Tobacco and Vapes Bill (Fifth sitting)

Sarah Bool Excerpts

Committee stage
Tuesday 14th January 2025 Public Bill Committees

[Andrew Gwynne]

I am grateful to the shadow Minister for that. We will come on to those issues in more detail when we eventually reach those clauses, which given the rate of progress so far may be in the early hours of tomorrow morning, if Members decide so. The only reason why such paraphernalia is on display and legally sold is to consume tobacco, but we will get more information on that for her when we get to clause 45, which covers that issue.

I was talking about the Windsor framework. We believe that this policy is in accordance with our international obligations. In terms of what products are in scope, the Bill captures all tobacco products, including shisha, cigars and heated tobacco. That is because all tobacco products are harmful. There is no safe level of tobacco consumption. For example, tobacco smoke from cigars leads to the same types of disease as the smoke from cigarettes. In England alone, around five times as many people smoke other tobacco products, such as cigars, as did a decade ago, and children are a part of that increase. Shisha, to which the hon. Member for Windsor referred, also causes the same diseases as cigarettes, including cancer, respiratory diseases and cardiovascular diseases. The volume of smoke produced in the average 45-minute shisha session is estimated to be the same as around 25 cigarettes’-worth of tar, 11 cigarettes’-worth of carbon monoxide and two cigarettes’-worth of nicotine.

Finally, there is clear evidence about the toxicity of heated tobacco. The aerosol generated by heated tobacco also contains carcinogens, and there will be some risk to the health of anyone using those products. The crucial point is that, unlike with vapes, there is no evidence that heated tobacco supports smoking cessation. We must ensure that the Bill is future-proofed to include new or novel products, such as heated tobacco, to protect the public from the harms of tobacco use.

Although cigarettes are the most used form of tobacco, we do not want to create loopholes in the Bill so that the tobacco industry can pivot and continue addicting people to tobacco. As I said previously, the issue is about saying, “The market share you’ve got now is it. We are stopping the conveyor belt.” As we know, if we block one road, the tobacco industry finds another route through. We are making sure that the Bill is as watertight and future-proof as possible so that the tobacco industry can no longer continue to trade with another product that harms and addicts future generations.

[Sarah Bool (South Northamptonshire) (Con)]

I want to look specifically at clause 1(3), which relates to identity documents. In the previous sitting, the Minister said that he would have powers to change the list of identity documents; I think he was referring to clause 46. But at the moment the definition of identity documents is very tight; only the six listed are permitted. My hon. Friend the shadow Minister mentioned veterans cards, and this would be an ample opportunity to include those, as was the intention, because the definition is very strict—people will be able to use only the listed documents.

A further question that has been raised is that the list rules out digital forms of identification, as those listed are physical. I want to understand how retailers can best enforce the measures in practice.

[Andrew Gwynne]

I do not want to go over the arguments that I have already put to the Committee in an earlier sitting, but there is an ability to use other forms of identification, as I set out. We will be working with the retail industry during the long lead-in time to get in place procedures that retailers are confident with. They will be able to ask for veterans cards, for example.

[Sarah Bool]

rose—

[Andrew Gwynne]

Can the hon. Lady let me finish answering the point she put to me? In fact, I have now forgotten the point she put to me—[Laughter.]

[Sarah Bool]

I was talking from a legal perspective. Clause 1(3) is about what “identity document” means, which obviously means that those listed are the six that people are allowed to use. I take the point that later the Minister could introduce regulations to allow for veterans cards, but legally a retailer’s defence would have to be that they were shown what appeared to be an identity document, which means:

“(a) a passport,

(b) a UK driving licence,

(c) a driving licence issued by any of the Channel Islands or the Isle of Man,

(d) a European Union photocard driving licence, or

(e) an identity card issued by the Proof of Age Standards Scheme”.

The clause is very specific. Whatever the intention, the retailer would not technically be able to use having been shown a veterans card as a defence. Hence I am asking whether we should consider the issue at this point, rather than relying on the regulations mentioned in clause 46.

[Andrew Gwynne]

I stand by what I have already said. The intention is to work with the retail industry during the long lead-in time to get the mechanisms in place that allow them to adequately enforce the measures in the Bill. We do not want to get this wrong. I politely say to the hon. Lady, however, that in the first instance it is highly unlikely that a veteran born before 1 January 2009 will seek to purchase cigarettes or other tobacco products and be queried about their age. I will take on board what has been said and, if what I said earlier is incorrect, we can perhaps come back to the issue.

I want to come back to tobacco products because the point is crucial. We want to ensure that the tobacco industry has that conveyor belt cut-off. It is therefore rational for all the products that I have mentioned to be included in the smoke-free generation legislation. That will prevent anyone from taking up use of the products in the first place.

As I stated in my opening speech, I am grateful to the hon. Member for Windsor for bringing the discussion before the Committee, but while I appreciate his intention, it is not something the Government support. In relation to the amendments, I say to the Committee that the Government do not believe it is appropriate to establish a more lenient penalty regime for the offences, or to introduce a mandatory age-verification policy.

The clause seeks to change the age of sale for tobacco products, herbal smoking products and cigarette papers in England, Wales, Scotland and Northern Ireland so that no one born on or after 1 January 2009 will legally be sold those products. The Bill will be the biggest public health intervention in a generation, breaking the cycle of addiction and disadvantage, and putting us on track towards a smoke-free UK. For those reasons, I commend the clause to the Committee.

Question put and agreed to.

Clause 1 accordingly ordered to stand part of the Bill.

--- Later in debate ---

[Dr Johnson]

Clause 48, which we obviously have not come on to yet, gives the interpretation of part 1 and all the definitions. The definition of cigarette papers in the Bill includes

“anything…to be used for encasing tobacco products or herbal smoking products for the purpose of enabling them to be smoked”.

Different chemicals are put in, believe it or not, to make the ash whiter—people are concerned, when they have burnt their cigarette, with the colour of the ash that has fallen from it, which seems remarkable to me. Calcium carbonate, magnesium carbonate and titanium oxide can be added to affect the colour of not just the paper, but the ash produced. Seignette salts—sodium potassium tartrate and sodium citrate—are also added to make it burn faster, so that people go through cigarettes slightly more quickly. Then there is the glue of the acacia gum.

As far as I can tell, it is impossible to find out what is in the cigarette papers that one might wish to purchase; if one looks online, it is very hard to work out what is in them. I have seen medical reports of people allergic to the ingredients having: cheilitis, or inflammation of the lips; circumoral—around the mouth—inflammation; and finger dermatitis. If one is selling a ham sandwich, it is important to include the ingredients so that people know what it is in it, but it seems that for cigarette papers that is not the case and I am not entirely sure why. It is also the case that some commercially available papers contain copper, chromium and vanadium. As they burn, the pigments can lead to very high levels of exposure. These are not inexpensive; Amazon sells a random choice of eight flavours for £9.99. The issues are worth considering. It has been proposed that individual cigarette papers have on them a message saying “Smoking is bad for you” or something along those lines, but does that not involve adding further chemicals to the paper and therefore further risk?

Clause 2(3) states:

“It is a defence for a person charged with an offence”

of proxy purchasing

“to prove that they had no reason to suspect that the other person intended to use the papers for smoking”,

To which the somewhat obvious question is, “What on earth else would one use cigarette papers for?” With some trepidation, I asked Mr Google. Initially, all I could find was that they are used for smoking joints of cannabis, which did not seem to me a particularly good reason—the smoking of another illegal substance—for the Government to exclude them. Then I found out that some people use them for woodwind instruments. They place them underneath the key and press the key down, which allows extraneous water to be soaked up. They then release the key and pull the paper out. That helps to dry the instrument, prolong its life and prevent damage. Clarinet players—I did learn the clarinet but I did not know this; maybe that is why I was not so good at it—or players of the oboe, bassoon, flute or saxophone can buy cigarettes papers for that purpose.

The question of whether the Government need to provide an exemption for cigarette papers hinges on whether there is an alternative for the public to use for their woodwind instruments—and there is, of course. It is obvious in some respects that the market would provide one were cigarette papers banned. Connoisseurs of such instruments tell me that cigarette papers are not ideal to use for this purpose because of the additional, potentially toxic chemicals they contain—one is potentially inhaling bits of the chemicals back in—and because it is not ideal to get traces of the gum on one’s instrument. It is possible buy Superslick Pad and Yamaha cleaning papers. As far as I can tell, they do not contain toxic chemicals, because nobody would be interested in whether the ash burnt from them was white or otherwise since no one is going to set fire to them. Is it therefore really necessary to have a specific exemption for the use of cigarette papers for instruments, when in practice that is unlikely to be what they will be used for? There is an alternative and the most likely use—I think the Minister will understand this—is that they will be used for smoking joints.

[Sarah Bool]

I agree with everything my hon. Friend says. My first question was, “Well, what else they would be using cigarette papers for?” The second question—which maybe the Minister can answer—is about the level of proof. This comes up not only in clause 2(3), but elsewhere in clause 2. I know that the Minister will say, in relation to clause 2(3), that this is in line with legislation as it currently stands, but if we are tightening up on the whole, perhaps this is an area that we should consider tightening up further?

