Anti-tobacco advocates have for years pushed for a “tobacco endgame”, where young people will be banned from ever buying cigarettes in their lifetimes. New Zealand got the ball rolling when it announced its intention to gradually raise the minimum smoking age, so that it would be illegal for anyone born after 2008 to buy cigarettes. Singapore said New Zealand’s proposal was “attractive”, while Malaysia said it was mulling a plan to ban the sale of tobacco products to people born after 2005. In the second report of a three-part series , This Week in Asia takes a look at discussions on kicking the habit in Malaysia, India and the Philippines. Read part one here and part three here . Twenty-one-year-old Parul is one of India’s legion of young smokers who give Big Tobacco a reason for cheer. Parul, who is just out of university and working as a social-media coordinator, started smoking at 17. “Everyone smoked at college – boys and girls,” said Parul, who didn’t want her last name used because her parents don’t know she smokes. “I was a social smoker but now it’s become a more regular habit,” she added. While India has made big strides in reducing tobacco consumption (users fell by 26 per cent between 2005-06 and 2016-17), more than one in four Indian adults still use tobacco, the leading preventable cause of cancer . “The national tobacco use surveys show the country has made considerable progress in lowering tobacco use,” said Indian health economist Rijo John, who teaches at the Rajagiri College of Social Sciences in the southern coastal city of Kochi. “But we need to get the number of tobacco users significantly lower,” he said. India has 275 million tobacco users, second only to China’s 308 million, and logs 1.35 million tobacco-related deaths a year, says the World Health Organization (WHO). By contrast, China’s tobacco-related deaths are estimated at 2.5 million by the WHO’s Global Adult Tobacco Survey. The WHO calculates tobacco use costs India nearly US$30 billion annually in health care and lost productivity, a huge sum for a developing country. If you tax more, you raise more revenue, you reduce consumption, you reduce the health burden – it’s win-win Rijo John And even though male smokers still heavily outnumber female smokers by three-to-one, more women are smoking, something Parul attributes to increasingly relaxed social attitudes. “Before, women couldn’t smoke because society was so conservative. It sounds strange to say, given the health dangers, but smoking is an expression of liberation. We’re doing it because we can,” she said. Parul said she knows about New Zealand’s groundbreaking plan to progressively end smoking by banning anyone 14 years or younger from purchasing cigarettes for their entire lifetimes. But she doesn’t believe such an initiative would work in India, noting that in Delhi until last year the alcohol drinking age was 25 but the rule was widely flouted. “It would be the same for smoking. It all depends on enforcement and that can be really lax in India,” she said. Philippines has 17m smokers, some as young as 10. Can a ban help them quit? Back in 2008, India made a bold move, outlawing smoking in public places, which has enjoyed patchy adherence. Overriding objections from India’s US$11 billion tobacco industry, dominated by India’s ITC Ltd whose largest shareholder is British American Tobacco, the government has also increased the size of health warnings – graphic images of diseased lungs and cancer sufferers – to cover 85 per cent of cigarette packages, up from 20 per cent. To the dismay of a tobacco industry seeking a new market for growth, India also banned e-cigarettes amid worries about their long-term effects. In films, smoking scenes must be accompanied by an on-screen warning that tobacco is bad for health. And last year, the government, which aims to cut tobacco use by an ambitious 30 per cent by 2025, proposed new tobacco controls to ban smoking zones in hotels, restaurants and airports and to increase the minimum legal smoking age from 18 to 21. “We should be able to meet the 30 per cent reduction target if we are able to plug loopholes” in existing legislation through amendments “that are in the offing,” said Monika Arora, a public health scientist at the Public Health Foundation of India. “We’re ‘denormalising’ tobacco use.” New figures from Statista show tobacco products growth was flat year-on-year in 2016, down from a rise of 5.4 per cent eight years earlier. Raise tobacco tax to protect youth against lifelong addiction Not just cigarettes Even if the planned rules become law, anti-tobacco messages often don’t reach most tobacco users due to the unique way India’s tobacco market is structured. “Cigarettes aren’t very popular – they constitute less than 15 per cent of the market because they’re more expensive,” John said. Also, at least 75 per cent of cigarettes are sold as single sticks (in violation of Indian law) which means buyers don’t see any packet warnings. In addition, 85 per cent of tobacco smokers get their nicotine hit from much cheaper, filterless “bidis” – tobacco handrolled in a leaf – or they use so-called “smokeless tobacco” products sold in small, plastic pouches. The bidis and smokeless tobacco products are made in cottage industry settings without any of the packaging warnings and sold in family-owned shops and stalls. Many of the chewable products contain high levels of nicotine, making them extremely addictive, and are spat out by users in bright red streams of saliva that discolour pavements. Indian superstars have given smokeless tobacco products a veneer of respectability by advertising pan masala, sold as a mouth freshener, but containing no tobacco. Pan masala products serve as proxies for gutka, a highly popular chewing tobacco made with crushed betel nuts that are a stimulant and for which advertising is banned. Fuelling the take-up of tobacco products is the frequent targeting of children by retailers, again in violation of the law. A 2019 survey conducted near 243 schools at 487 points of sales found half sold tobacco products to minors. Some 90 per cent of the products were displayed beside confectionery or toys. The findings are significant because WHO studies suggest the more young people are exposed to tobacco, the more they are likely to start smoking. This is particularly worrying as India has the world’s largest youth population, with 356 million 10-to-24 year-olds. Many Indian states have prohibited gutka but it is still sold and used even by some preteens. New Delhi security guard Rajesh Sharma, 42, started using gutka when he was in his early teens. Seven years ago, surgeons removed part of Sharma’s jaw after he developed a cancerous mouth lesion. “I didn’t know about the dangers. I’m lucky to be alive – except for this,” said Sharma, gesturing to the sunken, scarred side of his face where surgeons cut out the cancer. Due to chewing tobacco, doctors diagnose around 80,000 oral cancers a year in what they call an “oral cancer epidemic” while 27 per cent of all Indian cancer cases are due to tobacco use. Industry pressure Another argument confronting anti-tobacco campaigners is that India has the world’s third-largest tobacco industry after China and Brazil. The tobacco lobby says 45.6 million Indians – from farmers, cigarette factory workers, and low-skilled women who roll the bidis to retailers – depend on tobacco for their earnings. But Arora said the tobacco industry job figures were “highly padded”. John said worry over job losses “doesn’t have any public health rationale. It’s true this looks like a large number of people. But a decline in consumption wouldn’t happen all at once.” Also, he said, people would have more disposable income if they did not spend on tobacco so there would be more demand for other goods and services over time that would absorb unwanted tobacco labour. The WHO calculates many poor families spend up to 10 per cent of their income on tobacco. Also, Arora said, the costs of treating the tobacco-related diseases “push people into poverty”. John said higher taxation was the best way to crack down on tobacco use. The tobacco lobby insists this would create more illicit consumption of tobacco products, which it estimates already constitutes 25 per cent of the market. John said peer-reviewed scientific journals show that illicit cigarettes constitute between 2.7 per cent and 6.6 per cent of the market in India, well below the 11 per cent world average and “nowhere near the tobacco industry’s 25 per cent figure”. “If you tax more, you raise more revenue, you reduce consumption, you reduce the health burden – it’s win-win,” John said. As far as the tobacco industry’s claim that the government would miss the revenue from taxing cigarette products, John said this was “nonsense”. Rather, he said, “tobacco consumption is a major resource drain on the exchequer.” For every 100 rupees (US$1.31) received as excise taxes from tobacco products, tobacco consumption imposes 816 rupees (US$10.72) in medical and other costs on society,” he said. Two reasons Hong Kong should look at raising tobacco tax At present, the total tax burden is only 53 per cent for cigarettes, 22 per cent for bidis and 63.8 per cent for smokeless tobacco, much lower than the WHO-recommended tax burden of at least 75 per cent of the retail price for all tobacco products, he said. “There’s overwhelming agreement taxation is one of the best cost-effective ways to cut demand for tobacco products,” he said. “Research from high- and low-income countries has show that tobacco tax and prices hikes push users to stop and dissuade youngsters from starting. Higher taxes also can only help the poor in terms of better returns from having better health and more money thanks to lower consumption,” he added.