Good morning and welcome to the 30th meeting of the Health and Sport Committee in 2014. I ask everyone in the room to turn off their mobile phones as they can interfere with the sound system. Those present may note that some committee members and clerks are using tablet devices instead of hard copies of the papers.
The first item on the agenda is a round-table session on e-cigarettes. The committee has been waiting for some time to hold this first exploratory session on the subject. As usual with a round-table session, I ask everyone to introduce themselves.
I am the member of the Scottish Parliament for Greenock and Inverclyde and convener of the committee.
I am a general practitioner in Angus. I am a member of the British Medical Association board of science and a member of the BMA’s Scottish council.
I am an MSP for Glasgow and deputy convener of the committee.
I am from the Department of Health in England.
I am an MSP for Mid Scotland and Fife. I apologise for being late due to trains.
I am an MSP for North East Scotland.
I am a respiratory consultant in Nottingham and director of the UK centre for tobacco and alcohol studies.
I am an MSP for Central Scotland.
I am an MSP for South Scotland.
I am from the Scottish Government’s tobacco policy team, and I am leading the consultation on e-cigarettes and tobacco control.
I am the MSP for Edinburgh Western.
I am president of the Electronic Cigarette Industry Trade Association.
I am the MSP for Clydebank and Milngavie.
I am from ASH Scotland.
I am an MSP for the Highlands and Islands.
Thank you, everyone. Richard Lyle will ask the first question. I note for the panel that we do not intend to ask questions all the time—just when there is a break in the conversation. I will look to panel members in preference to committee members for contributions at all stages during the session.
I thank the committee for granting my request to hold a session on e-cigarettes.
The e-cigarette is a new invention that has come in during the past few years. There are concerns about what is in e-cigarettes and about what they are.
A number of organisations have made comments about e-cigarettes. In particular, I refer the committee to the report from YoungScot and the youth commission on smoking prevention, entitled “Young Scots support a smoke-free generation by 2034”. The report states:
“We want to see a ban on the sale of all e-cigarettes in shops and retail outlets—the product must be regulated and distributed as a medicinal product only.”
I have a question for Claire McDermott with regard to the Scottish Government’s position on e-cigarettes. As I understand it, there is no law against selling the product to children and the industry is self-regulating. However, as we know, anyone who walks into a shop may purchase something, and it concerns me that children could walk into a shop and purchase an e-cigarette. I know that the Scottish Government is considering a ban on the sale of e-cigarettes and that it is undertaking a consultation. Can you tell us where we are on that?
Yes. The consultation was launched on 10 October and will run until 2 January. We await the programme for government to see what the legislative timetable may be, but we will seek to consider the consultation responses as soon as possible. The Minister for Public Health has made it clear that he is committed to introducing legislation in this area.
Thank you for that.
We will see whether we can get a response on some of the other issues. Richard Lyle mentioned the recommendation to ban e-cigarettes, and I think that United Kingdom legislation is already in place. Can we have some feedback on the general questions that arise from Richard Lyle’s comments?
Katherine Devlin can go first.
I feel that I ought to respond on this one, as I represent the industry. I will speak in the broadest possible terms, if I may. On the precautionary principle, as expressed in the concerns and suggestions that Mr Lyle raised, we have to be enormously careful that we do not do more harm than good. We have been very pleased to see the Scottish Parliament’s approach to the issue, which is to consult widely, bring forward very few ideas initially and take time to gather further evidence before doing anything too drastic.
If we were to remove all the products from the market, the risk is that we could see all those people who have made the switch to electronic cigarettes returning to tobacco smoking, which would clearly not be good for public health on a population level or for individuals.
I agree with Katherine Devlin. I should say up front that I have no financial interest in or any conflict of interest with the industry and what it has to say.
Electronic cigarettes offer a huge potential benefit to public health by helping smokers to shift to an alternative source of nicotine. If all smokers in Britain were to do that, we would be talking about avoiding hundreds of thousands, if not millions, of premature deaths. When legislating and controlling the inevitable abuses of the market that will come with electronic cigarettes, and given their inherent risks, which we still know relatively little about—although we know that they are much less hazardous than tobacco—it is very important that we manage those risks, but not in a way that throws the baby out with the bathwater, because there is a huge potential public health prize in these products.
I agree with what John Britton said in the context of the UK Government taking an approach that is as evidence based as possible, recognising that there is not as much of an evidence base as we would like in order to be able to make good decisions about this category of products. We have tried to think about the risks and benefits, and rather than ban products that have, as John Britton said, great potential, we have taken a more measured approach in thinking about what regulatory framework and structure is necessary to enable the products to be made available.
On the risks and benefits, the position that the Department of Health has taken is that continuing to smoke is the riskiest thing that anyone can do—it costs 80,000 lives a year in the UK. It is important that we evaluate carefully anything that can help to manage those risks, and that we think about the potential benefits. As John Britton said, the market is such that we cannot be confident that the range of products available is safe, so we cannot recommend their use. However, what we do not want to do is remove from the market something that potentially has great value. We need a regulatory framework that gives us confidence that the products are of quality and will help people to cut down, to quit and to reduce the harm of smoking.
Likewise, we recognise—we develop this idea in the consultation paper—the potential for e-cigarettes to act as a cessation tool. However, as Katherine Devlin said, we do not think that there is enough evidence yet to make a decision on electronic cigarettes. That is why we ask the question in the consultation document. We are still seeking people’s views to inform future policy development. One of the reasons why we have not taken action is that we recognise that individual organisations and service providers can act to implement their own policies if they feel that there is an urgent need to ban the use of e-cigarettes on their premises.
