Professor Sanjay Agrawal and Tim Mitchell gave evidence.

Q154 We will now hear from Professor Sanjay Agrawal, the Royal College of Physicians specialist adviser on tobacco, and Tim Mitchell, president of the Royal College of Surgeons We have until 2.40 pm for this panel. Would the witnesses please introduce themselves for the record?

Professor Agrawal:

My name is Sanjay Agrawal. I am the specialist adviser for the Royal College of Physicians. To give a bit of background, the RCP has produced reports over the past 60 years on a whole variety of facets of tobacco control. Most recently, we published a report on e-cigarettes and an evidence review that looked at the trends of e-cigarette use, safety, efficacy and regulations.

As my day job, I am a consultant in intensive care and respiratory medicine in Leicester. Perhaps it is worth saying that in my lung cancer clinics and in the intensive care unit, I see week after week, year after year the impact of tobacco on my patients. In my lung cancer clinic, I frequently have to deliver bad news about lung cancer. Oftentimes I am left sitting there, thinking, “Why haven’t we as a society and a country done more about this? We have known about the harms for the past 60 years. Why haven’t we done more?”

I am really pleased to be here today, because it feels to me that this Bill is a momentous occasion where, once and for all, we can do something for people along their whole life course, whether that is people who are pregnant and are affected by tobacco smoking or their unborn children who are affected, or people with dementia, hearing loss or sight loss—diseases in old age related to tobacco.

The RCP supports the Bill. It is really well balanced. As a clinician in the medical profession, I, along with the RCP, which represents at least 30 different medical specialties, support the Bill. We know it will prevent ill health for future generations and reduce poverty and disparity.

Tim Mitchell:

I am Tim Mitchell, president of the Royal College of Surgeons of England, which hosts a number of national cancer audits, including lung cancer audits, so we are very familiar with the impacts of smoking. I and my colleagues across all surgical specialties see the impact of smoking on a daily basis. Lung cancer particularly is seen as being associated with smoking, but the risk of all cancers is increased by smoking, particularly in my field as an ear, nose and throat surgeon—mouth and throat cancer, for example. There is also a range of benign diseases, particularly those that affect blood vessels—so people who need to have coronary artery surgery or surgery to improve blood flow to the brain if they have had a stroke. Diabetics are affected, and the risk of diabetes is increased by smoking. There are vascular problems, such as with blood flow to the legs, which can result in amputations.

Aside from that, all patients undergoing surgery are affected by smoking. They may have specific disease processes affecting their heart and lungs that will have an impact on them having a general anaesthetic. Even if they do not have defined disease processes, we know that smoking affects healing. The other thing we are also very aware of is the impact of passive smoking, particularly on children.

Tim, coming to you first, from a surgeon’s perspective, why do you think that it is important to decrease the rates of smoking and vaping?Q

Tim Mitchell:

As I have alluded to, the burden of disease caused by smoking is huge, and there is no doubt that smoking is very bad for people’s health. As surgeons, we see that on a daily basis. We have talked about cancers and other disease processes. As I think you heard, the estimated cost to the health service is £2.5 billion a year, and the burden on surgeons across all surgical specialties, because of the impact of smoking, is huge.

In addition, as I said, smoking has an impact on all patients undergoing surgery under general anaesthetic. It increases the risk of complications and has an impact on wound healing, the risk of infection after surgery and, particularly, respiratory complications after surgery. It has been estimated that there may be an increase of as much as 40% in major complications after surgery in people who smoke. Decreasing the rate of smoking will have a massive impact on surgical activity.

Q Sanjay, the Royal College of Physicians has called for regulation to protect young people from vaping while still allowing smokers to use e-cigarettes to quit. Do you think that the Bill strikes the right balance in that regard?

Professor Agrawal:

I do, actually; I think that it is a very well thought-through Bill that absolutely gets the balance right. For example, we have 6.4 million people who smoke in this country. As Professor Sir Chris Whitty said today, they are doing that not out of free choice but because they became addicted to tobacco while they were children, as designed by the tobacco industry. Those 6.4 million people need a way out of smoking. I speak to patients in clinic who have successfully stopped smoking and ask them, “How did you do it?” I cannot remember the last one who did not say that they did it with vaping. We know that vaping is a very popular way to quit smoking among people who are addicted to tobacco; it allows them a sense of control about how they quit smoking.

