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Last week, the EU Commission launched a call for evidence to assess its legislative framework for tobacco control.  Its purpose is to evaluate if current tobacco control legislation has fulfilled its goals and whether or not it will further aspirations in Europe’s Beating Cancer Plan to achieve a tobacco free generation by 2040.

Various EU voices have been speaking of a “rapid rise” in emerging products such as nicotine pouches, heated tobacco, and nicotine free e-liquid which are not covered under the last Tobacco Products Directive (TPD) in 2014. They are also raising concerns about online sales and there is a sense amongst some that there is unfinished business from the last TPD. Many have expressed their wish for vaping to be treated in the same way as smoking. There is also much talk of bans on flavours, plus other restrictions on where products can be sold and used.

UK consumers may feel that this does not concern us now that we have left the EU but what emerges from this consultation will guide a review of the TPD which will be very influential globally and could have an impact here too. If you are a consumer reading this from an EU member state it will be a clear and present danger.

We hope many of you will take the opportunity to have your say by accessing the initiative here where you will also find a PDF file with extra information, available in 23 languages. Here is how to respond.

  1. Create an account and choose a password
  2. Click “give feedback” 
  3. Choose your preferred language 
  4. Type your comments in the box provided (up to 4000 words) and there is also an option to attach a file, should you wish.
  5. Then, once you are done, click to submit. Your comments will be instantly published. 

The call for evidence runs until 17 June, after which a 12-week consultation process will take place.

It is important that the consumer view is respected in an exercise such as this, so please do tell the EU your story and emphasise why the TPD review should embrace harm reduction, rather than imposing restrictions which will make reduced risk products less accessible and less appealing for smokers who may be considering trying them.

 

A fortnight ago we saw the publication of the government’s post-implementation review of the Tobacco and Related Products Regulations 2016 (TRPR). These are the regulations which govern vaping in the UK after having been transposed from the European Union’s Tobacco Products Directive.

The government has decided that the regulations “met their original objectives and they could not be better achieved through alternative regulatory measures”.

While it is disappointing not to see immediate signs of regulations being relaxed post-Brexit, such as the limits on tank and bottle sizes and a recognition that the limit on nicotine concentration is inadequate as we have commented on before, we are pleased that the UK has not been seduced by more restrictive regulations which are being pursued in other countries.

However, the report did signal amendments to the legislation could be implemented in the future.

“However, the Government will consider further regulatory reforms to TRPR as part of its plans towards meeting its Smokefree 2030 ambition, and to protect future generations from the harms of tobacco. This includes those reforms suggested by respondents to the consultation. Any proposed changes will be based on robust evidence and support improvements to public health.”

We would, of course, hope that any future reforms will be sympathetic to reduced risk nicotine options, but the summary does not exclude putting up more barriers.

As consumers who have experienced the benefits of harm reduction in our own lives, the NNA believes the arguments for relaxing regulations are far more evidence-based than those put forward in favour of imposing more restrictions.

It should be recognised that, although regulations remain as they are for now, by doing so the government has clearly signalled that vaping is beneficial to public health in the UK and that there is no cause for alarm despite misinformation rife in media and elsewhere.

However, we believe the regulations could be improved by relaxing pointless vaping controls which only serve to inconvenience vapers and deter smokers switching, but also by better acknowledging the positive contribution other harm reduction options can provide.

As we explained in our submission to the ongoing Independent Tobacco Review, which you can read here, the only credible approach which would achieve the government’s Smokefree 2030 goal is to go "all in" on tobacco harm reduction to encourage mass-switching to all smoke-free alternatives to cigarettes, not just vaping. Heated tobacco and nicotine pouches are available on the market, but many smokers know little about them, while snus has delivered remarkable results in Scandinavian countries but is subject to an unjustifiable EU-wide ban which should be lifted now we have left the European Union. 

We hope that regulations will be amended in the future to remove some of the pointless restrictions on vaping, but also to enable more accessibility and publicity for all non-combustible lower risk products. The NNA will continue to advocate for harm reduction in all its forms as a powerful tool in attracting smokers to safer alternatives.  

 

Last month, newly appointed Minister for Brexit Opportunities and Government Efficiency, Jacob Rees-Mogg, invited the public to suggest petty regulations that should be abolished now that the United Kingdom has left the EU.

Writing in The Sun newspaper, he said that “Brexit opportunities and government efficiency have the same ambition: Making the lives of British people easier.”, adding “I implore you all to write to me with the regulations you want abolished.”

The NNA has written to Mr Rees-Mogg to make the following suggestions which we believe would make life easier for millions of UK vapers and also help the government in its goal of achieving smokefree status for the UK by 2030.

  • Eliminate pointless restrictions on vaping tank and refill container sizes
  • Remove the 20mg/ml limit on the strength of nicotine e-liquid
  • Lift the EU-imposed ban on snus

You can read our letter here or below.

Supporters and followers can also make suggestions by emailing Mr Rees-Mogg at This email address is being protected from spambots. You need JavaScript enabled to view it..

 

Today is No Smoking Day, an annual event which seeks to encourage smokers to consider making an attempt to quit. This year’s theme is “Don’t give up on giving up. Every time you try to stop smoking, you’re a step closer to success.”

As the theme suggests, many smokers have made repeated attempts to quit without achieving their target. Currently, nicotine replacement therapy (NRT) options such as patches and gum are the first products offered to smokers and often fail to lead to the desired conclusion. It is good that vaping is increasingly recommended by smoking cessation services and the NHS but often it is considered only as a last resort.

We believe that people who smoke stand a much better chance of stopping smoking if they are comfortable in doing so, which is why we advocate for wide availability of reduced risk products as options for those who choose to quit. Combusted tobacco is the cause of harms, not nicotine, so devices which deliver nicotine in a safer manner should be widely promoted.

Unfortunately, we feel that current alternatives are being unnecessarily limited and that many smokers are either unaware of the products or have been misinformed about their safety and effectiveness.

Studies have shown that vaping is more effective for helping smokers to quit than traditional NRT and therefore public health organisations should be more willing to recommend vaping products to smokers, not just when all else fails. Many smokers are not comfortable with the clinical nature of NRT and smoking cessation services, as they do not consider themselves ill and requiring medical treatment but could more easily quit if reassured that a visit to a vape shop is not something they should be wary of.

Additionally, although UK authorities should be applauded for leading the world in seeing the benefits of e-cigarettes, which has brought very successful results by way of a significant decline in smoking prevalence in the past ten years, vapes are not the only lower risk choice out there.

It has been disappointing to note the reluctance of the UK government in recent months to fully recognise the potential of products such as nicotine pouches and heated tobacco, and it does not make any sense to perpetuate the European-wide ban on snus now we are no longer in the EU, as seems to be current government policy.

For smokers to be spared repeated failures, as this year’s No Smoking Day tacitly concedes, there needs to be better awareness given to the full range of reduced risk products on the market, not just the ones that government feels at ease with.

Many smokers who have tried vaping but found that it does not work for them may fare better with the more tobacco-like experience of heated tobacco, but as advertising of these products is banned, large sections of the smoking public are simply unaware that they exist. Nicotine pouches are on sale as a consumer product but there is little information about them from health groups as to how they may help people to quit combustible tobacco.

There also needs to be a more concerted campaign to counter the misinformation and confusion about reduced risk alternatives. The public has been so bombarded by scare stories about vaping that Public Health England’s latest Vaping in England report stated that 38% of current smokers believe vaping is as harmful as smoking when we know it is orders of magnitude safer. There is similar, if not worse, negative coverage of heated tobacco, especially, but also nicotine pouches. 

Lastly, it is also important to understand that smokers continue to smoke because they find it pleasurable. Reduced risk options which can replicate or exceed the enjoyment smokers get from combustible tobacco are more likely to lead to quitting. Not all people are the same and what works for some may not work for others, so all safer nicotine products have a role to play in order to maximise the number of people who successfully transition away from lit tobacco.

No Smoking Day’s theme is a good one, as it is right to encourage persistence if a person who smokes would rather not. However, for best results, we believe that all safer nicotine products should be made widely available, including lifting the ban on snus; smokers should be made fully aware of the variety of options on the market; and there needs to be far more emphasis on debunking misinformation about all reduced risk products.

If we want to help smokers to fast-track their way out of smoking, instead of enduring numerous failed attempts, let’s make every choice accessible and limit none.  

To learn more of how we believe tobacco harm reduction can help more smokers quit and contribute to the Smokefree 2030 goal, read the 20 proposals we put forward to the government’s Independent Tobacco Review here.