Richard Lyle made a point about the sale of e-cigarettes to children and young people. I think that we are clear about the effects of nicotine on that younger group, are we not?
The UK Government will shortly be consulting on an age-of-sale restriction of 18 and on a proxy purchase prohibition—that is, prohibiting adults from buying the products for younger people. If the regulations are passed, they will be in place next year. That is the intention in the UK.
John Britton is probably better placed than I am to talk about the impact of the products on younger people.
None of us would want any of our own children, or anybody else’s children, to start using nicotine for no good reason. That includes electronic cigarette use as well as smoking. I do not know what the figures are for Scotland but, across Britain, by the age of 25, 40 per cent of people have been smokers, and 25 per cent of people still are smokers.
There is a dilemma about young people’s use of electronic cigarettes: if young people who would never have become smokers are using electronic cigarettes, that is a negative step for their health and for population health. If the use of electronic cigarettes is predominantly among young people who would otherwise smoke or who are already smokers, the same potential benefits come to them as come to adults who make the switch. It is a very difficult balance to strike.
At the moment, the evidence from young people, according to the ASH surveys that are carried out by YouGov, I think—not those by Robert West, who does not consider information about smoking among children in particular—indicates that e-cigarette use among never-smokers is extremely low: it is of the order of 1 or 2 per cent.
I make it clear to the committee that we have always asked for a mandated age restriction. We introduced the voluntary code in 2010, and we are very pleased that it has gone wider than our membership. We absolutely support the mandating of an age restriction.
The difficulty that we hear about from enforcement officers and from retail colleagues who are out in the marketplace selling the products is that, as it is not mandated, the voluntary code is not enforceable. Retail outlets where members’ or sellers’ products are placed will not necessarily respect an age restriction unless it is mandated. I repeat: we support a mandated age restriction, although we completely agree with Professor Britton’s perspective on the potential benefits to children who already smoke.
That said, it is really important for the committee to recognise that there ought to be no difference between the treatment of nicotine-containing electronic cigarettes and the treatment of those that do not contain any nicotine. Unfortunately, to date, all the regulatory proposals and frameworks that we have seen from pretty much anywhere in the world fail to make that clear, so the products that do not contain any nicotine are frequently left outside regulatory discussions. We think that that is a significant mistake, because those are products for inhalation. Just as with nicotine-containing electronic cigarettes, we would not like to see children being sold non nicotine-containing electronic cigarettes.
I should make it crystal clear that I am not attacking e-cigarettes. I know a number of smokers in this building who have given up and who have been on e-cigarettes—although I have to confess that I am not one of them.
I think that Professor Britton said—I hope that I wrote this down right—that we know little of what is in an e-cigarette. Can you explain to us what is in an e-cigarette? People are concerned about that. What is contained in the liquid? I know that people can get liquorice, strawberry or raspberry flavour—or whatever flavour they want—but what else is in the liquid?
The basic ingredient is predominantly propylene glycol, which is well understood—it has been studied for many years, and Professor Britton is perhaps in a better position to talk about it than I am. There is also vegetable glycerine, or glycerol, which is also fairly well understood. Those are both GRAS—generally recognised as safe. There is a very small concentration of nicotine—I use quite a high concentration, at 2.4 per cent, but that is a very low level of nicotine.
There are also flavourings—they are usually food flavourings, although, in the case of tobacco flavours, sometimes flavourings from tobacco absolute are used, and those obviously fall outside food flavouring standards. Some products also contain food colourings.
As the committee may be aware, we are in the process of creating a pre-standard—a publicly available specification—with the British Standards Institution, which seeks to cover emissions gathering and analysis, so that we can understand fully not only what is present in the liquid but, far more importantly, what is delivered to the user in the vapour that they inhale.
10:00We are looking at gathering the emissions, analysing the analytes that are present in those emissions and then doing a full toxicological health risk assessment so that we have a better understanding of the impact on the human body of using the products.
It is with a certain amount of shame that I cannot provide that data to you today—and that it was not provided before the products went on sale. That is an error—a mistake. We should have done that analysis already. However, this has been a process of growth for the industry. Many of the businesses in the sector are not professional businesses. They were often created by vapers who got really excited about the products and decided to create a business. It is now necessary to try to push some standards on them in order to force the standards up, so that people know exactly what goes into the product, what comes out of it and what effect that will have on the human body.
Part of the problem with this debate is that we are not talking about one standard product; we are talking about up to 500 brands and well over 7,000 flavourings. Some of those flavourings, although approved for food use, work quite differently in the body when heated and inhaled.
Our position has been that we would love to see people who are addicted to tobacco being able to use these products instead of tobacco or to quit a tobacco addiction. However, there are so many unknowns, and at the moment the little evidence that we have supports both an optimistic approach and a cautious approach. We believe that regulation needs to look at maximising the potential benefits and minimising the potential harm. The products must work towards our vision for a generation free from tobacco in 2034.
It is very heartening, as a GP, to hear the view of the industry that it wants to make sure that e-cigarettes are not available to our children. Certainly, my interest in this issue as a clinician was first sparked when a parent came to me with a primary school child who had been found in the playground with an e-cigarette—that is wrong on so many levels.
I am very keen for e-cigarettes to be removed; I am very keen for them not to be seen in shops and displays at children’s height, so that children can no longer see those primary-coloured products or take them off the shelf to find out what they are. There needs to be a move to get the capsules—with the actual nicotine-containing liquid—into a child-safe form so that there is no risk to our children of them accidentally getting hold of that liquid and ingesting it. Although nicotine can cause vomiting and so on in overdose, it is not guaranteed that a child will bring up the liquid, so they may suffer harm.
