Tobacco (Control of Advertisements and Sale) (Amendment) Bill

Order for Second Reading read.

2.25 pm

The Parliamentary Secretary to the Minister for Health (Mr Amrin Amin) (for the Minister for Health): Mr Speaker, on behalf of the Minister for Health, I beg to move, "That the Bill be now read a Second time."

Smoking continues to be a significant public health problem in Singapore. While smoking rates have decreased from over 18% in the 1990s, they have stagnated at around 12% to 14% in the last decade. Twenty-three percent, or one in four, Singaporean men still smoke, much higher than in countries, such as Australia, which stands at 14.5% and the US at 15.6%. Every day, six Singaporeans die prematurely from smoking-related diseases.

Singapore adopts a multi-pronged approach to tackle tobacco addiction. This includes public education, taxes, tobacco control laws, regulations on smoke-free areas and help for smokers to quit. In recent years, we have enhanced our control measures. Our goal is to denormalise the use of tobacco products over time.

Mr Speaker, please now allow me to highlight the major provisions of the Bill. First, let me elaborate on the proposed increase in the Minimum Legal Age (MLA) for tobacco from age 18 to 21 for the purchase, use, possession, sale and supply of tobacco products.

Clause 2 of the Bill inserts a new definition of "under-aged person" in section 2 of the Act, to provide for a phased increase in the MLA. Consequently, provisions in the Act that refer to "persons aged below 18 years old" would be amended to an "under-aged person". The details of the changes are in clauses 3, 4, 5 and 9 of the Bill.

We are increasing the MLA for tobacco for several reasons.

First, adolescent brains are especially vulnerable to nicotine addiction. This is according to a 2015 report by the US Institute of Medicine. The 2012 US Surgeon-General's report also showed that the younger someone tries smoking, the higher the probability of him becoming a regular smoker. Smokers who start earlier also find it harder to quit smoking later in life.

Secondly, our data shows that we need to do more to discourage smoking among our young. Close to 95% of smokers had their first puff before they turned 21, 45% of smokers became regular smokers between their 18th and 21st birthdays. Based on HPB's student health surveys, among youths below 18, two-thirds of smokers get their tobacco from friends and schoolmates. Raising the MLA to 21 will mean that retailers cannot sell tobacco to youths between their 18th and 21st birthdays, thereby denying such youths and those in their social circles easy access to tobacco.

We know that social and peer pressures strongly influence youths to start smoking. By raising the MLA, we are further denormalising smoking, particularly for those below 21. This will further reduce opportunities for youths to be tempted and take up smoking before they reach the age of 21.

We have consulted extensively on the MLA increase. There is strong support from all segments of society, from youths, parents and businesses. The MLA will be progressively raised over a period of three years to minimise impact on smokers currently between the ages of 18 and 21. We plan to raise the MLA to 19 on 1 January 2019, 20 on 1 January 2020 and, finally, to 21 on 1 January 2021. Nonetheless, during the transitional years from now till 2021, we will encourage all youths to refrain from smoking as smoking is harmful.

Quitting is a journey and it will take time for smokers to successfully quit. The phased implementation recognises this. The Health Sciences Authority (HSA) will be distributing the new "no-sale of tobacco to underaged persons" signages and educational materials to all tobacco retailers. We will continue to work together with tobacco retailers, schools, Institutes of Higher Learning and agencies like MINDEF and MHA to ensure smooth implementation of the MLA increase.

During the public consultation, some have raised concerns that youths will turn to the illicit market for cigarettes if they are unable to buy cigarettes legally. We will work with Customs and relevant agencies to monitor the situation regarding illicit trade and step up enforcement and educational efforts.

Next, MOH will further tighten control over emerging and imitation tobacco products to protect our young and the general community.

At present, the importation, sale and distribution of shisha and other emerging tobacco products, such as smokeless tobacco, as well as imitation tobacco products, such as e-cigarettes and other types of vaporisers, collectively known as Electronic Nicotine Delivery Systems or ENDS, are prohibited. The purchase, use and possession of these products are, however, not prohibited currently.

The World Health Organization has urged countries to regulate ENDS, including banning them where feasible. Twenty-eight countries, including Australia, Brunei and Switzerland, currently ban the sale of ENDS.

To tighten regulation of emerging and imitation tobacco products in Singapore, clauses 6 and 7 of the Bill provide for new subsections under sections 15 and 16 of the Act respectively to prohibit the purchase, use and possession of these products.

Effectively, the importation, sale, distribution, purchase, use and possession of emerging and imitation tobacco products shall be prohibited with this Bill. Why are we taking this step?

First, ENDS and all tobacco products are harmful to health. ENDS produce toxic substances in the vapour, including carcinogens, which increase the risk of cancer of the throat, stomach and bladder. ENDS also contain nicotine, which is highly addictive. It is well-known that nicotine has harmful effects on fetuses and brain development in adolescents. There are claims that ENDS are less harmful than cigarettes. Some of these actually come from research sponsored by the tobacco industry. So-called lesser-harm tobacco products still expose the user to toxic substances that are harmful to health and keep the user addicted to nicotine.

Second, we do not want ENDS or other emerging tobacco products to become entrenched in Singapore. We have seen an exponential increase in the number of people using ENDS in other countries. For example, an estimated 2.8 million adults in Great Britain used e-cigarettes in 2016, representing a four-fold increase from 700,000 users in 2012. The use of e-cigarettes among students has also increased significantly in countries, such as New Zealand and the United States.

Overseas, tobacco companies are increasingly marketing ENDS the same way as tobacco products were marketed. There is also growing evidence that ENDS manufacturers are targeting the youth market, for example, by using flavours, such as chocolate, strawberry and mint, and with sleek videos and marketing them as trendy choices.

Third, ENDS can be a gateway or "starter product" which gets the user hooked on nicotine and lead to cigarette use later. A systematic review of nine studies involving more than 17,000 youths in the United States found that e-cigarette users were three times more likely to become cigarette smokers compared to non-users. Another study showed that among more than 19,000 Canadians, aged 14 to 18 years old, those who used ENDS were twice as likely to go on to regular smoking. Other studies in England, Scotland and Poland similarly support this "gateway effect".

MOH has received feedback arguing that we should consider allowing the use of ENDS by smokers to quit smoking. There are also views that offering a less harmful product like ENDS is a way to reduce the harm of smoking-related diseases in smokers. We have considered these arguments, but are not persuaded.

We have already approved nicotine replacement therapies, such as nicotine inhalers, gum and patches, to help smokers quit. These are registered as therapeutic products under the Health Products Act. Such products have undergone stringent evaluation of their safety, quality and efficacy as a smoking cessation therapy prior to registration. They are exempted from the Tobacco Act.

While there are some studies which suggest that e-cigarettes may help smokers to quit, the current limited evidence is neither robust nor conclusive. If any ENDS manufacturer has supporting data from credible and robust scientific studies, it can submit its product for evaluation as a smoking cessation therapy. Till now, none has done so. If registered under the Health Products Act, the product will be exempted from the ban in the Tobacco Act. For smokers who wish to quit, there are proven methods and products, and ENDS have not been proven to be one of them.

Next, I will turn to other amendments in the Bill.

Clause 8 of the Bill provides for a technical amendment to section 18 of the Act, to specifically restrict every licensed retail outlet to having only one point of sale. This amendment eliminates the need for HSA to specify the location of the point of sale in each licence issued.

Clause 2 of the Bill inserts new definitions of "tobacco product" and "tobacco substitute" to improve clarity.