 

The Scottish government has launched a public consultation exercise for a new policy paper entitled “Tightening rules on advertising and promoting vaping products”. As the title suggests, the proposals seek to place unnecessary obstacles in front of raising awareness about vaping products in Scotland. The EU Tobacco Products Directive, which the UK ratified prior to Brexit, already stipulates bans on vaping adverts on TV, in newspapers and in magazines, but this new initiative from the Scottish government aims to treat vaping products the same as cigarettes by prohibiting in-store promotional displays as well as ads on billboards, bus stops and anywhere else currently permitted. The plans would also prohibit vape companies from sponsoring any event or activity and ban free or cut-price samples.

This threatens to make vape products effectively invisible and would mean Scotland having the most draconian advertising regulations for vaping products in Europe. The Scottish government claims to be committed to a policy of being smokefree by 2034 yet are now proposing making the most effective cessation devices in recent years hidden from smokers.

In short, these proposals from the Scottish government will protect the cigarette trade by making safer alternatives less visible, less accessible, and by raising doubts in many people’s minds as to their relative risk compared with smoking.

The NNA will be submitting a comprehensive response to this misguided set of proposals, but it is open to individuals too, so we encourage all to respond. Here is our guide on how to do so.

Consultation details:

The closing date is 28th April. Be sure not to miss the deadline or your response will not be considered.

The online form is available at this link and will not take too long to submit. If you do have time, though, we would encourage you to make good use of the opportunity to fully explain why you chose your responses in the further comments box provided for every question.

You can also email your response to This email address is being protected from spambots. You need JavaScript enabled to view it. or print the questionnaire off and send it to:

The Health (Tobacco, Nicotine etc. and Care) (Scotland) Act 2016
Consultation on Regulating Domestic Advertising and Promotion of Nicotine Vapour Products in Scotland
Tobacco Control Team
Scottish Government
St Andrews House, 3E Regent Road
Edinburgh
EH1 3DG

Questionnaire:

The consultation consists of 10 questions after an initial declaration of whether the respondent has any direct or indirect links to the tobacco industry. We have provided a rough guide of the questions below with our thoughts on the issues involved:

Question 1: Do you agree that we should be seeking to limit use of these products as a cessation aid and restrict exposure to non-smokers?

The focus throughout the consultation is on vaping being treated “purely as a smoking cessation aid” with a view to “gradually quit[ting] completely”. Indeed, the Ministerial Foreword specifically states that “Vaping products should only be used as a tool to help people stop smoking tobacco. They are not a lifestyle accessory.”. This fundamentally misunderstands the appeal of vaping as an alternative to smoking and would render vaping products far less effective. While it is unwise for non-smokers to take up vaping, too heavy a focus on preventing them doing so would also deter smokers from switching. Furthermore, viewing vaping as just a different kind of nicotine replacement therapy takes away one of the most attractive features of vaping, which is that it enables smokers to continue enjoying nicotine but in a far less harmful way. Vaping also works for many people who did not intend to stop smoking but ended up doing so, known as accidental quitters. If vaping is marketed only as a smoking cessation device those people may never try vaping and would continue to smoke.

As with all the questions, a box is provided to explain why you chose yes, no, or don’t know as your answer. In this instance the NNA will be answering no due to the reasons we have given above.

Question 2: Do you agree with proposal to extend restrictions on advertising these products in the ways described above?

The consultation document prefaces this question by saying that the Scottish government is taking a precautionary approach due to “the limited evidence on the long-term health impact of vaping”. We would argue that making safer alternatives less visible to smokers is reckless rather than precautionary as it will mean fewer smokers being aware of vaping or, worse, more believing that vaping is as harmful as smoking. Vaping products have been available in the UK since 2007 with negligible evidence of any resulting harms. Restricting all marketing of the most popular aid to quitting combustible tobacco because of future harms that have not been seen in a decade and a half is a gross over-reaction. The NNA will be answering no to this question.

Question 3: Do you agree with proposal that in-store promotional displays should be banned?

Again, this would make vaping products less visible to smokers. The Royal College of Physicians has stated that e-cigarettes should be promoted “widely as substitute for smoking” so this proposal is counter-productive and would lead to fewer smokers switching. Vapers also need information as to which products are available in the marketplace to improve their experience and prevent relapse. The NNA will be answering no.

Question 4: Do you support the proposal to make brand-sharing an offence?

This measure seeks to “prohibit vaping products from either carrying another product’s brand on a device or packaging or have the branding of a vaping product on any other products”. This would mean vaping manufacturers could not produce branded items such as T-shirts, baseball caps or any other promotional item. This treats vaping exactly the same as cigarettes which can only persuade many people that they are equally harmful. The consultation document admits that this measure is just copied from regulations on combustible tobacco. It is important that a clear distinction is made between smoking and vaping so the NNA will be answering no to this question.

Question 5a: Do you support the proposal to make free distribution of vaping products an offence?
Question 5b: Do you support the proposal that nominal pricing of vaping products should be an offence?

Vaping products are new and competing with well-established incumbent products - cigarettes.  Marketing and promotions are needed to highlight the products and to provide information on how they work and how to use them, especially for new users. Many vapers will have initially switched from smoking after sampling a vape product, redeeming a coupon or taking advantage of a cheap deal. This proposal would make these illegal. The consultation document says that “Restricting free distribution and nominal pricing would stop businesses giving away to the public any product or coupon where the purpose or effect is to promote a vaping product”. There is a specific exemption for the NHS and charities which means the Scottish government is aware that such promotions are useful for attracting smokers to vaping. It is therefore counterproductive to ban methods by which smokers may be tempted to start vaping instead. The underlying message this proposal seeks to send is that vaping is for health professionals to give out, not businesses. Much of the appeal of vaping is precisely because smokers do not view themselves as sick and needing treatment and many favour a vape shop over a clinic. It is irresponsible to take away options for smokers and vapers in an attempt to recast vaping as purely for cessation rather than pleasurable too. The question comes in parts a and b, but it’s a no from the NNA to both of them.

Question 6: Do you support the proposal to make sponsorship agreements in respect of vaping products an offence?

There may be certain activities where it may be unwise to apply sponsorship from vaping manufacturers, but by no means all. Under the guise of protecting children and non-smokers, this proposal states that “Vape products should not be associated with clubs, events, activities, individuals or groups”. Again, the consultation document draws parallels with the tobacco industry in an attempt to demonise businesses which are helping smokers to quit. There are many events and activities where vaping sponsorship would be perfectly acceptable. We will be answering no to this question too.

Question 7:  Do you support the proposal to introduce exemptions to allow advertising at trade-only events?

It is essential for any business to advertise within the trade in order for products to improve over time, so the NNA will be answering yes to this question. However, it is worth noting that this exemption does not include public days at Vape Shows and Expos.   

Question 8a: Do you support the proposal that fines and penalties should mirror those already in place for tobacco products?
Question 8b: Do you support the proposal that defences should be as laid out as above?
Question 8c: Do you support the proposal that officers of local authorities should be responsible for enforcement?

Question 8 relates to punishments for contravening the new advertising restrictions. Question 8a specifically states that the proposals intend to mirror those applied to cigarettes. Numerous health bodies have advised that the distinction between vaping and smoking should be made clear, yet the Scottish government wishes to treat both products the same throughout these proposals. On the basis that we disagree with the advertising restrictions being proposed in this consultation, we would also disagree that business should be fined for attempting to help smokers to quit so the NNA will be answering no.

Question 9a: Please indicate the impact the proposed policy would have on individuals.
Question 9b: Please indicate your view on the impact of the proposed policy on people living with socio-economic disadvantage?
Question 9c: Please identify communities or groups who may be impacted by these proposals

Question 9 attempts to assess the impact these new regulations would have on the public. It is clear that if advertising is prohibited fewer smokers will be attracted to switch to safer products. Smoking is far more prevalent in lower socio-economic communities and taking away information will only lead to fewer of those smokers quitting by way of vaping. The proposal would also have a significant impact in convincing large swathes of the public that vaping is as harmful as smoking. We can only see negative consequences arising from the proposals, so the NNA will be choosing “negative impact” from the choices provided.

Question 10: Further comments

This question is an invitation to add your comments on the proposals in general. If you are a vaper, take this opportunity to tell your own story and how restrictions on advertising may have prevented you from switching to vaping in the first place. You may wish to point out that Scotland’s goal of being smokefree by 2034 will be threatened by these measures by hiding vaping products from adult smokers who may benefit from being made aware of them via advertising channels. You may also wish to comment on any aspects of the evidence provided in the consultation document which you find questionable. Much of the narrative seeks to present vaping as a harmful activity by cherry-picking sources and over-emphasising the threat of children taking up the products despite all surveys to date concluding that youth use of vaping products in the UK is very rare in those who were not former smokers. You could emphasise that the allure of vaping to very many is precisely that it is not considered as solely a smoking cessation product, but as an alternative way of consuming nicotine which is orders of magnitude safer than smoking. Or you may wish to comment on the potentially damaging consequences to the public perception of reduced risk products by treating vaping in the same way as smoking.