It is also heartening to hear that the industry is keen to do a full health study. My concern as a clinician is whether that is happening after the horse has bolted. There is huge use of e-cigarettes, yet we do not have good evidence as to their safety. I absolutely accept that e-cigarettes will do less harm than continued tobacco use. However, I am concerned that the use of e-cigarettes does not always take someone who is using tobacco down the path either to 100 per cent e-cigarette usage or to quit nicotine as an addiction altogether.
There is certainly emerging evidence that e-cigarettes are being used to reduce people’s reliance on tobacco, but those people possibly then maintain their tobacco use for longer. The evidence, certainly in terms of clinical harm, is that the length of period of tobacco use is potentially more harmful than the intensity of tobacco use. That is a significant concern.
There is a need for more evidence. Certainly, the BMA is very keen to see the quick development—or as quick as research ever allows for—of more evidence around the issue to the point at which I, as a GP, can feel confident to recommend the products to my patients as part of nicotine replacement or smoking cessation therapy. As part of the whole gambit, however, there has to be awareness of the evidence that all nicotine replacement therapies are more effective when they are combined with behavioural therapies rather than people just taking products off the supermarket shelf. We need to use e-cigarettes as a product to help reduce the impact of tobacco, but we must not take our eyes off the huge amount of harm that is caused by tobacco use in the UK, as other panel members have mentioned. I want us to be in a place where the evidence is there, but that evidence is going to take a very long time to develop and we need to be brave and move forward faster than that.
Andrew Thomson raised several points, for which I thank him.
First, child resistance is required by law—or that is what people thought until July, when we found out that it is not required for products that have nicotine concentrations of under 2.5 per cent. However, in our code and our standard, we still insist on child resistance. No product should be out there that contains nicotine and is not child resistant. We verify that with a Government expert, for our members.
There is a significant difference between quitting smoking and quitting nicotine use. As I am sure Professor Britton agrees, nicotine is similar to caffeine in its dependence potential and its effect on the body. Quitting smoking is essential to securing health benefits; quitting nicotine is not such a big issue, in our view.
On the notion of continuing tobacco use, using electronic cigarettes is not tobacco use, of course. Tobacco use has potential health risks, but the continued use of e-cigarettes removes the harms that are associated with smoking tobacco. The issues are not quite the same.
On the point about behavioural support, Louise Ross at the Leicester stop smoking service has seen significant success after recommending electronic cigarettes—or perhaps not so much recommending them as educating her clients about them and making it possible for her clients to access products.
I absolutely agree with Andrew Thomson that we need more research and that we need to move fast on that.
May I make a point of clarification? I agree that nicotine is about as hazardous as caffeine in terms of harm to the body—it is in the same order of magnitude. However, I suspect that nicotine addiction is harder to break.
I will pick up on two points that Andrew Thomson made. On dual use, the argument that has been advanced widely against electronic cigarettes is that they encourage people to continue to smoke and just to use electronic cigarettes when it is difficult to smoke. However, we actively recommend and encourage dual use of licensed nicotine products in exactly the same way. The National Institute for Health and Care Excellence guidelines PH45 on tobacco harm reduction, which I think came out at the beginning of last year, do the same.
The argument is that, although cutting down on smoking probably has a trivial impact on health outcomes, because it is the first cigarette of the day that does the most damage—the situation is more complex than that, but there is a certain truth in that—we know that people who smoke and use electronic cigarettes are far more likely to quit smoking than people who do not. That is about the learning process. People say, “If I can go through a four-hour meeting without smoking by using an electronic cigarette, why shouldn’t I go all day?” We encourage such an approach through nicotine replacement therapy, so it seems completely wrong to say that that is a bad thing in relation to electronic cigarettes.
Andrew Thomson mentioned behavioural support. I entirely agree with him that someone who wants to give up smoking is most likely to succeed if they use proper pharmacological support—which in my view can include electronic cigarettes; as a clinician I recommend them for people who have not found medicinal nicotine products satisfactory—plus behavioural support. However, the fact is that each year only about 8 or 9 per cent of our smokers go into behavioural support services. The other 90 per cent struggle on their own. Electronic cigarettes make the first step towards substituting cigarettes possible for people who are not engaging with medical services.
I agree that the more people we can persuade to go through the full monty of national health service support, the better. However, if smokers are not going to engage with NHS support, I would much rather that they tried an electronic cigarette and realised that maybe there is a way out of smoking than that they did nothing at all.
Robert West has described smoking as like being in a nightclub when a fire breaks out: people just need a way out—it does not matter what it is. Electronic cigarettes could well be a way out for many smokers who would not otherwise find an exit.
John Britton has clarified my point about dual use. Perhaps there was a misunderstanding about the point that I made. I absolutely recognise that we promote dual use and that it is promoted in the NICE recommendations for nicotine replacement therapies. However, that is in conjunction with behavioural therapy, with the aim of reaching a tobacco cessation date. That is far more of a pathway to quitting any use of tobacco, whereas such a pathway is less in place for e-cigarette use.
It is a learning process, as Professor Britton said—he mentioned people managing to go four hours without tobacco then thinking that they can go a bit longer without it and perhaps move to e-cigarettes. However, as he would agree, part of that process is the behavioural support that is built in to help people to gain that learning as opposed to it happening by default.
As for me as a clinician recommending e-cigarettes, I very much believe in the phrase “First, do no harm,” and I still lack confidence about the absolute safety of e-cigarettes. I need that confidence before I can recommend that my patients use e-cigarettes. Of course, if a patient comes to me and says that they are using an e-cigarette because they have found no other way to give up smoking, I will not turn round and say, “No, you should stop that and start increasing your tobacco use again.” However, it is a step further for me as a GP to recommend to my patients that they should use e-cigarettes, because there is a lack of evidence and I need to be absolutely sure that e-cigarettes are not causing any harm.