I think the balance in the Bill is just right: it recognises that vapes are important in helping people to quit smoking, but, by the same token, we all recognise that we do not want to see our children and grandchildren—young people—take up vaping. I was listening to the Committee proceedings yesterday, and I was struck by what the group representing schoolteachers said about the impact that it is having on children’s learning. It is important that we address young people vaping and do as much as we can to reduce the appeal of vapes, as well as access to them.

The Government have already outlined other measures: for example, raising excise tax and making vapes less affordable, as well as banning disposables, which have really fuelled the rise in youth vaping. We would hope that the whole package of measures, as well as this Bill, should see a significant reduction in youth vaping.

Q The Royal College of Physicians has also called for manufacturers to limit the production of toxic substances from vapes and for the Medicines and Healthcare products Regulatory Agency to be required to independently verify the contents of e-cigarettes. That is something I have taken a real interest in—you make a really good point. Whereas the notification scheme for tobacco tests products, the vaping scheme does not. Do you think we need to do more in the Bill to address that?

Professor Agrawal:

It is important that we make sure that these products are notified well, and I know that there is a colleague speaking after me today about the MHRA process. Independent verification will be an important thing to do, whether that is part of the Bill or something that comes about as part of the consultation process that the Bill and the regulations will go through.

One thing that is really important is that this Bill passes through this Parliament, so that we stop the 350 young people who take up smoking every day from doing so as soon as we possibly can. We know that two out of three of them will die as a result of smoking. What I do not want to happen is for the Bill to be slowed down in any way by a series of amendments. We need to get this Bill and the law on the statute book. The consultation process should hopefully take care of some of the finer details, which are really important, too.

Q Thank you both so much for being here today. As you will know, what witnesses are providing are the words and the arguments to enable the smooth passage of the Bill. Professor Agrawal, you have just said that you want this to go through smoothly, as do all of us here, so what you say is incredibly important.

As physicians and surgeons, what would you not have to do if people were not smoking? Could we say you would be writing yourselves out of a job? What are some of the things that are specifically on your day-to-day list that you think would be removed if people were not smoking?

Tim Mitchell:

I referred to the national cancer audits. For example, 37,000 people a year develop lung cancer, many of whom will need surgery. On the survival rate for lung cancer, fewer than 50% of people survive one year. There is a whole range of other cancers related to smoking, so the burden of that disease and the burden on the health service would reduce dramatically if we had a smoke-free society. I have alluded to other forms of surgery that are required—amputations and so forth. So the impact on society at large would be huge if we had a smoke-free society. In terms of other surgery, the complications would be avoided.

I know very much from my own personal experience how important this is. My mother died from lung cancer caused by smoking when I was seven years of age. My grandfather died from mouth cancer caused by pipe smoking when I was eight years of age. If we had a smoke-free society and there was one small boy or girl who grew up knowing and being loved by their mother or their grandfather, that would be very powerful.

However, that pales into insignificance compared with the impact that the Bill could have on society at large. Millions of people’s health would be improved. The impact on millions of families would be dramatically improved and the health of the nation would be significantly greater. We as a college fully support the Bill and, as my colleague said, we very much hope that it will pass through smoothly and get on to the statute book.

Professor Agrawal:

Just to add to that, for my clinical practice in the intensive care unit, I see people with life-changing illnesses, whether that is ruptured aneurysms, heart attacks, kidney failure, the need for mechanical ventilation in people who have severe lung infections or chronic obstructive pulmonary disease exacerbations. There is also my lung cancer clinic—really, the list goes on.

One of the other things that I am often struck by in our multidisciplinary meetings where we look at things like CT scans of people who have smoked all their lives—through no free choice, by the way, because they have become addicted to tobacco through means of the tobacco industry encouraging young people to take up smoking—is that they have multi-morbidity. So as well as having lung cancer, they may have a kidney cancer, they may have heart disease, as well as COPD. If they have one of those things, we can manage that, but unfortunately, the combination makes people multi-morbid and frail, and it impacts their ability to have treatment for the most serious of those conditions.

