Health and Social Care Committee
Oral evidence: Prevention in health and social care, HC 141
Monday 5 February 2024
Ordered by the House of Commons to be published on 5 February 2024.
Members present: Steve Brine (Chair); Paul Blomfield; Rachael Maskell; James Morris.
Questions 296-334
Witness
I: Professor Javed Khan OBE, author of the Khan Review, “Making Smoking Obsolete”.
Written evidence from witnesses:
– [Add names of witnesses and hyperlink to submissions]
Witness: Professor Javed Khan.
Q296 Chair: Good afternoon and welcome to the Health and Social Care Committee. We have a double-header across two days as we kick off the public evidence sessions for the alcohol, drugs, gambling and smoking workstream in our prevention of ill health inquiry, which has garnered huge interest. All parts of it have done so, but the smoking part has in particular, not least because the Government are bringing forward their smoking and vaping Bill imminently and brought forward the response to their vaping consultation last Monday, and primarily because of something called the Khan review, which has really made waves.
The review was chaired by Professor Javed Khan OBE. Professor Khan, “Making Smoking Obsolete” is a piece of work that you did for the Government very recently, so we are going to talk to you about that. More members of the Committee will join in as they come up from the Chamber. Just before we do, I want to place on the record, for 100% disclosure, that I met Imperial Brands in my constituency on Friday to talk about illicit smoking and vaping sales. Their people go out and about into the marketplace all the time to see where illicit tobacco and vapes are sold. I just wanted to make that clear.
Professor Khan, thank you so much for coming. It’s really nice to see you. Thanks for all your work. I guess you have to be pretty pleased with yourself at the moment, because your work is continuing to make great waves and the Government appear to be taking on board many of your recommendations. How pleased are you with your work?
Professor Khan: Generally speaking, I am quite a hard person to please, but on that spectrum of pleasure, this is a relatively good time. I still think there is more work to do, but we are in a good position.
Q297 Chair: Excellent. What is the typical or the average age after which, if you have not taken up smoking, you are unlikely to do so?
Professor Khan: In the review, which as you know was conducted in 2022, from January to June—the data is from that time, as opposed to being the very latest data—we found that if young people do not start smoking when they are relatively young, between the ages of 14 or 15 to about 25 or 26, or perhaps even 30, they probably never will smoke. So it’s the early stage of life, from just into adulthood.
Q298 Chair: Given that, why did you go for the one year every year approach, which is what will be legislated for in the smoking and vaping Bill? New Zealand is known for doing that that, but why did you go for it? For instance, do you remember the “21 now” campaign, which I remember Action on Smoking Health was very keen to promote at one point? As the smokefree ambitions in your review became known, that was obviously superseded, but why not 21 now instead of year on year?
Professor Khan: As I am sure you can imagine, I thought long and hard about this over the six months that we did the review. I spoke to people from across 13 nations and all the experts that you can imagine fed into it, as well as local stakeholders in the UK and so on. A range of views were put forward, such as raising the age of sale from 18 to 21, or even to 25, as opposed to raising it year by year, which I hope is where we will go now.
The context or my thinking on that is that—to state the obvious, which I am sure you are aware of—no other product legally sold in this country is likely to kill you in the way a cigarette will if you smoke it as the manufacturer expects you to. It is totally addictive, and two thirds of the people who smoke are likely to die as a result of it, or have great ill health before they die. That is part of the context. If you add that stopping people smoking is far harder than preventing them from starting smoking in the first place, surely doing something before they start must be the right thing to do.
The review gave due consideration of all the other available data, statistics and so on and looked at the Government’s stated ambition of a smokefree 2030, which was a surprise to me. The target was never smokefree; it was an average of 5% by 2030, and it still is. There were great variations from almost nothing to very high numbers of people still smoking and putting their lives at risk, so what was the best way to make an inroad into that? Based on that and the conversations that I had across the world, I decided that the increase by one year at a time until no one can buy a cigarette again is the right thing to do, because it creates a smokefree generation in a way that none of the other measures we could have taken would ever do.
Q299 Chair: I wonder therefore what your answer is to the nanny state argument, which I am very familiar with as a former public health Minister; I am sure you will have had it directed at you over this work, and it will come back again and again when the Bill is presented. What is your answer to the nanny state argument and on the practical problems that some will say will result? The Spectator wrote a very hostile piece on the legislation last week, where it said: “It’s absurd that in a few decades, a 45-year-old will be allowed to legally buy cigarettes and a 44-year-old banned.” They are legitimate questions to raise, and they are points of debate that will go on in the Chamber when we discuss the Bill. What is your answer to the nanny state argument and to the practical age of sale argument?
