Preparing for the tobacco generational endgame

The TFG concept works on the premise that once you have an educational ecosystem in place for tobacco prevention, youth will voluntarily say no to cigarettes. — Photos: AFP

In an ideal world, there would be no smokers, cigarettes or addicts of any kind, eliminating much of the suffering these can cause.

The reality: tobacco kills up to half of its users and is a significant health burden worldwide.

Since 1990, the frequency of smoking has decreased steadily around the globe, especially in high-income countries.

However, the pace of this decline is not equal across the world.

The burden of tobacco smoking is being increasingly borne by low- and middle-income countries.

Over 80% of the 1.3 billion tobacco users worldwide live in such countries, with China being both the world’s largest producer and consumer of tobacco.

In many households, tobacco use contributes to poverty by diverting household spending from basic needs such as food and shelter, to tobacco.

Ending the global tobacco epidemic continues to be a challenge as current measures to deter smoking, no matter how well thought of, have not been able to change the global statistics much.

In 2004, the national assembly of Bhutan (which was then an absolute monarchy) banned the sale of tobacco throughout the country, as well as smoking in public places, private offices, and even recreation centres like bars and pubs, in a radical move.

The Himalayan nation was lauded for being the first country in the world to go entirely smoke-free.

However, threatened by the risk of Covid-19 spread due to the continuous smuggling of tobacco products through Bhutan’s porous southern border during the early part of the pandemic, the government amended the bill to lift the ban last December (2021).

Hence, selling, buying, possession, distribution and transportation of tobacco and tobacco products in the country will be legalised once again if the bill is endorsed.

Meanwhile, in a move to crack down on smoking and eventually phase it out, New Zealand intends to ban the sale of tobacco to its next generation.

Under this “endgame”, anyone born after 2008 will not be able to buy cigarettes or tobacco products during their lifetime, as stipulated in a bill to be tabled in New Zealand’s parliament next month (June 2022).

Only older generations will be able to buy tobacco products under the “world-leading plans”.

Even then, the products will only be allowed to contain low levels of nicotine.

Malaysia is taking a similar stance.

Health Minister Khairy Jamaluddin is expected to table the much-talked-about new Tobacco and Smoking Control Act in Parliament in July (2022).

In a move called the Generational Endgame (GEG), this Act will ban the smoking and possession of tobacco products, including vape, to the generation born after 2005.

Under our current Control of Tobacco Product Regulations (CTPR) 2004, only traditional tobacco products like conventional cigarettes, cigars and shisha, are covered.

Electronic cigarettes (e-cigarettes) that contain nicotine are regulated under the archaic Poisons Act 1952, but there are no laws to regulate e-cigarettes that do not contain nicotine.

Preparation needed

Scaring young children with descriptions and statistics of diseases caused by smoking is not going to make an impact on them as they cannot relate to such information at that age.

While the reaction from the ground has been positive to the proposed Act, it is important that a strong foundational framework be put in place before it is implemented.

“The GEG is just a small part of it.

“The long-term sustaining of control efforts will be a challenge, especially with profit-driven individuals and companies.

“They will try their hands at everything to continue pushing for watered-down legislation, illicit smuggling, etc,” cautions National Cancer Society Malaysia (NCSM) medical director Dr M. Murallitharan.

The 2019 National Health and Morbidity Survey (NHMS) estimates that 4.9 million Malaysians aged 15 years and older smoke.

The survey also found the prevalence of current smokers to be 21.3% and e-cigarette users, 4.9%.

Those born in 2006 will be 18 in 2024 and will continue to have no legal access to tobacco if the new Act is passed.

But how then do we address the potential consequences for those who had already started smoking (illegally) before they were 18, as it is not only very hard to quit smoking, but relapsing after quitting is also very common?

“We should be focusing on what exactly the ban offers in terms of preventing generations from getting addicted – those who are already addicted should not be just left out to dry.

“We have emphasised to the government that a ban needs to come hand in hand with additional resources to support those who want/need to quit – this is a must.

“It will be difficult to wean them off, but it can be done.

“More importantly, we need to keep them off the habit in the long run with programmes in place that can support them being kept off,” he says.

Dr Murallitharan notes that the issue should not be on how easy or how difficult it would be to wean the teenagers off, but rather, how important and how much of a priority this should be.

“Each individual weaned off and kept off smoking means one less lung cancer or any of so many other diseases that they can contract and suffer from!” he says.

Khairy has admitted that enforcement of such a law would pose a challenge, although he also stressed that the authorities would work hard to plug any gaps.

Hard to give up

The World Health Organization (WHO) states that the tobacco industry is actively manipulating children and young people into consuming harmful products.

In recent years, the industry has also started to use influencers to promote products on social media to lure the young.

Data from a large number of studies reveal that smoking increased during the Covid-19 pandemic due to multiple factors, with new smokers taking up the habit.

Dr Murallitharan says: “It is a clear sign of how existing control measures have been subverted by the industry, which has made a return to normalcy long before any other sector (and is probably doing better)!

