Health and Care Bill

Baroness Finlay of Llandaff Excerpts

Committee stage
Friday 4th February 2022 Lords Chamber

Moved by

[Baroness Finlay of Llandaff]

244: Clause 144, page 123, line 39, at end insert—
“(2) The Secretary of State must, no later than one year after this Act is passed, consult on including alcoholic products in the definition of less healthy products for which advertising will be restricted, and publish a report on the consultation.”Member’s explanatory statement
This amendment would require the Secretary of State to consult on including alcohol in the proposed advertising restrictions for less healthy food and drink and publish a report.

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[Baroness Finlay of Llandaff (CB)]

My Lords, this is a very broad group. As part of the Government’s obesity strategy, Clause 144 and Schedule 17 introduce advertising restrictions on less healthy food and drink, a 9 pm watershed for TV and on-demand services and the prohibition of paid-for advertising online. I declare my interest as chair of the Commission on Alcohol Harm. I will speak only to my amendment, which addresses the problem that currently, the definition of “less healthy food and drink” does not include alcohol beverages as it was drawn from the 2001 Nutrient Profiling Technical Guidance.

The amendment requires the Government to consult on including alcohol in the proposed advertising restrictions, because alcohol is the leading cause of death and ill-health among 15 to 49-year-olds in England. Under the Bill, adverts for sugary soft drinks will be restricted but adverts for alcoholic drinks will not, even though they can be very obesogenic. To quote from the Government’s own obesity strategy, they recognise that

“alcohol is highly calorific … It has been estimated that for those that drink alcohol it accounts for nearly 10% of the calories they consume … each year around 3.4 million adults consume an additional day’s worth of calories each week from alcohol, that is nearly an additional 2 months of food each year.”

The calorie load of 100 millilitres of 40% spirit is 244 calories, compared to just 42 calories in 100 millilitres of coke. A pint of beer has the same calories as a Mars bar and a glass of wine equates to three Jaffa cakes.

Some sweet alcohol products contain more than 100% of the daily recommended sugar intake in a single serving. There is significant evidence that children exposed to alcohol marketing drink more and drink earlier than they otherwise would, and early-age drinking is linked to higher risk drinking and even alcohol dependence in adolescence and early adulthood.

Existing advertising codes are failing. In the past month more than 80% of 11 to 14 year-olds have seen alcohol advertising. Almost 60% of 11 to 17 year-olds had seen alcohol adverts on television and more than 40% saw alcohol adverts on social media platforms. One-fifth had interacted with alcohol marketing online in the past month, despite being underage and therefore not allowed to buy alcohol. These adverts achieve their aim. Children as young as 11 can identify, reference and describe brands and logos of various alcohol companies—which leads them to start drinking more and earlier—making these images most attractive. Ten to 15 year-olds are exposed to more TV alcohol marketing than adults.

Alcohol itself is linked to more than 200 diseases and conditions, including seven cancers, is obesogenic and should be classified as a less healthy product. It should be included in the advertising restriction codes proposed, because the current self-regulatory codes are clearly failing. Children would accept this. The Children’s Parliament investigators and the Young Scot health panel have recommended a TV watershed for alcohol advertising. I beg to move.

[The Deputy Chairman of Committees (Baroness Garden of Frognal) (LD)]

The noble Lord, Lord Howarth of Newport, should be taking part remotely. If the noble Lord is there, would he like to speak? We will continue with the debate and when we can get hold of him, we will bring him in.

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[Lord Lansley (Con)]

My Lords, I am pleased to follow my noble friend Lord Grade. The point he made relates to my own experience in that, when the nutrient profiles in question were introduced in January 2011, I was Secretary of State. They were very much in the context of precisely the programme that I think he is looking for. It was about the reformulation of foods in the manner that had been done in relation to salt and to do the same for sugar and fats and the voluntary removal of transfats, which I think has essentially been accomplished. I have to say to my noble friend and the Committee that we have to be very careful because a lot of progress was made, but much more could have been made on a voluntary basis with the industry.

The nature of the attack made upon the Government and the industry was that, I paraphrase, “You’re working with the industry and, therefore, your activity is undermined by that fact.” It was rejected by many of the organisations that were seeking to achieve a public health objective. That was misplaced, and I am very disappointed that it happened like that. It would be a justifiable approach only if less healthy foods—HFSS foods or, for that matter, alcohol—were in the same position as tobacco. We do not deal with the tobacco industry because there is no safe level of tobacco consumption; we deal with the food and drink industry because there are safe levels of food and drink consumption.