[Dr Johnson]

Indeed, it does seem contradictory, if not counterintuitive. It also leaves us with a bizarre situation where, were someone to be a bassoon player, for example, and they wished to buy these products to use for the alternative purpose of drying their keys, then they would have to get someone else to buy them because they would not be able to buy them themselves. For a child born after 1 January 2009 and learning to play such an instrument, either the market will need to provide another opportunity to buy such a product, or the child will need someone else to buy the product for them. That does not make sense. The rolling age of sale that we discussed in clause 1 means that, over time, the number of individuals wanting to buy the product for their instruments but not allowed to, compared to the number of people allowed to, would inevitably diminish. We would have a larger group of people trying to find an ever smaller group of people to buy their cigarette papers for them for that purpose. To some extent, it would be more sensible to remove subsection (3) all together because it creates a loophole that will be used almost entirely for illegal uses of these papers. There is a market already providing a reasonably priced alternative for people to use for their instruments—which in practice are better for instruments in any case.

The final point is on the burden of proof. As a defence, someone purchasing the product on behalf of another has to prove they have no reason to suspect that the person was born on or after 1 January 2009. What does that really mean? Is that a reversal of the burden of proof? Is it saying a person has to prove their innocence rather than the state having to prove them guilty? In what circumstances would it apply? In what circumstances is it necessary for someone to buy cigarette papers, other than the oboe player or the saxophone player? I guess if someone in his or her 70s attends a corner shop but has forgotten their ID, they could ask somebody older to buy the papers for them; I guess that would be okay. They may find that they have come with a veterans card, thinking that they can use it because it is usable for voter ID, but that particular type of ID is not included; we have discussed widening the scope of those documents.

--- Later in debate ---

[Dr Johnson]

As the Minister says, clause 3 outlaws the use of vending machines that sell tobacco or tobacco products, as well as herbal smoking products and cigarette papers. I note that there are no amendments to clause 3, presumably because it is somewhat settled and established law.

In the same way as vapes and other nicotine products, which we will come to later, vending machines make it much easier for people under the age of 18—or, under clause 1, those born after 1 January 2009—to buy age-restricted products that they are not legally allowed to purchase. They are self-service machines, so it is difficult to prove age and easy to get around if it is machine led. Historically, such machines have often been unsupervised by staff in a shop, thereby providing easy opportunities for younger people to buy from them.

It was coalition Government legislation—the Protection from Tobacco (Sales from Vending Machines) (England) Regulations 2010—that banned the sale of tobacco products from vending machines from 1 October 2011. That statutory instrument was made under section 3A of the Children and Young Persons (Protection from Tobacco) Act 1991, which was inserted by section 22 of the Health Act 2009. That is a complex chain to follow, so having this clause where everything is in one place is much simpler. The clause also adds herbal smoking and cigarette paper vending machines to the legislation—on a personal level, I welcome that, for the reasons I have given already—and clarifies the penalty, which was more difficult to establish when looking at the previous trail of legislation.

However, the clause does change the terminology. Previously, it was illegal on the basis of sale “from an automatic machine”; the Bill talks about an “automatic machine from which” products “may be bought”. It seems that they are the same thing, but of course we heard repeatedly in evidence how the tobacco industry tries to get round these things.

I found a trail of people discussing online how to get round the vending machine legislation, which raised various questions. If I buy a product from a major retailer online, I can choose to get that delivered to my home, I can collect it from one of its stores, and I can also pick it up from our local Co-op, the local post office, or from a box with a keypad door, at the garage and in other locations. If one were to buy tobacco products, herbal smoking products, or cigarette papers using an online app, and collect them from a dispensing machine—an automatic machine that dispenses cigarettes—in a pub, would that be covered by this legislation, or is that a loophole that could be exploited? I would be interested in the Minister’s comments on that, because we have heard how inventive the industry is. Would it be possible for people to circumnavigate the Bill’s intent by creating a machine that does not sell the product but simply gives to a person the product they have already bought?

Clause 70 applies to Northern Ireland. It will insert into the Health and Personal Social Services (Northern Ireland) Order 1978 the new article 4B, which is essentially the same as clause 3, so the same questions and comments apply. The only difference between the two clauses that I can see is that in Northern Ireland we have a level 5 offence, and in England and Wales we have a level 4 offence.

I wondered briefly why there was no clause for Scotland, but section 9 of the Tobacco and Primary Medical Services (Scotland) Act 2010 makes it illegal to have an automatic machine for the sale of tobacco products, regardless of whether the machine also sells other products, with a level 4 fine, so Members can be reassured that that is covered. I do not think the Minister answered this point in relation to the previous clause: clearly he chooses the fine levels for England and Wales in the Bill; why has he chosen to have the same penalty as Scotland but a lower penalty than that in Northern Ireland?

[Sarah Bool]

Clause 3(1) says:

“A person commits an offence if the person has the management or control of premises on which a tobacco vending machine is available for use.”

My first point goes to the point my hon. Friend the Member for Sleaford and North Hykeham made about the concept of that person, because that leads to some questions and confusion about where the liability sits. When it comes to the person who has management or control of the premises, we might expect there to be a landlord and a tenant, in which case perhaps the tenant has control legally under the terms of their lease. But if the landlord has a managing agent—the hint is in the name—could they be caught within the scope of the Bill if they have not done enough to prevent the machine from being on the property?

What about cases in which a landlord who is a licensor has a licensee? The concept is slightly different: it is not as official as a lease, but someone has the right to use the premises but not exclusive use or possession of the premises. We could potentially argue about who actually has the management and control of the property in that instance. It would be interesting to know whether in future landlords could be in trouble if they do not include in the lease a provision that bans the location and siting of a vending machine in the property. I do not think that would be where landlords currently stand, but that is perhaps worth considering. It seems pedantic but, knowing the way the legal system can go when people want to find defences, we do have to stress test the wording we use, so we need to examine the concept of a person having management and control.

[Dr Johnson]

My hon. Friend is making a very important point that I had not fully considered: who is responsible where you have a larger corporation with a group of shops beneath? You have the board level, the regional managers, the local shop manager, the shift supervisor and then the shop worker, so who has the control? Is that something the Government have a fixed position on, or would each company individually need to prove who that was? If trading standards was prosecuting such an offence and chose the wrong individual, would the Government allow the corporation to get off scot-free?

[Sarah Bool]

My hon. Friend makes an incredibly valid point. It is something we are duty-bound to explore and test, to make sure we can avoid any problems with the roll-out and implementation of this.

--- Later in debate ---

[Dr Johnson]

My hon. Friend is right that the offence of selling a product to a person born on or after 1 January 2009 is something someone could do unintentionally. They could genuinely believe the ID in front of them, or that the person looked so significantly older that it was not even necessary to ask them for ID, whereas selling cigarettes outside the packaging requires the deliberate act of removing them from the packet and selling them individually, in a way that is not normally done. I think my hon. Friend is right, and it is perhaps surprising to have a deliberate act at a lower fine level than a potentially unintentional one.

[Sarah Bool]

Why are we limiting this to cigarettes? Forgive me, I am not an expert—I have never bought herbal smoking products—but if we are applying the same rules and we just want an outright ban, perhaps we should apply it generally, in case there are rule changes, to the sale of not only unpackaged cigarettes but unpackaged herbal smoking products. That would add further to the emphasis on changing the term from “a tobacco retailer” to “a person”, as my hon. Friend suggested.

[Dr Johnson]

I thank my hon. Friend for her contribution, and she is right to talk about the quantity. If the principle behind this clause is to ensure that the quantity of sale is such that it restricts younger people from purchasing these products with their pocket money, what consideration has the Minister given to the quantities of herbal cigarettes, or herbal smoking products, and cigarette papers, so that they would be purchased in quantities not easily accessible to young people?

On the comments made by my hon. Friend the Member for Windsor about the fine levels, the fines are level 3, which in this case is consistent across the four nations of the United Kingdom. Clause 51 amends the Tobacco and Primary Medical Services (Scotland) Act 2010 to add proposed new section 4E, which essentially has the same effect—it is different wording, but it has the same essential effect of banning the sale of loose cigarettes. Clause 71 adds proposed new section 4C, which is essentially the same as clause 4, to the Health and Personal Social Services (Northern Ireland) Order 1978 to have the same effect. Again, it has the same fine, so there is some consistency across the four nations of the country, but I would be grateful for the Minister’s comments on the points I have raised.

--- Later in debate ---

[Sarah Bool]

I am concerned about whether we are accidentally and inadvertently creating a loophole here. If we are not going to ban someone from breaking down a cigarette packet and selling it, that is the way they will go about doing it. We should be going for consistency and tightness on this. I appreciate that that is the law as it stands, which is why we have applied it, but have we had the foresight to ensure that we do not create a loophole? It seems quite possible that we have.

[Andrew Gwynne]

If the hon. Lady is not talking about retailers breaking up packets, which is illegal, she is talking, effectively, about proxy purchasing—an adult buying tobacco products for children, splitting up the packet and selling those products on. It is already an offence for those children to get cigarettes—whether a full packet or part of a packet—even if they are not from retailers. It is proxy purchasing, and we have already covered that.

The shadow Minister raised the issue of messaging on individual cigarettes. I am not sure whether she was under the misapprehension that it is not covered in the Bill. The Bill restates the existing power to make regulations on the appearance of tobacco products, including cigarette sticks. Not only that, but it goes further by extending the power to other products, including cigarette papers. Although we do not plan to introduce dissuasive cigarettes at this time, as we believe we already have strong health warnings in the existing measures, we will continue to monitor the situation. We do leave an open door to it, and the powers are there. We will, however, mandate pack inserts into cigarette packs. We believe that that is proportionate at this time, while not closing the door to going further.

