Tobacco and Vapes Bill

Written evidence submitted by the Nottingham Centre for Public Health and Epidemiology, University of Nottingham (TVB30)

RESPONSE TO THE CALL FOR EVIDENCE FOR THE TOBACCO AND VAPING BILL

Introduction

1. This submission is authored by members of the University of Nottingham’s Centre for Public Health and Epidemiology. It focuses on the Centre’s research on raising the age of sale of tobacco in the United Kingdom, funded by NIHR/HEE grant NIHR302872

2. This submission will focus on clauses 1-6, relating to the age of sale of tobacco. We submit that the ban on sale of tobacco to those born in or after 2009 (the generational ban) is likely to have a far greater effect on prevalence, and to have broader support amongst young people, than raising the age of sale of tobacco to 21.

Evidence for age of sale rise and its implementation

3. There is clear historical evidence from England that increasing the age of sale of tobacco reduces cigarette use in the age group covered by the increase. Raising the age of sale from 16 to 18 in England has been associated with reduced smoking rates in the target population[1,2] and reducing health disparities.[3]

4. More recent evidence for increasing the age of sale above 18 comes from the United States, one of the several countries that has raised the age of sale of tobacco above 21 (Tobacco 21). Our systematic review of such laws included nineteen studies. We found the introduction of Tobacco 21 was likely to reduce smoking prevalence, particularly for older school-aged groups and those aged 18-20.[4]

5. Our systematic review also indicated that implementation is an extremely important component in ensuring age-of-sale laws work in practice. For example, the effect of Tobacco 21 was less clear in California, which exempted some 18–20-year-olds from the ban and did not optimise enforcement of the law.[5]

Tobacco 21 versus ban on sale on those born on or after 1 January 2009 (smokefree generation approach)

6. Although the evidence on Tobacco 21’s effect on smoking rates is strong, we would expect the generational ban to have an even greater effect on smoking rates in the long run. This is for the straightforward reason that the generational ban works by the same mechanism as Tobacco 21 (banning sale of tobacco products), but the pool of young people covered will grow each year. The generational ban sends a stronger signal that tobacco is a socially unacceptable product. Tobacco 21, despite its effectiveness, unwittingly portrays tobacco as a regular consumer product and thus a legitimate rite of passage into adulthood. The effectiveness of the generational ban is supported by the Government’s own modelling[6] and modelling from New Zealand[7,8] and Singapore.[9,10]

7. Crucially, there is evidence that young people may be more supportive of the smokefree generation policy than Tobacco 21. In 2024, we conducted seven focus groups with a sample of 36 young people aged 12-21, who were largely drawn from more deprived areas of England and had a history of tobacco and/or e-cigarette use. We expected young people to make the case against the smokefree generation policy, because evidence from international qualitative research in other nations finds that some young people can find the concept of Tobacco 21 difficult to support. Many participants in international studies, particularly those who have used tobacco products, felt Tobacco 21 contravened the traditional norm of 18 being the age of adulthood.[11,12]

8. However, the majority of young people in our sample, even those who had used tobacco, were very supportive of the idea of being part of a smokefree generation. One participant said, "It’s a good idea. Because young people can get addicted easily. At the age of 18, it’s too hard for them to make a decision. So I think it’s good for them not to smoke at all." A small minority of participants were opposed to the bill on grounds of philosophical principle and lack of expected effectiveness.

9. It is plausible that young people find greater logic in a generational ban that explicitly seeks to create a smokefree generation, rather than one that moves the minimum age of sale to a different point adulthood. It is also plausible that the generational ban raising the age of sale by one year each year is more acceptable to young people than a three-year jump from 18 to 21.

10. Our findings mirror those found in New Zealand at the time when smokefree generation laws had been tabled. 17- and 18-year-olds were found to be supportive of a smokefree generation ban and the positive freedom from addiction it entails. [13]

11. Many young people in our sample were also very supportive of young people being involved in scrutinising and implementing any new law on the smokefree generation e.g. being involved in designing communication campaigns. They also placed a strong emphasis on well-resourced, consistent enforcement of the law, to ensure retailers were less likely to avoid its provisions.[14]

12. There is also evidence that the tobacco industry may support Tobacco 21 as a damage limitation exercise for their profits. In the United States, for example, the tobacco industry pushed for watered-down versions of Tobacco 21 laws.[15] In accordance with the World Health Organization Framework Convention on Tobacco Control, it will be vital for those scrutinising the bill to only consider evidence submitted by those who do not hold a conflict of interest with the tobacco industry.

