Health and Care Bill (Twentieth sitting)

Philippa Whitford Excerpts

Committee stage
Thursday 28th October 2021 Public Bill Committees

[Mary Kelly Foy]

The Government’s prevention Green Paper, published in July 2019, included an ambition to make England smoke free by 2030. Admitting that bold action would be needed, the Government promised further proposals in order to finish the job. Two years on, and with less than nine years to go before 2030, we are nowhere near on track to achieve that ambition. Using Government data, projections by Cancer Research UK show that we will miss the target by seven years, and by double that for the poorest in society. Despite the promise of further action on tobacco, there are no measures to tackle smoking in the Bill. That is a major oversight, which my new clauses seek to address.

The new clauses are based on the recommendations included in the latest report from the all-party parliamentary group on smoking and health, of which I am the vice-chair. They set out a range of complementary measures to deliver the smoke free ambition, which will also significantly increase productivity and reduce pressure on the health and care system. Although the smoke-free 2030 ambition applies specifically to England, all parts of the UK have stated an ambition to end smoking, so I am pleased that members of the Committee from Wales and Scotland support the new clauses.

I will briefly run through the new clauses and why they are necessary additions to the Bill. New clause 29 would give the Secretary of State the power to require tobacco manufacturers to print health warnings on individual cigarettes and cigarette rolling papers. New clause 30 would allow the Secretary of State to require tobacco manufacturers to display a health information message on a leaflet inserted into cigarette packaging, which the Government promised to consider in the prevention Green Paper two years ago. Those are simple, uncontroversial and effective measures that would help deliver the Government’s smoke-free 2030 ambition at minimal cost.

New clauses 31 to 33 would allow the Secretary of State to close loopholes and regulations that allow tobacco and e-cigarette manufacturers to market their products to children and to undermine regulations that are designed to protect public health. New clause 31 would give powers to the Secretary of State to prohibit branding on e-cigarette packaging that appeals to children, such as branding that uses sweet names, cartoon characters and garish colours.

New clause 32 would give the Secretary of State powers to block a shocking loophole in the law that means that, although e-cigarettes cannot be sold to children under 18, they can be given out for free. There is no reason why we cannot seek to rectify that anomaly today. New clause 33 would give the Secretary of State powers to ban all flavouring and not just that defined as characterising. That term is subjective and ill-defined and has allowed tobacco manufacturers to drive a coach and horses through the legislation.

The Government were required by law to review the relevant tobacco regulations to check whether they are fit for purpose, and to publish a report in May 2021, which they have not done. It is time for them to address these egregious loopholes in the regulations, and the Bill is an ideal opportunity to do so. These new clauses are uncontroversial, and would be of clear benefit to child public health. I will therefore seek to divide the Committee on new clauses 31, 32 and possibly 33.

Following on from those new clauses, we must accept that if England is to be smoke free by 2030 we need to stop people starting smoking at the most susceptible age, when they are adolescents and young adults. There is a real and present danger that must be addressed: new figures from a large survey by University College London found a 25% surge in the number of young adults aged 18 to 34 in England who smoked during the first lockdown. New clause 38 would give the Secretary of State powers to raise the age of sale for tobacco products from 18 to 21. That regulatory measure would have the largest impact in reducing the prevalence of smoking among young adults, as demonstrated by what happened in the United States when the age of sale was increased to 21.

Finally, I want to address the issue of funding. The coronavirus pandemic has meant that the need for more investment in public health is greater than ever before. The Government promised to consider a US-style “polluter pays” levy on tobacco manufacturers in the 2019 prevention Green Paper. New clauses 34 to 37 would enable the Secretary of State to regulate prices and the profits of tobacco manufacturers and importers, which could provide funding not only for England, but for the devolved Administrations, with any excess allocated to other vital public health interventions.

I want to express my gratitude to my hon. Friends for supporting these new clauses. I hope the Government will engage with these proposals in a similarly constructive manner with regard to the forthcoming tobacco control plan, ensuring that public health is at the heart of any discussions around smoking and tobacco.

[Dr Philippa Whitford (Central Ayrshire) (SNP)]

Obviously, smoking has increased during covid, particularly during the lockdowns, which is quite depressing after some of the progress made in recent decades. This array of new clauses tries to tackle the issue from different angles. New clauses 32 and 38 relate to the age at which someone can purchase, along with other point-of-sale policies. Those issues are all under devolved control, so I have not got involved in those. However, the policy decisions around manufacturing, flavourings, packaging and so on are all reserved, and all four nations of the UK would agree that the biggest single favour anyone can do for their own health is to give up smoking.