Clause 6 repeals section 15(6) of the Act, to align the definition of smoking for section 15 with the general definition of "smoking" in section 2(1).

Clause 10 of the Bill amends section 35 to state that composition sums collected shall be paid into the Consolidation Fund, instead of being retained by HSA.

Clause 11 of the Bill inserts a new definition of section 35A, which provides that persons involved in the administration, collection and enforcement of payment of any composition sum collected under section 34 shall be treated as public officers for the purposes of the Financial Procedure Act.

Mr Speaker, Sir, smoking is a major cause of premature death in Singapore. The changes proposed in this Bill will go towards protecting our population and, especially the young, from the harms of tobacco products. There is mounting pressure, especially from self-interested parties, to relax our position on ENDS. Our interest is in protecting our people. I seek the Members' support for this Bill. Mr Speaker, I beg to move.

Question proposed.

2.38 pm

Dr Chia Shi-Lu (Tanjong Pagar): Mr Speaker, I rise in strong support of the Bill.

I am particularly worried that smoking prevalence remains sticky amongst the young. As Parliamentary Secretary Mr Amrin Amin has just noted earlier in his speech, 95% of Singapore's smokers first smoked before the age of 21 and 45%, became regular smokers between the ages of 18 and 20. If we were to look at the age of inception, that means, at the age at which smokers took their first puff, the statistics also bear grim reading. In 2001, our youth smokers started when they were 17. That was the age when they took their first cigarette. In 2013, we found out that they were actually taking their first puff at 16 years of age. And all these occurred despite current legislation which makes it illegal to smoke under the age of 18.

As noted, adolescent brains are more sensitive to the rewarding effects of nicotine. Hence, young persons who start smoking early are more likely to continue smoking into adulthood and become addicted. The intensity and persistence of smoking also correlate with how early smoking started. We should take note of the 2008 World Health Organization report which states that people who do not start smoking before the age of 21 "are unlikely to ever begin". Bearing this in mind, this leads to the first of my four clarifications.

First, this Bill proposes to increase the minimum legal age (MLA) over three years to 21 years. Twelve months from the day the law is passed, the MLA will be raised to 19. Then, we have to wait another 12 months for it to go up to 20, and another year before it is raised to the age of 21. As a result, smokers aged between 18 and 21 at the time the Act is amended will be exempted. The rationale is to give youth smokers who may be already addicted some time to adjust.

However, I am of the opinion that such stepped implementation is unnecessary and perhaps too gradual. If someone who has just turned 18 has also just started smoking, this gradual implementation will continue to allow him/her to buy and use cigarettes until he/she is well and truly hooked. If we stop this smoker at the early stage of the addiction, it may be easier for him to quit. Therefore, I would like to urge the Ministry to increase the MLA for smoking to 21 as soon as possible.

We should supplement our efforts with a stronger public campaign to highlight all the negative impact on smokers' health − from the more obvious damage to the lungs to less widely known disease-causing DNA damage which can last more than 30 years after a person has stopped smoking. We have to engage our youths through every platform available as their future can be greatly affected by this life-changing addiction. In addition, the adverse impact of smoking on our National Service personnel, and the financial and resource burden upon our national health system should also not be under-estimated.

Second, we also have to consider the impact on tobacco retailers' employees, some of whom are aged between 18 and 20. With this increase in the MLA, staff aged below 21 will not be able to sell tobacco. I think this is a move in the right direction, as constant exposure to tobacco products in the course of their work could tempt these young persons to try smoking themselves. Nonetheless, I would like to ask if measures can be taken to diminish the economic impact on these young employees over this period of implementation.

Third, while I laud the ban on Electronic Nicotine Delivery Systems (ENDS), I am concerned that there are many online vendors. And I would like to check with the Ministry what its strategy is to control this source of ENDS.

And for my final point of clarification, the Bill proposes to align the penalties for the possession of tobacco products and imitation tobacco products for the purposes of sale to that for import, distribution, sale or offer for sale. For a first offence, a fine of up to $10,000, or jail of up to six months or both; and for the second and subsequent offences, a fine of up to $20,000 or jail of up to 12 months or both.

May I suggest that we set minimum sums for the fines but remove the ceilings in order to introduce fines based on the quantity and value of the products seized? In addition, we should consider imposing fines on the logistics companies used by the importers to motivate them to inspect their cargo more carefully. An additional layer of checks would be useful. Thank you and I support the Bill.

2.43 pm

Mr Leon Perera (Non-Constituency Member): Mr Speaker, Sir, 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 United Kingdom, 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.

Mr Speaker, Sir, 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 would 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. I would like to explore if we can take a more nuanced position with regard 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 the 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 (PQ) about the Government's stance on e-cigarettes. The reply was that the Government will not relax its stance 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 (RCP) 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.

In response to my supplementary question, Senior Minister of State Amy Khor said – and I will quote this in full for a more well-informed debate: "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 the 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 legalising e-cigarettes may induce non-smokers to take up smoking of e-cigarettes. The second is that legalising 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 Senior Minister of State 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, say, the Health Promotion Board, for a smoking cessation programme 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 the smokers − both those seeking to quit and reduce consumption − an avenue to use a less harmful product.

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

Next, let me come to the clinical evidence about e-cigarettes. In a report released in February 2016, which I also referred to earlier this year in this House, the British Royal College of Physicians (RCP) 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 will quote from the report from Cochrane: "While our conclusions are limited because there are not many high quality studies available yet, overall the evidence suggests that one, e-cigarettes with nicotine can help people quit smoking; two, they do not seem to have any serious side effects in the short- to mid- term (up to two years); and three, in some cases, switching to them leads to changes in your blood and breath that are consistent with the changes you would 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 so much.

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 of benign chemical but would seem to be no more harmful in a significant way than many other substances that are perfectly legal, such as alcohol and trans-fats, for example.

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 RCP 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.

The first objection is that there is no evidence that e-cigarettes help people to quit. But there is. The RCP study and the Cochrane study I cited state, and I will quote again from the RCP study: "Among smokers, e-cigarette use is likely to lead to quit attempts that would not otherwise have happened…"

Public Health England also released a report in August 2015 and I will quote from some of the academics who collaborated on this report. Firstly, from Prof Anne McNeill of King's College London, "…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." From Prof Linda Bauld of Cancer Research UK, an expert in cancer prevention: "In fact, the overall evidence points to e-cigarettes actually helping people to give up smoking tobacco."

The second objection is that 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 areas of policies. For example, employers can and frequently do 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 to enforce. But we do enforce it by advertising penalties, investigating complaints, prosecuting offenders, encouraging whistle-blowing and so on and so forth.

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 reasonable methods to bring some degree of reasonable control over the moral hazards, downside risk, and if the downside risk outweighs the upside benefit. In this case, smokers who enrol into a programme 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, even physical tests, if possible, to ensure that they are, indeed, smokers. Penalties would be attached to false declarations.

The third objection would be that people could use this technique and procure e-cigarettes through such a programme and sell them into the black market for profit. However, each individual, under this suggestion, would only get enough for their own consumption, a controlled amount that could be reduced over time. The supply could be decreased over time to encourage them to quit. It would be risky, difficult and costly for a prospective 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 to bring in quantities in bulk that is often seen in cases where non-duty paid cigarettes are seized by customs authorities.

The fourth objection would be that e-cigarettes are a gateway to smoking. My suggestion is not to legalise e-cigarettes for the general public − I cannot emphasise this point enough − 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, in passing, I would note the point that the UK RCP study made, which is that they 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. We have a duty to explore every option to do so.

