Tobacco and Vapes Bill (Third sitting)

(Limited Text - Ministerial Extracts only)

Committee stage
Wednesday 1st May 2024 Public Bill Committees

[Preet Kaur Gill]

Q Finally from me, and this question is for Frank and Michael, the latest ONS figures in 2022 show smoking prevalence in Wales and Northern Ireland remaining constant rather than continuing to fall in the way that it did in England and Scotland. Do you think Wales and Northern Ireland have specific challenges related to smoking prevalence?

Sir Francis Atherton: It is certainly true that we are not going as fast in Wales as we would like to see. Smoking prevalence has dropped, from about 22% in 2020 down to 13% at present, but our target is to reach 5% by 2030, and we are not currently predicting that we will meet that target unless we go further and faster. We believe that this Bill will enable us to do that.

You asked for the reasons. One of the reasons is that we have deep-seated sociodemographic problems in Wales, which you have been referring to. Given the inequity that we see, meeting the needs of current smokers from those really deprived socioeconomic groups is really quite a challenge. We are doing everything we can in Wales to try to address that through “Help Me Quit” and smoking cessation support, but we really need to prevent the next generation from coming on board with smoking.

Professor Sir Michael McBride: Just following on from Sir Frank’s comments, you are absolutely correct that, while population prevalence of smoking sits at around 14% at the moment—behind the 12% in England and the 13% in Wales—we are doing slightly better than Scotland at the moment, which is sitting at about 15%. The figures for the Republic of Ireland are somewhere in the region of 18%. There is absolutely no doubt that we have the same socioeconomic drivers, in terms of social deprivation and health inequalities, that are fuelling this. Should the Bill succeed and pass into legislation, I see this as a once-in-a-generation opportunity to make a significant change to protect future generations and their children from all the harmful consequences of smoking tobacco and other forms of tobacco use.

[The Parliamentary Under-Secretary of State for Health and Social Care (Dame Andrea Leadsom)]

Q I thank all you chief medical officers for being here; we appreciate it. You will understand that your witness evidence is crucial to easing the passage of the Bill. I would like to get you on the record talking, first, about the start of life. The shadow Minister has just asked about pregnancy and, only this week, I was talking to a neonatal nursing lead, who said of the pregnancies of women who smoke that the children had a low birth weight and go on to have severe learning difficulties throughout their lives. That is heartbreaking, but also has significant implications for NHS and educational services, and for whole-life costs to the taxpayer. I would be grateful for your comments on that.

At the other end of the age range, elderly people who have smoked all their lives end up with decades of ill health brought on by a lifetime of smoking. I would be grateful, too, if you talked about some of the health outcomes for those who have smoked all their lives—some of the horrors of that. Sir Chris, you told me an anecdote of when you were a young vascular surgeon. For the record, it is important to talk about some of the heartbreak for those who wish they could stop smoking.

Professor Sir Chris Whitty: I completely agree with all the points you made. Starting off with the beginning of life, there are clear and significant increases in stillbirths, premature births, birth abnormalities and long-term effects from smoking just in the pre-birth period. Then, of course, if parents are smoking around babies and small children, that affects lung development and, if children have asthma, that will trigger asthma effects. Young children are significantly affected by passive smoking from their parents. The parents, of course, want the best for their children, but the problem is that they are now addicted to a product that has taken their choice away. We get those problems right from the very beginning, and we have talked about some of the issues in young pregnancies and where that leads.

Moving to the other end of the age spectrum that you were talking about, the full horrors of smoking for most people start to take effect from middle age onwards. At this point, people get a range of things. Everyone knows about lung cancer, I think, and most people know about heart disease, but there are effects on stroke or increases in dementia, which are significant—one of the best ways to delay dementia is not to smoke or to stop smoking at an early stage. That is a huge problem for all of us. Smoking also exacerbates any problems people have with diabetes—it makes that much worse—and people have multiple cardiac events leading to heart failure. In heavy smokers, we see extraordinary effects, like people having to lose their limbs. As you and I discussed, it is a tragedy to be on a ward with people with chronic obstructive airways disease, or on a vascular ward as a vascular surgeon with someone who has just had an amputation, weeping as they light up another cigarette, because they cannot stop, because their choice has been removed. I cannot hammer that point home firmly enough: this is an industry built on removing choice from people and then killing them in a horrible way.