As older people and people who have smoked for many years sadly succumb to the diseases we know are caused by smoking, such as heart disease, stroke and cancer, it is incumbent on tobacco companies to recruit a new generation. That is what ornate packaging and childish flavourings are clearly aimed at doing, and they are therefore completely counter to the policies of the UK Government and the devolved Governments.

This is an opportunity to stake the point, move forward and take action to prevent the recruitment of young smokers into cigarette smoking, which will inevitably cost the NHS—indeed the four NHSs—more, as they deal with the health issues over a number of decades, than is raised by tobacco duty. The Government need to stop looking at what they earn from cigarettes and focus on minimising their use. That is the Government’s stated policy, and these new clauses would take that forward.

[Alex Norris (Nottingham North) (Lab/Co-op)]

It is a pleasure to resume proceedings with you in the Chair, Mr Bone. I commend my hon. Friend the Member for City of Durham for her new clauses and the powerful case she made for them, but also for her leadership in the all-party parliamentary group on smoking and health, alongside the hon. Member for Harrow East (Bob Blackman). I know it is a truly impactful APPG and I have always been grateful for my opportunities to go to its sessions to contribute or to listen, as I know Ministers have as well. Reducing smoking and being smoke free by 2030 is a major public health prize. It was a bit disappointing and surprising that there were no tobacco control elements on the face of the Bill, so it is right that we spend a little time trying to change that.

Successive Governments have rightly taken real pride in the reductions in smoking over the past 20 to 25 years. Those reductions have not happened by accident, but through concrete interventions that were sometimes controversial and often challenging at the time, such as the smoking ban, plain packaging and packet warnings—things that we soon afterwards realised were very impactful, and very much the right thing to do. Of course, as the hon. Member for Central Ayrshire says, we have to view this in the context of covid, and there has perhaps been a bit of backsliding on that progress, but that should drive us not to despair, but to redouble our efforts. I hope we can move things forward in the spirit that my hon. Friend the Member for City of Durham suggested.

We have to understand that the gains we have made in recent years come with a caveat. Most of the quitting has been done by people from better-off communities, and the benefits have largely accrued to those communities. We are now at the point where smoking accounts for 50% of health inequalities between the poorest and the best-off communities. If we really are serious about levelling up or whatever we want to call it, health is surely a crucial part of that. We know that smoking accounts for half of that difference, so we really ought to be focusing on it.

Reducing smoking ought to be a major project for any Government, because poorer smokers are just as likely to want to quit as their better-off counterparts, and just as able to do so if they have access to good services. However, we have spent a decade cutting those services in general, but particularly in the poorest communities, so high-quality smoking cessation services—which are so effective—have withered on the vine in many of the places that need them the most.

I will now turn to the new clauses tabled by my hon. Friend the Member for City of Durham, beginning with new clause 29. About one in seven adults smokes. That is about 7 million people, and while health warnings have been displayed on smoking packages for well over a decade, there is evidence that the impact of warnings such as those wane over time. However, the dangers of smoking remain high—between 2016 and 2018, there were 1,167 deaths attributable to smoking in my city of Nottingham alone—so we need to build on the techniques that have worked, with new ones to refresh our under-standing of the dangers of cigarettes to smokers.

There is evidence that dissuasive cigarettes can make smoking less attractive to younger people and non-smokers, and the inclusion of warnings on individual cigarettes, as proposed by new clause 29, is one key way of doing that. Such warnings are already being considered around the world: an in-depth study from France found that warnings on cigarettes increased negative health perceptions, reduced positive smoker image and the perceived pleasure of smoking, decreased the desire to start smoking, and increased the desire to quit. There are therefore signs that such a policy would be impactful.

New clause 30 deals with cigarette pack inserts. Inserting leaflets that contain health information and information about quitting is an effective and cheap way to target existing smokers and help them get support to quit. Those inserts are easy and cheap to implement and, moreover, while the reading of cigarette pack warnings decreases over time, the reading of inserts increases. In Canada, package inserts have been a legal requirement since 2000, and a survey of smokers in Canada found that between one quarter and one third of respondents had read pack inserts at least once in the prior month, and those intending to quit or having recently tried to do so were significantly more likely to have read them. Pack inserts will support and reinforce the impact of other measures that will require more significant investment campaigns to go with them, such as behaviour change campaigns and stop smoking services. They are a really good evidence-based, low-cost addition to such campaigns.

