DOCKRELL, Martin, Tobacco Control Lead, Public Health England

NEWTON, Professor John, Director of Health Improvement, Public Health England

O'CONNOR, Rosanna, Director, Alcohol, Drugs & Tobacco, Public Health England

[19:41]

CHAIR: Thank you very much for joining us—this morning your time and evening our time, of course. The reason that we're delighted that you've been able to talk to us today is that our health committee, as you may know, is conducting an inquiry into e-cigarettes, which, by way of background, are, essentially, illegal in Australia. We've been fascinated by the approach of regulators in the United Kingdom and also the health sector in the United Kingdom, which, in some respects, seem to have a significantly different view on this issue than the health sector in Australia. We thought it might be useful to have a chat with you and to get your experience in the United Kingdom with e-cigarettes in relation to both the health issues associated with e-cigarettes and the issues surrounding the marketing, regulation, control of sale and so on. Does that make sense?

Prof. Newton : Yes. Thank you very much. We're delighted to be able to help with your inquiry. As you say, I think we have some experience, which we would be very happy to share. In fact, we have huge respect for what you've achieved in Australia in the area of tobacco control in the past—things like plain packaging. We very much look to you for leadership on this, so it's a pleasure for us to help in any way we can.

CHAIR: I should state that we've entered this inquiry with open minds. We're not pursuing a particular agenda at this stage. These proceedings are considered a private and confidential briefing for our committee. We do, however, record the transcript. Hansard record the meeting, and a copy of the Hansard transcript will be provided to you subsequent to today's discussion. It is possible that the committee may be so minded as to consider publicly releasing the transcript at some stage, but we would consult you before we did that.

Prof. Newton : That's absolutely fine.

CHAIR: Before asking whether you'd like to make an opening statement about how you perceive the progress of regulation in relation to e-cigarettes in Britain, I might get you to start by describing what the mandate of Public Health England is and what its role is.

Prof. Newton : Fine. I'm very happy to do that. Also, we sent you some slides and papers. Do you have access to the slides, or should I just talk around it?

CHAIR: We're getting them now.

Prof. Newton : While you're doing that, let me give you a thumbnail sketch of Public Health England.

CHAIR: We all have the slides in front of us now.

Prof. Newton : Excellent. They're for reference, but it's good to know you've got them to refer to. Public Health England was set up in 2013. We are a pretty comprehensive national public health agency. We cover the full range of health protection functions and health improvement. We run a large number of laboratories. We have a considerable research set-up. We also run a number of functions such as disease registration. We run the cancer registers and the congenital anomaly registers. We have a significant role in supporting drug and alcohol treatment services, particularly my colleagues here today, who are involved in that area. We also have a significant role in running both cancer and non-cancer screening programs.

We are a government agency. We are an arm's-length body of the UK Department of Health. We are civil servants, although many of us are professionals. Like your colleague Mike, I'm a doctor as well as a civil servant, and I think that's one of our assets—that we have scientists and professionals on board. We speak to ministers. Yesterday we had a meeting with our public health minister explaining where we are in our general strategy. We have very good relationships with our ministers, but we are an independent advisory body. We use a lot of science. We do many evidence reviews and we publish over 600 articles in the peer-reviewed journals every year. We live and die on the validity and the independence of our recommendations, which are based on evidence, which is a really a good introduction to this area and how we come to be where we are in terms of e-cigarettes.

The other thing that I was going to mention is that we have a toxicological function. We have a group based in the Centre for Radiation, Chemical and Environmental Hazards, in Public Health England, who provide government advice on, amongst other things, toxicology.

Martin Dockrell : There is also the National Poisons Information Service, which records incidents such as accidental and deliberate poisoning from nicotine, so we're well on top of that data too.

Prof. Newton : Yes. That's a brief sketch, but obviously there is a lot more detail behind it. We have about 5,000 staff. About a thousand of them are in my directorate. That's probably enough for context—possibly too much!

CHAIR: John, did you want to run through the slide deck?

Prof. Newton : Yes, let me do that.

CHAIR: I see from page 2 that you've been following our inquiry to some degree.

Prof. Newton : We have, yes—and, indeed, some of the news reporting as well. I have a few things to say on the inquiry. I'll be brief, and we'll take questions. We were concerned that some of the material that you have been presented with was misleading in relation to the position in the UK. I don't want to labour this. We sent you a note that gives chapter and verse. The headlines are that it would be wrong to think that what we're doing in the UK, particularly in relation to regulation, is different from what is going on in the rest of Europe. We are the same: we're all subject to the European directive, and we have implemented the directive to the letter. We have more regulation on e-cigarettes than any other country other than those that have a complete ban.