Lastly, the shadow Minister noted that, in some cases, fines are consistent across the United Kingdom, but that, in others, there are differences. I am afraid that that is the result of the devolution settlement. We have built into the Bill the ability for all four nations to walk together on making our country smoke-free, but the levels at which fines are levied are entirely a matter for the devolved Administrations. That is why there is sometimes an inconsistency in fine levels.

Question put and agreed to.

Clause 4 accordingly ordered to stand part of the Bill.

Clause 5

Age of sale notice at point of sale: England

Question proposed, That the clause stand part of the Bill.

Tobacco and Vapes Bill (Sixth sitting)

Sarah Bool Excerpts

Committee stage
Tuesday 14th January 2025 Public Bill Committees

[Jack Rankin]

That is exactly the kind of situation I am thinking of. The language could be a bit more practical, less legal and it might aid that shopkeeper to point to an external source for validation.

I have two further points. One is a point of ignorance for me as a new Member, for which I apologise. I do not know what subsection (5) means when it says that

“Regulations under subsection (4) are subject to the negative resolution procedure.”

I hope someone can help me with that. Clause 6 is being taken together with clause 5, because clause 5 applies to England and clause 6 applies to Wales. To me, they appear to be exactly the same, apart from the age of sale notice described in clause 6(2) and the fact that clause 6 obviously also includes the Welsh version. I am going to take at face value that it says the same thing in Welsh, although I do not speak Welsh. It would be nice to clarify whether it is either/or whether it is both together. That is of interest.

[Sarah Bool (South Northamptonshire) (Con)]

I want to follow up on the points made on clause 5(3) and clause 6(3) in particular. Both specify that

“The notice must be displayed in a prominent position”.

I agree with many of the points my hon. Friend the Member for Windsor made about what that means in practice. In the information pack that we have been given, there is a quote from the Scottish Grocers’ Federation, which I want to read for the record. It explicitly states:

“In most convenience stores, space is at a premium and the suggested wording set out in UK Government proposals will require a significant surface area in order to be legible and accessible to all customers. The complexity of a moving ban will require very clear public messaging. Appropriate and mandatory signage is essential for good practice and the sale of age restricted items, SGF is concerned that multiple messages throughout the store relating to various product ranges and items could potentially create confusion and lead to challenging interactions between customers and staff.”

To protect our retailers, we must ensure that we enforce these regulations correctly. When making the regulations, the Secretary of State should take into account the voice of the retailers.

[The Parliamentary Under-Secretary of State for Health and Social Care (Andrew Gwynne)]

It is a pleasure to serve under your chairmanship, Sir Mark. In responding to points that have been made, I want first to reiterate that these two clauses do not relate to enforcement; they concern the nature of the signage that will be required to be displayed. We can come to those other matters later in the Bill’s proceedings. I remind Opposition Members of what has been said in previous debates: we will use the very long lead-in time to engage fully with the retail sector to ensure that we get the delivery in shops right and to ensure that the Bill’s provisions can be implemented without any hiccups.

I also reiterate that we abhor any violence and abuse towards retail staff—or anybody else—and it is the intention of this Labour Government to introduce a new offence in this respect. Given the comments that have rightly been made in the course of this and earlier debates, I hope that it will command full support from all parts of the House.

The hon. Member for Windsor asked what is meant by “negative resolution procedure”. It is the procedure for the statutory instrument that will be have to be made to introduce these regulations. The fact that it is “negative” means purely that it will not require a parliamentary debate. It will be done through the usual secondary legislation processes.

There were questions about the nature of the clauses relating to different parts of the United Kingdom, and why we are approaching this with slightly different methods. I must say politely—particularly to the shadow Minister—that we have to respect the devolution settlement. These matters are entirely within the legislative competence of the devolved Administrations. Some things remain reserved for the UK Government, but for a lot of the measures in the Bill, the legislative competence rests with the devolved Administrations and their Parliaments.

--- Later in debate ---

[Dr Johnson]

That was the second question I considered when preparing for the debate on this clause. My first question was: what is snus? My second was: if it is a tobacco product, why is it treated differently? We have talked about all sorts of different tobacco products—cigarettes, cigars, snuff—yet this one has particularly robust regulation and a robust legal framework. The only reason I could find was that it is new, trendy and coming forward very quickly, and there were concerns that it would quickly take over the children’s market in the same way as vaping. That is the only suggestion I was able to find. I am sure the Minister will be able to help us to understand why snus is treated so robustly, although I am not sad to see that.

Clause 7 makes it an offence to manufacture oral tobacco products. Oral tobacco products are defined quite particularly as those that are for oral use but not intended to be inhaled or chewed, so they do not include chewing tobacco, which would be included under clause 1. They also have to be in either powder or particle form—as I said, they are in the form of ground tobacco. Currently, the Tobacco and Related Products Regulations 2016 define “tobacco for oral use” similarly, as tobacco “intended for oral use”, not to be inhaled or chewed, and

“in powder or particulate form or any combination”,

whether presented in a

“sachet portion or a porous sachet, or in any other way”.

Regulation 17 provides for a UK-wide ban on the production and sale of snus. Schedule 6 to the Bill, which we will come to, will repeal that measure and replace it with clause 7.

I want to ask the Minister why it is an offence to manufacture oral tobacco products in the UK, and not an offence to manufacture other tobacco products. He has talked about the need for a smoke-free generation and his worries that smoking tobacco harms individuals’ health, wellbeing and ability to choose, but he has not chosen to ban the production of other tobacco products. I found that the last time an English-produced cigarette rolled off the production line was at the Horizon Imperial Tobacco factory in Nottingham in May 2016, and the last UK-made cigarette was produced at Japan Tobacco International’s plant in County Antrim in October 2017. He may feel that such a ban is unnecessary because we are not producing any tobacco products, but I am interested in his thoughts on the matter.

The penalty here is the most severe so far. We have had some debate about different clauses containing fines at levels 3, 4 and 5 on the standard scale, but this clause contains a much more severe penalty for a product that may or may not be less harmful than cigarettes, although it has not been suggested that it is much more harmful. The fine for breaching clause 7 on the ban on manufacture of snus is, on summary conviction, imprisonment of six months, a fine or both. Six months is based on the current upper limit in a magistrates court, but the Lord Chancellor announced in October last year a plan to increase the maximum penalty for a magistrates court to 12 months’ imprisonment, which would presumably apply to this Bill. I will be grateful if the Minister could clarify whether that is the case and whether there have been any convictions under the existing legislation. The penalty for conviction on indictment would be imprisonment not exceeding two years, a fine or both—again, quite severe penalties when compared with other aspects of the Bill and other tobacco products. I am interested to understand why.

[Sarah Bool]

Will my right hon. Friend give way?

[Dr Johnson]

I am happy to give way—and to be promoted.

[Sarah Bool]

I apologise to my hon. Friend. I might have misunderstood, so may I clarify the intended purpose here? If snus is illegal under earlier regulations, what is this further provision? Is it to ensure that nicotine pouches are also caught? The UK has already banned the sale of all oral tobacco products, including snus, under the Tobacco for Oral Use (Safety) Regulations 1992, which implemented European Union directive 92/41. I am hoping for some clarity about that, but perhaps it will come from the Minister.

[Dr Johnson]

My understanding—I am sure the Minister will leap to his feet to correct me if I am wrong—is that the Bill does not apply to nicotine pouches per se, because nicotine pouches do not contain tobacco. As I understand it, the brands we see in our local supermarket in similar round pots contain nicotine, and they are put in the mouth and absorbed in a similar way, but they are not tobacco products. As I read the Bill, clause 7 will not apply to them, and obviously they are not currently illegal, because they are widely sold.

--- Later in debate ---

[Dr Johnson]

Sorry. Equally, I note that the vast majority of Members across the House, both in my party and in other parties, strongly agree with clause 10 and the other clauses that seek to ensure that children do not have access to these products. If someone sells a vaping or nicotine product to a purchaser who is under the age of 18, it is an offence. Under clause 10(2), the seller can defend themselves on the basis

“that they were shown what appeared to be an identity document belonging to the purchaser and it confirmed the purchaser’s age as at least 18 years old, or…that they otherwise took all reasonable steps to avoid the commission of the offence.”

The Minister has talked about the simplicity of the smoke-free generation and his view that it is easier for shop workers to look at a piece of identification and establish whether someone’s birthday was before or after 1 January 2009 than to establish whether someone was born 18 years ago by doing the mathematics in their head from the person’s date of birth. That brings me again to the question of why we will not have a nicotine-free generation as well as a smoke-free generation. Would it be classed as a reasonable step? If a shop worker had asked for ID, taken the proper ID, as defined in clause 10(3), and done the mathematics wrong in their head, would they have taken all reasonable steps or would their arithmetic error mean that they were to all intents and purposes a criminal? I would be grateful for the Minister’s comments.

Acceptable identity documents for the purpose of buying nicotine or vaping products if one is over the age of 18 include a passport, a UK driving licence, a driving licence from the Channel Islands or the Isle of Man, a European photocard driving licence or a proof-of-age standards scheme card with a hologram. During the discussions of voter ID, there was a debate about how many people had access to different forms of ID. Passports are reasonably expensive and not everyone drives a car, so how would someone who did not drive a car or have a passport provide ID? When it came to voter ID, the previous Government looked at a number of reliable sources of identification that could be used, which included the veterans card, certain travel documents and the like.

[Sarah Bool]

Recent announcements from the Home Office have confirmed that businesses will be able to legally accept the use of digital proof of age for alcohol products. I would like to see that approach extended to these products, to make the life of retailers easier as far as identification goes. It would be good to have further consistency and an extension of the definition of identity documents to allow for digital forms.