New clause 31 relates to the packaging and labelling of nicotine products. Over the decades, regulation has transformed traditional cigarette packaging, plastering it with warnings and preventing tobacco companies from selling a desirable image of smoking. However, regulations have not kept pace with the less traditional nicotine products, such as e-cigarettes and nicotine pouches. Tobacco companies are still able to sell e-cigarettes adorned with bright colours, cartoon characters and attractive images, as we have heard from my hon. Friend the Member for City of Durham and the hon. Member for Central Ayrshire, and I know that e-cigarette shops in my constituency offer vape liquids branded as vanilla ice cream, slushies and cookie dough, all of which appear targeted at young people, and children in particular.

I am enthusiastic about vaping—it still feels like that is an unfashionable thing to say, but I stand by it. I think vaping is a really good way to help people quit smoking and stay quit, and it is a really important part of a smoke-free 2030. However, it should be regulated properly to help make being smoke free a reality. Data shows that restrictions on the branding of e-cigarettes and refills reduce the appeal of vaping to young people, particularly children, while having little impact on adult smokers’ interest in using these products to quit smoking, so, again, it is cost-free.

[Dr Whitford]

I assume from the hon. Gentleman’s comments that he shares my concern that although vaping is considerably safer than traditional tobacco, as Public Health England reports on vaping show, vaping products still contain nicotine, which is a vascularly active substance. Therefore, we should still be concerned about non-smoking children being recruited on to vaping. We have no idea what decades of nicotine vaping will do to someone.

[Alex Norris]

I do share that view, particularly around children. Our preference would be for them to never start. There should not be packages with cartoons and child-friendly descriptors to develop a market among children. I think there would be a high level of consensus on that.

In that spirit, new clause 32 addresses an incredible loophole, which I cannot believe anybody thinks is a good idea. If the Minister is not going to accept new clause 32, I hope he will say when the issue will be resolved. The idea that you cannot sell e-cigarettes to children but that you can give them out as free samples to under-18s is quite hard to understand. It is time for us to get hold of this simple loophole, which goes against the spirit of the legislation, which is designed to protect children against nicotine addiction. I hope we can get some clarity, either because the Minister accepts the new clause or gives us a clear picture that we will see action very soon.

On new clause 33, about flavoured tobacco products, it again feels like the market is not acting in the spirit of the laws that have been passed. Flavoured tobacco is designed to make products more appealing, especially to younger people. In May 2020, we banned the sale of tobacco with a characterising flavour such as vanilla, spices and menthol. However, companies have adapted to this legal change with new innovations that skirt the law and provide smoking experiences that replicate flavoured tobacco. I can go to supermarket websites and find “green” branded cigarettes being sold, with many reviews stating how similar the flavour is to menthol cigarettes. I do not think that is in the spirit of the law.

In the year from May 2020, Japan Tobacco made over £91 million in profits from menthol brands. Clearly, the law has not worked as we want it to. Moreover, between January 2020 and 2021, a survey of smokers showed that the smoking of menthol cigarettes has not declined, despite the apparent ban, so I do not think the law is working. This new clause would do a good job of closing that legal loophole. If the Minister is not minded to accept it, I would be keen to know what the Government intend to do instead, because I cannot believe that they want laws that they passed, in possession of full facts, to be worked around in that way.

I will take new clauses 34 to 37 as a group, because they create the same thing: a tobacco control fund, paid for by manufacturers, combined with the regulation of tobacco companies’ profits. As my hon. Friend the Member for City of Durham said, when the Government announced their smoke-free 2030 ambition, they promised to consider a US-style “polluter pays” levy on the manufacturers, and included an ultimatum for industry to make smoked tobacco obsolete by 2030. My hon. Friend’s APPG has published a very strong option for how to do that. Ministers could lift and shift that very happily and get on with this. There are real benefits to that.

Action on Smoking and Health do some wonderful work, and I am grateful for its support in my work. It estimates that a comprehensive national, regional and local tobacco control programme—in many ways, we have lost that in recent years—to deliver a smoke-free 2030 would cost the UK about £315 million. That would involve adding back lost services. ASH’s estimate for a levy, based on the model the APPG talks about, is £700 million. This could be a “polluter pays” model, and we would have plenty left over to overturn all those poor public health budget cut decisions taken over the last decade. If the spirit of yesterday’s Budget was to try to rewind and erase the lost decade that we have had in this country, this would be a really good place to do that, and I think that is a good deal.

