29 November 2017
NNA has submitted this consultation response to the Mayor of London Health Inequalties Strategy Consultation:
Submission to the Mayor of London’s Health Inequalities Strategy Consultation from the New Nicotine Alliance UK (NNA). NNA is a consumer led national charity which aims to improve public health and reduce the toll of disease from smoking by improving understanding of reduced risk products such as e-cigarettes.
We are pleased to note the ambition of the Mayor of London’s Health Inequalities Strategy. The intention to help Londoner’s make healthier choices including those from the most disadvantaged groups is one we particularly applaud. This is an area where we believe the Mayor can and should play an important leadership role in terms of reducing ill health and premature death by endorsing evidence based approaches to support smoking cessation. Increasingly, around the world, it is cities which are developing new and effective approaches to improving health and we believe that London should be at the forefront of this movement.
The scale of harm associated with smoking is highlighted within the draft Health Inequalities Strategy, with 8,000 premature deaths of Londoners per year and smoking being the leading cause of preventable death. This toll of mortality and related illness illustrates the benefits of reducing smoking rates in a pragmatic and effective manner. While the striking variation in smoking rates between different social economic groups is acknowledged within the consultation document, this general statement doesn’t reveal the full scale of this health inequity. It is well evidenced and acknowledged by Public Health England and the Cochrane Addiction Group that existing tobacco control policies and cessation support have had the least impact on the lowest social-economic groups (1). New approaches are sorely needed.
Within certain groups the rates of smoking, and consequentially the levels of associated harm are at very high levels. For example, amongst the homeless smoking rates of 85% are recorded. In many areas those working with rough sleepers’ report that 100% of their clients’ smoke. This group are not well served by existing services. Nor will their smoking behaviours be positively improved by higher taxes on cigarettes or crack-downs on illicit tobacco supply, after all they frequently are smoking butts left by others.
Those suffering from mental health problems are also likely to experience very much higher rates of smoking. In December 2016 ASH estimated that nearly a third of smokers in the UK had a mental health condition. Smoking rates within this group remain around 40% where as within the general population smoking rates have reduced from 27% to 19% over the last 20 years. The more severe the condition the higher the rate of smoking. People with mental health conditions are dying 10-20 years prematurely and tobacco related disease is one of the chief causes.
The above paints a dismal picture. Using the well-worn approaches of increasing price and restriction is not going to prove effective. There is, however, action which can be taken and has already been highlighted by Public Health England. There are alternatives to smoking tobacco which have been proven to meet the needs of those who are either unable or unwilling to give up nicotine. E cigarettes and other products provide a significantly safer alternative to smoking cigarettes. This has been acknowledged by Public Health England, who are now helping place the United Kingdom at the forefront of efforts to save lives from smoking. It is worth reminding ourselves of a simple truth, observed by Professor Michael Russell 40 years ago, that “People smoke for nicotine but they die from the tar”.
However, there remain many barriers to vaping and the use of safer alternatives to tobacco. These include ignorance, with the actions of many public bodies and individuals leading to many Londoners believing that vaping is not safer than smoking. This disinformation is likely to especially impact those with limited ability to do their own investigation into these products. There are also regulatory barriers where vaping and smoking are treated identically. This is contrary to PHE advice and essentially means that those who have progressed to safer alternatives are confined into environments where smoking is the norm.
There is also the issue of cost. The most addicted smokers usually come from the most economically disadvantaged populations (2) . Standard 12-week therapy using traditional nicotine replacement therapies on their own are often not effective for these smokers. A starter kit for vaping costs a minimum of £10, with no guarantee that the first machine or liquid is going to work for the individual. E-cigarettes are also easily broken or lost. For many this represents a significant financial outlay compared to the cost of illicit tobacco and the guarantee of getting the product desired. There are also issues about recharging the kit. This barrier has been overcome with some of the most disadvantaged groups in Leicester where local arrangements have supported street homeless smokers to successfully transition to vaping.
We hope that this submission highlights the role the Mayor of London and the Greater London Authority should play in helping reduce the harm smoking causes to Londoners. The potential gains in reducing health inequality, individual health and closing the mortality gap are enormous. There is a clear leadership role, for example in supporting the position of Public Health England and seeking to ensure smokers do understand there are safer alternatives. The Mayor is in a position to help remove unintended and ill-conceived barriers that hinder people in making healthier choices for example by drawing a clear and positive distinction between smokers and vapers. It is also about supporting innovative work with those who are homeless, living in poverty or who are experiencing mental health problems to access a significantly safer mechanism for using nicotine.
These are all areas where the Mayor has a major role to play. In significantly reducing the harm caused by smoking to our most vulnerable citizens the Mayor would help ensure we don’t continue to leave behind those whose health suffers most. Action to reduce smoking addresses the whole breadth of the ambitions set out in this strategy and will help Londoners make this the healthiest City in the world.
(1) Leaving No Smoker Behind, Dr Sharon Cox, Dr Allison Ford, Dr Deborah Robson, Professor Linda Bauld & Dr Lynne Dawkins LSBU, KCL, UKCTAS, University of Stirling 2017
(2) Cambridge Handbook of Psychology, Health and Medicine, edited by Susan Ayers, Andrew Baum, Chris McManus, Stanton Newman, Kenneth Wallston, John Weinman, Robert West, Cambridge University Press 2007, page 9
NNA submitted a response to New Zealand Ministry of Health consultation for "Policy Options for the Regulation of Electronic Cigarettes". You can view our consultation response here.
Following the roundtable meeting on e-cigarettes with the Dept of Health in March NNA are keen to continue the dialogue, and in particular raise our concerns with regards to the 'unintended consequences' of policy and regulation. To that end we collaborated with our associate Clive Bates of the Counterfactual Consultancy and sent the following submission to DoH on Friday 29th of April.