Tobacco (Control of Advertisements and Sale) (Amendment) Bill – Speech by Leon Perera

(Delivered in Parliament on 7 November 2017)

Madam Speaker, smoking substantially harms human health. The health of the smoker. The health of those inhaling second-hand smoke. It has been causally linked to conditions like lung cancer, stroke, heart disease, emphysema and chronic bronchitis.

I support the raising of the legal smoking age to 21 as well as including online transactions under the Tobacco (Control of Advertisements and Sale) Act.

In fact, I would urge the government to make restrictions on tobacco marketing even more stringent by studying the case of Australia and emulating what Australia has done in imposing plain packaging, if legally permissible. This idea has been implemented in Australia, New Zealand, France, the UK, Norway, Ireland and Hungary. There is promising evidence that plain packaging can change people’s attitudes towards smoking and may help reduce the prevalence of smoking and increase attempts to quit. I hope the government will explore this in the next round of amendments.

I would like to spend the remainder of my speech on the issue of e-cigarettes or heat-not-burn tobacco products. Once this Bill is passed, we will be in a curious position – it will be illegal to possess e-cigarettes, but it will not be illegal to possess and smoke regular cigarettes. I am certainly not suggesting a ban on normal cigarettes – that would, I suspect, lead to consequences like what was seen in the USA in the 1920s when they attempted the prohibition of alcohol. But I would like to explore if we can take a more nuanced position with regards to e-cigarettes by allowing confirmed smokers access to them in a controlled way.

While there is some division of medical opinion about the extent to which e-cigarettes are less harmful than regular cigarettes, surely there is no evidence, and no one would argue, and surely it is not the government’s argument, that e-cigarettes are as harmful or more harmful than regular cigarettes. Yet after this Bill is passed it would seem that possession of e-cigarettes will be an offence but possession of normal duty-paid cigarettes will not be.

Earlier this year I asked a Parliamentary question about the government’s stance on e-cigarettes. The reply was that the government will not relax its stance on e-cigarettes because there is insufficient evidence that e-cigarettes are significantly less harmful than conventional cigarettes. The reply also stated that e-cigarettes contain similar levels of nicotine as normal cigarettes.

In my supplementary question I alluded to a study by the British Royal College of Physicians that concluded that there is evidence to suggest that e-cigarettes can reduce harm by enabling smokers to move from a more harmful to a not harmless but less harmful class of products.

I would like to repeat the observation that there is no evidence that e-cigarettes are more harmful than normal cigarettes. If the government has any such evidence it would be useful to share that evidence with the wider public, but to the best of my knowledge no such evidence exists. And yet with this Bill we would be imposing penalties on possession of e-cigarettes but not for normal tar-containing cigarettes.

In response to my SQ, SMS Amy Khor said, and I will quote this in full for a more well-informed debate, she said: “Our concern really is with the fact that allowing the use of such products could attract a much larger group of users, especially among the youths, and that could be the gateway to nicotine addiction and eventually, smoking. We note the UK reports but despite reports from the UK, the experience of US is quite different. The US CDC has reported that e-cigarette use among high school students between 2011 and 2015 increased by more than 10 times, from 1.5% to 16%. The US Surgeon-General also reported that the use of e-cigarettes is closely associated with cigarette smoking among youths and young adults.”

There are two distinct points here.

The first is that legalizing e-cigarettes may induce non-smokers to take up smoking of e-cigarettes. The second is that legalizing e-cigarettes may provide a gateway to smoking regular cigarettes.

I agree with preventing non-smokers from having access to e-cigarettes. We do not want to expand the pool of smokers of any kind of cigarette. We want to move in the opposite direction.

I would like to argue that both the points made by the SMS in her reply to my PQ on 2 March 2017 are not arguments against allowing smokers who are trying to quit to have access to e-cigarettes, which was the argument I made in March.

Why not allow a controlled quantity of e-cigarettes to smokers who register with the HPB for a smoking cessation program and sign a declaration that they are smokers trying to quit?

Why should we allow this? The reason is simple. If e-cigarettes are truly less harmful, allowing non-smokers access to e-cigarettes will enable them to reduce the harm they cause to themselves and others. Over 10% of adult Singaporeans are smokers. The number of people this could benefit is not small – in fact it is massive. If some of the claims being made about e-cigarettes are even remotely true – for example the headline claim is that they are 95% safer – this could end up extending the lives of smokers and reducing their suffering. This could also reduce state spending on treating the medical conditions associated with smoking normal cigarettes, state spending in the form of hospital subsidies and so on.

It is not easy for smokers to quit. Surely the humane thing to do is to allow to smokers – both those seeking to quit and reduce consumption – an avenue to use a less harmful product?

I agree with the MOH’s statement that there is no harmless level of smoking. Where I disagree is on what is the best, most humane path to take on the road to that goal.

Next let me come to the clinical evidence about e-cigarettes.