Of course, the EU tobacco tax directive is no longer a blocking factor, so we have complete agency to act in this area and it is in the gift of the Government, so I am very interested to know how far along the Minister or his colleagues are in the consideration, as they said, of this matter, and when we will see some proposals. Similarly, when will we see another tobacco control plan? That is something that everybody, from local government, public services, the private sector, community and voluntary services and all of us in this place, can organise around. The 2030 goal is a common goal. Pretty much everything that we have said in the new clauses are things that we are of one mind on. We can do something really good for the health of the nation, and I hope to find the Minister in action mode on that.

I will finish by referencing new clause 38, also tabled by my hon. Friend the Member for City of Durham, because I do not want it to look like I have ducked the question. It is important that we actively look at that and consider the evidence. I am perhaps not ready to say that it should be in the Bill, but it should be part of an active conversation in this area and part of a tobacco control plan. I think the Minister may be in a similar place on that, because we know that it is an effective part of the armoury. There are loads of really great things to go at in this set of new clauses, and I hope that he feels the same way.

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[Dr Whitford]

With regard to the free provision of e-cigarettes or nicotine substitutes, the provision that could be amended quite simply by referring to where they are being provided through smoking cessation services, as opposed to where someone is buying them and then dishing them out, or is trying to use them to recruit young smokers. Accessing them commercially is quite different from being given them as part of a public health smoking cessation project.

[Edward Argar]

That is the point I was seeking to make. Smoking cessation services would still continue as normal. The argument from the shadow Minister, the hon. Member for Nottingham North—this is where I might diverge from him, not necessarily in intent but in the timing—is that even if we cannot see this as a problem at the moment, we should act now on the basis of principle. His argument is: “Even if it is not happening, why would we let it happen? We should just close the loophole”—I paraphrase, but I think that is his argument. My counter-argument is that it would be appropriate to look at this, but to conduct further research to develop the evidence base further. Beyond that we have—from 2018, for example—more work to do on vaping first. That is essentially the point of difference.

The shadow Minister might say, “I accept that, but I still think we should do it now.” That is ultimately a difference in positions, not a point of principle about needing to look at this. It is about whether to act now or to do further research. That is the only difference, and the research is needed to evaluate the detailed benefits of the new clause. Also, there is the scale of the issue that we might be tackling. I know that the hon. Gentleman is fond of an impact assessment of the costs as well as the benefits. He rightly, as does his colleague on the Front Bench, the hon. Member for Ellesmere Port and Neston, and you on occasions, Mr Bone—

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[Edward Argar]

New clauses 39 and 40 focus on carers. First, I join the shadow Minister, as I suspect all hon. Members wish to, in recognising and paying tribute to the enormous amount of work that carers, both formal and informal, do. We want to strengthen the system by which carers are supported, and ensure that those receiving care have choice and control over how they access services.

New clause 39 would create an obligation on integrated care boards to collect information, and understand and respond to the needs of carers with regard to their health and wellbeing. The Bill provides an opportunity to ensure the views of carers are properly embedded in integrated care boards. The Bill confers a duty on integrated care boards to promote the involvement of carers, along with those who access care and support, in decisions relating to the prevention, diagnosis and treatment of illness, and care. There are equivalent provisions for NHS England-commissioned services.

Furthermore, the joint strategic needs assessment, prepared by health and wellbeing boards, will continue to have to consider the needs of carers, and that will shape the strategy developed by the integrated care partnership and the plans of the ICB. That means the services commissioned through these routes in the area where a carer lives will have considered the impact on carers in that community. Carers UK has welcomed the clauses for recognising

“the crucial role carers play day in, day out supporting their relatives’ health”,

and it says the clauses

“give carers more of the visibility they need within health legislation.”

[Dr Whitford]

Does the Minister recognise the difficulty in getting unpaid carers to recognise that they are unpaid carers? Particularly during covid, couples may have grown into a caring role without ever thinking of themselves as carers, and therefore they do not seek financial or other support. We need a campaign to try and get people to recognise that they are carers. A project that I was involved in when I was back in the NHS in the first wave used the community pharmacy system to interact with carers who were collecting medicines, and helped guide them to the available support.

[Edward Argar]

I entirely agree with the hon. Lady. There is a huge number of unpaid carers who we know about, and who recognise themselves as carers, but there will be a huge number who, as she says, do not see themselves in that way. They see caring for a loved one as part of their normal life, and as what they do; they do not recognise that they are providing care.

