Tobacco and Vapes Bill

Written evidence submitted by Asthma + Lung UK (TVB43)

House of Commons Public Bill Committee: written evidence

Tobacco and Vapes Bill

1. Introduction

2.1 At Asthma + Lung UK (A+LUK) we are fighting for everyone's right to breathe. We're the nation's lung charity and we're here for everyone who's living with a lung condition, regardless of what that condition may be.

2.2 We are submitting evidence to the Tobacco and Vapes Bill Committee because lung conditions are the third leading cause of death in the UK [1] and a huge number of these are being driven by smoking. We strongly support the government’s plans to stamp out smoking by raising the legal age of sale by one year every year and this submission reflects that.

2.3 This evidence submission has been informed by people living with lung conditions, respiratory clinicians, and policy experts.

3 Sale and Distribution (Tobacco etc)

3.1 We wholeheartedly agree with Clause 1(1) - It is an offence to sell any of the following to a person born on or after 1 January 2009- (a) a tobacco product; (b) a herbal smoking product; (c) cigarette papers. Preventing the next generation from ever being able to smoke is only a good thing. There are no downsides to implementing this policy change.

3.2 In the UK around 6.4 million people smoke [2] ; and smoking kills over 80,000 people in the UK every year [3] . Through devastating ill health and disability, it impacts even more peoples’ quality of life. This is because tobacco smoke is deadly for lung health . Smoking and breathing in second-hand smoke causes many lung conditions: 72% of lung cancer cases in the UK are caused by smoking [4] , smoking causes 9 out of 10 cases of chronic obstructive pulmonary disease (COPD) [5] , it can also cause obstructive sleep apnoea (OSA), pneumonia, and people who smoke are also at higher risk of getting chest infections, including flu, pneumonia, and COVID-19. If you smoke and get an infection, you’re more likely to have severe symptoms. If smoking was made obsolete, it could free up 75,000 GP appointments each month. [6]

3.3 Tobacco smoke contains over 5,000 chemicals, including nicotine, which is well known to be highly addictive. Nicotine is harmful for the body, but much of the severe harm comes from the tar, carbon monoxide, and other chemicals in the smoke. Many of these chemicals can cause cancer. Others are poisonous. When you smoke, these chemicals damage your lungs and can pass into your blood and spread through your body.

3.4 Making smoking obsolete in England would lift 2.6 million adults and 1 million children out of poverty, [7] something that would undoubtedly improve the physical and mental health of the nations as well. Respiratory disease is the biggest driver of inequalities in mortality between the richest and poorest communities, [8] and smoking is responsible for half the gap in life expectancy between richest and poorest in society. [9] Action to tackle smoking is the single most effective thing that could be done to tackle health inequalities.

3.5 People exposed to second-hand smoke face the same dangers as people who smoke themselves [10] . They too inhale the same poisonous gases and thousands of toxic chemicals found in tobacco smoke. Their risk of developing smoking-related diseases will also increase.

3.6 Research also demonstrates that both the children, and grandchildren, of smokers face worse health as a result of their parents or grandparents smoking, [11] with these vulnerabilities passed down the generations. Indeed children whose parent or caregiver smokes are four times more likely to smoke themselves, and when they try to quit, they find it even harder than others, passing on addiction and poor health.

4 This is why 85% of smokers regret ever starting in the first place [12] , and that 84% of A+LUK supporters support the generational smoking ban.

4.1 Most people who smoke want to stop, but the addictive nature of nicotine makes that incredibly hard. With more than 4 in 5 smokers starting before the age of 20 [13] , preventing smoking in young people is vital. Increasing the legal age of smoking by one year, every year, would protect future generations from this deadly habit.

4.2 Smoking doesn’t just cost lives. It also costs money. in 2023 it was calculated to amount to around £50 bn [14] includes productivity costs of £32 bn, covering lost earnings, unemployment, early deaths. The annual income generated by smoking through taxes comes in at just £10 bn. [15] All of these costs could be mitigated by leading the UK population into a smokefree future.

