Smoking is probably the single largest avoidable cause of death and disease in Singapore. The smoking habit also tends to be more prevalent among lower-income individuals; this makes smoking a major contributor to social inequality in health.
For decades, health authorities in Singapore and elsewhere have sought to reduce the harms caused by smoking in two ways. The first is to increase taxation of tobacco products; the second involves efforts to de-normalise smoking (for example, by banning tobacco advertising and restricting the places where smokers can light up).
This two-pronged approach has yielded some progress. In Singapore, the percentage of daily smokers fell from more about 20 percent in 1991 to just over 13 percent in 2001. But it has remained at this level for over a decadeprompting calls by some for the authorities to take more draconian measures to restrict access to tobacco products.
In recent years, the tobacco industry worldwide has also seen the emergence of what might be called lower risk products. These come in two main varieties. The first, and more widely known, is electronic cigarettes. With e-cigarettes, nicotine is vaporised and then inhaled by the user.
The second category is heated tobacco products. Large tobacco companies have, in recent years, invested billions of research dollars to develop products that heat (rather than burn) tobacco to release fewer toxic chemicals. The chief executive of the tobacco giant, Philip Morris, said recently that his company was preparing for the day when it would stop selling traditional cigarettes and replace them entirely with its heat-not-burn products.
How harmful are these lower risk products?
To be sure, e-cigarettes and heated tobacco products are not harmless. The inhaled vapours of e-cigarettes contain potentially harmful chemicals, albeit at reportedly much lower levels than cigarettes. The US Surgeon General's report in 2016 on the use of e-cigarettes among youth warned of the potential harms of nicotine exposure to the developing adolescent brain and to pregnant women.
But the harmful effects of e-cigarettes pale in comparison to the tar and other dangerous substances in traditional cigarette smoke. The Royal College of Physicians in Britain in its 2016 report, Nicotine without Smoke: Tobacco Harm Reduction, notes that the harm arising from long-term vapour inhalation from the e-cigarettes available in the market today is unlikely to exceed 5 percent of the harm from smoking tobacco. Research done for Public Health England also shows vaping products to be 95 percent safer than traditional cigarettes.
In an ideal world, no one would be addicted to harmful substances. But all societies have one vice or another. The issue that health authorities must confront is not just one of whether e-cigarettes are harmful. They obviously are; no health authority should encourage its people to use them.
But the real issue is not whether these alternative products are harmful; it is which addictions are more (or less) harmful than others. For example, an addiction to caffeine is much less harmful than an addiction to opioids. If a less harmful addiction cancrowd out or reduce the prevalence of a more harmful one, health authorities should consider allowing the former as part of an overall strategy to reduce the latter.
But are these products a good way for smokers to end their addiction to traditional cigarettes? The US Surgeon General's report says that the data supporting the argument that e-cigarettes might help with smoking cessation is extremely weak. But the Royal College of Physicians in Britain recommends that in the interest of public health it is important to promote the use of e-cigarettes as widely as possible as a substitute for smoking in the UK. Britain's Behavioural Insights Team (BIT) has also pointed to e-cigarettes as the most successful product at helping people to quit smoking, and the evidence shows that almost all users of e-cigarettes are former smokers. BIT's explanation is that it is much easier for people to substitute a harmful habit with a similar but less harmful habit than to eradicate it altogether.
Cognitive biases in tobacco policy
Singapore's health authorities have banned the use and importation of these lower risk products. This means that Singapore does not reap the potential benefits that a policy of encouraging substitution of traditional cigarettes with lower risk products might deliver. Health policymakers here should also be mindful of some common biases when considering whether to allow these products.
The first of such biases is associative thinking, or our tendency to make decisions on the basis of (shared) stories. Over the years, it is not only the smoking habit and cigarettes that have been demonised, but also tobacco companies. The tobacco companies are not blameless: for many years, they denied the science that showed a strong link between smoking and a whole host of diseases.
But our reflexive association of tobacco companies with harm may be outdated. If e-cigarettes or heated tobacco products are much less harmful than traditional cigarettes, it is incumbent on health authorities to not only allow their sale and consumption, but also to work towards eliminating traditional cigarettes and replacing them with less harmful substitutes. After all, the aim of tobacco policy is to reduce death and morbidity arising from tobacco use, not to vilify tobacco companies.
The second bias is a preference for the status quo. Health authorities are justifiably proud of having reduced smoking rates over the decades. They may well think that continuing with their current efforts would continue to drive down smoking rates.
But faith in the inevitable reduction of smoking rates is misplaced. Smoking rates in Singapore have been stuck at around 13 percent for many years. The current approach pins everything on the belief that existing policies would reduce smoking to negligible levels. Such confidence is quite reckless. It is akin to public health authorities believing that people can be persuaded to practise abstinence as a way of minimising sexually transmitted diseases and unwanted pregnancies, rather than promoting safe sex and making condoms widely available. The state, unlike a religious institution, cannot base (tobacco) policy on its moral preferences; it has to look at the evidence of what works.
The third bias is loss aversion, or the very human tendency to emphasise losses much more than gains. Health authorities fear that allowing these lower risk alternatives would re-normalise smoking, and that they are a "gateway drug" to more harmful products.
Such loss aversion is not entirely justified. It is just as likely (in fact, more so) that the lower risk products replace traditional cigarettes. The British health authorities regulate strictly the marketing of new products and monitor their sale and use patterns. They have found that e-cigarettes have been a significant gateway outof smoking for millions of adults without causing youths to experiment with nicotine. The Royal College of Physicians reports that the available evidence to date indicates that e-cigarettes are being used almost exclusively as safer alternatives to smoked tobacco, by confirmed smokers who are trying to reduce harm to themselves or others from smoking, or to quit smoking completely. Singapore seems particularly well-placed to put in place the regulatory and monitoring regimes to ensure that these lower risk products crowd out, rather than crowd in, cigarette smoking.
Regulate, don't ban, lower risk products
It is time that tobacco policy in Singapore consider the growing evidence of the potential usefulness of lower risk products. Banning them is lazy policy-making; regulating them in a way that reflects their potential benefits and risks is far more prudent. Such regulation could include restrictions on their marketing and advertising (especially to youth and non-smokers), public education on their health risks (and their risks relative to traditional cigarettes), and taxation.
There is already growing acceptance by health authorities in the developed world and anti-tobacco advocacy groups of the need to establish sensible, evidence-based regulatory frameworks (as opposed to a blanket prohibition) for these products. The US, UK, Australia, New Zealand, Canada, Switzerland and Japan have moved decisively in this direction.
Singapore's current policy stance forces smokers to choose between two unpalatable options: quit (which is extremely difficult for many) or risk premature death. Reduced risk products offer a third, more palatable option: switch to something much less harmful. If the authorities work towards a grand bargain with tobacco companies such that their cigarettes are no longer sold in Singapore, they may well succeed in reducing the death and diseases currently caused by smoking.
This piece was published in The Business Times on 17 February 2017.