According to the Thematic Household Survey 2015 Report published by the Census and Statistics Department in 2016, the overall prevalence of smoking in Hong Kong has remained consistently low in the past few years (11.8% in 2012 and 11.4% in 2015), one of the lowest figures worldwide. Such low smoking rates is thought to contribute to the longevity of Hongkongers, with the longest life expectancy in the world in 2017.

Despite this seemingly victorious fight against tobacco, Dr Ning Fan, Chairman of Health In Action (HIA), a humanitarian organisation with the vision to eliminate health inequity in societies, shared in an interview with MIMS the struggle in anti-smoking efforts and the growing threat of electronic cigarettes (e-cigarettes) behind the low smoking prevalence.

Beyond “smoking as a health hazard”: What are we missing?

“The government’s anti-smoking policies proved to be effective, with the prevalence of smoking more than halved over the past 30 years,” notes Fan. “However, it seems to have run into a bottleneck to further cut down numbers.”

“We are neglecting bigger pieces of the puzzle — pieces that stem beyond traditional perceptions of smoking as a health hazard to be tackled by health professionals, fines and warning labels alone,” he says.

Another easily missed piece is that while the overall prevalence of smoking has decreased significantly, the prevalence of female smoking has not shown the same decrease.

What is more disturbing is that tobacco manufacturers have shifted their focus to launching aggressive marketing campaigns — specifically targeting women — by promoting smoking as a symbol of, independence and charisma, according to the Smoking and Health Survey in Hong Kong Women jointly conducted by The University of Hong Kong (HKU) and Hong Kong Council on Smoking and Health (COSH) in 2014. Of note, most women surveyed were not aware of the female-specific health problems induced by smoking.

Furthermore, the Thematic Household Survey 2015 revealed that over 60% of daily cigarette smokers had never tried and did not want to quit smoking.

Are anti-smoking campaigns that emphasise smoking as a health hazard still effective?
Are anti-smoking campaigns that emphasise smoking as a health hazard still effective?

“Aside from female-specific health problems, most smokers, men and women alike, are actually aware of the harmful effects of smoking on general health,” Fan says. “This poses a question to us: Are anti-smoking campaigns that emphasise smoking as a health hazard still effective?”

“In the study conducted by HKU and COSH, the reasons for smoking initiation among current smokers and ex-smokers can be summarised into two main categories: (1) Social influence [ie, peer influence, social gathering, image] and (2) psychosocial factors [ie, feeling sad/bored, stress reduction, rebelliousness, control of negative emotions],” Fan points out. “Reasons categorised under social influence added up to more than 40%, while psychosocial factors accounted for almost 20% of the cases.”

Social influence and psychosocial factors are also the main motivations for current smokers to continue tobacco use.

“These data show that targeting physical health may no longer be effective in persuading smokers to quit… and more importantly, in preventing people from initiating smoking in the first place,” remarks Fan.

“We have to take a step back and look at the bigger picture. Are the broader socioeconomic factors of Hong Kong — such as academic stress and infamously long working hours — creating an environment that promotes initiation of smoking and reliance on tobacco? How is our social environment influencing such habits? And how does this bode for our vision of a tobacco-free Hong Kong?”, questions Fan.

The silent and growing threat of e-cigarettes

The HKU/COSH study highlighted another worrying threat: 25% of the respondents suggested “disgusting smell from smoking” as a significant reason for smoking cessation.

“Instead of completely quitting smoking, would this group of smokers switch to e-cigarettes as an alternative?” Fan questions. “While evidence on the long-term effects of e-cigarettes is inconclusive, particularly on the question of whether they are carcinogenic, there is sufficient evidence of their short-term adverse effects, particularly on the cardiovascular and respiratory systems.”

Globally, the sales of e-cigarettes have surged exponentially by over 120-fold, from USD20 million in 2008 to USD 3.5 billion in 2015. In Hong Kong, e-cigarettes are also well-received, particularly by the younger population. On Facebook, the page Hong Kong e-cigarettes is liked by more than 75,500 users.

Fan worries smokers might switch to e-cigarettes as an alternative.
Fan worries smokers might switch to e-cigarettes as an alternative.

Additionally, the HKU/COSH study also highlighted that awareness of e-cigarettes was associated with being female, younger, and having a higher education level.

“The current trend of e-cigarettes made me think of the introduction of soft drugs. At first, ketamine was quite expensive, so drug dealers targeted younger and richer groups,” Fan says. “The question is, are we already too late in preventing an epidemic of e-cigarette use in light of the accessibility and popularity among the younger population?”

The Hong Kong government is also aware of the growing threat of e-cigarettes. Professor Sophia Siu-Chee Chan, current Secretary of Food and Health, mentioned last year that various government departments were exploring the possibility of tightening regulations on e-cigarettes; including banning their import and sale in Hong Kong. Currently, 13 countries have imposed a complete ban on e-cigarettes, including Singapore, Thailand and Brazil. Ironically, however China has been investing more into the production of e-cigarettes, despite the first manufacturer being established in Hong Kong.