Sir Francis Atherton: Minister, you also pointed out the cost to the NHS. In Wales, we estimate that we have about 5,500 deaths every year from smoking-related diseases. If we look at admissions to hospital, about 28,000 in the over-35 group is about 5% of overall hospital admissions. That is an enormous burden to the NHS. On a more personal basis, in a former life I was a GP, and I remember sitting with an elderly gentleman who at the end of his life was suffering with chronic obstructive pulmonary disease. There is no worse death than not being able to breathe when just sitting there. I remember sitting with him as he was trying to talk to me and trying to express that same level of regret that Sir Chris talked about. If you talk to any smokers towards the end of their life, who are facing such terrible ends to their life, the sense of regret that you hear as a doctor is quite overpowering.

Professor Sir Michael McBride: It is estimated that in Northern Ireland there are more than 2,000 deaths each year directly attributable to smoking cigarettes; over the past five years, smoking makes up 12% of all deaths in Northern Ireland. Sir Frank and Sir Chris have clearly described the horrors of the impact that it has at an individual level, and as doctors we have all experienced that. We have all had those conversations with individuals who look back on a lifetime of regret.

On a more personal level, I also think at this moment about the impact that premature death, and the morbidity and mortality associated with smoking, has on families and children. My own father died at 46 years of age, when I was 16, from acute myocardial infarction as a consequence of a lifetime addiction to smoking cigarettes. So, we need to bear in mind the very human costs, family costs and wider societal costs as well. It is not just the cost to the health service, but the societal cost, the family cost and the cost to the wider economy.

Professor Sir Gregor Ian Smith: We should never forget the societal cost that Sir Michael just spoke about. I am the child of two smokers who died in their mid-60s from smoking-related disease. We see it all too often in Scotland. In fact, in Scotland we still have 9,000 deaths a year attributed to tobacco addiction and smoking. That is one death every 61 minutes that families suffer across Scotland as a consequence of addiction to smoking.

As a clinician, one of the diseases that I had become quite specialised in treating and led a lot of work on is chronic obstructive pulmonary disease. That is a smoking-related disease that people develop, often at too young an age, and begins to really impair their ability to participate fully in life—not only in employment, but in the pastimes that they love. Gradually, over time, it becomes worse.

Sir Frank touched on the sense of regret that people have that they ever started smoking in the first place and find themselves in this position. Beyond that, there is an even sadder element: many of the people who experience these chronic life-limiting illnesses have not only regret that they ever started, but guilt about the burden that they place on the health service and their family because of the illness and disability that they develop. That guilt sometimes reaches to the extent that they do not seek full care. Many people’s attitude is, “I deserve this. I started smoking; I need to pay the consequences.” That is a terrible psychological position for any person to find themselves in. Removing the starting point for that addiction, so that people will not experience that through their life, is the aim of the Bill.

Let me make one last point. We talk about the health impacts of all this. The Scottish burden of disease study projects that over the next 20 years, up until 2043, we will see a 21% increase in the general burden of disease across our population in Scotland, despite having a falling population during that time. Much of that projected burden of disease is smoking related; it relates to cancers, cardiovascular disease and neurological conditions such as dementia, which are all influenced by smoking. It is absolutely necessary for us to address this in a preventive way, and I believe that the Bill is a very good way of doing that.

Professor Sir Chris Whitty: I want to reinforce the point that Sir Gregor just made, with which I am sure the Committee fully agrees, that individual smokers should never be blamed for the situation they are in. An incredibly wealthy, very sophisticated marketing industry deliberately addicted them to something, at the earliest age it could get away with it, and they have had their choice removed. It is important that people do not feel guilt and come forward for care, and that no one blames them for a situation that was deliberately put on them by industry marketing.

