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Public Consultation on Tobacco Control Strategies: Set the stage for a tobacco-free future

Hong Kong enacted the Smoking (Public Health) Ordinance (Cap 371) in 1982 and adopted a progressive and multi-pronged approach to promote tobacco control, with the aim of reducing the adverse impact of tobacco use on personal health, public health, the healthcare system, society and economy. While Hong Kong's smoking prevalence has dropped to a record low of 9.5% in 2021, there were still over 580,000 daily smokers. Tobacco and its hazards remain the huge threats to the health of both smokers and non-smokers.

In mid-July this year, the Hong Kong Government launched a public consultation themed "A Vibrant, Healthy and Tobacco-free Hong Kong" with the goal of reducing the smoking prevalence to 7.8% by 2025 and ultimately achieving a tobacco-free Hong Kong. The consultation document outlines “Regulate Supply, Suppress Demand”, “Ban Promotion, Reduce Attractiveness”, “Expand No Smoking Areas, Mitigate Harm” and “Enhance Education, Support Cessation” as four strategies and invites public feedback. Please visit www.tobacco-free.gov.hk for more information.

This article proposes a number of tobacco control measures in response to the four strategies and examines the global situation as well as the implementation of these measures in Hong Kong.

(1) Regulate Supply, Suppress Demand

Regarding "Regulating Supply and Reducing Demand", the consultation document collects public views on proposed measures such as increasing tobacco tax, restricting tobacco product sales and provision to specified age groups, and combating illicit tobacco trade.

Substantially increase tobacco tax to WHO-recommended level

The current retail price for a pack of major brand cigarettes in Hong Kong is around HK$78, of which the tobacco tax is around HK$50, accounting for approximately 64% of the cigarette price. The tax rate falls short of the 75% recommended by the World Health Organization (WHO). Despite the Government has increased the tobacco tax by about 31% in this financial year, it was far below COSH’s proposal of a 100% increase.

Raising tobacco tax is a one-time measure that requires to undergo complex legislative and administrative procedures before it is formally legislated. Under this mechanism, the effectiveness of tobacco tax is hence hampered as the tobacco tax policy fails to respond timely to economic changes and tobacco industry interference. To address this, the Government should adopt a flexible tobacco tax policy to prevent its effects from being offset by inflation, income growth or price manipulation by tobacco companies. Also, it is essential to allocate the tax revenue to tobacco control, smoking cessation or related medical services, so as to accelerate the reduction of the smoking population.

Many places around the world have established tobacco tax policies that meet the WHO's recommended level and have implemented other measures to reinforce the impact of tobacco taxes and prevent interference from the tobacco industry. These policies are worth Hong Kong learning from:

• At least 41 countries (such as Australia, Brazil, New Zealand and the UK) follow WHO recommendations by setting tobacco taxes at a minimum of 75% of the retail price.
• At least 33 countries (such as Australia, Canada, New Zealand and the UK) have established automatic mechanisms to regularly increase tax rates.
• At least 50 countries (such as Denmark, Finland, the UK and Turkey) have set minimum tobacco prices or taxes.
• At least 43 countries (such as France, Iceland, Ireland and the Philippines) allocate tobacco tax revenues to tobacco control or health policies.
• At least 85 countries (such as Canada, the Netherlands, Singapore and Thailand) require tax stamps or other markings to be printed on cigarette packs and/or cigarettes.

The tobacco industry often exaggerates the impact of tobacco taxes on illicit cigarette markets to oppose tobacco tax increase. Nevertheless, WHO and the experiences of various countries have proven that there is no direct correlation between high taxes and smuggling. Addressing illegal tobacco trade and raising tobacco taxes should be viewed as mutually reinforcing and complementary actions. To ensure compliance and curb illicit cigarette trade, the Government should implement a track and trace system, require tax stamps on tobacco products to distinguish duty-paid tobacco and illicit cigarettes, and require tobacco companies to maintain relevant records for review by law enforcement agencies, etc. Robust and swift enforcement actions shall be taken to deter illicit trade.

