Tobacco Control Plan

Alex Cunningham Excerpts

Thursday 19th October 2017 Commons Chamber

[Sir Kevin Barron (Rother Valley) (Lab)]

I beg to move,

That this House has considered the Government’s publication of the new Tobacco control plan.

I begin by thanking the Backbench Business Committee for allocating time for this very important debate. I also welcome the Minister to his new post in the Department of Health, and I am sure he will hear much more about this issue in the months to come.

I have no financial interest, but I should mention that I am an honorary fellow of the Royal College of Physicians, as it is heavily involved in the debate on tobacco.

I have repeatedly called in this House for the publication of a comprehensive tobacco control plan to replace the Government’s previous plan, “Smoking Still Kills,” which expired in 2015. I welcome the Government’s publication of this new five-year strategy this summer, which seeks to achieve what they term a “smokefree generation”.

Despite a long-term reduction in smoking rates, tobacco use remains the leading cause of preventable premature deaths and ill health, accounting for about 100,000 deaths each year in the UK. In addition, 23% of all hospital admissions for respiratory problems in 2014-15 were directly attributable to smoking. I thoroughly welcome the falling adult smoking rates in England—down from 46% in 1974 to 15.5% in 2016—but I have to say to the Minister and to the House that we cannot take this work for granted. That is why we need the tough but achievable targets that the new current control plan contains.

Smoking and the harm it causes are not evenly distributed, as hon. Members will know. People in more deprived areas are more likely to smoke and less likely to quit. Smoking is increasingly concentrated in more disadvantaged groups and is the main contributor to health inequalities in England. Men and women from the most deprived groups have more than double the death rate from lung cancer of those from the least deprived areas of the UK. I am not saying there is exactly a north-south divide, but where money is divided in such a way that is likely to happen. Rates do vary between north and south on occasion, as we see if we examine smoking during pregnancy rates, which vary from 2% in the Central London clinical commissioning group area to 27% in the Blackpool CCG area.

[Alex Cunningham (Stockton North) (Lab)]

Data produced by Public Health England show that in my local authority area 18.1% of women smoke at the time of delivery compared with the national average of 10.6%. The plan says that it will reduce the prevalence of smoking during pregnancy. Does my right hon. Friend agree that every CCG and local authority will have to have sufficient funds to carry this work forward?

[Sir Kevin Barron]

Clearly that is the case. I agree with this publication and its intention, but there will be issues to address on different forms of funding. I will discuss that a little later in my speech. We can see from the two figures from central London and Blackpool that there is a challenge out there; this difference alone can have a dramatic impact on health inequalities, as maternal smoking causes up to 5,000 miscarriages, 300 perinatal deaths and 2,200 premature births in the UK each year.

In my area of Rotherham alone, the smoking rate among people in managerial and professional occupations is about 10.2%, but that leaps to 29.4% among those who have never worked or are long-term unemployed. Such facts clearly show that we are still struggling to get through to certain groups within society, and the Government must do more to identify ways of getting through to these difficult-to-reach groups.

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[Sir Kevin Barron]

I am going to go on to discuss some of the issues relating to that situation. As I said, dentists are the only ones who normally see healthy people. I am aware that some GPs—we have one sat here in the Chamber—talk to healthy people even though these people do not think they are healthy at the time, but the situation is a little different for dentists. This early identification is crucial, as mouth cancer patients have a 90% chance of survival if the condition is detected early, but that plummets to just 50% if their diagnosis is delayed.

I say to the hon. Gentleman that I worked in an industry where people used to chew tobacco because we could not smoke at work. I tried it once at the age of about 16 and I am pleased to say that I never went near it again, although I used to smoke cigarettes when I came up from underground—that is a long, long time ago now. The general health implications of smoking are well known and documented, but mouth cancer often gets overlooked. This is the point: despite its killing more people in the UK than cervical and testicular cancers combined, there is still an alarming lack of public awareness towards oral cancer. There are thousands of chemicals contained in a single cigarette, and their point of entry is the mouth. Smoking helps to transform saliva into a deadly cocktail that damages cells in the mouth and can turn them cancerous.

