Smoking is England’s biggest killer, accounting for nearly 80,000 deaths each year as well as a heavy toll of illness. We have made great strides in recent years in driving down the number of people smoking – it is now just under 20 per cent of adults – and I am determined that Public Health England deploys all available levers to continue this progress. Our aim is ambitious: to achieve a tobacco-free generation by 2025.
Our advice to smokers remains to stop immediately, completely and permanently. A combination of licensed medication and professional support increases the chance of success in quitting by up to four times. For those smokers not ready to make that commitment yet, PHE supports the approach set out in the NICE Public Health Guidance on tobacco harm reduction. This involves starting with something that feels more achievable and which may then lead them to stop completely.
Increasing numbers of people are turning to electronic cigarettes – more accurately described as nicotine vapourisers – as an aid to quitting or cutting down their smoking. According to the latest YouGov survey commissioned by ASH (Action on Smoking and Health), use among adults in Great Britain has tripled in the last two years to 2.1 million.
At the same time, Professor Robert West’s Smoking Toolkit Study shows quit attempts are up, success in quitting is up and smoking rates are down. With almost one smoker in five choosing e-cigarettes there are clearly opportunities, but there are also risks we must guard against. We need to develop an appropriate response that is firmly rooted in the evidence.
E-cigarettes haven’t been around for very long, so no reliable long-term studies of the risks they represent are available. The current diversity of unlicensed e-cigarettes and the variability of their contents also presents a challenge. With the regulation we currently have, as consumer products, it is hard to give smokers the reassurance they need about how safe e-cigarettes are or how effectively they deliver nicotine.
For this reason we continue to recommend the use of licensed nicotine replacement therapies to support smokers to quit or cut down. However, from what is known about the vapour and its contents, it is never better for the health of a smoker or those around them to smoke tobacco rather than use even an unlicensed e-cigarette. E-cigarettes, despite appearances, are not cigarettes and do not produce smoke. It is the smoke, not the nicotine, that causes the vast bulk of the harm. Recent analysis led by Professor David Nutt on the relative harms of tobacco and nicotine containing products demonstrates a stark contrast between the harm from cigarettes and from e-cigarettes.
PHE supports the regulation by the MHRA of nicotine-containing products – including e-cigarettes – as medicines, to give people access to safe products that are also effective. Previous evidence suggested that e-cigarettes were as effective in helping smokers to quit as nicotine replacement therapy. Professor Robert West’s latest study, published yesterday in Addiction, suggests that they are more effective. However, the nicotine delivered by these products is highly variable. Without reliable standards, smokers may find their attempts to cut down or quit undermined by products which fail to reduce nicotine withdrawal adequately.
Another significant area of concern relates to the potential impact on children and young people. Current evidence of use by young people in the UK does not support the hypothesis that e-cigarettes are acting as a gateway into smoking. The number of children and young people regularly using e-cigarettes remains small and their use is almost exclusively by current or ex-smokers. These findings accord with those from other international studies, but research in this area is limited and we must remain vigilant as further evidence emerges. We look forward to collating local data from across England and we will shortly publish the results of a programme of e-cigarette test purchasing by young people, undertaken in partnership with Trading Standards.
Marketing of e-cigarettes is extensive and growing. Effective regulation is essential to ensure that advertising and promotion of e-cigarettes acts to denormalise rather than renormalise smoking, by positioning the product clearly as a replacement for smoking. PHE recently responded to the ASA/CAP consultation on the advertising and promotion of these products, clearly advocating that rules should be in place to ensure they are not advertised in a way that appeals to young people.
Another aspect of the renormalisation/denormalisation debate is the use of e-cigarettes in work and public places. Does use of these products in places that are smokefree have the potential to renormalise smoking behaviour? What about potential harm from passive inhalation of vapour? Do we risk undermining vapers’ attempts to quit smoking by directing them to the smoking areas? These are all issues that have been raised, including in the CIEH/ASH briefing "Will you permit or prohibit e-cigarette use on your premises?"
Last week PHE published two independent evidence papers commissioned from leading academics Professor John Britton (University of Nottingham) and Professor Linda Bauld (University of Stirling) to examine the current evidence on e-cigarettes. We also held a national symposium in London, ‘Electronic cigarettes and tobacco harm reduction’, bringing together senior public health leaders to hear the evidence, discuss the issues and identify areas of consensus to inform future action. We were pleased also to welcome representatives of the vaping community to join the discussions.
All of the issues above were discussed at the symposium. The feeling at the end of a lively day of debate was that, while there is a lot of work to be done to address and manage the current concerns, most of us are ‘on the same page’ and all are agreed on the need for active and ongoing research and surveillance to assess the individual and population impact of e-cigarettes as use and technologies develop. We need to keep an eye on new research and go where the evidence leads us.
This is the beginning of an ongoing dialogue with a wide range of individuals and organisations as we develop our policy and action: I look forward to it.