Tobacco control in Singapore and New Zealand

• Tobacco use is regarded as one of the leading public health threats by the World Health Organization ("WHO"). It kills over eight million people globally each year^{1Legend symbol denoting See World Health Organization (2022).} and causes a wide spectrum of non-communicable diseases ("NCDs"), from cancers to heart diseases. The most common form of tobacco use is conventional cigarette smoking, but tobacco is also used in various forms such as cigars, e-cigarettes/vaping and smokeless tobacco products.
• While the smoking rate in Hong Kong has fallen to an all-time low of 9.5% as at 2021, tobacco use is responsible for some 7 000 premature deaths every year and has significant implications for healthcare costs.^{2Legend symbol denoting See Hong Kong Council on Smoking and Health (2022d).} In response, the Chief Executive has pledged in the Policy Address 2022 that the Government would release a tobacco control roadmap for public consultation in early 2023, with the goal of reducing smoking prevalence to 7.8% by 2025.^{3Legend symbol denoting See Policy Address (2022).} The issue of tobacco control has recently sparked public discussions. Members of the Legislative Council have also discussed the matter at relevant meetings.^{4Legend symbol denoting See GovHK (2022), Panel on Health Services (2022) and 東方日報(2022).}
• Tobacco control is multifaceted, often encompassing both measures to suppress the demand for and supply of tobacco. According to the WHO Framework Convention on Tobacco Control ("FCTC")^{5Legend symbol denoting FCTC, adopted in 2003 and entered into force in 2005, is the first international health treaty with 182 parties. The Mainland has signed and ratified FCTC, and the application of which has been extended to Hong Kong. See Secretariat of WHO Framework Convention on Tobacco Control (2003).}, such measures can range from mandating tobacco sale and packaging requirements, to hiking tobacco taxes and strengthening smoking cessation services. An emerging approach is to develop the so-called tobacco endgame strategy, which is a more drastic approach that goes beyond controlling tobacco harms, and towards creating a tobacco-free generation by phasing out tobacco use or adopting a total ban on related products.^{6Legend symbol denoting See Stone, E. and Paul, C. (2022).}
• This issue of Essentials first reviews pertinent measures in Hong Kong. This is followed by a discussion on Singapore and New Zealand, both of which have one of the lowest smoking rates in the developed world. Singapore is known for its comprehensive tobacco control legislation, not least its "hostile environment" for tobacco promotion and advertising.^{7Legend symbol denoting See Amul, G.G.H. and Pang, T. (2018).} Meanwhile, New Zealand has recently become the first advanced place to impose a lifetime ban on young people buying conventional cigarettes, as part of its strategy to create a tobacco-free generation.

