Examination of Witnesses

Tobacco and Vapes Bill – in a Public Bill Committee at 10:25 am on 1 May 2024.

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Professor Kamila Hawthorne and Professor Steve Turner gave evidence.

Photo of Siobhain McDonagh Siobhain McDonagh Labour, Mitcham and Morden 10:55, 1 May 2024

Q We now hear from Professor Kamila Hawthorne, chair of the council of the Royal College of General Practitioners, and Professor Steve Turner, president of the Royal College of Paediatrics and Child Health. We have until 11.25 am for this session. Before I call the first questioner, would the panel members like to introduce themselves?

Professor Hawthorne:

I am Kamila Hawthorne. I am a GP in south Wales. I work in a post-industrial, very deprived town up in the Welsh valleys. I am chair of council and have been for the past 18 months.

Professor Turner:

Good morning, everybody. Thanks for having me. I am Steve Turner, president of the College of Paediatrics and Child Health. My other job is as a paediatrician in Aberdeen. I have 20 years’ experience as a consultant looking after children with asthma and other breathing problems, and I have done 20 years’ research into the harm of tobacco exposure to children before and after they are born. I am an advocate for our 20,000 members in the UK, including one here, and our 4,000 members overseas. I am also an unapologetic advocate for children and young people. Finally, we believe this Bill is splendid. We would be happy for the version that we have seen to be approved unamended.

Photo of Dr Caroline Johnson Dr Caroline Johnson Conservative, Sleaford and North Hykeham

As a declaration of interest, I am an NHS consultant paediatrician and a member of the Royal College of Paediatrics and Child Health.

Photo of Preet Kaur Gill Preet Kaur Gill Shadow Minister (Primary Care and Public Health)

Q The point of this Bill is to call time on a system that privatises the profit from nicotine addiction but socialises the social costs. What is the impact that you see on your profession, which we know is already stretched on the frontline in terms of managing long-term chronic illness associated with smoking?

Professor Hawthorne:

Smoking-related illnesses cost the NHS about £2.5 billion a year. Everybody knows that lung cancer goes with smoking, but what I am really seeing is awful chronic obstructive airways disease. I work in a deprived area. Many of my patients have smoked ever since they were teenagers and find it very difficult to stop. Every winter, they come to see me repeatedly with severe chest infections that require courses of steroids and antibiotics and sometimes hospital admissions. It is really difficult.

I had a patient who sadly has passed away now with end-stage lung disease caused by smoking. The difficulty we had keeping her as well as we could at home was that she could not have home oxygen because she continued to smoke. It was a massive difficulty for her to stop smoking, even though it was causing her to virtually strangle herself. That just shows what a difficult thing this is.

Professor Turner:

To follow on briefly, you might think that children do not demonstrate some of the impacts that Kamila has just described, but that is not the case. Following on from the conversation before, nicotine is not good for you. If you are a foetus inside of your mam, it will cause uterine arteries to spasm and effectively strangle you—reduce the oxygen to you.

We know that vaping contains nicotine. Nicotine makes you small and, if you are born small, you are already on a trajectory for all the non-communicable diseases that Kamila and her colleagues will see in primary care: cancer, heart disease, stroke and hypertension. From the paediatric perspective, there are issues. Children do not concentrate so well when they are addicted to something, so their attention in school is changed. That will affect their learning outcomes and their future economic productivity. The devices sometimes set on fire, so if you have one in your mouth, it can create burns. Fortunately, there are few serious life-threatening complications, but you might have heard of popcorn lung, which is fortunately rare but is very serious. With popcorn lung, when you look at the lungs on a scanner, it looks like they are full of holes.

Photo of Preet Kaur Gill Preet Kaur Gill Shadow Minister (Primary Care and Public Health)

Q Do you think that the Bill goes far enough to protect young people from the harmful effects of smoking and vaping?

Professor Turner:

Yes, absolutely. The tobacco industry knows that, at the age of 15, we as a species are at the sweet spot for becoming addicted to nicotine for life. The proposed Bill will effectively stop that. Protecting our children from becoming addicted to something that will shorten their lifespan by 10 to 15 years has to be a good thing for us as a responsible society to do.

Photo of Preet Kaur Gill Preet Kaur Gill Shadow Minister (Primary Care and Public Health)

Q Finally, what are the harms of vaping to those who have never smoked?

