Tobacco and Vapes Bill (First sitting)

The Committee consisted of the following Members:

Chairs: †Peter Dowd, Sir Roger Gale, Sir Mark Hendrick

† Ahmed, Dr Zubir (Glasgow South West) (Lab)

† Al-Hassan, Sadik (North Somerset) (Lab)

† Barros-Curtis, Mr Alex (Cardiff West) (Lab)

† Bool, Sarah (South Northamptonshire) (Con)

† Chambers, Dr Danny (Winchester) (LD)

† Cooper, Dr Beccy (Worthing West) (Lab)

† Dickson, Jim (Dartford) (Lab)

† Foy, Mary Kelly (City of Durham) (Lab)

† Gwynne, Andrew (Parliamentary Under-Secretary of State for Health and Social Care)

† Jarvis, Liz (Eastleigh) (LD)

† Johnson, Dr Caroline (Sleaford and North Hykeham) (Con)

† Osborne, Tristan (Chatham and Aylesford) (Lab)

† Owatemi, Taiwo (Lord Commissioner of His Majesty's Treasury)

Rankin, Jack (Windsor) (Con)

† Stafford, Gregory (Farnham and Bordon) (Con)

† Stainbank, Euan (Falkirk) (Lab)

† Whitby, John (Derbyshire Dales) (Lab)

Chris Watson, Kevin Candy, Sanjana Balakrishnan, Committee Clerks

† attended the Committee

Professor Sir Chris Whitty, Chief Medical Officer for England

Sir Francis Atherton, Chief Medical Officer for Wales

Professor Sir Michael McBride, Chief Medical Officer for Northern Ireland

Professor Sir Gregor Ian Smith, Chief Medical Officer for Scotland

Hazel Cheeseman, Chief Executive, Action on Smoking and Health

Sheila Duffy, Chief Executive, Action on Smoking and Health Scotland

Suzanne Cass, Chief Executive, Action on Smoking and Health Wales

Naomi Thompson, Health Improvement Manager, Cancer Focus Northern Ireland

Dr Ian Walker, Executive Director of Policy, Information and Communications, Cancer Research UK

Sarah Sleet, Chief Executive Officer, Asthma and Lung UK

Public Bill Committee

[Peter Dowd in the Chair]

Tobacco and Vapes Bill

09:25:00

Good morning, everyone. Before we begin, I have a couple of preliminary announcements: Hansard colleagues would be grateful if Members emailed their speaking notes to hansardnotes@parliament.co.uk; please switch electronic devices to silent; and teas and coffees are not allowed during sittings. We will first consider the programme motion on the amendment paper. We will then consider a motion to enable the reporting of evidence for publication and a motion to allow us to deliberate in private about our questions before the oral evidence session. Given the time available, I hope that we can take those matters formally, without a debate. I call the Minister to move the programme motion, which was discussed yesterday by the Programming Sub-Committee for the Bill. Ordered, That— 1. the Committee shall (in addition to its first meeting at 9.25 am on Tuesday 26 November 2024) meet— (a) at 2.00 pm on Tuesday 7 January; (b) at 11.30 am and 2.00 pm on Thursday 9 January; (c) at 9.25 am and 2.00 pm on Tuesday 14 January; (d) at 11.30 am and 2.00 pm on Thursday 16 January; (e) at 9.25 am and 2.00 pm on Tuesday 21 January; (f) at 11.30 am and 2.00 pm on Thursday 23 January; (g) at 9.25 am and 2.00 pm on Tuesday 28 January; (h) at 11.30 am and 2.00 pm on Thursday 30 January; 2. the Committee shall hear oral evidence in accordance with the following Table:

Date	Time	Witness
Tuesday 7 January	Until no later than 10.25 am	Chief Medical Officers for England, Wales, Northern Ireland and Scotland
Tuesday 7 January	Until no later than 10.55 am	Action on Smoking and Health; Action on Smoking and Health Scotland; Action on Smoking and Health Wales; Cancer Focus Northern Ireland
Tuesday 7 January	Until no later than 11.25 am	Cancer Research UK; Asthma + Lung UK
Tuesday 7 January	Until no later than 2.40 pm	Local Government Association; Association of Directors of Public Health; Professor Tracy Daszkiewicz, Executive Director of Public Health and Strategic Partnerships, Aneurin Bevan University Health Board
Tuesday 7 January	Until no later than 3.10 pm	Royal College of Paediatrics and Child Health; Royal College of General Practitioners
Tuesday 7 January	Until no later than 3.30 pm	National Trading Standards
Tuesday 7 January	Until no later than 3.50 pm	British Retail Consortium
Tuesday 7 January	Until no later than 4.10 pm	Department for Education’s Secondary Headteacher Reference Group
Tuesday 7 January	Until no later than 4.30 pm	Medicines and Healthcare products Regulatory Agency
Tuesday 7 January	Until no later than 4.50 pm	Professor Linda Bauld OBE, Bruce and John Usher Chair in Public Health, University of Edinburgh
Tuesday 7 January	Until no later than 5.10 pm	Department of Health and Social Care

3. proceedings on consideration of the Bill in Committee shall be taken in the following order: Clauses 1 to 16; Schedule 1; Clause 17 and 18; Schedule 2; Clause 19; Schedule 3; Clauses 20 and 21; Schedule 4; Clauses 22 to 40; Schedule 5; Clause 41; Schedules 6 and 7; Clauses 42 to 64; Schedule 8; Clause 65; Schedule 9; Clauses 66 to 84; Schedule 10; Clause 85; Schedules 11 to 13; Clauses 86 and 87; Schedules 14 and 15; Clauses 88 to 127; Schedule 16; Clauses 128 to 141; Schedule 17; Clauses 142 to 146; Schedule 18; Clauses 147 to 152; Schedule 19; Clauses 153 to 157; Schedule 20; Clauses 158 to 160; Schedule 21; new Clauses; new Schedules; Clauses 161 to 171; remaining proceedings on the Bill; 4. the proceedings shall (so far as not previously concluded) be brought to a conclusion at 5.00 pm on Thursday 30 January.—(Andrew Gwynne.) Resolved, That, subject to the discretion of the Chair, any written evidence received by the Committee shall be reported to the House for publication.—(Andrew Gwynne.)

Copies of written evidence will be made available in the Committee Room and circulated to Committee members by email. Resolved, That, at this and any subsequent meeting at which oral evidence is to be heard, the Committee shall sit in private until the witnesses are admitted.—(Andrew Gwynne.) The Committee deliberated in private.

09:29:00

We are now sitting in public again and proceedings are being broadcast. Before we start putting questions to the witnesses, do any Members wish to make declarations of interest in connection with the Bill?

I am an NHS consultant paediatrician and a member of the Royal College of Paediatrics and Child Health.

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

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

I declare an interest as an NHS transplant and vascular surgeon. My wife is a lung cancer doctor.

I declare an interest as a public health consultant and a member of the British Medical Association.

I declare an interest as a practising pharmacist. [Interruption.]

I cannot hear everything because of that noise, but I am co-chair of the all-party parliamentary group on smoking and health.

I declare an interest as vice chair of the APPG on smoking and health. Examination of Witnesses Professor Sir Chris Whitty, Sir Francis Atherton, Professor Sir Michael McBride and Professor Sir Gregor Ian Smith gave evidence.

09:30:00

Sorry about the distracting noise; we are trying to sort that out. We will begin by hearing oral evidence from Professor Sir Chris Whitty, chief medical officer for England; Sir Francis Atherton, chief medical officer for Wales; Professor Sir Michael McBride, chief medical officer for Northern Ireland, who will participate via Zoom; and Professor Sir Gregor Ian Smith, chief medical officer for Scotland. We have until 10.25 am for this panel.