[Kirsten Oswald (East Renfrewshire) (SNP)]

Q I will continue on the theme of marketing. Do you have thoughts about the measures relating to the product restriction of vapes in the Bill? Are they robust enough, in your mind, to prevent the harm that is caused by vapes, particularly to young people? I am thinking of the study that came out yesterday that, concerningly, suggested a risk to teenagers who vape of exposure to toxic metals, potentially harming their organ and brain development.

As a follow-on from that, I am concerned about the advertising of vape companies on sports kits, which is profoundly unhelpful. When we look at sporting figures who young people can admire, that has absolutely no place. I wonder what your views are on that.

Professor Sir Gregor Ian Smith: My views are very clear on vaping in young people and on sales to the youth categories. This is an activity that we are still learning much about but that the evidence, as it emerges, appears to suggest is very harmful to them. In my conversations with my paediatricians and with the Royal College of Paediatrics and Child Health, they are very concerned about the impacts on health of young people from beginning vaping. Any attempt to make products such as single-use vapes or flavoured vapes, or the packaging used or the marketing around vapes, more attractive to that age group is something that we need to counter and resist.

I would say that the aims of the Bill will allow us the means by which we can properly consult on the way that we attempt to reduce overall vaping use in this age group. I am very clear in my views on this: while I understand that vaping may be an assistance to people who are already addicted to tobacco and nicotine products as a consequence of use of many years—I see that there may be an argument that it allows them to reduce the level of harm they are exposed to—I am not convinced or led by any of the arguments that starting vaping in a younger age group is a safe activity at all. I do not believe that that is the case; I believe that it is harmful to those groups. We must try to counter that, and to counter the marketing machine that Sir Chris has spoken about, by reducing the flavours and packaging that are attractive to younger people.

--- Later in debate ---

[Preet Kaur Gill]

Q We should all be concerned about the increase in the use of vapes by young children, so it is important that the Bill will ban the sale of vapes to under-18s. It will also close the loopholes for under-16s, because we know that vapes are being marketed and given out for free. That is the issue we must address. My concern with the Office for Health Improvement and Disparities being disbanded is on public health messaging. Parents and families are really concerned that some of their children are going through a number of these vapes per day or per week, and they do not know what is a safe amount.

There is a growing illicit vape market, but how would parents know what is illicit or what the Medicines and Healthcare products Regulatory Agency has notified as being compliant? Where is the public health messaging to support schools? We heard really good evidence yesterday from the union. This is my concern: where can people access support and information? We already have a generation of kids addicted to vapes that are marketed as having 0% nicotine, but we know that there is nicotine contained in them. What would you say to that?

Sir Francis Atherton: There is some messaging going on through the various Governments. In Wales we have a “No Ifs. No Butts.” programme, which tries to work at an individual level, to alert people to the dangers that we have been discussing, and with wider society, about the dangers and links between illicit tobacco and illicit vaping and organised crime. Bringing that awareness to the population is really important for those two reasons.

We work with trading standards to try to tackle the issue of illicit tobacco and vapes. It is important that we continue that. My understanding is that wherever we have been successful in reducing demand, which the Bill intends to do, the illicit supply also decreases. We would expect that to be a consequence of the Bill.

Professor Sir Chris Whitty: One of the many talking points of the cigarette industry is, “Well, any kind of downward pressure on cigarettes would lead to an increase in the illicit market.” All the evidence shows that the reverse happens. When you bring in reduced demand, the illicit market decreases.

[Dame Andrea Leadsom]

Q I think we might be out of time, but I have one more question. In the passage of the Bill, there is a concern that some may wish to fix flavours on the face of the Bill, rather than allow the powers. Sir Chris, can we have a comment on the record on how damaging that would be?

Professor Sir Chris Whitty: That would be very damaging, because we know that this is one of the most innovative marketing industries in the world. That is how they have managed to sell to people something that will addict them and then kill them. If we give them room for manoeuvre by nailing things down, they will find a way around it, because they always have found a way around regulations. I am absolutely supportive of the comment you have just made.

