Tobacco and Vapes Bill

Written evidence submitted by the Institute for Social Marketing and Health, University of Stirling, in response to the call for evidence for the Tobacco and Vaping Bill 2023-24 (TVB47)

1. This submission is the considered view from academics at the Institute for Social Marketing and Health (ISMH), University of Stirling, Scotland. ISMH is a world-leading centre for research in marketing, behaviour change and public policy with over 40 years’ experience of research. The ISMH has a national and international scientific reputation as evidenced by the award of the prestigious Queen’s Anniversary Prize for Higher Education in 2014: awarded in recognition of research on health and the effectiveness of policies designed to protect health by controlling marketing. The team involved in generating this written evidence includes Dr Allison Ford, Professor Sean Semple, Dr Rachel O’Donnell, Ms Anne Marie MacKintosh, Professor Michael Ussher, Dr Catherine Best and Ms Jennifer McKell. This team have published in excess of 200 academic tobacco control papers in high-impact, international, peer-reviewed scientific journals, covering topics spanning the evaluation of UK public spaces smoke-free legislation, tobacco product packaging, and young people’s response to e-cigarettes and other emerging nicotine products and their marketing.

Executive summary

2. Our response covers two key features of the bill: (a) increasing the age of sale of tobacco; and (b) reducing the appeal and availability of vapes to children.

3. Increasing the age of sale of tobacco

· The direct health and societal benefits of reducing smoking initiation among young people and lowering smoking prevalence in future adults are clear: tobacco kills approximately half of long-term users and the burden of chronic disease is substantial.

· Indirect benefits from a rising age of sale will be felt quickly among children born to young women who are prevented from starting to smoke.

· Within two years of implementation, by 2029 the impact of age restriction is likely to mean that children being born to mothers aged under 20 will be much less likely to have experienced the in utero harms that result from maternal smoking, and importantly, that child would be much less likely to live their early years in a home where smoking was permitted given that the mother is unable to purchase tobacco.

· Within a further ten years, by 2039, the majority of children being born in the UK would be to parents who were unable to purchase cigarettes. This is likely to lead to an increase in the number of smoke-free homes, and a step-change and further acceleration in the social norms making it unacceptable to smoke around children.

· Children born to younger mothers will experience the benefits of this legislation first – helping to reduce health inequalities.

· A fixed age of sale (age 21 is proposed as an alternative measure) would be unlikely to see these progressive and continuing benefits for the next generation.

· Increasing the age of sale will break the cycle of parental smoking, exposure of children to second-hand smoke, and those children growing up experimenting with tobacco and becoming young adults who smoke.

· When the age of sale was increased from 16 years to 18 years, on 1st October 2007 in England and Wales, our Youth Tobacco Policy Survey (YTPS) observed a reduction, between 2006 and 2008, in young people reporting that they had bought cigarettes themselves from a shop and also observed a reduction in prevalence of young people having ever tried smoking.

· We recommend that the rising age of sale clauses of the bill are maintained.

4. Reducing the appeal and availability of vapes to children

· Given the association between young people having tried vaping and being susceptible to smoking, it is critical to tackle the rise in youth vaping now to stem the potential risk of future increases in smoking susceptibility.

· Current vape packaging is colourful and utilises cartoonish font and language which taps into youth/slang culture. This has created a mismatch between what the product packaging is currently communicating (a product which people believe is targeted at young people) versus what vape product packaging should communicate (a product for adult smokers).

· The current retail display of vapes within shops and shop windows is extensive. There is increasing awareness among young people of vape displays which is feeding into youth appeal and vaping norms.

· To stem the appeal of flavours to young people, we recommend that, in the first instance, restricting flavour descriptors rather than flavours should be implemented.

· We recommend that the Bill allows for the provision of restricting other marketing channels in the future, such as, but not limited to, outdoor advertising and domestic sponsorship. The whole marketing mix of vapes has driven the recent rapid rise in youth appeal and use.

