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BackgroundAlthough Singapore has completely banned vaping, it is heavily promoted on social media. This study explored vaping-related social media content that Singaporeans are exposed to, and how it shapes vaping-related perceptions and experiences in the context of Singapore’s strict regulations.MethodsWe held 10 focus group discussions with 63 Singaporeans aged 21–40 years, with diversity by sociodemographics, smoking history, vaping history and self-reported exposure to vaping-related social media content. Participants provided screenshots of any vaping-related content they encountered on their social media. Subsequently, in focus groups, they were shown a variety of this content and asked to discuss. We coded transcripts using inductive methods.ResultsParticipants had encountered vape advertisements from neighbouring countries featuring attractive products, flavours, celebrity endorsements and entertainment shows, which they found highly appealing. Participants encountered posts that did not overtly advertise vaping but depicted people vaping in social settings, thereby normalising vaping despite its illegal status. They perceived government campaigns to deter vaping as biased and agenda driven, calling for a more nuanced message and use of local influencers and personal stories to communicate the rationale of the vaping regulations to the public.ConclusionHaving a law that bans vaping may not be enough; it needs to be complemented with more comprehensive marketing restrictions on social media platforms and effective enforcement of bans on social media promotions from overseas.

IntroductionInternational interest in a smokefree generation policy has grown as more local authorities and governments move to introduce this policy. Young people strongly support this measure, but we know less about how they view a nicotine-free generation policy that includes electronic nicotine delivery systems (ENDS). We addressed this gap by probing adolescents’ views on a birth-year policy that included all nicotine products.MethodsWe undertook in-depth interviews with 20 adolescents aged 16–18 who self-assessed as moderately or severely addicted to vaping and lived in Aotearoa New Zealand. In semistructured interviews, we explored participants’ views on a nicotine-free generation, its rationale, implementation and likely impact. We interpreted the data using a reflexive thematic analysis approach.ResultsMost participants supported a nicotine-free generation, rejected arguments that ENDS use was a ‘choice’, and called for government leadership to protect them and future generations; a small minority saw the measure as unwarranted interference. Several participants thought compliance would be low, given their experiences of lax age verification practices and the widespread social supply of ENDS, but suggested measures to improve compliance.ConclusionsAlthough participants thought a nicotine-free generation could impose personal hardship, most privileged the freedom they thought it could bring over the illusory ‘choice’ they currently had. Policy-makers should consider looking beyond a smokefree generation to a nicotine-free generation; alongside this measure, they should implement strong enforcement and provide comprehensive support so young people addicted to nicotine can be empowered to stop using ENDS.

As tobacco marketing restrictions intensify, tobacco companies increasingly turn to the cigarette product itself as a marketing medium with new flavours, capsules, novelty filter features and attractive cigarette stick designs. This paper considers a ‘standardised cigarettes’ policy as a potential next step in restricting tobacco marketing. This policy would remove from cigarette products all the elements that increase their appeal and addictiveness: added flavours, nicotine, and visual designs and branding. The result would be a cigarette that is flavourless, not especially addicting, and visually off-putting. This paper discusses what a standardised cigarettes policy might look like from a regulatory standpoint, and how it fits into current policy obligations under the WHO Framework Convention on Tobacco Control.

BackgroundAn increasing number of countries are pursuing a tobacco ‘endgame’. We sought to determine the combination of measures it would take to achieve a tobacco endgame in the city-state of Singapore.MethodsUsing an open-cohort microsimulation model, we estimated the impact of existing measures (quit programmes, tobacco taxes, flavours ban) and more novel measures (very low nicotine cap, tobacco-free generation, raising the minimum legal age to 25 years), and combinations thereof, on smoking prevalence in Singapore over a 50-year horizon. We used Markov Chain Monte Carlo to estimate transition probabilities between the states of never smoker, current smoker and former smoker, updating each individual’s state across each year with prior distributions derived from national survey data.ResultsWithout new measures, smoking prevalence is expected to rebound from 12.2% (2020) to 14.8% (2070). The only scenarios to achieve a tobacco endgame target within a decade are those combining a very low nicotine cap with a flavours ban. A nicotine cap or tobacco-free generation alone also achieve endgame targets, but after 20 and 39 years, respectively. Taxes, quit programmes, a flavours ban and minimum legal age increase do augment the impact of other measures, but even when combined are insufficient to achieve a tobacco endgame target within 50 years.ConclusionIn Singapore, achieving a tobacco endgame within a decade requires a very low nicotine cap coupled with a tobacco flavours ban, although this target can also be achieved in the long term (within 50 years) with a tobacco-free generation.