Q I thank the witnesses for coming along; we are interested to hear what you have to say about this Bill. For some time, I have been particularly concerned about children vaping. How will the restrictions on vapes in this Bill, particularly on colours, flavours and accessibility, help to reduce their appeal and accessibility to children? Professor Sir Gregor Ian Smith: First of all, thank you to the Committee for inviting me to give evidence. I think this is an incredibly important step. I have been concerned—

I apologise, but I think people are struggling to hear over the noise; I certainly am. Could everyone enunciate more clearly and speak a little louder? Professor Sir Gregor Ian Smith: First of all, thank you for the invitation to provide evidence. I think this is a really important step that we can take to protect children from vaping. I am very clear in my mind that vaping has a place in helping those already smoking to stop smoking. It has a place in smoking cessation, but children, young adults and indeed adults who have never smoked should never start vaping; there are too many uncertainties about the health consequences of vaping for that to be encouraged. In restricting children’s access to vapes and reducing the attractiveness to children of some of the vaping products currently marketed, the Bill will protect children from the potential health consequences of vaping itself and from the potential of vaping to be a gateway to the use of other nicotine products, for which there is emerging evidence. I am certain that the Bill will help to protect children from the dangers associated with starting to vape.

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.

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.

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

Q Good morning, CMOs. I would like to ask about the additions to the Bill; it is of course a reincarnation, as Professor Whitty says, of an earlier Bill from the previous Government, although we have sought to go further. In your professional opinion, what impact will the additions to the Bill have in terms of public health benefits for the four nations? Professor Sir Chris Whitty: May I take one impact that extends my previous points about outdoor smoking, and then maybe pass on to Sir Gregor and Sir Frank? For outdoor smoking, the previous Bill—the very good Bill put forward by the previous Government—did not have anything that addressed the needs of current smokers. It also did not address the needs of people exposed to smoke, despite the fact that, like over 88% of the population, they are not smokers and many of them are medically vulnerable. The Bill allows the Government to take powers to prevent outdoor smoking, first with additional public consultation and then additional measures in Parliament. Ministers—you, Minister, have demonstrated this in the House of Commons—have indicated the areas where they intend to use these powers to reduce the risks of passive smoking. These are the areas of the greatest vulnerability: around hospitals, where some of the most medically vulnerable are highly concentrated; and around children’s playgrounds, where children are—I think everybody who does not have shares in cigarette companies would agree that exposing children to second-hand smoke is an unacceptable thing to do. That is one area where the Bill has gone further than the previous one. Maybe Sir Frank might want to add to that. Sir Francis Atherton: In Wales, we have had smoke-free hospitals, schools and play areas since 2021, under our earlier public health legislation, and it is completely non-controversial. There are clearly issues around implementation and enforcement, particularly around hospitals, but if you go now to schools and hospitals there is no controversy whatever. So that will not make a huge amount of difference in Wales. The one thing that will make a difference, I think, is aligning the vaping legislation with the smoking legislation. I say that because, going back to the earliest question, vape use among young people in Wales has shot up over recent years—8% of 11 to 16-year-olds regularly vape, up from 5% and a bit in 2021. It has absolutely shot up. Bringing together vaping and tobacco legislation in terms of vape-free and smoke-free places is a really important thing and one for which I have been arguing for quite some time.

Q Ministers and officials have worked really hard, across the four nations, to put together a piece of legislation that is relevant to all four nations. How important do you think it is that the Bill extends powers and responsibilities on public health across the four nations? Professor Sir Gregor Ian Smith: Perhaps I can begin this answer; my colleagues may then want to come in. Alignment in this respect is really important, partly because of the clarity of message that exists to the public around about what is legally acceptable in relation to smoking and to vaping. Alignment across tobacco smoking and vape use is similarly important across the four nations. Public health messaging is incredibly important. Having a consistent message across our four nations helps to ensure that the message is much more clearly understood and adhered to by the public. I welcome the attempts by Ministers to ensure that alignment exists within the Bill, so that as we go forward we give protection to those who do not smoke in the way that we are planning on doing with the Bill as it proceeds. One of the most important aspects is to make sure that, although in Scotland, for instance, legislation prevents smoking within 15 metres of the likes of public places such as outside a hospital, we bring that much more closely in line with where the Welsh position is—so to the whole of the hospital grounds. Extending it to protect, as Sir Chris has said, more vulnerable places such as play parks is something I would certainly welcome in Scotland. We should do that in step across the four nations. I again emphasise that public messaging is incredibly important in making sure that we get the adherence we seek.

Q I turn to two criticisms of the Bill raised on Second Reading. We have already touched on some of the libertarian arguments, but I would like to know whether you think the issue of choice is addressed by the Bill. Do you have any sympathy with the libertarian argument, or do you think that the Bill—tackling tobacco and child vaping—is something that the libertarian argument does not stand up against? Professor Sir Chris Whitty: I have already given my view that, although I have a lot of sympathy for choice and freedom arguments in many situations, tobacco addiction and second-hand smoking are not among those. Sir Francis Atherton: If anything, choice is undermined by the addictive nature of nicotine. It is incredibly addictive. We know that now; we have known it for many years, actually. The tobacco industry has known it for many years, which is why the industry, through vaping and other means, is quite keen to have the next generation of people in our countries addicted to nicotine. Choice is completely undermined and taken away by the addictive nature of the product being marketed. Professor Sir Gregor Ian Smith: Nicotine addiction is horrific. Nearly 9,000 people a year still die in Scotland as a result of tobacco-related health issues. Two thirds of people who begin smoking are potentially at risk of dying as a consequence of their addiction. We know that the industry targets both the younger age spectrum and vulnerable groups to sustain their industry. If you have ever spoken to a patient with a serious tobacco-related illness such as chronic obstructive pulmonary disease, who is now suffering from the consequences of that—the limited ability to live their life—and the addictive nature of the disease, you soon begin to learn that they are filled with nothing but regret and guilt for the part that their addiction has played in the development of the disease. The stigma associated with tobacco-related disease is quite terrible for those who experience it. The basis of that is this lack of choice that they have developed as a consequence of the addictive nature of the nicotine products. Professor Sir Chris Whitty: If I could just add a specific example from—

Sorry, Sir Chris, but before we go further, I am trying to establish whether Sir Michael McBride has contact with us yet. If you can speak, Sir Michael, then we will know whether we have connection. It is as simple as that, really. Professor Sir Michael McBride: Yes. The problem is not on my side, so I asked that you unlock me. I think I have now been unlocked, so perhaps I can speak.

Q That is fine; we now have connection with mission control. Sir Chris, do you want to finish up? Professor Sir Chris Whitty: I just wanted to add an illustration of this, because it is such a fundamental point. I suspect that all doctors on the Committee, as well as my colleagues on this side of the table, will know this. I can remember the first time I was a vascular surgery house officer, watching people who had had one leg chopped off because they had smoked weeping as they had to take another cigarette, which was inevitably going to lead to their other leg being chopped off—and, incidentally, they were smoking over people coming into the hospital. It is an appalling addiction, and people who say this is about choice have never met someone who is seriously addicted to smoking.

Sir Michael, now that we have a connection with you, do you have any observations or comments to make in relation to any of the points that have been raised? Professor Sir Michael McBride: Yes, thank you, Chair, and apologies for the connection problems earlier. Following on from Sir Chris’s comments, all of us who have worked as clinicians on the frontline—I know members of the Committee have experienced that as well—know only too well the horrors of smoking tobacco, the premature death and illnesses that it causes, and the impact that it has on the next generation. We know for instance that, despite the fall that there has been in smoking, as per one of the Committee’s earlier questions, there are still 127,000 people each year in the United Kingdom who start smoking cigarettes as a result of the effectiveness of the tobacco industry’s marketing—blatant marketing—to children and young people, not just of tobacco and nicotine products, but of vapes. I too have seen at first hand the impacts of that. I know, as someone whose father was a smoker who died of an acute myocardial infarction aged 46, the impacts that it has on children—the next generation—who are three times more likely to take up smoking tobacco. This is a once-in-a-generation, lifetime opportunity, and we collectively need to seize it to prevent future harms for those who are most vulnerable, for children and young people, and for future generations.