We don't have a particularly clinical approach. For example, we've now introduced plain packaging. We take a very holistic approach. We very much value our specialist smoking cessation functions, but they are only one element of the tobacco control program.

There's a lot of nonsense talked about—this 95 per cent figure. It's getting beyond a joke really. We are very clear that this is just one of the figures that we have used, and there are plenty more. We say what really matters is the evidence underlying this figure from the Nutt report. Frankly, there's a lot of nonsense being said about what's going on in the UK. Some of it's accidental. Some of it, dare I say, appears deliberate. The thing that really upsets us is that people are not necessarily giving straight answers to straight questions. Perhaps I'll stop there.

Moving onto the data, I'll just quickly run through some of the key headlines. The really good news is that smoking rates in England are falling faster—in the last two years, we've had a reduction of 2.5 per cent, so we now have a smoking prevalence of 15.5 per cent, which makes us the second-lowest in Europe. We're absolutely delighted by that, particularly when you consider that we're starting from a relatively low base. We were anticipating things getting harder in terms of reducing smoking. So there's good news there.

In terms of the slide, let me just go onto the regulation. I made the point earlier that e-cigarettes in the UK are tightly regulated, and we've given you a little bit of detail on that. They are the sorts of things that you're probably familiar with, having done your inquiry. The whole objective of our regulation is to, firstly, ensure that the e-cigs themselves comply with standards of safety either as a medicinal product or as a consumer product; and, secondly, that they're only available to adults and to smokers so that they're used in the context of switching from smoking tobacco to using e-cigs.

I don't think I'm going to dwell on the regulation—we can come back to it, if you like; it's just to say that we have implemented the full range of regulations.

We've got some slides on the use of e-cigarettes. We think there are about three million people in the UK using e-cigarettes. They are either smokers or ex-smokers. The use of e-cigarettes by nonsmokers is extremely small—it's less than one per cent.

CHAIR: John, just because you're helpfully not going through in detail each slide, when you jump ahead, would you mind just giving us a page reference.

Prof. Newton : I think we're on page 13. If you've got the longer data, page 13 should be:

Most vapers have stopped smoking (and never smokers rarely vape)

Yes?

CHAIR: That's correct.

Prof. Newton : Great. We're particularly concerned about young people. We haven't got a slide on this, but smoking rates in young people are declining rapidly, and the use of e-cigarettes by young people—obviously, there are some who are experimenting but relatively few young people are using e-cigarettes.

Martin Dockrell : That's slide 14 and 15 for you there in Australia. The next slide is slide 16.

Prof. Newton : So then I think we're moving onto the issue of toxicity and, obviously, like everybody else, what we'd really like are long-term studies showing what happens to people who use e-cigarettes long term. But, clearly, as a new technology, that's not going to happen for a while. What we are doing is taking the approach we take to any potential new agent, new hazard, and we're looking at the components of the vapour, that e-cigarette, users inhale. We know a lot about what's in the vapour, and you can do comparisons of the levels of compounds which we would expect to see in cigarettes and those that you find in e-cigs. All the evidence is that, although obviously there's nicotine in there and the nicotine is delivered at a useful concentration—equivalent to cigarettes or other nicotine replacement—the level of toxic substances and potential carcinogens is much, much lower. It varies on the different compound, but it's between nine to 450 times lower in e-cigs than in smoking cigarettes.

Slide 20 has a nice graphic which illustrates this. This is just one toxic agent. The left-hand side of the slide compares cigarettes, nicotine replacement therapies and e-cigarettes in terms of their delivery of nicotine, and you can see that they are all comparable. If you look at the delivery of potential toxic substances, the level from e-cigarettes is low. This, I think, is the key finding. What we are doing is extrapolating from that to form our views on the safety of e-cigarettes. We have a few slides here. We will now move to slide 24.

Dr FREELANDER: Before you move on, could you tell us whether there have been any reported incidents of nicotine overdoses in children, for example, getting hold of the solution or in people overusing the inhalers?

Prof. Newton : Martin mentioned the poisons survey. That is where we get that data from.

Mr Dockrell : We have examples of a small number of children being exposed. There are roughly 150 calls per year to our National Poisons Information Service, of which under 10 are cases of severe toxicity. There have been no reported cases of fatal poisoning in children in the UK so far. We have had a number of attempted suicide by nicotine—all failed.

Dr FREELANDER: Thank you.