[Dr Johnson]

Digital ID is not something that I am particularly familiar with, but nevertheless it sounds sensible, where ID is reliable, reproducible, not easily faked and easily identifiable by staff. Broadening the forms of acceptable ID would ensure that when somebody is old enough to legally purchase a product, it is not excessively challenging for them to obtain an ID to do so. Clearly the Minister would want people to be able to buy age-restricted products if they are old enough, so I am interested to hear his view not only on my hon. Friend’s intervention about digital identification, but on veterans cards, bus passes and other cards that demonstrate the age of the user and include a photograph for added reliability.

Clause 10(4) states:

“A person who commits an offence under this section is liable on summary conviction to a fine not exceeding level 4 on the standard scale.”

On a personal level, selling vapes and nicotine products to children is a dreadful thing to do, as I am sure the chief medical officer has said. I am more than happy for the Minister to increase that fine if he wants to, but I am interested to understand why he has set it at that level. Notwithstanding any changes across the four nations, it is important that we look at the choices that the Minister has made. That is what we are here to scrutinise.

The problem that clause 10 seeks to address is vaping among children. Are children vaping? Yes, I am afraid to say that they are, in large quantities. The biggest report of which I am aware that looked specifically at rates of youth vaping was published in 2023 by Healthwatch Blackpool. It looked at over 4,000 children and found that just under a third of them—31%—said that they

“currently vape or sometimes vape”.

Of those children, 65%

“expressed a preference for fruity flavoured vapes”,

which we will deal with later in the Bill. There is clearly an issue that vapes are being directly marketed to children with bright, attractive colours. Some of the most popular flavours include bubble gum, cotton candy, strawberry ice cream and unicorn milkshake. What does unicorn milkshake taste like? I have no idea, but it is easy to see the appeal to children.

An investigation by The Observer in 2022 found that ElfBar, a company that makes vapes, was promoting its products to kids via TikTok. The TikTok platform is apparently used by half of eight to 11-year-olds and by three quarters of 16 to 17-year-olds. When I found that out, I had a look at the screen time of my own children to establish that they were not getting on it.

--- Later in debate ---

[Sarah Bool]

I echo what my hon. Friend is saying, particularly in relation to online sales. I think we are all very aware that one aspect is being in the shop and physically trying to buy a product with ID; I take it from the ingenuity of our younger generation that they will always find ways around that, especially online, so we should perhaps give some further thought to how we can ensure that the companies are operating effectively—that there is robustness without over-regulation and that we have the methods to ensure that people are not following another loophole.

[The Chair]

Order. Before we proceed, let me explain that Sir Mark has had to leave the Chair and I am taking over for the duration—for as long as you choose to sit. I have, however, been briefed, so I am sure that nobody in the room will seek to take advantage of a change of Chairman to cover the same subjects all over again.

--- Later in debate ---

[Sarah Bool]

I rise to speak in support of new clause 10, on banning those who are under 18 from vaping. Many know about the health risks of smoking. They see it as a bad habit and disgusting, as the children of my hon. Friend the Member for Farnham and Bordon noted, but vapes are seen as being new age and social. Parents are in danger of encouraging vaping by buying something that they think is safer than smoking or drugs. We must be very careful about that, so this ban will be important in restricting sales. Children fear being excluded, so, through peer pressure, they are forced into vaping. We need to stamp out this practice.

Children are often confused about vaping. The problem is that they get an accidental addition to nicotine and struggle to pay attention in school, which has a negative impact not just on them but on their classmates. Apparently, children vape to deal with stress and anxiety—they are almost self-medicating, which is appalling. It is right that we protect our children by introducing this offence.

[Dr Johnson]

My hon. Friend talks about children self-medicating, but are they not making the situation worse? The use of vapes and nicotine products may exacerbate, rather than ease, any mental health symptoms that they have.

[Sarah Bool]

Absolutely. Unlike my hon. Friend, I am not a medical professional, but I wholeheartedly agree that it is a self-perpetuating cycle, and we need to stop it as soon as possible to protect children.

[Gregory Stafford]

It is a pleasure to serve under your chairmanship, Sir Roger. I want to make two points about this part of the Bill. First, I support new clause 10, in the name of my hon. Friend the Member for Sleaford and North Hykeham. It is essential that we close off all avenues for children to purchase vapes. In the Bill, the Government have done a very good job of dealing with physical retailers, but there is a gap in relation to online retailers. I hope the Minister is minded to support the new clause, either when we come to a vote on it in a few moments, or by inserting something similar into the Bill on Report to ensure we close off online retailers.

In my opinion, online retailers are more dangerous than physical shops. A child—especially a very young child—has to depart from their guardian or their adult to go and buy something in a shop, whereas they can purchase products online on their phone or computer in the comfort of their own home, and it is very difficult for a parent or a senior person in their family to spot that. We know that that is where a number of children and young people are getting these products, so we have to close off that avenue.

My second point is about a more fundamental issue with the clause itself. My hon. Friend the shadow Minister has said this quite extensively, but it bears repeating so that we get some answers from the Minister. It does not seem obvious why the Government decided to ban vapes for anyone under the age of 18, whereas for other tobacco products it is for anyone born on or after 1 January 2009. I completely accept that vapes can be used as a smoking cessation tool; it is important that they are used in that way.

When we come on to vending machines, there are medical settings in which people require some form of intervention to help to stop smoking, and we should be looking at that. However, it is not beyond the wit of the Bill’s drafting to apply 1 January 2009 to tobacco products, and then to create an exemption specifically for smoking cessation. I want to understand why the Minister has decided to make this distinction. Does he not see the potential risks in doing so? Hopefully, we all want people not to be addicted to any products that are harmful to them, but both retailers and consumers, when faced with two sets of rules for very similar products, could become confused and accidently fall foul of the law. Because of that confusion, the law might not be enforced as the Minister would like it to be. I very much hope the Minister addresses those two points in his closing remarks on these clauses.

--- Later in debate ---

[Dr Johnson]

Amendments 65, 66, 82 and 83 were specifically there to provoke debate on the coherency of the penalty portfolio across the Bill. The Minister has clarified his position on that. It is very important that we see those who are selling vapes to children or, in the case of clause 11, buying vapes for children, appropriately deterred from doing so or appropriately punished. I beg to ask leave to withdraw the amendment.

Amendment, by leave, withdrawn.

Clause 11 ordered to stand part of the Bill.

Clause 12

Vaping and nicotine product vending machines

[Sarah Bool]

I beg to move amendment 96, in clause 12, page 6, line 8, at end insert—

“(1A) The offence set out in subsection (1) does not apply to vending machines that are located within specialised mental health units that provide care for mental health patients.”

[The Chair]

With this it will be convenient to discuss the following:

Clause stand part.

Clause 78 stand part.

--- Later in debate ---

[Sarah Bool]

This amendment states:

“The offence set out in subsection (1) does not apply to vending machines that are located within specialised mental health units that provide care for mental health patients.”

I tabled this amendment on the basis of the evidence provided to us. I put on record that the Committee received a letter by Peter Terry, a

“Smoke Free lead in a large Mental Health Trust in the North West of England”.

In his letter, he says,

“As you may be aware the success of hospitals and Trusts becoming smokefree environments (especially Mental Health units) is particularly challenging. Mental Health service users due to their conditions have little or no motivation to stop smoking. On the units of my trust the prevalence of smoking is consistently between 70-77%.”

He goes on to say:

“To ensure we allow service users who are hospitalized a safer way to manage their nicotine addiction...my Trust would require Vending machines. These would allow service users to purchase a closed pod system device, which is a lot less harmful than tobacco smoking. On admission they would be offered either free NRT products or to purchase a vape as described above.”

He is asking that we make an exemption.

The exemption was also supported in another submission from the Cambridgeshire and Peterborough NHS foundation trust. Ben Kingsbury, the tobacco dependency lead in that trust, wrote to express his concerns over the ban on the sale of vapes from vending machines. He indicated that his trust had installed vending machines back in May 2024

“to ensure that vapes are available to staff and patients at all times.”

He stated:

“Since installation of the vending machines in our Trust we have had over 2400 individual vends. Each vend represents a staff or service user making a positive decision to improve their health. 2400 individual vends in just 6 months represents a saving to the Trust of around £12,000.”

He argued:

“Removing the machines will reduce patients’ independence in buying their own devices while in hospital and will have a financial implication to our Trust, as wards would be expected to fund more vapes.”

He was also concerned that

“a lack of vape provision on our Trust premises may result in patients returning to smoking”,

which I am sure we all agree we do not wish to be the result. He also asked that we consider the financial implications, as well as health and wellbeing of service users, by implementing the exemption.

We can all empathise with those who are admitted to mental health units. They may have difficult and complex conditions that they need to work through, and coping with a potential addiction may be too much for them. There may be a logic to listen to the voices of the experts—especially if we end up having smoke-free places around hospitals and how that will work out—asking us to allow a mechanism to help someone with smoking cessation.

The Minister himself has just said that vaping can be good to help someone quit, but if they do not have access to a vape they may face difficulties such as cravings, anxiety, trouble concentrating and all the other elements that go with it, including potentially going back to smoking tobacco in its pure form. Taking away the option from those in mental health units will only make their recovery harder, longer and more expensive for the NHS. I heartedly commend to all members of the Committee that we all consider this amendment thoroughly, to ensure that we are not doing additional harm by taking an aggressive approach in this regard.

