Harm Reduction Principle in Policy and Regulations to Shape Consumers’ Behaviour

Since early 2020, the world has been living under various degrees of lockdown measures due to the coronavirus pandemic. I personally have found this period to be one of the most challenging times I have faced, but I also found some self-enriching moments as I spend greater time on self-reflection, planning, strategizing and thankfully, lots of invaluable companionship with my family.

Without question, this pandemic has been a trying and stressful experience, even to the best of us. I know that the prolonged lockdown and various demands that the pandemic has caused are placing a tremendous strain on people’s mental health, which has led to a host of other health risks.

This situation needs to be addressed immediately to avoid long-term risks and health repercussion, as asserted by World Health Organization (WHO) in its Big Event for Mental Health survey. Bereavement, isolation, loss of income and fear are triggering mental health conditions or exacerbating existing ones.

A study conducted by researchers in Malaysia between May and September 2020 in assessing the overall mental health of adult Malaysians found that there were increased depressive, anxiety and stress symptoms throughout the pandemic period, with depression rates showing the greatest increase compared to pre-pandemic period. The study also found that there were higher percentages of reported depressive (59.2%) and anxiety (55.1%) symptoms compared to stress (30.6%) symptoms.

Mental health deterioration has been reported to cause increased levels of harmful alcohol use, drug abuse, tobacco consumption, insomnia, anxiety, unhealthy eating and higher cases of domestic violence. Understandably, people find comfort in those vices and unhealthy behaviours to deal with their day-to-day stress, even more so during a pandemic period. As we are social beings, prolonged lockdowns that have essentially restricted our movements to socialise and to some extent, earn a living, have been putting an immense pressure on our wellbeing. The comfort that we find in binge drinking, eating, smoking and other unhealthy habits will unfortunately cause greater long term impacts that must be addressed now.

Among the harmful behaviours that may cause longer term health risk, tobacco use has been one of the hot topics. International research has shown that adult smokers reported higher tobacco consumption by 25% to 45% during the lockdown period compared to before the pandemic. There was also a substantial drop of 27% to 39% in the number of people calling in to quit line operators and smoking cessation services during the lockdown.

Experts believe that many turned to cigarettes in response to psychosocial stress, noting that people from lower income backgrounds and younger adults are among those who have been disproportionately affected by the pandemic and are more prone to tobacco use.

Malaysia has set key targets to reduce our smoking prevalence to 15% by 2025 and to 5% by 2045, in line with our commitment to WHO Framework Convention on Tobacco Control (FCTC). Unfortunately, we have not been very successful in making a dent towards achieving this target as our smoking prevalence has hovered around 21%–25% since 1986. Essentially, we have not been sustainably reducing our smoking prevalence for 35 years!

With the pandemic and movement restrictions, it is even more challenging to reduce the smoking prevalence, especially when there is relatively easy access for illicit cigarettes that have been flooding the market. According to the Nielsen’s Illicit Cigarettes Study commissioned by the Confederation of Malaysian Tobacco Manufacturers, the illegal cigarette trade in the country reached an all-time monthly high of 64.5% in August 2020. This means that 6 out of every 10 cigarettes sold in Malaysia are basically illegal, meaning they are not rightfully contributing to the duties and taxes collection to the Government. On top of the additional danger of consuming products that are noncompliant to authorities’ standards, Oxford Economics has estimated that illicit cigarettes business is costing the Malaysian Government around RM5 billion annually in evaded tax.

SMOKE FREE FUTURE

WHO’s vision of creating a ‘smoke-free’ generation is certainly a noble goal that we should all work towards. In fact, tobacco companies have already committed to that vision where a major tobacco company recently announced that they plan to stop producing combustible cigarettes by the year 2030. Ultimately, the goal is to get people to stop and eliminate smoking.

However, we all know how difficult it is to stop smoking. Research shows that annual quit smoking success rate remains low at 7%, which means there is fewer than one in ten adult smokers who succeed in quitting each year. It is a painful journey that many are used to embark as a resolution, but have struggled to accomplish.

I myself was a chain smoker when I was younger, where I smoked 2 packs of cigarettes every day. I never thought about quitting, until one day during a medical examination, a growth was found in my throat. Fortunately, the growth was diagnosed as benign. However, I made a promise to myself that I will never touch another cigarette in my life and I have kept my word for 24 years.

So my motto is simple: “Don’t start smoking. If you start, quit”.

But the question is, what if you are not able to quit?

Innovation in consumer products

Back in my day, the only cessation aid I had was nicotine patch and gum. But today’s innovation has given us range of alternative products that are less harmful such as electronic nicotine delivery system (ENDS), heated tobacco products and snus.

These alternative, innovative products that use no-combustion technology have undergone studies and scientific assessments, which have shown that these non-combustible products are over 90% safer than combustible cigarettes. Studies have also shown that smoking quit rate is over 60% higher for those using combination of licensed medications and non-combustible nicotine products.

Do the less harmful alternative products really work in reducing the smoking prevalence?

Japan, a good example of a progressive country, has a concept called harm reduction product (HRP) which fundamentally encourages households to choose HRP for at least 20% of household product consumption. This HRP concept aims to increase overall well-being and life expectancy of the Japanese public while trying to maintain the same lifestyle and minimise unnecessary stress of sudden change in behaviour.

By understanding the needs of the public, the Japanese policy makers have incorporated policy measures which have been successful in reducing harmful behaviours. For example, incorporation of HRP in the tobacco policy and regulations has seen the sales of conventional cigarettes reducing by 34% as people shift to healthier and cheaper option of alternative products, instead of continuing to smoke cigarettes. The introduction of alternative non combustible products such as the heated tobacco products (HTP) in Japan since 2016 has also accelerated the decline in cigarette sales, supporting the HRP concept implemented there.

Other countries such as New Zealand and United Kingdom have also acknowledged the benefits of harm reduction in tobacco control, and accordingly they have incorporated tobacco harm reduction in their respective policy and regulations. The advantage of such progressive policy is evident from the contrast difference between the rate of reduction in smoking prevalence of New Zealand (CAGR: –3.8%), United Kingdom (CAGR: –4.4%) and Japan (CAGR: –5.2%) in comparison to Malaysia’s reduction (CAGR: –1.0%) within the same period.

As these progressive countries focus on harm reduction concept that is more pragmatic in achieving their long term goals in smoking prevalence, it is high time that Malaysia also moves to adopt a similar approach and action, for the collective benefit of Malaysians.

Pragmatic policy and regulations that drive innovation and behaviour

I believe that competition and innovation should be the bedrock of policy making. This means establishing policy that encourages innovation, not only from the industry’s end but also from the consumers’ point of view. These could be in the simple form of risk-proportionate fiscal approach in applying tax and excise to harmful products which could shift consumers’ demand, or offering tax breaks for innovative companies with new marketable inventions in less harmful products or services that would influence supply.

These pragmatic policy and regulations that drive innovation are important, not just to enable better choices to consumers, but also to encourage and shift the behaviour of the masses. Ultimately, with the right measures and implementation in tobacco control, this pragmatic approach in policy and regulations would enable medium and long term benefit to the healthcare system and overall population.

Business-as-usual just won’t cut it to move the needle in our tobacco control approach. If we were to continue as is, current trajectory shows that we will only achieve our 15% smoking prevalence target in 2042, off target by 17 years. Essentially, Malaysia should adopt progressive policy changes, if we want to achieve and enjoy the vision of a smoke free future.

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