Moving Hong Kong towards a tobacco-free generation: rebutting counter arguments

Tobacco causes over 6900 deaths in Hong Kong and 7 million deaths worldwide every year.1Ho S.Y. Chen J. Leung L.T. et al.Adolescent smoking in Hong Kong: prevalence, psychosocial correlates, and prevention.J Adolesc Health. 2019; 64: S19-S27Summary Full Text Full Text PDF Scopus (18) Google Scholar Aiming at moving towards "a vibrant, healthy and tobacco-free Hong Kong", the Hong Kong government has consulted the public on, and is currently considering the proposal of enacting a tobacco-free generation law. The law, if enacted, will introduce a lifetime tobacco sales ban on the younger generations, who are born after a specified date and currently below the legal smoking age of 18.2Health BureauVibrant, healthy and tobacco-free Hong Kong: consultation document on tobacco control strategies.https://www.healthbureau.gov.hk/tobacco-free/assets/pdf/consultation_document_en.pdfDate: 2023, July 12Google Scholar To gradually achieve tobacco endgame, the UK government is also proposing the enactment of such a law, despite New Zealand's recent decision to repeal its tobacco-free generation law.3Department of Health and Social CareCreating a smokefree generation and tackling youth vaping: what you need to know.https://healthmedia.blog.gov.uk/2024/01/30/creating-a-smokefree-generation-and-tackling-youth-vaping-what-you-need-to-know/Date: 2024, January 30Google Scholar This comment evaluates and rebuts four objections, raised not only in Hong Kong but also in other jurisdictions, against the enactment of a tobacco-free generation law, that it (1) makes smoking appear tempting; (2) fuels the growth of the black market; (3) infringes personal freedom; and (4) is discriminatory.4McCall C. A smoke-free generation: New Zealand's tobacco ban.Lancet. 2022; 399: 1930-1931Summary Full Text Full Text PDF PubMed Scopus (0) Google Scholar,5Cheung E. Hung E. Lifetime ban on cigarettes for Hongkongers born after certain date proposed in public consultation on smoking. South China Morning Post.https://www.scmp.com/news/hong-kong/health-environment/article/3227418/lifetime-ban-cigarettes-hongkongers-born-after-certain-date-proposed-public-consultationDate: 2023, July 12Google Scholar First, it is unlikely that illegalisation would make tobacco products more tempting. Since 1982, Hong Kong has introduced a wide range of tobacco control measures, including the prohibition of tobacco sales to persons under 18 years old, printing mandatory health warnings on tobacco products, and a full smoking ban on indoor public places.1Ho S.Y. Chen J. Leung L.T. et al.Adolescent smoking in Hong Kong: prevalence, psychosocial correlates, and prevention.J Adolesc Health. 2019; 64: S19-S27Summary Full Text Full Text PDF Scopus (18) Google Scholar With 40 years of tobacco control efforts, especially in promoting the negative health effects of smoking, Hong Kong successfully lowered its smoking prevalence from 23.3% in 19821Ho S.Y. Chen J. Leung L.T. et al.Adolescent smoking in Hong Kong: prevalence, psychosocial correlates, and prevention.J Adolesc Health. 2019; 64: S19-S27Summary Full Text Full Text PDF Scopus (18) Google Scholar to 9.5% in 2021.2Health BureauVibrant, healthy and tobacco-free Hong Kong: consultation document on tobacco control strategies.https://www.healthbureau.gov.hk/tobacco-free/assets/pdf/consultation_document_en.pdfDate: 2023, July 12Google Scholar The current smoking prevalence of secondary 1–6 students, who are under the legal age to purchase tobacco products, is around 1.2%.2Health BureauVibrant, healthy and tobacco-free Hong Kong: consultation document on tobacco control strategies.https://www.healthbureau.gov.hk/tobacco-free/assets/pdf/consultation_document_en.pdfDate: 2023, July 12Google Scholar A lifetime tobacco sales ban targeted at the same group, most of whom either view smoking unfavourably or are deterred by the law from smoking, would likely only reinforce the perceived negativity of smoking.6Kelly B.C. Vuolo M. Frizzell L.C. Hernandez E.M. Denormalization, smoke-free air policy, and tobacco use among young adults.Soc Sci Med. 2018; 211: 70-77Crossref PubMed Scopus (38) Google Scholar Second, the tobacco-free generation law would not fuel the growth of the black market. Existing smokers need not turn to the black market since they are not affected by the proposed law.7Berrick A.J. The tobacco-free generation proposal.Tob Control. 