Pharmacy teams also have an important role to play in promoting and encouraging attempts to stop smoking; as Members will know, in Healthy Living pharmacies and others, this is part of the job they do in advising people. These teams can be trained to be very effective in that. This often occurs in the community, but hospital and GP-based pharmacists are also well placed to offer this support. They are well placed to offer stop-smoking interventions with behavioural support and medication. In fact, the National Pharmacy Association is re-evaluating its position on e-cigarettes. As frontline healthcare professionals, pharmacists and dentists are exquisitely positioned to make a difference to health outcomes.

The Government must look to protect public health funding for stop-smoking services in particular if their aims are to be achieved. A growing number of local authorities have already stopped providing stop-smoking services for general smokers. The King’s Fund also highlighted that in 2017-18 local authority funding for tobacco control faces cuts of more than 30%. We have seen the transfer of commissioning responsibilities for public health services to local authorities, and subsequent cuts to the public health grant. A study by Cancer Research UK and ASH—Action on Smoking and Health, an organisation I have been involved in for more than two decades—found that 39% of local authorities reduced their smoking cessation budgets, despite the public health budget being ring-fenced by central Government. These are the issues that are happening down below, but we need to be aware of them.

All this has led to a reduction in mass media campaigns to motivate quitting, which are so vital to direct people towards the services that are on offer. Only this morning, I saw that the British Lung Foundation has published a report showing, yet again, that stop-smoking support is one of the most cost-effective treatments for people with COPD—chronic obstructive pulmonary disease.

Recently, in my role as vice-chair of the all-party group on smoking and health, I visited a smoking-cessation service—the one led by Louise Ross in Leicester. The team in Leicester have been trailblazers in the use of e-cigarettes for cessation purposes. They told me that Leicester’s stop-smoking service was the first in the country to go “e-cig-friendly” on No Smoking Day 2014. Since then, the team has built up a comprehensive bank of knowledge and insights, developed from many discussions with both vapers and smokers, that can be drawn on to help people get the best advice when they decide they have had enough of smoking. I had a discussion with a nurse who works in that service and who was using e-cigarettes in working with pregnant women to try to address our awful statistics on the effect of smoking in pregnancy. Most smoking-cessation services could do worse than talk to the people in Leicester about exactly what they are doing on that.

There has clearly been an increase in e-cigarette usage since the publication of the previous strategy in 2011: in 2012, there were some 700,000 e-cigarette users, and that had risen to 2.8 million by 2016. There is growing evidence to support the successful use of e-cigarettes as a smoking cessation aid. The Office for National Statistics found that in 2016, some 470,000 people were using e-cigarettes as an aid to stop smoking, while an estimated 2 million people had used the products and completely stopped smoking. I believe that e-cigarettes played a huge part in the beating of the target in the previous tobacco control plan. It is clear that e-cigarettes do not suit everyone, though, so there still needs to be a wide range of licensed stop-smoking medication to use alongside much-needed behavioural support.

[Alex Cunningham]

Some 4,000 people in my Stockton North constituency use e-cigarettes and 14,000 people still smoke. Can my right hon. Friend envisage a day when e-cigarettes are available on prescription, like other products?

[Sir Kevin Barron]

I actually had this conversation in Leicester, although I was not going to mention it in my speech. There is an issue—I think it was in a column in one of the national newspapers many months ago and I have tried to avoid it. If somebody avoids spending £20 or £25 a week on cigarettes, should they get free NHS prescriptions, if they are eligible, to help them to quit? There is a debate there, but I shall say no more than that at this stage.

I asked the team in Leicester what they thought about e-cigarettes on prescription for people who are eligible for free prescriptions, and they said that there might be a case for doing it for a month to break the person away from the cigarette-smoking habit and get them on to e-cigarettes. For the purposes of this debate, I shall leave that where it sits, but there might be a case for it. We clearly need more evidence on the use of e-cigarettes for smoking cessation so that we can make a better estimate.