[Gregory Stafford]

I thank my hon. Friend the Member for South Northamptonshire for moving the amendment. One thing we have seen across the debate thus far, and indeed during oral evidence, is that we have been led by the evidence—the Minister has clearly said that. The evidence that my hon. Friend has provided is from medical experts. These are not vape peddlers or people from the industry, or people who want to make a quick buck out of those who are addicted to nicotine. These are health professionals who are trying to ensure that there is a balance between what is absolutely right—we do not want to see people vaping—and the reality of the situation in medical settings, especially in mental health settings, where the ability for patients to have a certain amount of autonomy is often vital to their mental recovery.

My hon. Friend also made the valid point that if we remove smoking and tobacco products from in and around hospitals, which is a suggestion in the Bill that I think I support, we must ensure that those who are addicted—and we accept that it is an addiction—are dealt with appropriately. Obviously, in most regular acute trusts, that would be dealt with through a nicotine patch, but for mental health services, as I said, the requirement for autonomy should sometimes outweigh the functional nature of a nicotine patch. Indeed, my understanding is that nicotine patches do not work for everyone, because some of the addiction is in the holding as well as the imbibing.

I welcome the Minister’s response. As I have said to him on previous amendments, even if he is not happy with the precise wording my hon. Friend the Member for South Northamptonshire has put forward, I hope that he can bring in some kind of exemption on Report, so that the medical professionals who have written to us are satisfied that their concerns have been heard?

--- Later in debate ---

[Dr Johnson]

In essence, in relation to clause 12, yes. I do not think that vending machines including tobacco and nicotine products or vapes are a good idea, and I moved a new clause for inclusion in the previous Bill because a ban on nicotine and vaping products in vending machines had not been included at the outset. Without such a measure, we will see an expansion of vending machines as a way of selling products to children and getting children addicted. It will be done as a way of making products more available to adults, but its effect will be that the products are more available to children. I do not want to see such products available to children, because they are clearly harmful for them. All the medical evidence we have had states that clearly.

With regard to individuals in mental health hospitals, some may be there as voluntary patients, and some under a mental health section. When someone’s liberty has been taken from them because they are being treated for a mental health condition, we need to be careful that we are not restricting them in other ways in which we would not restrict other people. That is a fair point to make.

We also have to be mindful of the staff. As we go through the Bill, the Minister will rightly be looking at exposure to vaping inside hospitals and at extending the tobacco regulations that limit smoking in public indoor places to cover vaping in indoor public spaces. Indeed, he and you, Sir Roger, will have seen the signs placed in the Tea Room by the Speaker, who rightly wants to see that we do not have vaping there. The public do not want vaping in their tea rooms or in the public domain either, so that is the right thing to do. We need to consider that there are staff and other patients in mental health hospitals who may not wish to vape and should not be inadvertently and unnecessarily exposed to vaping products.

I do not support the idea that 2,400 vends means that this is a positive choice. For some of these people, vaping may have been a positive change from smoking, but for others it may have been a decision to vape.

[Sarah Bool]

I appreciate that; those were the words of the NHS trusts themselves when they talked about positive decisions. We cannot always be sure exactly why someone made that decision, but we have to hope in the first instance that that move away from smoking would turn into vaping and, ultimately, into a smoke-free generation.

I am minded to tighten the wording of my amendment on Report to ensure that the vending machines are in those mental health units for the purpose of facilitating smoke-free policies and smoking cessation, because I do not necessarily want nurses and those working in those units to be exposed to any unnecessary products. When we are dealing with addiction, we all appreciate how difficult it is, and I want to ensure that a process is in place that means that we deal with both the mental health issues patients are dealing with and the addiction in a suitable and balanced fashion.

[Dr Johnson]

I know my hon. Friend’s heart is in a good place when she thinks about how we can protect individual mental health patients who also have an addiction to nicotine. She said that having no vapes on the hospital site could lead to patients taking up smoking, but there are of course no cigarettes on the hospital site either. I do not support the idea that the removal of one product will automatically lead to the use of another unavailable product.

If a member of the Committee, for example, wanted to leave the room now and go and get some vapes, they would need to leave the House, go and find a shop, and purchase them, and the same is true of an average patient: they would have to leave their home, find a shop, buy their vapes and come home again. The availability of a vaping vending machine on a ward in a mental health hospital would make vapes much more available to an individual and much more proximal than they would be under normal circumstances, which may lead to a greater consumption of nicotine than would be the case if the vapes had to be accessed elsewhere.

As we have mentioned repeatedly, nicotine is a very addictive drug, and I will not reiterate that beyond saying that if one is in a hospital unit and unable to leave because one is on a section, and one is used to using nicotine, the cravings would be extremely unpleasant and the withdrawal could be very nasty indeed. With that in mind, we wish to ensure that those individuals are cared for, and I know that the Minister wants to ensure that they are cared for too, but I remind the Committee that other nicotine replacements are available.

Several treatments are available from shops and pharmacies to help to beat the addiction, and those are available on prescription to individuals currently residing in a mental health unit, voluntarily or otherwise. Essentially, they are nicotine replacement therapies, by which I mean a proper medicine, as opposed to a consumer product, that provides somebody with a low level of nicotine without the tar, carbon monoxide and other poisonous chemicals present in tobacco smoke. They help to reduce unpleasant withdrawal effects, such as bad moods and cravings, and may affect mental health treatment too. They can be bought from pharmacies and shops, but a doctor can prescribe them and NHS stop-smoking services can provide them, and they are available in a whole range of forms. There are skin patches that provide a slower release, chewing gum and little inhalators that look like a small plastic cigarette. There are tablets, oral strips, lozenges, and nasal and mouth sprays.

There is a huge variety of different nicotine replacement therapies. Some, such as the inhalators, gums and sprays, act quickly to provide nicotine, and some, such as the patches, release nicotine slowly. The treatment depends on the stage of craving and the stage of giving up that somebody is at, and on what is most suitable for them. Sometimes patients find that the best way to use nicotine replacement therapy is to have a low-dose patch that is worn all the time, with top-ups from a gum, inhalator or nasal spray if they have particular cravings. Treatment with such nicotine replacement therapy usually lasts eight to 12 weeks before the dose is reduced and eventually stopped.

--- Later in debate ---

[Jack Rankin]

Perhaps it is an added thing that doctors in mental healthcare can try to address, but my hon. Friend the Member for South Northamptonshire read out a letter from someone at the coalface, who takes the opposite approach from that of the shadow Minister.

[Sarah Bool]

I will say a little about the intention behind the amendment. We have obviously stressed throughout this debate how addictive nicotine is, but I want to ensure that if we are trying to deal with mental health issues, we are not creating an extra burden. The intention was not to encourage people to smoke, vape or take up other bad habits, but to make sure that we offer the best possible healthcare in the round, which means giving support.

Nicotine is addictive and so stresses are associated with it. Perhaps there are alternatives to give patients, but if they are not suitable for a particular patient or they do not work as well for them as nicotine, they will effectively be going cold turkey, which has its own issues. The intention behind the amendment was purely to encourage us to listen to the evidence from trusts themselves, to try to come up with a practical solution to enable this transition and allow us to get to a smokefree generation.

[Jack Rankin]

I thank my hon. Friend for her intervention and I agree with everything she has just said.

I will just finish my remarks to my hon. Friend the shadow Minister. She talked about this measure being a further opportunity; I would suggest that the easy availability of nicotine products in certain instances would be an aid on that journey.

We should be working pragmatically on amendments such as this in Committee, to ensure that the evidence is considered and that the right balance is struck. I will support the amendment tabled by my hon. Friend the Member for South Northamptonshire. Because the nicotine product vending machine measure is part of clause 12, I will vote against clause 12 stand part.

--- Later in debate ---

[Andrew Gwynne]

I am grateful to my hon. Friend for that. This debate will not stop here at Committee stage; I am almost certain it will be raised on Report. If it is not concluded to the satisfaction of those who wish to see such provisions in the Bill, I have no doubt that it will be raised in the other place, too.

However, it is really important that we do not end up with unintended consequences. We have to get this legislation right. The smoking cessation services available are far-reaching in these settings, and I see no reason for an exemption, given that nicotine replacement therapies such as gums, patches, inhalers—important medicines—will still be still be available to patients with a nicotine addiction in mental health settings. It is for that reason that I ask the hon. Member for South Northamptonshire to withdraw her amendment.

[Sarah Bool]

I would like to press my amendment to a Division.

Question put, That the amendment be made.

Tobacco and Vapes Bill (Third sitting)

Sarah Bool Excerpts

Committee stage
Thursday 9th January 2025 Public Bill Committees

[Dr Johnson]

When Parliament brings in any law of any kind, most people will follow it—the vast majority of the public are law-abiding citizens who want to know what the law is and obey it. However, whatever law we bring in, there will always be people who will disobey it. Even if cigarettes were completely banned, people would buy them. Many products—cocaine and heroin, for example—are banned, but some people still access and purchase them, so the Bill would not eliminate the issue completely.

Perhaps I could answer the hon. Gentleman with a couple of statistics. According to the Government impact assessment, 66% of smokers begin smoking before they are 18, and 83% before they are 20. Yet the research shows that three quarters of those smokers, were they to have their time again, would prefer never to have started smoking.

The hon. Gentleman may be aware that the age of sale for cigarettes was previously 16 and that a previous Government made it 18 instead. The effect was reviewed by scientists at University College London in 2010, and we saw a fall in smoking in all age groups. That is in line with what we have seen across a lot of the western world: smoking rates have declined. Actually, if we look at the difference between the younger and the older people, that fall was 11% in those in the 18 to 24 age group, but 30% in those aged 16 to 17. That meant that the age group targeted by the ban was much more likely not to start smoking. That is the start of the smoke-free generation, and we hope that a similar pattern will be seen and roll forwards.

