7th October 2024
Can the UK lead the way in successfully becoming Smoke Free?
The Tobacco and Vapes Bill brought by the previous government was intended to, in their own words, “ensure the next generation grows up smoke free.” The Bill covered three main pledges; firstly, to create the first ever smoke free generation, by making it an offence to sell tobacco products to anyone born on or after 1st January 2009. The second pledge was to reduce the appeal and availability of vaping products by regulating flavours and packaging (particularly those thought to appeal to underage vapers). And thirdly, to strengthen enforcement of underage sales of tobacco and vapes with fixed penalty fines to those who sell those products to anyone underage.
I have always been intrigued by the concept of the gradual ban, whereby the minimum age will go up as each year passes. The idea first came to international prominence when it was proposed by a former New Zealand Prime Minister in 2022. The New Zealand ban was subsequently repealed by the new government before it could be implemented, but the idea has since been considered by other governments, including the UK.
Cigarettes and Me
My interest in the proposed legislation stems very much from personal experience. I smoked my first cigarette aged 15, because that is what every other 15-year-old I knew was doing. At that time in the early nineties, the legal age to buy cigarettes was 16 and you could buy a packet of ten for less than £1. You could smoke on the bus and on aeroplanes, in cinemas, restaurants and (eventually for me) clubs and pubs. People smoked in films (which meant they were cool), and celebrities smoked during TV interviews. I can even remember visiting my mother’s local government workplace a few years earlier and seeing her colleagues with ashtrays and packets of cigarettes on their desks.
By the time I entered the workplace, it was no longer acceptable to smoke at your desk in large communal office buildings, but regular smoke breaks were still taken and there was a designated area of the canteen where you could comfortably light up if you so wished.
Suffice to say for those first few years, it was extremely easy for me to start smoking, and it was very easy for me to continue smoking. What I soon discovered was that it was not easy in society at that time to stop.
It took many failed attempts using my will power alone before I finally managed to stop with the help of a delightful gentleman called Jack from the smoking cessation service based at Withington Hospital in South Manchester. Jack was retired and worked as a volunteer for the service and following a referral from my GP (and armed with a prescription for nicotine gum), I visited Jack on a weekly basis to check in on how I was doing. I could never bear the thought of letting Jack down by telling him I had caved and had a smoke, and for some reason that was everything I needed, because I am incredibly pleased to say that since then and around twenty years later, I’ve never smoked another cigarette.
I have no doubt that the interventions that came into place both before and after I stopped smoking put all the necessary building blocks in place to help me do it. Over the last 30 years, cigarettes have gradually disappeared from everyday life. We no longer see them advertised in newspapers, I never notice the tobacco display in shops, we do not smell other people’s cigarettes in pubs, and we don’t sit next to people who are smoking in restaurants. We don’t even see people smoking in films without being warned about it in advance.
The Current Tobacco and Vapes Landscape
I started smoking when I was too young to fully understand the consequences of nicotine addiction and today, 80% of smokers say they started before the age of 20 (Ref 1). Similarly, we’re seeing a situation now with young people and e-cigarettes or vapes, with the number of children saying they’ve tried vaping having tripled in the last three years. According to a Youth Vaping in England report (Ref 2) published in January this year, a 2022 study found that 24% of people aged 16 to 19 in England reported having vaped in the past 30 days. Much like my 15-year-old self, 54% of young people aged 11 to 18 in England have begun vaping “just to give it a try” even though 84% of young people aged 16 to 19 acknowledge some degree of harm associated with daily vaping.
Which brings us back to the Tobacco and Vapes Bill in the UK. The proposed bill had cross party support, with MPs voting in favour by 383 votes to 67 in April 2024. But when the General Election was called just weeks later, Parliament had only a couple of days to push through any uncompleted bills in a process called ‘wash-up’ and despite the strong support, the Tobacco and Vapes Bill hadn’t progressed far enough through the process to be included.
During the subsequent electoral campaigns, both the Conservative and Labour parties pledged in their manifestos to bring forward the Tobacco and Vapes Bill should they win the election. And indeed, the new Labour government reconfirmed its commitment to the bill in the King’s Speech on 17th July 2024, stating: “A Bill will be introduced to progressively increase the age at which people can buy cigarettes and impose limits on the sale and marketing of vapes (Tobacco and Vapes Bill)”.
Opposition to the Bill in its Current Form
It is no doubt clear I have a very personal perspective on this matter, but of course it is important to consider all arguments. It is safe to say, no one is shouting from the rooftops that smoking is a great thing for individuals or society as a whole. But there is resistance to the Bill, from the tobacco industry, from some MPs and from smokers themselves.
In an investigation by The Examination and The Guardian newspaper, Freedom of Information documents in response to a consultation (Ref 3) show Philip Morris International (PMI), owner of Marlboro which makes Camel and Benson & Hedges, supports the Government’s Smokefree ambition. They do not however support the age of sale ban, notably the inclusion of Heated Tobacco Products (HTPs) in the ban. They argue that HTPs (which contain tobacco and nicotine but heat rather than burn the product) are significantly less harmful than smoking combustible tobacco products (i.e. cigarettes, cigars etc). MBI also argue that HTPs have a valuable role to play in harm reduction (i.e. helping people to move away from cigarettes) so should not be included in the ban. Philip Morris said the inclusion of HTPs risked confusing adult smokers (the inference being this could suggest they are just as harmful as cigarettes) and said regulation should focus instead on helping adult smokers to quit or switch to less harmful smoke-free alternatives.