I will go to Gregory Stafford first, and then I will move over to the Government side.

Q Do you have any concerns about the impact of the Bill on vapes as a smoking cessation tool? As my hon. Friend the Member for Sleaford and North Hykeham said, vaping in children is abhorrent, and I am glad that the Bill is addressing that, but how can we ensure that, as a cessation tool, vapes remain part of the panoply of options for smokers who are trying to give up? Professor Sir Chris Whitty: That is a very important question. I think everybody would agree on two things, and then there is a way of making sure that we get to the exact middle point of this argument. First, as you imply, in this country—it is not universally true—there is a strong view that we should try to continue our support to allow current smokers who are finding it very difficult to get off because of their addiction, which has taken away their choice, to move to vaping as a step in the right direction. I think that is broadly accepted in this country. As I say, there are some countries where that is not accepted so, to be clear, that is not a universal view. At the other extreme, as you imply—or state directly, actually—I think everybody would agree that the marketing of vapes to children is utterly abhorrent. I think almost everybody would agree that marketing vapes to people who are current non-smokers, given that we do not know the long-term effects of vapes because we have not had them for long enough, is a big mistake. We should not allow ourselves to get into a position where, in 20 years, we regret not having taken action on them. The question then is: how do you get the balance? In my view, this is sometimes made more complicated than it needs to be. I think it can be very simply summarised: “If you smoke, vaping is safer; if you don’t smoke, don’t vape; and marketing to children is utterly abhorrent.” That is it, although it is sometimes made a lot more convoluted. Our view is that the Bill gets that balance right. In general, if people’s profession is getting people who are current smokers off, they tend to be more at the pro-vaping end, because they see the dangers for current smokers. People who deal with children, such as Dr Johnson, who has taken great leadership in this area and is very much in the centre of her profession, and the Royal College of Paediatrics and Child Health take a very strong anti-vape view, because they have seen the effects on children. It is getting the balance between those two, and I think that the Bill does that. But—and it is an important but—the Bill takes powers in this area, and that means that if we go too far in one direction or the other, there is the ability to adjust that with consultation and with parliamentary secondary legislation. That allows for the ability to move that point around if it looks as if we have not got it exactly right. It may also change over time as the evidence evolves.

Q My question is around inequalities. How effective or otherwise do you think the Bill will be in reducing inequalities? Are there any areas of the UK that have specific challenges related to tackling smoking prevalence that you would like to highlight? Professor Sir Michael McBride: That is a really important question. We talked before about the blatant marketing of tobacco and vapes. There is also the preying of the industry on those more socioeconomically deprived areas. If we look at smoking rates in those more socio- economically deprived areas, they are two to three times higher than in less socioeconomically deprived areas. If we consider the death rate from smoking-related conditions, it is twice as high. If we look at lung cancer rates, they are two and a half times as high in those areas. That is a direct consequence of the smoking incidence in more socioeconomically deprived areas. The health inequalities associated with the consumption of tobacco are significant and great. If we look at smoking in pregnancy and all its consequences in terms of premature birth, stillbirth and low birthweight, we see that smoking among women from more socioeconomically deprived areas is four and a half times higher than among those in less socioeconomically deprived areas. The health inequalities argument and the case to be made for addressing that within the Bill is huge. This is an opportunity that we must not pass up to narrow the adverse health consequences. Professor Sir Gregor Ian Smith: It is my very clear view that the provisions within the Bill will help us to tackle some of the inequalities associated particularly with tobacco smoking. If I look at the situation in Scotland, 26% of our lowest socioeconomic group are smokers, compared with 6% of our highest socio- economic group. The gradient that Sir Michael has spoken about in terms of the subsequent tobacco-related disease that those groups then experience is really quite marked, whether that be cardiovascular disease or the numerous cancers associated with smoking. All of those can be addressed by trying to tackle the scourge of these tobacco companies preying on more vulnerable groups within our society, whether that be those who experience socioeconomic circumstances that are much more difficult and challenging for them, or whether that be particular groups that are more likely to experience mental health conditions. All of these must be tackled; people must be assisted not to develop addictions that lead to lifelong smoking and problems with their health thereafter. I am very clearly of the view, both in terms of smoking and, it is important to say, of vaping, that the targeting of those groups that creates those inequalities within our society is something that this Bill can address.

Q Thank you for the evidence submissions so far. In your opinion, will the Bill’s restriction of flavours for vaping products prevent the appeal to children and ex-smokers, if they can no longer access such products? Sir Francis Atherton: The issue of flavours and colours speaks to the issue of marketing towards children that we have been speaking about so far. I have no reason to believe that taking away colours and flavours that are appealing to children would remove vaping as a stop smoking tool. It remains an important tool in the box that we have to have alongside nicotine replacement therapy and alongside education, and it will remain an important tool to stop people smoking. The prime aim here, of course, is to stop the marketing towards children. If you think back to when tobacco was advertised in shops, we saw big gantries in shops, and what we have seen in recent years is that we now have vape gantries in almost all our shops. Taking away that marketing opportunity towards children—the colourful and flavoursome displays—can only be of benefit to reducing childhood vaping and the nicotine dependency that comes as a consequence of that. Professor Sir Chris Whitty: Let us be really clear about this: the vaping industry will claim it is not marketing to children while putting in flavours, colours, cartoons and placements that are clearly aimed at children. You just look at them—you do not need anything else—and you see the rates going up in children. It is very clear that the industry is doing that, and it needs to be tackled. Professor Sir Michael McBride: If you look at products with names “gummy bear” and “rainbow surprise”, who are they actually aiming those products at? Our Public Health Agency did research with more than 7,500 children and young people in Northern Ireland, using focus groups and online surveys. Some 77% of them told us that what appealed to them about vapes was the colours and flavourings. The public consultation had the strongest and highest support for banning flavours and colourings. More than 75% of the population in Northern Ireland supported that ban. We should not delude ourselves about the exploitative marketing of those products. In terms of next steps, it is really important that those who want to use vapes to quit smoking, as Sir Frank has said, can continue to access them. The Government undoubtedly will consult carefully on those measures to ensure that we do not—as the question is rightly exploring—restrict access or discourage individuals from using vapes to quit smoking.

Q Comparatively, how addictive is nicotine in tobacco and vapes compared with other products? I seem to remember that it is harder to get off nicotine than methadone. Is that true? Professor Sir Gregor Ian Smith: I am not sure we have the data or the evidence to back that up, but I have certainly heard people claim that in the past about the addictive nature of nicotine. One of the important aspects of this issue is the very rapid re-emergence of that addiction by small exposures after people have managed to quit. Certainly we should be in no doubt about the addictive nature of nicotine and the risks—going back to the harmful effects of passive smoking or being in the company of people who smoke—associated with the re-emergence of that addiction and of people’s tobacco smoking habits. That is something very real. Therefore, the best protection is never to start in the first place. If we can prevent people from taking those first nicotine products and prevent the addiction from forming in the first place, there is obviously a much greater chance that they are not going to suffer the health consequences.