2013; 22: i22-i26Crossref PubMed Scopus (58) Google Scholar The current underage smoking prevalence of 1.2% hardly provides sufficient demand for a large tobacco black market to grow, not least to a scale comparable to the current white market. As most of those who will be subjected to the tobacco-free generation law are not addicted to tobacco, removing the social legitimacy of smoking7Berrick A.J. The tobacco-free generation proposal.Tob Control. 2013; 22: i22-i26Crossref PubMed Scopus (58) Google Scholar and the threat of criminal sanctions will strongly discourage them from starting to smoke. Recently, research also found that prohibitions on sales and use are generally effective in reducing smokeless tobacco use.8Chugh A. Arora M. Jain N. et al.The global impact of tobacco control policies on smokeless tobacco use: a systematic review.Lancet Glob Health. 2023; 11: e953-e968Summary Full Text Full Text PDF PubMed Scopus (12) Google Scholar Furthermore, Hong Kong's strong enforcement and punitive sentencing would likely deter illegal sales and use of tobacco when the generation ban is in force. As a reference, Hong Kong's tough approach towards illicit drugs has kept their use at a low level, with the number of reported drug abusers only accounting for 0.08% of the total population in 2021.9Census and Statistics DepartmentDrug situation in Hong Kong in 2021.https://www.censtatd.gov.hk/en/data/stat_report/product/FA100030/att/B72211FB2022XXXXB0100.pdfDate: 2022, NovemberGoogle Scholar Therefore, the tobacco-free generation law would likely reduce the overall demand and supply of tobacco products. Two normative objections remain. It is said that a generation ban infringes personal autonomy and liberty by prohibiting (later grown) adults from making an informed choice to smoke. This line of argument suggests that criminal law should be reserved to govern the most harmful activities, and many socially undesirable activities, such as gambling and binge drinking, are not always prohibited by the law. However, the justification for banning tobacco use is sufficiently strong. The enormous number of tobacco-related deaths and the huge public health expenditures for treating tobacco-related illnesses constitute grave social harm. Moreover, the high addictiveness of tobacco undermines people's autonomy to quit smoking. Decisions to start smoking were often not a fully informed choice,10Hoek J. Ball J. Gray R. Tautolo E.S. Smoking as an 'informed choice': implications for endgame strategies.Tob Control. 2017; 26: 669-673Crossref Scopus (13) Google Scholar and over 90% of adult smokers regretted having started smoking.11Fong G.T. Hammond D. Laux F.L. et al.The near-universal experience of regret among smokers in four countries: findings from the International Tobacco Control Policy Evaluation Survey.Nicotine Tob Res. 2004; 6: S341-S351Crossref Scopus (167) Google Scholar Secondhand smoke also jeopardises the health of others who did not make a voluntary choice to smoke.12van der Eijk Y. Porter G. Human rights and ethical considerations for a tobacco-free generation.Tob Control. 2015; 24: 238-242Crossref Scopus (19) Google Scholar With all these harms, a lifetime ban on tobacco can be justified for protecting citizens' right to life and right to health.12van der Eijk Y. Porter G. Human rights and ethical considerations for a tobacco-free generation.Tob Control. 2015; 24: 238-242Crossref Scopus (19) Google Scholar The final objection is that a generation ban unfairly discriminates between different age groups as it allows some to purchase tobacco while prohibiting the younger generation from doing the same. In response, the differentiation can be fully justified by the legal proportionality test. Imposing an absolute ban on those who were already addicted to tobacco may impose an unacceptably harsh burden on them, and is therefore disproportionate.13Chan J. Proportionality after Hysan: fair balance, manifestly without reasonable foundation and wednesbury unreasonableness.Hong Kong Law J. 2019; 49: 265-294Google Scholar In contrast, imposing a lifetime ban only on those who have never smoked strikes a reasonable balance by concurrently reducing the harm caused by tobacco use and minimising the level of distress caused to citizens. None.