Tobacco and Vapes Bill (Fourth sitting)

Andrea Leadsom Excerpts

Committee stage
Wednesday 1st May 2024 Public Bill Committees

[Preet Kaur Gill]

Q The Royal College of Physicians has also called for manufacturers to limit the production of toxic substances from vapes and for the Medicines and Healthcare products Regulatory Agency to be required to independently verify the contents of e-cigarettes. That is something I have taken a real interest in—you make a really good point. Whereas the notification scheme for tobacco tests products, the vaping scheme does not. Do you think we need to do more in the Bill to address that?

Professor Agrawal: It is important that we make sure that these products are notified well, and I know that there is a colleague speaking after me today about the MHRA process. Independent verification will be an important thing to do, whether that is part of the Bill or something that comes about as part of the consultation process that the Bill and the regulations will go through.

One thing that is really important is that this Bill passes through this Parliament, so that we stop the 350 young people who take up smoking every day from doing so as soon as we possibly can. We know that two out of three of them will die as a result of smoking. What I do not want to happen is for the Bill to be slowed down in any way by a series of amendments. We need to get this Bill and the law on the statute book. The consultation process should hopefully take care of some of the finer details, which are really important, too.

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

Q Thank you both so much for being here today. As you will know, what witnesses are providing are the words and the arguments to enable the smooth passage of the Bill. Professor Agrawal, you have just said that you want this to go through smoothly, as do all of us here, so what you say is incredibly important.

As physicians and surgeons, what would you not have to do if people were not smoking? Could we say you would be writing yourselves out of a job? What are some of the things that are specifically on your day-to-day list that you think would be removed if people were not smoking?

Tim Mitchell: I referred to the national cancer audits. For example, 37,000 people a year develop lung cancer, many of whom will need surgery. On the survival rate for lung cancer, fewer than 50% of people survive one year. There is a whole range of other cancers related to smoking, so the burden of that disease and the burden on the health service would reduce dramatically if we had a smoke-free society. I have alluded to other forms of surgery that are required—amputations and so forth. So the impact on society at large would be huge if we had a smoke-free society. In terms of other surgery, the complications would be avoided.

I know very much from my own personal experience how important this is. My mother died from lung cancer caused by smoking when I was seven years of age. My grandfather died from mouth cancer caused by pipe smoking when I was eight years of age. If we had a smoke-free society and there was one small boy or girl who grew up knowing and being loved by their mother or their grandfather, that would be very powerful.

However, that pales into insignificance compared with the impact that the Bill could have on society at large. Millions of people’s health would be improved. The impact on millions of families would be dramatically improved and the health of the nation would be significantly greater. We as a college fully support the Bill and, as my colleague said, we very much hope that it will pass through smoothly and get on to the statute book.

Professor Agrawal: Just to add to that, for my clinical practice in the intensive care unit, I see people with life-changing illnesses, whether that is ruptured aneurysms, heart attacks, kidney failure, the need for mechanical ventilation in people who have severe lung infections or chronic obstructive pulmonary disease exacerbations. There is also my lung cancer clinic—really, the list goes on.

One of the other things that I am often struck by in our multidisciplinary meetings where we look at things like CT scans of people who have smoked all their lives—through no free choice, by the way, because they have become addicted to tobacco through means of the tobacco industry encouraging young people to take up smoking—is that they have multi-morbidity. So as well as having lung cancer, they may have a kidney cancer, they may have heart disease, as well as COPD. If they have one of those things, we can manage that, but unfortunately, the combination makes people multi-morbid and frail, and it impacts their ability to have treatment for the most serious of those conditions.

By eliminating smoking and creating a smoke-free generation, we will transform aspects of our medical care and our NHS. We heard this morning that there is a person admitted every minute to hospital with smoking-related disease, and there are 100 people seen by GPs every hour with tobacco-related disease. So I think we can alleviate all that extra pressure on the NHS from tobacco addiction and use those resources differently.

[Dame Andrea Leadsom]

Q Thank you both. You have alluded to the fact that this is not a choice, but an addiction. Can you explain how that impacts on your patients? What do they say when you tell them, “I’m sorry, you are going to die.” How do they respond? Do they feel, “This was my choice and therefore it is great for me”?

Professor Agrawal: This is awful. One of the things I am struck by in my lung cancer clinic is that at least a third of the people we look after are still smoking despite the diagnosis of lung cancer, because they have no free choice and are addicted. They became addicted as young children. I know there are other panellists that you will hear from later on who may talk about the business model of the tobacco companies, but the sad reality of their business model is that two out of three people will die from smoking-related disease, and to maintain their profits they need to replace those smokers. They do that with young people. That is what we need to stop so that it is not just a production line for corporate profit.

[Dame Andrea Leadsom]

Q Mr Mitchell, what do patients say to you when you tell them, “I am very sorry, but you’re going to die”?