[The Chair]

I am afraid this brings us to the end of the time allotted for the Committee to ask questions. I thank all the witnesses, because you answered a huge number of questions and provided great information.

Examination of Witnesses

Professor Sir Stephen Powis and Kate Brintworth gave evidence.

--- Later in debate ---

[Preet Kaur Gill]

Q Would you like to say anything about admissions of young people in relation to smoking?

Professor Sir Stephen Powis: I will make a few broad comments on smoking, if I can. Seventy-eight years ago, Parliament passed the National Health Service Act 1946, which led to the formation of the NHS on 5 July 1948. In my view, the legislation that you are considering here today is one of the most important—possibly the most important—pieces of legislation since the passage of that Act. Why? Smoking has an extraordinary impact upon the health of the nation, and of course directly upon the NHS.

To put that into a bit more context—you have heard some of this already, but maybe I will provide some more detail—smoking is associated with, or causes, over 100 individual conditions that are managed and treated within the NHS. It impacts the NHS at all levels: almost every minute of every day there is a hospital admission related to smoking; there are over 100 GP appointments every hour for smoking-related disease; and 400,000 admissions a year are related to or associated with smoking. You have heard the chief medical officers briefly talk about the impact on specific diseases. Lung cancer is the one that everyone knows about, and 80% of lung cancers are caused by smoking. This Bill has the opportunity to transform lung cancer from a common disease into a relatively rare disease, and one that clinicians of the future will not see in any way as commonly as clinicians of my generation.

It is not about just lung cancer; you have heard about the impact on cardiovascular disease, and clearly, chronic obstructive pulmonary disease would again become a rare disease for the clinicians and the patients of the future. This Bill can also have an early impact on diseases that affect young people. Asthma is a disease not caused by smoking but a condition exacerbated by it. We see such admissions particularly over the months when asthma is worse and when there are respiratory infections, which are no doubt exacerbated by smoking.

In mental health, smoking doubles the risk of developing depression. More than one in two people with severe mental health conditions smoke, and the life expectancy of those with mental health conditions is reduced because of smoking. Mental health issues in our young people and children are well-known and well-described, and smoking simply exacerbates them. There is great potential, even in the early years, in the passage of this Bill for an impact on conditions that we see and manage in the NHS. Over the long term, that potential impact is extraordinary on those conditions, which number over 100.

You may know that I am a kidney doctor, but you may not know that smoking can impact on kidney disease. The kidney, like any organ, is supplied by blood vessels. When smoking impacts on the health of blood vessels and causes vascular disease, that can reduce the bloody supply to the kidney, which can cause kidney failure and lead to dialysis and transplantation. There is a large range of conditions that are impacted by smoking, and it will be extraordinary for those clinicians of the future not to have to do what we have done—tell patients and their families that people are going to die prematurely. That is an extraordinarily difficult thing for clinicians to do. Those are preventable diseases, and this Bill will prevent them.

[Dame Andrea Leadsom]

Q Thank you so much for being here today. As I said to the chief medical officers, you will appreciate that your words can be very helpful in smoothing the passage of this very important Bill. I would like to talk to Kate, please, about the impact of smoking on mothers who are pregnant. What is the impact on their babies, on the delivery of the baby, and on the baby’s health outcomes? If you could give us an outline, that would be very helpful.

Kate Brintworth: It is important to start with the fact that we know that smoking is the single biggest modifiable risk factor for pregnancy, and we know that every women who gets pregnant wants the best for her baby. As a midwife, I have never sat in front of a woman who does not want the absolute best for her baby. It is important to build on what Chris Whitty said around the removal of choice. Women will go to extraordinary lengths to protect their bodies and babies to ensure that their children have the best start in life, and yet the quit rates that we see in pregnant women are between 30% and 40%, showing how difficult it is for women to extricate themselves from the situation in which they find themselves.

