Professor Robert West and Professor Ann McNeill gave evidence.

Q We will now hear from Professor Ann McNeill from King’s College London and Professor Robert West from University College London. Before we begin, I thank the witnesses for their flexibility in accommodating our rearranged schedule. We have until 4.55 pm. Would the witnesses please introduce themselves for the record?

Professor West:

I am Robert West, professor emeritus of health psychology at University College London. I have been working in the field of tobacco and smoking since 1982. Most of my work involves clinical trials and large-scale surveillance of things such as smoking, vaping, quitting and so on.

Professor McNeill:

Good afternoon, everyone. My name is Ann McNeill. I am a professor of tobacco addiction at King’s College London. Sheila Duffy yesterday referred to me as just a psychologist. I wasn’t quite sure what she meant by that. Just for the record, my first degree was in psychology and zoology and my PhD was on dependence on smoking. That included biomarker research, which I think was the context in which she made that comment, but for nearly 40 years—not quite as long as Robert—I have devoted my career to reducing the harmfulness of tobacco smoking and covered prevention, cessation and harm reduction.

I welcome the Bill, but I have a few comments on it. The smoke-free generation will, if properly enforced, remove smoking as the anomaly that it is, because we should not have cigarettes in our society, given that they are so uniquely dangerous. It will not do anything directly for the 6.4 million smokers that we have heard about. However, the Bill has helped to put smoking back centre stage in terms of its unique harmful properties. There has been a lot of noise about vaping over the past few years, so it is really good to be discussing smoking and its unique harmfulness.

It is really important, moving forward, that the Bill is in the context of a comprehensive tobacco control strategy, for which there continue to be mass media campaigns about the dangers of smoking and other smoking control strategies. That will really help to drive down health inequalities, given that we know that smoking is higher among the more disadvantaged. We have heard about that during these hearings.

To add to what Mark Rowland said, because mental health is an area I have worked in quite a bit, most of the 15 to 20-year life expectancy gap is because of the fact that people with mental health conditions are more likely to smoke. But the reason I mentioned smokers is that I think we have got to be really careful not to have any unintended consequences from the Bill that keep smokers smoking or drive people who are vaping to relapse to smoking. Though I welcome things such as putting electronic cigarettes behind the counter in shops and removing some of the packaging and branding of e-cigarettes, one area we do need to be careful of is flavours, because we know from research that they are important for smokers when they are trying to stop.

Q Robert, can you talk about the UCL smoking and alcohol toolkit studies’ findings on public views on smoking cessation and measures in the Bill?

Professor West:

Yes. Probably even better is the ASH survey, particularly in relation to public views on the policies being proposed. What is interesting about both surveys is that, as many of you will be aware, there is widespread support for what some in years gone past might have seen as quite a draconian Bill that phases out smoking. That is testimony to how far we have come with the policies we have adopted, with credit to successive Governments—all Governments have kept their foot on the accelerator in addressing the issue, and it has paid off. Probably for the first time in any country in history, we are in a position where this is a serious, viable option in terms of public sentiment.

If you have not had a chance to look at the smoking toolkit study, go to smokinginengland.info. The study gives you a month-by-month analysis of key parameters, including things such as vaping and vaping in particular age groups. I do not want to bang on about vaping too much, because the key thing is smoking; but as is often the case with what they call a diffusion of innovation, when you look at the data you will see an acceleration and things look as though they are going in a terrible direction, and then at some point other factors kick in. For the last couple of months, vaping rates, particularly among never-smokers—the key people we are interested in—and young never-smokers have plateaued. We do not know whether the rates would go up again, but I think that means that if we can put a lid on it through the Bill, there is a very good chance that we could get the vaping rates down again.

Q Ann, do the measures in the Bill equitably benefit all people affected by tobacco and vaping products?

Professor McNeill:

As I mentioned in my opening comments, the people affected by the Bill will be people who are vaping and/or smoking, people who might take them up, and people around them. It will certainly drag down smoking uptake. My main issue is around encouraging people who smoke to stop, given that more people from disadvantaged groups smoke. As long as we maintain the focus on smoking with the Bill and provide support for smokers to stop—that includes vapes, which are effective tools—then yes, it can drive down the health inequalities caused by smoking.