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

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

2.56 pm

Er Dr Lee Bee Wah (Nee Soon): Mr Speaker, Sir, promoting a smoke-free environment in Singapore is an enduring challenge that is close to my heart. From championing for designated smoking points to rallying ambassadors to educate and spread awareness, it is my wish for residents to enjoy living in a clean and green environment. More importantly, good health is crucial for one to lead an active and fruitful lifestyle. I fully support the view that smoking and the presence of second-hand smoke are detrimental to one's well-being. It is also an immense burden on public health.

I am pleased to note that in recent years, the Government has been actively introducing new measures aimed at gradually making smoking a thing of the past. Having received disturbing feedback about students spotted smoking in their school uniforms, or even forming smoking cliques in school and National Service, I am supportive of the Bill to raise the legal smoking age to 21. I believe this will, to some extent, serve as an additional impediment to discourage teenagers and adolescents, at their most impressionable age, to pick up smoking. There are ample studies, including by the World Health Organization, to indicate that a huge percentage of smokers pick up the habit or get addicted before they turn 21. Cities across the US are raising the legal tobacco purchase age from 18 to 21. Experts have rationalised that this would reduce peer pressure to smoke.

Meanwhile, members of the Eliminate Cancer Initiative in Australia are lobbying to convince federal and state governments to raise the legal tobacco purchase age from 18 to 21, which they believe will not only save lives but up to A$3.1 billion a year from the government's coffers. So, we are catching up with what a number of countries had done.

I should add that this is only a small part of the solution. Determined young smokers will find ways to get around the law. They can ask their older friends or even strangers to help them to buy cigarettes. In spite of a smoking ban in many public places, that is not stopping smokers from lighting up, as long as no NEA officer is around to enforce the smoking ban. If enforcement is inadequate, the policy will become a white elephant.

Understandably, NEA has limited resources and is unable to station officers throughout Singapore at the right time, at the right place. I hope the agency would have to think of ways to overcome this. Perhaps more education, more campaigns by MOH and more enforcement by NEA.

May I suggest agencies work closely with the public to track down and penalise errant smokers. One way is to make it easier for the public to report illegal smoking. There should be a dedicated hotline for the public to call in. Or, better still, use mobile applications like OneService and incorporate a new function that allows people to quickly submit reports on the spot. Once multiple feedback is received about particular hot spot areas, then NEA can deploy more enforcement officers to book the culprits.

I have also had feedback from residents who would dutifully call NEA to report smoking on prohibited premises, such as HDB void decks. But they told me they did not receive any follow-up on their feedback. In fact, later on, they would see the culprit committing the offence again. So, they are disappointed. They told me their feedback was not taken seriously. We need to walk the talk.

Also important is equipping young Singaporeans with knowledge to make informed decisions for themselves. Our schools are doing a fairly good job imparting the relevant knowledge on hazards of smoking. There have been several anti-smoking campaigns as well. Perhaps, more must be done to highlight the financial and health burden of smoking on the individual, family, environment and the nation. We should home in on how smoking negatively impacts the eco-system, from littering to producing of carcinogenic smoke that can assassinate our young children.

Next, give assistance to addicted smokers, especially those under the age of 21. Just as we now have professionals in counselling and career guidance stationed in schools to meet changing demands of the youth population, are there counsellors in schools who are trained in smoking cessation?

In pursuing a smoke-free nation, we must not alienate the smokers. Many might have picked up the habit due to external influence and pressure or because they did not know what they were getting themselves into and now find it difficult to quit. Some grew up with smoker parents. Furthermore, there should also be more resources to educate family and friends on how they can help their loved ones. Smokers will require compelling reasons and supportive, accessible platforms to kick their addiction willingly. A well-informed and conscious decision to quit is more effective than any law and policy to keep the cigarettes away. In fact, I believe that no amount of law can keep both smokers and non-smokers happy.

Just two days ago, I had a block party. A young mother came to share with me her problem. She lives on the ground floor and, beside her block, there is a staircase that leads to the main road. And every morning, she says that there are lots of people standing at the staircase there, either waiting for friends or waiting for transport. And while waiting, they are smoking, puffing away. And she says that the smoke affects her child very badly because her child has asthma. She tried to talk to the smokers but the smokers stared blankly at her and looked into the sky and told her that, "This is open air. You go and call NEA, lah."

I have received another feedback from a resident. She says that she lives with her father-in-law. She has two young children. Her father-in-law always smokes in the living room. She wanted to protect her children, brought her children upstairs, because they live in an executive apartment. But then she says that the smoke went up and she is asking for help. But her father-in-law smokes in his own home − not against any law.

So, I would like to take this opportunity to urge all smokers − be responsible smokers, be more considerate. Before you light up the next cigarette, look around whether there are any other young children, whether the smoke will affect other people, because, in both cases, I can feel that the mothers are so helpless. Sir, in Chinese, please.

(In Mandarin): [Please refer to Vernacular Speech.] Smoking damages the health of our young people. Hence, I fully support the amendment to increase the minimum smoking age to 21. Besides upping the smoking age, I hope the Government can also think of ways to bring down the smoking rate in Singapore.

For example, there are many places that ban smoking in Singapore. However, when there are no NEA officers around, smokers will still light up. The public should be able to report these smokers via OneService or a designated hotline.

We should also step up anti-smoking efforts at IHLs, including educating students on the harmful effects to themselves and to the country. If the school finds out that a student is addicted, it should not just punish him but also find experts to help him quit smoking.

I hope smokers can be more considerate towards others. Before they light up the next cigarette, they should look around to see whether his second-hand smoke will affect his family, friends and neighbours, and be a responsible smoker.

Mr Speaker: Er Dr Lee Bee Wah's quote about our young smokers requires some time for reflection. I propose to take the break now. I suspend the Sitting and will take the Chair at 3.30 pm. Order.

Sitting accordingly suspended

at 3.09 pm until 3.30 pm.

Sitting resumed at 3.30 pm

[Mr Speaker in the Chair]

Tobacco (Control of Advertisements and Sale) (Amendment) Bill

Debate resumed.

Mr Yee Chia Hsing (Chua Chu Kang): Thank you, Mr Speaker. Sir, I rise in support of this Bill. However, I would like to bring up the issue of second-hand cigarette smoke, especially those suffered by HDB residents who stay above chain smokers.

Typically, the resident who is smoking will stand near the window and the smoke then blows up to the unit above. Prolonged exposure to second-hand cigarette smoke can be very harmful. During the Second Reading of the Community Disputes Resolution Bill in March 2015, Members, such as Er Dr Lee Bee Wah and Mr Zainal Sapari, had brought up this issue of second-hand smoke in HDB homes. And usually, the solution is for the residents to go for mediation. One of the main shortcomings of mediation is that it will not happen if one of the parties is uncooperative.

Sir, our current regulations allow smokers to smoke within their own homes. While we respect the rights of residents to smoke in their own homes, the right to clean air for the neighbours must also be respected.

Mr Speaker, Sir, there had been instances where the rights of residents in their own homes have been curtailed in the spirit of public interest. For instance, I understand it is unlawful for anyone to exhibit indecent exposure even within their own homes if their neighbours complain.

Sir, I would like to suggest that MOH set some guidelines, together with NEA, on what constitutes unhealthy levels of second-hand smoke. To the extent where there is evidence to prove that second-hand smoke in the upstairs' neighbours' homes have reached unhealthy levels, then the affected residents can apply to Court for the residents downstairs to take measures to reduce the level of second-hand smoke. Such measures may include prohibiting the smoker from smoking near the window.

Mr Speaker, Sir, notwithstanding my comments, I support this Bill.