Professor Hawthorne:

We know that vaping can cause people to start smoking; it can lead to smoking. We do not have much evidence—I think you have been told this already this morning—as to what the long-term effects of vaping are. We have known about smoking damage since the work of Sir Richard Doll in the 1960s, so this is relatively new. We know there are chemicals in what people are inhaling—that is what causes the popcorn lung—but it is actually only one particular chemical that has been linked, and there are lots. Since 2016, vapes have not been allowed to actually have that chemical any more, but there are other chemicals, and we still do not know what long-term effects they might have.

Photo of Preet Kaur Gill Preet Kaur Gill Shadow Minister (Primary Care and Public Health)

Q There seems to be an issue around what is contained in illicit vapes, which we know include things like lead, nickel and high levels of nicotine, versus other vapes that have gone through a notification process. Do you feel that the research on the impacts of illicit vapes is not there, or is it the impact of vapes that have gone through a compliant process?

Professor Hawthorne:

There is probably very little research on either.

Professor Turner:

If I could just bring a bit of clarity, it is well known that nicotine is bad for us. Sir Walter Raleigh brought it back with some potatoes, and we have known for hundreds of years that nicotine is an addictive drug. As I said previously, it will shorten your life expectancy by between 10 and 15 years. Because we know nicotine is in all nicotine-containing vapes, whether licit or illicit, it is harmful regardless of what the other components might be. It is likely that those other components add to the harm, but there is substantial and well-described harm from nicotine addiction to us as human beings.

Photo of Andrea Leadsom Andrea Leadsom The Parliamentary Under-Secretary for Health and Social Care

Q Thank you both so much for being here. As I said to the other medical professionals, your words today will be incredibly valuable in ensuring the smooth passage of the Bill. Professor Turner, could you explain to us what happens to a baby born addicted to nicotine in terms of the withdrawal symptoms and the impact on its health and development?

Professor Turner:

There is not a lot of research on that. Certainly, we know that if you are in utero and your mother is smoking, you will get the harmful effects of nicotine. That is a very good question—I honestly do not know what the effects on the unborn child would be. Certainly, we know that children born to parents who are addicted to morphine or cocaine have learning difficulties. I have to be honest and say that I might have to get back to you on that one, but I can assure you that it is not good to be in utero and exposed to nicotine.

Photo of Andrea Leadsom Andrea Leadsom The Parliamentary Under-Secretary for Health and Social Care

Professor Hawthorne, from a GP’s perspective, could you talk us through the impact of second-hand smoking on childhood asthma and how that presents in terms of the innocence of the child and the impact of something being done to them?Q

Professor Hawthorne:

We have known for a long time that passive smoking increases the risk of not just asthma, but upper respiratory tract infections and ear infections. It is very much part of a GP’s role when they are consulting with such patients coming in with these infections to ask about parental smoking. It is interesting that the responses are nearly always the same. If the parent smokes, they will always say, “But I only ever smoke outside.” Of course, one has to take that as it is, but I suspect that they are probably not always smoking outside. It is definitely a well-recognised link, but I am seeing it a bit less than I used to.

Everybody knows about the dangers of smoking. A lot of my patients, when I talk to them about needing to stop smoking, already know what I am saying. Quite often, I will say to them, “Well, you know what I am going to say next, don’t you?”, and they will say, “Yeah, I know. I need to stop smoking.” The conversation then proceeds from there.

We also have evidence that, in general practice consultations, a short intervention can be very effective. We know that people are very pressed for time, and there is only so much we can cover in a 10-minute appointment, especially if the patient is coming with three different problems. But there is good evidence that with even a very short intervention—I think in about 10% of cases—patients will actually stop smoking. It is always worth talking about, and if I get the time, I have a much longer spiel, because you need to think about the behavioural and addictive aspects of smoking. We go through, “When are you most likely to want to smoke? Is it after a meal, when you are on the phone or when you first get up in the morning?” We talk about what else they can do instead. I had one patient who went and dug the garden whenever she wanted to smoke. It is that kind of conversation.

Photo of Andrea Leadsom Andrea Leadsom The Parliamentary Under-Secretary for Health and Social Care

Q We know that it takes up to 30 quit attempts to actually give up smoking. Can both of you give us a clue as to what is it about the 30th attempt that finally gets people over the line? Specifically to Professor Turner, is it being pregnant or having a partner who is pregnant? Is that the thing that makes people finally achieve their goal?