Detailed evidence submission

5. We have prepared our response to cover the two key features of the bill: (a) increasing the age of sale of tobacco; and (b) reducing the appeal and availability of vapes to children. We have not made any comment on the strengthening enforcement around tobacco and vaping sales section, or the economic and financial impacts of the bill beyond noting the impact assessment published by the Department of Health and Social Care (March 2024) and the well-established scientific literature that tobacco is a net drain on the British economy due to the premature mortality and chronic disease health costs associated with smoking at a population level.

Increasing the age of sale of tobacco

6. The current Tobacco and Vaping Bill passing through the UK parliament proposes to make it an offence anywhere in the UK to sell tobacco products to anyone born on or after 1 January 2009. This is in line with the aim of creating a ‘smokefree generation’, driving down smoking prevalence through prevention of initiation. We do not intend to lay out evidence about the direct health benefits to those who do not become smokers as a result of this legislative change: the evidence of the benefits of smoking prevention (and cessation) is substantial and has been clearly described elsewhere. Instead, we provide a summary of evidence and our considered opinion about the likely indirect benefits that we consider will accrue in relation to the children born to those young adults who do not become smokers: through reduced exposure to the harms of tobacco in utero, and the benefits of growing up in a smoke-free home. We will consider these changes through the lens of inequalities and demonstrate how children living in poorer socio-economic environments are likely to experience the greatest benefits, and do so most quickly as a result of this law.

7. Protecting non-smokers from exposure to second-hand tobacco smoke (SHS) is one of the key pillars of the World Health Organization Framework Convention on Tobacco Control (FCTC) signed by the UK in 2003. The UK has been a global leader in introducing highly successful measures to comply with the FCTC, notably the smoke-free legislation introduced by all four member UK nations in 2006 and 2007. These legislative measures led to changes in social norms around where it was acceptable to smoke and produced substantial and sustained reduction in non-smokers’ exposure to SHS. Population surveys such as the Health Survey of England and the Scottish Health Survey have demonstrated falls in salivary cotinine (an objective measure of how much tobacco smoke a non-smoker has been exposed to).

8. The introduction of smoke-free laws covering workplaces and enclosed public spaces did not displace smoking behaviour to homes. In Scotland, smoke-free legislation reduced exposure to SHS in the home among young people, particularly among groups with lower exposure in the home. However, the major failing of the FCTC is that it does not address the home: the environment where most children are exposed to SHS, at highest concentrations, most frequently and for longest. Consequently, longitudinal evidence demonstrates that non-smoking adults have benefited more than children from smoke-free laws. Recent data in the UK demonstrates that approximately one in five adults have measurable levels of cotinine compared to one in three children: and that this exposure falls disproportionately on children living in poorer socio-economic conditions.

9. Children born to mothers who smoke experience the double-impacts of in-utero exposure to the toxins associated with tobacco and early-life exposure to SHS. Smoking during pregnancy raises the risk of miscarriage, stillbirth, premature birth, birth defects, lower birth weight and sudden infant death syndrome (SIDS). There is also strong evidence that SHS exposure leads to lower birth weight and increased risk of respiratory conditions and exacerbations of those conditions.

10. A rising age of sale will quickly help to protect children born into families who are no longer able to purchase tobacco. Parents who would previously have become smokers through youth initiation will now not be smokers. There will be direct health advantages to the baby in not experiencing the toxic impacts of tobacco in utero with increased birth weight, bigger lungs and airways, and reduced chances of respiratory conditions such as asthma. The benefits continue in the early days of life through a much greater chance of living in a smoke-free home: reduced risk of cot death and improved chances of living without conditions including otitis media, bronchiolitis, and other respiratory issues.

11. Across the UK there are approximately 700,000 births per annum: 10% of women identify as smoking at the time of their antenatal booking appointment equating to approximately 70,000 children per year who experience some degree of in utero toxicity from smoking. The average age of a mother having a child in the UK is 30.9 years but there is a substantial social gradient in age of first delivery, with, for example, rates of delivery among women under the age of 20 being over ten times higher in the most deprived quintile compared to the least deprived area, and smoking rates almost five times higher in the most deprived compared to the least deprived populations (data from Scotland: 24% v 5%).