[Sir Kevin Barron]

I shall address that briefly, because I know that other Members wish to get involved in the debate. The simple answer is that that is one of several issues that need to be addressed.

The best thing smokers can do for their health is of course to quit smoking altogether, but it is clear that e-cigarettes are significantly less harmful to health than smoking tobacco. Public Health England found that e-cigarettes are around 95% less harmful than smoking cigarettes. My instinct is that the remaining 5% is down to the fact that they have not yet been tested for long enough for it to be said that there is little or no danger at all. There is no evidence that e-cigarettes act as a smoking gateway for children or non-smokers, but research is still needed on their long-term use, and it should be carried out. Quitting smoking is always best, but there is clearly a hard core of smokers who have so far struggled to quit; they must be the people we focus on. It is worrying that an ASH survey found over a three-year period that the number of people who thought that e-cigs were “as or more dangerous” than cigarettes rose from 7% to 26%. That is why we need Government-funded research. I find it incredible that statistic is moving in that direction, rather than the opposite, although I must say that the debate on e-cigarettes, both in the Chamber and elsewhere, has not always been particularly clear.

Other innovations are continuing the “nicotine revolution”. Manufacturers are developing additional smoke-free products to persuade heavy smokers who would not otherwise quit smoking to switch to smoke-free alternatives, among which are the heated-tobacco products that have come on to the scene in the past year or so. Referred to in the “novel tobacco products” category of the tobacco control plan, such products could be the next step to reaching those hard-core smokers who, although they did not get on with e-cigarettes, are looking for another way out of smoking. I was pleased to see in the plan that Public Health England will continue to lead the investigation into the use of novel products as stop-smoking tools, with the evidence updated annually, and that PHE acknowledges that novel products are currently the most popular aid to stopping smoking in England.

Many people are wary of so-called novel products and the fact that many are produced or funded by tobacco companies. We must recognise that tobacco companies have in the past been extremely dishonest about the harms of smoking and the products they have sold, so we urgently need more research on these devices, and I hope the Government’s annual review will help to provide more information. I have been anti-tobacco for more than two decades in this House, but we should not ignore the potential benefits for people who have not been able to stop with more traditional smoking-cessation products just because some of these products have tobacco connections. It is vital that we all focus our minds on the reality of getting people off this habit that is still killing people and shortening the lives of more than 100,000 of our fellow citizens every year.

Many of the products I am talking about are covered by the EU tobacco product directive, which has resulted in many good things, including the establishment of reporting and notification requirements for tobacco products. Nevertheless, stakeholders have raised issues with some of the other requirements, and we may be able to use Brexit as a chance to look at the directive. I understand that we have been thrown into the TPD at the last minute. We have had the debate and I do not want to bore anyone with it further. We need to move on, because that is what happens in politics sometimes. We need to talk about what should be happening now and in future for the sake of our fellow citizens. Brexit is coming, so we should not be tied into a timetable for any changes to the TPD—although I do not even know the potential timetable for any further debate on Brexit. Nevertheless, if there is any discussion about changes to the TPD, we need to ensure that all stakeholders are involved in working groups to design a directive that works for the good of the United Kingdom, taking into account the issues I have mentioned.

For all its positives, there is a glaring problem with the tobacco control plan, and we all know what it is: money. Although not short on lofty ambitions, local authorities face huge strain and will not be able to deliver the kind of joined-up smoking-cessation services that the tobacco control plan deserves. Luckily, there are people who can help. Tobacco companies have made a fortune selling cigarettes. We might well argue that they got us into the mess we are now in, so it is only right they get should us out of it. They have the resources and customer base to help smoking cessation tools to get straight to the people who need them most. If the industry is willing to commit to a future based on e-cigarettes and other reduced-harm products, we should take them up on the offer and allow the Government and local authorities to partner with them to ensure we have the financial and technical assistance needed to help smokers to quit. I would not have said that five years ago, but five years ago we did not have these products that can clearly help a lot of our fellow citizens to get off cigarettes.

