Second-hand smoking in Hong Kong: Time to discuss and address this public health issue
Professor Padmore Adusei Amoah
Assistant Professor, School of Graduate Studies and Department of Applied Psychology, Lingnan University
Smoking is considered one of the top causes of morbidity and mortality globally. Chronic diseases relating to cancer, lung diseases, stroke and heart diseases have been associated with smoking. It is thus not a coincidence that governments and international agencies such as the World Health Organization have made it a priority to implement preventive measures and address the consequences of smoking head-on. This explains why measures such as ban on smoking, restrictions in smoking places, and taxes on tobacco products are rapidly becoming common globally. However, the effects of these policies across places are uneven regarding the prevalence of smoking. According to Figure 1, Hong Kong’s situation is one of the success stories in Asia and even globally when it comes to the prevalence of smoking. According to the Census and Statistics Department, around 10.8% of the population aged 15 years and older smoke in Hong Kong, although this is slightly higher than Singapore (10.1%) as of 2020. To many researchers and commentators, Hong Kong’s success in dealing with smoking habits explains the high life expectancy in the region.
Primarily, Hong Kong’s success can be attributed to the stringent and detailed public health policies such as prohibition of indoor smoking in a variety of public places (e.g. restaurants, schools, parks and leisure facilities, and public transport facilities), bans on categories of smoking equipment such as e-cigarettes, and prohibition of cigarettes advertisements as well as a significant role played by health education to kick the habit. While these measures continue to yield results, it is important that the city do not get complacent as there is more work to be done.
Figure 1: Prevalence of smoking across countries/regions. *Data for men only.
Sources: Census and Statistics Department Hong Kong, 2020; School of Public Health University of Hong Kong, 2021.
In particular, second-hand smoking is less tackled in current discourse and policy debates. Second-hand smoking comprises the smoke exhaled by active smokers and the smoke given off by the burning end of tobacco products inhaled by others. Studies show that second-hand smoking is just as deadly as active smoking since second-hand smoking can also cause heart diseases, cancer and a plethora of maternal and child health issues. However, for a region with such a low prevalence of smoking, previous report indicates that about 22.2% of householders in Hong Kong experience second-hand smoking in their homes. This is partly attributed to crowded living arrangements as many residents live in multiunit housing with shared ventilation systems. Nevertheless, aside from this housing-related issue, behaviours of active smokers in Hong Kong are one area to point to when it comes to second-hand smoking. While it is prohibited to smoke in many public places, it is common to see people smoke in crowded places such as around bus stops and on the streets. It is also common to see smokers walk several meters and even kilometres along public walkways during rush hours with lighted cigarettes. Although smoking in some of these places may not be prohibited by law, there is no denying that such behaviours are sources of second-hand smoking. Even more concerning, personal observations show a high frequency of smoking around children in various [permissible] outdoor areas.
Clearly, addressing the smoking habits and their effects through public education must go beyond the individuals involved. Such education must be upped to include ways of limiting the prevalence of second-hand. In some ways, public smoking behaviours and others that serve as source second-hand smoking are a demonstration of the gaps in current health education strategies. Specifically, the health literacy of the public when it comes to behaviours such as smoking must be improved. There is evidence in many places to show that a significant proportion of people who smoke tend to have low health literacy, and people with high literacy tend to understand messages on smoking better. This means people with high health literacy are likely to be able to access, interpret and utilise health information to make informed decisions. Therefore, by comparing the prevalence of active smoking and second-hand smoking in Hong Kong, it is not farfetched to argue that more must be done to capacitate the public to improve their knowledge about smoking and associated behaviours.
Efforts to reduce second-hand smoking must henceforth promote not only access to information about smoking and its consequences but also attempt to ensure that people understand such messages and are able to apply the information in their everyday lives. Evaluation surveys and interviews of the public’s understanding of the messages about smoking and their overall health literacy must be integral in existing approaches. While such efforts are likely to be financially costlier, the consequences of not taking action will be more devastating to the public and the health system if the prevalence of second-hand smoking keeps rising. Undoubtedly, the city cannot and should not have to deal with a rapid increase in smoking-induced chronic diseases among children, youth and other populations who are not active smokers. In the medium to long term, growing chronic diseases and developmental challenges among children and youth will only exert more pressure on the health system and social service arrangements for vulnerable populations. Along with the rapid ageing population, such a situation will only spur more needs for long-term care as older age has been associated with various forms of frailty and chronic illness.
While public health officials do their part, it is also incumbent on the public to support such actions. In particular, people who have sufficient knowledge and understanding of smoking and its different ways of affecting health must support government efforts by being each other’s keeper. We can gently remind our neighbourhoods and others who smoke in public spaces (even if permitted) to be mindful of those around them by not smoking or carrying lighted cigarettes along public walkways. During the times of COVID-19, such behavioural changes are even more important. Smoking and chatting, which happens so often together, have the potential to spread the virus. Exhaling smoke is said to transmit aerosols about 8 meters away compared to the 1.5 to 2 meters physical distancing measures recommended in public places as part of COVD-19 control measures in various places. This is why some countries have contemplated restricting or even banning outdoor smoking.
Thus, alongside working to reduce the prevalence of active smoking to the barest minimum, the incidence of second-hand smoking should not be ignored due to its similar effects on health outcomes, especially during the time of COVID-19.