Professor Hawthorne:

For adults, it is having that heart attack that maybe you could have avoided if you had stopped smoking before. Again, that is part of the conversation I have with patients. I say, “You are a heavy smoker, and you are at risk. Wouldn’t it be better if you stopped smoking before you have the heart attack, rather than after?” There are things like that, for sure.

We also operate a cycle of change psychological model—the Prochaska and DiClemente model. Essentially, it is a bit like having a clock face. We work out where the patient is on the clock face, and we are trying to get them round the clock to 12. If they are at somewhere like 2 o’clock, that is them saying, “Yeah, I know it is bad for me, but really no way am I going to do anything.” By 4 or 6 o’clock, they are saying, “Yeah, I know it is bad for me. I have tried a few times but it is just hopeless.” By quarter to, they are saying, “I’ve really got to do something”, and by five to, they are coming in and saying, “Doctor, you have to help me stop now.”

Professor Hawthorne:

Not necessarily. It is about pushing people psychologically around that clock face. I try to work out where they are on the clock face and see if I can nudge them a bit further round, until one day they come and say, “I’ve got to stop now. What can you do to help me?”

Professor Turner:

As Kamila says, there are myriad drivers—teachable moments. Sometimes, when your child is admitted to hospital with an asthma attack, that might be the thing that makes both parents say, “That’s it.” It might be that the grandmother says to her daughter, “You’ve got to stop for your child.” Legislation might also be one of those teachable moments that make people reflect on their 29 past unsuccessful attempts and think, “I’m going to do it again.” There is no one thing, but there are clearly teachable moments, as we all have when we change our behaviour. As I suggested, I think this legislation will be one of those.

Photo of Andrea Leadsom Andrea Leadsom The Parliamentary Under-Secretary for Health and Social Care

Thank you very much. One last question: do you think the financial incentives for pregnant women and their partners would help?

Professor Turner:

I think this is extremely contentious, but the evidence is that it does—sorry, you did ask me about pregnancy before. Pregnancy itself can be one of those opportunities to quit. Those parents who continue smoking—12% in Cumbria—feel terribly guilty. Anything we can do for that person, who has been addicted since she was 15 or 16, can help them to quit. There is no doubt—in Dundee, the trials have shown that, if you give mums incentives, in terms of vouchers rather than money, it helps them to quit, particularly if they are from deprived communities.

Photo of Rachael Maskell Rachael Maskell Labour/Co-operative, York Central

Q We have already heard how addictive nicotine is, but do we have an understanding of the dosage of nicotine that people inhale through vaping versus through smoking? Secondly, are we missing an opportunity not to introduce a nicotine-free generation?

Professor Hawthorne:

I am not a nicotine expert, but my understanding is that there is a risk from vaping, but it is about 5% of the risk from smoking. That is the best I can do in comparing the two. When I talk to patients about stopping smoking, vaping is one of the things we talk about as an alternative, with a view to eventually stopping vaping as well. Of course, there are all the other products: we use patches and chewing gum—all the usual things. It is difficult to quantify exactly how much less dangerous vaping is than smoking.

Professor Turner:

Just to supplement that, as a user—if that is the right word—or a customer buying a vape, you can select the dose you want. There are doses that are equivalent to cigarettes and doses that you can wean yourself down on.

You asked whether we would be missing an opportunity if we do not introduce a smoke-free generation. I think we would absolutely be missing an opportunity. If we look back, the legislation on smoke-free public spaces across the UK was landmark. We all remember the days when you went on a plane and there was a smoking bit up front and a non-smoking bit at the back. If we were to go back and say there would be no smoking areas, we would think, “Wow, that would be transformational.” We have come on a journey, and the legislation has been part of it. I see a smoke-free generation as the logical next step, and I really think we have to take it.

Photo of Rachael Maskell Rachael Maskell Labour/Co-operative, York Central

Q Just to come back on that, I said a nicotine-free generation.

Professor Turner:

To me, smoking and nicotine are two sides of the same coin. Nicotine addiction is smoking.

Photo of Siobhain McDonagh Siobhain McDonagh Labour, Mitcham and Morden

I just want to advise the panel that we have about 13 or 14 minutes to go, and four Members want to ask questions, so be kind to your colleagues.

Photo of Steve Tuckwell Steve Tuckwell Conservative, Uxbridge and South Ruislip

Q Thank you for coming along this morning. I am really interested to know whether you think there is a risk that the Bill’s restriction on vapes will lead to an increased use of illicit vapes.