[Alex Cunningham]

It was remiss of me earlier not to pay tribute to my right hon. Friend for all his work on this issue in recent years. Will he talk a little about people with mental health conditions and the fact that the tobacco control plan emphasises the need for parity of esteem in their treatment, in a similar way as there should be parity of esteem between the treatment of mental health conditions and the treatment of the general population? For that parity of esteem, the professionals who work with people with mental health conditions would need the necessary expertise and education. Will my right hon. Friend join me in encouraging the Minister to step up education for mental health professionals so that they, too, can be part of the campaign to help people to quit smoking?

[Sir Kevin Barron]

I will indeed. The use of e-cigarettes in mental health institutions or in prisons could go a long way towards alleviating some of the problems in such institutions. When I was Chair of the Health Committee, we looked into smoking in public places in 2005-06, and we saw tobacco in effect being used as a form of control in some institutions, and everyone knew the damage it was doing to the people in those institutions. A lot of institutions have moved on now, though. It is a matter for the Prisons Minister, not the Minister who is present, but we need to consider the availability of e-cigarettes in such institutions so that we can get people away from this life-threatening habit.

In conclusion, the tobacco control plan offers the groundwork for a comprehensive strategy that is much broader than just cessation and that must include measures that reduce uptake as well as those that increase quitting. They should include reducing the affordability of tobacco by increasing taxation, which has been happening in this country for many years now. I will certainly have a close eye on the Budget in a few weeks’ time, as we need a renewed commitment from the Government to the tobacco tax escalator. Any money that is raised should be ring-fenced for use in smoking cessation and mass media campaigns to motivate quitting and enforcement of age of sale, which is also an issue. When the mass media campaigns ended after the 2010 general election—people were no longer seeing them on television or in other parts of their life—the demand for smoking cessation services reduced.

We all want a smoke-free society as soon as possible. We on the Labour Benches, and even some tobacco companies, are now saying that as well, so the Government could not ask for a better opportunity to take this further, to do it more comprehensively and with more success. The challenge now is to make sure that reality lives up to these ambitions. The tobacco control plan needs to be properly implemented and built on if we are to achieve those goals.

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[Michelle Donelan (Chippenham) (Con)]

I am delighted to have the opportunity to speak in today’s debate on the Government’s tobacco control plan, which was unveiled in July 2017 and is supported by the British Heart Foundation. It is a co-ordinated effort to bring together the NHS, the Department of Health and local government to tackle smoking.

Although smoking in the UK is declining, the problem should not be underestimated. There are still 7.3 million adult smokers in the UK, and more than 200 smoking-related deaths a day in England, which costs the NHS millions every year. I welcome the plan and the £16 billion that has been ring-fenced by the Government for local public health services until 2021.

Those who use a local stop-smoking service are four times more likely to quit. The figures are astonishing. As the daughter of a smoker of more than 20 years, I have seen at first hand the journey that needs to be replicated to achieve the goal of a “smoke-free generation”.

The success of the 2011 to 2015 tobacco control plan reduced adult smoking rates from just over 20% to just over 15%. The aim now is to reduce rates to 12% and lower by 2022. That is not only right, but essential. We must work to save the 79,000 preventable deaths in England per year and the £11 billion that smoking is costing the economy.

Smoking is not a necessity. A cigarette is not a fashion accessory; it is the way towards lung and mouth cancer, strokes and heart disease and a host of other ailments and illnesses that kill. Let me be clear: I believe in choice and individual freedom, but I also believe that the Government have a role not only to guide, but to signpost and to promote the choices that will lead to healthier lifestyles. That is why I am so proud that the Government are prioritising the issue of smoking.

Some people have said to me: “Michelle if people want to smoke, let them.” I respond by saying that we must arm those people with all the information—the warnings and the facts. We must work together to deglamorise smoking. As has been pointed out, the smoking industry also has a responsibility to play its part. We must guide people and steer them to make informed choices. We must also discourage them, otherwise we will have to pay their NHS bills—money that could be spent in other sectors of the NHS. I often ask people, “If smoking were invented today and we knew all the risks and effects, would it be so freely available and popular?” Armed with the facts, we often make different choices in life.