Prof. Newton : The next issue to cover is the effect of passive exposure or environment exposure. This is really negligible. We perhaps don't need to worry about the detail of this slide, but there are data that show the dispersal of the vapour from e-cigarettes compared to dispersal of smoke from smoking tobacco. The smoke from tobacco smoking is much more dispersed than the vapour from e-cigs—and, of course, the point is that the vapour from e-cigs is a pretty benign substance. It is equivalent to what people use on stage to create a mist. So it is essentially water—

Mr Dockrell : We are looking at slides 23 and 24 in Australia.

Prof. Newton : The evidence on the risk of passive exposure to e-cigarettes is that it is not a health consideration. Moving on to slide 25, we wanted to point out that the views in England have developed and, having looked at and reviewed the evidence and considered this deeply, we are not the only organisation that has these views. They are very much shared by the Royal College of Physicians, and they have put this on record in their report published in 2016. The Royal College of Physicians—I'm not sure whether you are aware—have been at the heart of tobacco control since the 1960s, and they are a very significant organisation who have come to their own independent view about this, and it is extremely similar to our view.

I will now move on to some data about the use of e-cigarettes and their effectiveness as a quitting method. Slide 26 shows the rapid uptake in e-cigarette use around 2013. We know that e-cigarettes are the most popular quitting aid among smokers. That's without any promotion by us; smokers themselves have chosen them. Slide 27 shows that, if you combine the most popular aid with the use of a stop-smoking service, the effect is quite dramatic. The use of e-cigarettes alongside a formal smoking cessation service produces quit rates of up to 67 per cent over four weeks.

Mr Dockrell : I will just explain that UNCP is the NHS code for e-cigarettes—unlicensed nicotine containing products. Three of the top four red categories are e-cigarettes.

Prof. Newton : Clearly, this is not randomised control trial data, although there are some randomised control trials reported, and others which are underway. This is just reporting what's actually happening in the clinics around the country. This is, if you like, real-world evidence with all the strengths and weaknesses that follow from that. I don't want to go into a huge amount of detail on all these slides, except to say that we do think there is convincing evidence from around the world that electronic cigarettes do help smokers to quit. We think we've got about 1½ million vapers who have used e-cigarettes to quit smoking, which is a very significant health benefit for the population of England. Of those, we think about three-quarters of a million are now no longer using either tobacco or e-cigarettes. It's not that people get addicted to the nicotine in the e-cigarettes once they've stop smoking.

Mr Dockrell : That's in addition to the 1.5 million vapers who have stopped smoking. There is an additional three-quarters of a million who have stopped smoking and vaping.

Prof. Newton : Okay, so that's an even bigger number. We do surveys of public attitudes around tobacco and e-cigarettes and we know that, amongst smokers and the general public, there's a misconception that e-cigarettes are as dangerous as smoking tobacco. Clearly, as we know, there is some debate about how dangerous they are, but what we do know is that they are much less dangerous than smoking tobacco and that's really the essence of our position. We are trying to get that message across to the general public and to smokers in particular.

I've run through the main issues, so, in conclusion, I want to emphasise the fact that in the UK we have some of the most rigorous electronic cigarette regulations certainly in Europe and we think in the world. We've got a long history of tobacco harm reduction and we see e-cigarettes as just one part of that. We think it's consistent with everything else we're doing. The e-cigarettes used in the UK have a very low level of toxicants and we think we are safe to reassure smokers that it's much safer to switch from smoking cigarettes to using e-cigarettes. We have a good deal of evidence that smokers are using e-cigarettes to quit and that we are actively trying to communicate the relative safety of e-cigarettes to smokers. But at the same time we remain cautious and we are monitoring the situation closely and reviewing the evidence, which, I have to say, is all continuing to reinforce the position that we've adopted. In many ways the evidence is becoming more conclusive as we go on. I will stop there, and I am very happy to take any questions.

CHAIR: Thank you very much. That has been very helpful. Before we move onto questions can I just check on the two documents—the pack of slides and also the note on errors. Are you happy for them to be incorporated into our exhibits for this inquiry?

Prof. Newton : Yes, absolutely.

CHAIR: Fantastic. I might just start off with two questions. Firstly, I am interested to know whether you've had any contact from your peers or counterparts in Australia to discuss this issue and whether you've had the chance to form a judgement as to why the medical profession here seems to be far more cautious than we've seen in the United Kingdom. Secondly, flowing from that, probably the two most common threads for those who have urged us not to recommend the relaxation of rules in relation to e-cigarettes on health grounds are, firstly, the simple argument that we need 20 years of studies, in much the same way as the immediate health impacts of cigarette smoking took some time to manifest themselves; and, secondly, that in a lot of the products, either through the flavourings or the colourings, there are chemicals that could have a deleterious health impact. In the United States there are literally hundreds and hundreds of different varieties of flavours of the capsules, if I can put it that way.