My noble friends are nodding merrily, but I have to warn them that I actually agree with the Government’s proposals, partly because I think they are capable of being implemented in some respects in ways that meet some of the objectives that my noble friends are setting out. They can put practical timetables in place. They can give clear guidance about identifiable products, as distinct from brand sponsorship and the like. I do not like sunset clauses if we do not have to have them—if we have too many of them, as my noble friend Lord Moylan suggested, we would be clogged up with re-legislating all the time—but the Government can, by regulations, significantly change this.

I support the Government partly because they are clearly being attacked for doing too little and attacked for doing too much, so they are probably doing about the right thing. I think they are doing the right thing because we all know—the noble Baroness, Lady Boycott, said it—that obesity, and perhaps especially childhood obesity, is a multifactorial problem, so we must have multifactorial solutions. The one thing I would not accept is the proposition that I have sometimes heard from Governments of all persuasions: something must be done; this is something; therefore, it must be done. We need to implement many responses to this major public health issue—the noble Lord, Lord Stevens, is quite right—and we must tackle it as if it really matters. It is one of those missions that a mission-led Government should be seeking to achieve. It will need a wide range of different responses, of which this is one. All of them should be examined carefully to see whether they are evidence-based and effective.

I have to say that it is very difficult to say what is effective in this context because, for example, although we know that children who consume relatively more less healthy foods have a less healthy diet and are more likely to be obese, if we look at all the correlations, there are quite a lot of children who have a poor diet but it is not necessarily particularly heavy in less healthy foods. There are a lot of children whose poor diet is directly the consequence of their poverty, as my noble friend Lord Bethell said. The idea that we will see direct cause and effect is difficult to accomplish, but that does not mean we should not try. So, for public health reasons, I support what the Government are setting out to do.

I shall make one final point. The lead amendment in this group was tabled by the noble Baroness, Lady Finlay, and we have a later group on alcohol labelling. I have to say to her that I think that, in this context, her amendment is misplaced, first, because I think it derives from the idea that alcohol is like tobacco. For only a small minority of people is it necessary not to drink at all; most people who have a low or moderate alcohol consumption are at low risk. Secondly, she dismissed with a wave of the hand the codes and what has been achieved. I do not think that is fair. I think the alcohol marketing code has made a difference in relation to alcohol. I wish there was an HFSS marketing code that had been similarly effective because, where alcohol is concerned, the Health Survey for England 2019 said that, in 2003, 45% of eight to 15 year-olds had consumed an alcoholic drink and that, by 2019, that had dropped to 15%. These things can move in the right direction. We just need to make them do so. It does not automatically follow—

[Baroness Finlay of Llandaff (CB)]

Will the noble Lord clarify some of his statement about young people? We know that there are specific cultural groups among young people who do not drink at all, which has brought the average down, just as we know that there is a spectrum in poverty and obesity. Does the noble Lord feel that the current guidelines or whatever are working, given that there were 7,000 deaths from alcohol liver disease in 2020 and that there has been a 400% increase in the number of deaths from alcohol liver disease since 1972? If this had been working really well, we would not be seeing these increases. At the moment, we have a catastrophically large number of people dying from alcohol liver disease, which has got much worse during lockdown.

[Lord Lansley (Con)]

The noble Baroness is drawing me into what is a very important debate, but I do not think it is this one in this group. We will come on to it perhaps on Amendment 259 at a later stage. I do not disagree that we have not succeeded where alcohol consumption is concerned, but the nature of the problem has manifested itself more recently, especially in smaller numbers of people consuming alcohol, some not at all, but those who do very often doing so through binge drinking, which is exactly what is giving rise to what we are all most concerned about, which is the significant harm that is resulting for those people. We need to think behaviourally about the nature of the problem in order to find behaviourally what is the nature of the solution.

I need to stop, but I shall raise just one point with my noble friend on the Front Bench. I started with nutrient profiling. Nutrient profiling is terribly important. The noble Lord, Lord Clement-Jones, made the point that we do not get to look at that, but what it says is terribly important. As I understand it, we are due for a revision, but we have not yet seen it. There was a 2013 study that looked at our nutrient profiling and compared it to that of the WHO and five European countries. It concluded that, in relation to a large number of processed and packaged foods, under our system 47% would be able to be advertised to children, while under the WHO system it was 32%. There is a significant difference in what one puts into the nutrient profiling. It is not an objective truth, and putting alcohol in it completely misses the point, since it is not constructed around that proposition. I ask my noble friend to tell us a bit more about the nutrient profiling process, the timetable, the evidence and how we are going to put it together to meet the objectives under the Bill.