BackgroundSingapore has completely banned e-cigarettes and the government’s cautious stance against vaping has been consistent. Despite this, vaping appears to have gained popularity in Singapore, especially among younger people. With the heavy marketing of vaping products on social media, it is possible that such marketing, due to its cross-border nature, is reaching younger Singaporeans and driving changes in vaping-related perceptions or behaviours. This study examines their exposure to vaping-related content on social media, and whether such exposure is associated with more positive perceptions of vaping or e-cigarette ever use.MethodsAnalysis of cross-sectional survey data of 550 adult (age 21–40 years) Singaporeans recruited via convenience methods in May 2022, using descriptive statistics, bivariate analyses, and multiple linear and logistic regression models.Results16.9% of participants reported they had ever used e-cigarettes. 18.5% of those who used social media recalled seeing vaping-related content on a social media platform in the past 6 months, mostly from influencers or friends, and on Instagram, Facebook, TikTok and/or YouTube. Reporting exposure to such content was not associated with e-cigarette ever use. It was associated with having a more positive overall perception of vaping (β=1.47; 95% CI: 0.17 to 2.78), although no significant difference was observed when examining only health-related perceptions.ConclusionEven in a heavily regulated environment such as Singapore’s, people appear to be exposed to vaping-related content on social media platforms and this exposure is, in turn, associated with more positive perceptions of vaping, but not e-cigarette ever use.

BackgroundSingapore has implemented plain packaging, a measure that strips all colours, logos and branding elements from tobacco packs. In other countries, tobacco companies responded to plain packaging with a variety of marketing tactics. Our goal was to describe the tobacco industry’s marketing adaptations to Singapore plain packaging.MethodsQualitative analysis of 378 cigarette packs sampled from Singapore retailers in March 2019, March 2020 and January 2021, 12 months prior to, 2 weeks prior to and 6 months after plain packaging phase-in, respectively. For each pack, we collected descriptive information on the brand and variant name, pack and stick dimensions, pack shape, differentiating features and distinctive scents, as well as photographic data of the pack, cigarette sticks and any distinct features. We used the March 2019 collection as our baseline dataset, and March 2020 and January 2021 collections as comparison datasets to examine changes in tobacco marketing strategies just before and after plain packaging phase-in.ResultsAround Singapore’s plain packaging phase-in, tobacco companies launched variants with flavour capsules, novelty filter features and new flavours and used more descriptive variant names reflecting the variant’s colour coding or market positioning. Tobacco companies revamped some existing variants, often with Japanese marketing themes to convey a more premium product image. After plain packaging, tobacco companies used longer packs and variations in stick length, filter length and foil texture to further differentiate products.ConclusionsFollowing plain packaging in Singapore, tobacco companies rely increasingly on nomenclature and the cigarette stick itself to market and differentiate products.

BackgroundMultiunit housing residents are often exposed to neighbours’ secondhand smoke (SHS). Little is known on the current systems available to protect residents in places not covered by a residential smoking ban, or what constitutes an appropriate policy approach. This study explores relevant systems and policies in Singapore, a densely populated city-state where the vast majority live in multiunit housing and discussions on regulating smoking in homes are ongoing.MethodsIn-depth interviews with 18 key informants involved in thought leadership, advocacy, policy or handling SHS complaints, and 14 smokers and 16 non-smokers exposed to SHS at home.ResultsThe current system to address neighbours’ SHS comprises three steps: moral suasion, mediation and legal dispute. Moral suasion and mediation are often ineffective as they depend on smokers to willingly restrict their smoking habits. Legal dispute can yield a court order to stop smoking inside the home, but the process places a high evidence burden on complainants. While setting up designated smoking points or running social responsibility campaigns may help to create no-smoking norms, more intractable cases will likely require regulation, a polarising approach which raises concerns about privacy.ConclusionsWithout regulations to limit SHS in multiunit housing, current systems are limited in their enforceability as they treat SHS as a neighbourly nuisance rather than a public health threat.