Q It is clear, from the comments made about display and advertising, that child vaping is an issue that needs to be tackled; I think it is an issue that many of our constituents and many people in the country recognise. Especially for adult smokers, do you believe that there will be any impact from the display and packaging restrictions on the effectiveness of vapes as a tobacco cessation tool? Professor Sir Chris Whitty: Our view is that the benefits of preventing people who are not currently vaping, particularly children, from vaping through what is proposed in this Bill significantly exceed that risk. However, that risk exists; we all accept that. To go back to a previous point I made, that is why having these powers gives us the advantage that if, as a result of where we get to—remembering that this change will come after consultation and there will be secondary legislation going through Parliament—it looks as though we have gone too far, it will be possible to ease back. Our view, though, is that at this point in time, and subject to what the consultation shows, the net benefit in public health terms is positive for the prevention of children starting smoking, over any risk for adults. The area of greatest uncertainty is on flavours. There is some genuine debate around that, with a range of different views from people who are quite seriously trying to wrestle with this problem—rather than doing marketing masquerading as wrestling with this problem—but in all other areas, most people think that the benefit outweighs the risk.

Q Thank you, Sir Chris—your anecdote about the vascular war resonates strongly with me as a practising vascular surgeon; many of my patients leave hospital with fewer legs than when they entered. The comment I want to make is on the chronic disease burden. As you all know, there is a rising epidemic of chronic disease in our country, and it will probably require various public health measures to get back under control. I wonder if I could ask you to comment on how you feel this legislation might impact on the chronic disease burden on the NHS going forward, not only in the short term but in the long term? Professor Sir Chris Whitty: I will give a view, and I think Sir Gregor will want to add to it. It will make a very substantial difference. The thing to understand is that not only does cigarette smoking cause individual diseases, but many people as they go through life have multiple diseases from smoking. They will start off with heart disease, for example, as a result of smoking, and will go on to have a variety of possible cancers, and they might have chronic obstructive airway disease, and they will end up potentially with dementia. All of these would have not happened at all or would have been substantially delayed had they not smoked. Of course, this is heavily weighted towards areas of deprivation, people living with mental health conditions, and other areas where I think most people would consider it really unjust in society. All of us, and anybody who has looked at this in public health terms, would say that if you could remove smoking from the equation, the chronic disease burden would go down very substantially, and be delayed, and the inequalities of that burden of disease would also be eroded. The arguments for this are really clear. To give some indication of the numbers involved, we have thousands of people every year—millions over time—going into hospitals and general practices only because they are smoking. Had they not smoked, they would not have to use the NHS, and they would not have the chronic disease burden that disbenefits themselves, disbenefits their families and, of course, because of the impact on wider society, disbenefits everyone else as well. Undoubtedly this Bill—if it is passed by Parliament—will reduce that burden and have an enormous impact. Professor Sir Gregor Ian Smith: Thank you for raising this as a question, because it is a very important point to understand. I will speak to the experience in Scotland. The Scottish burden of disease study published by Public Health Scotland suggests that from now to 2043 we are going to see a rise of 21% in overall burden of disease across our society in Scotland. That burden of disease is very much weighted towards a number of conditions such as cancer, dementia including vascular dementia, cardiovascular disease, and others. There is no doubt in my mind that smoking contributes to those. Chris’s point about the multimorbidity that people experience is really important in this context. There are more people in Scotland who experience multimorbidity under the age of 50 than those who do over the age of 50, and much of that is related to smoking. Anything that we can do to reduce that burden of disease on people will not only make their own lives so much better, but make them more productive—they will be able to spend more time with their families, they will be economically active for longer, and they will also use health services less. So there is both a compelling health argument and an economic argument here on the preventive nature of stopping smoking and stopping people from beginning to smoke, which is really important to understand in the context of that projected increase in the burden of disease. The last thing to remember is that our experience of disease can sometimes be cumulative. As Sir Chris alluded to, people who have developed diabetes for other reasons but who smoke as well, will have accelerated disease as a consequence. Removing as much as we can, step by step, the risks that are associated with the development of that accelerated disease—you will have seen it very clearly in your role as a vascular surgeon—has to be a step that we take to maintain both the health and the economic prosperity of our nation. Professor Sir Chris Whitty: The numbers that I was looking for—

I am sorry, Sir Chris. Just for the purposes of timekeeping, which is my job, we have about 20 minutes left and five people wish to ask questions, so can we keep the questions as tight as possible, and within reason the answers as well? Professor Sir Chris Whitty: I wanted to give the exact numbers, which I just found in my notes. Some 75,000 GP appointments a month are caused by smoking—just think of that when you phone up the GP—and 448,000 admissions to the NHS: again, think of that when you look at these areas. So the impact of this is really very substantial.

Q May I ask a question about some of the arguments from tobacco companies for heated products to be excluded from the tobacco regulations and the Bill—and presumably therefore the age of sale regulations. Would you have a view on whether that is a sensible proposal? Professor Sir Chris Whitty: I have a very strong view. The tobacco industry is extraordinarily adept at pretending that it is on the side of the angels, and that it is trying to help with the problem. This goes along with slimline cigarettes, filters, low-tar cigarettes—many other marketing things, all of which claim to try and help with the health effects. Tobacco is extraordinarily dangerous, as well as being addictive. The heated tobacco products have probably slightly lower levels—they do have lower levels of the multiple chemicals that are toxic: multiple, not just one or two, but they are way away from safe levels. So heated tobacco products, while arguably being slightly lower in terms of the risk if someone had exactly the same amount, are a long way short of anywhere near safe, and they are still addictive. They also have some side-blow areas where they will have some issues for people around them as well. So the idea that this is some kind of solution only makes sense if you have shares in a company. So I would very strongly argue against trying to exclude these and carve these out. Sir Francis Atherton: Nicotine is addictive however you take it—whether it is in heated tobacco, in cigarettes, in snus, in chewed tobacco or in shisha pipes—so in terms of protecting the next generation, the great value of this Bill is the flexibility to deal with not just the issues that we see in front of us, but the things that may well come down the pipeline in the future. I believe the Bill is flexible enough to allow us to protect the next generation from these terrible problems that flow from addiction.

Sir Michael, you were nodding. Did you have any comment to make? Professor Sir Michael McBride: I simply echo Sir Frank’s comments on the flexibility that the Bill affords us, and again confirm my agreement with Sir Chris’s comments. Let us be clear: there is no other product that causes life-limiting addiction, that kills two thirds—kills two thirds—of the people who use it. It is staggering, and this Bill provides us with an opportunity to address a scourge on our society. There is no safe tobacco product —none.

Q This is a question specifically on vapes. You mentioned earlier that because it is a new product, there is a lack of scientific consensus on the medium to long-term effects. Are we going to see publications around this over the next five to 10 years—maybe sooner? Presumably there have been clinical trials on these products. Can you tell me perhaps the difference between the two? I accept fully the tobacco legislation; my concern is the evidence base for the vapes, and the potential for a cobra effect, where we might see people go back to tobacco-based products because they are cheaper to purchase. The second piece of evidence for this is that in the Regulatory Policy Committee report it says that it expects a 12% reduction in vaping, in a similar trend to tobacco-based products. Is that a reasonable assumption, given that there has been a long-standing public awareness of tobacco, versus perhaps a lack of awareness around the complexities of vaping products? Professor Sir Chris Whitty: Would Sir Michael like to go first? Professor Sir Michael McBride: Yes. Thank you for the important question. You are quite right that the evidence on the potentially harmful effects of vapes is still developing, and we are not at the stage that we are with our knowledge of tobacco. Certainly, as we have said already, the harmful effects of vapes are, and are likely to be, significantly less than those of tobacco, but are unlikely to be zero. This is an area in which there is ongoing research. The World Health Organisation has raised concerns about the potential impact, particularly in children, in terms of brain development. I know you will hear more about that later from other panellists. That is something that we will obviously need to continue to keep under review. The Bill provides us with the opportunity to introduce further measures, should that be required. However, in all this there is a need for balance. Obviously, the Government—and certainly the Northern Ireland Assembly, when they will be debating this in the coming weeks—will wish to ensure that there is a balance between ensuring that vapes are accessible to individuals to assist cessation of smoking and help them to quit, but also that we are guided by the evidence to ensure that any legislation that is introduced is proportionate. That is incumbent on all of us at this time. Certainly, should further evidence of harmful effects become available, there is the opportunity and flexibility within the Bill to look at this again. Professor Sir Chris Whitty: I would add only that it took us some decades to work out the extraordinary impact of smoking. Much of that tends to be cumulative over time, so you do not see the major effects of someone starting to smoke in their 20s till they are in their 50s, 60s and 70s. What we do not want is to be looking back in 20 years’ time and saying, “We knew these were addictive; we knew that people were smoking things.” Things that go into the lungs are much more dangerous than things you eat, for a variety of reasons. Just basing it on lab studies is not a safe way to proceed. I think all of us were therefore thinking that the sensible thing to do, while maintaining vapes as a smoking quit aid, is to avoid a situation where people who are currently not smokers take up vapes, because they will definitely get addicted—the nicotine is there, and there is a high chance in our view that they will have harms, although the size of those harms is currently difficult to put an exact number on over time. Some people come to extreme harms quite quickly, actually, but those numbers are fortunately relatively small.