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[Baroness Penn (Con)]

The date that I have for the commissioning of the work is 2016, which means that we are even further down the road on that piece of work. I am well aware of the time that has passed since then. I will undertake to see if I can provide any update beyond “in due course”, but I do not want to raise noble Lords’ hopes too far on that.

I hope that I have been able to provide noble Lords across the Chamber with assurances as to our plans and, therefore, that noble Lords will feel able not to press their amendments.

[Baroness Finlay of Llandaff (CB)]

My Lords, we are three hours and 49 amendments on and I am sure that everyone in the House will join me in saying that we have enjoyed hearing from the noble Baroness the Minister now that she is back in Committee with us.

It is perhaps a crumb of comfort to those who have been worried about advertising and the outcomes that Norway’s ban since 2013 has shown that other products moved into the space and there was not a total loss of income. Quebec has had the least rise in childhood obesity in Canada since its ban. I will not comment any more on that other than to say that we have all recognised that obesity is a serious problem that needs to be addressed. The Wild West digital space of the platforms needs to be addressed quite urgently and will be more difficult, but I hope that this will not deter the Government from their action to tackle obesity.

For my amendment, I just remind the House that alcohol adverts are tempting young people into early consumption. It is a highly obesogenic and highly addictive substance, which is why my amendment was there. I am disappointed that the Government are not even considering incorporating it in the list of substances, but I beg leave to withdraw my amendment.

Amendment 244 withdrawn.

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Moved by

[Baroness Finlay of Llandaff]

259: Clause 146, page 124, line 42, at end insert—
“(3) The Secretary of State must, no later than one year after this Act is passed—(a) publish a report on alcohol labelling, considering the question of whether to require the following on alcohol product labels—(i) the Chief Medical Officers’ low risk drinking guidelines,(ii) a warning that is intended to inform the public of the danger of alcohol consumption,(iii) a warning that is intended to inform the public of the danger of alcohol consumption when pregnant,(iv) a warning that is intended to inform the public of the direct link between alcohol and cancer, and(v) a full list of ingredients and nutritional information; and(b) lay the report before Parliament.(4) A Minister of the Crown must arrange to make a statement to each House of Parliament setting out in detail any steps which will be taken to implement the findings of the report prepared under subsection (3).”Member’s explanatory statement
This probing amendment requires the Secretary of State to report on the alcohol labelling consultation.

[Baroness Finlay of Llandaff (CB)]

My Lords, these amendments also relate to alcohol. Amendment 259 is about alcohol labelling to prevent harm and Amendment 296 concerns dealing with the harm when someone has become addicted to alcohol. I shall cut what I was going to say dramatically because of the time spent on other amendments earlier today.

Labelling is the way we inform the public of what they are getting. About 70 people die every day from alcohol-related causes in the UK. Alcohol is responsible for 12,000 cancers every year. Covid has compounded this harm, with deaths from alcohol now at the highest rate since records began. There is more information on a carton of orange juice than a bottle of beer. Awareness of the health risks of alcohol is very low. Just one in five people can identify the low-risk drinking guidelines and less than one-quarter know that alcohol can cause breast cancer. Alcohol is linked to the worst pregnancy outcomes and serious lifelong impacts for a baby, yet one in three people are unaware that it is not safe to drink in pregnancy. It has been estimated that 41% of pregnant women consume alcohol.

Alcoholic drinks are also extremely calorific, as we have heard. We have already spoken about the number of calories those who drink take in and I will not go there again, but calories need to be included on the labelling. People have a right to know what they are consuming, but they cannot make informed choices about their drinking. Voluntary inclusion of information on labels has not worked and has been very low: 70% of labels do not include the CMO’s low-risk drinking guidelines, over 70% do not list ingredients and only 7% display nutritional information, including calories. The public want the information. In July 2020, the Government agreed to consult on requiring calories and drinking guidelines to be on alcohol labels, yet here we are all this time later and we are still waiting for the consultation to even be launched.

Amendment 296 refers to treatment services. Alcohol addiction is a complex problem, with many factors driving and perpetuating harmful drinking. People who are trapped by alcohol dependence need help to move towards recovery. The benefits for the health service are reductions in emergency service call-outs and unnecessary hospital admissions, and the benefit for everyone is a reduction in avoidable deaths. These are the outcomes by which the effectiveness of any measure can be assessed.

