Written evidence submitted by NFRN (ECG0046)

Executive Summary

• In recent years, e-cigarettes have become considerably more popular with smokers than any other major smoking cessation aids (e.g. Nicotine Replacement Therapy purchased over the counter, prescription stop smoking medicines, and NHS stop smoking services). Multiple studies have reported high success rates, with one study, in particular, highlighting that 2.5 per cent of individuals using e-cigarettes as a smoke cessation aid succeeded where they would have otherwise failed if they had used nothing or a licensed nicotine product available through purchase.
• This is a positive development as evidence suggests that e-cigarettes have a considerably lower intake of toxic chemicals, carcinogens, TSNAs, and VOCs compared to smokers using conventional cigarettes and are, currently, more widely available than other smoking cessation aids.
• Evidence furthermore indicates that the impact of e-cigarettes on smoking might be influenced by the regulatory environment of a state. Comparing the effectiveness of e-cigarettes as a cessation aid in countries with restrictive policies towards e-cigarettes and countries with less restrictive policies, a 2017 report found that smokers in less restrictive policy environments were more likely to quit.[1]
• We must ensure that we enable those individuals pursuing a positive change in their smoking habits with medical access to e-cigarettes as well as psychological support. A combination of e-cigarettes with current stop smoking services would be highly beneficial to smokers wanting to quit.
• We further support the Mental Health & Smoking Partnership as well multiple other health bodies and charities in their calls for better access to e-cigarettes for smokers with mental health conditions.[2] Approximately 16 per cent of adults in the UK smoke. Yet, in psychiatric units, this number can be as high as 70 per cent. This warrants attention.
• Despite the many benefits of e-cigarettes, a great number of people are “dual-using” conventional and e-cigarettes, thus continuing exposing themselves to toxic and cancer-causing substances. Greater awareness of the benefits of e-cigarettes needs to be championed. The NFRN thus opposes any further restrictions on the distribution as well as advertising and marketing of e-cigarettes, as we believe that this would be detrimental to human health.

Introduction

1. The NFRN was founded in 1919 and is one of Europe’s largest employers’ associations with over 15,000 independent retailers in membership throughout the UK and Ireland. The NFRN exists to help the independent retailer compete more effectively in today’s highly competitive market.
2. Membership of the NFRN consists of a variety of independent retailers, including newsagents, convenience stores, confectioners, florists, petrol forecourts, news deliverers, off-licences, post offices, coffee shops, and card and stationery shops.
3. As a major provider of tobacco products to the public, the retail community has frequently been urged to look for alternatives to replace tobacco sales. E-cigarettes have great potential to incentivise tobacco consumers to reduce their intake and switch to entirely tobacco-free products in the long-term.
4. The NFRN is committed to improving public health and firmly believes that e-cigarettes are part of the solution to the public health issues caused by smoking.

The Impact of E-Cigarettes on Human Health and Their Comparative Advantage to Conventional Cigarettes

1. E-cigarettes are a relatively new technological innovation, making accurate scientific estimates of their long-term implications and effects difficult. However, preliminary results of multiple studies provide evidence that e-cigarettes hold significantly lower risks than conventional cigarettes.
2. In February 2017, researchers from University College London, the Roswell Park Cancer Institute, and the Centers for Disease Control and Prevention published the results of their study on the health implications of conventional smoking versus “vaping”, which was described by the NHS as “the first long-term study assessing these effects”.[3] The cross-sectional study monitoring 181 smokers or ex-smokers drew comparisons on exposure to nicotine and other tobacco-toxins and cancer-causing substances (carcinogens). Significantly lower levels of toxic chemicals, carcinogens, TSNAs, and VOCs were found in samples from former smokers who had been using e-cigarettes or NRT only, as compared to current smokers. Importantly, levels were lower than both of those who smoked conventional cigarettes only or used either e-cigarettes or NRT alongside conventional cigarettes.[4] Researchers concluded that “long-term NRT-only and e-cigarette-only use, but not dual use of NRTs or e-cigarettes with combustible cigarettes, is associated with substantially reduced levels of measured carcinogens and toxins relative to smoking only combustible cigarettes”.[5]
3. These results reinforce previous assessments by Public Health England, which reported in 2015 that “best estimates show e-cigarettes are 95 per cent less harmful to your health than normal cigarettes”. [6]
4. While e-cigarettes do contain nicotine – which is an addictive, albeit not cancer-causing substance – evidence indicates that potential risks would be “relatively minor”.[7] Furthermore, in contrast to conventional cigarettes, passive consumption of e-cigarettes – such as passively breathing vapour – is unlikely to be harmful.[8]
5. The other two major components of e-cigarettes, propylene glycol and glycerol, are also not thought to be dangerous on their own.[9]