12. While there is no data or other comparative international evidence to help model the likely effect of the increased age of sale on smoking prevalence within the cohort that will be impacted, we think, based on our collective experience of evaluating tobacco interventions and policies, that a reasonable conservative estimate would be that smoking rates among women and their partners are likely to be reduced by between 50-75% from current levels. We have selected a mid-point of this range (62.5% reduction in smoking prevalence) for the numbers we present in the scenarios below.

13. Direct impact on children being born by 2029

Children born to mothers aged under 20 make up 2.2% (15,000) of live births in the UK. Reduced prevalence of smoking in this age group (reduction in smoking prevalence at antenatal booking by 62% from 10% to 3.7%) would mean that approximately 950 babies born in that year would no longer be exposed in utero to maternal smoking. The benefits are likely to be highly weighted towards those from lower socio-economic populations and are thus likely to reduce health inequalities particularly in these early years of the legislation.

14. Direct impact on children being born by 2039

Children born to mothers of the current average age of delivery (30.9 years) would be similarly protected by the legislation by this timepoint. Using the same model as described above, this would equate to 22,000 babies born per year who would no longer be exposed in utero to maternal smoking.

15. Indirect impacts through the increase in smoke-free homes reducing children’s exposure to SHS

Current data suggest that approximately 6% of children in the UK are regularly exposed to SHS within the home setting (parents responding positively to a question on the child living in a home in which people are permitted to smoke indoors). This equates to approximately 760,000 children across the UK – who currently experience a daily exposure to a cancer-causing aerosol in their own homes, an aerosol that has been banned from the workplace. Using the same model as described above, we would anticipate that a significant proportion of these children will begin to benefit from a smoke-free home as their parents do not become smokers. Our model would suggest that by 2039 an additional 22,000 children per year would experience the health benefits of a clean-air, smoke-free environment at home. Again, these benefits are likely to be seen more quickly among those living in more deprived areas where smoking rates are highest and where data shows that children are exposed to smoking in the home at much higher levels (9% v 0% in most v least deprived quintiles in Scotland). Taken together with other smoking cessation progress, and continuing longitudinal reductions in smoking prevalence, it is likely that, the increasing age of sale of tobacco will help the UK achieve a scenario where very small numbers of children continue to be exposed to SHS at home by 2039. The UK would be leading the way internationally and providing an example that other countries could follow in terms of protecting children from the harmful effects of SHS.

16. Evidence from raising age of sale from 16 to 18 in 2007

Following the rise in age of sale from 16 years to 18 years which came into force on 1st October 2007 in England and Wales, we observed a reduction in young people reporting that they had bought cigarettes themselves from a shop and also observed a reduction in prevalence of young people having ever tried smoking. Our Youth Tobacco Policy Survey (YTPS), conducted with 11- to 16-year-olds across the UK, showed that, in 2006, 21% of ever smokers (aged 11 to 16) had bought cigarettes themselves in a shop. In 2008, this proportion had reduced to 12%. The same survey showed that prevalence of ever smoking in 2006 was 39% and in 2008 had reduced to 32%. The reduction in prevalence was likely linked to ongoing implementation of restrictions on tobacco marketing but the parallel reduction in young people reporting having purchased from shops suggests that the rise in age of sale contributed to this reduction in smoking prevalence.

Reducing the appeal and availability of vapes to children

17. We believe that the measures within the Bill, with timely consultation and adequate implementation, will likely have a positive impact on reducing youth vaping. The rapid recent rise in youth vaping has normalised vaping and nicotine use among some young people. This rise has occurred in parallel with rapid developments in the vape market and increased youth awareness of vape marketing, particularly within the retail setting. It may take some time to reverse the popularity and appeal of vapes to young people. In this section we draw upon our own recent programme of research on youth vaping and youth responses to the marketing of vapes and other nicotine and tobacco products such as nicotine pouches and heated tobacco, to highlight the importance of, and our support for, the measures contained within the Bill.