3.31 pm

Ms Joan Pereira (Tanjong Pagar):Mr Speaker, Sir, I am heartened that the Ministry has taken this step to increase the minimum legal age (MLA) for smoking from 18 to 21. I think it would have been better, however, that we increase it as soon as possible, instead of incrementally over three years. While I understand the logic for this decision, which is to provide time for smokers to adjust, I feel that it is even more important and more urgent to prevent any youth from getting started on smoking in the first place. The risk of addiction by those under 21 necessitates fast and firm implementation to reduce any exposure.

Furthermore, increasing the MLA year by year over the next three years will cause confusion. It is not easy for the man-in-the-street to keep track of the schedule and, even worse, this arrangement may tempt certain youths who are exempted to try their first smoke earlier, since they enjoy the so-called unique chance to be among the last batch of those who get to smoke legally below the age of 21. Hence, I appeal to the Minister to seriously consider removing the gradual phasing and raise the legal age in one swift stroke.

Next, I am concerned by the wide availability of cigarettes. One can purchase them anywhere: 24-hour stores, supermarkets, mom-and-pop shops. It is really so easy to lay one's hands on a packet.

Despite their fairly high costs, we still have a pretty high number of smokers − roughly about 13% of Singaporean residents smoke. Given the tremendous harm smoking and second- and third-hand smoke do to our people, I think it is completely justifiable to reduce the number of stores which are licensed to sell cigarettes.

I would like to reiterate what I had said here during the COS debates about third-hand smoke. Third-hand smoke refers to the residual nicotine and chemicals which accumulate on surfaces and resist normal cleaning. This is what clings to the hair, your clothes and any surface in the vicinity long after the smoking activity itself has stopped. Research has found that third-hand smoke poses a potential health hazard to anyone exposed to them, especially our young children.

It is imperative that we drastically reduce the availability of these toxic products. And, I would like to ask the Ministry how many licensed retailers there are presently and if we can aim to reduce these outlets, in phases, if necessary, say, by about 5% every year.

With the proliferation of social media, the general public has become more image conscious, especially the youths. I would like to suggest more targeted public education by tapping on this trend. As smoking is so damaging to health, smokers generally end up looking much older than their years. So, by the time a smoker reaches the age of 40, he or she would probably look 10 years older. We can use this awful impact on smokers' visages to encourage smokers to quit.

In addition, I urge the Ministry to work more closely with our Primary and Secondary schools to educate our young on the harmful effects of smoking. More can certainly be done to inform our children about the evils of cigarettes. Would the Ministry share with us what are the current measures and educational campaigns in our schools and how effective they have been? In addition, we should look into ways we can educate older family members and friends of our young about not sharing their cigarettes with impressionable teenagers.

Finally, I want to say that I am very glad that the purchase, use and possession of e-cigarettes will be banned. I hope the Ministry would consider placing a heavier onus on logistics companies to prevent their services from being used to deliver these noxious products. This is in view of the fact that most of our e-cigarettes have been delivered via Internet orders. I would like to conclude with my support for the Bill.

3.36 pm

Mr Alex Yam (Marsiling-Yew Tee): Mr Speaker, if I had a choice, I would very much prefer that we be introducing a replacement to this Act called the Tobacco (Prohibition) Act.

Cigarette smoking is the second highest risk factor contributing to the burden of disease in Singapore. I have seen first-hand how the bane of cigarettes has led to many health problems. In fact, according to the US Centre for Disease Control and Prevention, the number of deaths, directly or indirectly related to cigarette smoking causes one out of every five deaths in the US every year. That is more than 480,000 deaths in the US alone. This, compared to drug deaths, which only record a total of 64,000. That gives an idea of the scale.

I have seen it first-hand as well. My paternal grandmother was a heavy smoker. State Express 555 was her brand of choice. She was an opera singer by training and led an otherwise healthy life. But the puffs she took was to lead to a major heart attack and her untimely passing before she could undergo surgery. My dad was also a heavy smoker. He smoked packs, not a pack, but packs daily. Just before my grandmother passed away, he was trying to give up smoking. But perhaps the grief of losing his mother started him on cigarettes again.

I remember hiding his cigarettes in the garden, doing everything we could to convince him to give up smoking. He tried, but, like most smokers will tell you, it is hard to break the habit once it has started. Then, one day, while he was working in Shanghai, he broke out in cold sweat and had chest pains. He ignored it and slept over it. A few weeks later, he travelled to Macau. I was still in the army at that time. I remember receiving a call from my mother saying something had happened to him. He had said that it was appendicitis so we flew him home and he almost wanted to down some Po Chi Pills and just head home to rest. By sheer willpower, we managed to get him to hospital.

During the pre-surgery checks, the doctors noticed that there was something wrong with their ECG results. They changed to another machine and got the exact same results. He had had a major heart attack. What happened next was 24 hours of being in surgery for his appendicitis and, more importantly, for a major heart bypass. We are thankful that the doctors saved him. He is leading a healthy life with his grandchildren right now. But others do not have the same benefit like he had. I have also seen friends suffering from lung cancer, a slow lingering death, suffocating, painful, tragic.

These are just some examples, and there are many, of how something sometimes seen as cool or hip to have a cigarette in your hand, can lead to personal health risks and a major burden on our healthcare system. It is also a risk not borne just by the smoker himself, but also by those around them.

We have one of the strictest regimes in tobacco control in the world. We ban tobacco advertisements, we limit tar and nicotine, we ban shishas, we were the first in Asia to introduce graphic warning labels and we also have a strict Point of Sale Display (POSD) ban. Yet, while numbers have fallen, as pointed out by the Parliamentary Secretary, we are still amongst the highest in smoking rates amongst OECD countries.

I, therefore, welcome the efforts of the TCASA to further tighten regulations. The MLA has been raised to 21 in response to the statistics that show that the majority of smokers have their first experimentation before that age. Yet, I am confused as to why we should decide on a phased approach to this. Should we not have immediate implementation as the best way forward? Who does the phased approach benefit? If we believe that smoking is inherently unhealthy, should we not introduce the MLA with immediate effect? In fact, as I have mentioned earlier, if we believe that a burden on public health is a major one caused by smoking, should we not ban tobacco completely?

With regard to the use of ENDS, I applaud the Bill's response to these emerging products. However, I would like to ask how exactly will the Ministry police the import and use of these products, especially when travel is now very much a part of the Singaporean lifestyle. Many travel abroad and purchase items, such as vaporisers and nicotine substitutes, many of which are unregulated overseas and may contain harmful additives.

Just a few weeks ago, I was at Mount Alvernia Hospital and I saw a vape being used openly. When the user spotted me looking at him, he stuffed his vaporiser into his bag – something where you cannot really do with a lit cigarette – and boarded the shuttle bus. He is just one of those I have seen using vapes and e-cigarettes around Singapore. While we do not want to be inspecting every single online shopping parcel entering Singapore or to check every bag of a returning Singaporean at our ports or airports, how will we prevent such items from entering Singapore and being used?

The hon Member Leon Perera quoted a study in the UK on the low risk of vaporisers. The National Institute for Health in the US studied this particular report and came to the conclusion that only 181 self-selected respondents participated in this particular study and many other factors were not included in coming up with the results. So, I am highly doubtful that an initial study conducted with a very small group of respondents can be relied on for us to make exceptions to the rules that we are setting here today in this House.

Mr Speaker, Sir, I believe all of us in this House can agree that tobacco is harmful and a tremendous burden on families, for those suffering from the ill-effects of smoking, as well as a danger to the well-being of Singaporeans. I, therefore ask, why we should not be considering a complete ban on a product that we deem as having no benefit. Maybe not now, but perhaps at some point in the near future, such as the regulations that had been put in place by Bhutan since 2004.

