For those of us who expect a fairly quiet August, this last week has been rather busy with various releases on tobacco and e-cigarettes. (Apologies I know I should call them Electronic Nicotine Delivery Systems but I’m using e-cigarettes for convenience.) The upshot is even less people smoking, but a strident debate which seems to produce heath rather than light over where to next.
On Tuesday 14th, Thorax published a small experimental study, fairly well conducted, which suggested that there were inflammatory effects of vaping liquids in vitro and this meant e-cigarettes were not as safe as people think. Reactions to this from the Science Media Centre are useful to read. This is, in one sense, hardly news. Other lab studies have shown similar results (even though this present one feels much better designed than some of the junk science reported.) Public Health England were then drawn into comment on some fairly alarmist reporting in the media and shed some valuable light on what looked like fast becoming a fearful debate. One lab study does not undermine all the careful work to date.
On Thursday, the new figures for smoking cessation in England were published by NHS Digital.
And today (Friday 17th August) the House of Commons Science and Technology Committee published the report of its inquiry into E-Cigarettes which welcomed their potential public health benefit. The ASH response to this was one example of welcome. Today will see contrasting voices Let me try to do justice to this report (which needs careful reading) in a paragraph:
- The misconceptions about e-cigarettes mean we miss opportunities to tackle smoking related deaths, and still overlook the public health benefits of e-cigarettes too often.
- E cigarettes should not be treated in the same way as conventional cigarettes
- Government should consider new ways of regulation to allow more advertising and use in public places as a “relatively harmless option”.
- The risk for smokers of continuing to smoke tobacco is MUCH greater than the uncertainty about long term use of e-cigarettes.
- A long term research programme, which Public Health England should oversee, is required to gather further information and evidence on e-cigarettes and heat not burn products.
There has been a lot of noise around this, including press releases and comments from various quarters , and some (not all) of the media reporting has been poorly informed at best and alarmist at worst.
So, what do we make of all these goings on? Well my take would be as follows, and it falls into two parts. One is on e-cigarettes and the other on smoking trends.
1: E cigarettes
- Nobody is saying e-cigarettes are 100% safe, but all the evidence suggests they remain much safer than smoking and are a good harm reduction choice. Overwhelmingly most vapers are still ex-smokers
- Vaping is not the same as smoking (PHE and many vapers themselves point this out) and shouldn’t be treated like it
- There remains a cultural challenge on acceptability of vaping we have to address
- There remains still a great deal of misconception and misinformation that vaping is as risky or more risky than smoking.
- We still don’t know about the long term effects, but from what we do know we should not use that to allow ourselves to take extreme versions of precautionary approaches, in the face of the more than sufficient evidence which tells us e-cigarettes can and do save lives now. That flies in the face of harm reduction approaches.
- Use of e-cigarettes by young people and never smokers remains very low indeed. So the much feared gateway effect still hasn’t been found.
- ASH released data this week (week ending 17th August) which says that ” youth (11-18 year-old) use of e-cigarettes in Great Britain is rare and largely confined to those that already smoke tobacco cigarettes.
- The findings come from an annual YouGov survey, commissioned by ASH, which examines youth use of e-cigarettes in England, Wales and Scotland (Great Britain).” Just 2% of young people use e-cigarettes at least weekly while another 2% use them occasionally (once a month or less).
- There is a low level of experimentation with 12% of young people having tried e-cigarettes once or twice. Most young people haven’t tried e-cigarettes ever (76%) while 7% haven’t heard of them at all.
So for me it’s a case of keep on going with reaping the benefits of e-cigarettes, I think. That doesn’t mean we stop watching the evidence.
Meanwhile this new Select Committee report challenges us not just to look at its recommendations, but to look at the culture of vaping acceptability and also counter misconceptions. Time to reflect on what we should, and should not be doing. That doesn’t mean we are at risk or re-normalizing smoking. That Bogey Man, like the Gateway fear, has not been realized either.
The switch to vaping is and remains an important contribution to saving lives otherwise taken by tobacco. Nobody is pretending it’s 100% safe. But to reject adoption of a risk reduction approach given the lethality of cigarettes is unethical. And the assumption that current smoking cessation is sufficient on its own is unrealistic. Tobacco still kills, let’s use ALL the tools at our disposal which reduce harm and risk.
2: Smoking Cessation Service Figures
This brings me onto the smoking cessation figures. I’m not going to repeat the debate currently raging, but here’s my take on what has been happening. NHS Digital data on NHS Stop Smoking Services in England from April 2017 to March 2018, shows the number of people who stopped smoking after accessing these services has fallen by 11 per cent on the previous year. The number of people setting a quit date has fallen from a peak of over 816,000 in 2011/12 to under 275,000 2017/18. The mid-point in 2014/15 was just over 450,500.