Many people who require alcohol dependency treatment also have problems with other substance abuse, mental health, domestic abuse and homelessness. It is alarming that, during the pandemic, only 20% of people who need help for problem drinking have been able to access it and there has been a significant and sustained increase in the rate of unplanned admissions for alcohol liver disease. Since 2012, there have been real-term funding cuts in alcohol treatment services, yet every £1 invested in alcohol treatment yields £3 in return; that rises to a return of £26 after 10 years. Only 9% of people with alcohol dependence account for 59% of in-patient alcohol-related admissions. So, a cohort of more than 54,000 people accounts for 365,000 admissions and more than 1.4 million bed days, at an estimated cost of £858 million a year. There are also significant pressures on the treatment workforce because there is a shortage of psychiatry trainees.

I hope that these amendments are self-explanatory, and that the Government will look favourably on doing something about the problem of alcohol harm. I beg to move.

[Lord Scriven (LD)]

My Lords, I rise to support Amendments 259 and 296 in the name of the noble Baroness, Lady Finlay of Llandaff. I speak on behalf of my noble friend Lord Shipley, who, unfortunately, cannot be here today but has added his name to those amendments.

The amendments are on the Marshalled List to push the Government to move faster on something that the public want that has now been shown to be effective, particularly alcohol labelling. A recent YouGov poll showed that 71% of the British public want to know the number of units in an alcoholic drink, 61% want to know the calorific content and 53% want to know the amount of sugar in alcohol. There is clear public support for this, so it is interesting that we have not moved faster.

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[Baroness Finlay of Llandaff (CB)]

I am most grateful to the Minister, and particularly to the noble and right reverend Lord, Lord Sentamu, for pushing on the point of whether the amendment was overprescriptive or adequately prescriptive. Given that, and the rather disappointing remark that the consultation will happen “in due course”, I will withdraw my amendment but am minded to return to something like it on Report if we do not have even a provisional date for when the consultation might start. We seem to have been waiting for it to start for a long time. With that, I beg leave to withdraw the amendment.

Amendment 259 withdrawn.

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[Baroness Finlay of Llandaff (CB)]

My Lords, I declare my interest as an elected member of the BMA ethics committee, which looked at these issues and was involved in producing the statement quoted earlier by the noble Lord, Lord Ribeiro. I strongly support these amendments and cannot see any reason for anyone not to. They set a basic moral standard. As the noble Lords, Lord Hunt, Lord Alton and Lord Ribeiro, and the noble Baroness, Lady Northover, have laid out, the arguments they have given us are in many ways only the tip of the iceberg. There is so much more than could be said.

Our Human Tissue Authority’s guiding principles have a code of practice which has consent, dignity, quality, honesty, and openness as key pillars. These principles should reflect not only how human tissue is sourced from within our own nation but how we treat human tissue and organs from overseas. There is overwhelming evidence now that in China, Falun Gong practitioners and Uighurs, Tibetans and house Christians are being killed on demand for their organs. There is no consent, no dignity and no transparency. Only yesterday I received a letter from a woman whose mother had been a Falun Gong practitioner, and who has been in prison and effectively disappeared. She has no idea where her mother is; she has not heard from her. That is happening all over this population.

I will not repeat the statement that has already been read out, but I just hope that the Government can see that we have a moral obligation to accept these amendments. I hope that they will do so.

Amendment 297H, in my name, is supported by the Royal College of Pathologists. Post-mortem examinations here are subject to careful legislative control and we have the Coroners (Investigations) Regulations 2013, which oversee post-mortems. When a post-mortem happens, it happens without the consent of the next of kin, of course, because there are questions around the cause of death. The coroners’ statistics for England and Wales in 2020 show that 79,400 post-mortem examinations were ordered by coroners. A fifth included histology and a quarter included toxicology samples being taken.

When the coroner’s work is complete, the tissue samples and any fluids taken—the tissue being in the form of blocks and slides—must be destroyed unless specific consent has been provided by someone in a qualifying relationship. However, consent is logistically very difficult to obtain in practice. The McCracken review of the Human Tissue Act in 2013 recommended that:

“Consideration should be given (inter alia) to reducing the scope so that microscope slide and tissue block samples and bodily products such as saliva, urine, and faeces are excluded”.


The Government accepted this recommendation, but the issue has not subsequently progressed.