Professor Khan: Alongside the nanny state argument, if we can call it that, is this whole notion that people should have freedom and choice to do what they want to as adults, as long as they are above the age of 18 and so on. It needs some careful consideration. Again, you come back to the facts of what we know about cigarettes. There is a very large industry out there that preys on young people, on children, trying to get them to take that first cigarette puff. They work very hard at getting them to do that, and then they get addicted. Once you are addicted—and addiction needs understanding as well—it is no longer a choice; there is no freedom of choice once you are addicted. The right thing to do is to stop the availability before you get to that point.
If it is an addiction and there is no choice, the nanny state argument falls apart, because as a Government and as legislators, if I may say so, you have a responsibility to protect the public in every which way you can, and you do that in a whole range of scenarios. This is another area where you have the ability to protect the public from something that is being created to addict them and make them very ill or, ultimately, kill them. The case for your intervention is therefore very strong.
Q300 Chair: And the second part, about the 45 and 44-year-olds?
Professor Khan: Those arguments can be made, but you should not worry because when you look at the history of legislation that has imposed restrictions on people, those arguments are always made. If you look back at seatbelts being introduced, people found that really hard. More relevant, when smoking in public spaces was banned in 2007, could we have imagined that in 2024 we would be in a world where nobody thinks twice about it? You just do not expect anybody to be smoking in here or any other building. People will get used to it, and it will not be as difficult as some of the soothsayers predict.
Q301 Chair: Are you saying that those raising the practical arguments and writing articles about them really just do not like the idea of public health intervention on a population level?
Professor Khan: They probably do not like the idea of intervention in any kind of freedom and choice, as they see it. I do not think it is just smoking.
Q302 Chair: Finally, in “Stopping the start”, part 2 of your review, you recommend raising the age of sale of tobacco by one year every year, which we have talked about. Then, you recommend introducing a tobacco licence for retailers to limit where tobacco is available, and enhancing local illicit tobacco enforcement—one of the things I saw on Friday in my constituency—by dedicating an additional £15 million of funding per year to local trading standards. Can you talk about having a tobacco licence for retailers, and then about money for local trading standards, and whether you think they are resourced enough?
Professor Khan: The licensing issue is really important and does not feature in the current proposals from the Government. That is a weakness. There are lots of strengths, but that is one of the weaknesses. I find it quite surprising that anybody can sell cigarettes in this country. Not everybody can sell alcohol, as you all know, but anybody can sell a cigarette. It should be licensed. There are many advantages to that. This is not about restricting the retailers in any way; it is about regulating the retailers. The retailers that I spoke to in the review wanted to be regulated in that way, because they wanted to get rid of the cowboy operators out there—those who are breaking the laws. They wanted them to be stopped because it gave them all a bad reputation. There was no concern about the proposal from the retailers.
There are multiple other advantages, because the way I proposed it, this should be a national scheme administered by local authorities. Decisions on licences are made at the local level, and any local concerns can be included within the licence—for example, not selling cigarettes too close to a school, to reduce the appeal to children. Local authorities can do that if there is a licensing scheme. Whatever local authorities charge for the licence is also an additional income for them—we all know how stretched they are. There are multiple benefits to licensing.
In terms of trading standards, during my review I went on site visits with trading standards. I went out with the police and trading standards officials in Medway. We went into a shop that was known to the trading standards officers because they had raided it before—they had stopped it from operating, but within hours it had opened up again, because the trading standards people just did not have the powers to enforce anything. It has to go through the courts, which can take number of weeks and months, and then the shop gets a very small slap on the wrist and carries on operating. There is an issue around the legislative approach to enforcement at a local and national level.
Resourcing is also an issue, which was very clear from all the people I spoke to up and down the country. Trading standards just does not have the resources for enforcement. Hence, my recommendations suggested an increase in the resource available to them to enforce. I was very clear at the time, and still am, that my report was a holistic response to the challenge. It is a comprehensive strategy of 15 recommendations that are interlinked—for example, if you raise the age of sale by a year, and so on, but do not invest in enforcement at the same time and tackle the illicit cigarette market, it will not work. It has got to be taken in the round. It is not a pick and mix.