So, numbers are down. Some people point to this as evidence to cut smoking cessation services altogether because they are not needed or totally ineffective (I disagree). ASH meanwhile calls for more investment (not sure I agree there either. What we need to do is point out we need the right level of investment in the right places.)
Hazel Cheeseman, Director of Policy for Action on Smoking and Health (ASH), said:
“Local authorities remain underfunded for stop smoking services and this can be seen in today’s figures. The continued downward trend in treatment for smokers is bad news for people with higher levels of addiction and for those from the poorest communities who often need more help to quit. The Government must find a solution or else risk health inequalities widening. We want to see the tobacco industry pay for the harm they cause. Government should place a levy on the industry to fund these services.”
I agree with making the tobacco industry pay. But the dialogue around all this seems to continue to be cause and effect (services = reduction in prevalence) on both sides. I’m not sure I buy either of these sides. Why do I say that?
First, smoking cessation does not equal tobacco control. It’s much wider. We should remember that smoking in England is at an all time low (ASH itself said this in July 2018) for some people but remains high in poorer people and pregnant women. For those populations, the cuts have worst consequences.
But, the fact some people remain disproportionately affected accepted, the number of people smoking in England has fallen to 14.9 per cent, meaning there are 6.1 million smokers in England – one million fewer than in 2014, based just on this data. At the same time Councils’ public health budgets are being cut by £600 million between 2016/17 and 2020/21. Cuts have consequences, but it looks to me like Directors of Public Health are, coupled with a social trend anyway, trying to mitigate these.
That doesn’t mean we can say goodbye to smoking cessation services. But it does call for a bit more rigorous thinking than some of what has been going on this year.
Taking Stock: Tobacco Control and Smoking Cessation within it
If we take a total tobacco control approach, there is considerable debate over how much at population level the contribution to reducing smoking is made by tobacco control measures as a whole, and how much smoking cessation services contribute to reducing tobacco prevalence. We need to refresh our knowledge and thinking on this so we understand what measures we take going forward.
Second, numbers of people switching to vaping seem to be continuing to increase, as far as the various data sources we have suggest.
Third, five local authorities in England no longer provide services but the impact on the national quit rates and smoking prevalence does not appear to be significant – to me at any rate -or to prove the cause and effect people on both sides of the debate claim. We need to understand what trends are going on here and that needs light not heat. The debate – to such extent as it has started – has not allowed nuance.
Fourth, we recognize, from the recent Royal College of Physicians Report, that the NHS needs to do more on getting people using its services to quit smoking. Doing more of this would strongly help targeting people who still smoke. Councils are trying to target people, it is right that the NHS did more. That should not be about playing musical chairs with shrinking budgets.
The Local Government Association said “Councils remain committed to helping smokers quit and spend almost £100 million each year on these services and wider tobacco control. However, this is increasingly challenging due to central government reductions to the public health budget which is used to fund stop smoking cessation services and which will only compound acute pressures for NHS services further down the line.” We need to think through how best to do this, not preserve a service model we can no longer afford and where the prevalence trends suggest we need a rethink (even if only to much greater targeting) anyway.
Where does all this leave us?
It seems to me we are in a significant period of social change around smoking, which has multiple factors. Dare I hope that in England, the prevalence of smoking continues to decline partly because of all the historical work done and continuing to be done on tobacco control and social norms around not smoking, and partly because of the move of people to vaping? Smoking is becoming less acceptable. Smoking cessation services in and of themselves, while important for some people, are not the main contributor to this trend.
So we are left with sub populations of smokers who we still need to work on. These are the poorest people often, but also people with most difficulties and challenges giving up. We do need the right level of investment in these, but the government made the decision to cut public health budgets. The public health cuts have consequences, and they will cost the NHS money. Cuts to Public Health are cuts to the NHS. Every case of bronchitis from a smoker who couldn’t get help is a case of cost to the NHS caused by the government’s own decision to cut prevention and public health budgets. That is the plain truth.
First, we need a proper reappraisal of where we go next with what money we do have
Second, the NHS must do more to reap the benefits for its own services of getting people off tobacco.
Third, it seems to me we need to return ourselves to the focus on tobacco control as a whole, a social trend in reducing demand for tobacco. Various components contribute to this, including supporting moving to vaping, targeting smoking services, population measures like restricting smoking in public places and so on all need to be part of our focus.
I think it’s time to nuance the debate, and reflect a bit more. Protecting smoking services as they once were is becoming impossible – cuts have consequences – what can we do that will have impact for the next ten years? We need to think. And fast.
The Challlenge going forward