On the point about harm and how to proceed—whether to take a cautious approach or to act urgently—the evidence base is not as clear as we would like. If there was clear evidence, the situation would be easy and we would be able to take decisions rapidly. However, we do not know enough about the safety of the products or their long-term impact, and we do not know whether dual use is the same as with nicotine replacement therapy.
That is why we have taken a cautious approach to regulation. We have defined areas where we think that it is important to take action—in relation to the age of sale and advertising restrictions. The committees of advertising practice have just brought in a new regime to ensure that advertising of e-cigarettes is targeted at adult smokers and not at bringing young people into the use of the products.
We need to proceed with caution. It might be worth flagging up that the tobacco products directive, which is due to be implemented across the UK in 2016, will put in place a range of measures that will give greater reassurance about the variability in the range of products that are on the market. It will have standards for the contents of the products, for notification, for labelling, for packaging, for electrical safety and for enforcement arrangements. We hope that that regime will allow healthcare professionals to be able to recommend trying the products.
An important point is that, with the smoking population still at about 8 million people in the UK, one size does not fit all and we need a range of measures to help people out of smoking, so that we can look forward to a tobacco-free generation.
One of the harmful forces in the debate is the tobacco industry, which has been buying up the companies and technologies involved as if they were sweeties. We have Boots retailing an Imperial Tobacco brand; Lloyds Pharmacy retailing a British American Tobacco brand; and Rangers and Celtic being sponsored by E-Lites, which was bought out by Japan Tobacco International. With 98 per cent of its profits coming from lit smoked tobacco in the foreseeable future, we have to be conscious of how this deceitful and manipulative industry operates and watch closely its long-term strategy for the products.
We have been watching big tobacco’s involvement in our sector closely and with a certain amount of trepidation. However, it is important to remember that a handful of e-cigarette brands are owned by big tobacco companies at the moment, while hundreds and hundreds of brands—approaching 500—are totally independent of the tobacco industry. This is the tobacco industry’s Kodak moment. The tobacco companies have recognised the threat, but they are the few and we are the many in the sector, and I think that it is highly unlikely that the tobacco industry will have control over the sector in the future.
What we can all hope for as part of a move towards a tobacco-free generation—which we hope will go a bit further than Scotland and the UK—is that big tobacco will recognise the need to move away from selling combustible products at all and move fully into harm-reduction products and nicotine delivery in a clean way, so that it can change its business model for the future and stop doing so much harm.
10:15
What share of the e-cigarette market—as opposed to the number of companies—does the tobacco industry have?
I do not have data on that, but I will see whether I can find that out for you and submit information to the committee.
There is a good page on the website tobaccotactics.org that makes clear which tobacco companies own which brands. The guy who is in charge of the Scottish arm—which was Skycig but was bought over by Lorillard, the US tobacco giant, and is being taken over by Imperial Tobacco UK—has made it clear that he intends to reduce the number of brands to about 10 in the foreseeable future and that he intends his brand, as he put it in The Guardian, to be the Starbucks.
In a market so big—and if electronic cigarettes are effective products, as many clearly are—it is inevitable that the market will consolidate into far fewer brands. It is clear that the tobacco industry will own many—if not, ultimately, all—of them.
It is important to note that, irrespective of what we think of the tobacco industry—I am certainly not here to stand up for it—what we need to prevent is people smoking tobacco. Our target is that, and not the tobacco industry.
I am interested in the Trading Standards Institute research involving children that is mentioned in the Scottish Parliament information centre briefing. It states that between 23 and 80 per cent of retailers are selling e-cigarettes to children. The industry may say that the self-regulation rules are working, but the retailers are not following them.
It is questionable that Boots and Lloyds Pharmacy are selling the products when we do not yet know their effects. Can I take it that everybody agrees that we need an effective Europe-wide programme to be funded to research the potential for short-term harm? The product is addictive. I slightly disagree with John Britton, as I think that nicotine is substantially more addictive than caffeine, and we do not know what long-term harm it may cause. It has been suggested that there is the potential for it to cause dementia.
Do we also need research on the pathways—in other words, whether the products lead people on to smoking or take them away from it? We might also need long-term research.
Does everyone agree that we need research into those things? That is my first question.
That is your question. Can we have some responses, please?
Research is always good and we always want more of it, but it has to be carefully constructed, especially if it is a Europe-wide research programme, because what we have seen so far from the European institutions has not been terribly impressive, to be fair. We need to make sure that the research is shaped properly.
I am primarily a researcher, so I will not disagree with anybody who says that we need more money for research. I fully agree that we need to watch patterns of use carefully. If we see disturbing trends in the way in which young people are using the products, we will need to act on that, but unless we have regular—monthly or certainly three-monthly—monitoring in place, that will be missed.
We know a great deal about the long-term effects of nicotine from the long-term effects of oral tobacco use in Scandinavia, where people have used oral tobacco for many decades. It still delivers nitrosamines to the body and is not a harmless product by any stretch of the imagination but, because of the decades of use, we know a lot about the risk potential or the pattern of risk in lifetime users as opposed to non-lifetime users, and although I cannot say that there is no risk, it is very low.
I agree that we need research. There are a lot of long-term unknowns. We also need to be clear about the funding for the research, because there is a long, well-documented history of research funded by the tobacco industry that does not hold to the body of general science when tested.
I have a word of caution. We considered quite a lot of evidence when developing the consultation document. While more research would be great, the question is what can be achieved in a short time. Some of the research that is required into cessation and health impacts cannot deliver anything robust in the short term; it will take a number of years.