Chair: That is actually more dangerous, because the illicit market brings products onto the market that have not been through some of the procedures that we expect, and obviously no duty is paid.
There are so many questions to ask you. I deliberately did not touch on vaping in this initial exchange, but you cannot really talk about smoking without talking about vaping these days, because they are part of the same tapestry. James Morris will now ask you about prevention, and that section of your report.
Q303 James Morris: Professor Khan, the statistics show that there has been a decline in smoking in all regions over the past 10 years—for example, the reduction in the east midlands is -6.2%. There are variations on a regional level. Do you think that progress has been good?
Professor Khan: It has been progress. Again, the context matters: in 2002, when I looked at this in detail, we were trying to work out the trajectory and whether the 2030 ambition of a 5% average could be reached or not. We calculated that there would need to be a 62% relative reduction from 2022 to 2030 to hit the 5% target. What we found, though, was that although there have been great gains in the previous decade or two, what was happening in 2022 was that the annual rate of reduction was down to 0.5% per year.
Q304 James Morris: What did you attribute that to? Is it because it is getting harder and harder?
Professor Khan: It is the last yards of a marathon, essentially; it is much harder when you get to the truly addicted smokers.
Q305 James Morris: Does that mean that, over the last 10 or 11 years, public health interventions have been successful in driving down that number?
Professor Khan: That is a big question, and there are certainly many facets to the answer. Yes, of course, there have been great successes right back to 2007, when smoking in public places was banned; then there was not smoking in cars with children and so on. All that has helped, but alongside that, look at what has happened to stop smoking services, for example. The funds for local services to support people in stopping smoking in every patch across the country have been decimated over that period. I think that £23 million was being spent nationally on the marketing campaigns that existed over a decade ago; in 2022, that was down to £2 million. My interpretation is that some people thought that we were doing so well that we did not need to spend much more money on this, and that was a mistake. That is why the rate of reduction has dropped to 0.5%. In my recommendations, I asked for a catalytic injection of money for stop smoking services and mass marketing campaigns.
Q306 James Morris: Is this your £125 million?
Professor Khan: Yes.
Q307 James Morris: Is that £125 million what you think should be spent every year on smoking-related public health interventions?
Professor Khan: Per year, yes. I broke it down into six different spends. I suggest to the Government that that should be reviewed every three or four years, because not all of it will be required every year.
Q308 James Morris: There is a bit of stop press news: today, a £70 million investment into local authorities for smoking cessation has been announced, which is some way towards—
Professor Khan: £17 million?
Q309 James Morris: No, £70 million. I think that has happened literally in the last half hour; I just quickly googled it.
Professor Khan: But in the proposals coming in a Bill at some point, it is much higher than that, and that is what is needed.
Q310 James Morris: I think there was a suggestion in your work that somehow smoking cessation had been deprioritised by local authorities—notwithstanding the argument that maybe the money had also not been sufficient, there had been a deprioritisation. Is that part of people thinking that we had made sufficient progress and did not need to push any further? What do you think has been driving that?
Professor Khan: I think it is a bit deeper than that, more structural. The smoking cessation grant to local authorities sits within the public health grant that they get. The public health grant, since 2016, has gone down by 21%, but in the same period, that element of it that is then passed on to stop smoking services has gone down by 40%. Those are local decisions because local authorities have discretion. That is why in my recommendations I ask for an injection of £70 million to stop smoking services and for the money to be ringfenced for that purpose so that it cannot be diverted anywhere else.
Q311 James Morris: Smoking cessation is one thing. You are quite clear about the interrelationships, particularly when we are getting down to, as it were, the final mile of people who may be taking up smoking for lots of other social and economic reasons. Are there other things that we should be doing as public health interventions?
Professor Khan: I have a comprehensive set of recommendations, not all of which are currently being embraced. I can go through those, if you like.
Q312 James Morris: What about regional targeting? There is quite a lot of regional variation in the numbers for prevalence. Does that suggest that a targeted approach into some of the harder-to-reach areas and areas of deprivation—where there is a lot of smoking—is critical to the strategy?
Professor Khan: Smoking is a critical contributor to health disparities in this country. That is what the data shows. There is huge variation across the country. For example, some smaller places in the north have four and a half times the rate of smokers as the south-east. Some of the poorest communities who can least afford it are spending the most on smoking.
