Regulating Tobacco in Taiwan Requires Nuance

Two of the best-known celebrity anti-smoking activists in Taiwan were veteran actor Sun Yueh, left, and model Chen Shu-li, both of whom were previously heavy smokers. Sun died last year at the age of 87. Photo: John Tung Foundation

Smoking rates are declining, but smuggled untaxed cigarettes remain a major problem.

Draft amendments to Taiwan’s Tobacco Hazards Prevention Act, which passed their first reading in the Legislative Yuan in 2017 but have not yet proceeded further in the legislative process, have received a mixed reception from various interest groups. In addition to the Tobacco Hazards Prevention Act amendments, which expand the scope of smoke-free areas and stipulate a 50% increase of the warning label area on cigarette packs, an amendment to the Tobacco and Alcohol Tax Act that took effect in June 2017 raised the cigarette tax from NT$11.8 per packet to NT$31.8.

Many industry stakeholders have concerns regarding these changes. The Tobacco Institute of the Republic of China (TIROC), a non-profit organization that represents tobacco companies in the Taiwan market, has singled out the higher taxes for particular criticism. “The demand for low-priced illicit cigarettes that evade taxes increased considerably after the very significant and ill-advised increase in the tobacco excise tax in June 2017, impacting both the legitimate industry as well as the government,” TIROC said in a statement.

A recent scandal involving the attempted smuggling of nearly 10,000 duty-free cigarettes into Taiwan by two government officials in July is an example of the type of activity described by TIROC. In that case, the two National Security Bureau (NSB) officials traveling as part of President Tsai Ing-wen’s entourage on her visit to the Caribbean attempted to bring the cigarettes into the country by working with a senior official at China Airlines. The products were impounded by Customs.

Investigators now suspect a previous pattern of similar behavior, with NSB employees smuggling cigarettes in order to resell them for a profit in Taiwan. Internal investigations have been launched by both the NSB and China Airlines.

The recent amendments also ban flavored cigarettes. According to the Ministry of Health and Welfare’s Health Promotion Administration (HPA), young females are more likely to smoke flavored cigarettes, and more females smoke flavored tobacco than men overall.

However, this amendment is facing backlash from the tobacco industry as well. “The Dispute Settlement Body of the World Trade Organization ruled in 2012 that the U.S. measures restricting the ‘flavoring’ of tobacco products violated the Agreement on Technical Barriers to Trade,” states TIROC. “Since there is no evidence that a ban on flavors will contribute to reducing tobacco use, allowing the continued use of flavors and additives should be maintained.”

The 2018 Taiwan Tobacco Control Annual Report, published by the HPA’s Tobacco Control Division, finds that smoking is in fact sharply on the decline in Taiwan. The report found that the adult smoking population has decreased dramatically, from 21.9% in 2008 to 14.5% in 2017. A similar decrease occurred among student-aged smokers, with the percentage of senior high school students who smoke dropping from 14.8% to 8.3% during the same period.

Dr. Lai Chih-kuan, a physician in the Department of Family Medicine at Taipei Veterans General Hospital, notes that tobacco sales in developed countries, including Taiwan, have decreased since 2009. “For me as a healthcare provider, the thing we hope for is that that our people can be free from the harms of tobacco,” said Dr. Lai.

Despite the overall decreases in smoking, Taiwan still lags behind other developed East Asian countries in its progress in cutting back on smoking. The rate of males above the age of 15 who smoke on a daily basis is currently 27.9%, compared to 25.4% in Singapore and 18.6% in Hong Kong. “The rate is decreased now, but not enough,” says Dr. Lai. “For the end game, according to the [World Health Organization’s Framework Convention on Tobacco Control], a rate of less than 5% is our goal. We aren’t against tobacco companies, but we have to protect the population.”

In addition, the rapidly expanding electronic cigarette market threatens to derail further progress. Although e-cigarettes officially are banned in Taiwan, they are still widely available. The HPA found that e-cigarette consumption among junior and senior high school students rose from 2% and 2.1% respectively in 2014, to 2.5% and 4.8% in 2017, a significant increase. The HPA estimates that there are now around 52,000 minors in Taiwan who engage in vaping, as the use of e-cigarettes is called.