I support an increase in Europe-wide research, which would be very welcome, even with all the caveats that others have included. I also support on-going monitoring and not selling ourselves down a European research line that will take a long time to do. If we can mobilise good-quality research in the UK and Scotland faster, we should get behind that, in parallel with wishing for Europe-wide research.
We need to seize quickly on and stop any trend towards seeing e-cigarettes as a gateway product. The evidence for that is weak at the moment, but it is a potential risk that they are a gateway product or that they normalise the image of smoking.
On monitoring and research in the UK, Stan Glantz—an outspoken public health specialist from California—once described the UK, with the intention of disparaging it, as allowing itself to become a natural experiment in tobacco harm reduction. He meant that to be an insult, but it is a great tribute to the fact that we have a much more open mind about electronic cigarettes than most countries have. We are therefore in a position to do research that cannot be done anywhere else, because we are far advanced down the line of realising the potential of the products. I endorse the priority for research, which is national.
Robert West runs an excellent rolling survey of smokers, which covers electronic cigarette use. It is called smoking in England and, of course, it relates only to England. Such survey work can show us patterns of use quickly and it is vital that all components of the United Kingdom do that.
Richard Simpson may have a brief question—we did agree a timetable.
I understand from an ASH survey that 50 per cent of 15-year-olds have tried e-cigarettes. Does the Scottish schools adolescent lifestyle and substance use survey include a question about e-cigarettes? How soon will we get information on that?
That question is probably more for Claire McDermott, but the survey includes a question on e-cigarette use. I believe that the results will come out shortly.
In the next few weeks.
That is helpful.
I am a little worried about the flavourings in these things. I remember being put off cigarettes for life by one puff when I was a child because the taste was awful. If something that has a pleasant taste is being produced, I foresee children wanting to dabble in it and find out which flavour they like best, thereby developing the habit. Does anyone have any comments about that and what we can do about it?
E-cigarettes are perfectly set up to be a starter product for children because they are smooth, the flavourings in some of them seem to be tailor-made for children and they are high-tech and glitzy. That raises concerns and we have not solved the question whether they could be a gateway into smoked tobacco, particularly if higher-strength nicotine e-cigarettes are more restricted.
We must not forget the tobacco epidemic, which is claiming 13,000 lives in Scotland every year. The committee should not be distracted from that epidemic and e-cigarettes should not be allowed to be a distraction from tackling the availability and supply of the more harmful product.
There you go—now we have a few hands up. E-cigarettes are a distraction.
John Britton is far better qualified than me to discuss the relative merits of flavourings. Adult smokers who switch to using electronic cigarettes and away from tobacco flavoured e-liquids find that it is much harder to relapse to smoking.
Relapse is one of the biggest drivers of the tenaciously stubborn smoking prevalence figures that we continue to see. It is all too easy for people to relapse into smoking, whereas someone who has made the switch away from tobacco flavours to something that is fruity or sweet—or totally different, once they get their taste buds back—cannot go back to smoking. I tried to do that and it does not work—it is revolting. Such people stay off smoking, which is the ultimate goal.
I do not know what the best approach to flavours is. I have heard from some of my patients the same sort of comments as Katherine Devlin made but, at the same time, I agree with Sheila Duffy that e-cigarettes seem set up to be attractive to young kids. None of us wants primary school children to use electronic cigarettes—indeed, I would be interested to know where such a child got the cigarette from. That is why we need monitoring in place—an annual survey is not enough.
We would be treading a difficult path unless we prohibited all advertising, which is not the case at present. On the advertising that has recently been allowed, does the committees of advertising practice guidance apply in Scotland?
Yes.
So the same thing happened here last week as happened in England.
Will the advertising appeal to young people? We will find out only by monitoring carefully and frequently people’s behaviour in relation to the products and their use. I do not know about the flavouring question, but the answer in general is to measure who is using the product and at what age.
I have a couple of questions. We have in place cessation policies to help people to stop smoking. The support that supposedly goes with that help is all based on nicotine replacement. What is the difference between nicotine getting into someone’s body through a patch and someone vaporising nicotine? Is there a difference?
I think that I can answer that. If someone swallows nicotine, it is absorbed into the bloodstream and passes through the liver, and most of the substance is destroyed. It might give the person heartburn and make them feel a bit queasy, but it does not get into the blood at high levels. If someone inhales nicotine, however, it is absorbed across the lung surfaces directly into the bloodstream and straight to the brain, so they get a hit very quickly.
We do not have a medicinal inhalation product—yet. To avoid its breakdown in the liver, medicinal nicotine must be given through routes that involve absorption into the blood supply or blood circulation that does not track through the liver. That usually means through the skin, nose or mouth or the other end of the gastrointestinal tract. All of those areas absorb nicotine very slowly, and much more slowly than through inhalation.
So, irrespective of the speed of absorption, it is the entry system that matters. The nicotine levels that would be reached by vaporising or by using patches are very similar.
Cigarettes do two key things: they deliver nicotine to the brain extremely quickly; and they deliver very high doses—
But if you take away the cigarette, and compare vaporising with nicotine patches—
The early-generation e-cigarettes were all pretty hopeless and delivered fairly low amounts of nicotine. At best, they were on a par with the Nicorette inhalator, which is an oral device. It is supposedly an inhalation device, but it works by delivering nicotine into the mouth.
The second-generation electronic cigarettes—the vaporisers, which look not at all like cigarettes—deliver higher doses through a mixture of mouth, upper-airway and, probably, some lung absorption. I have not yet seen evidence to show that electronic cigarettes—any of them—have achieved the sort of lung absorption that a cigarette achieves. There is still a long way to go, but the products will get a lot better.
