Written evidence submitted by the New Nicotine Alliance (ECG0044)

1. We thank the Committee for undertaking this important inquiry, which concerns the health of millions of smokers and ex-smokers. The New Nicotine Alliance (NNA) is a registered charity in England and Wales, which has the objective of promoting public health by means of tobacco harm reduction. The NNA was established to reflect the interests of those who wish to switch from smoking tobacco to using safer nicotine products. Many of our Trustees, Associates and Supporters are ex-smokers who have stopped smoking with the help of safer nicotine products including e-cigarettes. The focus of our evidence is the interests of consumers, that is, current and potential users of e-cigarettes and other safer nicotine products.

2. In summary, our key conclusions are:

(a)               Tobacco harm reduction has been neglected in international tobacco control and we would urge the UK to use its influence (including links to funding) to ensure that the World Health Organization includes evidence-based tobacco harm reduction in its advice and plans, and that the UK promotes tobacco harm reduction at the Conference of Parties meetings of the Framework Convention on Tobacco Control.

(b)               It is misleading to refer to ‘e-cigarette addiction’, and the use of that term encourages a negative view of e-cigarettes which might discourage their uptake or long-term use. There are widespread professional and public misconceptions about the harms of nicotine, including misconceptions about addiction and that nicotine causes cancer, which urgently need to be addressed.

(c)               There should be a review of the ban on the sale of electronic cigarettes to under 18s and a review of the ban on proxy purchasing.

(d)               We note and welcome that the Tobacco Control Plan sees Brexit as an opportunity to sensibly de-regulate. NNA believes that a priority is to remove the current arbitrary limits on nicotine strength, tank size and refills. We suggest that general product safety regulations be applied to zero nicotine e-liquids.  

(e)               We would urge Public Health England to do much more to encourage employers, transport operators, and owners and managers of public places to be cautious about introducing bans on vaping and to develop policies which differentiate between vaping and smoking.

(f)                 The wide-ranging ban on the advertising of e-cigarettes should be removed.

(g)               The ban on snus across the EU (except across Sweden) is not in the interests of public health, and is contrary to the rights of consumers to be able to use a product which is much safer than, and protects them from smoking. We believe that the Department of Health’s intention to sensibly de-regulate should include the removal of the ban on the sale of snus.

Preliminary observations

3. The NNA supports tobacco harm reduction, that is, offering smokers safer forms of nicotine and delivery in order to avoid the risks of smoking. The Royal College of Physicians (RCP) recognised harm reduction as an option in their 2007 report stating that ‘Harm reduction in smoking can be achieved by providing smokers with safer sources of nicotine that are acceptable and effective cigarette substitutes’ [1].

4. Tobacco harm reduction is consistent with the World Health Organization (WHO) Framework Convention on Tobacco Control (FCTC), to which all European member states as well as the European Union are signatories [2].

5. Article 1 of the 2014 Tobacco Products Directive states that one of the objectives of the Directive is to meet the FCTC obligations. We would take this opportunity to note that this includes in Art 1(d) an obligation to include harm reduction as part of tobacco control. 

6. Tobacco harm reduction has been neglected in international tobacco control and we would urge the UK to use its influence (including links to funding) to ensure that the World Health Organization includes evidence-based tobacco harm reduction in its advice and plans, and that the UK promotes tobacco harm reduction at the Conference of Parties meetings of the FCTC.

7. At the time of the Royal College of Physician’s 2007 report, there were few alternatives to cigarettes, with the exception of nicotine replacement therapy (NRT) products such as gums and lozenges. That changed with e-cigarettes, which first came onto the market around 2007, the year of the report’s publication. For the first time, smokers could use an effective and acceptable safer consumer nicotine product as an alternative to smoking.

The impact on human health on e-cigarettes – themselves and relative to ‘conventional’ smoking – and any gaps in the science, knowledge base in this area.

8. E-cigarettes are substantially safer than smoking conventional cigarettes, based on the testing of the contents, emissions, and short-term clinical studies. The NNA concurs with the risk communication from Public Health England that ‘best estimates show e-cigarettes are 95% less harmful to your health than normal cigarettes’ [3].

9. The rapid increase in the use of e-cigarettes provides evidence that personal choice helps in the switch from smoking. There are 2.9m users of e-cigarettes in 2007, up from 700,000 in 2012. Of the 2.9m, 1.5m are now ex-smokers [4]. Most people who use e-cigarettes use them to reduce or stop cigarette consumption [5]. 

10. We note the substantial drop in smoking prevalence in the UK, which is currently 15.8% of adults, compared to 20.2% in 2011 [6]. This drop is coincident with the uptake of e-cigarettes.  E-cigarettes are now the most common method used by smokers who wish to stop smoking [7]. The experience of our supporters is that many of them have been able to switch from smoking - often after decades of using cigarettes - with the help of e-cigarettes. 