The effects are devastating: stillbirths are increased by 47%; you are twice as likely to have a baby that has not grown properly; and you are 27% more likely to have a baby that is born pre-term. You are more likely to have complications of pregnancy, such as bleeding, the placenta not forming properly or the waters that surround the baby breaking earlier with the risk of infection, so there are immediate effects that we can see. If a baby is small, it goes into labour more vulnerable to the stresses of labour, so we can have more complications there. If a caesarean section is needed, the mother is more vulnerable to recovery and it can be a much harder road to recovery for her, with the risk of infection and blood clots, but also for the baby. If the baby is born early, obviously the risk then is that the baby and mother are separated and you have this unnecessary trauma to a family of a baby having to go into a neonatal unit. The risks that come from prematurity are well-documented for children, for educational attainment and for their lung and health development, but when the children go home, they are more at risk of sudden infant death syndrome—up to three times more—in a smoking household.

There are then the long-term effects. We have already heard about asthma, chest infections and obesity. All those are heightened in children born into smoking households. You have a situation where children are at risk and women are at their most vulnerable when they are pregnant, and it really feels like it is our duty to support this Bill to protect the most vulnerable in our society, because there are the effects of having a child born with possible behavioural problems and malformations, which have been described. Those are really shocking events. I was talking to service users yesterday who have had children in the neonatal unit, and it is incredibly shocking when your pregnancy ends early and you are separated from your baby. There is a mental health impact on the family. There is also the point that this affects those coming from the most socioeconomically deprived backgrounds, for whom having any kind of health challenge makes it a much higher bar to fight.

[Dame Andrea Leadsom]

Q That is very harrowing to hear. Could you further expand on the impact on families of losing a baby due to stillbirth as a result of smoking? How does that impact on their mental health? As you said, parents will do everything they can to protect their baby, but the addiction to cigarettes is so strong that for many it must lead to them blaming themselves for the death of their baby.

Kate Brintworth: The birth of a child is so happily anticipated by every person who gets pregnant. From the moment that you see a thin blue line, you are having a baby. You have hopes and dreams for the expansion of your family, but not just for that individual family: a baby is born, and it is a niece, a nephew, a grandchild, a cousin. It really ripples out across the entire family. When there is then a 35% risk of miscarriage and a higher risk of ectopic pregnancy and, as you said, the absolutely awful, tragic and devastating news that your baby has died when it reaches term, that is something that no parent should ever have to face unnecessarily. It just feels like the worst thing you ever have to do as a clinician to tell someone that their baby has died. Every time I have ever had to do that, it has been the worst point in my career. It is difficult to explain how destroying it can be for families, and we see the long-term sequelae in terms of mental health, to the point where we have put in extra perinatal mental health support for families that have suffered that kind of trauma.

Professor Sir Stephen Powis: Can I pick up on the health inequalities aspect, because I think that is really important and I have the figures in front of me? In 2021-22, 21% of pregnant women in the most deprived areas smoked at the time of delivery, compared with 5.6% in the least deprived areas. That is a really stark difference. Smoking is widely accepted as the most significant driver of health inequalities in the UK. Detailed analysis has concluded that 85% of the observed inequalities between socioeconomic groups could be attributed to smoking. We spend a lot of time in the NHS quite rightly targeting our interventions and support to deprived areas to address health inequalities. At a stroke, this Bill would have the greatest impact that we could possibly see.

[Steve Tuckwell (Uxbridge and South Ruislip) (Con)]

Q Thank you for coming to address us this morning. We heard compelling insight from the chief medical officers earlier. Will you update the Committee on how you see this Bill supporting the NHS in the long term and the short term?

Professor Sir Steven Powis: I have already highlighted some of the short-term impacts, and there will undoubtedly be short-term impacts. Some conditions are exacerbated by smoking, with asthma in children being an obvious one. I have talked about mental health conditions and the way that smoking exacerbates conditions such as depression and chronic mental health illness.