• To align with WHO's global action plan for preventing NCDs, the Government issued in 2018 the "Towards 2025: Strategy and Action Plan to Prevent and Control NCDs in Hong Kong". The plan includes nine local targets, one of which is a 30% reduction in the prevalence of tobacco use among people aged 15 and above by 2025, when compared to 2010 levels. This translates into a target smoking rate of 7.8% territory-wide.^{8Legend symbol denoting See GovHK (2022).} The Government will release a tobacco control roadmap in early 2023.
• The Government's past tobacco control efforts have been primarily based on legislation, taxation and cessation services, among other things.^{9Legend symbol denoting See Department of Health (2018).} Since 2007, the Government has prohibited smoking in all indoor public places (including dining and shopping premises as well as workplaces) and outdoor public pleasure grounds and facilities^{10Legend symbol denoting Examples are beaches, public swimming pools, sport grounds and parks managed by the Government.}, and has expanded the smoking ban by phases to public transport terminuses/interchanges.^{11These include all indoor public transport interchanges and some 200 designated public transport facilities including outdoor bus terminuses.} Besides, it has tightened packaging requirements by mandating larger graphic health warnings on tobacco products^{12Effective from 2017, all tobacco products must (a) enlarge graphic health warnings to cover at least 85% of the packaging surface, (b) increase the number of warning forms from six to 12, and (c) show details of the Quitline.}, and increased the tobacco duty by 50.0% in 2009, 41.5% in 2011 and 11.7% in 2014. The Government also runs a Quitline, which offers counselling and referrals to cessation services at designated clinics, such as acupuncture and the mailing of medication (e.g. nicotine replacement therapy) to help people quit smoking.^{13See Tobacco and Alcohol Control Office (2022).}
• These measures have reaped some success. The share of daily cigarette smokers aged 15 and above fell from 14.0% in 2005 to 9.5% in 2021.^{14See Tobacco and Alcohol Control Office (2023).} Still, there were some 581 500 conventional cigarette smokers, who smoked 13 sticks of cigarettes every day on average in 2021.^{15See Census and Statistics Department (2022).} Analysed by age group, 76% of these smokers were middle-aged and older (i.e. aged 40 and above) rather than young people under 40. Although free smoking cessation services are available in public clinics/hospitals and subvented non-government organizations, a survey revealed that only 2.6% of current smokers had used these services.^{16See ibid.} Over 60% of current smokers also expressed that they had not and would not use such services, prompting calls for enhanced efforts to promote and incentivize the use of cessation services.^{17See ibid and Cheung, Y.T.D. et al. (2020).}
• The Hong Kong Council on Smoking and Health ("COSH"), a statutory body that advises the Government on smoking and health matters, is concerned that the city's current package of tobacco control policy may only make a few further strides on reducing smoking prevalence. For instance, there have been no substantial enhancements to tobacco control measures, while the tobacco tax has been frozen for a number of years.^{18See Hong Kong Council on Smoking and Health (2021a, 2022c).} The tobacco duty accounted for 62% of the retail price of cigarettes in 2022, down from about 67% in 2017.^{19See Hong Kong Council on Smoking and Health (2017, 2022b).} The only major advance is a ban on alternative smoking products (e.g. e-cigarettes, heated tobacco products, etc.) beginning in April 2022. In light of recent global developments, COSH has advised the Government to review the Smoking (Public Health) Ordinance (Cap. 371) and strengthen tobacco control measures, such as^{20See Hong Kong Council on Smoking and Health (2022a).}:
  • (a)
    Creating a smoke-free environment for future generations;
  • (b)
    Raising tobacco taxes substantially;
  • (c)
    Expanding statutory no-smoking areas; and
  • (d)
    Tightening restrictions on tobacco packaging and sale.
  It is generally expected that the upcoming tobacco control roadmap to be released for public consultation will provide specific proposals on each of these fronts. In fact, various developed places are making more advanced progress in tobacco control. The next section gives an update on relevant strategies and measures, specifically in Singapore and New Zealand.

• Singapore has put in place a comprehensive mix of strategies in line with global practices, from taxation to ensuring easy access to cessation services. While the city-state has no plan to adopt a tobacco endgame target at the current juncture, it has tightened the access to tobacco for youngsters through raising the legal minimum age to purchase related products, and has banned point-of-sale product displays. Its latest official data showed that smoking rates dropped to 10.1% in 2020, compared with 13.9% a decade ago.^{21See Singapore Ministry of Health (2022b).}
• Whereas in New Zealand, its smoking rate fell to a historical low with 8.0% of adults smoking tobacco products daily in 2021-2022, down from 16.4% in 2011-2012. It is noteworthy that the use of e-cigarettes as a substitute has been on the rise.^{22In 2021-2022, 8.3% of adults used e-cigarettes daily, up from 6.2% a year ago and 0.9% in 2015-2016. E-cigarette use was more common among young people aged 18-24, with about one in four (23%) being daily users. See New Zealand Ministry of Health (2022).} In December 2021, the government launched the Smokefree Aotearoa 2025 Action Plan . This plan was introduced in an effort to accelerate the progress towards the target of reducing national smoking rates to below 5% by 2025, which was unveiled by the government in 2011. Salient tobacco control measures in Singapore and New Zealand are outlined in the ensuing paragraphs.