Continuously raise the legal age of tobacco purchase to achieve a “Smoke-free generation”

The exposed internal tobacco industry document states that “If a man has never smoked by age 18, the odds are three-to-one (i.e. 75%) he never will. By age 24, the odds are twenty-to-one (i.e. 95%).”, revealing the likelihood of smoking initiation significantly decreases with age. Raising the minimum age restrictions for purchasing or using tobacco is an effective way to prevent the youth from initiating smoking. Globally, at least 23 countries or regions have set the minimum legal age for purchasing tobacco products at 19 or above, such as Sri Lanka (25 years old or above), Singapore (21), and Taiwan (20).

Smoking is harmful to health of people at any age. Minimum age of tobacco purchase should not be perceived as an indicator for smoking or justifying smoking behaviour. To progressively build a smoke-free generation, and to prevent the tobacco industry from misleading the public that smoking at certain age is safe or acceptable, some countries with advanced tobacco control standard and low smoking rate have proposed the “Smoke-free Generation” policy to eliminate smoking hazards in long run. This policy proposes banning the sale of tobacco products to people born after a certain year, and ultimately achieving a permanent ban on smoking after this cohort. New Zealand has legislated to ban the sale of tobacco products to those born on or after 1 January 2009, becoming the world's first country to implement this measure. Malaysia has also submitted a similar legislation to the Parliament.

Hong Kong should raise the legal age for purchasing tobacco as soon as possible and study the feasibility of implementing the "Smoke-free Generation" policy to safeguard the next generations from tobacco hazards.

Prohibit the possession of alternative smoking products (ASPs)

ASPs have emerged globally and posed a significant challenge to tobacco control in recent years. The tobacco industry's marketing strategies, including the use of appealing flavours and attractive designs, drove youth addiction to ASPs. Hong Kong has taken commendable steps to enact a ban on the import, promotion, manufacture, sale and possession for commercial purposes of ASPs including e-cigarettes, heated tobacco products and herbal cigarettes in 2022, becoming one of the most advanced regions in preventing the prevalence of ASPs. However, the current laws do not ban the use or possession of ASPs for non-commercial purposes, thus leaving loopholes for illicit markets.

According to the WHO Framework Convention on Tobacco Control (FCTC), governments should apply regulatory measures either to restrict or prohibit, as appropriate, the manufacture, importation, distribution, presentation, sale and use of ASPs to safeguard public health. Therefore, Hong Kong should consider banning the possession of ASPs for any purpose, and increasing the penalty so as to restrain the potential circulation and use of ASPs in Hong Kong and eliminate potential threats to tobacco control development.

(2) Ban Promotion, Reduce Attractiveness

Regarding "Banning Promotion and Reducing Appeal", the consultation document proposes regulating the additives in tobacco products, requiring plain packaging of tobacco products, and reducing tobacco product exposure at points of sale. Hong Kong has progressively banned tobacco advertising, promotion and sponsorship since 1988. However, the ban has been circumvented by the industry by the tactful formula, design and display of the tobacco products.

Ban flavoured tobacco products

Many tobacco products are added with flavouring additives during the manufacturing process. “Flavourings” generally refers to natural or artificial additives that are used to add smell or taste to tobacco products. Common flavours include but are not limited to fruits, candies, mint and herbs. Flavourings can reduce the irritation of tobacco and increase palatability as a results reduces vigilance about smoking harms and attracts young people to try and become addicted. In fact, adding flavours to tobacco cannot reduce the risks of smoking. Various studies have shown that flavoured tobacco may produce additional toxins when burned.

Various measures to restrict flavoured tobacco products were adopted in many countries, yet the tobacco industry used different tactics to circumvent the regulations, such as launching new flavours or accessories that allow users to add flavours on their own. Therefore, the Government should consider banning tobacco products with all kinds of flavours, additives and additive accessories such as flavoured filters, flavoured rolling papers, flavoured capsules, etc. Moreover, the language used to describe the flavour of tobacco products should also be banned. For example, it should be prohibited to use associative and subjective terms on tobacco products such as "Arctic Cool" or "Mid-summer Passion" to attract customers. Nowadays, at least 40 countries and regions (such as Australia, Canada, EU countries, the UK and the US) have formulated or are planning to formulate policies to regulate flavoured tobacco products.