Q313 James Morris: There is the proposition of a piece of legislation that will essentially lead to a smokefree generation. If we get the public health interventions correct, there is further investment and all your recommendations are implemented, will we need a law? If that were the case, would we need some kind of new law? Or would we get there anyway because the trend over time—among young people and adults—is that smoking prevalence is coming down, notwithstanding your argument that we are into the final mile of getting to those hard-to-reach people? Why do we need a law?
Professor Khan: I did not say we needed a law. In my report, I am very clear that I focused on the what, not the how.
James Morris: I understand.
Q314 Chair: That is a very fair point—that is our job.
I am not putting words into your mouth at all, Professor Khan; I am just asking the question. Could it be seen that this is happening because we took our foot off the pedal and thought, “Ah well, rates are coming down; they will continue to come down,” and what has happened is that although they are still coming down, they have slowed? Is this happening because we took our foot off the pedal?
Professor Khan: Yes.
Q315 Chair: James Morris was telling you the stop press news about the £70 million for the smoking services. You say that £125 million is needed and you give some options for where that could come from, one of which is the “polluter pays” industry levy, which I have spoken about in the House and voted for in the House. That is not where the Government is going, is it? Do you think that is a mistake?
Professor Khan: I set out what is needed and gave options for how it could be done, but it is not for me to decide. I think the “polluter pays” levy should be considered. There are two reasons for that: one is that it is a way of raising the money and putting it into that, of course, but there is a philosophical position as well. Right at the start, I said that we have a very successful £19 billion industry in this country that makes a £10 billion contribution to our taxes but creates a £17 billion cost to society. Surely that industry should take responsibility for the effect that it has.
Q316 Chair: There is great precedent for the “polluter pays” principle in other areas of policymaking. Presumably that is why you suggested it: you thought that it might find favour with Ministers. But it hasn’t found favour with successive Secretaries of State and Prime Ministers, has it? It has been put out there—I think my friend the Member for Harrow East mentioned it many times before it was in your review—and hasn’t found favour.
Professor Khan: We live in hope.
Chair: We live in hope. Maybe it will find favour in this new nanny state that we live in.
Q317 Paul Blomfield: Professor Khan, I want to explore your recommendation that we should “Embrace the promotion of vaping as the most effective tool to help smokers quit.” I want to talk about how that is to be achieved.
When the tobacco products directive was first agreed in the EU, years ago, it set the framework for much of our current approach in the UK. There was lively debate about whether vaping should be prescribed as a medical product and made available specifically to help smokers to quit, or whether it should be commercially available. Big tobacco won, and vaping became commercially available, so we are seeing a new generation of addicts. Was that a mistake?
Professor Khan: My report recommends a medicinally approved vaping approach so that vaping can be prescribed by GPs. That is a gap at the moment, although I understand the difficulties of that approach—somebody from industry has to come forward, and it is a pretty slow process. The Medicines and Healthcare products Regulatory Agency said that it would do its best to speed up the process if somebody came forward, but somebody has to come forward. Why people are not coming forward is debatable.
I support a medicinally approved vaping approach for a number of reasons—first and foremost, you might be surprised to hear, because I think there is a fair degree of scepticism among a range of health professionals about vaping. I met many of them, from primary care to secondary care and in very senior positions, and people are not sure whether vaping is a good thing and whether they can professionally recommend it. Generally, they were crying out for some kind of authoritative message, such as the MHRA and the National Institute for Health and Care Excellence saying, “Yes, you can do this.” It would counter that.
Why do I want to see that happen? Because all the evidence presented to me was that vaping is less harmful than smoking cigarettes. It is not a silver bullet. That is not to say that there are no harms—we do not have longitudinal studies over 40 or 50 years to tell us that, as we have for cigarettes—but all the academics around the world were telling me that smoking is between 50% and 95% safer than smoking a cigarette, and probably closer to the 95%.
Chair: Just for the record, it is vaping that is safer. You said that smoking is safer.
Professor Khan: Sorry, my apologies: vaping is closer to 95% safer than smoking a cigarette. We should therefore do everything we can to promote vaping as a quit tool, not as something that young people should take up because they think it is a cool thing to do. That leads on to the question of what we need to do about vaping to prevent young people from taking it up in the first place.