We will start to see immediate effects, but those effects will grow over time. I have given you some of the conditions that are impacted on by smoking—there are well over 100 of them—but I can give some more stats. By stopping children from ever starting to smoke, we estimate that we will prevent about 30,000 new cases of smoking-related lung cancer every year. More than 1.4 million people suffer from chronic obstructive pulmonary disease, which is a chronic disease of the lungs caused by smoking—it causes nine out of every 10 cases. As I said, that is a disease that clinicians commonly see. A common cause of admissions to emergency departments, through the winter particularly, is other respiratory infections on top of COPD—these are diseases that future clinicians will see rarely. They will not see them in the way that clinicians of my generation have had to manage them. The impact will begin immediately, but over time that impact will get greater.

--- Later in debate ---

[Preet Kaur Gill]

Q There seems to be an issue around what is contained in illicit vapes, which we know include things like lead, nickel and high levels of nicotine, versus other vapes that have gone through a notification process. Do you feel that the research on the impacts of illicit vapes is not there, or is it the impact of vapes that have gone through a compliant process?

Professor Hawthorne: There is probably very little research on either.

Professor Turner: If I could just bring a bit of clarity, it is well known that nicotine is bad for us. Sir Walter Raleigh brought it back with some potatoes, and we have known for hundreds of years that nicotine is an addictive drug. As I said previously, it will shorten your life expectancy by between 10 and 15 years. Because we know nicotine is in all nicotine-containing vapes, whether licit or illicit, it is harmful regardless of what the other components might be. It is likely that those other components add to the harm, but there is substantial and well-described harm from nicotine addiction to us as human beings.

[Dame Andrea Leadsom]

Q Thank you both so much for being here. As I said to the other medical professionals, your words today will be incredibly valuable in ensuring the smooth passage of the Bill. Professor Turner, could you explain to us what happens to a baby born addicted to nicotine in terms of the withdrawal symptoms and the impact on its health and development?

Professor Turner: There is not a lot of research on that. Certainly, we know that if you are in utero and your mother is smoking, you will get the harmful effects of nicotine. That is a very good question—I honestly do not know what the effects on the unborn child would be. Certainly, we know that children born to parents who are addicted to morphine or cocaine have learning difficulties. I have to be honest and say that I might have to get back to you on that one, but I can assure you that it is not good to be in utero and exposed to nicotine.

[Dame Andrea Leadsom]

Q Professor Hawthorne, from a GP’s perspective, could you talk us through the impact of second-hand smoking on childhood asthma and how that presents in terms of the innocence of the child and the impact of something being done to them?

Professor Hawthorne: We have known for a long time that passive smoking increases the risk of not just asthma, but upper respiratory tract infections and ear infections. It is very much part of a GP’s role when they are consulting with such patients coming in with these infections to ask about parental smoking. It is interesting that the responses are nearly always the same. If the parent smokes, they will always say, “But I only ever smoke outside.” Of course, one has to take that as it is, but I suspect that they are probably not always smoking outside. It is definitely a well-recognised link, but I am seeing it a bit less than I used to.

Everybody knows about the dangers of smoking. A lot of my patients, when I talk to them about needing to stop smoking, already know what I am saying. Quite often, I will say to them, “Well, you know what I am going to say next, don’t you?”, and they will say, “Yeah, I know. I need to stop smoking.” The conversation then proceeds from there.

We also have evidence that, in general practice consultations, a short intervention can be very effective. We know that people are very pressed for time, and there is only so much we can cover in a 10-minute appointment, especially if the patient is coming with three different problems. But there is good evidence that with even a very short intervention—I think in about 10% of cases—patients will actually stop smoking. It is always worth talking about, and if I get the time, I have a much longer spiel, because you need to think about the behavioural and addictive aspects of smoking. We go through, “When are you most likely to want to smoke? Is it after a meal, when you are on the phone or when you first get up in the morning?” We talk about what else they can do instead. I had one patient who went and dug the garden whenever she wanted to smoke. It is that kind of conversation.