The difference if you’re wondering (because I did) between an HTP and a vape or e-cigarette, is that HTPs contain tobacco but e-cigarettes do not, although they do contain nicotine derived from tobacco so that users still get the nicotine ‘hit’ without the additional harmful chemicals from the tobacco (although they still come with their own set of harmful chemicals of course).
Philip Morris also supports regulation of vape flavours, particularly those overwhelmingly chosen (and some might say targeted) at underage vapers, i.e. fruit, sweet and dessert flavoured. Although they argue that some flavour ingredients are still needed to make the products palatable to adult vapers.
Other Voices Against the Bill
Philip Morris is not the only industry voice against the ban, and some may argue that much like an ex-smoker’s perspective, the tobacco industry cannot be completely impartial in this matter. But there is another argument and that is to do with freedom of choice. The smokers-rights group Freedom Organisation for the Right to Enjoy Smoking Tobacco (FOREST) don’t believe the measures will stop smokers, saying: “increasing the age of sale of cigarettes won’t stop people smoking. It will simply drive more people to the black market and could make smoking cool again.” They added: “if you are old enough to drive a car, join the army and buy alcohol, you are old enough to buy cigarettes and other tobacco products.”
The Conservative MP and former business secretary Kemi Badenoch was one of the MPs to vote against the smoking ban at its second reading in the Commons in April and said at the time: “The principle of equality under the law is a fundamental one… We should not treat legally competent adults differently in this way, where people born a day apart will have permanently different rights.” She argued that in years to come, there will be a 50-year-old who is allowed to buy tobacco, and a 49-year-old who is not. Another MP who voted against was the former Foreign Office minister Anne-Marie Trevelyan. She spoke of her grandmother who smoked all her life and whilst the MP said she herself was very much against smoking; she did think her grandmother had the right to decide for herself. She suggested instead raising the legal age for smoking to 21, since most people start smoking before they are 20.
Smoking and its Impact on Public Health
We know that smoking causes a lengthy list of preventable diseases and shortens life expectancy and according to Public Health England research published in 2017, the total estimated smoking-related cost to the NHS in England was £2.6 billion in 2015 (Ref 4). At that time, there were an estimated 7.3 million smokers, and 14.8 million former smokers aged 18 and over in England.
You could argue that the cost to the NHS is covered by the billions of pounds raised from tobacco duties each year. But when you take into the account the human cost to individuals, families and communities through ill health, and the economic cost both to the health system, to the individuals buying the products and to wider society through working days lost through ill health, the argument starts to weaken.
Chris Witty, the Chief Medical Officer for England addressed the arguments against legislation in an interview with BBC News just before the Commons vote in April. He described the range of diseases caused by smoking, through the entire life cycle from still births to asthma in children, cardiovascular disease, dementia in old age and of course many cancers. He said people who were “trapped in smoking from a very young age,” then found themselves years later completely addicted, with their freedom of choice taken away because they were unable to stop.
The cost of smoking to the NHS is huge and the NHS Long Term Plan lays out how the health service aims tackle smoking as one of the top five causes of premature deaths in England (Ref: 5). According to ONS figures (Ref 6), in 2021, 33.3% of all smoking adults in England lived in the two most deprived deciles, which was up from 29.5% in 2017. Just over one tenth lived in the two least deprived deciles in 2021, which was down from 12.1%. If you include the same figures for Wales, the proportion of people who smoke in the most deprived areas of the country was more than three times higher than in the least deprived areas in 2021. So, supporting people to stop smoking, or ideally stopping them from starting in the first place, would also help to tackle health inequalities in those disadvantaged communities where smoking is most prevalent.
I do not believe there is a perfect solution to this issue – controlled or banned substances are always likely to create a black market – but I do think tougher regulations is the way to continue driving down smoking rates and to stop the tobacco issue being replaced by a generation of vapers.
Do I look at children I know now who are currently under 15 and feel sorry that they will never have the opportunity to buy cigarettes? No. Do I feel grateful that at 16 I had the freedom of choice to legally buy cigarettes? Absolutely not. I wish they had never been an option.
The key for me is to stop people smoking that first cigarette and that is where I think the generational ban will have an enormous impact and I for one will be watching its progress with great interest over the coming months.
If you would like to learn more about the TU and what we do, please get in contact.
E: transformationunit@nhs.net
W: https://transformationunit.nhs.uk/
L: https://www.linkedin.com/company/transformationunit/
T: https://twitter.com/tu_nhs
Ref 2: https://researchbriefings.files.parliament.uk/documents/CBP-9932/CBP-9932.pdf
Ref 3: DocumentCloud
Background Reading
The Tobacco and Vapes Bill https://bills.parliament.uk/bills/3703
NHS Long Term Plan https://www.longtermplan.nhs.uk/wp-content/uploads/2019/08/nhs-long-term-plan-version-1.2.pdf
ASH and Cancer Research ICB Report August 2024 https://ash.org.uk/uploads/ICB-Report-2024.pdf?v=1723634438
https://www.independent.co.uk/news/world/australasia/new-zealand-repeals-smoking-ban-b2503024.html
https://news.cancerresearchuk.org/2024/05/24/general-election-2024-tobacco-and-vapes-bill/https://ash.org.uk/resources/view/tobacco-advertising-and-promotion-in-the-uk