Tim Mitchell: Very often, when I see patients who smoke, I encourage them to stop smoking. A very large proportion say, “I would love to stop smoking. I have tried previously.” They might have been successful for a period of time. Many of them simply regret the fact that they ever started smoking in the first place. If we can stop them getting on to that ladder in the first place, one does not have that problem. Stopping smoking, as I think we are all aware, is an incredibly difficult thing to do. That is where I see vapes as certainly having a useful role in smoking cessation, but trying to stop people smoking in the first place is absolutely key.

[Dame Andrea Leadsom]

Q Could I ask you both to agree that it is therefore not a matter of free choice? This is an addiction that removes people’s choice; would you both be willing to agree with that?

Professor Agrawal: I think it is a lethal addiction.

Tim Mitchell: Undoubtedly, I would agree with that.

[Kirsten Oswald (East Renfrewshire) (SNP)]

Q I know that the Royal College of Physicians has called for regulation to protect young people from vaping. I thought that what Professor Agrawal said about the importance of helping people to stop smoking was very interesting. At the same time, that balance is really important.

I am interested, however, in the harms of vaping to those who have never smoked, particularly young people, and the challenges we have heard about with them being advertised to in various ways, including on sports kits and in online spaces. What are your thoughts on how we best deal with that?

Professor Agrawal: I agree that it is awful and that we need to restrict it. The tobacco industry has a playbook on how it attracts young people to smoking, and it is not dissimilar to vaping. Billboards, influencers on social media, brightly coloured, garish packaging and the names of flavours are all used to appeal to young people. The provisions in the Bill will provide the powers to restrict that. That is really important and is exactly what we should be doing.

There is also the influence of social media, and we should not forget that. Whether this Bill will deal with that or whether it will be some secondary legislation that does that, that is fine, but we certainly need to curb the impact of social media and other influences on young people starting to take up vaping.

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[Rachael Maskell]

About prescribing.

Professor Agrawal: Prescription, yes. That might be a helpful adjunct, inasmuch as it would give healthcare professionals safety in the knowledge that a product has been tried and tested and could be prescribed. If they were unsure about e-cigarettes and which to recommend to patients, having a prescribable e-cigarette could be helpful.

The only downside is that, as I am sure the Committee knows, the e-cigarette market changes at lightning speed. What is licensed one day, the very next day would not attract anybody, or nobody would want to use it. That is the only con, as it were. It certainly might have a role in helping medical professionals prescribe and have confidence in using a product that has been deemed to be safe.

[Dame Andrea Leadsom]

Q Further to that, I would like to probe a bit on that, because it has been put forward that some colleagues would prefer prescription-only vapes. However, from speaking to vapers myself and having done some visits to meet with enforcement officers and so on, it seems that users of vapes like the variety. They say, “I don’t want to vape tobacco flavour; I want to vape strawberry flavour.” There is another side to this argument, which is that you should keep different flavours in order to avoid people who are smokers going back to smoking because they are not getting enough choice. You just said that it would be good to have prescription-only vapes, but would that not fly in the face of how people use them? That is why that is not in the Bill at the moment. I do not want to set hares running where, in fact, the practical reason for not saying that vapes should be prescription-only is exactly that of consumer choice and trying to avoid people going back to smoking.

Professor Agrawal: Maybe I was not clear. I do not think that we should have just prescription-only vapes. It would be an adjunct to all the other vapes out there to give that choice to people who want to use vapes to quit and access all those flavours and different types of vapes. There are several different types of vapes as well as the flavours and so on, and that choice has driven people who smoked to use them to help them to quit. They can do it themselves, they have the hand-to-mouth movement—a whole combination of things attracts them to vapes to help them to quit smoking. Having only one product would be a disaster.

[Dame Andrea Leadsom]

Q The chief medical officer said earlier that he would encourage the vaping sector to perhaps try for registration for a particular vape for prescription. Nobody has done that as yet, because it is a complete free-for-all out there. We are all really keen to see better, safer products and help adult quitters to quit. The CMO said that they could be prescription-only for people who are both in poverty and deprivation and trying to quit smoking, but not to in effect prescribe in a Bill such as this, “You shall now have only prescription vapes.” Would you agree with the CMO?

Professor Agrawal: I completely agree with that. I completely agree with what the CMO said.

[Dr Johnson]

Q In order to be a prescribable drug, an e-cigarette or vape would need to go through an awful lot of testing to demonstrate its effectiveness in what it does, the safety of its components and the safety of the product as a whole. Are you aware of any vape that has gone through the safety testing to demonstrate that it is safe in that way that can currently be prescribed?

