April, 2012:

On a three-day camp last month in Sai Kung, businessman Chan Chi-kin was in no mood to enjoy the greenery and pristine beaches around him. The 44-year-old, who smoked three packs a day since he was 17, had to summon all his willpower to fend off the urge to light up.

Chan, who had tried to quit on his own but failed, says the camaraderie among the quitters in the camp – organised by Tung Wah Group of Hospitals’ (TWGH) Integrated Centre on Smoking Cessation – boosted his confidence in overcoming his addiction.

“My failed attempt crushed my confidence. I am afraid that I will fail again,” he says. “But the people in the camp supported and motivated me. With others also struck by cravings but unable to light up, I feel I am not alone.”

The first quitting camp in Hong Kong, with seven heavy smokers, was one of several initiatives launched by the government and anti-smoking groups.

Even though Hong Kong has the lowest smoking rate in the world, at 11.1 per cent, smoking still accounts for 6,000 deaths per year in the city. The annual economic loss due to damage caused by tobacco is HK$5.3 billion. As a sign of the government’s seriousness in cracking down on tobacco addiction, investment in smoking cessation has risen from HK$3 million in 2008-09 to HK$80 million in 2012-13.

The first government-sponsored cessation centre was set up by the Council on Smoking and Health in 2000 at the outpatient department of Ruttonjee Hospital. There are now 40 cessation centres under the Health Department and the Hospital Authority.

The government further commissioned TWGH to provide free cessation services in 2009 – it now runs six centres. Last year, a quit-line aimed at youths was set up by the University of Hong Kong’s School of Nursing.

Health Department senior medical and health officer Edmond Ma says Hong Kong must enhance cessation services if it is to further drive down the smoking rate.

“Given the boost in resources, different forms of cessation are available, including counselling and nicotine replacement therapy,” he says.

Ma spelled out the achievements attained by Hong Kong last month at the 15th World Conference on Tobacco or Health in Singapore, where 2,600 delegates from 124 countries shared their anti-smoking strategies. “We need to train more medical personnel in smoking cessation. Helping people to quit requires lots of skills and knowledge,” he says.

The department has trained more than 100 health care workers in the field over the past two years. Novel approaches to kicking the habit are also being used.

Raymond Ho Lei-ming, head of the Tobacco Control Office, says free acupuncture has been available at Pok Oi Hospital since 2010. Sessions can help relieve withdrawal symptoms such as fatigue, lack of concentration and dryness of the mouth. “It has helped around 2,400 people so far,” says Ho.

Tobacco kills one person every six seconds – or about six million people, including 600,000 non-smokers through second-hand smoke – globally every year.

The burden of tobacco-related illness and death is greatest in low- and middle-income countries. As a result of cessation efforts, the developed world accounted for 24 per cent of worldwide tobacco consumption in 2009, a drop from 38 per cent in 1990.

Hong Kong got serious in combating tobacco after China ratified the World Health Organisation (WHO) Framework Convention on Tobacco Control in 2005. Financial Secretary John Tsang Chun-wah increased the tobacco tax by 50 per cent in 2009. A further 41.5 per cent rise was implemented last year. A pack of cigarettes now costs HK$50, HK$30 of which is tax. An indoor smoking ban in 2009 finally included bars and restaurants previously exempt.

But Judith Mackay, senior adviser to the World Lung Foundation, says Hong Kong should increase the tax further and extend smoke-free areas to the outdoors.

“Taxation and cessation are twins,” she says.

Lisa Lau Man-man, chairman of the Council on Smoking and Health, agrees: “Tax should be raised to a minimum of 75 per cent of the retail price [the level recommended by the WHO].”

Mackay says Hong Kong’s pictorial warnings on packaging are five years old and need to be updated. Quit-line numbers should be placed on the packs, she says.

The latest government figures on smokers’ awareness of cessation services show more than 30 per cent of the 700,000 smokers in the city do not know about them.

Lau says restricting the display of cigarettes at points of sale should be considered, since showing them is itself a form of promotion.