18. Association between smoking and vaping

Our Youth E-cigarettes Policy Survey 2023 (YEPS 2023),1 conducted with 11–16-year-olds across the UK in July 2023, shows an association between having tried vaping and being susceptible to smoking. In 2023, 43.0% of young ever vapers were categorised susceptible to smoking compared with 18.9% among young never vapers χ2=65.658, df=1, p<0.001.

19. With increasing youth vaping, this potential risk of future smoking becomes more of a concern. It is vitally important to tackle youth vaping now, to stem the potential risk of future increases in smoking prevalence. While susceptibility cannot tell us that young never-smokers will go on to smoke, it is a well-validated measure of smoking intent.

20. The association between vaping and susceptibility to future smoking is concerning given the emergence of heated tobacco products on the UK market. Our EMERGE qualitative study highlighted consumer confusion and misunderstanding around heated tobacco products, which can look similar to vapes.2 It is important to prevent young people being drawn to other tobacco products through the normalisation of vaping.

21. Restricting the retail packaging

Our Epacks study included a pack analysis of a representative sample of 156 vape products’ packaging available on the UK market in 2022. 85% of packs were deemed to be colourful, almost one in five packs had cartoonish script or crayoned font on the front of the pack, and some packs contained brand names and descriptors which tap into youth/slang language.

22. The Epacks study qualitative component highlighted that some vape packaging communicated to young people that the product was targeted at them. Adult smokers and dual-users also believed these products targeted young people. There is a mismatch between what vape product packaging should ideally communicate (i.e. vape products are for smokers), and what it communicates (i.e. vape products are for young people).

23. The use of nicotine descriptors to communicate nicotine content and/or strength across vape products’ packaging is varied and inconsistent, utilising metric indicators, e.g. mg, mg/ml, mg/g; percentages; graphic and text indications of strength; dosage information; and equivalent number of cigarettes. This likely contributes to consumer misunderstanding on the strength of vapes. For example, some young people and adults believe a nicotine descriptor of ‘2%’ indicates low strength, despite this being the highest level of nicotine permitted in the UK (20mg/ml).

24. The Bill provides an opportunity to standardise the appearance of vape packaging so the pack can inform consumers about the product in a responsible way. Our YTPS 2016 and YEPS 2023 evidences the success of restricting packaging within the context of tobacco. The introduction of standardised packaging for tobacco products in 2016 was accompanied by declines in youth ever smoking prevalence (20% in 2016; 9% in 2023) and brand awareness (47% in 2016; 21% in 2023).3

25. Restricting the display of vaping or nicotine products in retail outlets

Our surveys show that vape displays impact young people in the retail setting. Vapes are visible on display anywhere within shops, and make up substantial displays in shop windows. There has been a substantial increase in youth reporting awareness of vape displays inside or at shops from 40% in 2020 (YTPS 2020) to 68% in 2023 (YEPS 2023). Additionally, 59% of 11–16-year-olds reported seeing signs/posters in shops or shop fronts in the past month (YEPS 2023).

26. The retail display of vapes influences youth appeal, social norms, and beliefs around vaping. In July 2023, within our sample of 11–16-year-olds:

§ 58% thought vape displays are colourful

§ 48% thought vape displays are tidy

§ 36% thought vape displays are eye-catching

§ 22% thought vape displays are attractive

§ 29% reported that vape displays make them think it’s ok to vape

§ 64% reported that vape displays make them think that a lot of people vape.

27. Restricting flavouring of vaping and nicotine products

Our qualitative research shows that flavours contribute to the appeal of vaping for young people.4 Evidence also shows that flavours are liked by adult smokers who vape for smoking cessation and can help transition smokers away from tobacco. Flavour descriptors can be categorised as ‘single recognisable flavours’ (i.e. Cherry, Menthol), ‘flavour blends’ (i.e. Strawberry Ice, Vanilla Custard), and ‘concept flavours’. Concept flavours do not convey a taste or recognisable flavour but refer to sensations or ambiguous descriptors (i.e. Energy, Smooth, Red Lips, Tropical Tsunami).