• Following a total ban on e-cigarettes in 2018, Singapore has progressively raised the minimum legal age from 18 to 21 for the purchase, use, possession, sale and supply of conventional tobacco products (the transition was made by raising the legal smoking age one year every January from 2019, thereby reaching 21 years old in 2021). This measure aims to limit youth access and exposure to tobacco products, as research has shown that young people are less likely to become addicted to nicotine after the age of 21.^{23See Parliament of Singapore (2017).} The government also set up hotlines and an online form for the public to report illegal sale or supply of tobacco products to minors so as to facilitate enforcement.^{24See Singapore Ministry of Health (2020).} This measure reportedly contributed to a slight decline in smoking prevalence among young adults, from 9.8% in 2017 to 8.8% in 2020.^{25See Singapore Ministry of Health (2022a).}
• New Zealand has adopted a more audacious approach. As part of its 2025 Action Plan, the government passed legislation in December 2022 to phase out conventional smoking for younger generations. The legislation forbids the sale, delivery or supply of smoked tobacco products (excluding e-cigarettes) to anyone born after 2008 and penalizes offenders with hefty fines of up to NZ$150,000 (HK$747,000) starting from 2027.^{26See New Zealand Legislation (2022).} Additionally, the legislation requires manufacturers to reduce the nicotine content in smoked tobacco products and cap the number of eligible retailers to 600 (equivalent to around 10% of the current number of retailers).^{27See ibid.}
• It is estimated that New Zealand's tobacco-free generation legislation could halve smoking rates within 10 to 15 years of implementation.^{28See New Zealand Ministry of Health (2021a).} However, there are concerns over the consequential emergence of a black market for conventional tobacco products, and that more young people might turn to alternative smoking products.^{29See New Zealand Parliament (2022) and Quartz (2022).} Enforcement could be another challenge, especially in view of the difficulty and intense resources required to combat illegal tobacco supply from older cohorts not subject to the ban to the young cohorts (e.g. family and friends).^{30In fact, Singapore cited enforcement challenge as a reason for not adopting the "tobacco-free generation" approach. Singaporean authorities further noted the different contexts in the two places: New Zealand's ban is aimed at the younger generation, whereas Singapore's youth, like Hong Kong's, are generally not becoming smokers. See Singapore Ministry of Health (2022a).} While the implementation experience remains to be seen, some other Western countries such as Ireland and Sweden have revealed a similar endgame plan. However, it is noted that such an approach appears yet to gain ground in Asian places.

• Taxation is considered another effective measure for motiving smokers to quit. According to WHO estimates, every 10% increase in tobacco price reduces consumption by 4%-5%.^{31See World Health Organization (2014).} As such, WHO recommends at least a 75% tax share of the retail price of tobacco, a target that has been met by 40 places globally, including New Zealand.^{32See World Health Organization (2021c, 2023a).} The country has specifically implemented a mechanism to adjust the tobacco tax regularly. Between 2010 and 2020, the New Zealand government increased tobacco excise tax by inflation plus an additional 10% each year.^{33In January 2020, New Zealand ended the decade-long increase in tobacco tax by 10% annually, citing that retail price for tobacco products was already high. Since then, tobacco excise was only adjusted for inflation. See New Zealand Ministry of Health (2018, 2021a).}
• While such a mechanism is absent in Singapore, its government has pledged to constantly review the tobacco tax rate, which was raised twice by 10% in 2014 and 2018.^{34See Singapore Ministry of Health (2022a) and Ministry of Finance (2014).} In 2020-2021, a standard pack of 20 cigarettes in Singapore costs S$14 (HK$83) on average, compared to about HK$60 in Hong Kong and HK$185 in New Zealand.^{35See World Health Organization (2021a) and Hong Kong Council on Smoking and Health (2021b).}

• Extension of smoke-free areas is also a critical step towards discouraging smoking and protecting non-smokers, especially youngsters, from second-hand smoke. Contrary to Hong Kong where indoor no-smoking areas are mainly in buildings, New Zealand, alongside some developed places like Australia and the United Kingdom, has taken a step further to bar smoking in private vehicles with children under 18 years old. The law, effective from 2021, empowers the police to issue fines of NZ$50 (HK$249) on the spot, give warnings or refer people to cessation services.^{36See Beehive (2020).}
• Meanwhile, Singapore's outdoor smoking ban is widespread. It covers not only bus terminuses as in Hong Kong, but also bus stops, queues in public places, and even areas within five metres of commercial and industrial building entrances.^{37See National Environment Agency (2022).} Furthermore, since 2019, public areas within the Orchard Road precinct, Singapore's famous commercial district, have been declared a no-smoking zone, with smoking permitted only in designated areas. In the first three months of implementation, the government took an advisory approach, and offenders received only warnings during the period. After that, people caught smoking in the zone are subject to fines of up to S$1,000 (HK$5,900).^{38See National Environment Agency (2021).}