Q318 Paul Blomfield: May I explore that point? In your report, you make a recommendation for Government to provide accurate information to healthcare professionals on the benefits of vaping, but you are now telling us that although it is clearly not as toxic as tobacco, there are nevertheless big questions about the health issues associated with it.
Professor Khan: I would say that there is a lack of clarity of information from the authorities. They need to make this information clear, whether it comes from the Department of Health and Social Care, NHS England or wherever. I met GPs who said that they had never seen any kind of guidance that would encourage them to direct their patients. Pharmacists said exactly the same. They needed clarity. If we are convinced that it is safer, if the “swap to stop” packs are about to go out and if we agree with the principle that vaping is a good quit tool because it has been proved to be relatively successful, let us clarify that for all the health professionals out there who are asking for it.
Q319 Paul Blomfield: But vaping should be directed towards smokers to enable them to quit, rather than being available in the way that it is at the moment.
Professor Khan: I think there will be a natural knock-on effect. If there was a medicinally approved vaping approach, the market would change, because people would be getting vapes on prescription.
Q320 Paul Blomfield: There is clearly enormous concern about vaping among young people, who should not be getting access to these products. Your report shows a chart of the decline in smoking among 11 to 15-year-olds; over the same period, we have seen vaping go up on an inverse trajectory to almost fill the gap. You have made a number of recommendations about how we should stop young people taking up vaping, but they are clearly not working. What more should we be doing?
Professor Khan: My recommendation came out in June 2022, based on what I knew then. I think the situation has got worse since then. Some of that might be due to media coverage, but I think it is more than that. It has got worse. For example, there is the whole issue of disposable vapes, which I didn’t touch on in my report because it was not raised as a significant issue at that time, but in the last 18 months it has become very significant. I was very clear—
Q321 Chair: So disposable vapes were not raised as a significant issue with you in the lead-up to June 2022? That shows how quickly this has moved.
Professor Khan: Exactly—and who knows what’s to come? I was very clear that the industry is preying on young children. For example, there is no law to stop them from handing out vapes for free to kids. I think that is proposed in the legislation that will come, which I am very pleased to see. I asked for a ban on images appealing to children—the cartoon characters and all that—and for a review of the flavours. Why is there a bubble-gum flavour and so on? It is all designed to appeal to very young kids.
I also asked for something that has not been picked up yet, which was that the school health curriculum is updated to include the risks of vaping. Within the school curriculum, there is the personal and social health education section, where they generally cover alcohol, drugs and smoking, but vaping is not covered, and it should be. There should be education alongside restrictions, and tackling the appeal is also needed. I am really pleased to say that most of that seems like it is being embraced, alongside disposable vapes being banned.
Q322 Chair: Are you happy, Professor Khan, with the Government’s pronouncements last week around the regulations that they will bring forward off the back of the consultation on youth vaping? Do you think that is robust?
Professor Khan: Generally speaking, yes, I think it is very positive. The only thing we have to watch out for is to strike the right balance between the restrictions around vaping and the encouragement to adult smokers of cigarettes to start vaping—for them to switch to something safer. We do not want one to work to the detriment of the other.
Q323 Chair: I completely agree with you about the prescription, and other jurisdictions do that, but of course disposable vapes are about five quid—in fact, less than that if you are buying a multiple deal. A prescription charge is significantly more than £5 so, unless you receive free prescriptions, of course, you would be paying more for it. It would have to be accompanied by some form of subsidy to prescription, in the way that certain HRT products, for instance, are subsidised on prescription or free on prescription, wouldn’t it?
Professor Khan: I think that should be considered, most definitely. But having said that, when you look at the statistics to see who are the people with the most prevalence in smoking, they are the poorest in society. They are the most unemployed, the least skilled—
Chair: Smoking or vaping?
Professor Khan: Smoking. If you are trying to get them off smoking and into vaping, I would hazard a guess that a large number of them would not have to pay the prescription price.
Q324 Chair: Here is my worry; let me share a worry with you, because you know how I worry. Not all the companies, because clearly there are new entrants to the market who are manufacturing vapes legally—products that are sold—but some of the companies that are selling them are the companies that 50, 60, 70 years ago were producing posters of the Marlboro Man and telling us that smoking was a happy, safe lifestyle choice. Given that smoking rates came down, they lost a lot of revenue, so guess what they did? They produced a new product that filled the gap in that revenue. The cynic could say they are now telling us that vaping is this healthier, safer alternative. Is the Elf Bar advertising just the new Marlboro Man? In 20 or 30 years’ time, are we going to look back with horror at what we have done?