In a report released in Feb 2016, which I also referred to in my SQ in Feb this year in this House, the British Royal College of Physicians reviewed the clinical evidence and concluded that e-cigarettes are beneficial to public health and much safer than smoking. I quote from their press release: “…the possibility of some harm from long-term e-cigarette use cannot be dismissed due to inhalation of the ingredients other than nicotine, but is likely to be very small, and substantially smaller than that arising from tobacco smoking. With appropriate product standards to minimise exposure to the other ingredients, it should be possible to reduce risks of physical health still further. 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% of those associated with smoked tobacco products, and may well be substantially lower than this figure.” A report from Cochrane, a global non-profit group that reviews all the evidence on healthcare interventions and summarises the findings, came to similar conclusions. I quote: “While our conclusions are limited because there aren’t many high quality studies available yet, overall the evidence suggests that (1) e-cigarettes with nicotine can help people quit smoking, (2) they don’t seem to have any serious side effects in the short- to mid- term (up to 2 years), and (3) in some cases, switching to them leads to changes in your blood and breath that are consistent with the changes you’d see in people who give up smoking altogether.”

We can say that the evidence on e-cigarettes is not 100% fool-proof. But is the evidence for any policy ever 100% fool-proof? Rarely so.

The point is – where is the evidence that e-cigarettes are as harmful or more harmful than normal cigarettes? There is none.

The reason is well-known among professionals in the field but not among the wider public. The vast bulk of the harm caused by cigarettes is from tar and other harmful chemicals, not nicotine. Nicotine in and of itself is not benign but is no more harmful than many other substances that are perfectly legal, like alcohol and trans-fats.

Again, I am not arguing that e-cigarettes be made legal but that we allow confirmed smokers access to e-cigarettes at least for a certain period of time as part of their efforts to quit smoking or reduce consumption. To quote from the Royal College of Physicians report: “…among smokers, e-cigarette use is likely to lead to quit attempts that would not otherwise have happened, and in a proportion of these to successful cessation. In this way, e-cigarettes can act as a gateway from smoking.”

There are a number of possible objections to this suggestion. Let me deal with them one by one.

Objection #1: That there is no evidence that e-cigarettes help people quit. But there is. The RCP study I cited states, and I quote: “among smokers, e-cigarette use is likely to lead to quit attempts that would not otherwise have happened, and in a proportion of these to successful cessation. In this way, e-cigarettes can act as a gateway from smoking.” I will quote from a report by Public Health England dated August 2015. Professor Anne McNeill of King’s College London, the independent author of the review, wrote: “…the evidence consistently finds that e-cigarettes are another tool for stopping smoking and in my view smokers should try vaping and vapers should stop smoking entirely.” Professor Linda Bauld of Cancer Research UK, an expert in cancer prevention, wrote: “In fact, the overall evidence points to e-cigarettes actually helping people to give up smoking tobacco.”

Objection #2: Non-smokers could game the system and declare themselves to be smokers trying to quit just to get access to e-cigarettes. But this moral hazard argument applies to many other existing policies. For example employers could over-declare the salaries of workers on employment passes and special passes and take kick-backs in cash from those workers. Willing buyer, willing seller. Very hard enforce, no? But we enforce it by advertising penalties, investigating complaints, prosecuting offenders, encouraging whistleblowing and so on. The possibility of moral hazard is not a reason not to enact a certain policy in and of itself. It would only be so if there are no means to reasonably control the downside risk and if the downside risk outweighs the upside benefit. In this case, smokers who enrol into a program to get access to e-cigarettes could be asked to sign a declaration that they are smokers, have friends or family members sign a declaration too, and they could be given a detailed questionnaire and perhaps, if possible, some physical tests to ensure that they are indeed smokers. Penalties would be attached to false declarations.

Objection #3: People could procure e-cigarettes through such a program and sell the same into the black market for profit. However each individual would only get enough for their own consumption. The supply could be decreased over time to encourage them to quit. It would be risky, difficult and costly for a black marketer or syndicate to use this method to obtain such small quantities of e-cigarettes when they can simply resort to the kind of smuggling that is often seen in cases where non-duty paid cigarettes are seized by customs authorities.

Objection #4: E-cigarettes are a gateway to smoking. My suggestion is not to legalize e-cigarettes for the general public but only for confirmed smokers who are trying to quit or reduce smoking. So this objection is not applicable as it would give access to e-cigarettes only to those already smoking conventional cigarettes, people who have already gone through the gateway, as it were. But in any case, I would repeat the point that the UK Royal College of Physicians study in 2016 did not find any evidence that e-cigarettes were a gateway to smoking conventional cigarettes or that they normalise smoking.

In conclusion, I would urge MOH to review its position and allow some degree of access to e-cigarettes for confirmed smokers. If we can extend the lives of smokers and those exposed to second hand smoke, if we can reduce their suffering and at the same time reduce medical costs borne by the state and individuals, we should explore every option to do so.

If the MOH will not change its positon, would the MOH at least agree to review the evidence and reconsider its position if more evidence emerges that e-cigarettes really do reduce harm? What standard of evidence would satisfy MOH on this issue?

Having said that, I believe the good in this Bill outweighs the bad and I do support the Bill with the reservations mentioned above.