I support any efforts to safeguard the health of Singaporeans and to discourage smoking. I, therefore, add my voice to call for the Ministry to consider all the possibilities to lead to an eventual ban on tobacco in Singapore. Perhaps, a rolling system of bans. But, that being said, with the current proposals in this TCASA, I support the amendments to the Bill.

3.43 pm

Ms K Thanaletchimi (Nominated Member): Mr Speaker, Sir, I rise in support of the Motion. Increasing the MLA for smoking from 18 to 21 is a move in the right direction and making it an offence to own tobacco substitutes, such as e-cigarettes, will surely prevent potential addiction to those substitutes.

Many youths today succumb to smoking for social acceptance by friends or peer pressure or falsely believing that it would reduce stress and for other reasons which they feel are justified. There is much anecdotal evidence, which we often heard, that the young male adults picked up smoking habits while serving National Service. Youths below 21 tend to be more vulnerable to fall into such undesirable and unhealthy habits as presently; at 18, they are able to purchase cigarettes freely. Research has shown that young adults would be less likely to start or be addicted to nicotine after the age of 21. However, there is apprehension whether by increasing the MLA, will the desired effects and intended outcome of having fewer young people being addicted to nicotine be realised in the local context.

Increasing the MLA will increase the social distance or age gap from social sources who can buy the cigarettes for them legally, but it may not deter teenagers who have been smoking daily. The main effect of doing so may simply be to drive 18 to 20 year-olds to find other means of obtaining tobacco, legally or illegally. For instance, purchase of cigarettes from commercial stores by this age-group will see a decrease, but this will mean that they will simply turn to their social sources, that is, soliciting help from someone who is 21 or above or being offered tobacco by relatives, friends or strangers.

One possible way to "effectively" pass a law to eliminate smoking or its onset in youth could be to introduce stiffer or greater penalties or punishments for the "middlemen" or social sources. There are existing laws in Singapore as deterrent that penalise underage teens who are caught smoking and teenagers or adult peddlers and commercial stores which sell them illegally. However, there is no safeguard from temptation; temptation aroused by social sources or acquaintances that continually provide easy access to tobacco or cigarettes as a form of temptation.

Introducing financial penalties that will progressively get harsher could be one way in which the state can not only ensure cigarettes are not sold to underage teens, but also ensure a reduction in access to social sources. Raising the age limit may potentially be a cosmetic deterrent that will not be effective enough if the availability of cigarettes from social settings in social events is not addressed.

Secondly, more needs to be done to change the image of smoking being "cool". Experimental smoking can stem from peer pressure, as a form of coping mechanism, but likely because these underage teens still think it is cool to smoke, and the Government needs to tackle mindset change in the way they view smokers.

Many youths look upon celebrities to be their role models and, therefore, it is important for such celebrities to be promoting abstinence from smoking. A series of public awareness campaigns and testimonies by famous sports talents and celebrities will be more impactful and a force to be reckoned with. It would also be worthy to consider helping individuals make their own decision to stay away from the smoking habit so that they feel empowered.

HPB pro-quitting campaign in 2014 was useful in the sense that it had moved away from the traditional campaign model of focusing on "anti-smoking" publicity as well as displays of debilitating and ill-effects of smoking on the individual and those around them by instead focusing on empowering individuals who had quit smoking. One should feel "more cool" not to smoke or quit smoking completely.

Perhaps, the Government can consider a campaign that is specifically targeted at youths below 21 years old and understand the psychology of preventing them from catching the habit of smoking at an early age. In addition to that, there could be more effective publicity put up in public spaces and crowded areas with the hotlines or alternative avenues, such as support groups or services, which current smokers can dial or visit if they ever want to consider quitting.

Our home is the first defence for our youths to stay away from cigarettes. Schools and social places where youths congregate should help in the education and sharing of testimony from fellow youths who had quit smoking and the start of an empowering journey of self-realisation for many other youths who have the intention to embrace smoking.

Importantly, public education campaigns will have to be met with sufficient funding so that the media components can achieve the necessary outreach to be effective. Perhaps, there can be more local research convened to study the ill-effects of smoking on the fertility of both genders and the effects on foetal development in pregnant women in the local context. Such facts can add to the realisation of not picking up the habit and, if individuals have done so, there is a possibility of such individuals dropping the habit due to better understanding of the perverse outcomes of smoking.

From the preventive health perspective, it is important that, as a society, as a caring community, we must put in all efforts to stop our young from being preyed upon by the smoking habit which will result in more chronic and critical illnesses, if left unchecked. Similar to the "War on Diabetes", HPB could consider a "War on Smoking" to stop this social ill and to mitigate against rising healthcare costs in the long run and reduce the environmental risks smoking poses. Mr Speaker, Sir, notwithstanding the concerns, I support the Bill.

3.50 pm

Dr Intan Azura Mokhtar (Ang Mo Kio): Thank you, Mr Speaker, for this opportunity to speak on this amendment Bill. To me, this is a very important Bill − one which complements our current laws against drug consumption and abuse. In my speech, I will address two issues. One, that adolescent smoking leads to a propensity for drug consumption and abuse; and two, that more needs to be done to curb adolescent smoking.

Data from the national health surveillance surveys conducted in 2010 and 2013 have shown that the number of smokers below the age of 30 years old has dropped from 16% to about 13% from 2010 to 2013. However, according to HPB, the proportion of youth that picked up smoking and who then became hooked on smoking before the age of 21, remains high at about 80%. This is very worrying.

I support the amendments to this Bill that will raise the minimum age for the sale or purchase of cigarettes and other tobacco products from 18 to 21. I would go one step further to make it illegal for any person below the age of 21 years old to even smoke a cigarette or other tobacco products. Hence, I strongly support the amendments to section 11 that prohibit underage persons from using, possessing or buying tobacco products.

Here, I must disagree with the hon Member Mr Leon Perera who advocates allowing controlled use of e-cigarettes.

I am not convinced that addiction treatment which has used so-called safer substitutes has worked. Let us not forget when we introduced subutex as an alternative to opiates back in 2002. This use of subutex created a whole breed of addicts and a disturbing increase in the emergence of needle culture among these addicts, even more than that during the peak of the heroin addiction. The subutex used primarily came from licit or lawful sources and not from illicit sources, because it was meant to treat opiate addiction by General Practitioners.

A comprehensive study published in 2000 from the Johns Hopkins School of Public Health shows that "cigarette smoking increases a person's risk of using illegal drugs" and that, "For all age groups combined, the 65.8% of participants who had ever smoked were: seven times more likely to have tried marijuana; seven times more likely to have tried cocaine; 14 times more likely to have tried crack; and 16 times more likely to have tried heroin. The results were even more startling when the statistical evidence was sub-divided by age groups. Associations between smoking and illegal drug use were significantly stronger for young people. For instance, people aged 12 to 15 who smoked cigarettes were 44 times more likely to use crack, compared with only a twofold risk in those 50 or older."

This study involved more than 17,000 respondents. Some may say this study is somewhat dated as it was published 17 years ago. However, another more recent research found that "Adolescent regular smokers showed significantly higher odds of using marijuana, cocaine and heroin", according to a longitudinal study spanning more than 35 years and which involved more than 1,200 individuals conducted by Strong, Juon and Ensminger, published in January 2016.

Research and academics aside, we cannot deny that curbing smoking among the young is not just about preventing them from picking up a bad habit. It is more than that. It is to help them to not pick up any form of substance addiction or abuse, as far as we can help it.