Q Thank you both very much for being here. As I have said to other health professionals, what you say can be incredibly helpful in allowing the Bill to pass through smoothly, because people make some very big challenges, namely that this is all just about freedom of choice, vaping is fine and there is nothing wrong with it. With that in mind, I would be grateful if you could try to ensure that you give us material with which to address some of those challenges.

Professor McNeill, we heard earlier that there is no evidence on what happens to a baby born addicted to nicotine or what the impacts are for that baby. I was advised that you might have a view on that.

Professor McNeill:

We can certainly ensure that we provide written evidence afterwards. The more concerning issue is some of the other constituents that go through to the foetus, such as carbon monoxide, which can have a devastating effect on the baby. On vaping in relation to pregnancy, we have seen in research that when people have used vaping, it is an effective tool for stopping smoking, which is really important, and it does not have any more adverse effects than nicotine-replacement therapies. My concern would be about smoke constituents more than nicotine addiction, which is highly unlikely if nicotine is used during pregnancy. I hope that makes sense.

Q To push back slightly, we know that babies are born addicted to crack cocaine or heroin. Does nicotine pass through as an addiction for the newborn baby in the same way?

Professor McNeill:

I do not have the evidence for that.

Professor West:

There are a lot of misconceptions about what addiction is and how it operates. We need to distinguish some of it from what we might consider to be physical addiction, which is a physiological adaptation —for example, with a baby born to a mother who has been drinking heavily, that baby’s physiology will have got used to alcohol, and there will be things like foetal alcohol syndrome and so on. There are those physiological adaptations.

In the case of nicotine, as far as we can tell from the studies of people who have used nicotine replacement therapy, such as e-cigarettes or, in other countries, things like snus—a form of smokeless tobacco with pretty high nicotine levels—we do not really see evidence of that sort of syndrome. In fact, those kinds of physical withdrawal symptoms that we see with alcohol—potentially fatal—and with heroin and so on, are more often a feature of sedative or opiate-type drugs than of stimulant drugs and are not so much a feature of nicotine.

The addiction to nicotine some people think of as psychological, but it is not really psychological; it is the impact of nicotine on our motivational system, which causes people to feel an impulse for whatever it was they were doing when they got that nicotine in the system. It forges an association in the brain. What that means is that the craving for nicotine is the thing that is driving the behaviour, rather than the need to escape the withdrawal symptoms.

That means that, for example, even non-daily smokers —in the UK, that figure has gone up quite a bit, with about 25% of smokers being non-daily—find it very hard to stop smoking. That would be odd if it were just a physiological adaptation. The craving is the big issue there. In terms of damage to the foetus from nicotine per se, the trials that have been done have not shown the kind of serious damage that we would be worried about.

Q So it is other damage from smoking that is caused to newborn babies. For the record, it is important to say, in answer to those who say smoking is about freedom of choice, that a newborn baby does not choose to be impacted, or killed indeed—stillborn. What thoughts do you have about that argument of freedom of choice versus freedom of addiction?

Professor West:

I think it is nonsense. One can get philosophical, so let us not do that, but the issue is that a choice is something that you make in situations where the forces operating on you are not so compelling that you end up going down a particular road. In a way, if someone puts a gun to my head and says, “You can choose to do this, but if you do it, I will shoot you,” that is not really freedom of choice, although in a way it is. What addiction does is to limit your freedom of choice. If you market a product that causes people to be addicted, the only people who really have the choice in the matter are the people who use the product for the very first time and the companies that are marketing the product. Once you have a level of addiction, that level of choice becomes constrained. That is my view.

Q Thank you; that is very helpful. Professor McNeill, may I ask you again about the vape flavours? The Bill takes powers to restrict packaging, location in store, and flavours. I would like to get your views on the record. Some say, “Let’s choose and put the actual flavours on the face of the Bill,” while other medics say, “No, you can’t do that, because you will never stay ahead of the vape industry.” What would your view be?