Q Building on what my colleague and yourselves are talking about, specifically on vaping, I am trying to drill into your confidence levels on the flexibility in the legislation, which you have been talking about. As has been indicated—you have all talked very eloquently about it—there is not as much of an evidence base when it comes to vaping, for all the reasons you have outlined. If we think of a new car or a new product in the market, it will go through a lot of testing before it is put out there, in order to ensure it is safe. I recognise that in that regard, the genie is out of the bottle. However, the evidence underpinning vaping, as regards the integrity and safety of public health, is not as rigorous. Therefore, should the Bill not go further in terms of putting in more stringent requirements in that regard, until we have confidence in the impact on public health across all our four nations? Professor Sir Gregor Ian Smith: It is very difficult to disentangle the evidence about vaping, because so many of the people who are currently vaping are either current or ex-smokers as well. To do some form of longitudinal study that actually gets to develop the evidence base for any potential harm that is caused by vaping is difficult—although there are attempts to try to do that, such as through the Our Future Health study. At this moment, I think the provisions within the Bill represent a proportionate and reasonable approach with the flexibility that exists within it to be able to respond as new evidence develops, either towards or against the harms that are associated with vaping. I think it is proportionate in that it maintains vaping as a potential tool in the armoury to help people to stop smoking, but similarly it is proportionate in stopping the abhorrent marketing of vapes to children, which Sir Chris has already mentioned, and in allowing the position, which I think is correct, that if you have never started vaping or smoking, you should not. The proportionality of the provisions just now is heading in the right direction, but with the ability to flex as future evidence emerges.

We have one more question, which I am afraid is probably the last one to this set of witnesses, from Liz Jarvis.

Q I would like to understand more about how you think the gradual change in age of sale will affect tobacco and vaping behaviour, compared with increasing the age of sale in one go. If a child has an older sibling or someone who may be bringing the products into the home, or has older friends, I do not see how this will change the behaviour or the desire to try the products. Professor Sir Chris Whitty: It is important to be realistic about the fact that—as I suspect you will all remember from your schooldays, and if you have children, you will know from them—people do not stick exactly to the current law as it is. The idea that, magically, there will be a cut-off and people will exactly follow it strikes me as flying in the face of lived reality. However, as the age of sale moves up over time, I am very confident that it will lead to a significant reduction over time in the number of children buying cigarettes, because it will be illegal for people to sell them to them. It will not be illegal for them to possess cigarettes—that is an important distinction—but it will be illegal for people to sell them to them. If you are a 17-year-old you can usually pretend to be an 18-year-old, but pretending, or even wanting to pretend, to be a 30-year-old is a different thing completely. Over time this measure will become more effective. The impacts will be seen first in things such as children’s asthma and developing lungs. It will probably next be seen in birth effects, because the highest smoking rates are in the youngest mums: the rates are up to 30% in people who have children before they are 20, but much lower in people who have them in their late 20s or early 30s. In that younger cohort, the effect on stillbirths, birth defects, premature births and so on will be the next big impact that the Bill will have, and gradually it will roll over time. It is not a perfect mechanism—I do not think any piece of law that has been designed is a perfect mechanism—but, as a way of gradually driving smoking down in a way that does not take away anyone’s existing rights, it seems to me a reasonable balance between those principal aims. To go back to my first point, in reality the borderline will probably be a bit fuzzy, because it always is, but over time the effects will be very substantial.

I have about three minutes left, so I will ask Mary Kelly Foy to ask a very brief question with a very short answer, because we will be finishing spot on 10.25 am.

Q Do you have any view on how restricting vapes in public places, which is obviously a very welcome power, should be implemented so that it does not deter smokers from switching to vapes and they do not relapse back into smoking cigarettes? Professor Sir Chris Whitty: I will suggest that Sir Frank takes this question, because it is his very last answer to a parliamentary question; he is about to stop as chief medical officer, so he is going out on a high. Sir Francis Atherton: What the Bill does is to simplify matters, making it as simple as possible: a smoke-free place is a vape-free place as well. That does not take away people’s ability to go into a place where smoking and vaping are allowed, but it helps to disentangle the confusion that currently exists about where people can legitimately use those products. It is a simplification that can only help to lead, in the long term, to that reduction that we need. In Wales, 13% of people continue to smoke. Our ambition is to get to 5% by 2030; we will struggle to get there, but this Bill will help us to get there.

I am afraid that that draws this particular session to a close. I thank our witnesses, Sir Chris Whitty, Sir Francis Atherton, Sir Gregor Smith and Sir Michael McBride, for their attendance and for their helpful contributions, and I thank Members for their helpful questions. Thank you very much. Examination of Witnesses Hazel Cheeseman, Sheila Duffy, Suzanne Cass and Naomi Thompson gave evidence.

10:25:00

We will now hear evidence from Hazel Cheeseman, chief executive of Action on Smoking and Health; Sheila Duffy, chief executive of ASH Scotland; Suzanne Cass, chief executive of ASH Wales; and Naomi Thompson, health improvement manager at Cancer Focus Northern Ireland. We have until 10.55 am for this panel. I call the first Member to ask a question—the Minister.

Q Good morning, all. As we know, this is a resurrected Bill from the previous Government, with additional measures. How do you think it compares with the previous iteration? Hazel Cheeseman: We are all delighted to see this Bill return, and in such a strong form. There is complete consensus across the ASHs of the four nations that this is a Bill that is needed, wanted and workable. As the chief medical officer said in the previous session, the improvements in this Bill are that there are more provisions that will assist in reducing smoking among people who are already smoking and in protecting those exposed to second-hand smoke. It also creates a comprehensive set of regulations around all tobacco and nicotine products and provides us with that future-proof—the flexibility to respond to evidence as it emerges and changes and to the market as it emerges and changes over time. The Bill is enormously welcome for its comprehensiveness and robustness, and therefore for the opportunity to significantly reduce the uptake of smoking among the next generation and to aid people in quitting. The Minister will not mind me saying that I think there is more that the Government will need to do to accelerate that progress, in terms of investing in support for those who are already smoking and ensuring that we have the right strategy in place for that, but the Bill is a really good step in the right direction.

