How is vaping promoted in an illegal market? A qualitative study of Singaporeans' social media encounters.

BACKGROUND: Although 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. METHODS: We 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. RESULTS: Participants 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. CONCLUSION: Having 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.

Commercial milk formula marketing following increased restrictions in Singapore: A qualitative study.

The promotion of commercial milk formula (CMF) negatively impacts breastfeeding outcomes. In 2019, Singapore updated its 1979 Code of Ethics of the Sale of Infant Foods Ethics Committee Singapore (SIFECS) to increase marketing restrictions on CMF for infants 0-12 months. However, little is known about industry tactics to undermine these restrictions. This qualitative study explores health workers' and mothers' experiences with CMF marketing in Singapore following the 2019 restrictions. We conducted a qualitative study, using semistructured interviews with 14 mothers of infants aged less than 5 months and 20 health workers with expertise in antenatal, maternity, or paediatric care. We analysed data thematically using inductive coding. Five themes were identified. Mothers and health workers reported digital marketing, product line extensions with toddlers' milk and milk for mothers, and CMF sponsorships in the healthcare setting. Expert endorsement, competitive price, nutritional claims, and brand reputation influenced mothers' infant formula choices, yet both mothers and health workers appeared to be unaware of the impact of CMF marketing tactics on their own perceptions. The restriction of CMF marketing and infant feeding practices varied widely between hospitals, with private hospitals and practices having less strict controls on CMF marketing. Despite the updated SIFECS restrictions, CMF companies continue to target mothers and health workers in Singapore. SIFECS restrictions should be tightened to align with international guidelines, by increasing their scope to include toddlers' milk and prohibiting cross-promotion, digital marketing, and any sponsorships of events targeting health workers that may create a conflict of interest.

Tobacco industry's 'behind the scenes' tactics in Singapore.

BACKGROUND: Tobacco 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. METHODS: Analysis 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. RESULTS: In 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. CONCLUSIONS: Countries 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.

Tobacco industry strategies for flavour capsule cigarettes: analysis of patents and internal industry documents.

BACKGROUND: The global market for flavour capsule variants (FCVs), cigarettes with a crushable flavour capsule, has grown exponentially. To inform further regulatory efforts, it is important to understand tobacco industry strategies for FCVs. METHODS: Analysis of data from 65 patents and 179 internal tobacco industry documents, retrieved via snowball searches in Patsnap and the Truth Tobacco Industry Documents Library, describing tobacco industry developments related to FCVs. We used an inductive coding method to identify themes relating to FCV features or developments. RESULTS: Tobacco companies were developing FCVs since the 1960s, with little market success until the 2000s following the launch of Camel Crush, a brand which targeted millennials (in their teens or early 20s at the time). Tobacco companies have patented, but not yet marketed, FCVs with microcapsule surface coatings, adjustable or heat-triggered flavour release systems, airflow manipulation features, transparent filters to visualise flavour release, and various flavours and additives for capsules including nicotine/tobacco extracts for an on-demand nicotine hit. Tobacco companies developed FCVs purported to be reduced harm, although their own tests showed that FCVs have higher toxicant concentrations. They have also developed loose flavour capsule units designed to fit into cigarettes, packs, or recessed filters to enable users to customise cigarettes and circumvent tobacco flavour bans. CONCLUSIONS: To prevent tobacco companies from targeting young people and exploiting regulatory loopholes, regulations on tobacco products should ban flavours and consider the broad variety of FCV designs, additives and loose products designed to impart flavour into tobacco products.

Systems and policies to reduce secondhand smoke in multiunit housing in Singapore: a qualitative study.

BACKGROUND: Multiunit 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. METHODS: In-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. RESULTS: The 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. CONCLUSIONS: Without 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.

Residential secondhand smoke in a densely populated urban setting: a qualitative exploration of psychosocial impacts, views and experiences.

BACKGROUND: People remain exposed to secondhand smoke, a serious health hazard, inside their home as households face challenges in setting no-smoking rules or are exposed to secondhand smoke drifting in from neighbouring homes. This study explores the psychosocial impacts, views, and experiences with residential secondhand smoke in a densely populated urban setting.  METHODS: In-depth online or face to face interviews with 18 key informants who had been involved in public discourse, policy, advocacy or handling complaints related to residential secondhand smoke, 14 smokers, and 16 non-smokers exposed to secondhand smoke inside their home. All participants were residents of Singapore, a densely populated, multi-ethnic city-state. Interview transcripts were coded in NVivo using a deductive and inductive coding process. FINDINGS: Secondhand smoke has wide-reaching impacts on physical and psychosocial wellbeing, even if smokers tried to minimise secondhand smoke. Feelings of anxiety and stress are generally tied to feeling discomfort in one's personal space, a perceived lack of control over the situation, resentment towards smokers, and concerns over the health effects. Family, community, and cultural dynamics add complexities to tackling the issue, especially in patriarchal households. Secondhand smoke exposure from neighbours is considered a widespread issue, exacerbated by structural factors such as building layout and the COVID-19 pandemic. Resolving the issue amicably is considered challenging due to the absence of regulations and a reluctance to stir up conflict with neighbours. While smokers took measures to reduce secondhand smoke, these were described as ineffective by other participants. Smokers appeared to have contrasting views from other participants on what it means to smoke in a socially responsible manner. CONCLUSION: Given the wide-reaching psychosocial impacts of residential secondhand smoke, there is a case for stronger interventions, especially in densely populated urban settings where it is more difficult to avoid.

Tobacco industry targeting of health-conscious youth with 'lighter' cigarettes: the case of Singapore.