Professor McNeill:

My view would be that it is quite a complex issue. As I have said, there are dangers of unintended consequences by removing flavours. Certain research that I have been involved in has shown that the flavours were important in people transitioning out of cigarette smoking, so I think one has to be quite careful about doing it. We also know that it is very difficult to characterise flavours, and that has happened with tobacco cigarettes. That is something for the secondary regulations, where it can be properly thought through. However, I think that removing flavoured descriptors from cigarette packs—as I think Dr Ford said in the last session—would be a really important measure. Our group at King’s has done some work showing that that would have an impact in reducing interest in young people, while being unlikely—we think—to affect adult smokers.

Q I want to ask about this tension that you have kept coming back to throughout the past couple of days. Particularly on flavours, it is the idea that we need to help grown-ups who may have made the choice, have the conviction, and have some purpose to quit—bearing in mind that we know the average person takes 30 times in total to quit, so they are likely to relapse at some point—versus the need to prevent children from starting to vape. We know, and we have heard today and yesterday, that they are particularly vulnerable to addiction in their mid-teens, and that those who develop addiction to nicotine in their mid-teens—whether that be vaping or smoking—are highly likely to get their choice removed, because they will be unable to stop it. We also heard that some of those who vape will then go on to smoke. If the Government are to choose, and it may be that we have to make a choice in this matter, do you think it is more important to prevent relapse to smoking in adult smokers, or to protect children from starting on a lifetime of nicotine addiction?

Professor McNeill:

I don’t think it has to be a choice of one or the other; you can do both. It is a difficult balancing act to achieve, but it is important to do so. It is not about just avoiding relapse to smoking among adult vapers; it is about the 6.7 million smokers who we need to support to stop smoking quickly. They are in disadvantaged groups, and we know that children will also emulate what their parents do, so it is cyclical in disadvantaged communities. I don’t think it has to be a choice. It is a delicate balancing act that we have to get right, and this Bill is trying to do that. I want to pick up on one comment—you implied that vaping is a gateway to smoking.

That is what we heard from the doctors earlier.

Professor McNeill:

I think the jury is out on that. I would say that the gateway hypothesis is highly contested. It used to be invoked quite a lot in the drugs field but was abandoned because it is quite difficult to test. You cannot randomise children to environments where there either are cigarettes and vapes or are not. It has been contested, and our research and other research has shown that it goes both ways. An argument against the gateway theory is the common liability theory, which says children who take risks will try different products. That said, we obviously want to try to stop young people from vaping.

The other thing I would look at is the epidemiological evidence. In the UK, when vaping was increasing among young people, smoking was declining, and that has happened in the US and Canada, which is the opposite of what you would expect with the gateway theory. I think we can get that balance right. It should not be an either/or, and it would be detrimental to think about it in that way. Adult smoking will continue to influence generations to come, if we do not support them to stop smoking as quickly as possible.

Professor West:

I agree with what Ann has said. I would put it like this: I think we can have our cake and eat it, and we have. Until the advent of disposables, the UK had a very rational policy, and it was working. The prevalence of vaping and e-cigarette use among never-smokers of all ages was very low, and it was not really going anywhere. If we look at the course of time when these new products came in and the particular rise in youth vaping, the game changer has been the disposables. The key is addressing that. I even think, if we look at the evidence, that it may be an interaction with disposables—flavours per se have been around for a long time. On their own, they were not doing much in the UK to drive vaping prevalence up. The way the Bill is crafted at the moment—if I may say so, though it is not my area of expertise—means that from an implementation point of view, it is well crafted to allow Governments to adjust their policies on vaping as might be required.

As we saw in the rapid rise in new vaping with the advent of disposables, we need to be agile. The industry is constantly coming up with things, and we need to be able to figure out how we are going to deal with that quickly, before things start to get out of hand. For example, and I agree with Ann, on a population level, we do not see a population gateway effect, in the sense that as vaping has increased, we do not see a knock-on effect on smoking—but we could. We could have a situation where, if we have loads of vapers out there who have never smoked, and somehow we discourage them from vaping, smoking becomes the easiest thing to do. These are difficult balancing acts—there is no question about it—but the fact that we have achieved a pretty successful strategy in the past gives me confidence that we could do so again.