There are some real difficulties with post-mortems. A post-mortem is effectively a snapshot of the deceased at the point of death. It is only by going back into the clinical records that the pathologist gets some picture of what happened pre-mortem, and many of the other factors. But at the end of the day, it is often subjective in terms of determining the likely cause of death for the report that is then signed off. In Scotland, tissue blocks and slides are deemed to be part of the clinical record and therefore do not have to be destroyed after the procurator fiscal’s investigations are complete. However, no whole organs can be retained in Scotland without explicit consent. In the light of Alder Hey, it is important to stress that point.

Changing to a system that reflects Scottish law could be beneficial because it would provide information about the cause of death if new circumstances came to light months or years after an investigation was complete. Indeed, we have recently had the case of the Farquhar family, where the evidence of long-term poisoning probably came to light many years after the person had died. Crucially, forensic deaths can be masked by natural disease processes and storage of tissues and fluids as part of the medical record would help clarify these at a later date when new information came to light. In a way, that is essential for completion of justice.

In addition, genomics research is rapidly developing, so the family may want to access the tissue later on as disease processes become more clarified. Metabolic storage disorders such as Fabry or Gaucher disease have been examples of this.

The tissue blocks from post-mortems are usually larger than the small pieces of tissue in a biopsy from a living person. That is particularly relevant where you want a piece of the heart or the brain, because a large biopsy from a living person would be impossible. There is also a third use of these tissue blocks and slides, which is as teaching material for autopsy pathologists. There is now a real shortage of teaching material, not only for pathologists who are in training but for ongoing audit of pathology processes.

So this amendment would bring the Human Tissue Act in line with the position in the Human Tissue (Scotland) Act 2006, where tissue samples as blocks and slides, but not—I stress not—organs, automatically become part of the person’s medical record after a post mortem. Explicit consent to keep them does not have to be sought from a grieving family, but it would allow justice in the long term to be pursued if necessary, and it would allow better development of autopsy pathologists.

[Lord Cormack (Con)]

My Lords, I apologise for missing the first minute—but it was only the first minute—of the splendid speech of the noble Lord, Lord Hunt. I am delighted to add my support to his initiative, most splendidly supported by my noble friend Lord Ribeiro. We entered this House on the very same day and it was very good to hear what he had to say. Of course, the noble Baronesses, Lady Northover and Lady Finlay, and the noble Lord, Lord Alton, all have an impeccable record on these matters.

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[Earl Howe (Con)]

The noble Lord makes a very good point and, if I may, I will investigate the feasibility of doing that and what systems are in place to capture that kind of data.

I am grateful to the noble Baroness, Lady Finlay, for her Amendment 297H, which covers the retention and use of tissues after coroner post-mortem examinations. I of course share the commitment to promoting education and research. However, I am afraid I do not believe that this amendment represents the right approach to supporting this aim. I appreciate that the noble Baroness emphasised that she was referring to blocks, slides and urine samples; the amendment refers to tissue samples. The advice I have received is that it is important that we remain committed to the principle that consent is fundamental to how we treat the remains of the deceased. I remember the passage of the Human Tissue Act; the noble Lord, Lord Alton, was absolutely right in what he said earlier about that. All of us should have a choice about what happens to our bodies after we die, and if we cannot exercise that choice, those close to us should be able to.

Post-mortems can already be distressing to the families of the deceased. Denying them a say as to what happens to the remains of their loved ones will compound that distress—often unnecessarily, as many of the retained tissues will never be put to use.

There are three other defects, as I see them, in the amendment; I am concerned that it would allow tissues to be stored indefinitely; it would allow for an overly broad interpretation of what constitutes a tissue sample —that is, in fact, my main concern; and it does not address the considerable challenge of how to effectively catalogue, audit or access the large amount of new material that would have to be retained.

Having said that, I believe that under the current consent-based model we can and should do more to encourage the active identification of tissues that could serve an important purpose, and to communicate the significance of retaining this tissue to the deceased’s family when seeking their consent. I understand the force of what the noble Baroness is trying to achieve and there may be different ways of doing that.

While I am grateful to noble Lords for their amendments in this area, I respectfully ask them to withdraw or not press them at this stage.

[Baroness Finlay of Llandaff (CB)]

Will the Minister undertake that the Government ask the Scottish Government about their experience of retaining tissue blocks and slides? Only tissue blocks and slides—not, I stress, organs—are being retained as part of the clinical record, so that we have some information about problems that have arisen. Also, given that the Government accepted the McCracken review, how do they then intend to implement that acceptance? If you accept the need to have consent, there has to be a process by which consent is obtained. You cannot ask for consent prior to the post-mortem because the post-mortem is a judicial process.