Professor Agrawal: I think a colleague from the MHRA is on after me who might be able to answer. I believe there are products that industry has taken to the MHRA and got to the point of licensing, but it has not marketed them or wanted to take them further. I do not think that it is impossible. In fact, as the CMO said this morning, I think manufacturers should be encouraged to go through that process.

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[Preet Kaur Gill]

Q Nicotine, whether by smoking or vapes.

Mark Rowland: The commitments that were made in relation to the long-term NHS plan—the five-year forward view for mental health—were really important, but our NHS colleagues say that they are not well-funded. We are roughly £10 million to £20 million short of completing the opt-in in mental health settings. It is currently an opt-out, and that has been hugely successful. About nine in 10 inpatient services are now adopting the smoking cessation offer, but you are right to say that it has not extended anywhere near far enough in terms of community settings.

Community mental health services, for example, have only had a pilot for smoking cessation. It is on an opt-out as well, but there are only seven pilot sites. It is relatively cheap; £10 million to £20 million could expand community smoking cessation to mental health services and integrate it within that. That would be a really smart thing to do.

We can also see that most people who experience distress, depression or anxiety will go through talking therapies. There is a really big opportunity there—my wife is a therapist—but there is no standard mechanism for therapists to check smoking status as they are coming forward to help. One of the things on which we have really accrued evidence, through Cochrane and systematic reviews, is the mental health benefits of stopping smoking. We think there is much more that could be done at those access points, such as talking therapies. Why not think about a holistic approach to stopping smoking alongside the psychological talking therapies assistance that is being offered to about 1.6 million people? There is more to do.

In relation to young people, I think that could be added to that component in child and adolescent mental health services as well to understanding. Let us have a whole picture of what our young people are facing, because we know that the causes of mental ill health are often multi-varied, so we need to understand what the causes are and also what the coping mechanisms are. One of the reasons we are so passionate about this Bill is that what smoking does is provide an out for young people and adults to be able to really look at the emotional distress that they are experiencing and manage those difficult emotions in a healthy, life-affirming way, so there is much more to do.

[Dame Andrea Leadsom]

Q Thank you so much for being here this afternoon. It is incredibly helpful. Can I ask you the chicken-and-egg question? Does smoking make you depressed, does depression cause you to smoke or is it both? I think you are possibly saying both.

Mark Rowland: I think five or 10 years ago we would probably have said that it is more likely that, if you are depressed or anxious, you will reach for a cigarette to appease the emotional distress in the short term. The work from academics at the University of Bristol has found that there are now good population studies looking at the impact of smoking leading to a first instance of mental health problems and the fact that there is a causal relationship between smoking and mental health. We are already facing, as this Committee will be aware, a mental health crisis in this country, and 23% of the health burden is a result of mental ill health—one in four in any year, one in six in any week. The efforts to reduce smoking will, we think, have both an impact in reducing prevalence and in reducing acuity of mental ill health.

On the chicken and the egg, it is difficult to disaggregate exactly for many people, but we know that both are a real issue. We talk about this cycle of smoking increasing the risk of poor mental health and poor mental health increasing the chances of smoking and the number of cigarettes someone smokes. People with mental health problems smoke far more, and that addiction then exacerbates psychiatric symptoms. Those psychiatric symptoms also then lead to increased poverty and increased chances of being unemployed, and that leads to poorer mental health. It is a complex picture, but we are really starting to see the causal drivers of mental ill health.

I will finish by saying that this Government should be applauded for introducing this progressive, bold and far-sighted piece of legislation. We have called for a long time for a cross-Government approach to mental health, and we would have been calling for exactly this type of legislation in that approach to give young people—give us all—a fighting chance for better mental health, so that we can reap all those benefits.

[Dame Andrea Leadsom]

Q We have seen that the number of 11 to 17-year-olds vaping has trebled in the last three years, which is terrifying. We have also seen the mental health of young people fall off a cliff. A lot of people would argue that that is to do with social media and the act of scrolling and what that does to the brain and so on, but would you say that smoking is another factor that should be taken into the mix of what is happening to young people’s mental health, or would you say that it is not proven yet?

Mark Rowland: Are you asking whether increased smoking and vaping is a driver of young people’s mental ill health?

[Dame Andrea Leadsom]

Very specifically the increase in children vaping, which is nicotine as well. It is the same addiction.

Mark Rowland: The causes of the deterioration of young people’s mental health are really complex. There are a number of different factors, and it is difficult to disaggregate them all. There is social media and what we call the social evaluative threat, which emerges from being in a context where you are able to see how you are doing in life against everyone else in the world. It is the first time we have had that in human history, so no doubt we need greater protections in the use of social media for young people.

