Tobacco and Vapes Bill

Written Evidence Submitted by UCL Tobacco and Alcohol Research Group (UTARG) to the Tobacco and Vapes Public Bill Committee (TVB27).

Introduction

1. UTARG is a research group within the Faculty of Population Health Sciences at UCL . Its primary purpose is to further our understanding of smoking and smoking cessation to help develop, implement, and evaluate interventions to reduce smoking prevalence. It hosts the Smoking Toolkit Study, a monthly series of national surveys in England aimed at tracking smoking and smoking cessation activities nationwide and understanding what underlies changes at individual and population levels. Top line findings are reported monthly at www.smokinginengland.info .

2. Statement of competing interest: members of UTARG (LS and JB) have received research funding from, and undertaken consultancy for, companies that develop and manufacture smoking cessation medicines (Pfizer, J&J and GSK; most recently in 2018). UTARG does not have any financial links with tobacco companies or e-cigarette manufacturers or their representatives. Its research is funded primarily by Cancer Research UK.

 

Summary

3. UTARG strongly supports the tobacco measures set out in the Bill on raising the age of sale and greater regulation of tobacco products. The Smokefree Generation (SFG) policy is vital to achieve the government’s Smokefree 2030 ambition to make smoking obsolete. UTARG is generally aligned with the position taken in the Action on Smoking and Health (ASH) submission to this committee on both tobacco as well as vaping and other nicotine products sections of the bill.

Key points covered in this submission

· The age of sale legislation should not be limited to an increase only to 21.

· The age of sale legislation should include all tobacco products.

 

· The age of sale legislation should not include e-cigarettes (vapes).

· Legislative measures to reduce youth vaping should be proportionate and prioritise measures least likely to have unintended consequences.

· The Tobacco and Vapes Bill should be implemented alongside a comprehensive approach to tobacco control.

Age of sale legislation should stay as currently set out in legislation

The increase in age of sale should not be limited to 21

4. UTARG has calculated that every day around 350 young adults aged 18-25 start smoking regularly, [1] most of whom will continue to smoke long-term, resulting in entirely avoidable morbidity and mortality, with two-thirds of lifelong smokers dying prematurely. [2]

5. We judge this policy will be highly effective in reducing smoking prevalence. An approach we used to model raising the age of sale from 18 to 21 was adapted and used in one of the modelling scenarios on the SFG policy published in Annex 1 with the command paper. We support the approach and judge the forecasts to represent a plausible range of outcomes. [3]

6. While direct evidence on a new world-leading tobacco control policy is impossible to collect until after its implementation, the likely effectiveness of the SFG policy is supported by various other sources of evidence. Our group showed that the increase in age of sale from 16 to 18 in England resulted in greater reduction in smoking prevalence in this age group compared with older adults in the period immediately following the change. [4] In a more recent evaluation of this policy, we found that increasing the age of sale was also associated with a greater long-term decline in ever smoking between 2007 and 2018 among those aged 16–17 compared with those aged 18–24. [5] Critically, this shows it is possible that many people aged 18-24 who took up smoking between 2007 and 2018 may have avoided doing so if the age of sale had been increased to include them. The new proposed law could protect this age group in future. Raising the age-of-sale to 21 just goes a part of the way. The goal is to create a smoke free generation.

7. Further, beyond those directly affected by the legislation, social norms are a main driver of population smoking rates. This is, for instance, shown by the pronounced gender disparity in smoking rates in countries (e.g., China) [6] where anti-smoking norms apply to women not men, by the rapid decline in smoking rates across the lifespan (as fewer and fewer friends and family smoke) [7] and by the reduction in smoking rates following the introduction of smokefree legislation in the UK in 2007, denormalising smoke indoors. [8] Adopting SFG policy will therefore lower smoking rates not only by reducing smoking initiation in those born after 2009 but also by increasing smoking cessation rates among smokers of all ages in an environment where smoking becomes increasingly uncommon. As a comprehensive policy to denormalise smoking in society as a whole (not just in those aged below 21 years of age), SFG will therefore have a bigger impact on driving down smoking rates to achieve the Smokefree 2030 ambition, as has also been shown in modelling to support a similar bill in New Zealand. [9]

