Conclusions and recommendations
Reducing Harm
1.There is clear evidence that e-cigarettes are substantially less harmful than conventional cigarettes. Public Health England estimate e-cigarettes as 95% less harmful, although the evidence available does not currently allow a precise figure to be determined. E-cigarettes lack the tar and carbon monoxide of conventional cigarettes—the most dangerous components of conventional cigarettes—which are produced by combustion. Some potentially harmful components are present in both products, such as heavy metals, but at substantially lower levels in e-cigarettes. Researchers have found it almost impossible to measure the risks from ‘second-hand’ e-cigarette vapour because any potentially harmful compounds released into the surrounding area are so negligible. (Paragraph 27)
2.More recently introduced ‘heat-not-burn’ products—producing nicotine from tobacco but without the combustion—have been estimated to be around 90% less harmful than conventional cigarettes, although there is a lack of independent research to validate this claim. (Paragraph 28)
3.There are uncertainties, nevertheless, especially about any long-term health effects of e-cigarettes, because the products have not yet had a history of long use. The studies needed to guarantee the safety of e-cigarettes are inevitably frustrated by the absence of a population of e-cigarette users who have never smoked conventional cigarettes before taking up vaping. Ultimately, however, any judgement of risks has to take account of the risk of not adopting e-cigarettes—that is, continuing to smoke conventional cigarettes, which are substantially more harmful than e-cigarettes. Existing smokers should always be encouraged to give up all types of smoking, but if that is not possible they should switch to e-cigarettes as a considerably less harmful alternative. (Paragraph 29)
4.To help fill remaining gaps in the evidence on the relative risks of e-cigarettes and heat-not-burn products, the Government should maintain its planned annual ‘evidence review’ on e-cigarettes and extend it to also cover heat-not-burn products. It should support a long-term research programme, to be overseen by Public Health England and the Committee on Toxicity of Chemicals in Food, Consumer Products and the Environment, to ensure that health-related evidence is not dependent solely on the tobacco industry or the manufacturers of e-cigarettes. That PHE/COT research should include examining health risks arising from the flavourings added to e-cigarettes. The Government should report each year on the state of research in its Tobacco Control Plan, and establish an online hub for making the detailed evidence readily available to the public and to health professionals. (Paragraph 30)
E-cigarettes and smoking cessation
5.There remain some gaps in the evidence about how effective e-cigarettes are as a stop smoking tool in comparison to other nicotine replacement therapies. Nevertheless, an estimated 2.9 million people in the UK are using e-cigarettes, and tens of thousands are using them to successfully quit smoking each year. Concerns about the risk of e-cigarettes potentially providing a ‘gateway’ into conventional smoking have not materialised to any significant degree. Similarly, the risk of the variety and type of flavours being attractive to young non-smokers, who would be drawn into e-cigarette use, also appears to be negligible. (Paragraph 37)
6.A medically licensed e-cigarette could assist smoking cessation efforts by making it easier for medical professionals to discuss and recommend them as a stop smoking treatment with patients. It would also make it easier for claims to be explicitly made about their harm-reduction relative to conventional smoking, which regulations currently prevent (Chapter 4). The Government should review with MHRA and the e-cigarette industry how its systems for approving stop smoking therapies could be streamlined; to be able to respond appropriately should manufacturers put forward a product for licensing. (Paragraph 46)
7.Smoking cessation is a particular challenge in mental health. People with mental health issues smoke significantly more than the rest of the population and, as the Government warns, if we do not reduce smoking prevalence among this group, “we will have failed to reduce inequalities”. Patients in mental health units who are smokers would benefit from using e-cigarettes to help them stop smoking conventional cigarettes whilst also encouraging them to engage with treatments within the facilities, because they can continue to engage in treatment sessions, when as smokers they would have to leave. Some NHS mental health units are allowing unrestricted use of e-cigarettes—Nottinghamshire Healthcare NHS Foundation Trust is an exemplar—but it is unacceptable that a third of mental health NHS trusts still ban e-cigarettes within their facilities. Three-quarters of NHS trusts are mistakenly concerned about ‘second-hand’ e-cigarette vapour, despite evidence that it presents a negligible health risk. (Paragraph 55)