In terms of the evidence of vaping and young people’s mental health, we have not seen a causal relationship between vaping and poorer mental health. We know that all addiction is bad for all of us, especially young people. We did a Delphi study a couple of years ago looking at the most important protective factors for people’s mental health, and No. 1 was, “Don’t become addicted to drugs.” That had the most deleterious impact. It is not going to help if more young people are addicted to nicotine, for absolute sure. It comes back to the original point that we need to equip our young people with skills to be able to manage difficult emotions and not look for the quick dopamine hit that nicotine provides. So it is not helping, but is it the major driver of children’s mental ill health? We do not have the evidence to be able to point to that right now.

[Kirsten Oswald]

Q I am interested in the exchange that has just taken place. You have said that all addiction is bad for us, which makes sense to me. We heard evidence yesterday about the impact of young people vaping in schools. Some of that impact is the disruption to education and the challenge for young people if they a need to go out of the classroom to vape because the pull of the addiction is so strong. I wonder what your thoughts are on the mental health impact of the addiction in the education setting. I would also welcome your thoughts on the connections with sports; I am particularly interested in sports organisations advertising vapes, which I think is a poor choice. I think sport should have a positive impact on the mental health of young people, but I am not sure that connects properly when these vapes are being advertised.

Mark Rowland: I really support the Bill’s efforts to regulate and protect young people from ever engaging in vaping. As you say, it is about the unintended consequences. We are not quite clear on the mental health consequences of vaping for young people. We know that young people who have lower levels of mental wellbeing are more likely to vape. We know that the targeting of young people drives them into addictive behaviour, so we need to protect young people from that. We need a regulatory environment that does not allow young people to be exposed to advertising that is particularly targeted at them. I would support such a measure.

I think the unintended consequence of children missing out on education due to vaping cannot be underestimated. We also have an issue around the mental health of young people who are not attending school—the school rejectors. We need to bring them into an education environment in which we can see what that young person needs and what the consequences for their mental health have been from not being in school. I would rather kids were in school and that that educational setting was protected for them.

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[Preet Kaur Gill]

Q Does that mean that you communicate with every trading standards department in the country and get them to go out and remove the product? Is that how it is done?

Dr Squire: That depends on where it starts. They get their own intelligence as well, so they would lead on enforcement operations. That is their role, not ours, within the UK tobacco products regulations. They do that and they ask for our help to support them, and we will give them intelligence when we do that.

[Dame Andrea Leadsom]

Q Thank you very much for being here this afternoon. Can you talk us through the work you do with some vape companies in order to take non-compliant vapes off the market?

Dr Squire: The work that is done with vape companies to take products off the market would be done by trading standards.

[Dame Andrea Leadsom]

Q So you do not work directly with vape companies?

Dr Squire: We do not have the powers, no. Our work with vape companies would be from the perspective of their wanting to get a product licensed as a medical product. We would have discussions with them on that, as we would with anybody else who is bringing a medical product to the market for licensing, but we do not have a role in enforcement or in withdrawing products from the market. If we were to identify a safety concern, there would be a collaboration with trading standards to get the products off the market.

[Dame Andrea Leadsom]

Q I think there is still some slight confusion among colleagues about the exact relationship between the MHRA and trading standards vis-à-vis the huge rise in illicit vapes. Could you have another go at explaining it from start to finish? You get a—well, you do not get a request through if it is an illicit vape, presumably.

Dr Squire: No, if it was an illicit vape, they would not put it on our list. We might work with them if they found a product that had a problem with it—often products are under different brand names but they are the same product—and our notification system would help to understand what products are affected by that. We do not have any powers to do enforcement activity. That is not a power given to us under the tobacco products rules at the moment; it is just a notification scheme. It was never designed as an enforcement tool; it was designed really as a single version of the truth of what is out there. That then enables enforcement because it is information, but we are not the enforcing authority; trading standards are.

[Dame Andrea Leadsom]

Q Thank you—that is clear. Can you also explain the process? You said that you published some guidance for vape companies that want to produce a prescription-only type of vape. You said that one was produced, but then was not marketed in England. Do you know why that is, and whether that might change in the future?

Dr Squire: I do not know why that is, but I products agree with what was said earlier: those products move and develop very fast. The requirements to obtain a medicines licence under the Human Medicines Regulations 2012 go a long way beyond those to produce a consumer vape. You have to produce evidence of the quality of the product; we also look at the quality of manufacturer, and have requirements around that.

In terms of efficacy, while nicotine is a well understood substance, so there are some things that producers do not have to do, we still need to ensure that the product works in the way we would expect equivalent products to work. We have clinical assessors and quality assessors, and we think about manufacturing as well. To get a product licence, producers have to put together a dossier of all that evidence. Putting together that dossier is both costly and time consuming, because they have to demonstrate that the risks of the product are outweighed by the benefits. The dossier will also describe what we call the indication—that is, how they expect the product to be used. It would be licensed only for a particular use, which would be smoking cessation. Producers would have to go through all that in order to get the product on to the market.