Sheila Duffy mentioned the potential for the products to be a distraction. I would put that slightly differently. My responsibility in the Department of Health relates to tobacco control. There is a range of things that we can do to impact on smoking. Some relate to nicotine replacement therapy and some relate to other central nervous system drugs that have been, or are currently being, developed. There is also cognitive behavioural therapy, and there is the environment, which includes standardised packaging of tobacco products, advertising and availability. All those things impact on the smoking epidemic, and they are tools that help us reduce the size of the population that still smokes.
10:30We could think of electronic cigarettes as a distraction, or we could think of them as presenting an opportunity. Different levers will work for different people. We need as many tools as possible in the toolkit to help us. That is why we have taken a cautious approach in England, recognising that the opportunity and the risks of e-cigarettes need to be managed—but still recognising that they present an opportunity, rather than something that we should not focus on.
I will add to what Professor Britton said about the comparison between nicotine in licensed medicinal products for NRT and nicotine in electronic cigarettes. It is important for the committee to recognise that the nicotine is of the same grade: it is pharmaceutical-grade nicotine that is used in both electronic cigarettes and NRT products. That is built into our standard, but it is already pretty much standardised across the industry anyway.
I am going to invite MSPs who have not already spoken to ask questions. Then, if there is time, I will let other members in again.
I have a question of my own on something that we have not yet covered. What justifies the ban on the use of e-cigarettes in public places? If people have to leave a public place—a pub for example—in order to go outside and smoke an e-cigarette, why would they not just go out and have a cigarette?
The legislation that we have on cigarette smoking in enclosed public places was brought in primarily to protect people who work in those environments. The evidence on electronic cigarette use in indoor public places is that it releases nicotine into the atmosphere. It may well release other substances into the atmosphere, some of which may be toxic. Therefore, it is not a completely clean, innocuous product, although the levels of those things are extremely low.
Personally, I think that it is a matter of courtesy not to use electronic cigarettes indoors—for example, in this room as we speak. However, using the law to say that people cannot use an electronic cigarette indoors engenders exactly the process that you have just described: if people are treated like smokers, they might as well be smokers.
What about controversial circumstances, such as in-patient settings in general hospitals? Some of my patients smoke electronic cigarettes under the sheets, because they are not allowed to use them openly. In mental health settings, the prevalence of smoking is incredibly high, and it has not shifted over the past 20 years. In prisons, too, the prevalence of smoking is extremely high, and it is very difficult to control, although I am sure that going smoke-free can be done, and electronic cigarettes may be part of the solution.
I would be very cautious about a legislative prohibition of electronic cigarette use in enclosed public places, although I accept that the courteous thing for all electronic cigarette users to do is not to use them indoors.
I could not agree more with John Britton—hence, my e-cigarette is in my bag and not in use. The prison population example is a very good one. We have a working example of that at Guernsey prison, where arrangements were rolled out to make e-cigarettes available to prisoners there, alongside NRT and behavioural support. That has been very successful, and the prison has gone completely smoke free.
When it comes to mental health institutions, there is a significant body of evidence to support the fact that mental health patients—particularly schizophrenics, but all those with mental health disorders—find nicotine enormously helpful, and that is why the prevalence of smoking tends to be much higher among mental health patients. I am sure that there are doctors present who could attest to that better than I can.
When it comes to bans in public spaces, however, we need to be very careful about our obligations in relation to every citizen’s human rights. If we say to someone who wants to use an electronic cigarette, “You can’t use it in the building; you’ll need to go outside to the smoking shelter,” we are putting them in harm’s way, because we are telling them to stand with the smokers, and we know about the risks of passive smoking.
I agree with John Britton that the matter should not be mandated and should be left to courtesy and public policy decisions by each business, building owner or whoever. If people decide that vaping should not be allowed in their building, they will need to offer separate spaces for smokers and vapers.
The BMA was keen for electronic cigarettes to be included in the legislation on smoke-free public places. There is currently no evidence that they are not harmful, and there is an issue to do with the normalisation of the image of someone puffing.
Albeit that it is a vapour that is produced, as more and more people use e-cigarettes, the vapour is more and more visible, and there is an issue to do with whether you can tell the difference between smoke and vapour. That is partly why companies such as JD Wetherspoon have banned e-cigarettes. It is difficult for staff to ascertain whether someone is breaching the smoke-free legislation or using an e-cigarette, and when staff challenge people they are potentially put in harm’s way.
We absolutely understand Katherine Devlin’s point about the potential for putting someone in harm’s way by exposing them to passive smoking, but we are not suggesting that solution—people can have a space in which they can use e-cigarettes away from the risks of passive smoking. However, we very much think that having a dual standard for tobacco use and e-cigarette use potentially undermines the current legislation on smoking in enclosed public places, so we are keen for e-cigarettes to come within the scope of the legislation.
The industry purports to say that it is promoting e-cigarettes only as tools to help to decrease tobacco use, so it should not be afraid of e-cigarettes and tobacco being treated in a similar way. We talked about flavourings, but there are even e-cigarettes with Bluetooth connectivity, so that people can use them to play music and so on. Such things are clearly designed to capture a young audience and not as a tool to reduce the impact of tobacco on society.
Most scientists say that there are risks, but the BMA came off the fence and said, “We cannot prove that e-cigarettes are bad but we cannot prove that they are good.” Why did you come down on that side of the fence?