We hope you will take the opportunity to respond to this consultation as the tone and content of the proposals are sinister and can only result in less favourable outcomes than the status quo. If you choose to respond, make your case clearly and firmly but please remember to be polite and constructive. 

 

Although other priorities have occupied politicians for many months, government minds are beginning to focus on other policy areas which have been side-lined during the pandemic. On 31st January, it was announced that there would be a refocus on advantages to be gained from the UK leaving the European Union with the release of a report entitled The benefits of Brexit - how the UK is taking advantage of leaving the EU. Page 83 of this report spoke of the government’s tobacco policy and potential post-Brexit reforms:

Helping people to quit smoking. The UK is already recognised as a world leader in tobacco control and has made good progress reducing smoking rates. However, with around six million smokers in England and stark health disparities associated with smoking, more still needs to be done to help people to quit smoking. We have now launched a rapid independent review to identify which policies and regulatory reforms will be most impactful in supporting our 2030 Smokefree ambition, including where it may be beneficial to go further than the EU’s Tobacco Products Directive allowed us to. We will set out proposals for our regulatory reforms in a new Tobacco Control Plan due to be published later this year. 

Furthermore, just a couple of days later a new long-awaited levelling-up white paper was launched which includes a series of medium-term “missions”, or targets. Amongst them is a goal of reducing the gap in healthy life expectancy between the richest and poorest areas and improving wellbeing in every area of the country.

Tobacco harm reduction can play a significant role in advancing both these government agendas and the NNA has already formulated a set of proposals which will do exactly that if they are adopted.

We wrote to the Department of Health and Social Care and the Number 10 Policy Unit to suggest post-Brexit tobacco and nicotine policy reforms in October 2020 and followed up with another letter in May 2021 with proposals set out a wider policy agenda along the same lines.

Our recommendations are just as relevant now – in fact more so considering the announcements this week – as they were then and fit both post-Brexit reform and the levelling-up initiative well. Based on driving behaviour change through consent and consumer choice rather than what some members of the public see as coercion, the proposals are simple, involve minimal cost to the taxpayer and we believe they would be effective in aiding the government’s Smokefree 2030 aspiration. Namely:

1. Lift the ban on oral tobacco (snus) and properly regulate all smokeless tobacco 

2. Raise the limit on nicotine concentration in vaping liquids to allow vaping products to compete more effectively with cigarettes 

3. Replace bans on advertising of vaping products on TV, radio, internet and in publications with controls on themes and placement 

4. Replace blanket bans on advertising of low-risk tobacco products with controls on themes and placement 

5. Replace excessive and inappropriate warnings on vaping products with risk communications that encourage smokers to try switching 

6. Replace excessive and inappropriate warnings on non-combustible tobacco products 

7. Allow and enable candid communication of relative risk to consumers 

8. Adopt a fresh approach to pack inserts for both vaping products and cigarettes to encourage switching to lower risk products 

9. Remove wasteful restrictions on vaping product tank and e-liquid container size that have no discernible purpose 

10. Recognise and regulate novel oral nicotine products

You can read our previous communications here and here.

On the opportunities presented by Brexit, the government has many more options for helping people to quit smoking now we are out of the EU, but we have seen very little appetite for taking advantage of these so far. In fact, we have noticed a worrying trend of parliamentary messaging which seems to be favouring vaping but moving away from harm reduction in all its other forms. The regularly repeated government mantra that “all tobacco products are harmful” fails to recognise the huge difference in risk between combustible tobacco and far safer non-combustible alternatives such as heated tobacco and snus.

As our proposals set out, the UK government now has the option of removing some of the arbitrary rules imposed on vaping products under the Tobacco Products Directive such as bottle and tank sizes which serve no valid purpose except to frustrate vapers and deter smokers who may otherwise choose to switch, and the UK could also choose to liberalise the cap on nicotine strength which we believe is set too low under TPD regulations to adequately attract hard-to-reach smokers.

There is also still no reason whatsoever for perpetuating the EU ban on snus in the UK. Sweden and Norway – where snus is widely available – both recently reported even lower smoking rates than ever with combustible tobacco becoming a niche product as people switch to snus instead. Smoking prevalence in Sweden is now down to an enviable 6% while Norway looks to be on the verge of a smoke-free generation as smoking among 16- to 24-year-olds has dropped from 12% to 1% in a decade.

On levelling-up, research has consistently shown that smoking is more prevalent in lower socioeconomic groups. The government can seek to improve economic conditions for less well-off communities but to achieve the levelling-up of life expectancy and improve wellbeing, ensuring wide availability of all reduced risk nicotine options for smokers – and, crucially, ensuring they are aware of them - is not just a wise idea, but also a cost-effective one.

We intend to write again to the government soon to re-emphasise the value in our proposals and how they dovetail with this week’s policy announcements. We invite NNA supporters to do the same by contacting their MP and directing them to our sensible proposals.  

 

 

Tobacco: preventing uptake, promoting quitting and treating dependence

In a world where tobacco harm reduction, specifically vaping, is stigmatised daily by policy-makers and scientists desperate to search for harms and dangers of a technology that, if adopted and supported worldwide, could have already slashed rates of smoking, the new NICE guidance Overview | Tobacco: preventing uptake, promoting quitting and treating dependence | Guidance | NICE published 30.11.21 is a welcome breath of fresh air. Although conservative and cautious, as NICE guidance has to be, based on evidence rather than testimony or optimism (as my Stop Smoking Service’s vape-launch was in early 2014), this provides a clear message to the rest of the world that here in the UK at least, there is support for the use of vaping to stop smoking. Vaping for recreational purposes is not considered, of course; that is outside the scope of the guidance, but longer-term nicotine use is addressed, and that is welcome.

NG209 provides a disclaimer about medically-licensed products:

"At the time of publication (November 2021), no nicotine-containing e-cigarettes were licensed as a medicine for stopping smoking by the Medicines and Healthcare products Regulatory Agency (MHRA) and commercially available in the UK market. All nicotine-containing e-cigarettes in the UK that are not licensed as a medicine by the MHRA are regulated by the Tobacco and Related Products Regulations 2016, and cannot be marketed by the manufacturer for use for stopping smoking."

Whether a product ever gets a medicinal license remains to be seen. The barriers are high and the costs even more so. Opinion is divided on whether this helps get more ‘respectability’ for the category, but it cannot be denied that being able to prescribe to young smokers, or those in hospital, could be a benefit.

The NICE take on nicotine is something that other countries’ medics, researchers and policy-makers could well heed:

Provide the following information about nicotine:

  • smoking is highly addictive mainly because it delivers nicotine very quickly to the brain and this makes stopping smoking difficult
  • most smoking-related health problems are caused by other components in tobacco smoke, not by the nicotine
  • nicotine levels in medicinally licensed nicotine-containing products are much lower than in tobacco, and the way these products deliver nicotine makes them less addictive than smoking.

The references are about licensed nicotine-containing products, because that’s where the evidence is found, and the emphasis on relative harms of smoking and non-combusted nicotine use serve to strengthen the argument for nicotine without the smoke.

"Provide the following information about the effectiveness and safety of medicinally licensed nicotine-containing products:

  • any risks from using medicinally licensed nicotine-containing products are much lower than those of smoking; nicotine replacement therapy (NRT) products have been demonstrated in trials to be safe to use for at least 5 years
  • lifetime use of medicinally licensed nicotine-containing products is likely to be considerably less harmful than smoking"

The language used by NICE makes a positive and welcome contribution to de-stigmatising the use of nicotine, and the term ‘dependence’ has begun to replace ‘addiction’. Even more importantly though, there is a distinct move towards an open-minded and person-centred approach, not regarding vaping as an option of last resort. It also recommends that extra information on how to make that first step wouldn’t go amiss.

"Offer behavioural support to people who smoke regardless of which option they choose to help them stop smoking. Explain how to access it.

Advise people (as appropriate for their age) that the following options, when combined with behavioural support, are more likely to result in them successfully stopping smoking:

  • varenicline (offered in line with NICE’s technology appraisal guidance; see stop-smoking interventions in the NICE Pathway on tobacco use)
  • a combination of short-acting and long-acting NRT
  • nicotine-containing e-cigarettes"

A criticism that I would raise is the assumption, below, that youth vaping leads to youth smoking. This confuses correlation with causation and should be corrected; many factors influence the uptake of smoking and must be taken into consideration.

"The committee wanted to discourage e-cigarette use among young people and young adults who do not smoke because evidence shows that use of e-cigarettes is linked with a higher chance of ever smoking later in life. The committee members agreed that ideas about smoking and what is normal can start from a young age so the recommendation should also apply to this age group."

The simple statement below should be noted, especially where evidence reviews cherry-pick research to ‘prove’ that vaping does not help smoking cessation. If more was done to give people who smoke the confidence that vaping can help, and is not the same as smoking, more people would switch.