Q What impact have tobacco control measures had over time to date, and what impact do you expect this Bill to have in addition? Sheila Duffy: We have seen that tobacco control measures work. We have seen that they have reduced adult smoking rates over time. The points made by the chief medical officers were well made: we are looking to the generation growing up now in the UK; we are looking to protect them from addictions that so many now regret and that are claiming lives unnecessarily. Suzanne Cass: I would add that tobacco control policies that are put in place are popular, and are really welcomed among members of the public; they are also welcomed among people who smoke. There is a huge surge of public support for tobacco control policies, and that grows—it does not diminish—as we introduce new policies; it grows, and that public support increases. Naomi Thompson: In Northern Ireland, we are working towards a smoke-free Northern Ireland by 2035, and the reality is that tobacco control over the past 10 years has managed to bring things down to a stage where 2035 has potential. That is why tobacco control needs to continue. A Bill like this is just brilliant to keep that focus. If we can prevent people from starting, that will be absolutely key to making Northern Ireland, certainly, smoke-free by then.

Q Let me ask a question of Suzanne Cass. We heard from the CMO for Wales in the session before that the extension of smoke-free to outdoor places—such as outside hospitals, in playgrounds and outside schools—is already in place in Wales. What lessons do we need to learn from that? Suzanne Cass: As you know, ASH Wales and the Welsh Government have been at the forefront of implementing smoke-free spaces. We campaigned for smoke-free playgrounds and smoke-free school gates, both on a voluntary basis. Luckily, the foresight of the Welsh Government has made that provision legislation when it comes to hospital grounds, playgrounds, sports grounds, mental health units and a raft of other smoke- free spaces. We are obviously delighted that the Welsh Government has implemented that legislation. The legislation has made a huge difference, in that it has allowed a platform for communication—communicating the message that it is not okay to smoke around children. There is a massive amount of public support for that messaging, and we have had the opportunity to communicate it. When it comes to smoke-free hospital grounds, a lot of us are looking at that legislation and the possibility of implementing it. We have obviously had the legislation in place in Wales since 2021, and what we would say on the lessons learned is that there has to be a package when it comes to implementation. We cannot just legislate; we need to be looking at the support that is in hospitals for smokers to quit, we need to have trained staff and we need to have enforcement on the ground. There needs to be a whole package that comes with that legislation. That is the enormous lesson that we learned. We implemented that legislation in 2021—in the midst of covid, which was tricky—but we have had problems around enforcement and problems around compliance. It is a very different kind of tobacco policy from that in the other smoke-free spaces. When it comes to the other smoke-free places—playgrounds, sports grounds and other areas like that—there is a lot of compliance, but when it comes to hospital grounds, you have to do a bit more of the legwork. But it is well worth it, because what comes with that is on-site hospital support for stopping smoking, and the message to everybody coming on to that site that smoking is not okay and that there is support available if you want to quit. So it comes with a whole raft of measures that support that smoke-free message.

I call Caroline Johnson—apologies; I should have called you before the Minister.

Q The current advice, which was reiterated by the chief medical officer in the last session, is that if you do not vape, do not vape, but that if you smoke, vaping may be a better alternative. How will the measures in the Bill make it easier or harder for that message to be conveyed to the public who smoke? Hazel Cheeseman: That will be a really crucial question as this Bill progresses, and it was touched on by the chief medical officers. The nature of this Bill is that we are taking powers across a range of areas, which we know will help us to prevent the uptake of vaping among children, which we are all concerned about. We are restricting the marketing of vapes and the way they are branded, and taking powers around the design of products and in relation to flavours. It is important that those powers, as was discussed in the last session, are broad in the Bill and defined through further consultation and regulation, giving us that flexibility to shape policy going forward. We know from our experience in reducing smoking among children that the things that will work are reducing the appeal, reducing the availability and reducing the affordability of products. The Bill, alongside the excise tax that is planned for 2026, will take us a long way on that journey to addressing those aspects and reducing the appeal among children. We also want to ensure that products remain available for adult smokers to switch to. We know from our own research that adult smokers have very inaccurate views at the moment about the relative harms from vaping compared with smoking. Part of the issue is the way in which products are branded and pushed in people’s faces when they go into every corner shop up and down the country. That prevents the understanding that these products might be valuable for smoking cessation and promotes the idea that they are a kind of lifestyle choice for teenagers. Removing the branding and the displays in shops will allow the message that these products could be valuable to help people stop smoking, and will allow that message to land more easily than it currently does. That will hopefully realign those misperceptions and get us back to the position that we were in in, say, 2019 or 2020, where these products were being used as a smoking cessation tool and not really being used by other groups in the population. If we can get back to that, that would be the ideal scenario. Hopefully, the legislation takes us a bit closer to that.

Q How do you think the Bill will address health inequalities? We have heard that smoking is more prevalent among poorer individuals than among richer individuals. Will the Bill help address that? Sheila Duffy: We see that socioeconomic inequalities and smoking rates are closely patterned. ASH Scotland’s work with low-income communities in Scotland suggests that people regret beginning tobacco, but find it hard to move away from it. It also identified the dangers of less regulated novel products such as e-cigarettes in enticing their children and grandchildren into the kind of addiction that they themselves so regret. One of the real strengths in the Bill is the ability to bring some of these tobacco-related products into the kinds of control and regulation that we have fought so hard over decades to get for tobacco products.

Q Do you think the introduction of a generational ban on smoking could cause an increase in the use of other nicotine products, such as vapes or smoke-free tobacco? Hazel Cheeseman: The purpose of the legislation is to reduce smoking. The Department’s projections in the impact assessment clearly show that, even on conservative estimates, it will achieve that goal over time. So the question then is, does that lead to displacement into other products? Given that the legislation is comprehensive in relation to tobacco products, it is to be hoped that it will not lead to displacement into other kinds of tobacco products, but it might lead to some displacement into other nicotine products. As the chief medical officer said in the previous session, it is unlikely that nobody will take up smoking in the affected age group. Some people will; some of the 15-year-olds who will be affected by this legislation have already tried smoking. So we need there to be a legal nicotine product that those people will be able to use, with the restrictions that are coming into place in relation to vaping and other nicotine products in this legislation. One would not expect the overall consumption of nicotine to be greater than it otherwise would be, if that makes sense, but there may be some displacement into other nicotine products as we transition away from smoked tobacco and from tobacco being used widely in that group. Sheila Duffy: Dual use is a real concern in Scotland. Nearly 43% of people are dual-using cigarettes and e-cigarettes. The international longitudinal cohort evidence clearly shows a higher risk of progression to using combustible tobacco for young people that start vaping. I think this legislation has the real potential to move us away from that. Suzanne Cass: We also have to remember that the killer in the room is tobacco. The generational ban is the most crucial part of this legislation that we need to push forward. Therefore, we need to keep our eye on the ball when we are looking at the health impact, and the potential public health impact, of this Bill, and to make sure that we focus on driving down that tobacco use. Naomi Thompson: Just to reiterate what Suzanne has said, tobacco is the issue. The impact of tobacco was repeated multiple times in the previous session. If young people start, they continue, and they find it very difficult to stop. Therefore, if we can sort that, it is a great first step. There may be a small move towards other nicotine products, but we can work on that. Tobacco is the one that kills.

Can I just, as is my job, remind everybody that we are finishing at 10.55 am, which is in about 15 minutes or thereabouts? I have six people who wish to ask questions, so can I ask that the questions and responses are as tight as possible? Thanks.

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.

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.

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.