There is also a large, often unidentified, number of child carers. They care for their parents, grandparents and others, but they will not think of it in that way. They just think they are doing their bit to look after mum or dad, or granny or grandad. The hon. Lady is right to highlight the need for all of us—both in government and other Members—to make it as clear as possible that these people are carers and should be able to access support and help. There is support and help available, but people need to understand that they are in that category and are entitled to it. That is a long answer to basically say that I entirely agree with the hon. Lady.

We are not convinced that the provisions of new clause 39 are appropriate for the ICB, as a similar duty to that in the new clause is already held by and imposed on local authorities, so it risks causing duplication. The local authority will be part of the ICB and of the ICP, so we feel that the issue is captured.

Carers already have a legal right to an assessment of their needs from their local authority. Local authorities have a legal duty to meet needs identified through a carer’s assessment where the carer is deemed eligible. In 2019-20—the latest figures I have to hand—376,000 unpaid carers in England were assessed, reviewed, and/or supported. However, the number may well be a lot higher than that figure, which goes to the point made by the hon. Member for Central Ayrshire.

We continue to work closely with stakeholders, care organisations and the wider sector to support carers. We will work with care users, providers and other partners to co-develop more detail on our plans for the reform of adult social care. We will publish further detail of our plans for reform in a White Paper later this year, building of course on the strong foundations of integration we are setting in this legislation. The shadow Minister, the hon. Member for Ellesmere Port and Neston, would have been disappointed or concerned about me if I had not said that, and would have wondered what was going on.

New clause 40 introduces a definition of carer that includes—this goes to the point to which I have just responded—young carers, parent carers and adult carers. It seeks to bring clarity and to ensure that all carers, regardless of their age or their relationship with the person they care for, benefit from the measures in the Bill related to carers. The circumstances and needs of every unpaid carer are unique. Unpaid carers make a vital contribution to the lives of those they care for, and I know that every member of this Committee would want to put on record a tribute to them. It is important that we continue to work to understand carers’ needs and how to best support them, while reflecting the diversity of carers.

I have already discussed the measures in the Bill designed to promote the involvement of carers. “Carers” in this context should include anyone, child or adult, who cares, unpaid, for a friend or family member who, due to a lifelong condition, frailty, illness, disability, serious injury, mental health condition or even addiction, cannot cope without their support. In seeking clarity and inclusion, it is important that we do not inadvertently exclude groups of carers. The legislation as drafted is based on an everyday use of the term “carer”, and this allows for flexibility and the inclusion of all who provide unpaid care, in any shape or form, to a loved one or friend.

I appreciate, and to a large extent share, the shadow Minister’s intention of strengthening the legislation and seeking to bring clarity, so that those who are entitled to support know it, and can claim what they are entitled to. I want to reassure members of the Committee that we have today heard the concerns expressed about carers. I will take that away and carefully consider the issues, and see if we can continue to address them through the wider work of the Department on carers, and our ongoing discussions with organisations, many of which we deal with as constituency MPs, week in and week out, on their work in our constituencies.

For these reasons, I encourage the hon. Member for Ellesmere Port and Neston to consider not pressing his new clauses to a Division, but I look forward to hearing from him.

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[Dr Whitford]

Many of the labels simply say, “Drink responsibly” or, “Drink aware”, but, as the hon. Gentleman is highlighting, the lack of information on labels introduces quite a complex step of that person having to go and look up the risk of harm or the unit measures. Yet we have just been debating the need to have warnings on cigarettes. Alcohol introduces harm both to the individual and, if they are heavy drinkers, to those around them, and therefore we should be taking this seriously. We have tried to do so in Scotland with measures such as minimum unit pricing, but information to the consumer is the first step.

[Alex Norris]

I am grateful for that intervention. I would certainly not talk down including the very broad messages that the hon. Lady mentions; I know that in an overwhelming number of cases that is available, but, as she says, that is not enough. People are conscious of that message and we should keep reinforcing it, but the jump-off point is, “So what? What am I going to do differently, or what do I need to understand differently?” At the moment, we are not helping them in that process.

This new clause, mirroring clause 127, asks the Secretary of State to introduce secondary legislation to compel the inclusion of this sort of information on products. It is a relatively modest ask, but it promotes informed choice, which in this area would be a very good thing. I do not think we should miss the opportunity to put it in the Bill.