The benefits and risks of e-cigarettes as a ‘stop smoking’ tool, any gaps in the knowledge-base on this, and whether any approaches are needed to tackle e-cigarette addiction.

11. We believe that due to the availability of e-cigarettes there is now a new landscape of ‘smoking cessation’. Many of our supporters had tried various methods to stop smoking including cold turkey, NRT, and behavioural support, but for them, e-cigarettes worked when nothing else did. We believe that this is because e-cigarettes are a pleasurable alternative to smoking: people enjoy using the devices themselves and the variety of flavours.  The person switching to e-cigarettes doesn’t have the sense of being a ‘patient’ who is being ‘treated’. There is a wide variety of products, and widely available informal support from current vapers: one of the largest e-cigarette internet fora receives 10,000 visits a day [8]. Vape shops appear to be taking on a role akin to that provided by smoking cessation services.

12. The uptake of e-cigarettes has not come about because of any public health campaign or professional advice: it has been consumer led. It has happened at no cost to the tax-payer.

13. There is no need to ‘tackle e-cigarette addiction’ and indeed this is an odd concept. Addiction is defined as continued use of a substance despite harmful consequences. As stated on the US National Institute for Drug Abuse: ‘Addiction—or compulsive drug use despite harmful consequences—is characterized by an inability to stop using a drug; failure to meet work, social, or family obligations; and, sometimes (depending on the drug), tolerance and withdrawal.’ [9]

14. Once nicotine is separated from the contaminants in smoked tobacco, it is unclear what harmful consequences are associated with its use. The habitual use of nicotine then becomes more of a psychological, moral or religious issue, not one of addiction: it is hard to see what is wrong with a harmless dependence. NNA believes that it is misleading to refer to ‘e-cigarette addiction’, and the use of that term encourages a negative view of e-cigarettes which might discourage their uptake or long-term use. There are widespread professional and public misconceptions about the harms of nicotine, including misconceptions about addiction and that nicotine causes cancer, which urgently need to be addressed.

15. This comment from a vaper on the UK Vapers forum is relevant here; ‘in terms of the gaps in the evidence, the most pertinent and crucial question has to be why nicotine used outside of smoking is not deemed addictive with respect to NRT products yet vaping using the same pharmaceutical grade nicotine is viewed as addictive’.[10]

The uptake of e-cigarettes among young people and evidence on whether e-cigarettes play a role in ‘re-normalising’ smoking

16. There are misconceptions and misinformation about ‘gateways’ and ‘re-normalisation’. These assertions, including from some public health leaders, have proved to be wrong. There is only a negligible uptake of e-cigarettes by young people or by those who have no previous experience of smoking [11]. There has been no increase in the use of smoked tobacco amongst younger populations. A more accurate assertion might be that the use of e-cigarettes normalises not smoking.

17. NRT is available (on prescription) from the age of twelve, yet there have been no concerns about NRT leading to nicotine addiction and to smoking. NNA believes that there should be a review of the ban on the sales of electronic cigarettes to under 18s and a review of the ban on proxy purchasing. Although the current ban on sales to under 18s may send a desirable symbolic message (that it is inappropriate to use nicotine at a young age) the evidence is that the uptake of cigarettes occurs before the age of 18 and so consideration should be given to e-cigarettes being available to those under the age of 18, as a preventative against smoking.

Whether there is any regulatory variation between the EU and UK, and across UK nations, and the implications of Brexit on regulation in this area

18. The European Tobacco Products Directive (TPD) has not led to market harmonisation and there are countries which have added regulations beyond the basic elements of the TPD. This includes bans on cross-border and internet sales, bans on all forms of advertising and the inclusion of vaping in bans on smoking in public places.

19. The Tobacco and Related Products Regulations 2016 (TRPR) includes arbitrary limits on strengths of nicotine liquids (20mg/ml), on tank sizes (2ml) and refill sizes (10ml). There is no scientific evidence on which to base such restrictions [12]. These limits place obstacles in the way of those who need higher concentrations of nicotine. The 10ml bottle limit is not in the interests of consumers and produces wasteful and unnecessary packaging.

20. The arbitrary limit on the volume of refill containers together with the notification requirements have led to a market in ‘short fills’ and ‘nicotine shots’ (a larger bottle of nicotine free flavoured diluent sold together with one or more 10ml bottles of unflavoured nicotine containing liquid, which are mixed together by consumers after sale). These products are popular because a larger volume bottle is more convenient and generally cheaper. A bottle of nicotine free e-liquid is not subject to the requirements of the TRPR, and so may contain ingredients which are banned in nicotine containing liquids. The removal of the 10ml limit on refill containers would reduce demand for short fills by restoring the previously popular market in 30-100ml bottles.