BACKGROUND: Despite Singapore's strict tobacco control policies, smoking rates have not decreased since 2004. We examined the primary targets, motivations and strategies behind targeted marketing activities in Singapore from the tobacco industry's perspective to understand how tobacco companies continue to target people in their marketing. METHODS: Snowball search in the Truth Tobacco Industry Documents Library for documents covering the industry's targeted marketing activities in Singapore. Information from the documents was subsequently triangulated with market data obtained from the Euromonitor Passport database, analysed for trends by tar segment and data from cigarette packs purchased from Singapore retailers, analysed in terms of product positioning. RESULTS: In the 1970s and 1980s, as young people in Singapore became more health-conscious, tobacco companies positioned 'light' cigarettes for growth in the 1990s. Many of these 'lights' contained similar tar and nicotine levels as regular brands; they were only light in their branding. In the 1990's, 'lights' became more popular in Singapore and this demand was largely youth driven. Into the 2010s, while the low tar (<6 mg) segment comprised only a small portion of Singapore's cigarette market, most cigarette variants were marketed as 'lighter' or as having harm reductive benefits to appeal to more health-conscious people. CONCLUSIONS: The differentiation of 'lighter' cigarettes remains an important marketing tool for tobacco companies amidst Singapore's strict regulations. Legislation to remove all remaining avenues for tobacco companies to make harm reduction claims on their products, explicit or implicit, coupled with improving health literacy and exposing industry deception, could help to further bring down smoking prevalence in Singapore.

Encouraging Breastfeeding Without Guilt: A Qualitative Study of Breastfeeding Promotion in the Singapore Healthcare Setting.

Introduction: In Singapore, the healthcare system strongly encourages mothers to breastfeed and breastfeeding initiation is near-universal. However, sustained breastfeeding rates remain low. Little is currently known about how breastfeeding information disseminated in the healthcare setting influences women's breastfeeding experiences. This study explored breastfeeding promotion and educational resources from the perspective of Singaporean mothers and healthcare workers. Methods: Semi-structured interviews with 14 mothers of infants aged 1-5 months and who had used obstetric, maternity, and/or paediatric services in Singapore, and 20 health workers with experience in general, obstetric, maternal, or paediatric care recruited using purposive sampling methods. Interview transcripts were coded using an inductive method. Results: Breastfeeding communications were viewed as too moralized and too focused on nudging women to breastfeed, with relatively little emphasis on timely, practical information or solutions for mothers unable to latch. Hence mothers tended to rely on alternative resources such as blogs. They lacked in-depth knowledge of the benefits of breastfeeding and viewed it as detrimental to maternal mental wellbeing due to the perceived stress and guilt when experiencing difficulties, notably with milk supply and latching, and from the inability to meet breastfeeding expectations. Husbands, older family members, confinement nannies, and employers were considered influential individuals to encourage breastfeeding, but they commonly discouraged breastfeeding due to social and cultural factors which led to supplementation with formula. Conclusion: For better breastfeeding outcomes, future informational sources on breastfeeding should be morally neutral, practical, set realistic expectations for the demands of breastfeeding, and target influential individuals such as family members, confinement nannies and employers.

Is It Time to Ban Flavored Cigarettes in Asia-Pacific Countries? A Scoping Review.

Flavored cigarettes encourage youth smoking and deter quitting. No country in Asia-Pacific, a region with some of the world's highest smoking rates, has regulated tobacco flavors. We examined market data, academic literature, and gray literature to describe what is known on flavored cigarettes in the Asia-Pacific region. Of the 12 countries for which market data were available, ten had substantial flavored cigarette market shares ranging from 10% to 97%. With no regulations and growing markets for flavor capsule variants, the tobacco industry's ongoing promotion of flavored cigarettes, which targets primarily youth and women, is expected to drive further increases in smoking prevalence. There are significant research and monitoring gaps on the industry's marketing tactics and use of flavored cigarettes in the region. Given the large market shares, Asia-Pacific countries stand to benefit substantially from a tobacco flavors ban.

A Systematic Review of Tobacco Industry Tactics in Southeast Asia: Lessons for Other Low- And MiddleIncome Regions.

BACKGROUND: Transnational tobacco companies (TTCs) have a well-established presence in Southeast Asia and are now targeting other low- and middle-income countries (LMICs), especially Africa. While the tobacco industry's tactics in Southeast Asia are well documented, no study has systematically reviewed these tactics to inform tobacco control policies and movements in Africa, where the tobacco epidemic is spreading. METHODS: We conducted a systematic literature review of articles that describe tobacco industry tactics in Southeast Asia, which includes Singapore, Indonesia, Malaysia, the Philippines, Myanmar, East Timor, Thailand, Cambodia, Vietnam, Laos, and Brunei. After screening 512 articles, we gathered and analysed data from 134 articles which met our final inclusion criteria. RESULTS: Tobacco transnationals gained dominance in Southeast Asian markets by positioning themselves as good corporate citizens with corporate social responsibility (CSR) initiatives, promoting the industry as a pillar of, and partner for, economic growth. Tobacco transnationals also formed strategic sectoral alliances and reinforced their political ties to delay the implementation of regulations and lobby for weaker tobacco control. Where governments resisted the transnationals' attempts to enter a market, they used litigation and deceptive tactics including smuggling to pressure governments to open markets, and tarnished the reputation of public health organizations. The tobacco industry undermined tobacco advertising, promotion and sponsorship (TAPS) regulations through a broad range of direct and indirect marketing tactics. CONCLUSION: The experience of Southeast Asia with tobacco transnationals show that, beyond highlighting the public health benefits, underscoring the economic benefits of tobacco control might be a more compelling argument for governments in LMICs to prioritise tobacco control. Given the tobacco industry's widespread use of litigation, LMICs need more legal support and resources to counter industry litigations. LMICs should also prioritize measures to protect health policy from the vested interests of the tobacco industry, and to close regulatory loopholes in tobacco marketing restrictions.