By eliminating smoking and creating a smoke-free generation, we will transform aspects of our medical care and our NHS. We heard this morning that there is a person admitted every minute to hospital with smoking-related disease, and there are 100 people seen by GPs every hour with tobacco-related disease. So I think we can alleviate all that extra pressure on the NHS from tobacco addiction and use those resources differently.

Q Thank you both. You have alluded to the fact that this is not a choice, but an addiction. Can you explain how that impacts on your patients? What do they say when you tell them, “I’m sorry, you are going to die.” How do they respond? Do they feel, “This was my choice and therefore it is great for me”?

Professor Agrawal:

This is awful. One of the things I am struck by in my lung cancer clinic is that at least a third of the people we look after are still smoking despite the diagnosis of lung cancer, because they have no free choice and are addicted. They became addicted as young children. I know there are other panellists that you will hear from later on who may talk about the business model of the tobacco companies, but the sad reality of their business model is that two out of three people will die from smoking-related disease, and to maintain their profits they need to replace those smokers. They do that with young people. That is what we need to stop so that it is not just a production line for corporate profit.

Q Mr Mitchell, what do patients say to you when you tell them, “I am very sorry, but you’re going to die”?

Tim Mitchell:

Very often, when I see patients who smoke, I encourage them to stop smoking. A very large proportion say, “I would love to stop smoking. I have tried previously.” They might have been successful for a period of time. Many of them simply regret the fact that they ever started smoking in the first place. If we can stop them getting on to that ladder in the first place, one does not have that problem. Stopping smoking, as I think we are all aware, is an incredibly difficult thing to do. That is where I see vapes as certainly having a useful role in smoking cessation, but trying to stop people smoking in the first place is absolutely key.

Q Could I ask you both to agree that it is therefore not a matter of free choice? This is an addiction that removes people’s choice; would you both be willing to agree with that?

Professor Agrawal:

I think it is a lethal addiction.

Tim Mitchell:

Undoubtedly, I would agree with that.

I know that the Royal College of Physicians has called for regulation to protect young people from vaping. I thought that what Professor Agrawal said about the importance of helping people to stop smoking was very interesting. At the same time, that balance is really important.Q

I am interested, however, in the harms of vaping to those who have never smoked, particularly young people, and the challenges we have heard about with them being advertised to in various ways, including on sports kits and in online spaces. What are your thoughts on how we best deal with that?

Professor Agrawal:

I agree that it is awful and that we need to restrict it. The tobacco industry has a playbook on how it attracts young people to smoking, and it is not dissimilar to vaping. Billboards, influencers on social media, brightly coloured, garish packaging and the names of flavours are all used to appeal to young people. The provisions in the Bill will provide the powers to restrict that. That is really important and is exactly what we should be doing.

There is also the influence of social media, and we should not forget that. Whether this Bill will deal with that or whether it will be some secondary legislation that does that, that is fine, but we certainly need to curb the impact of social media and other influences on young people starting to take up vaping.

Q Do you have anything to add?

Tim Mitchell:

Just that the scientific evidence in relation to surgery and vaping is very limited. Clearly, as I have said, we see vaping as being much less of a risk to people than smoking, and from that perspective, it is very good. But otherwise, I would defer to Professor Agrawal and what he said.

I absolutely accept what you both have said about wanting to get the Bill through as quickly as possible with no amendments. However, is there anything in the Bill that you think we have missed and that you would like, if this was possible—I am not saying it is—to add in? What have we missed, if anything?Q

Professor Agrawal:

I thought it was such a well-balanced Bill, with all the objectives, whether that is making sure they are available to help people quit, or really focusing on preventing young people from being attracted to vaping. The Bill is not in isolation, as I have alluded to. The ban on disposables is undergoing consultation, and there is the excise tax. All of those measures form a whole. Yesterday, we heard about the potential for track and tracing, for example, to be used with vapes, which would therefore mean that things like retail licensing are probably not needed because a good track and tracing system will actually do the job. I think the Bill has been well thought through, not by accident, and I cannot think of anything that will not get picked up in the consultation. I suppose the one thing that is not in there is interference from the tobacco industry, front groups and lobbyists with any part of tobacco regulation, and making sure that that does not occur.