Two of the best-known celebrity anti-smoking activists in Taiwan were veteran actor Sun Yueh, left, and model Chen Shu-li, both of whom were previously heavy smokers. Sun died last year at the age of 87. Photo: John Tung Foundation

According to a study published in the International Journal of Environmental Research and Public Health, the unique danger posed by e-cigarettes is their ability to attract adolescents who are unlikely to try traditional cigarettes. This risk is facilitated by “sophisticated strategies of targeted marketing” that promote a wide variety of attractive flavors and claims that e-cigarettes are less harmful to human health, the study says. “Once nicotine use is established, adolescents become more open to conventional smoking.”

The study shows that the switch from e-cigarettes to traditional cigarettes generally takes place after two years. Considering the greater availability and lower cost of such cigarettes, the choice to switch over may be due to convenience.

Given the concerns about e-cigarette use, the Legislative Yuan has also been considering adding the regulation of these products into the pending Tobacco Hazards Prevention Act amendments.

High cost to health

Smoking is responsible for 27,000 deaths annually in Taiwan, according to the 2018 Taiwan Tobacco Control Annual Report. Added to the human cost is a NT$185.8 million price tag, consisting of “direct national health expenditures of NT$65 billion and indirect losses of productivity [totaling] NT$120.9 billion.”

Despite the hikes on the cigarette tax provided for in the recent amendments, the John Tung Foundation, a non-profit organization focused on making Taiwan smoke-free, argues that taxes on tobacco in Taiwan are still too low. The Foundation emphasizes that over the past 30 years, the price of cigarettes around the world has risen dramatically. In Australia, prices rose by a multiplier of 12.7, in New York by 8.5, and in Hong Kong by 4.75. In contrast, the price of cigarettes in Taiwan slightly more than doubled during the same period.

“The price of tobacco in Taiwan is really cheap,” says Lin Ching-li, director of the Tobacco Hazard Prevention Section at the Foundation. “We have thousands of [convenience stores] which are open 24 hours a day where people can fuel their cigarette addiction for as low as NT$100. It’s too convenient.” He and others at the Foundation hope to see the tax raised to 75% of the total price of tobacco in the future.

The popularization of smoking in Taiwan has been linked to the country’s system of military conscription in past decades, when free cigarettes were often provided to soldiers. Today, smoking is still widespread among military personnel, but appears to be less prevalent than in the past. A study published by the journal Military Medicine reported a smoking rate of 49.2% in 2006, while a follow-up survey in 2014 found that this number had decreased to only 30.1%.

This decrease can be attributed in part to targeted efforts by the HPA and Ministry of National Defense to minimize smoking among military staff. The Integrated Tobacco and Betel Nut Control Program, which consists of awareness sessions, educational opportunities, and psychological consultations, was launched in 2003. Smoking areas in military facilities have also been gradually reduced and the policies strictly enforced.

The Smoking Cessation Guidance Network has also been instrumental in changing smoking culture within the military. The organization’s team of specialist medical officers offers support to military personnel to help them through smoking cessation treatments and potential symptoms of nicotine withdrawal.

Although progress is being made in this area, smoking rates are still higher in the military than in the general population. Young conscripts are particularly susceptible to this influence. Education is important, as those with a better understanding of the health implications are less likely to start smoking.

As for smoking among civilians, the John Tung Foundation cites considerable success in changing how Taiwanese view the habit. The Foundation has used educational programs and celebrity partnerships to promote education and awareness about the potential dangers of smoking.

“Forty years ago, for my father’s and mother’s generation, smoking was considered someone’s personal business – there was no reason why I shouldn’t be able to smoke,” says Lin. “The international trend of smoking awareness helped a lot, but we were the first in Asia to have celebrities come out against smoking and become volunteers.”

The Foundation’s extensive network of celebrities regularly join campaigns to spread awareness in order to combat the notion that smoking is cool. Those who have worked publicly with the Foundation include Jackie Chan, Ariel Lin, Jay Chou, and Jam Hsiao.

The Taiwanese government is also doing its share to reduce smoking. Government agencies sponsor a number of programs aimed at encouraging smoking cessation. The Taiwan Smokers’ Helpline, a telephone counseling service administered by the HPA has helped over 140,000 people quit smoking over the 15 years it has been in operation. In addition, hospitals and clinics that provide smoking cessation treatments are reimbursed, and the government continues to partner with NGOs and other groups to produce ad campaigns that target youth smoking.

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