28. To stem the appeal of flavours to young people, we recommend that restricting flavour descriptors will be a quicker and easier measure to implement than restricting the flavours themselves. However, it is important that the Bill provides power to restrict flavours in the future as and when appropriate.

29. Make it an offence to sell non-nicotine vaping products to under-18s

Data from YEPS 2023 shows uncertainty among 11-16-year-old ever vapers re the presence or absence of nicotine in the vapes they had used. A third, 34%, were not sure if the vapes they had used contained nicotine, while 36% said they all had nicotine, 23% said some had nicotine and some did not, and 8% believed none had any nicotine.

30. Marketing channels beyond those outlined in the Bill

It is also critical to note that it is the whole marketing mix of vapes which has driven the recent rapid increase in youth appeal and use. Other important features of the marketing mix communicating appeal to young people include the product design, low price and price promotions, free distribution, youth cues and messages in social media content and adverts such as those in shop posters, ease of underage access, wide variety of retailers, and visibility/sponsorship within sport and music events.4

31. Our YTPS 2020 and YEPS 2023 data show an upward trend in youth awareness of marketing generally, including 11–16-year-olds’ awareness of:

· Special price offers: 12% in 2020 rising to 27% in 2023;

· Free trials/sample: 4% in 2020 rising to 9% in 2023;

· Pictures/videos of vaping/vapes on social media: 25% in 2020 rising to 41% in 2023).

32. We recommend that the Bill allows provision for restricting other marketing channels and routes of access for young people. In our most recent research, we see evidence of underage access via channels such as social media and grocery delivery apps.

33. The importance of future proofing the Bill for other nicotine products e.g. nicotine pouches

We strongly support that the Bill includes scope to regulate other nicotine containing products. The nicotine market is innovative and developing rapidly. For nicotine pouches, retail displays are becoming more elaborate, some on-pack imagery is youth-oriented, and some products are extremely strong (up to 150mg nicotine). We have noted a lack of clarity on pouch packaging about what the product is and what it contains.

34. Our qualitative research has indicated a growing awareness among young people around nicotine pouches. This is accompanied by recent development of positive product imagery in the minds of young people, for example, the association with a ‘hit’ or ‘boost’ of energy/focus, and positive user imagery such as the association with professional footballers.

35. The range of nicotine pouch brands appearing in the UK is rapidly growing. There is potential for cross-over between youth vaping and using nicotine pouches, especially given pouches can be used discreetly in places where vaping is not allowed. Elf-bar, a well-established and popular youth vape brand has recently entered the nicotine pouch market.

36. We recommend that restrictions for vaping should also apply to nicotine pouches, including a maximum product strength. In our view, pouches have the potential to become a growing market and appeal to young people. Our latest survey (EMERGE) conducted with 11–24-year-olds across the UK in March/April 2024 showed that:

· 17% of 11-15-year-olds have heard of nicotine pouches (63% of 16-24-year-olds)

· 2% of 11-15-year-olds have ever used a nicotine pouch (10% of 16-24-year-olds).

References that are not provided as hyperlinks in the above text

1. MacKintosh AM, Mitchell D, Ford A. Young people’s awareness, views and experiences of disposable vapes in the UK: findings from a cross-sectional survey. Poster presentation, SRNT 20-23 March 2024, Edinburgh, Scotland.

2. Ford A, Mitchell D, MacKintosh AM. Developing robust survey measures to assess awareness and use of heated tobacco products and nicotine pouches among young people (aged 11-24 years) in the UK (EMERGE Study). Poster presentation, SRNT March 20-23 2024, Edinburgh, Scotland.

3. MacKintosh AM, Mitchell D, Ford A. Young people’s response to standardised tobacco packaging in the UK, pre-, during-, and post-implementation (Youth Tobacco Policy Survey). Poster presentation, SRNT 20-23 March 2024, Edinburgh, Scotland.

4. Ford A, Mitchell D, MacKintosh AM. Young people’s response to e-cigarettes and other nicotine products and their marketing (EMERGE study). International Scientific Conference on E-cigarettes, Paris, December 5th-6th, 2022.

May 2024