Mr Mitchell?

Tim Mitchell:

I have nothing more to add.

Excellent.

Q There are still 6.4 million people who smoke. With this Bill, how do we prevent future generations from smoking and become a smoke-free country? What incentive is there in this Bill for persistent smokers to stop smoking now? Are there physical health benefits for long-term smokers to quit that could be an incentive if they have not tipped over the edge and have an incurable disease?

Professor Agrawal:

It is never too late—that is what I say to patients who are currently smoking. I see people in their 60s, 70s and 80s, so it is never too late to quit. There are always benefits. Even when people have been diagnosed with lung cancer, we can provide treatment in the form of surgery, radiotherapy and so on, and quitting smoking still helps. I think the Bill sends a clear message that we recognise that there are 6.4 million smokers and we need to support them to quit. Vaping is one means of doing that, and we are not trying to take it away from them if that is the only way they have been able to quit smoking. The Bill contain provisions to help all groups. It is not just about stopping young people taking up smoking; it recognises the need to do something for the people who are still currently smoking.

Tim Mitchell:

I would say that there is still an imperative to encourage people who smoke to stop smoking, and vaping can be a mechanism for helping with that. Certainly, as surgeons, when we see people who smoke who require surgery, we encourage them to stop smoking. We know that their risk profile through surgery is improved if they can stop smoking, even just a few weeks before they have surgery. Even if they do not smoke on the day they have their operation, that has some benefits. Encouraging people who smoke to stop smoking remains a very good thing to do, in addition to the provisions in the Bill.

Q Professor, you talked about choice, and about business and the need to maintain profits by addicting a new generation of people to a nicotine-based product that will be hard for them to quit. That applies to vaping as much as it does to smoking, although one may be more harmful than the other. Could you talk about the effects of vaping on those who have never smoked—particularly things such as e-cigarette or vaping use-associated lung injury, and the effects of nicotine on their lungs?

Professor Agrawal:

In the report we have just published, we looked at a range of studies related to safety. Ann McNeill, who will be talking this afternoon, is in a much better position to talk about that work. We measured the range of toxins and the degree of exposure. E-cigarettes expose people who use them for a short time to quit smoking—which is the only thing we advocate them for—to a much narrower band of toxin, and the degree of exposure is lower. In comparison with tobacco, it is much lower, but in comparison with not using either, unsurprisingly the levels of toxins are higher. The RCP is very clear about that: if you do not smoke, do not vape.

Q Do you have any more details about the medical effects of vaping on non-smokers?

Professor Agrawal:

Nicotine itself can raise the heart rate and raise blood pressure, although usually less so than tobacco. As I said, we do not advocate vaping for anybody who does not smoke.

Good afternoon to you both. You have explained to us the horrors and the multitude of harms that tobacco smoke can have on an adult who smokes. Can you explain a bit about the effects that second-hand tobacco smoke has on children, who have even less choice in the matter?Q

Professor Agrawal:

We know that second-hand smoke causes a range of diseases for children, whether that is triggering asthma exacerbations or infections, such as middle-ear infections. There is a bunch of infections that are much more likely in children whose parents, carers or siblings smoke, and they are exposed to that second-hand smoke. By treating adults who smoke and helping them quit, you will also help their children.

One thing I did not talk about earlier was the impact on poverty. Helping adults to stop smoking increases household income and reduces child poverty. Action on Smoking and Health has estimated that something like 250,000 children live in households that are below the poverty line because of adults spending on smoking. Stopping smoking has myriad benefits, whether helping children, reducing poverty or reducing health inequality. That is why this Bill is so pleasing.

Tim Mitchell:

From a surgical point of view, in my practice as an ear, nose and throat surgeon, one of the commonest conditions we see is glue ear in children. That is a condition where fluid behind the eardrum affects hearing, and potentially affects speech. That is the condition for which children sometimes have grommets or ventilation tubes put in their ears. It is one of the commonest operations that children undergo. The risk of that is significantly increased in children who live in households with smokers. There are other disease pressures as well, as my colleague alluded to. It has a significant impact.