"They also agreed that offering behavioural support to people using nicotine-containing e-cigarettes would increase their chances of stopping smoking.

Evidence showed that nicotine-containing e-cigarettes can help people to stop smoking and are of similar effectiveness to other cessation options such as varenicline or long-acting and short-acting NRT.

There was a small amount of evidence about short-term adverse events of e-cigarettes that did not show that they caused any more adverse events than NRT, e-cigarettes without nicotine or no treatment."

On health harms, the guidance is clear that so-called EVALI outbreak was restricted in place and time, and the risks controlled by effective regulation.

"The committee discussed the outbreak of serious lung disease in the US in 2019, which US authorities identified was largely caused by vaping cannabis products containing vitamin E acetate. They also noted there has been a Medicines and Healthcare products Regulatory Agency (MHRA) Drug Safety Update highlighting serious lung injury with e-cigarettes issued in January 2020 (E-cigarette use or vaping: reporting suspected adverse reactions, including lung injury). The committee discussed that the UK has well-established regulations for e-cigarettes that restrict what they can contain. Experts from the MHRA described to the committee the monitoring process for both short- and long-term harms of using e-cigarettes. Monitoring is ongoing and the evidence may change in the future, but the committee was not aware of any major concerns being identified."

The following paragraph could have been strengthened, in my opinion. Less harmful – good to emphasise, and I sincerely hope that the healthcare community takes note of this, instead of telling their patients that vaping is as bad as, or worse than, smoking. The caveat about only as long as they need is a mixed message. Some people will need that for life. I’ve seen too many people lapse even years later, and if vaping keeps them smokefree forever, that’s a win. However, pleasure from vaping (outside the scope of NICE guidance), should also be recognised, especially when put in the context of pleasure from enjoying alcohol, eating chocolate and drinking coffee.

"The [committee] agreed that because many of the harmful components of cigarettes are not present in e-cigarettes, switching to nicotine containing e-cigarettes was likely to be significantly less harmful than continuing smoking. So the committee agreed that people should be able to access them as part of the range of interventions they can choose to use. They also agreed that people should be given up-to-date information on what is known about e-cigarettes to help them make an informed decision about whether to use them. The committee agreed that with the limited data on effects of longer-term use, people should only use e-cigarettes for as long as they help prevent them going back to smoking. They also agreed that people should be discouraged from continuing to smoke when using e-cigarettes, even if they are smoking less, because there is no information on whether this will reduce their harm from smoking."

I was concerned about the guidance for healthcare professionals that they should talk to patients about:

  • How long the person intends to use nicotine-containing e-cigarettes
  • Using them for long enough to prevent a return from smoking and
  • How to stop using them when they are ready to do so

No one really knows how long they intend to vape – as experience develops, minds are changed. An individual may decide to stop sooner than they really should, and risk going back to smoking, or they could choose to continue vaping for the foreseeable future. They will not know, within weeks of switching, how their choices will change. Also, there are certain or universally-applicable ways of stopping vaping; clinical experience in my service demonstrated that people are generally comfortable with reducing the strength of their vape, and stopping if that’s their choice, without any intervention from support services. 

The statement below is a hidden gem, appearing as it does towards the end of a very long document. Not enough nicotine is one of the primary reasons for failure when trying to stop smoking. Even would-be quitters who use a vape tend to think they are better off with a non-nicotine vape, and wonder why they cave and grab a cigarette. Use enough, people!

"The committee discussed that it is more likely that people will not get enough nicotine to help them stop smoking, than get too much. They agreed that not getting enough nicotine is likely to increase the risk that the person will return to smoking, so they recommended that people should be encouraged to use as much as they need and told how to use the products effectively."

And finally, an appeal to the interests of commissioners and providers: a little extra effort could increase success in quitting, and save money in treatment costs for smoking-related illness.

Extra time may be needed to discuss e-cigarettes with people who are interested in using them. If these recommendations lead to more successful quit attempts, this may mean fewer appointments per person and substantial savings in downstream costs associated with smoking.

I believe that the committee worked extremely hard to get the balance right, and I’m sure that some members deserve a special round of applause for their determination to have the vaping category included. It would have been so easy to default to licensed medications only, thus missing an exceptional opportunity to push down rates of smoking, by recognising that switching to vaping will save lives.

Louise Ross, December 2021

 

 

On Tuesday the Office for National Statistics – the UK government’s official agency for assessing economic and social behaviour – released their latest statistical bulletin on smoking prevalence. It made for interesting reading:

    • The proportion of current smokers in the UK has fallen significantly from 14.7% in 2018 to 14.1% in 2019.
    • In Great Britain, 5.7% of respondents in 2019 said they currently used an e-cigarette, which equates to nearly 3 million adults in the population.

Figure 1 Smoking prevalence has fallen in all four countries of the UK since 2011

The number of vapers in the UK has not changed much since previous assessments, but smoking prevalence continues to decline at a significant rate.

Many of the direst predictions of the effect of safer nicotine products – not just here but in other countries - have often focussed strongly on the possibility of a ‘gateway’ from vaping to combustible tobacco use, especially amongst youth. However, in the UK where regulations on reduced risk products are arguably the most liberal in the world, this is simply not happening.

These figures seem to endorse the government’s willingness to allow vaping and other safer nicotine delivery systems to flourish. Who knows how many dual users have now transitioned entirely to vaping amongst that static population of 3 million e-cigarette users? Additionally, how many of the statistically significant number of smokers have switched to other safer products not studied in this analysis such as heated tobacco and tobacco free nicotine pouches which are now sold in UK supermarkets?

One thing that seems certain is that if anywhere was to see a big gateway effect from widespread use of vaping products and other alternatives, it would be here in the UK. But there is no apocalypse as predicted by negative soothsayers, it would appear that normalising alternative products merely normalises switching away from smoking. 

It is also worth noting that this decline is in the face of some atrocious media headlines and heavy funding of bad news from conflicted sources. One can only conclude that if the fear merchants would stop spreading myths and half-truths to the British public, the declines could be even more impressive than they already are.

So, it seems that the end is not nigh at all if a government supports tobacco harm reduction; these statistics suggest the complete opposite is true.  

It is a shame that other nations are not enlightened enough to recognise the benefits of vaping and other reduced risk products, and that their governments refuse to take their blinkers off and look at the overwhelming scientific evidence in favour of alternatives to smoking. The ONS has just added to that evidence and there must surely come a time when common sense prevails not just here but in other jurisdictions too.

If anything, this news should encourage the UK government to be even bolder and further relax restrictions on safer nicotine products to make them more visible to the 52.7% of smokers who the ONS has concluded want to quit. Outside of the EU, this is an eminent possibility for the UK, and we hope that the opportunity will be embraced.

Franklin D Roosevelt is famously quoted as saying that, sometimes, there is nothing to be feared except fear itself. This latest evidence shows that this is especially true of tobacco harm reduction policies.

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It has come to our attention that Kind Consumer – the company behind medicinally licensed smoking cessation device, Voke – is exploiting deaths attributable to black market THC liquids in the USA to promote its product.

A slide presentation to investors by the company made the claim that Voke is preferable to e-cigarettes because there have been “numerous recent cases of lung disease and death in individuals who use vape products”. This is completely untrue of legal vaping products and we unreservedly condemn their approach.

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We realise that business is business and Kind Consumer wish to differentiate their new product from vaping, but repeating information that they know very well is false is not the way to do this. It is especially scurrilous when you consider that they are using the fraudulent information to raise significant levels of funding to the tune of tens of millions of pounds.

There is room in the safer nicotine market for many players, and we would ordinarily welcome Voke adding a new option for smokers wishing to quit. However, they should not be trying to build their success by shoving vaping under a bus.

Kind Consumer should instruct their fund-raisers and marketers to abandon this approach. It is unhelpful and shameful opportunism. If their product has merit, they should not have to sink to employing baseless scare stories which have deterred large swathes of smokers from switching away from lit tobacco.

As we said in September last year on this subject:

We … condemn the many bad actors who are fanning the flames of this false panic. Whether it is journalists chasing click-bait or ideologically driven harm reduction sceptics in the UK health community, they are actively deterring many thousands of smokers from either opting to switch to a far safer form of nicotine consumption or guiding those who may be using e-cigarettes to move back to smoking, based on no proper evidence whatsoever.

This is not a game. Their crass conflation of vaping with illicit, unregulated and deadly illegal drug-containing liquids will cost lives and they should be thoroughly ashamed of themselves.

It is sad to see Kind Consumer endorsing such a shabby business model and we hope that they will ensure that it is not pursued any longer.

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There is much talk of further measures to control the outbreak of Coronavirus, but closure of vape shops should on no account be considered.