Mr Speaker, may I seek your permission and indulgence to do a little "show-and-tell" and share something with the House?

Mr Speaker: Sure. Please proceed.

Dr Intan Azura Mokhtar: This is a packet of loose tobacco leaves or "Roll-Your-Own Tobacco" that we can find in a lot of mom-and-pop shops here in Singapore. I think there are about five to 10 pieces of cigarette paper in here, and it is very cheap, costing only $2.60 a packet. Two persons I know have told me it is easy to buy them and that even students below the age of 18 have bought them, especially so when they are this cheap. Other than affordability, I have another concern regarding such "Roll-Your-Own Tobacco" products.

A few of our very enterprising students in our Institutes of Higher Learning are mixing such loose tobacco leaves with weed and selling them as drug-laced cigarettes to their schoolmates. When you see some of our students hanging outside our IHLs, since they can no longer smoke within the premises, and they are smoking, you might begin to wonder if it is just tobacco that they are smoking. While these numbers are small, it is still one too many. The possibility of having such numbers growing is high.

I would urge the Ministry to review the public sale of such small and affordable packets of loose tobacco leaves. If there is a need to sell such packets of loose tobacco leaves to cater to a select group of smokers who prefer rolling up their own tobaccos, there must be some parity to the price of rolled cigarettes sold in packets. If a packet of rolled cigarettes cost more than $10, so should these packets of loose tobacco leaves. Better still, ban them altogether. At this point, Mr Speaker, please allow me to say a few words in Malay.

(In Malay): [Please refer to Vernacular Speech.] Smoking is a habit that we must continue to eradicate, especially amongst our youths. Apart from causing health problems and wasting money, smoking is also a time-wasting habit. Just imagine, a stick of cigarette takes about five minutes to finish. If a person smokes 10 sticks each day, around one hour per day is burnt away − burning away the cigarette, burning away money, burning the lungs, as well as the health of that person. Is this habit not wasteful and highly unproductive?

Data on smoking from the National Health Surveillance Survey conducted by MOH in 2013 showed that the number of Malay smokers is more than twice the number of Chinese or Indian smokers. In addition, the proportion of our Malay youths under 30 years old who smoke is relatively higher, compared to Chinese or Indian youths. Malay youths who smoke daily are about 30%, whereas the national average is only 12.7%. This is a worrying trend.

Therefore, I strongly support the amendment Bill on advertisement and sale of cigarettes and smoking accessories, especially to our young people who are under 21 years old. Studies and research have shown that those who start smoking in their teens are more susceptible to drug abuse. If we wish to eradicate the problem of drug abuse, we must also stamp out the smoking habit. The amendment Bill that is being tabled is timely.

I would like to urge our youths to focus their time, effort, minds and energy on activities and projects that are useful and beneficial to others.

One example is the These-Abled group started by Ms Nur Aryssa Jumadin, Mr Mohd Haiqel Jamaludin and Mr Muhd Asyraf Mustaffa, who organised the IQRA Project where religious knowledge is taught using the Qur'an in Braille for the visually handicapped.

Another example is Mr Riduan Zalani. He is a well-known percussionist and a recipient of the Singapore Youth Award 2013 as well as the ASEAN Youth Award 2013. Mr Riduan used to smoke, but he successfully kicked the smoking habit. Currently, his time is spent on creating music and enhancing his artistic abilities, which have brought him to the regional and global stage. Mr Speaker, I will end my speech in English.

(In English): Mr Speaker, I would also like to propose for the Ministry to review current efforts in curbing smoking among the young and in public places. The Health Sciences Authority officers and employees may be authorised to take to task those who flout the laws governing the sale of cigarette or tobacco products, while NEA officers and employees may be authorised to take to task those who flout the laws governing littering, including errant smokers who litter their cigarette butts and ashes around.

However, at the same time, there has to be a more concerted effort to curb both smoking and littering in public places and should involve more public officers to extend this outreach effort and raise public awareness against smoking and littering, similar to how our Pioneer Generation ambassadors reach out to seniors. It would also be useful for MOH to appoint members of the public who are trained to advise and or even issue summons as to errant litterbugs and smokers who continue to litter and/or smoke in prohibited places.

More importantly, the role of these MOH-appointed representatives is to ramp up outreach and public education against smoking, specifically among our youths. Granting these appointed members of the public with some level of authority will also help alleviate the demand on our current HSA or NEA officers to carry out similar responsibilities. The remuneration framework for these MOH-appointed members of the public can be similar to that for our PGAs.

Mr Speaker, enacting new laws to curb smoking is just one of the various approaches we need to rein in on smoking among us. The public education and awareness efforts have to continue, as do efforts to reach out to our young to redirect their energies and focus on meaningful activities and projects and away from smoking and addiction. "What hurts more than losing someone is knowing you are not fighting to keep them from harm." We need to continue to fight to keep our children safe from the harms of smoking and drugs.

Mr Speaker, notwithstanding the concerns and proposals I have shared above, I strongly support this amendment Bill.

4.00 pm

Mr Louis Ng Kok Kwang (Nee Soon): Sir, as I have shared several times in this House, I was a former smoker and I smoked for 17 years. I celebrated my quitting anniversary just last month, on 12 October. I have not smoked for more than four years now.

I started smoking when I was about 18 years old and it was during my National Service days between 18 and 21 years old that I smoked the most.

When we debated the previous Tobacco (Control of Advertisements and Sale) (Amendment) Bill, I shared with this House that "research by WHO shows that people who don't pick up smoking before the age of 21 are unlikely to ever start smoking". And I asked why the proposal to raise the minimum age, 21 years old, was not included in that Bill.

I am heartened to see that it is included in this Bill and that we will be increasing the minimum legal age of smoking from 18 to 21. This is a positive and huge step forward.

However, I would like to seek some clarifications about other aspects of this Bill.

Firstly, we are proposing to extend the prohibition on importation, distribution and sale of other tobacco products, such as e-cigarettes, to include possession, purchase and use of such tobacco products.

Can the Parliamentary Secretary clarify whether other than the preliminary research by HSA mentioned by Senior Minister of State Amy Khor in March 2017, any detailed research or study has been done on the potential of such e-cigarettes or other reduced-risk products as a means to assist smokers to quit smoking as an alternative step-down from traditional cigarettes? If so, whether details of such cigarettes and data can be shared in this House?

I can attest to the fact that quitting smoking is not easy. I can tell you that looking after twins at 3.00 am is difficult but quitting smoking is more difficult.

Quitting smoking is probably one of the most difficult things that I have accomplished in my life. The withdrawal symptoms are severe and the urge, the craving to have a puff, is extreme. Having gone through it, I know that people who want to quit need more help.

Through a Facebook comment, Mr Daniel Yap shared with me that research has shown that allowing alternative reduced-risk tobacco products has been proven to be an effective means for smokers to quit smoking.

I understand that the United Kingdom, New Zealand and most states in the United States have conducted studies and endorsed policy approaches which allow for alternative reduced-risk tobacco products as ways for smokers to gradually quit the habit of smoking.

I do understand the Ministry's position and fear regarding, one, the gateway effect of allowing such alternative reduced-risk tobacco products; and two, that such products contain similar nicotine levels as traditional cigarettes.

However, on the gateway effect fear, there are numerous studies done and publicly available results which show that this fear may be overstated.

As Mr Yap pointed out, the Minister's evidence in the March 2017 reply supporting the rise in the use of e-cigarettes amongst US youths ignores the other data trend across the same period which shows a significant decline in the use of cigarettes.