The Benefits and Risks of E-Cigarettes as a “Stop-Smoking” Tool

1. Although e-cigarettes have both benefits and risks as a “stop-smoking” tool, evidence indicates that benefits greatly outnumber the risks.
2. As previously stated, while e-cigarettes do contain nicotine – which is an addictive, albeit not cancer-causing substance – evidence indicates that potential risks would be “relatively minor”.[10]
3. A 2014 Cochrane review that looked at 13 studies found conclusive evidence that e-cigarettes that contain nicotine can be a useful tool in helping individuals to stop smoking. Based on two randomised controlled trials that involved more than 660 individuals, the review concluded that nicotine-containing e-cigarettes could increase the likelihood of individuals giving up smoking, with 9 per cent of individuals using e-cigarettes stopping smoking for at least six months, compared with 4 per cent of those using e-cigarettes without nicotine.[11] A 2016 updated review confirmed these trends.[12] While these results should be treated with caution due to the small number of participants, they affirm a definite trend: e-cigarettes are supporting smokers in their efforts to either quit or substantially reduce the number of cigarettes they consume.
4. Interestingly, data collected by Smoking in England from March 2013 to March 2017 indicates that e-cigarettes are considerably more popular with smokers than any other major smoking cessation aids. According to Smoking in England’s data, 33 per cent of adults who smoke and tried to stop or who stopped used e-cigarettes, compared to 11 per cent using Nicotine Replacement Therapy purchased over the counter, 9 per cent using prescription stop smoking medicines, and <5 per cent using NHS stop smoking services.[13]
5. More importantly, a 2016 report by researchers of University College London’s Department of Epidemiology and Public Health estimated that 2.5 per cent of individuals using e-cigarettes as a smoke cessation aid succeeded where they would have otherwise failed if they had used nothing or a licensed nicotine product available through purchase.
6. A recent study surveying data from 170,490 individuals in England between 2006 and 2015, including data from the NHS stop smoking services which supports more than 8 million individuals, concluded that “changes in prevalence of e-cigarette use in England have been positively associated with the success rates of quit attempts”.[14]
7. This apparent success of e-cigarettes as a “stop-smoking” tool is also reflected at the European level.  Data collected by the 2014 Eurobarometer showed that from the approximately 7.5 million present e-cigarette users, 35.1 per cent reported that they had stopped smoking due to e-cigarettes. Furthermore, an additional 32.2 per cent reported reduced smoking consumption.
8. E-Cigarettes could prove particularly useful as a smoke cessation aid for people with mental health conditions. At present, the national average of smokers is approximately 16 per cent. However, in psychiatric wards, this number quadruples, with current estimates putting the number of smokers as high as 70 per cent.  As Cancer Research UK’s policy adviser, Alyssa Best, pointed out; “E-cigarettes offer another opportunity for smokers with mental health conditions that haven’t been able to stop using other methods. They should be offered as a legitimate method of quitting across all mental health settings”.[15]

The Uptake of E-Cigarettes among Young People and Their Role in “Re-Normalising” Smoking

1. Recent media reports and headlines have given the impression that e-cigarettes are contributing to an uptake of smoking. However, analyses of the latest surveys and scientific studies show that e-cigarettes are neither resulting in the formulation of regular smoking habits nor contribute to higher smoking rates.[16] On the contrary, data shows that smoking rates in young people are continuing to decline.[17]
2. A 2017 study drawing on five, large-scale surveys conducted in the period from 2015 to 2017 with over 60,000 participants aged 11 to 16 concluded that “surveys across the UK show a consistent pattern: most e-cigarette experimentation does not turn into regular use”. [18] Furthermore, researchers pointed out that “regular use among 11–16 year olds remains very low, at 3% or less, and remains largely confined to regular smokers”.[19]
3. These conclusions echo a 2015 assessment by Public Health England; “cigarette smoking among youth and adults has continued to decline and there is no current evidence in England that [e-cigarettes] are re-normalising smoking or increasing smoking uptake. Instead, the evidence reviewed in this report point in the direction of an association between greater uptake of [e-cigarettes] and reduced smoking”.[20]

NFRN’s Position

1. The NFRN fully supports regulations in the interest of human health, such as age restrictions on e-cigarettes.
2. However, the NFRN cautions against over-regulation, considering the substantial health benefits of e-cigarettes as well as the positive financial impact the product has on stores hit hard by increasing duty rates on tobacco.
3. E-Cigarettes present an important replacement for tobacco, both for smokers wishing to reduce their tobacco consumption and independent retailers trying to maintain profits while supporting health initiatives.
4. Despite the many benefits of e-cigarettes, a great number of people are “dual-using” conventional and e-cigarettes, thus continuing exposing themselves to toxic and cancer-causing substances. Greater awareness of the benefits of e-cigarettes needs to be championed. The NFRN thus opposes any further restrictions on the distribution as well as advertising and marketing of e-cigarettes, as we believe that this would be detrimental to human health.

December 2017