We are living through extraordinary times, with restrictions on personal freedoms – understandably - not seen since the second world war. It is essential that all of us observe the advice of the government, but the NNA hopes that if a rumoured ‘lockdown’ were to happen, vape shops would be excluded on public health grounds.

We have seen other countries such as France and Italy recognise this by exempting premises supplying vaping equipment and liquids from their general order for businesses to close. They have acted wisely, and we would urge the UK government to follow their lead.

These are very stressful times and access to safer nicotine products must be maintained. Supermarkets do sell some vaping products, and - while they are very helpful to many former smokers - they are expensive, with little variety, and do not cater for a large sector of society. Vaping has made a large contribution to the UK’s public health by attracting smokers away from combustible tobacco, and furthermore preventing relapse. It is important that this continues.

Vape shops are typically low key and do not attract crowds, so there are sensible social distancing measures which can easily be taken to ensure that vapers can continue to access the products they have found so useful in reducing risks to their health. There are online options for purchasing vape products, but it would be irresponsible to deny those who are not ‘net savvy’ the services that a bricks and mortar outlet gives them.

The NNA represents all current and future consumers of safer nicotine products, not industry, but we agree with trade bodies IBVTA and UKVIA who have both indicated that vape shops are a key resource and should remain open. The last thing we need during a public health crisis is to encourage another by closing off reduced risk options and leading many to return to smoking widely accessible tobacco.

We hope all our supporters stay safe during this difficult time and that availability of the supplies you need are considered as essential by government as we all know they are.

 

Last week we reported on a quite shameful ITV ‘investigative’ programme – broadcast during prime time – which smeared e-cigarettes and vaping products without editorial balance, and seemed to have been put together without any serious investigation whatsoever.

We said that ITV should be ashamed of the misinformation that they thrust on the public and described it as “scientifically ignorant scaremongering” which “misled millions of people with the message that they should just carry on smoking”.

You can watch the appalling show at this link, and if you are inclined to complain to OFCOM about its shockingly poor standards – as many others have - you can do so here.

Fortunately, genuine investigative journalism – not the unthinking tabloid kind exhibited last week by ITV - has not yet fully died in favour of ignorant and sensationalist clickbait, as The Economist has proved with this very astute guide to vaping, published last week.

See the video below for something far more sensible.

 

Last night, the ITV ‘investigative’ show Tonight broadcast a 30 minute probe into vaping which can generously be described as poor.

One wonders what the terms of commissioning were that resulted in a complete absence of balance and no information whatsoever being conveyed to UK viewers about harms in the US being exclusively caused by illegal black-market products involving contaminated liquids sold by criminals.

You would think that a responsible broadcaster would want to make that kind of vital and life-saving information available to viewers, but they didn’t. As ‘investigative journalists’, they could surely not have been unaware of this fact – as stated publicly by the US CDC - so we have to wonder at their motivation for producing something so slanted and irrelevant to the UK viewers they were broadcasting to.

Scant, and almost dismissive, attention was given to prominent UK voices such as Public Health England and ASH, while financially conflicted outliers from America were handed prominence without even a cursory examination of their pronouncements. An MP in the UK, however, was grilled extensively about non-existent conflicts which only proved that the presenters were catastrophically ill-informed about how parliament works.

Jonathan Maitland is a good broadcaster who has produced interesting shows in the past but came across in this programme as a gullible and incompetent researcher dancing to the tune of those above him who played him like a patsy.

Fortunately, social media has been harsh on the show, so whoever it was that decided on the gutter hit-piece that they delivered may hopefully realise they have misjudged the public mood in this country.

But more important is the fact that public perception of the relative safety of e-cigarettes has been nose-diving for years, precisely because of scientifically ignorant scaremongering such as the ITV broadcast last night. Public health officials in the UK are exasperated that the positive messages they give are drowned out by chancers out to make a buck on misleading information, click-bait and short-term notoriety.

ITV produced a show that was ignorant, lacked balance and that will harm many people’s lives, not just now but in the future. They should be thoroughly ashamed of themselves.

Professional journalists have long bemoaned the impact on news reporting that bloggers and social media have created. They criticise those channels for not having standards and lacking in objectivity when scrutinising important issues, yet their programme last night was so lacking in research and basic fact-checking that they have helped the country to realise that broadcast media is on the decline. They had a chance to prove that responsible investigative journalism wasn’t dead, but instead decided to jump in the coffin and nail it shut themselves with their own partial alarmism.

With their show, Jonathan Maitland and ITV have misled millions of people with the message that they should just carry on smoking, and that public health officials and politicians in this country should be ignored.

The British public deserves better than their shamefully bottom-of-the-barrel partisan propaganda.

 

Considerate vaping welcome NNA

For a long time now, the NNA has warned that bans on vaping in public and private places are harmful to the success that use of safer nicotine products can provide for the benefit of the public’s health.

It’s simple logic. The UK smoking ban in 2007 was designed by public health advocates to send a message that second-hand smoke is harmful to bystanders, and the same organisations have since sought to emphasise the threat of exposure at every opportunity. The result is that the wider public now believe that they can be harmed by smokers and, in turn, smokers believe that they are not only harming those around them, but also many now have adopted an acute belief that their habit is not doing them any good.

Most people have a great faith in policymakers to only ban behaviour if it has been proven to be harmful, so when vaping is banned in publicly accessible venues, there is an implied assumption that it is as dangerous as smoking. Why, after all, would state organisations and private venues act so drastically if that is not the case?

The NNA has argued against this huge downside to arbitrary – and often lazy - vaping bans consistently in the past few years to anyone who will listen. We gave evidence to MPs to that effect as well as urging public health groups supportive of reduced risk products to consider the negative connotations that such bans can have on the public’s understanding and to do more to counteract it. As recently as June, our Chair also suggested to industry at the ENDS Conference in London that they should be using their resources to campaign against vaping bans which damage public perception still further.

Now, it seems, public health research agrees with us. A newly-released study from the Indiana University School of Public Health sets it out very clearly:

Adults living in the states with an aerosol-free policy (including vaping in legislative smoking bans) were less likely to use ENDS (e-cigarettes) compared with those living in the states without an aerosol-free policy, controlling for individual- and state-level covariates (adjusted odds ratio = 0.79, 95% confidence interval = 0.64, 0.97). Stratified analyses showed that the association varied by age group; the statewide aerosol-free policies was associated with lower odds of ENDS use only in adults aged 25-59 but not young adults (aged 18-24).

In simpler words, where comprehensive vaping bans apply, adult smokers are less likely to take up vaping as an alternative.

The deficit in understanding of the safer nature of vaping in the UK has been spoken about for quite some time. Cancer Research UK has long expressed concerns that public perception about the relative safety of e-cigarettes compared to smoking is declining rather than increasing, and evidence submitted to the government’s Science and Technology Committee by the Royal Society of Public Health described the deficit in understanding very well:

Research has shown that perceptions of harm can indeed inhibit the use of e-cigarettes among smokers, and this barrier will only be exacerbated if the concerns of the public go unaddressed.

The most accessible message that the public sees about vaping is when a venue they frequent states that e-cigarettes are banned just about everywhere and treated the same as cigarettes. The subliminal take from that will always be that it is harmful both to vapers and those around them, and that there is no benefit to be derived from switching to a safer product. No amount of stressing the safer nature of vaping from public health groups will ever be as powerful an opinion-former to the general public as a prohibitive and dramatic “no vaping” sign or announcement on a public tannoy.

This unintentional and irresponsible implied negative messaging needs addressing urgently, and this new research emphasises just how damaging it is.

Sadly, the public health researchers in this case come from a deeply flawed viewpoint that stopping smokers from vaping is a good thing. However, their ignorance does not disguise the clear evidence from observed policies that vaping bans are actively deterring smokers from contemplating vaping instead.

What is required from more enlightened public health advocates is to be more pro-active in recognising the threats that vaping bans present. Our Challenging Prohibition campaign was designed to highlight negative messaging from organisations – public and private – who are blithely unaware of how their policies are harmful to the public, and often installed without any research and a distinct lack of care about the consequences.

We have a great opportunity in the UK to drive global acceptance of reduced risk products like e-cigarettes. To do that, it is incumbent on those in public health who are amenable to vaping – if they are serious - to redouble efforts towards recognising the threat of vaping bans and actively objecting to them.

This latest research succinctly shows that bans on vaping in public venues are an obstacle to adult smokers switching. It agrees with the NNA’s consistent messaging that bans are harmful and is now officially recorded in the literature. We hope that those in public health who believe in harm reduction will take this more seriously and dedicate resources to tackle the threat of bans which have no evidential, moral or health-related justification.

"Vaping welcome” artwork, kindly designed for NNA by Dan Pidcock, is available to download here.

 

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Boris Johnson is now our Prime Minister. He has a lot to do, but one of his jobs should be to water down his predecessor’s misguided proposals towards e-cigarettes and other safer nicotine products.