• To reduce the appeal of tobacco products, WHO recommends the use of plain/standardized packaging, apart from graphic health warnings.^{39See World Health Organization (2023b).} As at 2021, plain packaging legislation has been passed/proposed in at least 20 places, including New Zealand and Singapore.^{40See World Health Organization (2021b).} In both places, tobacco packaging must remove distinguishing features including all brand logos, images and promotional information.^{41In New Zealand, e-cigarette products are not subject to plain packaging, although the law requires health warning message be displayed on the package.} Manufacturers may only display brand and variant names in a standard colour and font style, alongside prescribed health warnings.
• In a bid to minimize public exposure to tobacco products, New Zealand and Singapore have also banned product display at points of sale. In short, tobacco products must be kept out of customer sight at retail outlets, and only a price list (text only) may be shown upon request.^{42For New Zealand, display of e-cigarette products inside a shop is permitted. See also Health Sciences Authority (2022) and New Zealand Ministry of Health (2012).} To lessen the impact on small retailers, the Singapore government conducted engagement sessions to help them prepare for the ban and allowed a one-year grace before the ban took full effect in 2017.^{43See Parliament of Singapore (2016).}

• Legislation aside, smoking cessation is a vital element of a comprehensive tobacco control strategy. New Zealand's Budget 2021 committed an extra funding of NZ$13.9 million (HK$69.2 million) to support an increase in smoking cessation services in the next three years.^{44This include plans to support maternity care and childcare practitioners to make targeted referrals to smoking cessation services, and invest in the delivery of culturally appropriate cessation services for Maori and Pacific populations, who tend to have higher smoking rates. See New Zealand Ministry of Health (2021b).} The country has also extended cessation services beyond clinics and hospitals to reach out to more smokers. For instance, Auckland's health authorities have partnered with community pharmacies to provide subsidized nicotine replacement therapy and follow-up support services.^{45In New Zealand, those who are eligible for publicly funded health services pay only NZ$5 (HK$25) for subsidized medicines. See Auckland District Health Board (2019).} Cessation services by pharmacies have shown to be effective as no appointment is required, and pharmacies often open extended hours to offer timely and flexible access for smokers wanting to quit.^{46See ibid., Brown, T.J. et al. (2016) and Saba, M. et al. (2014).}
• Likewise, Singapore offers smoking cessation services via a network of touchpoints from retail pharmacies to healthcare facilities. Specifically, the Health Promotion Board organizes the "I Quit Programme", an all-year-round programme that offers a customized quit plan with face-to-face counselling at pharmacies, and rewards successful quitters with shopping vouchers worth up to S$100 (HK$590).^{47Vouchers are handed out in stages. Participants who have their smoke-free status validated can redeem vouchers worth S$50 (HK$295), S$30 (HK$177) and S$20 (HK$118) on the 28th day, the third month and the sixth month respectively. See Singapore Ministry of Health (undated).} It also promotes a social network of support by encouraging smokers and ex-smokers to exchange advice and share success stories on a social media page with over 50 000 followers.^{48See Health Promotion Board (2022).} Since inception in 2013, the Programme has attracted 10 000 sign-ups every year, with about one in five participants staying smoke-free during a 28-day period.^{49See Parliament of Singapore (2016) and Singapore Medical Association (2017)., 50Different from Singapore's, Hong Kong's smoking cessation campaign is mainly delivered in the form of a smoking cessation contest (known as "Quit to Win") organized by COSH annually since 2009. Recruitment periods usually span from June to October every year, and successful contestants will be awarded cash vouchers and the opportunity to enter a lucky draw.}

• Tobacco use imposes a significant public health burden on society. Notwithstanding a decline in smoking prevalence, there remain calls for the Hong Kong Government to ratchet up tobacco control efforts in light of global trends and favourable experience overseas. Singapore has opted for the more progressive approach of raising the legal smoking age, whereas New Zealand has taken a bold step by imposing a lifetime ban on smoked cigarette sale for younger generations. Additionally, both places have adopted measures to considerably/regularly raise tobacco taxes; extend statutory no-smoking areas and the reach of cessation services; and adopt plain packaging and sale regulations in line with WHO recommendations. These examples may facilitate a healthy discussion in the community and provide inspirations for Hong Kong in its fight against tobacco use.

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