My mother started smoking in an era when the health consequences were not known. I saw her struggle, desperately trying to give up. My Dad describes that time as a caricature, with my mother wearing anti-smoking patches and smoking cigarettes, while chewing anti-smoking gum and seeing a hypnotist, all at the same time. She simply tried everything. All the hypnotist did was to get her on to menthol cigarettes and give her a fear of hypnotists, so that did not go quite to plan. That taught me that, to break the cycle, it needs to be killed at the root, and people need to be prevented from smoking in the first place. I must add that my Mum has now not smoked a cigarette for seven years. [Hon. Members: “Hear, hear.”] Instead, she has e-cigarettes. Although that cannot be seen as the answer, it is very much part of the solution.

As part of the tobacco control plan, I want to touch on the support provided for pregnant workers, which aims significantly to reduce the likelihood of a person smoking while having a child. Currently, more than 10% of pregnant women smoke, and the plan is to get it down to 6%. Smoking during pregnancy increases the risk of stillbirth. Babies born to mothers who smoke are more likely to be born underdeveloped and in poor health. It is important that we give those mothers all the support and information available. For example, within the plan, NHS England will work to reduce smoking in pregnancy through carbon monoxide testing at antenatal care facilities and referrals to stop smoking services through the Saving Babies’ Lives care bundle.

Support, advice and information are crucial. We must make sure that all mothers are aware of the dangers of smoking. I urge us to be bold—bold with our information and bold with our warnings.

[Alex Cunningham]

Information is key to this matter as well. ASH has told me that the Government no longer have the measure of the number of people with mental health conditions who smoke. Does the hon. Lady agree that the Government need to re-establish a national measure for smoking rates among people with mental health conditions, as that will aid planning and the provision of services?

Autism Diagnosis

Alex Cunningham Excerpts

Wednesday 13th September 2017 Westminster Hall

[Alex Cunningham (Stockton North) (Lab)]

I was asked to speak in this debate by one of my constituents, Nichola, who has a three-year-old son called Thomas. My hon. Friend the Member for Stockton South (Dr Williams) referred to them.

This is a very personal story but, before I get into it, I add my tribute to Daisy Chain, the charity based only a few hundred yards from my home in Stockton North that supports children with autism and their parents. I am pleased that the great Daisy Chain team are represented here today.

Thomas has many autistic traits, such as communications difficulties and limited speech, and is behind in all areas of development, including having sensory issues. He will have to wait more than three years for a formal autism diagnosis. That is simply not good enough, and the consequences could follow Thomas through the rest of his life. He has been refused an education, health and care plan; the very fact that he does not have an official diagnosis of autism means that it is harder for him to get one, so Thomas is at severe risk of falling even further behind his peers.

High-quality and appropriate early years education is critical for all children. I am sure that we are all aware of how important those years are in the development and future opportunities of a child, and yet we are in danger of denying that high-quality and appropriate education to Thomas and many children like him.

Thomas struggles in busy, loud environments, and he can lash out as a result. He needs special attention, extra care and that education, health and care plan. He attends a mainstream nursery that has gone beyond what it needs to do for Thomas, ensuring that he has a one-to-one staff member with him at all times. However, that has cost implications for the nursery, and it is not fair on Thomas or the other children. He needs a place in a specialist nursery—again, that takes us back to the education, health and care plan, and the official autism diagnosis. What a vicious circle!

Nichola has to begin applying for schools for Thomas to attend next September, but there is no education, health and care plan—I keep having to say that—so the process will be all the harder. At the moment, he is facing the prospect of mainstream school, which would not be suitable. Thomas is still in nappies and does not have the self-awareness that other children his age have.

I have already mentioned the Daisy Chain Project. It was founded in 2003 and serves as a haven for families across the Tees valley. Nichola speaks highly of the support that they get there. It provides a respite service but, again, without an official diagnosis, Nichola cannot access that support. I worry that young children such as Thomas will be left behind while their peers flourish. I worry that parents do not and will not have the support they need.