[Earl Howe (Con)]

I noted that the amendment tabled by the noble Baroness is closely modelled on the current law in Scotland. Because of that, it fails to account for the significant differences between how Scotland, and England, Wales and Northern Ireland, regulate the storage and use of human tissue. In England, Wales and Northern Ireland, that storage and use is regulated by the Human Tissue Authority. In Scotland, there is no equivalent body and the amendment is silent as to what impact it would have on the authority, especially given the challenges involved in managing the great quantity of tissue that would be retained.

I am aware that many Scots share my concerns about consent for retaining tissue. A recent petition to the Scottish Government highlighted the anguish faced by a grieving mother on learning that she did not have the choice to have some of her child’s remains returned to her. She was upset at how long it took for those remains even to be located, so although this amendment would apply only to adults the same kind of issues would apply.

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[Baroness Northover (LD)]

My Lords, I have put my name to Amendment 270, which requires the Government to consult on raising the age of sale for tobacco to 21, and which the noble Lord, Lord Faulkner, has just introduced. I also express my support and that of these Benches for all the anti-smoking amendments in this group. My noble friend Lord Rennard will speak on them shortly. Together, these amendments seek to close loopholes, strengthen regulation and provide a mechanism to reinstate vital funding for tobacco control and smoking cessation. Tackling tobacco and the tobacco industry has strong cross-party support, as the noble Earl well knows, having been very much part of that himself over the last 20 years. He will note the number of us speaking to support these amendments, even though only four can sign each one. He will also note the contribution made by his noble friend Lord Young, not only here but in his Private Member’s Bill, and he will no doubt note that there are very few voices—possibly one—who tend to speak against such measures.

I welcome the progress that the Department of Health has made in this area, and that of local government, but other parts of government are not always totally aligned. We found that with pavement licences—the noble Earl will remember this—in the now-termed Department for Levelling Up, even though the new White Paper on levelling up has, rightly, as the noble Lord, Lord Faulkner, pointed out, identified addressing health inequalities as vital, and addressing smoking as part of that. Two cities in the north have the highest smoking rates in the country: Kingston upon Hull, at over 22%, and Blackpool, at over 23%. The average in the south-east is just over 12%.

These amendments are designed to help the Government and the Department of Health take forward their very welcome apparent intention for the country to be smoke free by 2030. The Government say they are committed to delivering a smoke-free country by 2030 but keep putting off what they have themselves declared to be the “bold action”, promised in 2019, needed to deliver what they said was an “extremely challenging” ambition. The tobacco control plan promised in July 2021 has been delayed again. When will it be published? No doubt “in due course”.

Meanwhile, instead of those bold actions, according to a recent leak to the Sunday Times, the Secretary of State “plots vaping revolution”, by providing e-cigarettes on the NHS. I agree that vaping has a role to play in a comprehensive strategy to end smoking. Vaping doubles people’s ability to quit smoking compared with existing nicotine replacement therapy. However, as we know, smoking is highly addictive, and even doubling success means that only a small proportion of smokers who were trying to quit would remain quit at the end of one year. Vaping is not a magic bullet and, although it will increase quitting, it will not prevent youth uptake, as raising the age of sale would, as the noble Lord, Lord Faulkner, has indicated. He set out extremely cogently the evidence for why this measure would be highly effective. I will briefly focus on why it would be proportionate and justified.

The age of 18 is often considered to be the age at which someone acquires all the rights and obligations associated with adulthood. However, this is not the case, and there are several examples of rights or obligations which are acquired earlier or later than the age of 18. Raising the tobacco age of sale to 21 would be consistent with the flexible approach that we apply to other age-restricted activities: those prohibited to under-21s in England include adopting a child, driving a large passenger vehicle, and supervising a learner driver, for example. Thresholds change over time, as demonstrated by the Government’s support for a Private Member’s Bill, which I welcome, to raise the age of marriage from 16 to 18.

It is now accepted that the late teens through to the early 20s—ages approximately 18 to 26—are a distinct period of life: young adulthood, when young people may still need support and protection. It was the period during which I hoped that my sons would develop what I thought of as a judgment gene—a gene that my daughter seemed to have had from at least the age of four, but they noticeably lacked. For care leavers it was excellent, for example, when in recent years social care was extended from 18 to 25. That had long been needed.

As we know, smoking is highly addictive and uniquely harmful, and an addiction which, if not begun by the age of 21, is very unlikely to happen at all. Tobacco is the only legal consumer product which kills when used as intended, causing the death of more than 200 people a day in the UK. This means that a unique response is required to minimise the burden of preventable death and disease that smoking inflicts. The evidence is surely sufficient to proceed with raising the age of sale, therefore this amendment is simply a modest proposal requiring the Government to consult. I commend this proposal and the other amendments in this group.