Q By restricting vaping products in this Bill in the same ways that tobacco products are currently restricted—be that packaging, display or potentially flavourings, as we discussed with the CMOs earlier—do you think that this will lead to greater misconceptions by the public and, quite crucially, current smokers about the relative harm between the two products? Suzanne Cass: We obviously have an issue when it comes to the understanding of and the misconceptions around the harms of vaping. In particular, the most worrying stats are among smokers considering them as harmful as or more harmful than tobacco. That is that a significant issue. This legislation allows us to reset the clock and promote these products as smoking cessation products, using health professionals to promote them and getting the right language around them. Rather than their being seen as a recreational toy, they can be seen as a product that is going to help people to quit smoking. When it comes to the positioning of these products, it is essential to readdress those misconceptions and re-place this product. On standardised packaging, what we did with tobacco was put it in the ugliest packaging you could ever imagine. We are not talking about that when it comes to vaping products; we are talking about plain packaging—something that is informative but not necessarily attractive to young people. There is a big difference between something that is repulsive and something that is not attractive. That is where we see the difference, and that is where we see this legislation coming into its own and allowing us to reset and to have that different conversation. Hazel Cheeseman: I am sure we will tease more of it out through the consultation process that will follow this legislation, but some of the early research that has been done has indicated that you can, to some extent, have your cake and eat it on this. If we remove some of the attractive branding elements on packaging, which we know appeal to children, that does reduce the products’ appeal to children, but it does not damage their appeal to adult smokers and it does not damage harm misperceptions. We can progress with this legislation, via the consultation and looking properly at the evidence, to make sure that we get the balance right. There are also provisions in the Bill to allow public health bodies to do marketing and public health messages around vapes as a smoking cessation tool. It will be important that the Department of Health and Social Care and the Advertising Standards Authority work with public health bodies to make sure that they have the right guidance to be able to do that and to give smokers directly the right information about how vapes can be used as a cessation tool.

Thank you. I am afraid this will probably be the last question before the next panel of witnesses. Tristan Osborne, we have about two and a half minutes left.

Q To go back to my earlier question on product displacement, which you have alluded to, you said there is concurrent evidence that people who are smoking are also vaping. Is there any evidence that there might be a cobra effect whereby, because we are banning disposable vapes, we are increasing the price of vaping, so you might then see people return to the product you were originally trying to get them off? Has there been any conversation in this space around what the evidence would be to show that the legislation is a success, beyond the overall reduction of smoking? Hazel Cheeseman: Currently, vapes are much less expensive than smoking, and that is the kind of gap that we need to maintain. As the excise tax comes into force in October 2026—that is its planned enforcement date—the intention is to raise the tax on tobacco at the same time to maintain the price differential. That is crucial. We do want to find a sweet spot for the price of these products that makes the entry level for young people and non-smokers higher. It is a dissuasive technique so that people who do not need to be using these products do not use them. We obviously want them always to be cheaper than smoked or combusted tobacco, so that there is always that incentive for people to switch from the more harmful to the less harmful. As has been repeatedly said, there is flexibility in the legislation: it allows us to calibrate. In particular, unlike the previous Bill, it allows us to regulate around product design and the size of products, so you could, for example, look to make them more expensive by changing the minimum size of the amount of liquid that could be sold. All this needs to be looked at once the Bill has passed. There is an awful lot of work to be done to calibrate around things like price, branding and so on, as the Bill passes and we move on to the secondary regulations. Sheila Duffy: Absolutely—

I do apologise, but I have to bring the session to a close as the time has been used up. I am sorry for interrupting. I thank our witnesses Hazel Cheeseman, Sheila Duffy, Suzanne Cass and Naomi Thompson for their evidence, and I am grateful for the questions that have been asked. Examination of Witnesses Dr Ian Walker and Sarah Sleet gave evidence.

10:55:00

We have the third panel of witnesses from now until 11.25 am. We will hear evidence from Dr Ian Walker, the executive director of policy at Cancer Research UK, and Sarah Sleet, the chief executive officer of Asthma and Lung UK.

Q What effect do you think vapes have on the health and the lungs of young people? Do you think the Bill will help to reduce the take-up of vaping in children? Sarah Sleet: In general, there is very little evidence around vaping, and we need a really considerable effort to get the evidence in place, but we do know that nicotine in general is not healthy for children, and vaping nicotine products will not be good news. We have some evidence about the harms that it causes—we know that nicotine in particular is very problematic for very young children and developing brains—but we do not have the same level of evidence base that we have with tobacco. That is why this Bill and the precautionary approach that it takes in terms of restricting children’s access to vapes and the attractiveness of vapes to children is very important.

Q Smoking is a huge cause of cancers. Do you expect that this Bill will reduce the number of cases of cancer and increase the age of people who get cancer across the country? Dr Ian Walker: First, thank you very much for the opportunity to be here. I start by thanking Parliament for boldly introducing this Bill; it is genuinely world leading. I have spoken to organisations across the world that are envious of the position we find ourselves in. That is a very important question, and the answer is absolutely yes—I think this Bill will be very important in reducing the number of cancers caused by smoking tobacco. We know that there is no bigger thing we could do to actually influence that going forward for the next generation and generations thereafter. As you have heard this morning, we know that we still have 6 million people smoking across the UK, and we know that we can expect hundreds of thousands of cases of cancer caused by smoking over the term of the next Parliament. As we move towards a truly smoke-free generation over the next 20, 30 or 40 years, we will absolutely expect to see the number of cancers caused by smoking—and, alongside that, the number of other illnesses associated with smoking—reduce.

Q Can you tell us about the evidence of the impacts of second-hand smoking on cancer in your case, Dr Walker, and on asthma and lung conditions in your case, Sarah? What difference do you think that the measures outlined in the Bill will have on those conditions? Dr Ian Walker: To start with smoking and cancer, the links between passive smoking and cancer, particularly lung cancer, are very clear. It is fair to say that there is less evidence around different scenarios that you might predict through this Bill, such as different outdoor environments and so on, but that is more because those studies have not necessarily been done. It is an important point to make that there is an absence of evidence, rather than evidence of absence. You heard from the CMO of England this morning that if you can smell cigarette smoke, you are exposed to it. The direct risk, then, is linked to how long you are exposed to it, how concentrated the environment is, how close you are to it and so on. Nevertheless, passive smoking is harmful—not just for cancer, but for vulnerable people with many other conditions as well—so we are very much supportive of the introduction of smoke-free places and the ability to restrict people smoking in particular outdoor spaces. Sarah Sleet: When it comes to people with lung conditions, second-hand smoke is incredibly important; it is a well-known, severe risk factor for people with lung conditions. About one in five of us in the UK will experience a lung condition—there are around 7 million people with asthma and about 1.6 million people living with chronic obstructive pulmonary disease. Those are two major conditions that are profoundly affected by second-hand smoking, and are clear risk factors in terms of deaths from asthma and people being hospitalised with exacerbations, so it is incredibly important that we deal with the issue of second-hand smoking. People said earlier that there is no choice about second-hand smoking, and yet it profoundly affects those with lung conditions. It is incredibly important that we ensure that we protect those vulnerable people as far as possible. When it comes to the discussion about how far we should go in terms of smoke-free and vape-free places, we would consider going further than what has been suggested already and looking at other areas to make smoke-free. I know there has been discussion about hospitality and trying to balance the potential economic impact that has been talked about if we make the outside of hospitality places smoke-free. However, we think, given the balance between the public health impact and what we have seen with smoke-free indoor spaces and its impact on business, we could go further and should go further, there.

Q The Bill takes powers to introduce restrictions on vaping, which are obviously subject to consultation after the Bill receives Royal Assent. What factors do you think will need to be taken into consideration as part of that further consultation? Sarah Sleet: People with asthma and lung conditions are in the middle, where they are affected by both smoking and vaping. It is really important to get the balance right. Smoking is terrible—it is terrible for people with lung conditions—and we need to make sure we can drive down smoking rates as much as possible. Vaping can play a part in helping with smoking cessation, but it should only be used for smoking cessation. People who have never smoked, and definitely children, should not be taking up vaping. We see vaping as a staging post to being completely nicotine-free. It is important to get the balance right between making vaping available for those who need smoking cessation and not encouraging people to try vaping or to keep vaping longer than they need to. The legislation is good in allowing that flexibility for adjusting over time, as we get more evidence in. It is really important to put evaluation in place and make sure that robust evaluation does flow through over time, so we can adjust and respond to it. Traditionally—certainly in respiratory diseases—there has generally not been enough research and evaluation, so we need to correct that now. Dr Ian Walker: First, I want to confirm that we are very much supportive of taking those powers. I think one of the real strengths of the Bill is the ability to adjust, moderate and titrate those powers and the actions that we take over time, not just as new evidence emerges, but as the tobacco industry and new products may emerge to try to circumvent the regulation that is in place. That is a really important part of the Bill. I think the crux of the question was about what is important to consider through the consultation. From our perspective, it is important to get a balanced view on what the right actions are in this area. Of course we all agree that we want to limit, reduce and stop access for children and young people and to limit the appeal to never-smokers, while balancing that carefully against making cessation tools available to people who are trying to quit. It is important not to forget the 6 million people who are currently smokers and the long-term health implications ahead of them. We need a balance so that it is as easy as possible for those people to quit when they have chosen to do so. There will be many balancing features and balancing points of evidence that will be really important through the consultation in coming to the right outcome.

