Profit Before People: The commercial determinants of health and lessons from the tobacco epidemic (2023)

What are the next steps in finally ending the tobacco epidemic and placing the harms caused by these products firmly into history? 

The end of smoking

Public support to end smoking is greater than ever from both smokers and non-smokers alike. Surveys show that 69% of adult smokers in England want to quit and that 75% regret ever having started smoking, but it takes on average thirty attempts before a smoker successfully quits²⁵. As of 2021, 26.5% of the population of Gateshead are estimated to be ex-smokers²⁶. 

We are fortunate to have the continued support of Fresh and our comprehensive approach has seen consistent rates of decline in smoking prevalence, but as we've seen above there is significant work still left to do. We have a shared vision regionally to reduce smoking prevalence to 5% by 2030 which is mirrored in the 2019 stated national governmental ambition²⁷. Based on the current trajectory we will miss our target by over seven years²⁸, even more in our most at-risk groups, and without continued focus and action, smoking will remain as a leading cause of health inequalities. In June 2021, The All Party Parliamentary Group (APPG), a crossparty group of Peers and MPs, published a report and twelve recommendations to secure the Government's ambition of a Smokefree country by 2030²⁹. A key ask of this report was an increase in funding, legislation to ensure tobacco manufacturers pay for a Smokefree 2030 Fund to bring an end to smoking, and a call for a consultation on raising the age of sale for 18 to 21. In June 2022, an independent review commissioned by the UK Government was conducted. Known as the Khan Review: Making Smoking Obsolete²⁸, this report once again laid out a series of recommendations on how the Government's ambition to reduce the national smoking rate to less than 5% by 2030 can be achieved. Four critical recommendations are below:

1. Urgently invest £125 million per year in a comprehensive smokefree 2030 programme. Options to fund this include a 'polluter pays' levy.
2. Raise the age of sale of tobacco by one year, every year.
3. Offer vaping as a substitute for smoking, alongside accurate information on the benefits of switching, including to healthcare professionals.
4. The NHS needs to prioritise prevention with further action to stop people from smoking, providing support and treatment across all of its services, including primary care.

Khan concludes in his report that: "Taken together, and if implemented in full, I believe these actions will get the government to its 2030 target and then lead to a smokefree generation. It is this level of comprehensive approach which will allow us to change the smoking landscape and secure a smokefree society for future generations whilst targeting our most vulnerable target groups to support them to quit smoking and ensure we reach our target of 5% smoking prevalence by 2030". 

Gateshead has officially endorsed the recommendations set out in both the APPG report on smoking and health and The Khan review. As a Council we continue to work towards our vision for a smokefree society, free from the burden of tobacco addiction and the devastating impact it has on our local populations and health and social care services. In October 2023, theDepartment of Health and Social Care (DHSC) published a policy paper called 'Stopping the start: our new plan to create a smokefree generation' (opens new window). In this, the government sets out an intention to create the first 'smokefree generation' through the introduction of a range of proposals. 

These include: 

• increasing the age of sale for tobacco year on year so that someone born in 2009 will never be able to legally buy tobacco
• funding for initiatives to improve smoking cessation support
• increased funding for LA led stop smoking services and the national vaping 'Swap to Stop' scheme
• proposals on the regulation of e-cigarettes. 

Of these measures, the proposal to increase the age of sale has the potential to be very effective in cutting of the supply of new smokers to the TI. While these proposals are to be welcomed, they fall short of a national comprehensive TC plan. A consultation on these proposals ended on 6 December 2023 and further details are awaited. 

E-cigarettes 

E-cigarettes or vapes have generated media interest recently and so it makes sense to briefly set out the current evidence-based position at this point. While we can't say that vaping is risk-free, we do know that it is far less harmful than smoking tobacco. They have been available for more than a decade, have become the most popular way to quit smoking, and there is strong evidence that they are an effective quitting aid. This is confirmed by an ongoing research study³⁰ which looks at the evidence in several areas related to vaping.

This found that in the short and medium term, vaping poses a small fraction of the risks of smoking, but vaping is not risk-free, particularly for people who have never smoked. 