[Sarah Bool (South Northamptonshire) (Con)]

On that point, according to Cancer Research, about nine in 10 people start smoking before the age of 21. Surely, if we increase that to 25, by default we are preventing more people from starting by that point. Going back to enforcement, I think that 25 is more of an age by which we have caught the youth and stopped them from starting.

[Dr Johnson]

I understand that opinion, and I guess that is what is behind amendment 17, which was proposed by the hon. Member for Epsom and Ewell. The evidence—certainly that which we heard on Tuesday from the chief medical officer and others—suggests that raising the age as far as 25 will help, and the Government’s impact assessment says they considered that option; they thought it would help to reduce smoking levels, and I think that that is true. However, it does bring the risk of either creating a great delay in bringing these measures in, because we want to wait until all current 18-year-old smokers are 25, or criminalising people who are currently legal smokers. If we still ended up with people starting smoking at 25, we would have not created that smoke-free generation, because we would not have brought those rates of smoking down as close to zero as possible. Given the harms caused by smoking—I am sure we will go through them in the debate on clause 1—it is important that we do all we can to reduce the number of smokers.

--- Later in debate ---

[Dr Johnson]

I think this comes down to the libertarian argument. Someone can be an adult either because they are over the age of 25, as per amendment 17, or because they are born before 1 January 2009, as per clause 1, unamended by amendment 17. Essentially, whichever type of adult someone is, we would normally say, “If you are an adult, you make an informed choice about which substances to take and what risks you want to take with your life.” But two thirds of people who take cigarettes will die as a result.

There are other substances that we do ban, and there is a scale. There is the libertarian who would have us make all drugs—whether cannabis, cocaine or heroin—free for everyone to use and to buy as they choose. That is not a position I subscribe to, but it is a position that some subscribe to. There are also those who would go further and ban many more substances, such as certain foods that are particularly sweet or fatty but otherwise enjoyable. There is a spectrum, and I think—society probably agrees—that the judgment is that tobacco is very harmful to those who consume it, and potentially to those around them, in a way that does not offer them any significant benefit. I am a doctor, and when we prescribe medication, we look at the risk balance between the benefits of the substance that we are giving somebody and its potential harm. However, with smoking, as far as I can tell, there are no real benefits, other than an emptier pocket—because an individual has spent so much money—worse lungs and worse health.

[Sarah Bool]

Just to play devil’s advocate, there will be some who will say that they have a cigar from time to time, and that will be caught by this legislation. Cigars are not used in the same way as cigarettes, and they are not seen to be as highly addictive. People do not chain smoke cigars. Is it fair in that instance to remove their liberty to smoke a cigar? I am just pointing that out as a non-smoker.

[Dr Johnson]

I will come back to that point when we get to the debate on clause 1 and tobacco products. It is an important point, but I am aware of the Chair’s tolerance, and the discussion at the moment is on amendment 17.

On the rise in age of sale, I talked about research that UCL did in 2010. Further research done in 2020 looked at the effect of raising the age of sale from 16 to 18 and found that the rates of ever smoking—people who had ever had a cigarette—had declined more among those aged 16 to 17 than among those aged 18 to 24. That supports the position that if access is restricted for younger people, they are less likely to smoke, which goes back to the point that most people are law-abiding citizens and wish to follow the rules. Restricting sale also emphasises the dangers to people in their own minds, which is a point we will come back to in the discussion on vapes.

Let me move on to amendment 18, which is linked to amendment 17. It would leave out the words

“shown on that document was before 1 January 2009”

in clause 1 and insert the words

“showed that the purchaser was not under the age of 25”.

This is a technical point to allow the ID to reflect the principle of who is allowed to purchase tobacco. It is a broad shift. In the view of the proposer, transitioning from a birth date-specific restriction to a general age-based restriction simplifies compliance for sellers by focusing on the current age. In my view, it actually makes it more complicated, because there is more mathematics to do in one’s head. If one is fortunate enough to work in a pharmacy, as the hon. Member for North Somerset discussed, it requires two dates in the computer, which is more difficult than one.

[Sarah Bool]

I understand the point about the potential complexities, but there is a risk on enforcement that whenever anyone goes to buy cigarettes in the future, they will have to have some form of ID. That creates a distortion: someone could just be assumed to be over the age of 25, whereas under the Bill they will always have to be checked.

[Dr Johnson]

My hon. Friend is making a point about ID for purchasing things. It is reasonable to ask people to have ID when they go and collect a parcel, to make sure that they are getting a parcel for the right address. In my view, it is reasonable—I do not think my hon. Friend voted for it, but I suspect she would support the idea—to provide ID in order to vote to maintain our democratic process. Having ID to buy an age-restricted product does not seem overly burdensome. I accept that it makes it more difficult for people below that age, because it provides a hurdle for them to overcome, in terms of potentially accessing some sort of fake ID. Most people want to obey the law, and that is an extra step in breaking the law that they would have to take, which they would not wish to do. I think we may have to agree to disagree on this point.

Amendment 22 would amend clause 5, substituting the words

“born on or after 1 January 2009”

with the phrase

“under the age of 25”.

That is consistent with the changes that would be made by amendment 17 to clause 1. Amendment 23 would make a similar amendment to clause 6, again changing the date. The other amendments in this group are amendments 24, 44 and 48, which is in Welsh—I trust that it says the same thing, but since I do not speak any Welsh, I cannot be clear on that. This group also includes amendments 46, 47 and 39 to 43. Again, they all seek to change the thrust of the Bill away from a rolling smoke-free generation to a fixed age of 25.

Tobacco and Vapes Bill (First sitting)

Sarah Bool Excerpts

Committee stage
Tuesday 7th January 2025 Public Bill Committees

[Sarah Bool (South Northamptonshire) (Con)]

My mother has some shareholdings in British American Tobacco, but that links to my parents’ having worked for Imperial Tobacco 50 years ago.

[Euan Stainbank (Falkirk) (Lab)]

I am an officer of the responsible vaping all-party parliamentary group.

--- Later in debate ---

[Dr Johnson]

Q Thank you; that is helpful. My other question is about the difference between indoor and outdoor exposure to smoke. In this country, we have had laws preventing smoking in certain indoor spaces for many years now. How does exposure to smoke inside differ from exposure to it outside? Imagine sitting next to someone smoking on a park bench and someone smoking at a neighbouring table in a restaurant—what are the comparative health risks between those two?

Professor Sir Chris Whitty: I think the first thing to say is that second-hand smoke is a very serious problem. I think that is underestimated among the general public because, if I am honest, the cigarette industry has been very successful in muddying the waters on this.

There are three key things that really make a difference. The first is the degree of concentration of the smoke. The second is the duration of exposure—let us say you sit next to someone for half an hour; the effect is more significant than if it had been just a couple of minutes. The third is the vulnerability of the people being exposed to it. That is one of the things that this Bill will help with.

Over 88% of the population do not smoke. There are roughly 6 million smokers still. There are significantly more people in the UK, non-smokers, who have medical vulnerabilities that mean that the smoke is particularly dangerous to them, perhaps acutely. They can be exposed to smoke and have an asthma attack, and that lands them in hospital. In severe cases it could land them in a very dangerous situation. The situation may also be chronic—for example, people living with diabetes already have a disease that is going to accelerate things like cardiovascular disease. If people are smoking on top of that, it will accelerate those things still further.

Although outdoor smoking is less in terms of passive smoking than indoor smoking, in most situations if you are close to someone, exposed for a long period or vulnerable, it can have very significant health impacts. In broad terms, if you can smell smoke, you are being exposed to significant amounts of smoke, and that is one of the things that the Bill is aiming to address.

I would like to make one additional point: the cigarette industry has been extraordinarily good at trying to pretend that to be pro-smoking is to be pro-choice. Nothing could be further from the truth. Smoking is highly addictive. Most smokers wish they had never started and want to quit, but they are trapped by addiction. Their choice has been taken away deliberately by these companies as part of their policy. And if you are talking about second-hand smoke, indoors or outdoors, the person downwind or next door has no choice at all at any point. They are exposed to the risks with no advantages at all. If you are pro-choice, you should be firmly in favour of the principles of the Bill. Frank, do you want to add to that?

Sir Francis Atherton: The only thing I would add is that there is no safe level of smoking. As Chris says, if you smell it, you are breathing it in, and there is no safe level. Obviously, indoors is worse than outdoors. The dose response is a big issue, but there is no safe level. I think that is a really important point.

[Sarah Bool]

Q You mentioned that 88% of the population do not smoke, and the numbers are now declining. Can I ask why you supported a generational ban as opposed to raising the age from 18 to 21 or even 25? It is predominantly younger people whom we want to stop smoking.

Professor Sir Chris Whitty: I might ask Michael to come in. I can have the first go and Michael might want to come in after that, because this is a critical point. Historically, the cigarette industry, despite what it claims, has always targeted children. It always deplores it in public, but if you look at its internal documents you discover that that is what it has been aiming to do. Most people, the great majority, start as teenagers before they are 20—you are, of course, correct. To refer back to Dr Johnson’s original question, the same thing is now being done with vaping and exactly the same playbook is being followed. You get people at their most vulnerable and you addict them. That is the aim.