Q In a nutshell, how important is it that the measures in the Bill are passed? Dr Ian Walker: Critical. Without a doubt, there is no single bigger action that you could take to reduce the cancer burden on the country. The cancer burden sits at a very personal, individual level for people getting their own diagnosis; it sits at a family level and at a friend level. It also sits at an economic level for the country and at an NHS level, in terms of the burden that smoking-related illnesses cause for the NHS. From my perspective, this is a world-leading piece of legislation. It is absolutely an opportunity for generational change and a long-term legacy that will see our children and grandchildren never able to legally buy tobacco in the UK and never exposed to the harms that that would cause them.

Q Is there any research into passive vaping risks to bystanders, who do not have a choice if someone is vaping next to them? Sarah Sleet: As I said earlier, the research evidence around vaping harms is currently very poor. There has not been enough. It takes a long time to build up evidence of things that are generally very progressive rather than having an immediate impact, so we will have to wait. We need to put that in place, and we are going to have to wait to get that evidence back. We have had anecdotal reports from our beneficiaries and those who contact the organisation about places—particularly in closed spaces, but sometimes outside—where there is a concentration of vaping. It is that classic thing where you go through a door and suddenly everybody around you is vaping immediately outside it. We get reports that that exacerbates people’s asthma and sometimes their COPD, but they are anecdotal. We really need the evidence base to support what is happening. Dr Ian Walker: The only thing that I would add specifically from a cancer perspective is that although there is very little long-term evidence, because the products have not been around long enough and the cumulative effects have not been seen yet, what we do know, based on the current evidence, is that vapes are far less harmful than cigarettes. You heard the advice earlier that if you smoke it is better to vape or take other nicotine products, but if you do not smoke you should not vape, because we do not know yet what the long-term effects will be. In particular, we are very light on evidence on what the impact of vaping will be on bystanders.

Q Do you believe that there is a substantial health impact on people working in certain sectors who unavoidably encounter second-hand smoke in the course of their employment? What impact will the measures in the Bill have on that? Dr Ian Walker: The impact of the Bill will reach every sector, on the face of it. Obviously the aim of making a smoke-free UK will impact everybody in whichever sector, but I think you are probably referring specifically to increasing smoke-free places, or places where smoking is not allowed. For people who are exposed unavoidably by their working environment, of course this will be good news and a good expansion. As you heard from Sarah, we did not quite get to hospitality in the Bill, but it will be interesting, as we go through consultation, to review the evidence and understand the sentiment. Clearly, people working in hospitality are likely to be exposed to smoke in their work environment, even if that is outside. The Bill makes important steps in increasing the number of smoke-free places and reducing exposure to tobacco smoke. Sarah Sleet: As the CMO said earlier, it is about the duration as well as the density of smoking. If you work in hospitality in those outdoor spaces, the duration will clearly be longer; if you work on a coach concourse, you will be exposed for longer. It is really important to remember that. Another issue is inequality. There is a concentration of working lives that are more exposed to second-hand smoking, which is exacerbated by inequality.

Q Some of the evidence that has been submitted referred to the gateway effect and how there is perhaps not the evidence to suggest that there is a transition from one to the other. Are your organisations still concerned about the increase in vaping among groups who have not previously smoked cigarettes? Sarah Sleet: That is a tricky one. We know that a lot of people who use vaping to stop smoking end up dual-using for a while. Some then move on to just vaping, and some eventually move completely away from it. We seriously need a comprehensive programme for nicotine cessation and smoking cessation to support people on that journey and make sure that people who go on that journey do not come back in. We heard earlier from ASH Wales about some really good measures that have been put in place, but without that wider context it is hard to cement the behaviour needed to move completely away from it. We need to think broadly about the whole support structure to help people to get off smoking and eventually to move away from nicotine altogether. Dr Ian Walker: I agree. The real killer in the room, if you like, is cigarettes and tobacco. There is no safe way of consuming tobacco. The alternative of smoking versus vaping is very clear; even though we do not know the long-term health implications of vapes, we know that you are much better off vaping than smoking. Having said that, of course we do not want young people and never-smokers to vape either. The power of the legislation is its double-pronged approach: preventing people from ever smoking in the first place by raising the age of sale by one year every year, and putting in place a comprehensive package of measures alongside that to control vaping, particularly the access to vaping and the appeal of vaping for young people, to reduce uptake in those communities. All those things together, alongside—you will forgive me for saying this—the investment that will be required for smoking cessation services and to support enforcement by Border Force, HM Revenue and Customs and retailers, will be important components of the Bill’s ability to drive the change that it can make.

Q Thank you for all your work to advocate for smoke-free legislation. Can I ask you about differential smoking rates across the country? Which parts of the country are likely to benefit most from this legislation as we see a decline in smoking rates and in tobacco use more generally? Sarah Sleet: Health inequalities relating to lung disease are profound. The three conditions with the biggest gap in health outcomes between rich and poor are lung conditions: asthma, COPD and lung cancer. All three are profoundly affected by smoking, and smoking is concentrated in socially and economically deprived areas. Those in the poorest part of the country are twice as likely to smoke as those in the richest part of the country. It is even more profound in certain segments. We heard that young mothers are four times more likely to smoke in poorer parts of the country than in richer parts. If we can drive down smoking, particularly among young people, the impact will be greatest in those areas that are most in need of help and support. This is probably one of the biggest things that can be done to tackle health inequalities. For that reason, I think the Bill is probably the most important public health measure being passed through Parliament in a very, very long time. Dr Ian Walker: Thank you for the question, which I think is a really critical one. At CRUK, we have done a lot of research and work on cancer inequalities, which are part of broader health inequalities and which generally mirror similar trends. We know that people in the most deprived communities have higher incidences of cancer. They typically present at a later stage, they typically engage less with screening, they typically have worse outcomes and they typically do not get optimal treatment —it is a pretty difficult story right along the pipeline. The reasons behind that can be very complex and involve lots of different things. Despite all that, the one thing we do know is that higher smoking rates, particularly among children and young people in the most deprived communities, are a really significant contributor to health inequalities. It is very clear from the evidence that the most deprived communities across the UK are the ones that suffer most from the impacts of tobacco. This Bill is clearly not a magic switch—it will not change those things overnight—but it sets us on the pathway to fundamentally reversing some of those inequalities and to reducing some of the cancer inequalities that we see across the UK. Alongside the important measures in the Bill, a really clear, targeted set of actions around health marketing interventions in those communities and the effective funding of cessation services where we need them most will contribute to reducing health inequalities much more quickly and much more effectively. Again, it is a very positive story in terms of the potential impact on health inequalities.

Thank you very much. As there are no other questions from Members, let me thank the witnesses, Ian Walker from Cancer Research UK and Sarah Sleet from Asthma and Lung UK. Ordered, That further consideration be now adjourned. —(Taiwo Owatemi.)

11:17:00