Professor Turner:

That is a fair question. We recognise that there is a thriving illicit vape market, and the vaping industry is aware of that. As to whether the legislation will exaggerate that should it be passed, that is difficult to tell because, by definition, we do not know how much illegal activity there is. It is a reasonable consideration, and probably a lot of illicit vapes are already being sold. It is one of those things that you might consider when you vote, but I do not think the problem is sufficient to mean that the Bill should not go through.

Photo of Mary Foy Mary Foy Labour, City of Durham

Q This question is particularly for Professor Hawthorne. From your experience, can you tell us what impact smoking tobacco has on our most deprived communities?

Professor Hawthorne:

It is much more prevalent. There is a theory called future discounting. If you have few choices—if you do not have much money and much choice in what you eat, what you do and where you work—you do not think about your health in 20 years’ time; you think about today. Many people feel that smoking helps them get through the day, and that is what they do. It is a really difficult thing to talk to people about because some people will say to me, “I’ve just got to. I can’t get through my day otherwise.” I can say, “There are alternatives. There are other ways that we can help you get you through your day,” but you have to get them round the clock face that I was talking about, until the point comes when they say, “I’ve got to do it now.”

Photo of Nickie Aiken Nickie Aiken Conservative, Cities of London and Westminster

Q Vapes—or e-cigarettes, whatever you want to call them—were introduced to help people to stop smoking. Professor Hawthorne, I would be particularly interested in your view on this, as a GP. We know that vaping has been turned into a massive industry now, but if the whole point of vapes, or e-cigarettes, is to get people to stop smoking tobacco, what is your view about vapes being prescribed?

Professor Hawthorne:

Do you mean as part of a smoking cessation programme?

Photo of Nickie Aiken Nickie Aiken Conservative, Cities of London and Westminster

Yes, rather than having them sold as they are at the moment.

Professor Hawthorne:

That is an interesting question. I prescribe nicotine patches; why should I not prescribe vapes? That would be my thought.

Photo of Siobhain McDonagh Siobhain McDonagh Labour, Mitcham and Morden

I call Dr Caroline Johnson—you have all been so kind to one another, we are now ahead of time.

Photo of Dr Caroline Johnson Dr Caroline Johnson Conservative, Sleaford and North Hykeham

Q Professor Turner, Dr Helen Stewart from the Royal College of Paediatrics and Child Health gave evidence last summer to the Health and Social Care Committee, of which I am a member. She talked about some of the passive effects of vaping on children, such as in the toilets on school premises, where many children had been vaping in an enclosed environment, and children with asthma and other lung conditions were frightened to go into those toilets because their conditions were triggered by being in the presence of second-hand vaping.

Do children breathe in second-hand chemicals when they are proximal to adults vaping, or in an enclosed environment? If they do, what effect does that have on children’s lungs? Would you, or the royal college, support a ban on vaping in public places in a similar way that we currently ban smoking?

Professor Turner:

I think that vaping in schools and school toilets is a big problem. First, it means that fire engines come out and that disrupts school. As you say, there are some children whose asthma will get set off by exposure to vapes, for example. So I think that it is a big problem, and you have already heard from schools. We are still not sure what components of the exhaled second-hand vape, if you will, are causing symptoms, but, as you described, that happens.

On your third question about banning vaping in public spaces, I would not have an opinion on that. If they are being used by people who are nicotine-addicted to help to come off their nicotine addictions, I would not be unhappy with that. Most of the second-hand vape is water vapour, but if you walk behind somebody who is vaping, you can tell what the taste is, so there are chemicals in there. I think that banning them in public spaces, at this point in time, is something that I would not have a strong opinion on.

Professor Hawthorne:

I think we are on a journey, over the years, towards stopping smoking as a nation, so this Bill looks like a great step forward. I think that it is a landmark suggestion, and now that New Zealand has backtracked, I think we will be ahead of the game.

Professor Turner:

And we have a proud record of doing this, from a legislative point of view.

Professor Hawthorne:

Also, to some extent, sometimes, when you make a big step—which this is—you then might want to stop and wait, consolidate, check and gather more data before you make the next step.

Photo of Siobhain McDonagh Siobhain McDonagh Labour, Mitcham and Morden

If there are no further questions, I thank the witnesses for their evidence. That brings the morning’s session to an end. The Committee will meet again at 2 pm this afternoon, here in the Boothroyd Room, to continue taking oral evidence.

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

Adjourned till this day at Two o’clock.