Prof. Newton : In regard to the first one—I will ask the team in a moment if we've had specific contact from colleagues in Australia—the general issue is the same here. There are a minority of clinicians who are opposed to e-cigarettes in the UK. We have regular discussions with them, some of which are published in TheBMJ. The first thing to say is that everyone is starting from a position of wanting the same thing. People are genuinely concerned about safety. There are two things which we need to knock on the head. The first thing is that there's a very strong conspiracy theory that all the people who support e-cigarettes are in some way in the pay or being subliminally influenced by the tobacco industry. That is simply not the case. The idea that anybody sitting around this table in London is in any way influenced by the tobacco industry is a joke. The idea that the Royal College of Physicians is in some way influenced by the tobacco industry is also beyond response. But there is a genuine concern that the tobacco industry is in favour of this and, therefore, we ought to be against it. I appreciate that we do need to be very cautious on that ground. We would be having a completely different discussion if we were talking here about heat-not-burn tobacco products, but let's leave that one for now.

There is this general problem that many of the people who are opposed to e-cigarettes are starting from a position that any smoking is bad and we need to have a firm line. It probably goes back to a more generic discussion about harm reduction, and many similar discussions were probably had at the time of management of HIV and drug use. Australia has an excellent, admirable record in the implementation of harm reduction policies —for example in the management of HIV and drug use. I'm sure that all the same arguments were played out there. It does come down to one's attitude to the precautionary principle. We think that, rather than waiting 20 years to get definitive evidence, we have to make the best decision on the evidence that's available now, and that points us towards cautious use of e-cigarettes.

On the point about flavours, you're absolutely right. We need to make sure that the products themselves are regulated so that manufacturers only put in things which we know about. We have to, again, return to our toxicological colleagues to advise us based on all the mass spectrometry and the things that can be done to assess the likely impact of these chemicals. It'd have to be cautious. We also have to make sure that we're only recommending e-cigarettes as an alternative to smoking tobacco, which we know is killing 70,000 people a year in England. That's the context in which we're making these decisions.

Rosanna O'Connor : Martin will probably tell you about contact with Australian colleagues, but it might be useful to say that we take this area very seriously, as does the public health minister. We have been commissioned to revisit the evidence on e-cigarettes on an annual basis for the duration of this parliament. The update of our evidence review will be ready towards the end of this year, beginning of next. In that evidence review, we will be looking at the flavourings, as you mentioned. We will have a specific focus on that aspect in this next evidence review.

Martin Dockrell : On the subject of contacts with Australian colleagues, yes, as you would hope, we have been in fairly regular contact. I particularly enjoy my exchanges with Professor Chapman on this and a range of issues. On some things, like standard packaging, we're extremely well aligned. On others, we're still thrashing through the evidence and the issues. We've also been in contact with Dr Colin Mendelsohn and Professor Coral Gartner, who are among your leading tobacco harm reductionists, and others. We've been following this fairly closely.

You asked why we think the view in Australia is different from the view in the UK. There's a spectrum of opinion in both countries, it has to be said, and there are certainly those in the UK who would agree with Professor Chapman—though a dwindling minority, I think. In Australia, similarly, there's a spectrum of opinion. Colleagues I respect enormously, Mike Daube and Simon Chapman, have led the Tobacco control movement in Australia and have very strong opinions. I think the tobacco control movement in various countries is particularly disciplined, and that's why it has been so effective.

On the question of flavourings and the wide number of flavourings that are available, this is one of the strongest arguments, in my view, for regulation. In the UK and, indeed, across Europe we have a range of flavourings which are permitted. Member states can then be even more restrictive if they choose. Some members states only permit tobacco flavouring. It's been argued, however, that flavourings are one of the principal success ingredients of electronic cigarettes—they taste much better than cigarettes. They taste fresh, sometimes fruity and sometimes sweet, and there is strong evidence that flavours have helped large numbers of smokers switch completely and stay switched. There isn't really any evidence that flavourings have attracted non-smoking youth into regular e-cigarette use. That case doesn't exist anywhere in the world.

Mr GEORGANAS: We heard some evidence here that there perhaps are some dangers in teenagers taking up e-cigarettes and then progressing to cigarettes. In your experiences over there looking through this area, has there been any evidence or anything of that sort in the UK that you can point towards?