BackgroundTobacco companies have maintained a profitable business in Singapore, despite its strong anti-tobacco climate and commitment to protect public health policymaking from tobacco industry interference in line with Framework Convention on Tobacco Control Article 5.3. This study describes how tobacco companies influence policymaking in a highly regulated environment such as Singapore’s, where there is a strong government commitment to Article 5.3.MethodsAnalysis of internal tobacco industry documents detailing the industry’s lobbying activities in Singapore, retrieved via snowball searches in the Truth Tobacco Industry Documents Library. Subsequently, we conducted one-on-one interviews with key informants from sectors mentioned in the documents (academia, arts, government, public health, media, trade, education) to fill gaps in information and provide context to events described in the documents.ResultsIn the 1980s and 1990s, tobacco companies observed that, to influence policy within Singapore’s ‘hostile’ environment, they needed to use ‘behind the scenes’ tactics, targeting influential individuals at social functions or industry-sponsored events. Tobacco companies used arts and education sponsorships primarily for political purposes, to gain visibility with policymakers. Tobacco companies cultivated relationships with academic researchers and the media to avoid smoke-free legislation in the 1990s and, in the 2010s, appear to have used similar tactics to challenge Singapore’s e-cigarette ban.ConclusionsCountries with a strong commitment to Article 5.3 should consider the tobacco industry’s potential interference in policymaking beyond relationships in the government sector, particularly in academia, arts, education and the media, and the more subtle or indirect manners in which these relationships are built.

BackgroundDespite a strict vaping ban also covering purchase, use and possession, vaping has become more prevalent in Singapore. As more countries seek to regulate vaping, with no tailored services or guidelines for vaping cessation, clinicians may face additional challenges in identifying or treating vaping cases due to stigma or patients’ reluctance to disclose their vaping. Few studies have explored how clinicians identify or manage vaping cases in a context where vaping is heavily regulated or stigmatised.MethodsWe conducted semistructured interviews with 12 Singapore practitioners from pharmacy, psychology, respiratory medicine, smoking cessation or youth welfare settings, all of whom had encountered vaping cases in their practice. Interviews explored how they manage vaping cases. We analysed data using inductive thematic methods.ResultsPatients were described as reluctant to disclose their vaping for fear of being reported to authorities, and some clinicians were unsure of their duty to report, making it challenging to identify vaping cases. Variability in usage patterns and inaccurate e-liquid labelling posed difficulties in estimating nicotine dependence, leaving practitioners to trial and error or to adapt from smoking cessation guidelines. Tailored quit support for people who vape was lacking, especially in the form of subsidised nicotine replacement therapy.ConclusionEven in contexts where vaping is heavily regulated, given the rising incidence of vaping globally, it is important to record patients’ vaping history as part of routine practice and to provide services to help people quit vaping without facing stigma or legal repercussions because of their vaping.

The aim of this paper is to overview progress made with respect to the adoption of plain (or standardised) packaging, key challenges faced, evaluative evidence and opportunities for extending this policy. It has been a decade since Australia became the first country to require tobacco products to be sold in plain packaging; after slow initial uptake, 16 countries have now fully implemented this policy. Since 2020, plain packaging laws have become more comprehensive in some countries, expanding coverage beyond traditional tobacco products to include heated tobacco, tobacco accessories (rolling papers) and other nicotine-containing products (e-cigarettes). Laws have also become more innovative: some now ban non-biodegradable filters, include provision for a periodic change of the pack colour or require both plain packaging and health-promoting pack inserts. The tobacco industry has and will continue to use multi-jurisdictional strategies to oppose this policy. Evaluations suggest that plain packaging has improved health outcomes and has not burdened retailers, although research is limited to early policy adopters and important gaps in the literature remain. While the power of packaging as a sales tool has diminished in markets with plain packaging, tobacco companies have exploited loopholes to continue to promote their products and have increasingly focused on filter innovations. Opportunities exist for governments to strengthen plain packaging laws.