21. We note and welcome that the Tobacco Control Plan sees Brexit as an opportunity to sensibly de-regulate. NNA believes that a priority is to remove the current arbitrary limits on nicotine strength, tank size and refills. We suggest that general product safety regulations be applied to zero nicotine e-liquids.  

22. We welcome the fact that neither Public Health England (PHE) nor the Department of Health supports the inclusion of a ban on vaping in smoke free legislation. However. we note that there is uncertainty about the legal status of vaping, and an increasing encroachment, despite the law, on vaping in public places and workplaces. Bans on vaping in public places send the wrong message to smokers and e-cigarette users, and place obstacles in the way of people who wish to use e-cigarettes. Exhaled vaper does not contain any unwanted products which would be considered a danger to others[13]. There is no scientific basis therefore to include bans of vaping alongside bans of smoking.

23. We would urge Public Health England to do more to encourage employers, transport operators, and owners and managers of public places, to be cautious about introducing bans on vaping, and to develop policies which differentiate between vaping and smoking.

The effectiveness of regulation on the advertising and marketing of e-cigarettes.

24    It is important to advertise life-saving products and important for advertisers to be able to make a health claim.  The current severe limitations on advertising are inappropriate, as too are the restrictions on the making of health claims for e-cigarettes. The wide-ranging ban on the advertising of e-cigarettes should be removed.

The impact of the Tobacco and Related Products Regulations on the vaping industry and the prevalence of e-cigarettes

25    The NNA considers the uptake of e-cigarettes has possibly been slowed because of the TRPD due to the restrictions on device characteristics, and the severe limitations on advertising.

The safety of e-cigarette devices, and any safety regulation requirements.

26    E-cigarettes are covered by a variety of EU directives and regulations in addition to the TRPD. We consider the current safety regulations adequate, with the exception of short fill containers. It is our understanding that most of the unfortunate incidents involving e-cigarette electronics have been due more to user behaviour than being inherent in the devices themselves. It is also notable that the main causes of injury and death in domestic premises is caused by smoking cigarettes [14].

The economic impact of the UKs e-cigarette industry

27. No comment

The public finances implications of e-cigarettes, including how the rise in e-cigarette consumption can affect NHS costs

28.                                                                                                               Given that e-cigarettes are safer than smoking, there will be reduced demands on the health service. NNA would also like to draw the committee’s attention to the fact that the uptake of e-cigarettes has been at no cost to the taxpayer.

The Committee would also like to hear views on whether government policy and regulation has kept up with the full range of ‘smoking’ and novelty tobacco products (such as ‘heat not burn’) that are becoming available to the public, and if it takes account of their impact on human health.

29. The NNA believes that the rise of e-cigarette use shows that smokers want to avoid smoking-related harms, and the potential to reduce smoking if effective, attractive and safer alternative products are available, including heat-not-burn products and snus.

30. Heat-not-burn products deliver nicotine by warming tobacco rather than combusting it. They have recently been introduced to the market in the UK and there is as yet little indication of their popularity. We note the high levels of consumer interest in heat-not-burn products in Japan. Since their introduction in 2014, heat-not-burn products have now taken a significant share of the tobacco market with concomitant declines in sales of tobacco cigarettes. This is a further example of how market facilitated consumer driven behaviour can achieve major outcomes in helping people switch from smoking.

31. Snus has a very low risk profile and the recent report from the Global Burden of Disease Study found that snus does not have any elevated risk of cancer or other tobacco related diseases [15].

32. Snus is banned in the UK and across the EU except for Sweden. The NNA has joined a legal challenge against the ban on snus, which is currently being considered by the European Court of Justice.

33. In Sweden the increase in the use of snus has been accompanied by a dramatic decrease in smoking. The prevalence of smoking in Sweden is now the lowest in Europe and smoking is fast disappearing: only 5% of adult Swedes are daily smokers in 2017, compared with an EU 28 average of 24%[16].

34. Sweden provides evidence also of impact of snus on tobacco-related disease. Sweden has the lowest rate of tobacco related disease for the EU 28 for males aged 30 and older, at 152/100,000 compared to the EU 28 average of 373/100,000 [17].

35. Evidence provided to the NNA is that over 350,000 deaths in the EU could have been averted if the original 1992 ban on snus in the EU had not been introduced and if truthful public education about snus had been sufficient to bring about Sweden tobacco use patterns [18]. The ban on snus across the EU (except across Sweden) is not in the interests of public health, and is contrary to the rights of consumers to be able to use a product which is much safer than, and protects them from smoking. We believe that the Department of Health’s intention to sensibly de-regulate should include the removal of the ban on the sale of snus.

December 2017