Tobacco and Vapes Bill

Written evidence submitted by the Institute for Social Marketing and Health, University of Stirling to The Tobacco and Vapes Public Bill Committee (TVB29).

This submission is the considered view from two 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. Professor Sean Semple and Dr Rachel O’Donnell have generated this written evidence. They have published over 80 academic papers describing research on tobacco control science in high-impact, international, peer-reviewed scientific journals.

Executive summary

1. Our response covers two key features of the bill: (a) the impact of the rising the age of sale of tobacco (smoke-free generation) (Parts 1-3); and (b) the powers to create additional smoke-free places (Part 7).

2. 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.

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

3. Introducing powers to designate additional smoke-free places

 

· The bill provides powers to designate new smoke-free spaces. There is no safe level of exposure to second-hand tobacco smoke and although concentrations in outdoor settings are much lower than those in indoor environments, there is still evidence of adverse health impacts, particularly on those with respiratory and cardiovascular disease.

· The powers to protect the proportion of the UK workforce who continue to be exposed to SHS are welcome. Those working to serve customers in outdoor hospitality settings should be afforded the same protection from the health harms of SHS as those who work indoors.

· Denormalisation of smoking in settings such as children’s playgrounds, school entrances and parks, is likely to reduce consumption, aid quit attempts and reduce youth smoking initiation.

Detailed evidence submission

4. We have prepared our response to cover the two key features of the bill: (a) increasing the age of sale of tobacco; and (b) introducing powers to create additional smoke-free places. 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 (November 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

5. The current Tobacco and Vapes 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.

6. 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).

7. 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.

8. 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.

9. 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.

10. 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%).

11. 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.

12. 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.

13. 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.

14. 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 are 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.

15. 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. The 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.

Introducing powers to designate additional smoke-free places

16. Part 7 of the bill provides the powers to designate as smoke-free place any workplace or any space open to the public. These are significant new powers that will enable the Secretary of State or equivalent in the devolved nations to make regulations to provide protection from SHS in a range of potential spaces such as children’s playgrounds, school entrances, parks, hospital grounds and other settings. We note that the bill would also make it possible to designate outdoor hospitality spaces (beer gardens, restaurant terraces etc) as smoke-free spaces. Recent media reports suggest that the Secretary of State for Health in England is minded to use these powers to make it illegal to smoke in children's playgrounds and outside schools and hospitals but not in outdoor areas of hospitality settings.

17. We welcome the desire to extend the protection of non-smokers and children in these additional spaces in line with the World Health Organisation Framework Convention of Tobacco Control Article 8. While dilution and air mixing mean that the concentrations of SHS are lower in the outdoor environment compared to indoor spaces, there is no safe level of exposure to SHS. Even low concentrations for short periods of time can cause adverse health effects, particularly for those with pre-existing conditions. Recent data from 11 countries across Europe, including the UK, has demonstrated SHS exposure in children’s playgrounds, at school entrances and in outdoor hospitality settings.

18. In terms of the powers to designate outdoor hospitality settings as smoke-free spaces, we note that this could be achieved under both the workplaces and/or the ‘open to the public’ section of clause 2 of paragraph 136 of the bill. We note that while the exposure to SHS of customers may be short and occasional depending on the frequency of their visits to such venues, those working in hospitality are likely to have much more sustained and regular exposure. Those collecting glasses, serving drinks and food to outside tables etc may experience exposure to SHS for much of their work shift. Given that almost all of the UK workforce receives protection from SHS within their workplace under the Health Act of 2006, there is an issue of inequity here for those in hospitality who are required to work in beer gardens and outdoor terraces.

19. A policy of creating smoke-free settings is not just about protection from the harmful particles and chemicals in SHS. There are additional benefits that will accrue in terms of reduced opportunity to smoke which may reduce consumption, improve cessation attempts and reduce relapse by ex-smokers. Importantly, the visibility of adult smoking will be further reduced and children in these settings will not see parents, carers and other adults smoking when they are within these spaces. Visibility is a form of product marketing and removal of this visibility is likely to have a denormalising impact and shifting the social norms away from smoking being accepted in these and other similar settings.

20. A recent estimate by our group suggests that over 1 million workers in the UK are likely to be exposed to SHS while performing their job. While hospitality workers will make up a proportion of that number, occupations with the highest frequency and intensity of SHS exposure include those where workers carry out work tasks in private, domestic settings: including care workers and home carers. There is a need for protection of these workers in line with Article 8 of the FCTC.

December 2024.