4.3 In 2022, 12.9% of people aged 18 and over smoked cigarettes [16] , more than twice the government’s Smokefree 2030 target of 5%. To achieve a smokefree 2030, bold policies need to be implemented such as this one thus is vital this legislation is implemented .

4.4 We also support th at this legislation cover tobacco products; herbal smoking products; and cigarette papers as in Clauses 1, 2, 41 and 48. We should maximise this opportunity to prevent individuals from accessing products that can lead to tobacco use, and therefore tobacco-based harm, therefore all these products should be included. And it is important to have clarity and simplicity across borders for enforcement, and to prevent cross-border purchasing.

4.5 Proxy sales are already prohibited under existing tobacco age of sale legislation, there is no reason for this not to continue with the change to the legal age of sale, thus we agree with Clause 2(1) - It is an offence for a person aged 18 or over to buy, or attempt to buy, any of the following on behalf of a person born on or after 1 January 2009- (a) a tobacco product; (b) a herbal smoking product; (c) cigarette papers.

4.6 This model is also used for other products that are unsuitable for children including alcohol, and we believe it essentially to implement consistency across prohibition legislation to make enforcement easier for retailers to enact.

4.7 Despite the current ban on proxy sales, evidence shows that proxy sales of cigarettes are a key method of sourcing cigarettes for young smokers, particularly those living in disadvantaged communities [17] , thus it is vital that there is sufficient resource for the enforcement of this legislation change.

4.8 This support extends to Clauses 37-42 for the sale and distribution of tobacco etc in Scotland, and Clauses 48-50 for Northern Ireland.

4.9 We vehemently oppose Amendment 1 to change the age of sale to a blanket age of 21: this bill has the opportunity to save lives continuously for generations to come and by removing the rolling increase in age of sale takes away this power. This amendment, and all amendments linked to Amendment 1, should be disregarded.

5 Sale and Distribution (Vaping and nicotine products)

5.1 Our position is clear: vaping needs to be available for smokers wanting to quit tobacco. However, children and those who do not smoke should not vape.

5.2 It is now considered with some certainty that vapes are less harmful than tobacco smoking [18] , making them a less harmful alternative for smokers looking to quit tobacco. A recent Kings College report into e-cigarettes found that the use of vaping products in place of smoking lead to a substantial reduction in exposure to toxicants that promote cancer, lung disease and cardiovascular disease. However, for those who used e-cigarettes but had not smoked, the study found some increase in exposure to these toxicants compared with non-smokers, although overall levels were still significantly lower than amongst smokers [19] .

5.3 The number of adults choosing to vape has increased by 6.4% in the past decade [20] , this is indicative of the number of adults using vapes instead of tobacco. It is vital that this trend continues and vapes are available for those who want to quit smoking. However, the number of under 18s vaping has also increased, and so it is vital the a ge of sale C lause 7 (1) - It is an offence to sell a vaping product to a person who is under the age of 18, is maintained and enforced.

5.4 We are particularly concerned by the increase in children and young people vaping because we do not yet know the full extent to the harms that these products can cause, particularly on developing lungs.

5.5 The short-term effects of vapes can include throat and mouth irritation, headache, cough, nausea. [21] The long-term effects are currently unknown. More evidence, and time, is needed to understand the real impact of e-cigarettes.

5.6 Some people with lung conditions have told us that vaping, or even second-hand vape fumes, can be a trigger for them. [22]

5.7 Evidence is clear that vaping is an effective quit tool for smokers looking to give up tobacco, and in fact more effective than traditional quit aids such as nicotine replacement therapies. [23] Therefore we believe that vapes are an important tool for people looking to quit smoking, but we only want to see vapes used as a quit tool for those looking to give up tobacco.