All tobacco products should be included

8. As cigarette smoking prevalence has decreased in the UK, the use of non-cigarette tobacco has increased. UTARG recently published work showing that nearly 800,000 smokers are now exclusive non-cigarette tobacco users (five times more than a decade ago), with higher rates seen among younger adults. [10] UTARG therefore supports the legislation as is, which includes all tobacco products. Given recent calls to exclude certain product categories, in particular heated tobacco products (HTP), we outline our reasons for including HTP below.

Heated Tobacco Products

9. Heated tobacco products (HTP) are tobacco products and as such should be included in the age of sale legislation, as otherwise it will create opportunities for the tobacco industry to circumvent the legislation.

10. Evidence reviews undertaken by UTARG, in collaboration with the King’s College London Nicotine Research Group, suggest that although HTP reduce exposure to harmful combustion products relative to cigarettes, results are limited by relatively short follow-ups in laboratory-based studies that do not reflect normal use behaviour. [11]

11. Further, our own (not yet published) work, which compared longer-term users of HTP, cigarettes and e-cigarettes in a real-world setting, suggests that HTPs have a more limited harm reduction role than e-cigarettes, providing lower reductions in biomarkers of harm such as nitrosamines. [12]

12. In addition, our work has shown that using HTP, compared with e-cigarettes, may lead people to maintain a stronger smoker identity, likely due to the behavioural similarity with smoking cigarettes: both use sticks that are consumed in discrete sessions (unlike the more continuous use seen with e-cigarettes). Users also self-report higher levels of dependence on HTP than e-cigarettes. [13]

13. Consistent with these findings, there is only limited data available on whether HTP help people stop smoking conventional cigarettes, with most published work (including work involving our group) [14] mainly finding an impact on reducing cigarette sales rather than on smoking cessation. [15] The "stickiness" created by the greater similarity between cigarettes and HTP may also explain why some analyses suggest that HTP tend to lead to dual use with cigarettes rather than to complete cessation. [16]

14. HTP have been available for nearly a decade, but they are still not commonly used, including - as we have shown - among ex-smokers, [17] and are rarely used by smokers to quit. Latest data from the Smoking Toolkit Study shows they are used by less than 1% of smokers attempting to quit in the last year in England (compared with 35-40% of smokers attempting to quit using e-cigarettes and, more recently, 7% using pouches). [18]

15. While HTP should be, and would remain, available to current adult smokers as a harm reduction alternative, if HTP are not included in SFG, the obvious concern would be that they could be marketed to non-smokers, who do not have access to cigarettes anymore, despite their potential to maintain addiction and greater harm (compared with non-tobacco products).

Vaping and other nicotine products should not be added to the age of sale provisions

16. E-cigarettes are the most popular cessation treatment in England by far. [19]

17. The Cochrane review of randomised controlled trials finds that nicotine-containing e-cigarettes are as effective an aid to quitting as the most effective prescription medicines for quitting smoking (varenicline and cytisine) and much more effective than nicotine replacement therapy. [20]

18. Our analyses of real-world effects suggest that the use of e-cigarettes in quit attempts has helped in the region of 30,000 to 50,000 additional smokers to successfully quit each year in England since they have become popular. [21] These population results are broadly consistent with real-world analyses at the individual-level that assume e-cigarettes increase success for an individual by 1.5 to 2 times compared with not using e-cigarettes. [22]

19. Further, work carried out by our group, [23] included in an authoritative review led by the King’s College London Nicotine Research Group, [24] shows that e-cigarettes expose users to only a fraction of the harmful substances users of cigarettes are exposed to.