Limit nicotine levels to reduce tobacco addictiveness

The tobacco industry has been spending vast resources on modifying the physical design and chemical composition to make tobacco more addictive and keep smokers addicted to its products. WHO Study Group on Tobacco Product Regulation published an advisory report on the feasibility of reducing tobacco addictiveness through very low nicotine content cigarettes (VLNCCs). The group suggested that reducing nicotine content to 0.4 mg per gram of tobacco would not significantly increase craving or cause users to increase smoking volumes. While VLNCCs still contain tobacco and are not harm-reduced, restricting and standardizing the nicotine content across all tobacco products on the market could reduce users' nicotine intake, dependence and smoking volumes. By doing so, it can help smokers overcome smoking cravings.

Adopt plain packaging

A number of countries now require cigarette packs to use "plain packaging". Brand name and product information of all tobacco products can only be displayed in specific colours, at designated locations and in mandatory fonts with large pictorial health warnings (PHWs) and health warning messages. No brand logo, colours, brand images or promotional messages can be displayed on the cigarette packs. A standardized package can eliminate promotional elements and branding effects between different products, and hence reduce the attractiveness of tobacco products.

At least 38 countries around the world (e.g. Australia, Canada, France, New Zealand, Singapore and Thailand) have implemented or are planning to adopt plain packaging. Canada further requires smoking cessation information cards to be inserted in the packet and warnings to be printed on each cigarette to strengthen the warning effect and encourage smoking cessation. Hong Kong should also consider implementing the above innovative packaging requirements. Meanwhile, additional set(s) of PHWs should be developed (currently only one set of 12 images) for rotation to prevent desensitization due to the prolonged use.

Ban point-of-sale tobacco displays

To eliminate promotional elements, regulations should also be extended to the tobacco display at points of sale. The Government should consider prohibiting the display of tobacco products at points of sale (including retail outlets and stalls). For tobacco sale, only a text list of prices should be allowed without any promotional elements, so as to prevent the tobacco industry to promote tobacco products through fancy display boxes. At least 36 countries and regions (such as Finland, Macau, Singapore and Thailand) have banned point-of-sale tobacco displays.

(3) Expand No smoking Areas, Mitigate Harm

Regarding "Expand No smoking Areas, Mitigate Harm", the consultation document collects public opinions on expanding the coverage of no smoking areas and penalties for smoking offences.

Extension of no smoking areas to cover most public places

To justify smoking behaviours and to create legitimate areas for smoking, the tobacco industry often advocates for establishing smoking areas in dealing with passive smoking. However, secondhand smoke (SHS) and third-hand smoke (THS) can spread and linger everywhere, the harms of SHS and THS can only be eliminated by creating a 100% smoke-free environment. Allowing any type of smoking area is not an effective measure for protecting public health and achieving a tobacco-free environment.

In Hong Kong, all indoor public places, including restaurant premises, and workplaces, and a number of outdoor public places were designated as no smoking areas (NSAs) in 2007. Starting in 2009, some more enclosed or outdoor public transport facilities were included as NSAs. However, the progress of expanding NSAs has been slowed down over the past decade. The Government should prioritize designating crowded outdoor public places that are difficult to avoid SHS, such as public transport waiting areas and footbridges, as smoke-free. It should also gradually expand to more and more public places, so as to minimize the risk of SHS and THS exposure.

Globally, 74 countries have achieved best practices for a smoke-free environment in line with WHO standards, i.e. designating eight types of venues (healthcare facilities, educational facilities, universities, government facilities, indoor offices and workplaces, catering premises, cafes and bars, and public transport) as NSAs. An increasing number of countries and regions are including more private, public, and outdoor venues as NSAs, such as private vehicles carrying children (Australia), public transport waiting areas (Macau), outside building entrances (Thailand), and crowded streets (Singapore).

The Government should enhance public awareness (particularly among managers of smoke-free venues) on NSA requirements such as coverage of NSAs and penalties.  Tight monitoring and swift enforcement should be carried out to promote greater self-discipline among the public and reduce enforcement costs in long-term. On the other hand, increasing fixed penalties for smoking offenses can serve as a deterrent to discourage misconduct.