[Dame Andrea Leadsom]

Q We know that it takes up to 30 quit attempts to actually give up smoking. Can both of you give us a clue as to what is it about the 30th attempt that finally gets people over the line? Specifically to Professor Turner, is it being pregnant or having a partner who is pregnant? Is that the thing that makes people finally achieve their goal?

Professor Hawthorne: For adults, it is having that heart attack that maybe you could have avoided if you had stopped smoking before. Again, that is part of the conversation I have with patients. I say, “You are a heavy smoker, and you are at risk. Wouldn’t it be better if you stopped smoking before you have the heart attack, rather than after?” There are things like that, for sure.

We also operate a cycle of change psychological model—the Prochaska and DiClemente model. Essentially, it is a bit like having a clock face. We work out where the patient is on the clock face, and we are trying to get them round the clock to 12. If they are at somewhere like 2 o’clock, that is them saying, “Yeah, I know it is bad for me, but really no way am I going to do anything.” By 4 or 6 o’clock, they are saying, “Yeah, I know it is bad for me. I have tried a few times but it is just hopeless.” By quarter to, they are saying, “I’ve really got to do something”, and by five to, they are coming in and saying, “Doctor, you have to help me stop now.”

[Dame Andrea Leadsom]

Q And is that related to their declining health?

Professor Hawthorne: Not necessarily. It is about pushing people psychologically around that clock face. I try to work out where they are on the clock face and see if I can nudge them a bit further round, until one day they come and say, “I’ve got to stop now. What can you do to help me?”

[Dame Andrea Leadsom]

Thank you.

Professor Turner: As Kamila says, there are myriad drivers—teachable moments. Sometimes, when your child is admitted to hospital with an asthma attack, that might be the thing that makes both parents say, “That’s it.” It might be that the grandmother says to her daughter, “You’ve got to stop for your child.” Legislation might also be one of those teachable moments that make people reflect on their 29 past unsuccessful attempts and think, “I’m going to do it again.” There is no one thing, but there are clearly teachable moments, as we all have when we change our behaviour. As I suggested, I think this legislation will be one of those.

[Dame Andrea Leadsom]

Thank you very much. One last question: do you think the financial incentives for pregnant women and their partners would help?

Professor Turner: I think this is extremely contentious, but the evidence is that it does—sorry, you did ask me about pregnancy before. Pregnancy itself can be one of those opportunities to quit. Those parents who continue smoking—12% in Cumbria—feel terribly guilty. Anything we can do for that person, who has been addicted since she was 15 or 16, can help them to quit. There is no doubt—in Dundee, the trials have shown that, if you give mums incentives, in terms of vouchers rather than money, it helps them to quit, particularly if they are from deprived communities.

[Rachael Maskell]

Q We have already heard how addictive nicotine is, but do we have an understanding of the dosage of nicotine that people inhale through vaping versus through smoking? Secondly, are we missing an opportunity not to introduce a nicotine-free generation?

Professor Hawthorne: I am not a nicotine expert, but my understanding is that there is a risk from vaping, but it is about 5% of the risk from smoking. That is the best I can do in comparing the two. When I talk to patients about stopping smoking, vaping is one of the things we talk about as an alternative, with a view to eventually stopping vaping as well. Of course, there are all the other products: we use patches and chewing gum—all the usual things. It is difficult to quantify exactly how much less dangerous vaping is than smoking.

Professor Turner: Just to supplement that, as a user—if that is the right word—or a customer buying a vape, you can select the dose you want. There are doses that are equivalent to cigarettes and doses that you can wean yourself down on.

You asked whether we would be missing an opportunity if we do not introduce a smoke-free generation. I think we would absolutely be missing an opportunity. If we look back, the legislation on smoke-free public spaces across the UK was landmark. We all remember the days when you went on a plane and there was a smoking bit up front and a non-smoking bit at the back. If we were to go back and say there would be no smoking areas, we would think, “Wow, that would be transformational.” We have come on a journey, and the legislation has been part of it. I see a smoke-free generation as the logical next step, and I really think we have to take it.