Q I find what you say about the disposables interesting. A year ago last February I proposed a ten-minute rule Bill to ban disposable vapes to protect the environment and children, and the Government now have a statutory instrument to do just that. I heard today from representatives who have been to those meetings that the industry is already working around those many pages of regulations to find a way to create something that just sneaks in under the balance.

Professor West:

That is the tricky thing. We can ban disposables as currently construed, but once the genie is out of the bottle, as it were, and with humans being innovative, as they tend to be, especially when they can make money out of it, it will be terribly hard to nail it so that, basically, we can put the genie back in the bottle. That is why the sort of approach that is being adopted makes good sense to me so that we can respond quickly, or so Governments can do what is necessary.

Q Professor West, I found your introduction on addiction absolutely fascinating. One of the things that people have said to me—I am sure it has been said to all of us here—is that could be a slippery slope, the thin end of the wedge, because there are other addictive things in society, such as alcohol, ultra-processed foods or gambling. Where do we start? What is it about tobacco products, uniquely, that gives such a compelling reason for the Bill being so necessary?

Professor West:

That is a really good question. The wedge issue comes up a lot. Essentially, what is unique about tobacco is the significant degree of harm at low levels of use. With alcohol, it has been and could be argued, there is at least some degree of harm from so-called moderate use, the level of harm is of an order such that, I think, most people in society would say, “Well, you know, this is okay.” Even non-daily smoking, however—even smoking one, two or three cigarettes a week—can present significant harm, particularly of cardiovascular disease, for example, which has a very nonlinear function relating the exposure to the risk. So there is that, the unique harm.

The other unique thing about tobacco is the proportion of users who become addicted. With alcohol, alcohol dependence as it would normally be measured is present —depending on your definition—in between 5% and 10% of users. With tobacco and cigarettes in particular—not all tobacco or nicotine products are identical, but with cigarettes in particular—it is much higher than that. A majority of people who use any amount, and any form, of smoked tobacco probably have a significant level of addiction. That would be my response.

Q We know that in deprived areas there is high incidence of smoking. Professor West, you have been talking about the fact that disposable vapes becoming more readily available has perhaps made more people vape. Is that in any way linked to people in deprived areas being able to afford vaping more than they could if they have to buy a unit, vials, batteries and everything else? Although the Bill does not ban disposable vapes, how valuable and important is the economic value to people in deprived areas of being able to vape cheaply as opposed to smoking?

Professor McNeill:

Very. Keeping vapes accessible, both in terms of price and where they can be purchased, is really important for smokers to stop.

Professor West:

I was going to reinforce the point about young people, smoking and disposables. It is about the unit cost, or having a low start-up cost. With disposables, if you look at it over the long run they are more expensive than having a tank device and refilling it with the liquid, but the upfront cost is greater. We do not know for sure, but certain bits of evidence point in particular directions. If you put the unit cost, or the start-up cost, together with the potential ease of use, the appeal and all the rest of the things in the package, you reach a point at which arguably you cross a threshold and then it begins to take off. Then it becomes a self-fulfilling thing, because it becomes fashionable and faddy. It is possible, if the plateau we are seeing now carries on or if it starts to go down in the absence of what we might do, that will also be testament to the social norm side of it. Running against that is the fact that nicotine is addictive, so that will drive it up. However, I think you make a good point.

Q I am interested in the psychology of vaping. Do you see that as being somewhat different, particularly for younger people, from smoking? Is it seen as more fashionable because of the packaging and the social media around it, perhaps because of the flavours and so on, or is the psychology for both much the same?

Professor McNeill:

I certainly think the cartoon packaging and names are inappropriate and clearly targeted, at young people, as I think the previous speaker said, and they are unnecessary. As she said, they are probably not having the effect we want with adult smokers in making them feel that these products are for them, so I do think about reducing that branding. The promotions on social media seem to be important and influential, so if something can be done about that, that would be good. I also think the easy accessibility in shops is a factor.

Q But is it more fashionable to use vapes for young people than to smoke?

Professor West:

I think that is right. What was interesting is that I talked about having your cake and eating it, and we were doing pretty well until recently. A key factor there, if you look at the sentiment among young people and what they thought of vaping, was that it was an old person’s thing to do to help them stop smoking. That is what we want; we want people to think of vapes as a thing you use to help you stop smoking. Unfashionable, but useful.