On Monday, the Cabinet Office and Department of Health and Social Care joint-released their intentions in a Green Paper, reportedly forced through by outgoing Theresa May against her Secretary of State’s advice. 

We are setting an ambition to go 'smoke-free' in England by 2030. This includes an ultimatum for industry to make smoked tobacco obsolete by 2030, with smokers quitting or moving to reduced risk products like e-cigarettes.

While it is welcome that the government has exhibited confidence in reduced risk products, these proposals are extremely problematic and fail to understand the regulatory landscape, as well as the appeal of products like e-cigarettes which have been so effective at drawing smokers away from combustible tobacco. They should be revisited, if not scrapped in their entirety.

It is implied that a first ever developed world ban on smoking is on the cards. This is not only a dangerously naïve idea but could further distance current smokers from considering vaping as an option. Many smokers are suspicious of vaping because they feel it may just be a tool that government might use to coerce them into quitting; these proposals simply reinforce that fear.

For years, we have seen perception of the relative safety of vaping decline, and an idea such as this may dispel that amongst some smokers, but many more will see this as use of a stick instead of a carrot and reject it.

It is the quit or die mantra all over again but with added menace. Before, smokers were told they should use pharmaceutical products or else be abandoned to a lifetime of smoking, but they were free to make that choice. The suggestion now is more sinister. They are being told quit or we will force you to quit because we will make your chosen products illegal.

One reason that e-cigarettes have been successful since they went mainstream about seven years ago is that they are not seen as coercive. Smokers feel they are making their own choice rather than being forced into it. The same effect has been seen in Scandinavia where snus has transformed nicotine consumption to the point that lit tobacco use is becoming a rarity. Government has not encouraged the use of snus, nor mandated it, but smokers have chosen to use far safer snus instead.

If politicians want to see increased uptake of safer nicotine substitutes for smoking, they should do so by optimising the choice of alternatives such as e-cigarettes, snus and heat not burn products, not by the blunt tool of coercion and prohibition. A policy like that suggested in the Green Paper would instantly remove the allure of safer products for many smokers.

There are other impracticalities too that have either not been considered or ignored.

A demand that the tobacco industry force people onto safer products can only work if government institutions and public health acknowledge the role that the industry can play in this transition. Yet currently, industry is prohibited to even talk to policymakers and the public health community has spent the last decade attacking not only the tobacco industry for producing risk reduced products, but also portraying it as a sneaky covert campaign to further prolong smoking.

So are these public health organisations now going to come on board and engage with industry as to how to make these proposals work, because if not the proposal is dead before it has even begun.

Are we going to see UK public health groups now standing up to their global counterparts in defending industry and the reduced risk products they make because government has mandated that industry should focus on them? We very much doubt it.

Even if they do, how will this play internationally? The WHO and FCTC has set itself against harm reduction. If our public health organisations truly support this initiative, they have a reckoning ahead of them. They will have to divorce themselves from the overwhelming opposition from global tobacco control institutions and say they are now engaging with Big Tobacco, by order of the UK government. This is not remotely likely.

Will a set date of 2030 for prohibition remove objections from the WHO about involvement of tobacco companies in supplying vaping products to attract smokers? If tobacco companies were full square behind the government’s proposals, would this change the landscape between industry and NGOs? It’s another no.

E-cigarettes have become popular because they are not a medicine and are not seen as a government-mandated solution. Smokers do not see themselves as sick, they do not require treatment, so the use of coercion will only turn smokers off the products and prohibition will simply create a big black market in tobacco. France is not far away as we have seen before with high taxation.

A better policy from the government – if it truly wishes to tempt smokers from combustible tobacco – would be to stand up strong at COP9 in The Hague next year and strenuously defend reduced risk products against the contrived hysteria which is prevalent the world over and perverting debate about safer products globally. On a local level they could instruct their civil service to object to the EU ban on snus and demand that it be lifted now rather than later.

Reduced risk products have a huge role to play in moving towards a smokefree society, but they will not be helped by government committing to a blunt and misguided policy such as this.

 challenge 25

Tuesday saw the publication of the latest research by Action on Smoking and Health (ASH) into the subject of underage vaping in the UK.

Sadly, the media mostly avoided reporting on the good news that the proportion of under 18s who try vaping has dropped to the lowest level since 2016. There was also little coverage that those who had tried an e-cigarette once or twice in 2019 was lower than in 2015 and that regular use of e-cigarettes amongst 11-18 year olds has declined in 2019 compared to 2018.

MD
We suppose - in this click-chasing world - that bad news sells, but it is disappointing, nonetheless.

Disappointing because the media is very quick to seize on any cherry-picked negative news about vaping from a dwindling band of UK public health professionals who still harbour irrational doubts about the benefits of safer products in this country, many of whom centre their arguments around not only a fear of youths using nicotine, but also that this will lead to a gateway into combustible tobacco use. We can only presume the gateway must be remarkably rusty at the hinges for it not to translate into any prevalence statistics that anyone can actually see in real life.

Both would seem to be fears that are refusing to become a potential problem, let alone a crisis which should make the UK government and a plethora of public health institutions change course and object to e-cigarette use rather than encourage it amongst adult smokers as they currently do.

The research by ASH began in 2013 and has consistently shown that there is no real problem to be solved in the UK regarding youth uptake, although it is always worth being vigilant. This is despite increasing, and now almost universal, knowledge of vaping amongst children, as the ASH report describes.

“Awareness of e-cigarettes amongst young people has risen significantly from 2013, when 67% of 11-18 year olds were aware of e-cigarettes, and 2015 when it reached 93%, and it has remained at this level since then”.

The simple fact is that despite the global panic about e-cigarettes, in a properly regulated market we are seeing safer nicotine products such as e-cigarettes consistently delivering hugely positive benefits for public health. The UK now boasts over 3.2 million vapers and the country’s smoking prevalence is at a record low after dramatic declines which coincide with the period in which vaping has ballooned here. Vaping by children and teens, by comparison, is negligible and mostly made up of those who either already smoked or would have done absent of an alternative. Other countries should take note.

The NNA has made this point recently too. Earlier this month, our Chair addressed industry at the ENDS Conference in London to warn that talking up non-existent problems is playing into the hands of those whose only purpose is to create mischief and obstruct the success of safer products like e-cigarettes in attracting smokers. We also held a press briefing at the Global Forum on Nicotine in Warsaw to emphasise that flavours are an integral part of the harm reduction offering, rather than an inducement to children. We were happy that the views of academia, independent industry and consumers were brought to the table for that event and issued a press release which you can read here.

Tuesday’s ASH research was also accompanied by their own release which declared that “In Britain young people vape just to give it a try, not because they think it’s “cool””, with Deborah Arnott remarking that:

“Smoking prevalence among children and young adults in Britain has fallen substantially since 2010, which doesn’t indicate that vaping has been a gateway into smoking. And to date there is little sign that vaping is the “super-cool” phenomenon among young people here that it is said to be in the USA.”

We agree, and the evidence agrees with us. We would go further and say the same could be said in the future about other reduced risk nicotine options if only public health institutions would have the imagination to be brave and embrace tobacco harm reduction, starting with abandoning the disastrous EU ban on snus, a product which has led to dramatic success in Nordic countries.

It really is time that the stubborn outliers who still cling to evidence-free assertions of imminent youth nicotine Armageddon stopped flogging their ideological long-dead horse at the expense of real progress for adult smokers who choose to quit via alternatives. It is an ex-equine, it has ceased to be.

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Dr Christian UKVIA Forum

Thursday saw the staging of the second UK Vaping Industry Association Annual Forum and the NNA was invited to participate. The keynote speaker was TV’s Dr Christian Jessen, an outspoken supporter of e-cigarettes as an innovative solution for smokers who wish to switch away from tobacco.


He delivered a highly amusing and thought-provoking speech on the “mistrust of science” in many policy areas, and how vaping suffers from the same interferences from people whose intentions are far from altruistic. Particularly disturbing was his passionate account of how vaccines have revolutionised the world and led to many diseases – which used to account for vast amounts of deaths globally – now being all but extinct, but how just a few miscreants can cause immense damage to public perception.


Dr Jessen referenced Andrew Wakefield, who produced a now very much discredited study on how the MMR vaccine causes autism and described the drop in public acceptance of vaccines which resulted. The upshot was that measles particularly is enjoying a resurgence and doubt in proven health interventions has proliferated.


Those of us who are involved in the debate around safer nicotine products all know a few prominent individuals who are the equivalent of Andrew Wakefield towards tobacco harm reduction, but Dr Jessen was optimistic that over time their message will be diluted and become increasingly irrelevant. We hope he is correct.