However, were we to stop at, let us say, 21, the cigarette industry, which is extraordinarily good at regrouping around whatever regulations are in place, would simply regroup around 21. To go back to my very first point about addiction, if you are a 21-year-old and you start, you become addicted and then you wish you had stopped. That does not change the fact that your choice has been taken away. So the logic of saying 21, 25 or 30—various people have looked at various ages—is no better than the logic of the current situation.

The advantage of the current model, which was first put forward by Conservative Prime Minister Mr Sunak, to whom we should all pay great tribute on the basics of the Bill, was to ensure that current children are not addicted and do not have their choice taken away, but that rights are not taken away from existing smokers. That is the reason why this particular model was chosen. Michael, do you want to add to that? You are on mute.

[The Chair]

We cannot hear; we will come back to you in a moment.

--- Later in debate ---

[Dr Cooper]

Q Thank you so much to our witnesses for being here. I just want to take you back to a conversation you were having with a previous questioner about smoking cessation in hospitals. Could you give us your thoughts about vaping being available in hospitals, to allow people in hospitals who are quitting smoking, or who want to continue quitting, to continue vaping? Our CMOs talked about a smoke-free place being a vape-free place. What are your thoughts about vaping in hospitals—where it is a smoke-free place—and about access to vapes?

Suzanne Cass: In Wales, we have obviously implemented smoke-free legislation. We have seven different health boards and various approaches to that legislation when it comes to the implementation alongside vaping. When it comes to indoor spaces, there is already a huge amount of compliance with voluntary bans. People generally do not smoke in indoor spaces, so there is already that public consensus in those areas. When it comes to the outdoor spaces, there is not necessarily a consistent approach across Wales regarding smoking and vaping, which can cause confusion among the public.

I think that we need to be considering this very carefully, in terms of providing as much support to smokers as possible in these areas. We need to be considering exemptions to vape-free spaces, particularly in smoke-free spaces in hospital settings, mental health units and places where vulnerable patients who smoke are situated. That would be the message: we need to really consider those exemptions.

Sheila Duffy: In Scotland, we put medicinally therapeutic products front and centre with smoking cessation. Smoking cessation is vital, but we need to remember that there is no medicinally licensed e-cigarette product anywhere in the world, and that medicinally licensed products have a very different set-up. With e-cigarettes, you are talking about more than 30,000 different variants listed with the Medicines and Healthcare products Regulatory Agency, and four or five generations of devices, with very different health profiles.

Most of the comparisons are made with the toxins in tobacco, but there are different additional toxins in e-cigarettes, and there is new research—for example, AI modelling—on the impacts of heating some of the chemicals in e-cigarettes to vapour point, where they produce highly toxic outcomes. We need to bear that in mind. We also need to look at the research on air quality, because e-cigarettes conclusively contain the kind of particulates that we worry about for air quality and that cause harm to health. I think that that is an issue arguing for vape-free spaces.

In Scotland, we are supporting people to quit smoking in whatever way works for them—we are supporting individuals—but we are actively recommending only medicinally licensed products, because they have that context of appropriate use, safety and quality control, which e-cigarettes do not have.

[Sarah Bool]

Q I want to follow up on that point, because clause 12 of the Bill will actually include a ban on vending machines for vaping, but I know that there have been mental health trusts that have said that, actually, they would call for those to be exempted. Is that one of the exemptions that you would perhaps go for, and actually allow those vending machines in hospitals?

Suzanne Cass: Absolutely. I think we need to consider the vulnerable smoker at the heart of this and how they are managing to abstain from that addiction. It comes back to that addiction all the time. With smoking, nicotine is such an addictive substance that it is very difficult just to tell somebody that they cannot do it. You need to give them the right support, as well as the support that they want. When it comes to choice, that is where we need to be looking at what their choices are and how they choose to move away from that deadly tobacco use.

Hazel Cheeseman: On the mental health settings, we have done a lot of work in England with mental health trusts, and vending machines have been one way in which they have been facilitating access to vapes in quite a large number of mental health trusts. It is certainly something that we would be interested in looking at, because it will make it a bit more challenging for them to implement smoke-free policies in mental health settings if the vending machine rule applies across the NHS estate.

Also, going back to Dr Cooper’s question, in mental health settings and those places with vulnerable smokers, vapes have been really important in England in facilitating. We do not have legislation in relation to smoke-free grounds in England, but obviously it is the policy across the NHS estate that they are smoke free. Allowing vaping, particularly in those mental health settings, has been very facilitative of creating smoke-free grounds and supporting those people to maintain their smoke- free status as they move out of mental health settings as well.

Sheila Duffy: Scotland already has a ban on e-cigarettes in vending machines and has had for some years.

[Mary Kelly Foy]

Q I notice in your submission that you have a recommendation:

“The government should make good on their pledge to publish a ‘roadmap to a smokefree country’…with a strong focus on tackling inequalities.”

I am from the north-east region, where we have high deprivation and high smoking prevalence. It is the only region that has a clear vision—if you like—and declaration from Fresh and the directors of public health for how to achieve a smoke-free country. Could you explain a bit more why we need that vision and that strategy going forward?

Hazel Cheeseman: The legislation is fantastic; it is world-leading and brilliant, and it will really set us on that path toward being a smoke-free country. However, it will not be the last word in how that is achieved. We have 6 million smokers across this country, and we need to ensure that all of our agencies are lined up to do the job that they need to do to help those people stop smoking—the NHS, local government and integrated care boards across the system need to have the right approach. We also need to ensure that the funding is there to do that too. The Government have committed to the funding in stop-smoking services in local government, but we also need to see funding in mass media campaigns. The chief medical officer was talking earlier about people’s waning understanding of the harms of second-hand smoke. One way to address that would be to go back on TV and radio and explain to people what the harms of second-hand smoke are. That package of measures alongside this legislation would really help us to accelerate progress.

The Bill will massively raise the saliency of the harms of smoking with the public—there is no doubt about that. There has been, and there will continue to be, a strong public debate on the measures in this Bill. By really riding the wave of that public understanding through that coherent strategy and that investment, we could really see smoking rates start to drop, particularly in those disadvantaged populations where we continue to have persistently high levels of smoking.

Tobacco and Vapes Bill (Second sitting)

Sarah Bool Excerpts

Committee stage
Tuesday 7th January 2025 Public Bill Committees

[Andrew Gwynne]

Q Finally from me, in the previous iteration of this Bill, the fixed penalty notices were to be set at £100. There was criticism and concern from trading standards representatives, who advocated for increasing the value of the fixed penalty notice. Notwithstanding your answer to the shadow Minister’s question, do you think that doubling the fixed penalty notice to £200 strikes a better balance?

Lord Michael Bichard: Yes, I think we feel that. You might also consider an increase for second offenders before you move to prosecution. I do not think anyone wants to move to prosecution, because it is such a time-intensive process. I know we have limited time, but one thing we have not talked about is retailers. We also ought to be concerned about the online market—or rather, you should be concerned, as we are. It is a difficulty for us and for local authorities, because no single local authority thinks it should be responsible for enforcing legislation in an online marketplace.

We have a solution to that, which is that we have a lead authority that we think could deal with this and avoid the problem with individual local authorities. I think that will become an increasingly important element of the vape marketplace.

[Sarah Bool (South Northamptonshire) (Con)]

Q To build on a point my hon. Friend the Member for Sleaford and North Hykeham made a moment ago, the Scottish Grocers’ Federation has indicated in some of the information it sent to us that, in its latest crime report, the most prevalent cause of threatening behaviour in stores is the refusal of sale and asking for proof of age. I am concerned about that rise in retail crime and what more can be done. I know that the education piece is needed, but is any thought being given to how we can further prevent some of these problems?

Lord Michael Bichard: It seems to me that it is now such a part of life that it is not as big a problem as it was; I think it is a problem that will diminish.

Wendy Martin: Certainly the retail violence is of concern and has been well publicised. It is clearly a policing issue rather than a trading standards issue. I guess it needs activity to make sure that everyone understands what is being done and why it is being done, and to make sure that there is a policing response, if possible, where there are issues. I know that local authorities work through community safety partnerships and things like that in local areas if there are particular incidents. Again, it is not specifically a trading standards response, but local authorities and local police forces will work together to do their best to address these things, because nobody wants anyone to be threatened with violence.

[Sadik Al-Hassan]

Q Thinking specifically about vapes, do you feel that this Bill goes far enough in providing tougher regulations and more resources for enforcement, while balancing the burden on businesses that probably have not had this level of regulation?

Lord Michael Bichard: We think it does. You have to look at the package, because you do not just have age regulation or display and promotion regulation; you also have the proposal for licensing—which, by the way, we do not see trading standards being equipped to do; that is a local authority business and, as a former local authority man, I would have to say “with the resources”, because there is always a danger that you give local authorities more power but you do not give them the money.

You have regulation, you have licensing and you have registration of products. If you put all that together, I think it is quite a powerful package, but it does need to be backed up with the resources, because it is delivering it that really matters. We are all used to legislation that sounds great and never gets delivered.

Wendy Martin: I agree; we think the balance is there, hopefully with good communication to businesses. Again, in a similar way, this is not going to be entirely new territory—certainly for those businesses that are already involved in the sale of alcohol and tobacco in particular—in understanding where to go for support and the kind of controls that are in place. Certainly, if the changes are made to the product registration scheme, which should then make it more effective for businesses to be able to check that a product they are stocking is legal and compliant—if the package is right, as Michael said—it should not be too complex for businesses to comply with it.

Diabetes Treatments

Sarah Bool Excerpts

Tuesday 29th October 2024 Westminster Hall

[Carolyn Harris (in the Chair)]

I will call Sarah Bool to move the motion, and then call the Minister to respond. There will not be an opportunity for the Member in charge to wind up, as is the convention.