Singapore is considering such a display ban, which would require shops to keep tobacco products out of the sight of customers. In countries where such a ban is enforced, such as Canada and Britain, cigarette packs are kept under the counter and produced only on request.

Besides anti-smoking policies, hard-hitting media campaigns portray the tobacco industry as evil money grubbers, hell-bent on killing people while raking in huge profits.

During a session at the Singapore conference, Norwegian Minister of Health and Care Services Anne-Grete Strom-Erichsen showed an advertisement run on a regional television channel in Norway that is aimed at arousing people’s revulsion against the industry.

A fat, insolent man tells the camera that they only target the black, stupid and poor. While he spouts his mantra “we don’t smoke it, we just sell it”, a pretty young girl is shown buying cigarettes, and her money ends up lining his pockets.

Strom-Erichsen says people should hold the industry in contempt. “Philip Morris took our government to court in 2010, claiming our display ban for tobacco products is in breach of European free trade rules … we will fight the intimidation to fulfil our legal duty to protect public health,” she says.

Michael Eriksen, director of the Institute of Public Health at Georgia State University in the US, says the industry makes US$35 billion in annual profits.

“It’s nearly US$6,000 in profit for every death caused by tobacco,” he says.

Besides media campaigns, Singapore has taken a step further by mobilising its people to become anti-smoking activists. Ang Hak Seng, chief executive of the city state’s Health Promotion Board, says government policies must be supplemented by aggressive bottom-up strategies.

Former smokers have been mobilised to become activists in the board’s outreach activities.

“They help us engage smokers by sharing their personal quitting journey and follow up with the smokers after events,” Ang says.

An initiative called Blue Ribbon was launched recently, in which 10 markets and food centres received a Blue Ribbon award for promoting smoke-free messages to customers.

Residential estates, says Ang, will adopt a voluntary smoking ban in public areas such as common corridors. Grass-roots volunteers, trained by the board as cessation counsellors, will go door to door, handing out blue ribbons and quit kits.

“We provide them with specialised training on how to talk to smokers so that they don’t come across as confrontational and aggressive,” says Alice Ong, a manager with the board’s substance abuse department. “We teach them how to deal with defensive smokers, to ensure that neighbourhood harmony won’t be affected.”

Singapore, whose smoking rate has fallen from 18.3 per cent in 1992 to 14.3 per cent, is leading the Asian charge in combating smoking. Its tobacco tax is 60.7 per cent; it was the first country in the world to ban duty-free cigarettes in 1991; and it has a total of 150 cessation outlets across the island.

Ang aims to mobilise everyone in Singapore to create a social movement to counter smoking.

“International studies show that most smokers have a relapse within eight days of an attempt to quit, and only 5 per cent manage to stay smoke-free beyond 12 months,” he says.

“This is why it is so important for smokers trying to quit to have a community-based supportive network made up of family, friends, ex-smokers and even Facebook acquaintances to encourage them not to give up.”

A 2011 study by TWGH of 301 smokers showed that 42 per cent remained smoke-free for six months, and the figure dropped to 36 per cent after a year.

Smokers were given nicotine replacement therapies (gum, patch, and inhaler), drugs such as bupropion and varenicline, and counselling to help them quit.

Patrick Fok Wai-yin, senior counsellor with TWGH, says support from family and friends can make a huge difference.

“It’s important not to negate the feelings of smokers,” he says. “We acknowledge that smoking brings pleasure to them. Our role is to help them find alternatives.”

Dr Wong Chi-hong, a medical officer with TWGH, says many smokers have misconceptions about nicotine replacement medicines, thinking the drugs will make them resistant to cigarettes. The medicines, in fact, help relieve withdrawal symptoms such as insomnia, irritability and depressed mood.

“Their psychological urges to light up may not go away completely,” Wong says. “They still have to make the effort to suppress them.”

Chan Chi-kin, who takes bupropion, says he still feels the urge to light up under stress, as smoking relaxes him and helps sharpen his mind. He fends off the urge by thinking of his two girls studying at university abroad.

“I must be healthy so my daughters’ studies will not be affected,” he says