Because we always come down on the side of the “first do no harm” principle. As doctors, that is our prime directive. We cannot prove that electronic cigarettes are safe to users and to those around them, for example in environments in which there might well be a lot of people using e-cigarettes. Therefore, we do not want to sit on the side where there is potential harm; the benefit is in taking the safest option, which in our view is to include e-cigarettes in the legislation on smoking in enclosed public places.
The converse of that argument is that the riskiest thing to do is to continue to smoke, so anything that can help to bring people away from continuing to smoke tobacco is potentially helpful.
In England there are no plans to extend the ban on smoking in public places to electronic cigarettes. The products are different. The risks that are associated with second-hand smoking are clear; there is an evidence base in that regard. There is no evidence to support treating the two products the same, in the context of the level of risk in exposure to them.
However, we support the right of companies to take action on their premises. There are a range of reasons why people might want to do that, including for ease of enforcement of the smoke-free legislation.
I have heard the argument that the risks are different in different places. We heard about prisons and mental health institutions, which are examples of places where the normalisation argument—for example, the idea that children will see products that look like cigarettes being used—does not apply. There might well be different arguments for different settings.
The one thing that has come across clearly to me is that no one, so far, has said that the products are safe. Nobody knows. For me, the idea of not putting in place a ban similar to the ban on smoking sends the signal that e-cigarettes are safe and that we know that they are okay, rather than being proactive on the matter—particularly regarding children.
As regards the question whether the practice will become commonplace, I have never smoked in my life and I have never really worried about someone else smoking, other than encouraging them not to because I know that they are damaging their health. I have a weird attitude about what people do, whether it is drinking or smoking. Signals are very important to me. If the message is, “Don’t go there,” I will not go there; if there is no such message, I am allowed to go there.
I stress the point that the Department of Health in England is not recommending the use of e-cigarettes. In fact, the chief medical officer for England has expressed concern, particularly about children and young people and the idea of a potential gateway. We have taken a cautious approach because tobacco is so harmful. It kills 80,000 people a year in the UK, which is something like 200 people each and every day. It is more harmful than alcohol, obesity or lack of exercise—it is more harmful than any other public health issue; it is the single biggest killer. For that reason, we need to do all that we can to support tobacco control. If the use of e-cigarettes is potentially helpful, we need to take a cautious approach to enable it, rather than banning something without sufficient evidence.
I wish to clear something up.
I call Claire McDermott.
Convener, before anyone—
I am calling Claire McDermott next.
These are very much the debates that we considered in developing our consultation paper. However, I echo Jeremy Mean’s point that the smoke-free legislation was brought in on the grounds of really robust evidence on the significant harm of second-hand smoke. That is why our consultation focuses on the points that Mr Paterson makes about protecting young people and non-smokers and trying to achieve a balance through reducing young people’s access to e-cigarettes and reducing the appeal of e-cigarettes for young people and non-smokers. We ask questions about how the products are marketed to those groups.
I would like to make a point of clarification. I am sorry: I misrepresented what I meant to say. I was not talking about a ban of these products; I was talking about a ban on their use in public places. I do not think that it is logical to have a separation in that respect. It is not about banning the products, but they should be treated in the same way as cigarettes when it comes to their use in public places.
Has any cost benefit analysis been done in relation to health—for example, on reduced deaths? There is an indirect claim that tobacco causes 80,000 deaths a year and e-cigarettes will reduce the level of harm, but by what extent? What health benefits are being claimed, if any?
The best or closest analogy that I can use to answer that question relates to the pattern of health harms that arise from oral tobacco use in Sweden. Sweden has the lowest lung cancer rates in Europe, alongside the lowest smoking rates. Tobacco use is the same in Sweden as it is elsewhere, however; it is just that many more tobacco users there use oral tobacco. That is partly because smokers in Sweden have switched to oral tobacco—as smokers have switched to electronic cigarettes in this country—and partly because a whole cohort of young people who were going to become smokers have instead become oral tobacco users and are growing through without the risk.
We know from that experience that whereas lifelong use of smoked tobacco takes about 10 years off life expectancy, lifelong use of oral tobacco probably takes off a couple of months or so—it is of that order of magnitude; it is a fairly trivial risk.
On that point, convener—
No, no—I always take the panel members first.
I would like to ask one last question.
You might get in with it later if you do not delay the committee’s proceedings now.
10:45
The health gains and savings from people stopping using lit-smoke tobacco are huge. We do not yet know, for the whole body of smokers, whether dual use of e-cigarettes with lit-smoke tobacco will perpetuate or whether people will switch to e-cigarettes completely. We just do not know that yet.
I will clarify my point about oral tobacco. An electronic cigarette is an inhalation product and we do not know the long-term risks of propylene glycol, glycerine or any of the other by-products. There are theoretical risks in that regard, but to my eye those risks are of a similar order of magnitude to those that relate to the use of oral tobacco, which causes other hazards that electronic cigarettes do not.
I entirely agree with Sheila Duffy that we do not know what the long-term pattern of use will be. That is why we must monitor use carefully, repeatedly and frequently. We should be able to get those figures in days, rather than in a year or two, as happens in England with many Government surveys.
I completely agree with Sheila Duffy and John Britton that we do not know the long-term effects yet: we cannot, because e-cigarettes have not been used for long enough. We know that the use of e-cigarettes, like the use of the oral tobacco products that John Britton described, completely removes the by-products of combustion. There is no combustion, so there is no tar or carbon monoxide: all of that sort of stuff is completely absent.
Professor West, who presented at a summit that was held last week, has said that the residual risks will be of such a tiny order in comparison with the massive risks of continued smoking that they will be almost negligible.
Professor Britton talked about harm and the differences in Sweden. Were you comparing figures for lung cancer or all cancers? Some argue that nicotine can enhance tumour growth and the like.