[Baroness Finlay of Llandaff (CB)]

My Lords, it is a great pleasure to follow the noble Baroness, Lady Northover, because I would like to pick up almost where she ended, on raising the age for the sale of tobacco. That measure has been successfully implemented in the United States, where smoking among 18 to 20 year-olds has been reduced by nearly a third as a result, so I support Amendment 270.

On Amendment 271, which affects the sale of nicotine products to children, it is rather horrifying to realise that it is not illegal for free samples of e-cigarettes to be given out to those under 18, even though it is illegal for them to be sold to those under 18. Amendment 271 would cover this. It would also cover the novel nicotine products, such as Japan Tobacco International’s widely advertised nicotine pouches—I do not particularly want to use their name because I do not want to advertise them. Unlike e-cigarettes, the marketing of these products is currently completely unregulated, despite the high levels of nicotine, which is an addictive substance. A quick search on the internet to look at the questions around them reveals that it is admitted that they are highly addictive, that they could affect the development of the brain and that they could result in mood changes in the user as well, possibly making them emotionally volatile. These are loopholes in the law, which can easily be fixed by our Amendment 271.

In Amendment 278, the noble Lord, Lord Rennard, seeks to ban all flavours in smoked tobacco. Again, this is another gaping legislative loophole which has allowed tobacco manufacturers to flout the current flavour ban.

I have led on Amendment 279, which relates to the packaging and labelling of nicotine products such as e-cigarettes. A cursory search online for these reveals that widely available electronic cigarette e-liquids feature cartoon characters in garish, appealing colours, with child-friendly descriptors, including sweet names such as gummy bears. Such branding is clearly unacceptable; it is targeted at the young. It is therefore deeply disappointing to discover that an amendment giving the Government powers by regulation to prohibit child-friendly packaging was voted down by them in the other place. The Minister said then that the Government

“are committed to ensuring that our regulatory framework continues to protect young people and non-smokers from using e-cigarettes.”—[Official Report, Commons, 22/11/21; col. 88.]

The Government can prove their commitment by supporting Amendment 279, which requires the Secretary of State to consult and report to Parliament on e-cigarette packaging, in particular the branding elements designed to be attractive to children.

[Lord Naseby (Con)]

My Lords, I have never smoked and I have no wish to smoke, but I am a marketing man by profession. We have here a legal product, the consumption of which has been steadily falling, particularly in recent years, in every age group throughout the country.

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[Baroness Brinton (LD) [V]]

My Lords, I support the noble Baroness, Lady Cumberlege, in her Amendment 283, which would include financial and non-pecuniary interests of medical practitioners alongside clinical interests and their recognised and accredited specialisms on a register. I particularly thank her for explaining exactly why this is so important for patients. Currently, the GMC does not require them to hold or publish that data, but it is the obvious place for it to be held—and then linked, as she explained, to local employers, contractors and organisations. Anything that reduces the complex maze for a patient or a member of the public trying to find out whether a doctor is being paid for doing some work or using particular devices, and might therefore have an interest, has to be one of the cornerstones of a truly accessible and accountable register of interests. In today’s data-rich society, patients and the wider community want to understand what interests a doctor may have, but which may not be obvious.

A website called whopaysthisdoctor.org at Sunshine UK—so-called, I presume, because sunlight is always the best disinfectant—was set up by number of doctors, including Ben Goldacre. It is a database where doctors who want to be transparent about their interests can declare and register them, and the public can see whether their doctor is listed. The problem, of course, is that those who do not want to make these declarations voluntarily may be those we most want to see. That is why the amendment would make it compulsory.

I thank the GMC for its helpful brief, in which it recognises that the

“current arrangements to register conflicts of interest fall short of delivering adequate transparency and assurance for patients.”

However, the GMC would prefer this register to be maintained just at a local level and

“published by a doctor’s employer, contractor or organisation”.

The noble Baroness, Lady Cumberlege, has already referred to the recommendations in the First Do No Harm review and the Government’s response, in which they said that it was proposed that information would be published locally at an employer level. However, I believe that there is also a golden thread from the obvious place to go, where doctors already have a duty to register other information, and that is the GMC.

Like the noble Baroness, Lady Cumberlege, I am keen to see action on this. Personally, I believe that the registration body is a good place to hold that data and, as she said, we need to start somewhere. But, frankly, we need to see progress on a register of interests. I hope the Minister can give your Lordships’ House some encouraging news on this.