5.8 We believe that including nicotine and non-nicotine vaping products is essential: Vaping, whether containing nicotine or not, does not have an in-depth body of evidence to support its safe use. A harm minimisation approach to this is justifiable and we suggest that there is no way that they could be good for lung health, with the likelihood being that they would have some negative effects, and therefore should be restricted. There is no positive argument for them as there is for nicotine vaping as an aid to quit smoking cigarettes. And if we look to other jurisdictions, Australia has opted to ban non-nicotine vapes [24] .

5.9 As above, it is essential Proxy sales are prohibited, as tobacco and other age restricted products are ( C lause 8 ) .

5.10 We strongly support C lause 9 (1) - A person commits an offence if, in the course of business, the person- (a) gives away a vaping product, or a coupon for a vaping product, to someone who is under the age of 18, or (b) causes or permits that to happen. Free distribution of vapes to under 18s is a driver of their consumption evidenced by nearly half ( 46% ) of young people sourc ing vape s by being given them [25] . This is, in part, being facilitated by the loophole that allows vapes to be given to children for free despite it being illegal to sell them to under 18s. N o amendments to this clause are acceptable ; we have a zero tolerance approach to this.

5.11 We also support C lause 10 - Power to extend vaping provisions to nicotine products, as a mechanism to allow further restrictions on nicotine products that are not yet necessary but may become necessary. There is little evidence about the gateway effect of nicotine products including vapes and nicotine pouches leading people to smoking [26] , but if this trend becomes obvious, legislation to protect people from them will become essential, and this clause future-proofs the bill.

5.12 Regarding C lause 11 - Displays of vaping and nicotine products, we believe vapes must be kept behind the counter and cannot be on display, like tobacco products. Vaping products need to be available for those wanting to use them as a smoking cessation device and should therefore be no less accessible than tobacco, however they should not be displayed in any way that promotes their uptake by children and young people, and those who do not smoke. Physical stores hold 74% of the market share, and ASH data shows that 48% of under-18s who are current vape users are buying them from a shop suggesting their in-store presence is a key opportunity to impact their purchase and use.

5.13 There are restrictions on the advertisement and promotion of vapes including being banned from TV and newspapers and magazines [27] . However, vapes are allowed to be displayed in retail outlets, and advertised on poster campaigns. Research has shown that point-of-sale displays have a direct impact on young people’s smoking [28] , [29] , [30] , [31] and as such the advertising of tobacco products is illegal, and so is displaying tobacco products in general retail outlets; this is a technique that works.

5.14 Recent research by CRUK found that high visibility and exposure to e-cigarettes had a normalising effect and colourful displays were the main aspect of disposable e-cigarette packaging that appealed to all ages, particularly in windows and at point-of-sale in shops [32] . It is well recognised that in-store visual merchandising is hugely powerful in influencing purchasing choices and driving sales, therefore these visual marketing techniques must be restricted to reduce the appeal of vapes therefore their use by young people. Keeping them behind counters and out of view provides an obvious solution to achieve this.

5.15 Furthermore, under current regulations, specialist tobacconists can display and advertise tobacco products inside their shops provided they are not visible from outside. The same should apply to specialist vape shops.

5.16 Clauses 11(1c) and 11(2c) allows the regulation of prices of vaping products or nicotine products, which we deem essential to driving these products out of the hands of children and young people.

5.17 The price of vaping is significantly cheaper than the cost of smoking: the majority of high street disposable vapes cost around £5 for 600 puffs (the equivalent of ~40 cigarettes), with some disposable vapes being available from as little as £1-£2. This is further driven by the ability to have discounts and deals on vapes; something that is prohibited for tobacco products [33] , but regularly seen on vaping products. These pocket money prices are not at all a barrier to young people accessing these products, and although children do not report price as a motivator to vape, a substantial body of evidence demonstrates that children are highly price sensitive.

5.18 Reducing the affordability of tobacco was highly effective in reducing smoking rates [34] and affordability has the most impact on those who are most price sensitive, such as low SES smokers and younger smokers [35] , it seems reasonable to assume the same relationship applies to vaping. Furthermore, there is specific evidence that young people are highly responsive to changes in the price of vapes: a US study showed an increase of e-cigarette prices and taxes was associated with significant reductions in past 30-day use as well as reductions in the intensity of use [36] .