There is evidence that nicotine can promote tumour growth but there is no evidence that nicotine causes tumours. If you are a nicotine user and you develop cancer, it could progress quicker than it would in someone who is not a nicotine user. I have never argued that nicotine is safe; I have argued that it is not the cause of most of the harm from smoking. In terms of safety, it is probably on a par with caffeine, which causes heart arrhythmias and other problems.
I can only speak to the Swedish cancer figures. From memory, for men in the 25 to 45 group, which is a very good marker of future mortality, the figure is about half—it is certainly the lowest in Europe. For heart disease risk, things are slightly different in Sweden, but there are many more influences on heart disease than just smoking, whereas smoking accounts for nearly all the influences on lung cancer.
I do not know whether that answers your question.
Lung cancer is obviously a by-product of smoking tobacco, but I was keen to know whether the figures for other cancers were the same.
I cannot answer that except to say the other known potential risks from oral tobacco are oesophageal cancer and pancreatic cancer, the figures for both of which—this certainly applies to pancreatic cancer—are slightly higher for oral tobacco users than never users, but less high than for smokers. The risks are all relatively low. I appreciate that that is slightly tangential to your question.
Richard Lyle may now come back in.
Professor Britton spoke about damage to lungs. At the European Respiratory Society’s annual congress in Vienna in September 2012, researchers from the University of Athens, in Greece, presented a report that said:
“Electronic cigarettes could ‘damage your lungs’ as they cause less oxygen to be absorbed by the blood.”
Do any panel members have any comments on that report?
I specialise in lung disease. The lung is a fascinating and very complex organ. It is also extremely delicate, so inhaling things that you should not inhale probably does not make sense. What matters is the relative perspective against inhaling tobacco smoke. I take with a huge pinch of salt any study—and there are such studies out there—that argues that electronic cigarette inhalation generates as much damage to certain in vitro or laboratory-based cellular measures as cigarette smoking. There is no question but that inhaling toxins into the lung causes the lung to object, but whether that will translate into lung cancer or chronic obstructive pulmonary disease—which smoking certainly leads to—we just do not know. My suspicion is that it will a little bit—but it will be trivial.
I have a fairly intimate working knowledge of that particular set of studies and headlines, having been around at the time and having had to deal with them on behalf of my industry. The reporting was egregious, to be fair. What the study found was that there was an acute effect on the lungs and the respiratory system that is almost certainly attributable to propylene glycol, which is an irritant. That is why we enjoy it—it gives us the throat hit that makes using an e-cigarette feel like smoking. It is an acute effect, but it is very transitory. Within about 10 minutes of stopping, the effect is gone. Unfortunately, the way that the study was reported transmuted those fairly ordinary findings into Daily Mail headlines of magnificent proportions that suggested that e-cigarettes can damage your lungs and cause permanent damage and all sorts of nonsense. Those conclusions simply were not in the findings of the study.
I have one quick comment. I do not think that England has registration of tobacco outlets, but Scotland does. It was one of the moves that were made to control illicit sales. It seems to me that it is only a matter of time before the criminal fraternity get into this area and supply tobacco material to go into these products in some way. Do other people feel that that is likely to happen, and pretty quickly? If so, should we limit sales to registered outlets so that we can make sure that children are not sold e-cigarettes? That is clearly happening everywhere, with the figures ranging from 80 per cent at car boot sales down to 25 per cent—which is the best figure—at supermarkets, according to the Trading Standards Institute report. Should we limit sales? I do not know whether that issue is addressed in the Government’s consultation, although I expect that it is.
I agree that sales should be limited to enable us to control the supply of e-cigarettes and avoid the very thing that I have experienced: a child coming into the surgery with an e-cigarette. To answer John Britton’s question, the child got it by accident—they went into a newsagent and bought it thinking that it was a toy. That was how that seven-year-old child got it.
Sales restrictions are addressed in the Scottish Government’s consultation, which contains a proposal to introduce age restrictions for e-cigarettes, which will help trading standards with its enforcement role.
At the moment, there is no record of who is selling e-cigarettes, so identifying who is selling e-cigarettes would also help trading standards with enforcement and with its educational role. Much of the work that trading standards does is about educating retailers to help them not make illegal sales.
I can confirm that England does not currently have a registration scheme and there are no plans to introduce one. However, we have been working closely with our colleagues in the Trading Standards Institute and locally to ensure that age-restricted sales are controlled carefully and that these products—once they are restricted by the regulations that we will publish shortly—will be well controlled under local arrangements.
The question of illicit trade has been raised. Recognising the potential role that registration can play in controlling illicit sales, Her Majesty’s Revenue and Customs recently consulted on a range of measures in England to help control illicit trade.
We have seen that illicit trade tends to fall as prevalence falls. The lower the smoking rates, the more illicit trade tends to come down. Our action on tobacco control should impact on illicit trade. That is certainly a priority for the Government in London.
It is clear that smugglers will shift anything that makes money, whether it is tobacco, fish or e-cigarettes, so we can expect the issue to come up. The retail register in Scotland has been tremendously helpful, in that it has allowed the enforcement community to engage with retailers, to offer them education and to counter the misinformation that they have had from the tobacco industry. I would certainly support those who sell e-cigarettes and vaping devices being part of the register. However, we need to go beyond that for tobacco. I think that we need to start looking at putting it further out of sight, out of mind and out of fashion.
That brings an end to this session. I am sure that the debate will go on. As a committee, we look forward to following that debate and to working with the Scottish Government to address the issue.
Thank you all for your attendance this morning and for the evidence that you have provided.
10:56 Meeting suspended.Previous
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