Most recently, a study by Prof Linda Bauld at the University of Stirling published in the International Journal of Environmental Research and Public Health, showed that this fear of the gateway effect is overstated.

In fact, the study involving data gathered from 2015 to 2017 of youths in the UK, shows that e-cigarette experimentation by teenagers is simply not translating into regular use.

So, I do question the argument of youths picking up the habit of smoking via e-cigarettes. If we increase the minimum legal age and if HSA follows up with enforcement efforts, our youths under the age of 21 will still be protected from access to such e-cigarettes.

Hence, can the Parliamentary Secretary clarify the scientific basis of this fear of the gateway effect in our policy? And whether Singapore may be missing out on a chance to benefit from a policy which allows controlled use of alternative reduced-risk tobacco products to continue our fight against smoking?

Further, I understand that Phillip Morris has a research lab facility in Singapore researching and developing such e-cigarettes. Hence, access to primary data and resources for a study partner does not appear to be a challenge. Can the Parliamentary Secretary clarify whether there are plans to conduct in-depth studies on potential ways to use such e-cigarettes as a means to help smokers quit?

Secondly, on the similar nicotine levels, Mr Yap raised this point and I quote: "Smokers are addicted to nicotine but killed by tar and other chemicals. Shouldn't the answer be about tar and carbon monoxide instead? Or at least one of the many other chemicals in cigarettes that could harm your body? And if lower levels of other chemicals are detected in heat-not-burn products, then the same level of nicotine would be a good thing because it would be easier for addicts to switch products because they get the same high while causing less harm to themselves and others. We practise 'reduced harm' policies for other vices. If heat-not-burn products and e-cigarettes reduce harm, we should allow them, and then the health authorities should commit to this and research". Can the Parliamentary Secretary provide clarifications on the above points raised?

Sir, raising the minimum legal age is a positive step forward and it will prevent people from starting smoking. I do hope we will also devote more resources into helping people to quit smoking and look into every available means to help them in the quitting process.

Sir, notwithstanding the above clarifications, I stand in support of this Bill.

4.05 pm

Mr Gan Thiam Poh (Ang Mo Kio): Speaker, Sir, much work has been done over the years to curb the scourge of smoking and I appreciate the difficulties of this task as mentioned by other Members. On one hand, we want to discourage Singaporeans from picking up this harmful habit or kick the addiction. On the other hand, we also do not want to drive it underground. This is a setback that we have to guard against. I think that raising the minimum legal age of smoking from 18 to 21 over three years is reasonable. In fact, in my recent house visit, I did check with some residents. They have also pointed out that by having it staggered over three years is a good move.

In view of the existing measures to control smoking, I would like to ask the Parliamentary Secretary if he can share with the House how effective the current measures have been in reducing the prevalence of smoking. These include, for example, the illustrations of the harmful effects of smoking on cigarette packaging, the increase in the number of non-smoking public areas and the implementation of non-display at points of sale.

In addition, I would suggest that the authorities consider public education through more intensive media advertisements, such as over the radio, television and the Internet. I understand from some of my residents that the recent advertisements on our free-to-air channels which promote upcoming programmes are overly repetitive. Perhaps the Government can consider tapping on these pockets of under-utilised television time slots to run various public education advertisements which share different aspects of the harmful impact of smoking and methods for quitting.

Next, I am curious how we can enforce the ban on unauthorised imports of tobacco products. How does the Government check on online purchases and curb online sales by overseas vendors or suppliers? All these foreign sellers are not within our jurisdiction, how can we take these overseas suppliers to task? Do we have any collaborative enforcement agreements with foreign governments?

Another issue which we need to address is that of smokers smoking at home at their windows and in lifts, affecting their non-smoking neighbours, as pointed out by hon Member Mr Yee Chia Hsing. The problem here is second-hand smoke, as mentioned, which drifts out and pollute the environment and, especially the third-hand smoke, which are the harmful chemicals which accumulate on surfaces in the vicinity of smokers. Is it possible to require smokers to close their windows or require buildings to install smoking cubicles or cabins to solve this perennial problem?

Lastly, I would like to suggest that we look at having empowered volunteers, especially the youth volunteers, to help carry out public education and enforcement, similar to the community volunteers who tackle litterbugs. I would like to conclude with my support for the Bill.

Mr Speaker: Parliamentary Secretary Amrin.

4.09 pm

Mr Amrin Amin: Mr Speaker, I thank Members for speaking up in support of the Bill. I will now address Members' queries on the Bill.

Mr Gan Thiam Poh and Ms Joan Pereira asked about the effectiveness of our current measures. MOH tobacco control measures are based on best practices recommended by the World Health Organization and are designed to work at multiple levels. 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.

Our smoking rates have fallen from 18% in 1992 but they have remained at about 12%-14% for the last decade. Progress has been made but we need to do more.

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 need some time. The phased implementation provides a realistic timeframe.

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.

Educational efforts and support for youth smokers to quit must complement legislative measures. I agree with what Dr Intan Azura Mokhtar 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 which we have adopted.

HPB's smoking cessation programmes for youths adopt a strengths-based approach to build confidence for behaviour change. In response to Er Dr Lee Bee Wah's question, there are Student Health Advisors trained in smoking cessation who are stationed full-time in 50 schools and Institutes of Higher Learning. And Er Dr Lee Bee Wah will be happy to know that there are also Student Health Advisors stationed in schools in Yishun. Since 2015, HPB's smoking cessation programmes have reached out to more than 4,400 youths.

We also work closely with MOE to incorporate anti-tobacco messages into the curriculum. HPB conducts additional educational programmes in schools and, in 2016, we reached out to close to 50,000 youths. Youths are also taught skills to refuse cigarette offers in social settings.

In response to Mr Louis Ng, we have looked at Prof Linda Bauld's study in detail. It was actually 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 have been studies in the US, the UK and Canada, which followed up with more than 40,000 youths over time and found that e-cigarette users had a greater risk of becoming cigarette smokers. All these studies have found evidence to support the gateway effect.

On Mr Leon Perera's question regarding standardised packaging, we are still studying standardised packaging. Our final decision on whether to proceed with the measure will be made only after the upcoming public consultation. The decision on whether to proceed on standardised packaging would 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.

Mr Leon Perera has asked whether 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, and the answer is yes. E-cigarettes expose users to chemicals and toxins that cause adverse health effects.

Mr Louis Ng and Mr Leon Perera asked about MOH's stance on tobacco harm reduction. We opt for high and precautionary levels of public health protection. While there are studies to claim that there is no gateway effect, there are as many, more authoritative, studies which point to a gateway effect.

In response to Mr Leon Perera and Mr Louis Ng's comment on other countries allowing ENDS, there is actually no consensus among public health authorities. 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 and, in other countries, sale of ENDS remains banned.

We have looked at the claim that ENDS are "95% safer than cigarettes" made 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.

Mr Leon Perera cited the Cochrane Review to support the claim that e-cigarettes can help smokers to quit. We have studied the report, I have read the report, but what he did not emphasise was the report found that the overall quality of evidence that e-cigarettes 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 am sure Mr Leon Perera does not want to put our smokers who are trying very hard to quit at risk.

Of note also is that e-cigarettes are still not available to the UK National Health Service for Smoking Cessation. No electronic cigarette has been licensed by the UK Medicine and Health Regulatory Agency. Why? The World Health Organization does not recognise e-cigarettes as a legitimate cessation aid. Why? It is because there is no conclusive scientific evidence proving the product's safety and efficacy. Australia, too, does not recommend ENDS until there is more evidence on safety. And Australia also does not recommend ENDS until there is more evidence on its effectiveness in smoking cessation.