8.We are concerned that NHS England declined our invitation to give evidence on how it was working to encourage innovative solutions, such as e-cigarettes, to battle the worryingly high numbers of smokers amongst those with poor mental health. NHS England stated that it was unable to provide a representative to put in front of the Committee. NHS England explained that there was no one responsible centrally with “oversight” of e-cigarette policies amongst NHS mental health trusts, nor did NHS England do anything centrally to enforce any type of policy approach. NHS England should take a strong leadership role in ensuring that everything is done to reduce the numbers of smokers amongst those with poor mental health, as smoking is the single largest cause of premature mortality within this group. We also find it very concerning that there is not a dedicated person within NHS England responsible for implementing the Government’s Tobacco Control Plan. NHS England should as a matter of urgency ensure that such a position is created. (Paragraph 56)
9.NHS England should set a clear central NHS policy on e-cigarettes in mental health facilities which establishes a default of allowing e-cigarette use by patients unless an NHS trust can show reasons for not doing so which are demonstrably evidence-based. NHS England should issue e-cigarette guidance to all NHS mental health trusts to ensure that they understand the physical and mental health benefits for their patients. (Paragraph 57)
10.Many businesses, public transport providers and owners of other public places do not allow e-cigarettes in the same way that they prohibit conventional smoking. There is some hostility towards the use of e-cigarettes in public areas, if only because some bystanders find its vapour unpleasant. As we have described in this Report, there is no public health rationale for treating use of the two products the same. Indeed, forcing vapers to use the same ‘smoking shelters’ as conventional smokers could undermine their efforts to quit. There is now a need for a wider debate on how e-cigarettes are to be dealt with in our public spaces, to help arrive at a solution which at least starts from the evidence rather than misconceptions about their health impacts. A liberalisation of restrictions on e-cigarettes, which provide a popular route for people to stop smoking, would result in non-vapers having to accommodate vapers (for a relatively short period of time). (Paragraph 60)
Regulation
11.Some aspects of the regulatory system for e-cigarettes appear to be holding back their use as a stop smoking measure. The limit on the strength of refills means that some users have to puff harder to get the nicotine they seek and may put some heavy smokers off persisting with e-cigarettes. The tank size restriction does not seem to be founded on any scientific rationale. A prohibition on making claims for the relative health benefits of switching to e-cigarettes from conventional cigarettes means that some who might switch are not getting that message. A ban on advertising ‘tobacco’ products, has prevented manufacturers putting ‘pack insert’ information about e-cigarettes in cigarette cartons. The Government, together with the ASA and the MHRA, should review all these regulatory anomalies and, to the extent that EU directives do not present barriers, publish a plan for addressing these in the next annual Tobacco Control Plan. (Paragraph 81)
12.The level of taxation on smoking-related products should directly correspond to the health risks that they present, to encourage less harmful consumption. Applying that logic, e-cigarettes should remain the least-taxed and conventional cigarettes the most, with heat-not-burn products falling between the two (Paragraph 82)
13.The Government should conduct a review of regulations on e-cigarettes and novel tobacco products which are currently applied under EU legislation, to identify scope for change post-Brexit, including an evidence-based review of the case for discontinuing the ban on ‘snus’ oral tobacco. This should be part of a wider shift to a more risk-proportionate regulatory environment; where regulations, advertising rules and tax/duties reflect the evidence on the relative harms of the various e-cigarette and tobacco products available. While an evidence-based approach is important in its own right, it also may help bring forward the behaviours that we want as a society—less smoking, and greater use and acceptance of e-cigarettes and novel tobacco products if that serves to reduce smoking rates. (Paragraph 83)
Published: 17 August 2018