It is difficult to say how the Bill would affect that. When you have two systems, one of which is an awful lot easier than the other, I can see why there was a commercial attractiveness to going down the consumer route, but I think that anything that introduces more controls over consumer vapes has to be a good thing.

[Dame Andrea Leadsom]

Q Would it be reasonable for those of us who are suspicious about, for example, the marketing of vapes to children to suspect that the reason we do not see vape companies coming forward to try to license a medicinal prescription vape is that the products and the manufacturing processes are not good enough, and it would be very hard to meet the bar for a medicinal product, or would that be unfair?

Dr Squire: I would be speculating if I said that. It takes time and money to collate the dossier to prove the products’ quality. The products are not necessarily worse, but they have to go through quite a process to prove it, so I think it is that, rather than anything else.

[Rachael Maskell]

Q I have just one question, which is a particular concern of mine. Vapes are a delivery product for a liquid. I am concerned about the illicit market, which is now utilising vapes for Spice, cannabis and a new generation of synthetics as well. Is there work going on to produce testing kits, so that the liquid can be tested? I understand that testing kits would have to go through a regulatory process with you as well. If not, why not? Surely we need to get ahead of the curve in keeping people safe from a new generation of illicit drugs.

Dr Squire: I think that would probably be under the consumer products regulations. If it was testing the actual product, that is not something that the MHRA would do as it is not a medical product. What we test is medical products and whether they are safe, effective and made to the right quality, but testing part of the device—

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[Preet Kaur Gill]

Q We heard yesterday that with tobacco, you have track and trace. Do you foresee that if we had a track and trace system for vapes, it should largely address some of this?

Mr Lawson: My personal opinion is that if the current regulations were enforced thoroughly, most of the issues we see today would not be a problem. If we go back two or three years, I would say that almost all products on the market would be compliant. We did not see large tanks or these characteristic products that are now illegal. If the Tobacco and Related Products Regulations 2016, which are the current UK regulations, were implemented or enforced properly, we would see a huge reduction in youth use, because those products that appeal to the youth would not be on the market.

[Dame Andrea Leadsom]

Q Thank you very much for coming today. Would you support an excise duty on vapes?

Mr Lawson: I am not sure that that is an appropriate question for me. I am a scientist, rather than a policymaker.

[Dame Andrea Leadsom]

Q But in terms of behaviour, you have been talking about the targeting of children and so on, so I am asking you for your opinion. Are you also employed by the vaping industry?

Mr Lawson: No. I work in pharmaceuticals and medical devices. The issue around excise duty is that the illegal products that we see youth buy are actually a lot more expensive than legal products. You might buy a legal product for £5 or £6, and an illegal product is probably £10 or £15. The cost does not seem to be a deterrent; larger products with these characterising flavours are what they are looking for. I think you may penalise adult smokers switching more than you would benefit children by preventing them from using products, if you applied a tax on vaping.

[Dame Andrea Leadsom]

Q Okay, but obviously an excise duty then enables more enforcement and the track and trace scheme to which the hon. Member for Birmingham, Edgbaston referred to come into play for vapes, which could then mean better knowledge of which are legal and which are illicit. Would that be true?

Mr Lawson: I guess the source of funding is a separate question, but if there was enforcement of the current regulations there would be a lot of revenue generated from the enforcement and penalties under the current regulations, which may fund track and trace or other policies.

[Mary Kelly Foy]

Q To follow on from Andrea, most of the experts we have heard from to date have been from the NHS or the medical profession—people with skin in the game and promoting good health and tobacco cessation. Who funds you to do your work?

Mr Lawson: We are self-funded. We work with trading standards, so they fund part of our work. We work with the industry ensuring products are compliant. My other company develops medical products for quitting smoking and vaping. We straddle both sides—the tobacco side and the medical side.

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[Preet Kaur Gill]

That is great—thank you.

[Dame Andrea Leadsom]

Q Thank you all very much for being here today. Are any of you able to talk through the economics of the smoking industry, the vaping industry and, in particular, the illicit vaping industry? Do any of you have information on that?

Dr Branston: I can speak to at least some of your questions, so thank you for them. I think the starting point for understanding the tobacco industry is to understand that it is incredibly profitable. It is profitable like almost no other industry that we currently face. Not only are those profits large in total—I can tell you the world’s six largest cigarette manufacturers made profits totalling about $55 billion in the most recent year that I was able to track, which was 2018—but they make large profits in the UK. I last estimated that for 2022, and it was about £900 million annually. Equally, they make a large amount of profit for each unit sold. Their profit margins are in the region of 70%, meaning that for every £100 they get to keep, having paid all excise duty, £70 of that is just pure profit. The actions of the industry are entirely guided by wanting to maintain and expand those profits going forward.