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 hire researchers and lobbyists to help them with this pivot. The form of nicotine delivery may differ. Smokeless, electronic, but make no mistake, the revenue-generating base product is still nicotine. ENDS are marketed as "healthier" alternatives and youths are targeted. We must not let our guard down and we must protect our young.

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 ways 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, as I have mentioned earlier, can submit evidence for us to evaluate their products for registration as smoking cessation therapy under the Health Products Act. But, so far, none has done so.

A number of Members have raised concerns on the online sales and smuggling for ENDS. MOH is similarly concerned. 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.

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. But 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 Singapore. We also take action against Singapore-based sellers. Since 2012, HSA has prosecuted 14 sellers of e-cigarettes and other types of vaporisers.

Dr Chia Shi-Lu highlighted the possible impact of the MLA increase on retailers, in particular, how employees who are below 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 below 21 but they just cannot participate in selling tobacco. Current employees who are above 18 will not be affected as the MLA increase would be phased in. We have also conducted a survey among tobacco retailers. We have found that 5% of retailers currently hire employees who are aged 18 to 21 to sell tobacco products. Thus, a small number of businesses will face challenges after the MLA is implemented. We seek the support of the industry in supporting the MLA policy. This is to ensure we achieve our wider public health objectives. We will continue to work with tobacco retailers to ensure the smooth implementation of the MLA increase.

Dr Chia Shi-Lu and Ms Joan Pereira suggested that we place greater onus on logistics companies to curb the importation of prohibited products. We have been reaching out to major logistics companies, as well as the Singapore Aircargo Agents Association, to educate and remind the industry of the ban on emerging and imitation tobacco products.

Dr Chia Shi-Lu 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 Dr Chia's suggestion and will consider it when we next review the penalty framework of the Act.

Public education remains a key pillar of our tobacco control programme and it is vital to make the public aware of the harms of smoking, including prohibited products, such as ENDS.

A number of Members have asked MOH to enhance our public education. Through portals like the Health Hub as well as the Healthy Lifestyle Festival Singapore, we raise 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.

Ms Joan Pereira and Ms K Thanaletchimi highlighted the importance of stemming social supply for underage smokers. Supplying tobacco to underage persons is already an offence under the Act. You can be fined up to $1,000 for giving tobacco products to an underage person, and up to $5,000 for buying for them. We will look into ways to raise greater public awareness of this and to educate older family members and friends on this.

Mr Gan Thiam Poh suggested enlisting the help of volunteers to carry out public education and enforcement. Currently, we do not deploy volunteers for enforcement. However, we have volunteers for public education efforts, such as our "I Quit" Ambassadors. But we will study the suggestion.

Dr Intan Azura Mokhtar has expressed concern that the number of Malay smokers remains 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 to quit. 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.

I thank Dr Intan Azura Mokhtar for highlighting a potential problem of roll-your-own tobacco cigarettes among youths. Although Ang Hoon and other loose tobacco leaf products make up less than 2% of all tobacco 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 mixed with tobacco, and will take the necessary enforcement action against traffickers and abusers.

In response to Ms Joan 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 September 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.

Er Dr Lee Bee Wah, Mr Gan Thiam Poh and Mr Yee Chia Hsing have spoken up 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 their 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.

Er 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 the public to tackle errant smokers. I will refer her suggestions to my MEWR colleagues for their consideration.

Ultimately, by discouraging those below the age of 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.

Mr Alex Yam asked if we should ban tobacco 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.

Mr Speaker, Sir, cigarette use had become so entrenched that millions world-wide are addicted and exposed to the harm. We should not make the same mistake with ENDS. We do not need nor want another addictive and harmful product to take root here in Singapore. This is why we are strengthening our regulatory measures against ENDS.

With the increase in MLA, we aim to reduce opportunities for youths to be tempted to take up smoking. Our aim is to ultimately denormalise tobacco use and protect our young from being lured into a lifetime of nicotine addiction.

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.

Mr Alex Yam: Thank you, Mr Speaker, Sir. I thank the Parliamentary Secretary for his response and I am happy to hear that the Government will not rule out consideration for a ban. But, perhaps, if we could take the lead in this and set the standard for the international community and, perhaps, proceed on a ban at a far earlier stage. Opium use was quite entrenched in the early days in Singapore. We bit the bullet and we introduced —

Mr Speaker: Please keep it short.

Mr Alex Yam: — a ban and we no longer have the problem.

Back to the point on the staggered system of introducing the increase in the age limit, can I ask the Parliamentary Secretary what exactly are the numbers that would be affected if we introduce an immediate ban? I understand that it is hard to break the habit. But if it is a relatively small number between the ages of 18 and 21, why not introduce it now?

Mr Amrin Amin: We estimate the numbers to be around 4,000 per birth cohort. But that is something that we need to take into account. It is not just a numbers issue. It is also to allow them some time to phase in because, as I have mentioned, smoking is an addiction. So, we are phasing in to allow them time to adjust.

Mr Leon Perera: Thank you, Mr Speaker, Sir. I thank the Parliamentary Secretary for his details. I have just three clarification points.

Firstly, I cited three studies − Royal College of Physicians, the Cochrane Report and Public Health, UK. Is it the Ministry's view that all three studies seem to provide some initial grounds, even though they are not foolproof grounds, but some initial grounds that e-cigarettes, a controlled supply can be given to smokers? Is it the view of the Ministry that all three are methodologically flawed? And, if so, in what manner is that the case?

Secondly, the Parliamentary Secretary mentioned that the relevant question is not to ask whether e-cigarettes are harmless. Nevertheless, I would argue that that is a relevant question because, if there is evidence that e-cigarettes have reduced harm, then we should seriously consider that can be an option for smoking cessation. And, in this context, the Parliamentary Secretary cited an article in the Lancet. The author of the Cochrane Report, Jamie Hartmann-Boyce, actually talked about some of the studies that his committee reviewed that purport to show that e-cigarettes prevent people from quitting, such as the one published in the Lancet − respiratory medicine which the Parliamentary Secretary cited from. And he mentioned that some of these studies are flawed because they did not follow the research gold standard of randomised control trials. He said that, I quote, "The studies have found that —

Mr Speaker: Keep it short, please.

Mr Leon Perera: Yes, just 20 seconds. "The studies...that find that e-cigarettes stop people from quitting are not randomised controlled trials. Instead, they surveyed smokers and asked if they are using e-cigarettes. Then, some months later, they asked the same people if they are still smoking." So, I would like to ask for that.

The last point is that I am heartened to hear that if new clinical evidence presents itself, the Ministry may review its position. What would constitute definitive proof in that sense? Would it be a randomised controlled trial?

Mr Amrin Amin: With regard to the three studies, I have explained in my response the counter studies or criticisms of the studies that were made and this is the Cochrane Review, as well as the Royal Physicians Report, that were cited. So, that has been dealt with. But, in any case, the door is still open for them to submit their evidence to be considered under our Health Products Act. And if they qualify as a smoking cessation therapy, it will be exempted from the Tobacco Act.

The examples cited in various countries from the UK, Canada, have shown that the prevalence, once you introduce e-cigarettes to the community, there is an increase in the number of e-cigarette users, especially among young people.

Question put, and agreed to.

Bill accordingly read a Second time and committed to a Committee of the whole House.

The House immediately resolved itself into a Committee on the Bill. – [Mr Amrin Amin].

Bill considered in Committee; reported without amendment; read a Third time and passed.