(4) Enhance Education, Support Cessation

Regarding “Enhance Education, Support Cessation” the consultation document proposes to enhance smoking cessation services, strengthen smoking cessation training for primary healthcare workers, and assist smoking cessation through mobile apps.

Discussions and directions for enhancing smoke-free education and enhancing smoking cessation services

In Hong Kong, an integrated smoking cessation hotline (1833 183) is operated by the Department of Health to provide cessation information, and smoking cessation services are also provided by several non-governmental organizations. To further promote cessation, the government should focus on the need of quitters and improve the quality of smoking cessation services in the following aspects:

• Improve accessibility of smoking cessation services: Disseminate information about smoking cessation services more widely, increase service locations (such as utilizing the network of district health centres), set more flexible service hours and simplify the registration for smoking cessation services or collection of smoking cessation medications;
• Strengthen communication and relationship between service providers and quitters: Incorporate smoking cessation training into the ongoing training programmes for all primary healthcare practitioners to enhance their counselling skills, including skills in proactive intervention, ability to recommend appropriate programs based on quitter’s status;
• Utilize digital communication to assist smoking cessation: Provide two-way communication and tracking of cessation progress via mobile apps or instant messaging apps, as well as promoting latest and personalized smoking cessation services and information;
• Enhance the use of health record systems: Provide healthcare practitioners with proper equipment or tools to record smoking status, establish standard workflows, and integrate relevant data into health record systems. This will enable tailored smoking cessation services, benefit analysis and research to enhance overall service quality.

Data from the Census and Statistics Department shows that smoking prevalence among the youth in Hong Kong remained low at 1.2% in 2021, reflecting the effectiveness of smoke-free education. High level of knowledge and support for tobacco control among the next generation are vital to the long-term enhancement of tobacco control policies and elimination of tobacco harms. The Government should strengthen smoke-free education with the ultimate goal of achieving a tobacco-free Hong Kong by continuing to reinforce students' attitudes against smoking, denormalize the tobacco industry and tobacco sales:

• Designate smoke-free education as a regular curriculum and regularly strengthen youth's smoke-free knowledge and anti-smoking attitude.
• Expand the curriculum coverage: Include comprehensive knowledge on smoking harms, cessation techniques and tobacco control framework to improve students’ understanding on the risks of different smoking products, learn the skills to support smokers in quitting, and foster a deeper understanding of tobacco control efforts.

A comprehensive plan is needed to advance towards a tobacco-free future

Guided by the WHO FCTC, Hong Kong has implemented the MPOWER tobacco control measures recommended by WHO including monitoring tobacco use (M); protecting people by establishing NSAs (P); offering help to quit (O); warning about the dangers of tobacco by regulating tobacco packaging (W); enforcing ban on tobacco advertising, promotion and sponsorship (E); and raising taxes on tobacco (R); to reduce the smoking population. Yet, the last significant advancement of tobacco control policies was made around 20 years ago. In the past two decades, only one-off legislative amendments were made. To address evolving challenges from new smoking products, changing social environments and industry marketing tactics, tobacco control policies must keep pace in order to prevent the resurgence of smoking.

In this public consultation exercise, the measures proposed under the four strategies cover policies on products, users and supply. Some policies recommendations have a legal basis and strong public support, e.g. expanding NSAs to more public places. Some measures are tailored to Hong Kong's situation, e.g. further prohibiting possession of ASPs, while some are innovative to Hong Kong but proven effective overseas, e.g. banning flavoured tobacco products and plain packaging. By garnering opinions and consensus through this consultation, the Government can formulate a comprehensive plan to maximize the policy effectiveness through complementary efforts. Besides, the Government should also engage the public in ongoing dialogue, so as to prevent the tobacco industry and the affiliating parties with vested interests from misleading the public and hindering the development of tobacco control.

Tobacco endgame (i.e. complete phase-out of all smoking products) becomes a prominent topic globally, Hong Kong should also review to work out a plan towards tobacco endgame by setting clear targets and proactively exploring more aggressive tobacco control measures, and realize the vision of a tobacco-free Hong Kong as soon as possible.