The interesting facet is that big tobacco currently does not make much, if any, profit on its new-generation products, which include e-cigarettes and other products, such as heated tobacco products. The vested interest of big tobacco is to maintain the status quo. The issue of profitability in e-cigarettes is more difficult to talk about for the private companies because many of them are based in China and do not publish their accounts, so it is difficult to tell how much, if any, profit they are making. Ultimately, companies cannot continue in existence if they are losing money, so it is a reasonable presumption that they are making some levels of profit, because they want to continue selling these products. Hopefully that gives you some background.

[Dame Andrea Leadsom]

Q That is helpful. Do you have any information—a guestimate—of what the illicit vape industry is worth?

Dr Branston: I would not like to speculate on that because, as we heard earlier today, the illicit sector has increased significantly in the past two years. It is difficult to work out what is licit and what is illicit, so I think it would be inappropriate to speculate. Given the number being sold, however, it would be reasonable to think that a significant amount of money is being made by those illicit products.

[Dame Andrea Leadsom]

Q We have seen youth vaping treble between the ages of 11 and 17 in just the last three years. It has already been mentioned that the vaping and tobacco industry seeks to prevaricate and keep hold of its young customers in a number of ways. Can you tell us some of the ways in which it will argue during the passage of the Bill? Do not forget that we are trying to get you on record today giving us some answers that we can then put to colleagues who challenge us because the sector has given them some lines to take. What should we be looking out for, and what should we be saying to our colleagues?

Dr Branston: I am fairly sure that the first thing it will say is that this is a charter for the illicit market and will lead to a big explosion in the rate of illicit tobacco in particular. I know that the industry always trots out that line whenever a tax increase, or any other regulation, is suggested. However, the facts simply do not support that line of argument. When the age of sale was increased from 16 to 18 in 2007, the rate of illicit actually went down in 2007-08. Illicit tobacco is driven by a whole host of reasons. It is very complicated, but ultimately it is an issue of enforcement, as we heard before. We need to ensure that we have the rules in place to make sure that products on the market comply with the law and all the regulations therein. I do not feel that illicit is a particular concern at this stage.

The idea of the generational ban is that it will only increase by one year every year. We are not going to suddenly outlaw a habit that millions of people currently have. It is something that many young people will be unable to do going forward, but they are not currently smokers, so we do not have to worry about all those people wanting to buy these products. The fact that they are banned will go a long way towards addressing the issue in and of itself.

The new excise duty due to come in on e-liquid will go a long way to addressing some of the concerns on illicit vapes. Having the products within the excise system means that more enforcement powers will be available, which will in itself help to reduce the rate of illicit. We can be reasonably confident that there will not be a big wave of illicit products in the future.

[Dame Andrea Leadsom]

Q Professor Ford, do you want to add anything on what we should be looking out for?

Professor Ford: I think Professor Gilmore is the expert on tobacco industry strategies.

Professor Gilmore: I am happy to speak on that if it helps. The model that we developed to understand how the industry argues about policy is called the policy dystopia model, because the industry will argue for a whole host of dystopian outcomes: “The regulation will not work”; “There is no evidence”; weirdly, “It will increase youth smoking”; “It will increase illicit”, as Dr Branston has said.

The other key thing the industry will always claim is that it will be bad for business, but it will never admit that it will be bad for its own business, which is obviously its key concern. It is always trying to claim that the negative impacts will be on others, such as retailers. We are seeing those arguments now: “It is impractical”; “It is untested”; “It will be impossible to enforce”—that is the other favourite argument; “It reduces freedoms”.

Those are the typical industry arguments. It might present them quietly itself, but it acts directly less and less—increasingly, it acts through the third parties I flagged. I would be careful of all those arguments, and of approaches from people who might seem credible but, very often, have industry links behind them or are meeting with industry and simply believing those arguments without question. Generally, the arguments have some plausibility, but they have never materialised with any previous policy. They simply have not come true.

On illicit cigarettes, it is worth remembering that the tobacco industry has a very long history of orchestrating the smuggling of its own products on a vast scale, which is well documented through its own documents, which it had to release through litigation. That may sound counter-intuitive, but the more expensive the product, the less is sold; the cheaper the product, the more is sold. If the product is illicit and the excise duties on it are not paid, it sells more cheaply and more is sold. That also enables the industry to make the illicit argument: if there are illicit products on the market, it makes the illicit argument stronger.

It is also worth noting that the last time we looked at rates of illicit and published on that, the biggest share of the illicit cigarette market in the UK was the tobacco industry’s own products. At best, that means that it is failing to control its supply chain. It makes a big song and dance about counterfeit and illicit whites, but there remains a problem with the tobacco industry’s own products ending up in the illicit market. That is really important to bear in mind.