Professor Khan: If, in my review, I had spent all my time with the tobacco industry, which may well have presented to vaping me in that way, I may not have recommended it as the right thing to do. I spent 99% of my time with non-industry-related people—the leading academics around the world, who have done the research to back up what I recommended. That is what vaping being the safest alternative that we should be promoting was based on. It was not because of anything that the industry said to me.
Q325 Chair: I’m loving your short answers, by the way, Professor Khan. A lot of people could take lessons from you.
Finally, on the point about young people vaping, any MP will tell you that if they speak to headteachers in their constituencies, the headteachers will tell them that the number of young people vaping is just out of control. Clearly, young people are not getting them legally, because they are not 18, so they are either buying them illegally through shops that are selling them and shouldn’t be, or they are getting them through some other means—maybe adults are buying vapes for them. Do you have any insight into that, or any evidence that you took when you did your review as to where young people are getting these vapes from?
Professor Khan: I spoke to a number of headteachers who expressed exactly those views. They were very concerned about vaping in toilet cubicles—the old back of the bike shed stuff is now inside the school because you cannot smell it—and they were racking their brains about what to do about it.
There is an enforcement challenge in the school—checking bags and so on—but they talked quite a lot about availability. I asked the same question: “Where do you think the kids are getting them from?” They said, “The local corner shop is selling them and is not paying attention to the age of the child.” Clearly, they are wearing a school uniform and are under the age of 18, but the shopkeeper is letting them buy. However, some of them said that proxy sales are going on too—older friends or relatives are buying them and passing them on. This is where the enforcement bit comes in. I am really pleased that the Government is talking about challenging proxy sales in the enforcement, and I think that is a really important step.
Q326 Chair: Because of the concerns that some have expressed about the illicit market being even more flooded with tobacco and vapes that are not legal, you can understand why some proxies—parents—might say, “I know you are going to do this, so I am going to make sure you have something that is safer and legal.” The concern that many have expressed to me is that what will happen as a result of these moves is that the illicit market in cigarettes and vapes will grow.
Professor Khan: History shows that that is not what happened in the past. When the smoking age was raised from 16 to 18, all the same arguments were made about an illicit market in cigarettes and what it would do, but when you look at the data, it did not happen. Those fears were unfounded. The past is all we have to go on; we can’t predict what will happen next. It is reasonable to accept that there will of course be some issues for a period of time, but the journey to a smokefree generation is essentially a massive cultural shift for the country. When cultural shifts take place, people’s behaviours change. That takes time, but it does work.
Q327 Rachael Maskell: Thank you so much, Professor Khan. I want to continue on the theme of vaping. When Totally Wicked were sitting where you are now, they made the arguments that the tobacco industry made 50 years ago about the importance of promoting their products and having the liberty to do so without Government intervention. In the measures the Government are bring forward, do you think there should be the same limitations—not just on packaging but on advertising and limitations on place in the same way as Labour introduced limitations on smoking in indoor places? Should those measures be applied to vaping in the same way as they are to smoking? Are there lessons to be learned?
Professor Khan: I go back to my earlier answer about striking the right balance. We are really careful about how vaping is marketed, particularly to young people, but we don’t restrict it so much that adults cannot get hold of vapes in order to stop smoking cigarettes, because it will help their health in a whole range of ways. We have to strike the balance. There is a need to do more. I am looking out for what the Government are going to propose in the Bill itself to see how much they embrace of what I suggested in my report.
You mentioned cigarettes and the changes that have taken place. I am saying that even cigarette packets should be changed. We should have inserts in there that help people to understand the effect and refer them to stop smoking services and websites that can give them more information. Cigarette sticks themselves should have writing on them telling people that they have just lost 20 minutes of their life by their last puff. It is that kind of thing. No one thing will be enough, so we need a collective approach.
We should change the colour of cigarettes. The research shows that if you change them to brown and green, they are far less attractive. I wasn’t aware of that. I do not know why it is those two colours, but that is what the research shows. We need to learn from that and embrace as much of it as possible. The vaping stuff—restricting the flavours, restricting the marketing, taking them off the counter—will be important steps in the right direction.