[Baroness Finlay of Llandaff (CB)]

My Lords, I was—it is fair to say—flattered when the noble Baroness, Lady Cumberlege, asked me to co-sign her amendment, because I have admired all the work she has done, and I think her report, First Do No Harm, has had influence way beyond the group of patients she was looking at. Indeed, I was vice-chair of a NICE review, and we referred to it in terms of helping to empower the voice of the patients we had in that review process, which was, first, very important and, secondly, particularly helpful because they were very clear in their thinking, and they worked extremely hard.

I am also grateful to the noble Baroness, Lady Brinton, for referring to the General Medical Council’s briefing, because the GMC agrees that a solution to this needs to be

“Accurate, up-to-date, accessible and presented in a way that is useful for patients, so that they can have confidence in it”.

It also said that it must be “Enforceable”, and the GMC also wants it to be “Multi-professional”. However, I agree that we have to start somewhere. Your Lordships may think that the advantage of a local register is that it is more accessible, but the disadvantage is that doctors move around in different jobs, particularly trainees—but even consultants’ time in one post is now relatively short; it used to be a lifetime appointment.

It is important that, as a doctor, I am prompted to be completely open so that there can be no subliminal influence on my decision-making. The most dangerous influences are the subliminal ones—not the ones where you are completely open about what is going on. There has been a great clamp-down over recent decades on the pharmaceutical industry because of sponsorship and so on, and that has decreased influences on prescribing. But when it comes to using other products in medicine, the same can apply. I think that a register would help the profession itself in making clinical decisions. I do not see this in any way as inhibiting research; on the contrary, it would display who is research active and who is achieving results through their research.

A register would support the development of innovative healthcare and support novel thinking because it would be declared and open. It would also support the move that people should always publish their results, whatever they are.

[Baroness Neuberger (CB)]

My Lords, I support Amendment 283 in the names of the noble Baroness, Lady Cumberlege, and my noble friend Lady Finlay. Like my noble friend Lady Finlay, I want to say how grateful I am and how touched I was that the noble Baroness, Lady Cumberlege, asked me to add my support to this amendment. I also need to beg your Lordships’ indulgence: if we do go beyond 7 pm, which I sincerely hope we will not, it is actually the beginning of the Jewish Sabbath. I should not be here now, and I certainly cannot be here after 7 pm. I will pretend that I am just slipping out briefly, but I am vanishing at 7 pm whatever happens. Your Lordships will be very glad to hear that I am not going to talk until then.

When the noble Baroness, Lady Cumberlege, asked me to support the amendment, I said that I would consult with the medical directors at the two NHS trusts that I chair, the University College London Hospitals Foundation Trust and Whittington Health NHS Trust. I did exactly that, and I have never had emails back so quickly from the medical directors—there are four of them between the two trusts. The amendment was welcomed unreservedly; they really want this to happen. The medical directors had no doubt that this was both an ethical requirement and indeed something to be encouraged in how doctors think about their own practice. That is the point that my noble friend Lady Finlay made. It is something about the subliminal; it makes you start thinking differently and your reactions become different.

One of the medical directors pointed me to Patrick Radden Keefe’s superb book about Purdue in the United States, Empire of Pain, and said that in a way that is exactly the issue here. Some of the people clearly knew that what they were doing was totally wrong, but some did not realise that what they were doing was wrong, because they had not got the subliminal way of judging, because this was accepted practice. That is the really strong argument for this: we need to be able to encourage people to think differently. There are lots of doctors who desperately want it, as the medical directors at my two hospitals have made entirely clear.

I pay huge tribute to the noble Baroness, Lady Cumberlege, for her report First Do No Harm—as well as for the many other things she has done, but in particular for that report. It has changed the way that quite a lot of people think; it is quite hard to achieve that with a report and it is a very remarkable thing to have done. This is a national and international issue. We are concerned here only with the national, but we could—and should—set an international example of good practice.

After the Paterson review and First Do No Harm, this is now urgent. The GMC is obviously the right body to hold such a register, and I say so as a former member of the GMC. I was rather sad to see its somewhat lukewarm reaction in its briefing and I think that it has got this wrong. They are the right people to hold the register and to make it available to patients. The public must be able to access it. The employers, individual doctors, the Medical Royal Colleges and others must all play their part and, of course, other health professions must follow suit.

Let us start here. This needs to happen, and it needs to happen fast.