Following his speech, Dr Jessen then joined a session on smoking cessation services chaired by MP Sir Kevin Barron of the APPG on Smoking and Health. Sir Kevin introduced the panel by explaining why he is in favour of industry getting involved in making reduced risk products after a lifetime of his opposing the companies’ very existence. As far as he was concerned, if the products switched smokers away from lit tobacco, he didn’t care much who makes them, and he described how this is one of the few areas where he disagrees with Action on Smoking and Health (ASH).


Sir Kevin was not the only MP on display at the event, with APPG on Vaping founder Mark Pawsey MP chairing a panel entitled “Has the UK become vape unfriendly?”. This is where the NNA came in with our Chair Martin Cullip being invited to speak on the subject.

Martin Cullip VApril ForumMartin Cullip speaking at the VApril Forum last week

As you can imagine, considering we have a Challenging Prohibition campaign, Martin expressed our concern that vaping consumers are not being afforded places where they can vape while at work or at leisure, and that this illustrates a general lack of understanding of how e-cigarettes are designed to function. One of the other panellists was Andrew Green of the British Beer and Pub Association who described the concerns of his organisation’s member pub owners and managers towards vaping. It was a robust discussion but Martin spoke to Andrew after the panel finished and there was a definite willingness from the BBPA to better inform their members about the benefits of welcoming vapers – even if only for the boost to their profits which could result – and we hope to continue a dialogue with them so that more pubs might welcome vapers in the future.

Of course, the debate around over-cautious vaping bans is not restricted to pubs. As our last blog article describes in relation to the NHS and other places, there is a lot of undue panicking about vaping which needs to be addressed if the public are to fully understand safer products and to not fall victim to the increasingly isolated siren voices of Andrew Wakefield-esque fearmongers in public health.


For example, one of the highlights of Dr Jessen’s speech – and one which attracted many a laugh from the room – was his account of an appearance on lunchtime ITV show, Loose Women. Following Colleen Nolan describing how she had struggled to quit smoking for years without success, Dr Jessen had produced an e-cigarette starter kit and simply said try this. “You would think I had crapped on the studio floor on live TV”, said Jessen, “such was the Twitter storm I had to suffer after that!”.


It is clear that - even in the UK where vaping is relatively well-regarded and where the success of harm reduction is highly visible and understood by legislators and regulators alike - there is still much to do. It is encouraging to see MPs like Mark Pawsey and Sir Kevin Barron actively taking time to advocate in favour of vaping and we were thrilled to hear that an NNA ‘considerate vaping allowed’ sign is now installed in Mr Pawsey’s office.

Sarah Jakes presents Mark Pawsey with a NNA Considerate Vaping signSarah Jakes presents Mark Pawsey with a NNA Considerate Vaping sign, November 2018

It is also great to see such a prominent TV doctor nail his colours to the mast of vaping despite the objectors, and to once again endorse e-cigarettes as he did when we last met him at the launch of the VApril campaign.

Long may his doctor’s orders be that his colleagues – and the public - should embrace products which we, as consumers, know are a radical and successful solution which will benefit many more smokers if allowed to reach full potential.

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GUEST POST FROM TERRY WALKER, NNA ASSOCIATE

In March, I was looking forward to a local dance event I had planned for the evening but became ill and ended the day in an Acute Medical Unit for the night rather than “tripping the light fantastic”. The cause was an infection which required a long period on antibiotics.

The hospital concerned had a strict no vaping rule which I challenged each day to provoke a meeting with senior staff until I was interviewed by Matron and Ward Manager. Far from treating my concerns seriously, I was told that what I had done was classified as Aggression to Staff”! I did not think that attempting to convey guidance from Public Health England could be classed as shocking behaviour, so I explained my research into vaping since 2012 and told them that I wished to offer my services to their Hospital Trust, and work with their team to update their policy on vaping, which was sadly out of step with current advice.

To their credit, they listened to my concerns and promised me a meeting with the Stop Smoking Sister. Sadly, the meeting never materialised but, in the meantime, I requested a copy of their vaping policy.

As is disappointingly common, there wasn’t one. Instead, they had simply added e-cigarettes to their smoking policy to say that vaping was only allowed in a smoking shelter and not within any car or building. This had been amended in mid-2018 and was not due for another review until 2023!

I suppose I should not have been surprised even though it was as far back as July 2016 when Public Health England said that workplace policies “should make clear the distinction between vaping and smoking” and that “it is never acceptable to require vapers to share the same outdoor space with smokers”. One can only assume this hospital had not noted this advice or, worse, ignored it.

So, I wrote to the Chief Executive of the NHS Trust to offer my services in assisting them in reviewing their policy to bring it more in line with latest guidance and to align with the government’s Tobacco Control Plan. Encouragingly, he replied to thank me for my message and to say he would “welcome some discussion on this for a future update of the policy” and forwarded my message to those who have the relevant responsibility.

Was my hospital stay fortuitous? Only time will tell. However, it does go to show that citizen advocacy can have an impact if conducted in the right manner.

I am an 87-year-old retired R & D scientist who smoked strong, unfiltered cigarettes for 69 years before making the switch to vaping in 2012. At that time, I was diagnosed with Chronic Obstructive Pulmonary Disease (COPD), the same disease which caused the death of my only son at the age of 47. Since then my lung function has improved immeasurably.

There can be no doubt that for those of us who cannot, or choose not, to live without nicotine, and wish to enjoy the tactile, oral and psychological elements associated with smoking, electronic cigarettes are a much safer alternative, being orders of magnitude less dangerous to our health than inhaling the products of combustion arising from smoking tobacco.

Some who enjoy nicotine may choose to continue smoking, but there are many who – like me – would find great benefit in switching to something far safer. A hospital, therefore, should be the very last place where such a decision is frowned upon.

I am hopeful that the NHS Trust will see sense and change their policy to be more welcoming to vaping, just as the UK government and its public health institutions have done. If nothing else, it has started a conversation amongst a group who had been blindly unaware of the advice currently available from those higher up the public health chain.

On my last cruise I again challenged the no vaping rule on an area of deck not designated for vaping. When a deckhand came over and “chastised” me, saying that is not allowed here I said “ I know, and I am here to stop that”. He then just walked away. I would urge my fellow vapers to challenge this ruling wherever they can as this will not only help awareness, but get the rule changed in the future.

So, if you see a vaping policy that is wrong-headed, it could well be worth politely enquiring as to why.  If I can do it, so can you.

Terry Walker, NNA Associate

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NNA Associate Terry Walker meets with Hon Lik at the GFNTerry Walker (right) with Hon Lik, inventor of the e-cig, at the GFN 2017

 

Hong Kong

A recent TV showing of the Hong Kong Rugby 7s tournament was introduced by a commentator as being broadcast from a place “where the world comes to party”, but a recent development from the country’s government would suggest that this is poor marketing of Hong Kong for the unwary traveller.

The Legislative Council of Hong Kong – after initially toying with the idea of regulating e-cigarettes sensibly – instead made an about-turn and has now produced a draft law which will criminalise possession of e-cigarettes and heated tobacco. In short, anyone caught vaping could be facing huge fines and possibly a jail term of up to 6 months.

The NNA submitted a response to the consultation for this draft bill which you can read here, but considering the severity of the punishment Hong Kong is proposing for anyone who chooses to quit smoking using e-cigarettes, we felt it was worth writing about the clear danger that UK vaping citizens may face if planning to visit.

The proposed Hong Kong law is based on the Thailand model where an internet star was brutally arrested for possession of e-liquid in 2017 and a French tourist was arrested, fined, jailed and deported for merely holding an e-cigarette in February.

Why Hong Kong has decided to go down this route when, in enlightened democracies, the direction of travel has been to relax regulations on harm reduction products rather than criminalise them is anyone’s guess. It does, though, impact on how UK citizens should view Hong Kong as a tourist destination.

Our government advises that anyone visiting Thailand should be aware that they could be imprisoned if they bring their device to the country, and we expect that similar guidance will be forthcoming from the Foreign and Commonwealth Office if Hong Kong decides to proceed with its draconian proposals.

According to the Hong Kong Tourist Board, last year there were approximately 570,000 leisure visitors from the UK and current statistics say that around 6 per cent of those will be vapers. That is around 35,000 who would be at risk of being jailed simply for following advice to switch to e-cigarettes on the advice of public health authorities in this country. In fact, probably more than that considering uptake of e-cigarettes is more amongst middle class smokers who are more able to afford a trip to an exotic location such as Hong Kong.

As anyone who understands how vaping works will know, reduced risk products rely on a regular low level of nicotine being delivered to the user to replace a large blast of nicotine from regular cigarettes. The simple fact is that under these plans, vapers would visit Hong Kong at their peril with their e-cigarette and risk imprisonment or leave their vaping device at home and get their nicotine from conventional cigarettes, which will still be available everywhere, and perfectly legal to smoke.