5.19 We suggest the immediate implementation of a minimum floor price for all vaping products, so they are less affordable for children, accompanied by the expansion of the Swap to Stop scheme, to allow more people on low incomes to access a free vaping device to help them stop smoking, so that these individuals are not priced out of accessing vapes as a smoking-cessation tool.

5.20 The power to enable the introduction of prohibitions, requirements, or limitations in relation to the display of vaping or nicotine products and their prices, as well as the display of empty retail packaging, is essential, and we look forward to contributing to the consultation on this promised by the Secretary of State for Health and Social Care on 16th April.

5.21 These statements also apply to Clauses 43-45 for the sale and distribution of Vaping and nicotine products in Scotland, and Clauses 51-55 for Northern Ireland.

6 Enforcement

6.1 We support Clauses 12 to 23 on restricted orders and enforcement: Sufficient funding and capacity for enforcement of these restrictions must be considered to ensure there are no loopholes, and that they do not foster the growth of an illicit market.

6.2 We also support Clause 15 and 56 - Power to extend restricted premises orders in order to future proof this bill.

6.3 Clause 24 – Fixed penalty notices is important. On the spot fines appear to be a sensible approach to reduce the time and capacity taken by trading officers to take the offender through conviction. However, on the spot fines mean no criminal record is made and this must be considered through escalation of enforcement means for recurring offenders.

6.4 We do not oppose Amendment 20 proposed by Preet Kaur Gill MP to increase the value of a fixed penalty notice to £200 and encourage a number be chosen that will act as an effective deterrent, which may need to be higher still.

7 Product Requirements (Tobacco)

7.1 We support Clauses 58, 59 and 60 for regulations on the packaging, flavour and other requirements of tobacco products. Any quality of a tobacco product that would make it appealing should be prohibited.

7.2 As such we support Amendment 22 by Bob Blackman MP to enable the introduction of health warnings on cigarette papers, and Amendment 26 by Dr Caroline Johnson MP about font usage.

7.3 We also support Amendment 18 by Preet Kaur Gill MP to strengthen the language in Clause 58 to ‘must’ instead of ‘may’.

8 Product Requirements (Vaping and nicotine products)

8.1 With respect to Clause 61 - Retail packaging of vaping products and nicotine products, we believe that the legislation should prohibit the use of all imagery and colouring and branding (standardised packaging) for both the vape packaging and vape device.

8.2 Historically, the branding of tobacco products made them more appealing to children, this led to the government introducing standardised packaging across tobacco products in May 2016, requiring cigarettes and rolling tobacco to be sold in standardised green packs, with the brand name in standard font and no brand imagery or logos [37] . This has been effective for reducing the appeal of tobacco cigarettes, particularly among young people [38] , [39] . The Standardised Packaging of Tobacco Products Regulations 2015: post-implementation review found evidence that suggested the ban on branding reduced the appeal of tobacco products to children, with young non-smokers and occasional smokers potentially affected the most [40] . This evidence base should be applied to vaping products and be an opportunity for action against under-18s vaping.

8.3 Marketing of vapes, including their packaging, has been found to influence the appeal of vaping products to youth and adult smokers [41] , [42] , the use of cartoon characters being a clear example of packaging used to appeal to younger customers, thus a similar approach to standardising the packaging that vapes come in could impact the appeal of vapes to young people. This is supported by a 2023 study that when compared with fully branded packaging, green standardized e-cigarette packaging with no brand imagery was associated with decreased interest in trying the vaping products among youths but not adults [43] , therefore restricting packaging designs in this way should be used to reduce the appeal of vaping to young people, whilst having little impact on adult smokers’ interest in using the products to quit smoking. As the packing of vapes is often quickly discarded, unlike cigarette boxes, these restrictions need to be applied to the vape device itself as well as the packaging it is purchased in.