Are e-cigarette users smokers?

Stated by the Pharmacy and Poisons Ordinance (Cap 138), any e-cigarettes containing nicotine are categorised as pharmaceutical products and must be registered with the Pharmacy and Poisons Board of Hong Kong before sale or distribution. Department of Health (DH)’s Drug Office has also made vigorous efforts to tackle use and distribution of unregistered e-cigarettes.

Nonetheless, research and social media has found that e-cigarettes containing harmful substances can be easily purchased online and from local stores. Studies also observed the use of e-cigarettes is higher among younger age groups in both Chinese and ethnic minorities (EM) populations.

“Although the government’s census and thematic surveys have included e-cigarette users in their analysis of smokers, is the number underestimated because e-cigarettes are unregistered in Hong Kong?” questions Fan. “Right now, the majority of data suggest that younger people are more likely to use e-cigarettes. Will they continue to use these products? Will they even switch to cigarettes in the future?”

A recent study published in Tobacco Control looked into 2,836 adolescents aged 13–14 years from 20 schools in the UK. Results showed that ever-use of e-cigarettes at baseline was strongly associated with subsequent initiation and escalation of cigarette use.

According to the Smoking (Public Health) Ordinance (Cap 371), use of e-cigarettes in nonsmoking areas is an offence. Yet, the government has not clearly stated that use of e-cigarettes is equal to smoking cigarettes.

“E-cigarette users might not see themselves as smokers,” says Fan. “If we treat e-cigarettes and cigarettes as the same, why are graphic health warnings not placed on e-cigarette packages?”

Positioning anti-smoking from the public health perspective

When asked why HIA is involved in addressing the smoking issue in Hong Kong when they are primarily focusing their work on eliminating the health disparities among working poor populations, EM and asylum seekers and refugees (ASRs) in the city – Fan recalled their experiences when they were partnering with the United Christian Nethersole (UCN) Smoking Cessation Project for Ethnic Minorities and New Immigrants.

Health In Action providing engaging with EM participants on World No Tobacco Day festival
Health In Action providing engaging with EM participants on World No Tobacco Day festival

“The Hospital Authority (HA) offers smoking cessation hotlines; but UCN experienced that EMs cannot use the service due to language barriers,” highlights Fan. “HA’s smoking cessation programmes are all outsourced to external organisations, with Tung Wah as the largest centre. However, the centre does not offer cessation programmes that cater to EM. While we have around 450,000 EM in Hong Kong, their access to smoking cessation services is limited,” he elaborates.

Not only their access to smoking cessation services; but also research or data on smoking in EM in Hong Kong. While HK Census data exploring smoking trends does not differentiate by ethnicity, surveys measuring the characteristics of EM also neglected their smoking habits.

“We have looked into one small-scale study conducted by UCN before. From their information, we can speculate that on average, the number of cigarettes smoked by EM smokers per day equal to or more than that of the general population. Most of them starting in their youth (18 – 22 yrs),” remarks Fan.

Meanwhile, overseas research suggests that there are variations in smoking prevalence amongst different ethnic groups within the same country. However, generalisability is poor due to the demographics of EM groups across different countries.

Health In Action providing engaging with EM participants on World No Tobacco Day festival
Health In Action providing engaging with EM participants on World No Tobacco Day festival

“Instead of simply positioning anti-smoking as a health issue, we need to be looking at it from a broader perspective,” emphasises Fan. “Although smoking leads to premature death, the age of death has been delayed due to longer life expectancy. On one hand, the patient suffers longer. On the other hand, this brings upon a tremendous value of health expense to the society,” he cautions.

Next, data from the World Health Survey shows smoking in male was disproportionately prevalent among the poor in the majority of countries. In some countries, the poorest men were over 2.5 times more likely to smoke than the richest men. Smoking in women was no better—with their socioeconomic inequality more varied—showing patterns of both pro-rich and pro-poor inequality.

Apart from looking at the bigger picture of anti-smoking, Fan also hopes healthcare professionals could reassess the various kinds of issues from the standpoint of public health and social, rather than simply the health impact.

“Does a higher GDP represent better health?” asks Fan. “We have been improving our medical technologies to improve patient outcomes. However, the true meaning of health care is to reduce patients’ suffering. Even though patients may recover after we treat them, but they might still suffer afterwards due to all kinds of social and public health issues. If we do not prevent the suffering from happening – are we still fulfilling the meaning of health care?” highlights Fan. MIMS

Read more:
Should there be a complete ban on e-cigarettes in Hong Kong?
HK and Japan top Asian life expectancy, experts say due to low smoking rates
Ethnic minorities and ASRs in Hong Kong: How to achieve equal health care for all?