mr Chia’s suggestion and will consider it when we next review the penalty framework of the Act.
24. Public education remains a key pillar of our tobacco control programme. It is vital to make the public aware of the harms of smoking, including prohibited products such as ENDS.
Public education
Enhancing public education
25. A number of MPs have asked MOH to enhance our public education. Through portals like the Health Hub as well as the Healthy Lifestyle Festival Singapore, we raise general awareness among smokers on how their habit has an impact on their children and motivate them to stay smoke-free. We will continue to explore ways to improve, and are reviewing our public education and outreach strategy.
26. Ms Perera and Ms Thanaletchimi highlighted the importance of stemming social supply for under-aged smokers. We will also take the opportunity to educate the public that supplying tobacco to under-aged persons is an offence under the Act. You can be fined up to $1,000 for giving tobacco products to an under-aged person, and up to $5,000 for buying for them. We will look into ways to raise greater awareness on this and to educate older family members and friends on this.
Volunteers for public education
27. Mr Gan Thiam Poh suggested enlisting the help of volunteers to carry out public education and enforcement king. Currently, we do not deploy volunteers for enforcement, however we have volunteers for public education efforts, such as I Quit ambassadors. But we will study this suggestion.
Malay-Muslim smokers
28. Dr Intan had expressed concern that the number of Malay smokers remain high. We are similarly concerned. HPB holds over 200 roadshows in the community island-wide every year. Specific to the Malay community, HPB is partnering with Majlis Ugama Islam Singapura (MUIS) and mosques to help Malay Muslim smokers. The response to the I Quit Ramadan roadshows, held since 2012 has been encouraging. This year, we have over 5,700 sign-ups. We are studying ways to expand outreach and public education efforts to all segments of the population all year round.
SUGGESTIONS FOR TOBACCO CONTROL
Roll your own tobacco
29. I thank Dr Intan for highlighting a potential problem of roll your own tobacco cigarettes use among youths. Although Ang Hoon and other loose tobacco leaves products make up less than 2% of all tobacco products imported in 2016, MOH will continue to monitor their use among youths, and act accordingly. The MLA also applies to these products. MHA monitors the trend of the sale and abuse of controlled drugs including those laced with tobacco, and will take the necessary enforcement measures against traffickers and abuses.
Reducing number of tobacco licences
30. In response to Ms Pereira’s question on reducing the number of tobacco licences. We regulate where tobacco should not be sold. These places include healthcare institutions, educational institutions, and places which may disproportionately attract the young such as gaming arcades. The number of tobacco retailers has declined from 5,555 in 2012 to 4,663 as at 30 Sep 2017. This is an average decrease of about 3% per year. We encourage retailers to diversify their businesses to reduce their dependence on profits from sale of tobacco products.
Banning smoking in neighbour’s flats
31. Dr Lee, Mr Gan and Mr Yee have spoken out strongly against second-hand smoke and asked if there is more that we can do to minimise their effects in housing estates. I empathise with the residents’ frustrations. MOH works with MEWR to minimise exposure to second-hand smoke in the community. MOH’s measures are aimed at reducing the number of smokers over time, while smoking prohibitions in public areas will protect non-smokers from the immediate harm of second-hand smoke. We urge smokers to be socially responsible and considerate when smoking in private spaces so that their neighbours will not be affected. Residents who are affected should approach their neighbours to resolve the matter amicably, in the spirit of neighbourliness. Residents can also approach the Community Mediation Centre for assistance.
Not enough enforcement of smoking ban
32. Dr Lee Bee Wah made some suggestions to enhance the enforcement of the smoking ban in public spaces. I agree that we should work more closely with members of public to tackle errant smokers. I will refer her suggestions to my MEWR colleagues for their consideration.
33. Ultimately, by discouraging those below 21 from smoking, this Bill helps to reduce the number of adult smokers in the population in the long run, and will help reduce second-hand smoke.
34. Mr Yam asked if tobacco should be banned completely since it is a major public health scourge. Cigarettes are entrenched in Singapore and globally. Our tobacco control strategy aims to reduce the prevalence of tobacco use significantly over time, and in the longer term, we do not rule out banning tobacco completely when tobacco use is at very low levels.
Conclusion
35. Mr Speaker, cigarette use had become so entrenched that millions world-wide are addicted and exposed to the harm of smoking. We should not make the same mistake with ENDS. We do not need nor want another addictive product to take root in Singapore. This is why we are strengthening our regulatory measures against ENDS.
36. With the increase in MLA, we aim to reduce opportunities for youths to be tempted to take up smoking. Our aim is to ultimately de-normalise tobacco use, and protect our young from being lured into a lifetime of nicotine addiction.
37. I believe I have responded to the main concerns of members. We are grateful for the support of the public received during consultations and the support from this House.
Thank you.