8.4 We support Clause 62 - Contents and flavour of vaping products and nicotine products too and suggest the limit of flavours of vape products to tobacco, mint, menthol and fruits only.

8.5 There is clear evidence that the growth in children vaping is in part being driven by their flavours: 12% of those under-18 who have never smoked, choose to vape because they ‘like the flavours’ [44] .

8.6 There is some evidence to suggest health risks of the chemicals used to flavour e-cigarettes, e.g. the flavouring ‘cinnamaldehyde’ is a cause of concern [45] , and flavourings linked to Bronchiolitis Obliterans were subsequently banned from e-cigarettes [46] . However, the evidence-base on whether different flavourings affect health is limited.

8.7 [47] As this legislation only came into force in 2023, the impact is still yet to be seen. However, some evidence suggests that flavour bans in the US led to a decline of e-cigarette use and an increase in cigarette consumption, disproportionately consumed by young people [48] .

8.8 Evidence suggests that some flavour options are important. A study found that adult users of flavoured e-cigarettes reported greater satisfaction and self-perceived addiction than users of non-flavoured e-cigarettes [49] ; and another study found that over time adult long-term e-cigarette uses migrated from preferring tobacco and menthol/mint to preferring sweeter flavours such as chocolate/candy [50] . And a decision tool developed by the University of Bristol concluded that there would be a negative net population impact of a flavour ban on the UK population particularly those of low-socioeconomic position [51] . And a number of studies have found an association between quitting smoking successfully using flavoured (e.g. fruit, sweet, menthol) as opposed to tobacco flavoured or unflavoured e-liquids [52] , [53] , [54] .

8.9 Overall, restrictions on flavours could be effective in reducing the appeal to children but need to be balanced with the unintended consequences of reducing the appeal of vaping to adults trying to stop smoking, or driving people to choose cigarettes instead. We want to see flavours clearly designed to appeal to children banned, but are aware that there is likely to be some need for flavour options and so recommend the limit of flavours of vape products to tobacco, mint, menthol and fruits only. We also suggest the implementation of generic flavour descriptions.

8.10 We also support Clause 63 - Other product requirements of vaping and nicotine product, all mechanisms to reduce the appeal of these products to children should be considered.

8.11 For these reasons we oppose Amendment 16 to edit Clause 62 to remove the power of the Secretary of State to make regulations about flavours of vaping products and nicotine products.

9 References

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[6] Cancer Research UK. Ending smoking could free up 75,000 GP appointments each month. 2023. Accessed here .

[7] Department of Health and Social Care . Towards a smoke-free generation: a tobacco control plan for England . 2017. Accessed here .

[8] Office for National Statistics . Inequalities in mortality involving common physical health conditions, England . 2023. Accessed here .

[9] Jha et al. Social inequalities in male mortality, and in male mortality from smoking. The Lancet. 2006 Jul 29; 368(9533): 367-70.

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[24] Australian Government. Tobacco and Other Smoking Products Act.

[25] Action on Smoking and Health. Use of e-cigarettes (vapes) among young people in Great Britain. 2023.

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[30] A systematic review on the impact of point-of- sale tobacco promotion on smoking. Robertson L, McGee R, Marsh L, Hoek J. 2014, Nicotine & Tobacco Research, Vols. 30;17(1):2-17.

[31] The association between point-of-sale displays and youth smoking susceptibility. MacKintosh AM, Moodie C, Hastings G. 2011, Nicotine & Tobacco Research, Vols. 8;14(5):616-20.

[32] Cancer Research UK. E-cigarette packaging and retail appeal in the UK: Summary for policymakers of two commissioned research projects examining e-cigarette packaging in the UK and recommendations. 2023.

[33] Tobacco Advertising and Promotion Act 2002. 2002. Vol. CHAPTER 36.

[34] World Health Organisation. Effectiveness of Tax and Price Policies for Tobacco Control. 2011. IARC Handbooks of Cancer Prevention Volume 14.