Prof Newton : Clearly, that is a concern. The evidence from the UK—and we accept that some of this is specific to certain settings—is that that is not the case. There are, clearly, some teenagers who have tried. We do regular surveys and we have pretty good data on this. We know that there are some young people who are trying e-cigarettes, but the number of young people who are using e-cigarettes regularly is very small, and there is no evidence that the use of e-cigarettes is encouraging young people generally to smoke. It is quite the opposite, in fact: we are finding smoking rates in young people going down at the very same time that the use of e-cigarettes in adults is going up, strongly suggesting that that is not the case.

Martin Dockrell : Slides 14 and 15 refer, and I particularly draw your attention to slide 15. That tells you which young people are using e-cigarettes. You can see that the greatest use is among the very small number of teenage smokers that we have in the UK. If you look at the bottom line, that represents regular vaping among youth who have never smoked, and it is 0.4 per cent. Just this summer we published with colleagues a report that combined five big surveys of a total of 60,000 young people. All the surveys were consistent in that finding.

Mr ZAPPIA: Professor Newton, you said in your comments earlier on that you are doing what you can to get the message out that e-cigarettes are less harmful than tobacco cigarettes. Can you give me some examples of what you are doing to get that message out.

Prof Newton : For example, we run a very successful campaign called Stoptober, where we encourage smokers in England to take the 28 day challenge and stop smoking for 28 days. We used a variety of social media, TV adverts and so on to launch that. This year, for the first time, we had film showing people using e-cigarettes, to normalise the use of e-cigarettes among that particular group of smokers who want to quit. It's a finely targeted message: if you are a smoker, e-cigarettes are worth considering alongside other nicotine replacement substances, and they are very much safer than continuing to smoke tobacco. We use social media a lot, but also blend it in to our general campaigns.

Mr ZAPPIA: I have one more question. Have there been any unintended consequences since e-cigarettes have been used in the community?

Prof. Newton : I think the simple answer to that is no. We monitor poisons incidents. We have the odd episode of a pack catching fire or something, but they are minimal—the batteries and so on. Martin may wish to add something here.

Mr Dockrell : We have had a small number of electrical shortages. I guess the biggest surprise has been that when we introduced standard packs over the last year we saw a much bigger shift away from smoking than we expected. Quit attempt successes in the UK are at unprecedented high, with one in five quit attempts in the last six months having been successful. The only bad news is that there's an increasing harmful misperception that e-cigarettes are at least as harmful as smoking. The reason that is harmful is that smokers who believe that are less likely to try e-cigarettes and much less likely to switch completely. So, in effect, these scare stories are scaring smokers into staying smokers.

Prof. Newton : To answer your question, Tony, it hasn't made it any more difficult to enforce smoke-free legislation. It is very easy to distinguish somebody using an e-cigarette from somebody who is smoking tobacco. Of all the various things mentioned none of them have come to pass. I can't think of anything.

Rosanna O'Connor : I suppose one marginal unintended consequence might be that smoking rates are going down in this country and local authorities are under pressure in terms of their budget and see the smoking cessation and tobacco control effort as having been a huge success. With e-cigarettes coming along and smokers clearly choosing to use them as a way of helping them stop smoking, I think it has possibly added to a perception at a local level that local authorities can cut back stop-smoking services even further, because there is an option on the market that smokers can use and choose for themselves. I think John said earlier that the evidence shows that the use of e-cigarettes along with professional stop-smoking support is the way in which people manage to stop smoking most successfully. So we are attempting to guard against the cutbacks in local stop-smoking services. But I guess it could be one intended spinoff, couldn't it?

Mr Dockrell : The government is committed to reviewing the e-cigarette regulations within this parliament and basing that review on the evidence update of Public Health England. Certainly there is reason to think that our regulations need fine-tuning as the evidence emerges. One of the downsides of having a maximum nicotine concentration is that, to get the desired amount of nicotine, people might take more of the other things—for example, the flavourings. Like to get enough gin from your gin and tonic, if you only had a single gin, you might drink twice as much tonic.

CHAIR: On that note, it's probably time for us to go and have a gin and tonic. Thank you very much. Your evidence has been really helpful, and I'm very grateful that you have been able to make your time available. Also, thank you for the two written documents. Our committee secretariat will provide you with a copy of the Hansard transcript. Once you have seen that, if there is anything that you would like to add or if there are any errors, please let us know as soon as possible. We hope that you continue to watch the progress of our inquiry.

Prof. Newton : Thank you very much. If there's anything more we can do, just let us know. As I say, we have a lot of respect for what Australia has achieved in this area. We do think you have an opportunity in Australia, and we watch you with interest. Again, if there is anything that we can do to persuade you that we are not corrupt, misled or deluded, let us know.

CHAIR: Thank you very much for your time. The committee has accepted that the two documents be included as exhibits.

Committee adjourned at 20:20