Our advice, if you are one of the 35,000 or more vapers, would be simply to choose an alternative destination than Hong Kong. There are many others you could visit which will not treat you like a criminal for making a healthier choice in accordance with the UK government’s Tobacco Control Plan and the annual Stoptober campaign.

It is curious to note that the tourist figures also show that Hong Kong annually receives more than 50 million visitors from China where e-cigarettes were invented; more than 2.5 million from Japan and Korea where reduced risk products are incredibly popular, and more than 1.2 million from the USA where vaping is hugely prevalent. If Hong Kong’s ill-judged proposals result in concrete legislation, we could be seeing a lot of stories about tourists being jailed for no valid reason. If they start arresting swaths of visitors from mainland China, one can only imagine the consequences that might entail.

The Legislative Council may well believe that they are doing the right thing with their proposals, but criminalising possession of products designed to help smokers quit tobacco is in direct contrast to their stated aim to 'discourage smoking, contain the proliferation of tobacco use and minimise the impact of passive smoking on the public'.

If they had said they wanted to decimate their tourist industry, it would have made much more sense. If this law passes, vapers would be best served by just not going there.

 

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Just last month, we published a blog describing how government messages on reduced risk products are not getting through to the NHS. You can read the whole thing here but this was the summation.

We are in the second decade of the 21st century but NHS trusts seem to be stuck in the past and not yet caught up on where the government is going. If NHS England truly seeks to reduce smoking by any means, it should be more imaginative in its approach and, if nothing else, at least listen to the messages coming from government and its institutions.

This week, we were also contacted by the Daily Express about new research that revealed only a pitiful 7% of GPs felt confident enough to recommend e-cigarettes to smokers who present themselves to surgery. The NNA was quoted in the article.

Martin Cullip, a trustee of the New Nicotine Alliance, a charity which raises awareness of safer nicotine products, said more education was needed for doctors.

“This is a common theme I’ve come across before where many GPs believe vaping to be harmful,” he said.

“Vaping takes most of the harmful chemicals out – any that are left in there are at very low levels - so you’re delivering the nicotine in a much cleaner form.

“There’s no reason why doctors cannot recommend these devices but if they are not aware of the reduction in harm then they’re not going to do that.”

It is very disappointing that we should still have to make these arguments on the deficiencies of the health system considering the resounding support for vaping as an option for smokers wishing to switch to safer nicotine delivery by groups such as, and not restricted to, The Royal College of Physicians, Public Health England, Cancer Research UK, The Royal Society of Public Health and Action on Smoking and Health.

As our trustee pointed out, the lack of understanding amongst GPs is a recurring theme and does not appear to be receding. In 2013, Nursing In Practice reported on the clear disconnect between government advice and what is being relayed by GPs to their smoking patients:

The survey findings show that a substantial proportion of GPs (40%) believe nicotine to be the first or second riskiest component of cigarettes, incorrectly identifying it as more harmful than smoke.

Many (44% UK, 56% Sweden) also wrongly believe that nicotine in tobacco products is associated with cancer, while 15% in the UK and 22% in Sweden believe the same for pharmaceutical nicotine.

“Although GPs clearly understand that smoking is more dangerous than NRT use, it is worrying that so many associate nicotine with cancer.

This may have been an understandable mistake six years ago, but it certainly isn’t now. Late last year, another study from the University of Oxford came to the same conclusion.

Current dissemination strategies for guidelines are not effective in reaching practitioners, who are offering more cautious advice about e-cigarettes than guidelines suggest is reasonable.

We are now into 2019, with a government so committed to harm reduction as an option for smokers who choose to quit that they see reduced risk products as a core part of the Tobacco Control Plan; that e-cigarettes have been included in stop smoking adverts during Stoptober for two years; and a government which has also fully endorsed vaping following a report by the Science and Technology Committee which called for more acceptance of safer nicotine delivery to tempt smokers to choose safer options.

Yet here we still are with GPs disappointingly badly informed. This statistic from the Express article is starkly damning.

“A worrying 93 percent of healthcare professionals were unaware of Public Health England’s position that vaping is at least 95 percent less harmful than smoking.”

You have to wonder about what messages are being promoted by government institutions if this is the current state of play with GPs. NNA Trustee Louise Ross was particularly surprised on Twitter.

LR PHE tweet

We obviously share her concern. It is disturbing that there is so much misunderstanding still prevalent amongst GPs who are the first responders in the NHS to people who smoke. Something is going desperately wrong here if official guidance from high level public health organisations is not filtering down to GPs who are tasked with meeting smokers face to face.

There is an urgent need for a framework whereby the national guidance on safer nicotine products feeds down to where the knowledge is most needed, which is quite clearly not happening now.

There is no point whatsoever in proposing policies on a macro level if those who meet the public daily do not know of its existence. It certainly does exist, and the Royal Society of General Practitioners has also presented a fact sheet on the subject fairly recently. It is disappointing that GPs are either unaware of, or are wilfully ignoring, the advice of their own professional association along with guidance from national government-backed institutions.

GPs need to be better informed; their misunderstanding has not only continued for six or seven years but it doesn’t seem to be abating. It is well past time that there was a mechanism to ensure that they are more educated about the difference between nicotine and smoking.

 

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VApril 2019

 

Today sees the launch of the second Vapril campaign organised by the UK Vaping Industry Association (UKVIA). The NNA was pleased to be consulted on the initiative in the months leading up to today and we wrote the campaign’s “switch on to vaping plan” which the website accurately describes as “written by vapers for smokers”.

Our contribution was to offer hints and tips from our personal experiences in switching and it is important to highlight why we believe that our input is, indeed, intended to be beneficial to smokers and not yet another hammer to beat them with.

Traditional campaigns aimed at smokers have always focussed on nicotine abstinence and nicotine replacement therapy as the only options; public health organisations have only seen quitting smoking through the lens of clinical treatment without recognising that smokers do not see themselves as being ‘sick’. It is all very well setting up clinics and waiting for smokers to come and ask medics to wean them off lit tobacco, but most find that option unpalatable.

The rapid drop in smoking prevalence in the UK since e-cigarettes have gone mainstream illustrates this very well. Prior to that the decline in smoking rates had flatlined, and tobacco control organisations were scratching around trying to find new angles to get smokers to quit, most of which involved hopeful and unproven policies centred around stigmatisation rather than encouragement.

In fact, the only decline which has mirrored the dramatic reduction in smoking prevalence since vaping became recognised by the public is the uptake of stop smoking services by smokers, with smoking cessation clinics seeing a huge drop in demand since around 2012. As a result, stop smoking services have encouragingly been forced to embrace vaping as an option or become irrelevant.

UK anti-tobacco organisations have increasingly recognised the benefits of vaping with only a few ideological outliers still holding out hope that there might be some disastrous Armageddon to come along and confirm their baseless opposition to tobacco harm reduction.

If you ask smokers why they smoke, they will consistently tell you that it is because they enjoy it. Public health groups can push the argument that they are not actually experiencing pleasure but instead satisfying an addiction, but this approach only speaks to those who are most committed to quitting anyway. If a smoker is absolutely determined to quit, they will do so, but most are not like that and require their enjoyment of tobacco to be replaced by something else. If public health groups wish to speak significantly to smokers they should be doing so by engaging where smokers are rather than from an ivory tower..

As former smokers ourselves, we recognise this and know that reduced risk products can help smokers switch because they can replicate many of the cues of smoking and provide much of the pleasure too, over time. The pleasure aspect is something very much overlooked by most public health bodies – irrespective of whether they support vaping or not - but something that we at the NNA have been emphasising for some considerable time.

The Vapril campaign, although industry-led, should not be dismissed by public health, because it not only speaks to smokers who are looking to choose to quit smoking but is also consistent with recent government advice..

A report by the Science and Technology Committee in August recommending that more should be done to encourage smokers to take up alternative nicotine products was endorsed in full by the government, and last year’s Tobacco Control Plan pledged “to support consumers in stopping smoking and adopting the use of less harmful nicotine products”. Additionally, vaping has been included as an option for smokers seeking to quit by the annual Stoptober campaign for two years now.

Lastly, the VApril campaign can hopefully have an impact in redressing the disappointing decline in perception amongst smokers about the merits of switching to safer products. An avalanche of unscientific scare stories and click-bait media articles promoted by health professionals who should know better has turned many smokers away from the idea of trying vaping to see if it could work for them. Considering the Royal College of Physicians assesses vaping to be at least 95% less risky than smoking, it is to the VApril campaign’s credit that it includes messages like that in its literature along with more populist and accessible advice for smokers who have dabbled with trying vaping but may have been put off before.

TV’s Dr Christian Jessen, a long-time advocate in favour of vaping, has fronted this campaign as he did last year and the NNA is happy to lend our support to him and VApril this time round.

For full information on the VApril campaign, visit their website here.

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