Rachel Maskell. Yours will probably be the last question.

Q I want to follow on from that theme on advertising and to take your opinion about advertising, promotion and sponsorship. We have seen the vaping industry very much following the lines of how the tobacco industry evolved in the way that it is very adept at promoting its products. Should there be a ban on advertising as there is for tobacco? First, for simplicity, so everyone knows what the rules are, and secondly, for effectiveness—that is, to discourage a new generation of vapers?

Professor McNeill:

My view is that there is a bit of a danger if we put smoking and vaping on exactly the same footing. One problem we have behind the perception about the relative risks of the two products is that, for example, fewer than one in 10 smokers knows that vaping is a lot less harmful than smoking, so I would be wary of putting them on exactly the same footing. It is important that we try to distinguish the relative risks through what we do. I think we can further reduce the advertising of e-cigarettes, particularly, as I have said, in shops, because that seems to be one area where young people can buy these products that are heavily promoted, and the branding is in itself a form of advertisement.

Professor West:

I agree. I think the key thing is the messaging in the advertising. It is already the case, if I understand it right, that you are not allowed to advertise e-cigarettes as a fashion item or leisure product.

Q They are on football shirts. When we pressed a company that came to our Select Committee, they said, “This is a public health message.” They did not have “do not smoke” on the shirts, so I did not buy that, because they are trying the same tactics.

Professor West:

That, in a way, is a question of implementation. I agree with you. Just putting a brand on a shirt is not a message saying, “This can help you stop smoking.” If they had put, “Use this to help you stop smoking” on the football shirt, maybe it would be a different thing. Ann’s point is also a very important one.

The weirdest sort of miscommunication that we have had over recent years is that as evidence has accrued that e-cigarettes are less harmful than smoking, the perception that they are more harmful than smoking has increased. Obviously, there is a whole bunch of things going on, but it is a deterrent. Not only do we know this from the surveys, but I have been talking to a lot of people—intelligent academics even—who say, “Why would you switch to e-cigarettes? They are just as harmful as smoking.” We are not getting that message across.

Whatever we do in relation to indirect messaging that might create a sense of equalisation or equality between e-cigarettes and smoking, we have a big comms job to do to make sure the message gets across that it is not the only method of stopping smoking, but it is an important one that a lot of people can use even if they do not, for example, use stop smoking services.

Mary Kelly Foy has the final question.

Q When I was first involved in tobacco control over a decade ago, at the advent of vapes it was said, “This is shocking. It’s awful. It will keep that normalisation of smoking, because it is that habit of putting something in your mouth and it is cool. Let’s not use vapes.” But over time I have come to learn that that habit is great for people who are trying to quit smoking, so vapes are seen as a positive tool. Has that put back the denormalisation of smoking for young people? I do not think they would go around saying “Let’s get a nicotine patch”. You have not seen any aspect of that? It has not slowed down that denormalisation?

Professor McNeill:

No, and that is why it is important to keep them separate, and their relative risks.

Professor West:

What is really interesting about the concern that people had, which is perfectly reasonable a priori, is that people can tell the difference. There has been no sense in which the increase in vaping has led to an increase in the sense that all smoking is okay.

On behalf of the Committee, thank you. That brings us to the end of this afternoon’s sitting.

Ordered, That further consideration be now adjourned. —(Aaron Bell.)

Adjourned till Thursday 9 May at half-past Eleven o’clock.

TVB 19 Japan Tobacco International (JTI)

TVB 20 Nishi Patel

TVB 21 New Nicotine Alliance

TVB 22 Hunters & Frankau Ltd.

TVB 23 David Francis, Senior Enforcement Officer, Aberdeen City Council

TVB 24 European Smoking Tobacco Association (ESTA)

TVB 25 Andrej Kuttruf, CEO, Evapo

TVB 26 The Asian Trader, Asian Media Group

TVB 27 Carol Fraser, Senior Trading Standards Officer, North Lanarkshire Council

TVB 28 UK Vaping Industry Association (UKVIA)

TVB 29 Hon. Wan Saiful Wan Jan, Member of Parliament for Tasek Gelugor, Malaysia