Q328 Rachael Maskell: We know that banning smoking in indoor places had a significant impact. However, you can now vape in many of those places where you cannot smoke. Should there not be a single rule to make it really clear and simple, for vapers and smokers, about where and how they can smoke or vape?
Professor Khan: In my report, I talk about smokefree places and needing to do more, and I would like the Government to embrace that as well. For example, we have all been in buildings that you can’t smoke in, but at the entrance outside you see all the smokers gathered, either in a smoking bunker or just standing around. We even see it in hospitals. Hospital grounds should be totally smokefree, in my view, and they should be vapefree too. Anywhere outside within the vicinity of civic buildings should be completely smokefree and vapefree. That is what I say in the report. That hasn’t been embraced yet, but there is a lot to be said for it. Anywhere where children gather should be smokefree. For example, on public beaches in the summer, people can smoke wherever they want to at the moment. Some may argue that this is going too far, but I think it is part of the cultural journey that we want to shift to as a country to be able to celebrate that we are going to be smokefree.
Q329 Rachael Maskell: When you say smokefree, is that vapefree as well, so that we have a single rule? Is that the best way for people to understand that?
Professor Khan: Not at the moment, because vaping is one of the best alternatives to help the 6 million smokers quit, but perhaps in years to come. The latest predictions are that if the new age-related legislation is adopted, by 2040, there will be nobody under the age of 30 smoking. They wouldn’t need vapes either, because hopefully that means they wouldn’t have started. Maybe a future independent review might suggest that it is time to go a stage further, but not at this time because we have to help those 6 million people get healthier.
Q330 Rachael Maskell: There is a range of reasons why people develop dependencies, and we know the arguments around smoking. Whether it is peer pressure or stress factors, whatever those reasons are, are we doing enough to tackle the causes of smoking as well as the use of the product, and what else could we do in that area?
Professor Khan: Peer pressure has always been very strong, particularly for young people, but there is still a way to go in our country about how we set the tone for what we believe in. For example, in my report I talk about film and television. You just have to turn on the television or go to the cinema, and there is no logic for why an actor will pick up a cigarette and smoke in a particular scene. It doesn’t add any weight to the drama that you are witnessing, so why is it being done? I don’t think that we as a country can ban directors from getting their actors to smoke, but we can expect them to put a health warning on the screen as they pick up a cigarette. That is happening in many other countries. If you watch any film or television from south Asia, for example—from India, Pakistan or Bangladesh—as soon as somebody lights up, a message flashes across: “Smoking is bad for your health.” It doesn’t add much to the director’s cut, as it were, but why can’t we do that? That in itself will discourage people from doing it because it damages the quality of what they are presenting. Perhaps anybody smoking on screen should not come on until the watershed at 9pm. Those kinds of restrictions add to the cultural journey of what we are trying to do. If you are going to smoke or you want to promote smoking for no good reason, then we are putting restrictions in place to a point where hopefully you just won’t want to do it any more.
Q331 Rachael Maskell: I want to turn to the issue of class, because the demographic that is most affected by these policies comes out incredibly strongly. What more can be done to target groups who smoke or vape? In particular, what kind of role could occupational health play? Many of those concentrations of people could well be in a peer group with other people they work or associate with.
Professor Khan: There were two particular groups that I spent quite a bit of time looking at in terms of a higher prevalence in smoking in connection with deprivation or disadvantage of one sort or another. The first group was people with mental health issues. Their likelihood of being smokers is very high in comparison. There are two categories within mental health. I am not an expert in it, but often in health circles people talk about people with mental health issues and people with severe mental illness. The acute services come into play with the latter.
At the moment, the NHS long-term plan—introduced a while ago—does include measures to support people with smoking habits. In terms of mental health, however, it tends to focus on severe mental illness at that level. There is very little, if anything, at the upstream, if you like—those exhibiting early signs of mental health issues, and are smokers or have been driven to smoking through bad advice, peer pressure and so on. Their prevalence is very high, so we need to do much more around that.
I heard some horror stories of young people receiving mental health support in centres where, in order to calm them down, they were handed a cigarette by health workers. There is a myth, challenged by all the experts I met, that smoking calms you down or improves your mental health, when actually it makes you worse and it gets you addicted. There is lots of evidence that if you stop smoking, within five or six weeks, once you have got past the initial stages, your health improves—including your mental health. There is a lot of work around that issue.