[Sarah Bool (South Northamptonshire) (Con)]

I beg to move,

That this House has considered diabetes treatments.

It is a pleasure to serve under your chairmanship, Mrs Harris. On 21 May 2021, my world changed forever when I was diagnosed with type 1 diabetes at the age of 33. While my diagnosis was a shock, given its late onset, the feelings of fear, disbelief and sadness are shared by all those diagnosed—young or old, with type 1 or type 2.

Diabetes is a complicated condition that has been done the great disservice of being stigmatised through misunderstanding. It is not necessarily that we have eaten too many sweets or not looked after ourselves. Type 1 is an autoimmune condition—we did nothing to cause it—and people can develop it later in life; Mr Speaker and I can attest to that. Type 2 is not just for the over-40s and the unfit; someone can be slim and active, like Sir Steve Redgrave, and still be diagnosed. That is why I have secured today’s debate. Breaking down the stigma and investing in early treatment of diabetes is so important to allow patients to live fulfilled lives, and to do so in the most long-term, cost-efficient manner for the Government.

Our understanding of how to treat diabetes has come on leaps and bounds since the discovery of insulin back in 1921, but there is still so much more that we can do. Some 5.6 million people in the UK are diagnosed with diabetes. That includes 4,329 people in my constituency of South Northamptonshire—more than 6% of the population. However, last year, just 54% of my constituents with diabetes received all eight of their essential checks, which are important for identifying and preventing complications.

The total cost of diabetes to the NHS is estimated at £10.7 billion, and 60% of that is spent on the costs of diabetes complications. Every week, complications from diabetes lead to 2,990 cases of heart failure, more than 184 amputations, 930 strokes and 660 heart attacks. Those should be preventable with the right education, the right support, and the right attitude from individuals and the Government.

There is so much that I could talk about on diabetes, but this is a short debate, so my initial ask of the Government, on type 1, is that we end the postcode lottery, with equitable treatment for those living with diabetes wherever they live in the UK.

[Jim Shannon (Strangford) (DUP)]

I commend the hon. Lady for securing the debate. I declare an interest: I am a type 2 diabetic. In our discussion before the debate, I informed the hon. Lady that, when I was first diagnosed some 18 years ago, believe it or not, I was at least 17 stone and probably getting bigger by the minute. I went on a diet because that was what the doctor recommended; I am down to a nice trim 13¼ stone.

I am thankful for the NHS and the treatment offered, but there is a clear disparity between the treatment offered in different areas of the United Kingdom. Does the hon. Lady agree that diabetes does not have to be a death sentence, but does not have to adversely affect quality of life either? We must ensure that, no matter where someone is in this great United Kingdom of Great Britain and Northern Ireland, they should get a level of diabetic care that enables them to live life to the fullest. Does the hon. Lady agree?

[Sarah Bool]

Absolutely. I totally agree, and the hon. Gentleman makes a very powerful point. It does not have to be a death sentence; it can even lead someone to No. 10 Downing Street, if they are Baroness May, so it should not prevent anyone from achieving anything.

Going back to my asks for type 1, we must also commit to greater access to technology for diabetes, such as hybrid closed loop technology, and increase awareness of the condition and treatments in schools and among the public. We also want to see the expansion of early testing for type 1 diabetes to identify children who are living with the condition and to make sure that they and their families get the right support.

I apologise in advance to hon. and right hon. Members if I suddenly start to beep during this debate, or in the Chamber in the future. They can be assured that it is not because I am some form of 21st century R2D2; it is because I wear an insulin pump and sensors. When my blood sugar is running low, it will alert me so that I can consume a lifesaving sugary treat. This hybrid closed loop system has dramatically improved the quality of my life with type 1. It does not just benefit adults with diabetes like me; there are parents of young children with a HCL who feel they can finally sleep at night without fear of missing a nighttime low blood sugar for their little ones.

Type 1 is also a condition that creates a serious mental burden on those who live with it and their loved ones. As a condition where someone’s pancreas stops working and no longer produces insulin, it requires constant thought and calculations alongside normal activities. Each day, a person with type 1 is assessing how many carbohydrates there are in their food and how much insulin they should dose, taking into account whether they have exercised, will be exercising, or generally rushing around; how hot or cold it is; how tired they are; how stressed they are, with public speaking adding to the mix for me; for women in particular, what their hormones are doing; and, when they have low blood sugar, how quickly they can access a sugar supply.

My insulin pump and sensor have ensured that many of those burdens have been eased. I just wish that more of my fellow diabetics had the same opportunity. I know of one lady from the south-west of England whose local integrated care board did not prescribe HCLs, so she had to move to London, away from her support network, just to access that vital technology. That cannot be right. As part of building an NHS fit for the future, Ministers should ensure that wherever someone is in the UK, they can access vital treatments for diabetes, such as the HCL.

There are other treatments that the Government should commit to fully exploring, such as early detection and new drugs. As with my diagnosis, more than 80% of type 1 diagnoses occur in people with no known family connection to type 1 diabetes. Many people are not aware of the four “T” symptoms that they should look out for: thirst, toilet, tiredness and thin. Early detection is vital in preventing complications such as diabetic ketoacidosis, which one in four children with type 1 are diagnosed with, and which can be lethal. Early detection can also identify people who would benefit from early intervention clinical trials and treatments.

The ELSA study is a programme funded by Breakthrough T1D that offers children between the ages of three and 13 a simple finger stick blood test to determine their risk of developing type 1 diabetes. The study is currently open to families across England, Scotland, Wales and Northern Ireland, with over 20,000 children having been screened so far. I ask that the Government work to have the programme expanded and implemented on the NHS nationwide, as it could drastically reduce the instances of future complications from type 1.

[Jim Shannon]

I thank the hon. Lady for giving way again. One of the things that we have noticed back home in Northern Ireland is that even if someone gets a type 1 diabetes diagnosis early on, it does not mean that their life is over—they can still go on. We have a high prevalence of young children in Northern Ireland who have type 1 diabetes, and for them it is rather scary but also a fact of life. I have seen some of those young boys and girls growing up and the diabetes has not affected their life at all. It is important to know that those being diagnosed early with diabetes can have a normal life and family.

[Sarah Bool]

I absolutely concur with the hon. Gentleman; people can live a fulfilling and fulfilled life, but they do need a little more help along the way. If we get that at the right time, it can literally transform a life so that they can live like everyone else.

One of the promising new treatments coming forward is teplizumab, which will delay the onset of type 1 in children by an average of three years. Approved by the Food and Drug Administration in the US in 2022, it is about to start a technological appraisal by the National Institute for Health and Care Excellence. In conjunction with the national early detection programme, teplizumab could drastically reduce the complications associated with type 1.

With the rise of social media, we have seen an ever-growing societal preoccupation with body image. Earlier this year Baroness May and Sir George Howarth released a parliamentary report into type 1 and disordered eating, also known as T1DE. T1DE is an eating disorder where someone might restrict their insulin to lose weight or experience an eating disorder such as bulimia or anorexia alongside type 1. Evidence suggests that up to 40% of women and girls and up to 15% of men and boys with diabetes experience some form of disordered eating, so we really must continue the work of Baroness May and Sir George in raising the profile of diabetes and its complications.

On type 1, I ask the Minister to ensure that the Government work with the NHS to increase awareness of the hybrid closed-loop technology, particularly among lower socioeconomic groups, and to fund its roll-out nationally; to provide comprehensive training for healthcare practitioners on HCL technology; and to establish a national diabetes registry to support technology adoption and track health outcomes.

Turning to type 2 diabetes, right hon. and hon. Members will have heard a lot about and might even have been tempted by Ozempic and Wegovy, known as the GLP-1 medications—seemingly magic solutions that have helped many in the public eye to shed unwanted pounds. However, that class of medication is an important treatment for those with type 2 diabetes as it is prescribed to lower blood glucose levels. My concern, and that of some of my constituents who have written to me, is that there is a real risk of a shortage of those medicines for type 2 diabetics while they are being prescribed for weight loss. It is therefore essential that the supply of those drugs is protected for diabetics. Will the Minister take action to ensure that everyone with or at risk of type 2 diabetes can access the medications that they can benefit from?

Alongside medications, we should ensure that newly diagnosed type 2 diabetics are given the right support. In some cases it is possible to put type 2 into remission, so it is essential that access to evidence-based services such as the NHS path to remission programme is increased for people in the first three years of their diagnosis. Likewise, people under the age of 40 with type 2 are at increased risk of developing diabetes complications, but are less likely to receive their essential care. The NHS type 2 diabetes in the young programme—T2Day—provides extra support for that group, including confirmation of diagnosis, additional checks, contraception and pre-conception planning, and assessment of cardiovascular risk. The Government must commit to sustainable long-term funding for the programme to ensure that the rise in type 2 diabetes in working age adults does not lead to a drastic increase in serious complications.

There are also inequalities across the diagnosis of diabetes. Those living in deprivation and people of black and south Asian ethnicity are more likely to develop type 2 diabetes but less likely to receive their diabetes care, and they go on to experience worse health outcomes. As the Government develop their plan for the NHS, they should use health inequality impact assessments for all diabetes-related policies to understand how reforms affect different groups.

As right hon. and hon. Members might have worked out by now, I could speak about diabetes all the way to the moment of interruption this evening, but I will draw my speech to a close. Acting as our own pancreas is hard and our illness requires 24-hour attention. Diabetes treatment is relentless, but so are we.