Expert proposes ban on cigarette sales to younger generations – forever
JUST stamp it out, once and for all. That is the proposed solution to the scourge of nicotine addiction – fast spreading among the young – by a National Cancer Centre Singapore (NCCS) lung surgeon. A few anti-tobacco activists, led by Associate Professor Koong Heng Nung, 44, are proposing legislation to outlaw the sale of tobacco to any Singapore citizen born in or after 2000.
It is a simple, once-and-forever fix, he says, far more effective than current bans that prohibit those below the age of 18 from buying cigarettes. The senior consultant and head of the NCCS surgical oncology department says the year 2000 was chosen for its easy recall by all parties. “It is an empirical number, so if you want it implemented faster, you can use 1990 or 1995. But 2000 is a very easy year to remember; it makes enforcement easier,” he says, adding that vendors, for example, would not need to calculate if a tobacco buyer is above the age of 18. More importantly, he adds, the proposal will result in tobacco-free generations that will never legally be able to light up.
Last week, he presented the radical proposal to health-care professionals at the SingHealth Duke-NUS Scientific Congress 2010 in Suntec City. The paper was also published in the British Medical Journal last month. He co-authored the proposal with Professor Jon Berrick from the mathematics department of the National University of Singapore, who came up with the idea in 2005; Dr Deborah Khoo and Dr Priscilla Ng, who are medical officers with the NCCS; and Ms Yvonne Chiam, a civil servant and volunteer with the NCCS.
Yes, Prof Koong is well aware the controversial proposal will invite criticism and opposition, not least from influential tobacco companies. His defence is swift: “Our proposal doesn’t stop the current smokers from smoking, and it is in line with what tobacco companies say: That they do not seek to attract new smokers, and they want to protect the young too.” And, of course, he anticipates human rights activists will consider the blanket ban an affront to free will and future generations by imposing limitations on what they can and cannot do.
He volleys back with questions of his own: “Do you want legislation that will protect children from the harms of tobacco forever? Don’t we have a moral responsibility to protect our young?” The surgeon, who cuts and patches up to 300 patients suffering from tobacco-related diseases such as lung and oesophagus cancer in a year, cites data to show that 90 per cent of lung cancer cases are caused by smoking, and that 900 to 1,000 people in Singapore die from lung cancer every year.
He adds: “If you set good values in the young, what would be their free will? Their free will would be, ‘Thank you for protecting me from the addiction that is tobacco, thank you because you have protected me from heart disease, stroke and cancers’.” The principle of protecting future generations, he says, is not new. “Have we done it before? Yes, we vaccinate people against diseases, tuberculosis and polio,” says Dr Koong, adding that the proposed measure will also result in long-term health benefits and savings in health-care costs.
A study published in 2002 showed that the social cost of smoking to Singapore in 1997 amounted to between $674 million and $839 million. Meanwhile, he says research has shown that young smokers form the principal battleground in the war against tobacco. Internationally, the percentage of smokers increases fastest between the ages of 12 and 18; there is also a worldwide trend for those who begin smoking in their teens to become long-term adult tobacco users.
Since the 1970s, Singapore has unleashed a slew of initiatives – from taxation to legislation banning underage smoking and smoking in enclosed public places – to curb nicotine addiction. These measures, coupled with various campaigns and outreach programmes, have succeeded in bringing the overall percentage of adult Singaporean smokers down from 20 per cent in 1984 to 13.6 per cent in 2007.
However, according to the 2007 National Health Surveillance Survey, the rate of tobacco use is highest among those aged 18 to 29, and has gone up from 12.3 per cent in 2004 to 17.2 in 2007, thanks to peer pressure puffing. “The beauty of this proposal is that it completely reverses the drive that leads to peer pressure smoking,” he says. He cites a 2008 study by a group of Harvard University researchers which tracked more than 12,000 people over three decades and found that the tendency to smoke spreads through close and distant social ties. “Another interesting finding was that people who stopped smoking usually do so in a circle of people who have also stopped smoking. The effect just spreads and spreads, and the numbers get smaller,” he says.
The researchers also discovered that smokers tended to migrate to the peripheries of social circles. “It tells you that in order to have good success rates of quitting, you need to create the peer pressure effect,” he says. “Just think about it,” adds the father of four children aged between four and 10. “What happens if you have a cohort of Primary 4 pupils who declare themselves smoke-free, or the school organises an activity that declares that this is the smoke-free generation?
“You are creating a positive self-image early on, and hopefully they will exercise internal peer pressure and internal enforcement not to start smoking .” With his proposed ban, he hopes smoking will also cease to be a “rite of passage”, as there is no longer an age at which tobacco may be obtained legally. “Right now, many teenagers aspire to smoke once they turn 18 because it is their right to do so. It signifies autonomy and independence,” he says.
But does his proposal also suggest punitive measures for flouters? “Punitive measures are a downstream issue to this, and thankfully, Singapore already has a beautiful mechanism of addressing underage smokers. They have to undergo a programme, attend counselling and follow-up sessions.” He adds: “Singapore has been cited as having one of the most organised programmes to help smokers quit. It has a quit line, it has quit programmes in all polyclinics, but is it solving the problem yet? “Are we doing a good job? Maybe. Is there a solution to do a better job? I think we have found one.”
He is conscious that any proposal cannot be out of sync with public opinion, and he and his team believe the public is ready for a smoke-free Singapore, based on the results of the Singapore Lung Cancer Awareness Study in 2007. A total of 500 Singaporeans and permanent residents aged between 18 and 65 were interviewed, and 494 – including smokers – felt it was “important” or “very important” to prevent children from taking up smoking.
“They were also asked the question, ‘Would you support a proposal to prevent tobacco being made available to Singaporeans born in and after the year 2000?’” “Over 70 per cent are in favour of the proposal,” he says. And, he notes with a measure of delight, these include smokers and those without children.
The proposal by Prof Koong and his team is available online at tobaccocontrol.bmj.com/content/19/5/355.full.pdf
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