Families and education providers up and down the country are doing their best to cope, but they should be able to do so much more than just cope. We need a specific strategy for young people to secure early diagnosis and we need appropriate plans to support them. I hope that the Minister will tell us how we can do so much better.

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[The Parliamentary Under-Secretary of State for Health (Jackie Doyle-Price)]

It is a pleasure to serve under your chairmanship this morning, Mr Howarth. Thank you for giving so many Members the opportunity to speak, because the debate has been extremely valuable. I congratulate the hon. Member for Enfield, Southgate (Bambos Charalambous) on securing it. The discussion was highly informed and showed how important Members consider the issue to be. That is to be celebrated, given the 2009 starting point that my right hon. Friend the Member for Chesham and Amersham (Mrs Gillan) mentioned.

There have been significant advances in the treatment of people with autism, notwithstanding the serious issues raised today. I will not pretend that things are as they should be, because clearly they are not. Our ambition is for people to receive a timely autism diagnosis, but the cases that hon. Members have raised today make it clear that the standards that families deserve, and that they have a right to expect, are not being met. All Members who said that we need to do more are right. I give the House an assurance that I am determined about our need to do better.

I look forward to cross-party work with the all-party parliamentary group, and to the review of where we have reached since the Autism Act 2009. I welcome the input of all Members, because only by understanding the real-life experiences can we make everything work better. In Government we tend to work through such things as targets and processes, which ignore the fact that we are dealing with real people. When we are dealing with people who have conditions such as autism, the processes can leave them behind. It is down to all of us to be the conscience and to ensure that all our public services work better in this field. We do have a sense of urgency on this.

I want to deal with some of the common points that have been raised. Many Members wished to know when the autism data will be published. Our intention is that the data will start to be collected from next April, with a view to publication in 2019. That is hugely important, because it will enable us to see which local areas are doing the job and which are not. There is nothing like transparency to hold people to account and to ensure that we get the consistency and delivery of service so that nobody is left behind.

The Care Quality Commission and Ofsted are currently undertaking a five-year rolling programme of inspections, looking at how things are being implemented in local areas, how health services are working and how education authorities are dealing with education, health and care plans, which were mentioned in earlier contributions. We all know, and have witnessed, that so much is dependent on local leadership. If we can highlight good practice and where things are going well, as well as where things are not, we will be able to generate the pressure to increase performance across the board.

My right hon. Friend the Member for Chesham and Amersham mentioned mortality rates for people with autism. I know that the Minister for Disabled People, Health and Work, my hon. Friend the Member for Portsmouth North (Penny Mordaunt), shares my concern that people with autism and learning disabilities tend to get left behind when it comes to employment and access to health, which has an impact on mortality rates. She and I are very much prioritising that. I look forward to engaging with the all-party parliamentary group on those issues too, because we will have much to learn from its expertise.

The hon. Member for Worsley and Eccles South (Barbara Keeley) specifically asked whether we would commit to including autism in the primary care register. We have said that we expect GPs to do that and that we want to spread that good practice. We will be working with NHS Digital to do exactly that. Again, I am open to any suggestions in that space.

With regard to access to further services following a diagnosis, that is very much the space of local commissioners, but the inspections by the Care Quality Commission will enable us to hold local commissioners to account on exactly that.

[Alex Cunningham]

The Minister knows how frustrated parents are by the delay in getting an official diagnosis, but it is the knock-on effect on other assessments, such as education support plans, that really adds to their burden. Will she give any advice to local authorities and CCGs to look beyond the official diagnosis, to make some of those other things happen?

[Jackie Doyle-Price]

We very much send the message that parents of children with autism are entitled to good services and that is what they should expect. We need to spread that good practice and collect those data, in order to highlight exactly where it is not happening. When we look at the work that the Care Quality Commission has done to highlight good practice, we should be able to get some messages. We are looking for transparency to drive performance and to have those conversations. The NHS mandate for 2017-18 sets a priority for the NHS to reduce health inequalities for autistic people, so that is very much part of NHS England’s conversations with local CCGs.