Are we missing an opportunity to create a nicotine-free generation, alongside a smoke-free generation? We heard earlier that GPs were not able to prescribe vapes. Would that help your practice and help people quit, if you had those tools in your hands when seeing your patients, to encourage them to transition from smoking, which is so dangerous, to vapingQ ?

Professor Agrawal:

The first question was?

It was about a nicotine-free generation.

Professor Agrawal:

Because people are addicted to nicotine, often at an early age, they find it impossible not to have some nicotine. The danger of banning nicotine altogether is that it will perpetuate smoking. People will go to the only form of nicotine they can buy, let us say, and if that is tobacco, they will just carry on smoking. I would worry about banning nicotine and all nicotine products, because it means that the 6.4 million smokers will not have anything else to go to.

Q It will rise in line with the smoke-free generation. These would be people who are non-smokers, because they would be children born after 1 January 2009.

Professor Agrawal:

Oh, I see. I do not know, is the answer to that question. The second question—

About prescribing.

Professor Agrawal:

Prescription, yes. That might be a helpful adjunct, inasmuch as it would give healthcare professionals safety in the knowledge that a product has been tried and tested and could be prescribed. If they were unsure about e-cigarettes and which to recommend to patients, having a prescribable e-cigarette could be helpful.

The only downside is that, as I am sure the Committee knows, the e-cigarette market changes at lightning speed. What is licensed one day, the very next day would not attract anybody, or nobody would want to use it. That is the only con, as it were. It certainly might have a role in helping medical professionals prescribe and have confidence in using a product that has been deemed to be safe.

Q Further to that, I would like to probe a bit on that, because it has been put forward that some colleagues would prefer prescription-only vapes. However, from speaking to vapers myself and having done some visits to meet with enforcement officers and so on, it seems that users of vapes like the variety. They say, “I don’t want to vape tobacco flavour; I want to vape strawberry flavour.” There is another side to this argument, which is that you should keep different flavours in order to avoid people who are smokers going back to smoking because they are not getting enough choice. You just said that it would be good to have prescription-only vapes, but would that not fly in the face of how people use them? That is why that is not in the Bill at the moment. I do not want to set hares running where, in fact, the practical reason for not saying that vapes should be prescription-only is exactly that of consumer choice and trying to avoid people going back to smoking.

Professor Agrawal:

Maybe I was not clear. I do not think that we should have just prescription-only vapes. It would be an adjunct to all the other vapes out there to give that choice to people who want to use vapes to quit and access all those flavours and different types of vapes. There are several different types of vapes as well as the flavours and so on, and that choice has driven people who smoked to use them to help them to quit. They can do it themselves, they have the hand-to-mouth movement—a whole combination of things attracts them to vapes to help them to quit smoking. Having only one product would be a disaster.

Q The chief medical officer said earlier that he would encourage the vaping sector to perhaps try for registration for a particular vape for prescription. Nobody has done that as yet, because it is a complete free-for-all out there. We are all really keen to see better, safer products and help adult quitters to quit. The CMO said that they could be prescription-only for people who are both in poverty and deprivation and trying to quit smoking, but not to in effect prescribe in a Bill such as this, “You shall now have only prescription vapes.” Would you agree with the CMO?

Professor Agrawal:

I completely agree with that. I completely agree with what the CMO said.

Q In order to be a prescribable drug, an e-cigarette or vape would need to go through an awful lot of testing to demonstrate its effectiveness in what it does, the safety of its components and the safety of the product as a whole. Are you aware of any vape that has gone through the safety testing to demonstrate that it is safe in that way that can currently be prescribed?

Professor Agrawal:

I think a colleague from the MHRA is on after me who might be able to answer. I believe there are products that industry has taken to the MHRA and got to the point of licensing, but it has not marketed them or wanted to take them further. I do not think that it is impossible. In fact, as the CMO said this morning, I think manufacturers should be encouraged to go through that process.

Q So you think vapes are available that could be prescribable in the United Kingdom.

Professor Agrawal:

No, I am not saying that there are: I am saying that companies have started to go down that route, but they have not proceeded.

Q Why do you think that is?

Professor Agrawal:

I do not know. Presumably it is related to what they feel is a good commercial bet or not.

If there are no further questions, can I thank the witnesses? We will move on to the next panel.