[Kirsten Oswald]

Q I have a question for Professor Ford. Can you describe for us how the packaging of vapes attracts young people to purchase them, and how the visuals advertising vaping that young people might see on social media or sports kits, for instance, might attract them and influence their desire to purchase them?

Professor Ford: Packaging in the UK just now is doing two things: first, it is communicating a message to young people, and secondly it is having a huge impact in the retail setting. I will deal with those separately.

First, we recently conducted a pack analysis of a representative sample of vape packaging that was legally available for purchase in the UK. We found that 85% of those packs are really brightly coloured. A proportion of them have a childish cartoon font on the pack, and the language and terminology on a proportion of the packs utilised youth language and slang, so it is tapping into something that young people could be receptive to.

There is also an issue with how the nicotine content is displayed on the front of the pack. There is no consistency. Some of the packs say that the nicotine content is 2%. We know from our qualitative work that young people misinterpret that as a low percentage, but it is actually the maximum legally allowable amount in the UK. All of that together is communicating to young people that this product is for them; in our qualitative work, that is what they have told us that they believe. We have also spoken to adult smokers, and they also believe that a lot of this colourful packaging is targeting young people. At the moment, there is a mismatch between what we would ideally like vape packaging to do—we want it to speak to adult smokers—and what it is doing. It is not speaking to adult smokers; it is communicating to young people.

The second part is the impact of the packs in the retail setting. I am sure you have noticed that in the retail setting—within the store, but also in the shop front—the display made up of brightly coloured packs is vast. We did a youth tobacco policy survey in 2020 and followed that up with the youth e-cigarettes policy survey last year, in July 2023. We are finding an increased awareness of vape displays in shops among 11 to 16-year-olds across the UK, from 40% up to 68%. That is a substantial increase.

We asked those 11 to 16-year-olds last year what they think about these displays in the retail setting. Some 58% think they are colourful, 36% think they are attractive, 36% think they are eye-catching and nearly a quarter think they are attractive. That shows not only how the display feeds into the appeal but, perhaps even more importantly, how it feeds into the social norm around this product and this behaviour. To give you just a couple of other statistics, nearly a third of our sample reported that displays make them think it is okay to vape, and 64% reported that vape displays make them think that a lot of people vape, so they are really feeding into this social norm. Thankfully, the Bill covers those aspects of promotion.

There has also been an increase in young people reporting seeing vapes and vaping imagery on social media: 25% of 11 to 16-year-olds reported that in 2020, and 41% reported it last year. On your final point about sponsorships, we are seeing quite a lot of sports-associated imagery with nicotine pouches. I know that nicotine pouches should be included in the Bill, because that is another nicotine product. We are starting to see the terminology, awareness and imagery of nicotine pouches take off among young people. This is concerning, and it is one to watch. The imagery is of it being a hit or a boost that helps you to focus. There is a big association with professional footballers; we definitely saw a gender difference in terms of the males picking up on that. For nicotine pouches, there is also sponsorship on Formula 1.

--- Later in debate ---

[Preet Kaur Gill]

Q Ann, do the measures in the Bill equitably benefit all people affected by tobacco and vaping products?

Professor McNeill: As I mentioned in my opening comments, the people affected by the Bill will be people who are vaping and/or smoking, people who might take them up, and people around them. It will certainly drag down smoking uptake. My main issue is around encouraging people who smoke to stop, given that more people from disadvantaged groups smoke. As long as we maintain the focus on smoking with the Bill and provide support for smokers to stop—that includes vapes, which are effective tools—then yes, it can drive down the health inequalities caused by smoking.

[Dame Andrea Leadsom]

Q Thank you both very much for being here. As I have said to other health professionals, what you say can be incredibly helpful in allowing the Bill to pass through smoothly, because people make some very big challenges, namely that this is all just about freedom of choice, vaping is fine and there is nothing wrong with it. With that in mind, I would be grateful if you could try to ensure that you give us material with which to address some of those challenges.

Professor McNeill, we heard earlier that there is no evidence on what happens to a baby born addicted to nicotine or what the impacts are for that baby. I was advised that you might have a view on that.

Professor McNeill: We can certainly ensure that we provide written evidence afterwards. The more concerning issue is some of the other constituents that go through to the foetus, such as carbon monoxide, which can have a devastating effect on the baby. On vaping in relation to pregnancy, we have seen in research that when people have used vaping, it is an effective tool for stopping smoking, which is really important, and it does not have any more adverse effects than nicotine-replacement therapies. My concern would be about smoke constituents more than nicotine addiction, which is highly unlikely if nicotine is used during pregnancy. I hope that makes sense.

[Dame Andrea Leadsom]

Q To push back slightly, we know that babies are born addicted to crack cocaine or heroin. Does nicotine pass through as an addiction for the newborn baby in the same way?

Professor McNeill: I do not have the evidence for that.