I am also very concerned about some data I saw recently. It suggested that because of the challenges the NHS has at the moment, guidance has been issued to local integrated care systems saying that, within the whole range of work they are supposed to be doing, there are some areas where budgets must not be touched, and other areas listed as “flexible” for funding cuts. Support for mental health and smoking is one of those areas where it seems to be flexible. I think that is unacceptable. There may be reason to raise this with the Secretary of State for Health and Social Care before it becomes really damaging. I refer back to your point about what we have not done, which has created this situation. There is an example of something that may happen very soon, which later we will regret.
The second group of people I would suggest you look at is people in social housing. Again, the percentage of people in social housing who are smoking is far higher than most other categories. In my report, I recommend that the local authorities should consider everything possible in their local housing strategies to reduce smoking in social housing. I also suggest that 70% of all new social housing should be smokefree. In the USA, 100% of social housing is smokefree. I am not suggesting that we go to that in one leap. I say 70% because 70% of people in social housing are not smokers. We should match that. There are a number of interventions like that we can make.
You mentioned occupational health. This issue was not raised with me for the report specifically, but I think it has a role to play. When you think about the £17 billion cost to society, quite a large proportion of that is productivity loss—people who are missing more days from work because they are smokers. With occupational health, all major employers have schemes in place, but I am not sure how active they are. If they are not, then this should be on their radar.
Q332 Rachael Maskell: Finally, I want to ask about education. We know about the threats and challenges around maternal health. We also know that around the new communities in the UK, including refugees, there is a higher prevalence of smoking. Is the education package properly targeted, whether for schoolchildren or adults in particular communities? Does it need reviewing, and if so, what else should be included?
Professor Khan: I saw very little evidence of that work going on, partly because the budgets have been decimated. That is why I have recommended that there is an injection of cash—£15 million a year—on marketing campaigns and educational programmes for all of society to understand better the risks, the harms and where they can get support, such as stop smoking services and so on.
You mentioned new communities. I think that is a really interesting area. I discovered in my review that there was very little data out there, actually. That is why I have suggested that the Government should invest a relatively modest sum of £2 million a year for additional research on a whole range of areas about which there is little information, and new communities—refugees, asylum seekers—and smoking habits is one of those.
An example posed to me was that, for many people who travel from other parts of the world, smoking cigarettes is not necessarily the issue, but chewed tobacco can be. For example, shisha—water-based tobacco inhalation—can be their norm, as opposed to smoking cigarettes, so we just need much more information. I am really pleased that the Prime Minister’s intervention has led to proposed legislation—dare I say, if it doesn’t change—that includes those other tobacco products as well. Chewed tobacco khat, for example, is very prominent within the Somali community, and there is shisha. I am really pleased that that is in there.
Q333 Chair: Obviously, the tar in the tobacco is the evil that will eventually kill you, but nicotine is really wicked. It is quite interesting hearing from teachers about just how addicted young people are to vaping, as they were to cigarettes before vaping existed. Some of the stories I have heard have horrified me, as a parent of teenage children, as to what young people will do to get their hands on vapes, and therefore the exploitation that they could be subject to. Did you do any work on or have any comments about the online sales, going back to the thing we were talking about about how young people are getting these vapes? Do you have any thoughts on the online marketplace to buy these products?
Professor Khan: There was some anecdotal information—not hard research, as it were—so it is difficult to comment. In my recommendations, I have said that online sales of tobacco products should be banned, because it is just too easy for it to be manipulated and get into the hands of the wrong people. You can impose bans and say, “Nobody under 18 should be accessing them,” but you know with the online harms Bill how difficult that is to implement.
Q334 Chair: But sellers will get round that. There are examples of smart Nike trainers being the image, but sitting behind them are packets of illicit tobacco. Would you go further and just say that online vape sales should not be allowed either?
Professor Khan: If we are committing, ultimately, to a smokefree generation and we really sign up to that, then yes, we should be considering those kinds of issues because nothing should be off the table. It comes back to why we are doing this. What is the logic? What is the cultural shift that we want to make? Let’s consider those issues.
Chair: Great. Wow, we have covered a lot in 45 minutes. I am really grateful to you, Professor Khan. Thank you for your work. I know you will be watching keenly, as we will be, when the Bill is published. That concludes our session for this afternoon. Thank you for your time.