Conclusions

13. There is strong evidence from real world evidence and international modelling that raising the age of sale of tobacco is an extremely effective tool in reducing tobacco use amongst those the law covers. Tobacco 21 has been shown to be an effective policy, but the generational ban stands to make a much more significant long-term contribution to reducing smoking prevalence and appears to be more acceptable to the young people it will affect.

Authors: Nathan Davies1, Specialty Registrar in Public Health and NIHR Doctoral Fellow

Manpreet Bains1, Associate Professor in Qualitative and Mixed Methods Health Research

Tessa Langley1 2, Associate Professor in Health Economics

Joanne Morling1 3, Clinical Associate Professor and Honorary Consultant in Public Health Medicine

Rachael Murray1 2, Professor of Population Health

1Nottingham Centre for Public Health and Epidemiology, University of Nottingham, UK

 2 SPECTRUM consortium, Edinburgh, UK

3 NIHR Nottingham Biomedical Research Centre, Nottingham University Hospitals NHS Trust with the University of Nottingham, UK

Conflicts of interest: None to declare

References

1 Fidler JA, West R. Changes in smoking prevalence in 16-17-year-old versus older adults following a rise  in legal age of sale: findings from an English population study. Addiction (Abingdon, England). 2010;105:1984–8.

2 Beard E, Brown J, Jackson S, et al. Long-term evaluation of the rise in legal age-of-sale of cigarettes from 16 to 18 in England: a trend analysis. BMC Med. 2020;18:85.

3 Millett C, Lee JT, Gibbons DC, et al. Increasing the age for the legal purchase of tobacco in England: impacts on  socio-economic disparities in youth smoking. Thorax. 2011;66:862–5.

4 Davies N, Bogdanovica I, McGill S, et al. What is the relationship between raising the minimum legal sales age of tobacco above 20 and cigarette smoking? A systematic review. medRxiv. 2023;2023.10.18.23296747.

5 Zhang X, Vuong TD, Andersen-Rodgers E, et al. Evaluation of California’s ‘Tobacco 21’ law. Tob Control. 2018;27:656–62.

6 Department of Health and Social Care. Modelling for the smokefree generation policy. 2023. https://www.gov.uk/government/publications/smokefree-generation-policy-modelling-report/modelling-for-the-smokefree-generation-policy (accessed 8 March 2024)

7 Deen FS van der, Wilson N, Cleghorn CL, et al. Impact of five tobacco endgame strategies on future smoking prevalence, population health and health system costs: two modelling studies to inform the tobacco endgame. Tob Control. 2018;27:278.

8 Ouakrim DA, Wilson T, Waa A, et al. Tobacco endgame intervention impacts on health gains and Māori:non-Māori health inequity: a simulation study of the Aotearoa/New Zealand Tobacco Action Plan. Tob Control. 2023;tc-2022-057655.

9 Zeng Z, Cook AR, Eijk Y van der. What measures are needed to achieve a tobacco endgame target? A Singapore-based simulation study. Tob Control. 2023;tc-2022-057856.

10 Doan TTT, Tan KW, Dickens BSL, et al. Evaluating smoking control policies in the e-cigarette era: a modelling study. Tob Control. 2020;29:522.

11 Lee JK, Lin L, Lim MJR, et al. National Tobacco Control Policies from the Perspectives of Singapore Young Male Adults. J Psychoactive Drugs. 2020;52:5–12.

12 Youth A, Tompkins LK, Sears CG, et al. "If You Are Old Enough to Die for Your Country, You Should Be Able to Get a Pinch of Snuff": Views of Tobacco 21 Among Appalachian Youth. Journal of Applied Research on Children:  Informing Policy for Children at Risk. 2018;8:2.

13 Hoek J, Lee E, Teddy L, et al. How do New Zealand youth perceive the smoke-free generation policy? A qualitative analysis. Tob Control. Published Online First: 2022. doi: https://dx.doi.org/10.1136/tc-2022-057658

14 Davies NP, Murray RL, Langley T, et al. Perceptions of children and young people in England on the smokefree generation policy: a focus group study. medRxiv. 2024;2024.04.29.24306422.

15 Whyte L, Náñez D. Big Tobacco’s surprising new campaign to raise the smoking age . The Center for Public Integrity. https://publicintegrity.org/politics/state-politics/copy-paste-legislate/big-tobaccos-surprising-new-campaign-to-raise-the-smoking-age/ (accessed 30 April 2024)

 

May 2024