“Coming in under the guise of assisting with the pandemic through donation of materials; the narrative of smoking to combat stress due to the pandemic; the narrative of how smoking and the tobacco industry are essential services needed for national economies to function; the pseudoscience narrative behind the use of ‘smoking’ as a prohibitive substance or deterrence to Covid-19; the ‘safety’ of vape – these are just some of the many efforts that the tobacco industry has been actively engaged in during the pandemic.”

As a result, the tobacco industry has done well during this time, both in Malaysia and globally.

Quitting smoking successfully is difficult, but there has been little attention given to the amount of unsuccessful quitting activity.

In 2019, former Deputy Health Minister Dr Lee Boon Chye revealed that 73,836 people had participated in smoking cessation programmes over a seven-year period, but only 16,980 of them were able to successfully quit in six months.

By contrast, the 2019 NHMS estimated that over 27,200 deaths occur due to smoking every year.

In fact, lung cancer is the leading cause of cancer-related deaths in Malaysia.

In its 2016 Quit Smoking programme conducted in four schools in the Klang Valley, NCSM found that 70% of those who smoked started between 12 and 15 years old.

There are an estimated 500,000 underaged smokers in our country.

“The programme comprised of fortnightly sessions for six months and had an average quit rate of almost 75%.

“We continued to monitor these students in the year after the quit programme; less than 20% went back to smoking.

“Unfortunately, the programmes were discontinued with Covid-19 as schools switched to online-learning mode,” shares Dr Murallitharan.

An alternative narrative

Youths can create better and more relatable tobacco harm and smoking prevention content, as well as naturally communicate better with their peers, according to Dr Koong. — AP

One organisation that has steadily been working with youths to create an educational ecosystem on tobacco prevention is Tobacco Free Generation International.

The tobacco-free generation (TFG) concept works on the premise that children born in and after a pre-defined birth year are better educated and will no longer want to smoke.

“Once your new generation is educated better, beyond just the harms of smoking and vaping, there will be no more demand for these products.

“Imagine the natural downstream rapid reduction of resources needed to treat smoking and vaping-related diseases?” says its Singapore-based founder Dr Koong Heng Nung.

“Get the young people involved, groom future leaders – they are very capable of delivering the TFG message either face-to-face or on social media platforms – not old people like me!

“They have to be out there standing and representing the future generation.

“Youths are greater content creators of the tobacco prevention messages and naturally relate better to their peers.”

The world’s first TFG law was proposed by him in 2015, when he was invited to present a week-long community programme to educate the people in the Bataan province of the Philippines.

“We needed to get the fundamentals of TFG out to the community so that there was proper understanding and no questions about its weakness.

“People were so supportive that 32,000 persons signed the petition the following week to legislate it.

“Within two years, the world’s first TFG law was drafted in Bataan, and eventually, other countries started showing interest and implemented it in their communities,” he shares.

In schools, most textbooks try to instil fear in young children when teaching tobacco prevention, by talking about death and diseases.

Unfortunately, kids that age cannot grasp these concepts.

“The best age to start educating them on TFG is around 12 or 13, as it takes two or three years for kids to develop maturity and eloquence in speech.

“Build the first cohort and continue on.

"We need masses of young people to say TFG is good and that our parents were undereducated then and victimised by the industry into smoking.

“If you are a smoker, you don’t want your kids to smoke, and you will support this TFG,” says Dr Koong, who is also a surgeon specialising in thoracic and breast surgery.

He adds: “My aim is to ensure that the TGF narrative and discourse is so positive, rigorous, academically sound and socially uniting, whereby people are so supportive of it that when you draw up legislation, there is no resistance from anyone.

“Even the tobacco industry is deterred from influencing it,”

Incidentally, he was driven to do something about the tobacco epidemic after witnessing countless patients die of lung cancer.

There was even a time he treated three members of the same family – one smoker and two non-smokers – for this cancer.

All didn’t make it and he was devastated.

That’s when Dr Koong, along with other researchers, published a paper in the Tobacco Control journal in 2010, on denying access to tobacco for those born from 2000.

Instead of having laws that are punitive, divisive and negative, he believes the TFG is a better, friendlier narrative.

He points out: “The minimum age law is flawed because it hopes no one below a certain age will smoke.

“You’re telling young people below 18 (or 21) that smoking is bad, but if they’re above 18, it’s okay.

“If the teenager is curious and he wants to show that he is invincible to his friends, he will find ways to buy tobacco products.

“The analogy here is: at what age will it be okay to take off the helmet when you ride a motorbike?

“The answer is obviously never, so you’re sending mixed messages to the young people about tobacco.

“Stop blaming smoking parents as they were inadvertently addicted in the curious and experimental phase of their teenage years, while the minimum legal age to smoke sends the wrong message that it is acceptable to smoke or vape on reaching an ‘adult’ age.”

He concludes: “When there are masses of people supporting this TFG narrative, the politicians and other stakeholders will come on board.

“If Malaysia can do this properly, the rest of the world will follow.”