We know that vaping products remain the most common aid used by people to help them stop smoking and more people successfully quit when using vapes compared with traditional nicotine replacement therapy or behavioural support alone. Despite this, misunderstandings about potential harms persist and around a third of adults believe vaping is as harmful or more harmful than smoking. This is worrying, as it means that people who would benefit from using vapes to reduce and quit smoking, could be missing out whilst continuing to experience harms and damage to their health from tobacco smoke.

We need to be clear that for those who have never smoked, developing a nicotine addiction through vaping would not be in their best interests. Vapes are not risk free and we do not yet know the long-term effects of many vape ingredients³¹. Therefore, vapes shouldn't be made appealing, or marketed towards young people, and adults who do not smoke. Tobacco companies are involved in the e-cigarette and vaping market and have promoted and advertised these products in several ways including through social media, paid celebrities, and influencers³². These are proven TI marketing strategies which appeal to young people³³.

There is also concern that this issue provides a route in for the TI to influence policy, where it was previously excluded as part of tobacco control. (University of Bath Tobacco tactics - e-cigarettes (opens new window)) The WHO Framework Convention on Tobacco Control includes the need to prevent the TI from influencing health and tobacco control policy due to their vested commercial interests³⁴.

Regarding young people, use of vapes was estimated to be 8.6% of 11 to 18 year olds in 2022, which is an increase on previous years³⁰, but a recent study looking at 16 to 24 year olds found little evidence that vapes are a gateway to smoking, as smoking rates would be expected to change line with vaping rates over time³⁵.  In reality, youth smoking rates are at an all-time low with 88% of secondary school (11 to 15yrs) pupils having never tried smoking and 3% estimated to be current smokers in 2021³⁶. Most young people that have never smoked, haven't vaped, and it is important to remember that while some young people will try vaping as the likelihood of risk-taking behaviour increases with age, in the recent past that behaviour would likely have been smoking.

It's illegal to sell vapes to under 18s and proposals to strengthen regulations around e-cigarettes in the recent government announcement are broadly welcomed. In Gateshead, Trading Standards officers work on preventing and stopping underage sales of vapes and alcohol. In 2023, local officers identified vapes specifically targeted at children and seized large quantities of teddy bear shaped vapes. 

In summary:

• Vapes pose a small fraction of the risk of smoking but are not completely risk-free. 
• For those who smoke, switching to vaping could help them successfully quit. 
• To protect their health, those who have never smoked shouldn't vape. These products shouldn't be marketed or promoted to children and young people, and those who don't smoke.
• Vapes are not intended to be used by children and it is illegal to sell them to under 18s

References

25. Chaiton, M. et al (2016). Estimating the number of quit attempts it takes to quit smoking successfully in a longitudinal cohort of smokers. BMJ attempts to quit smoking (opens new window)

26. Annual Population Survey (APS) 2019: Smoking Prevalence in adults (18+)- Current Smokers Local Tobacco Control Profiles - Data GOV.UK HID - tobacco control data (opens new window)

27. HM Government (2019). Advancing our health: prevention in the 2020s - consultation document. GOV.UK - Advancing-our-health-prevention-in-the-2020s (opens new window)

28. Office for Health Improvement and Disparities (2022). The Khan Review: making smoking obsolete.GOV.UK Khan review making smoking obsolete (opens new window)

29. ASH - delivering a smoke free 2030 (opens new window)

30. Office for Health Improvement and Disparities (2022) Nicotine vaping in England: 2022 evidence update main findings.GOV.UK - HID vaping England 2022 evidence update (opens new window)

31. GOV.UK - Chief Medical Officer for England on vaping (opens new window)

32. University of Bath. Tobacco tactics - E-cigarettes. Tobacco tactics - e-cigarettes (opens new window)

33.  Smith MJ and Hilton S: Youth's exposure to and engagement with e-cigarette marketing on social media: a UK focus group study (opens new window)

34. FCTC - WHO (2013) Guidelines for implementation of Article 5.3. (opens new window)

35. Beard, E et al (2022) Association of quarterly prevalence of e-cigarette use with ever regular smoking among young adults in England: a time-series analysis between 2007 and 2018. Addiction, 117 (8), p 2283-2293. Wiley - e-cigarette use among young adults 2007 - 2018 (opens new window)

36. NHS - smoking drinking and drug use among young people in England 2021 (opens new window)