Professor West: There are a lot of misconceptions about what addiction is and how it operates. We need to distinguish some of it from what we might consider to be physical addiction, which is a physiological adaptation —for example, with a baby born to a mother who has been drinking heavily, that baby’s physiology will have got used to alcohol, and there will be things like foetal alcohol syndrome and so on. There are those physiological adaptations.

In the case of nicotine, as far as we can tell from the studies of people who have used nicotine replacement therapy, such as e-cigarettes or, in other countries, things like snus—a form of smokeless tobacco with pretty high nicotine levels—we do not really see evidence of that sort of syndrome. In fact, those kinds of physical withdrawal symptoms that we see with alcohol—potentially fatal—and with heroin and so on, are more often a feature of sedative or opiate-type drugs than of stimulant drugs and are not so much a feature of nicotine.

The addiction to nicotine some people think of as psychological, but it is not really psychological; it is the impact of nicotine on our motivational system, which causes people to feel an impulse for whatever it was they were doing when they got that nicotine in the system. It forges an association in the brain. What that means is that the craving for nicotine is the thing that is driving the behaviour, rather than the need to escape the withdrawal symptoms.

That means that, for example, even non-daily smokers —in the UK, that figure has gone up quite a bit, with about 25% of smokers being non-daily—find it very hard to stop smoking. That would be odd if it were just a physiological adaptation. The craving is the big issue there. In terms of damage to the foetus from nicotine per se, the trials that have been done have not shown the kind of serious damage that we would be worried about.

[Dame Andrea Leadsom]

Q So it is other damage from smoking that is caused to newborn babies. For the record, it is important to say, in answer to those who say smoking is about freedom of choice, that a newborn baby does not choose to be impacted, or killed indeed—stillborn. What thoughts do you have about that argument of freedom of choice versus freedom of addiction?

Professor West: I think it is nonsense. One can get philosophical, so let us not do that, but the issue is that a choice is something that you make in situations where the forces operating on you are not so compelling that you end up going down a particular road. In a way, if someone puts a gun to my head and says, “You can choose to do this, but if you do it, I will shoot you,” that is not really freedom of choice, although in a way it is. What addiction does is to limit your freedom of choice. If you market a product that causes people to be addicted, the only people who really have the choice in the matter are the people who use the product for the very first time and the companies that are marketing the product. Once you have a level of addiction, that level of choice becomes constrained. That is my view.

[Dame Andrea Leadsom]

Q Thank you; that is very helpful. Professor McNeill, may I ask you again about the vape flavours? The Bill takes powers to restrict packaging, location in store, and flavours. I would like to get your views on the record. Some say, “Let’s choose and put the actual flavours on the face of the Bill,” while other medics say, “No, you can’t do that, because you will never stay ahead of the vape industry.” What would your view be?

Professor McNeill: My view would be that it is quite a complex issue. As I have said, there are dangers of unintended consequences by removing flavours. Certain research that I have been involved in has shown that the flavours were important in people transitioning out of cigarette smoking, so I think one has to be quite careful about doing it. We also know that it is very difficult to characterise flavours, and that has happened with tobacco cigarettes. That is something for the secondary regulations, where it can be properly thought through. However, I think that removing flavoured descriptors from cigarette packs—as I think Dr Ford said in the last session—would be a really important measure. Our group at King’s has done some work showing that that would have an impact in reducing interest in young people, while being unlikely—we think—to affect adult smokers.

[Dr Johnson]

Q I want to ask about this tension that you have kept coming back to throughout the past couple of days. Particularly on flavours, it is the idea that we need to help grown-ups who may have made the choice, have the conviction, and have some purpose to quit—bearing in mind that we know the average person takes 30 times in total to quit, so they are likely to relapse at some point—versus the need to prevent children from starting to vape. We know, and we have heard today and yesterday, that they are particularly vulnerable to addiction in their mid-teens, and that those who develop addiction to nicotine in their mid-teens—whether that be vaping or smoking—are highly likely to get their choice removed, because they will be unable to stop it. We also heard that some of those who vape will then go on to smoke. If the Government are to choose, and it may be that we have to make a choice in this matter, do you think it is more important to prevent relapse to smoking in adult smokers, or to protect children from starting on a lifetime of nicotine addiction?

Professor McNeill: I don’t think it has to be a choice of one or the other; you can do both. It is a difficult balancing act to achieve, but it is important to do so. It is not about just avoiding relapse to smoking among adult vapers; it is about the 6.7 million smokers who we need to support to stop smoking quickly. They are in disadvantaged groups, and we know that children will also emulate what their parents do, so it is cyclical in disadvantaged communities. I don’t think it has to be a choice. It is a delicate balancing act that we have to get right, and this Bill is trying to do that. I want to pick up on one comment—you implied that vaping is a gateway to smoking.