[35] Action on Smoking and Health. Smoking: Price and Affordability. 2019.

[36] Investigating the Impact of E-Cigarette Price and Tax on E-Cigarette Use Behavior. Megan C. Diaz, Elexis C. Kierstead, Bushraa S. Khatib, Barbara A. Schillo, John A. Tauras. 6, 2023, American Journal of Preventive Medicine, Vol. 64, pp. 797-804.

[37] Public Health England. Health matters: tobacco standard packs. 15 September 2016.

[38] Chantler, Sir Cyril. Standardised packaging of tobacco: Report of the independent review. 2014.

[39] Department of Health. Equalities Analysis: Standardised Packaging of Tobacco Products. 2014.

[40] Department of Health & Social Care. Post-Implementation Review of Tobacco Legislation. 2022.

[41] Youth self-reported exposure to and perceptions of vaping advertisements: findings from the 2017 International Tobacco Control Youth Tobacco and Vaping Survey. Cho YJ, Thrasher JF, Reid JL, Hitchman S, Hammond D. 105775, 2019, Prev Med. , Vol. 126.

[42] Design and marketing features influencing choice of e-cigarettes and tobacco in the EU. Laverty AA, Vardavas CI, Filippidis FT. 5, 2016, Eur J Public Health, Vol. 26, pp. 838-841.

[43] Association of Fully Branded and Standardized e-Cigarette Packaging With Interest in Trying Products Among Youths and Adults in Great Britain. Taylor E, Arnott D, Cheeseman H, et al. 3, 2023, JAMA Network Open, Vol. 6, p. e231799.

[44] Action on Smoking and Health . Use of e-cigarettes (vapes) among young people in Great Britain. 2023.

[45] Office for Health Improvement & Disparities. Nicotine vaping in England: 2022 evidence update main findings. 2022.

[46] EU Tobacco Products Directive (TPD). 2016.

[47] Netherlands Enterprise Agency, RVO. Dutch Tobacco Act. 2023.

[48] Supplementary written evidence submitted by Action on Smoking and Health (YVP0005). 2023.

[49] The role of flavors in vaping initiation and satisfaction among U.S. adults. Robyn L. Landry, Allison L. Groom, Thanh-Huyen T. Vu, Andrew C. Stokes, Kaitlyn M. Berry, Anshula Kesh, Joy L. Hart, Kandi L. Walker, Aida L. Giachello, Clara G. Sears et al. 106077, 2019, Addict Behav doi: 10.1016/j.addbeh.2019.106077, Vol. 99.

[50] Changes in Flavor Preference in a Cohort of Long-Term Electronic Cigarette Users. Ping Du, Rebecca Bascom, Tongyao Fan, Ankita Sinharoy, Jessica Yingst, Pritish Mondal, and Jonathan Foulds. 5, 2020, Annals of the American Thoracic Society, Vol. 17.

[51] A decision aid for policymakers to estimate the impact of e-cigarette flavour restrictions on population smoking and e-cigarette use prevalence among youth versus smoking prevalence among adults. Gibson MJ, Munafò MR, Attwood AS, Dockrell MJ, Havill MA, Khouja JN. 2023.

[52] E-cigarette support for smoking cessation: Identifying the effectiveness of intervention components in an online randomised optimisation trial. Dawkins, L. and Kimber, C. s.l.: London South Bank University, 2023.

[53] Associations of Flavored E -Cigarette Uptake With Subsequent Smoking Initiation and Cessation. Friedman, A. and Xu, S. 2020, JAMA Netw Open, Vol. 3(6):e203826.

[54] The Role of Nicotine and Flavor in the Abuse Potential and Appeal of Electronic Cigarettes for Adult Current and Former Cigarette and Electronic Cigarette Users: A Systematic Review. Gades, M. et al. 9, Nicotine & Tobacco Research, Vol. 24, pp. 1332–1343.



[54] May 2024



Prepared 14th May 2024