20. Taken these findings together highlights the fact that e-cigarettes have an important role to play in reducing the burden of smoking-related morbidity and mortality. While raising the age of sale for tobacco one year every year will significantly reduce smoking uptake and - as we argue above - likely increase attempts to stop smoking in the wider population of smokers, it will not eliminate uptake completely. Those who do take up smoking should have access to the most effective quitting aids to help them stop, which include e-cigarettes.

21. In addition, including e-cigarettes together with cigarettes in SFG would give the false impression that they are equally as harmful as cigarettes, which may deter current smokers from using them as a tool to stop smoking. Recent work from our group has shown that 60% of those most likely to benefit from trying e-cigarettes to stop smoking (current non-vaping smokers), now wrongly believe that e-cigarettes are as harmful as, or more harmful than, cigarettes. [25]

22. The foremost aim of this bill should be to reduce access to cigarettes, a uniquely harmful product killing 75,000 people per year in the England alone, [26] while offering those already addicted to cigarettes with the best treatment options to stop smoking and live a longer and happier [27] life.

Legislation to reduce youth vaping should be proportionate and begin with measures least likely to have unintended consequences for adults using them to quit smoking

23. Many of the measures included in the bill to curb youth vaping are likely to have the intended effect, without adversely affecting the use of e-cigarettes by smokers to help them quit. This includes planned action to ban the advertising, promotion and sponsorship of vapes and nicotine products, given evidence of the effectiveness of such measures to reduce tobacco use and intitiation. [28]

24. Further, some restrictions on vapes and nicotine product characteristics, including POS display bans and plain packaging, are likely to reduce the appeal of these products to youth without reducing their appeal for adult smokers to use e-cigarettes to quit smoking. [29]

25. However, others proposed measures that are subject to a statutory duty of consultation, including a potential flavour ban, have a greater risk for negatively affecting the use of e-cigarettes for smoking cessation, potentially driving up tobacco use, [30] as flavours also play a role in getting adult smokers to switch to less harmful e-cigarettes. [31]

26. The anticipation of policy changes itself often is sufficient to change behaviour, as was shown for the implementation of standardised cigarette packaging where smoking rates reduced before measures came into effect. [32] We have recently shown that since the announcement of a disposable vapes ban, recent increase in vaping prevalence have stalled – and may even be reversing – including among young adults. [33]

27. This provides some reassurance that vaping rates are no longer continuing to rise rapidly. Therefore, stricter policy options under the Tobacco and Vapes Bill may not be necessary to halt the rapid rise in vaping, while some restrictions may be needed to bring the high rates of vaping that persist down further. Given the potential for unintended consequences of some of the proposed measures, it would therefore be prudent to start with those measures that are unlikely to undermine the potential of e-cigarettes to function as a smoking cessation tool for current smokers or which would encourage ex-smokers who vape to return to smoking tobacco.

The Tobacco and Vapes Bill should be implemented alongside other comprehensive tobacco control measures

28. In 2021 UTARG, in collaboration with ASH, undertook modelling for recommendations by the All Party Parliamentary Group on Smoking and Health for the Tobacco Control Plan 2021 to achieve the Smokefree 2030 ambition. [34]

29. This modelling, which is currently being updated, showed that targeted investment to fund anti-smoking mass media campaigns, additional help for those living in social housing, those with mental health conditions as well as pregnant smokers can reduce smoking prevalence across priority health groups by between 0.4% and 1.8% compared with baseline scenarios. By far the most impactful measure was the provision of opt-out (rather than opt-in) smoking cessation advice and referral to Stop Smoking Services at every clinical contact with smokers, which would yield close to 500,000 additional smokers by 2030. The report concluded that these measures are required to move the dial to have a chance to achieve the Smokefree ambition.

30. We note that the Tobacco and Vapes Bill does not have special provisions to implement these recommendations. Given that the UK is currently on a trajectory that likely misses the 2030 target, [35] we therefore urge the government to include adequate funding for mass media campaigns, stop smoking services, enforcement, the swap to stop scheme and financial incentives for pregnancy.

December 2024.