The Department of Health (UK/England) today released its tobacco control plan for England: Towards a smoke-free generation: tobacco control plan for England (PDF)
The embrace of vaping and other low-risk alternatives to smoking runs through the text. This is probably the first significant government policy paper anywhere that recognises and pursues the opportunities of tobacco harm reduction, rather than defining these technologies as a threat to be suppressed. For that, the Department of Health and its allies deserve considerable credit.
Some extracts on tobacco harm reduction. Quotes from the plan are in blocks…
On targets focussed on smoking…
The objectives of the tobacco control plan are to:
- reduce the number of 15 year olds who regularly smoke from 8% to 3% or less
- reduce smoking among adults in England from 15.5% to 12% or less
- reduce the inequality gap in smoking prevalence, between those in routine and manual occupations and the general population
- reduce the prevalence of smoking in pregnancy from 10.5% to 6% or less
The aim is to achieve these objectives by the end of 2022.
The focus on smoking, rather than on nicotine use or other goals is appropriate from a public health perspective, because it is the smoke that causes the harm. The way the targets are specified does not, therefore, preclude the use of reduced-risk tobacco and nicotine products to achieve the smoking-related targets.
On in-principle support of harm reduction
4. Backing evidence based innovations to support quitting
We are committed to evidence-based policy making, so we aim to:
• Help people to quit smoking by permitting innovative technologies that minimise the risk of harm.
• Maximise the availability of safer alternatives to smoking.
The best thing a smoker can do for their health is to quit smoking. However, the evidence is increasingly clear that e-cigarettes are significantly less harmful to health than smoking tobacco. The government will seek to support consumers in stopping smoking and adopting the use of less harmful nicotine products.
This embraces the opportunity of new technologies instead of defining them as threat. I suspect this is also a subtle rebuke to the Chief Medical Officer, who has consistently fought an evidence-free rearguard action against “innovative technologies that minimise the risk of harm“.
On indoor vaping
Public Health England has produced guidance for employers and organisations looking to introduce policies around e-cigarettes and vaping in public and recommend such policies to be evidence-based. PHE recommends that e-cigarette use is not covered by smokefree legislation and should not routinely be included in the requirements of an organisation’s smokefree policy.
PHE will support local areas looking to implement local smokefree policies differentiating the levels of harm caused by existing tobacco products including e-cigarettes and other novel products.
This recognises that decisions on vaping policy should rest with owners and managers of premises, and steers them not to include vaping in organisational smoke-free policies by default. This implicitly acknowledges that there is no justification (for example, material harm to bystanders or workers) to override the preferences of property owners with blanket vape-free laws. This is an ethically robust position to take.
On “heat-not-burn” or heated tobacco products
In addition there has been the development and very recent introduction of novel tobacco products that claim to reduce the harm of smoking. We welcome innovation that will reduce the harms caused by smoking and will evaluate whether products such as novel tobacco products have a role to play in reducing the risk of harm to smokers.
A welcome open mind to innovation that could reach more people with a product they find acceptable and pleasurable. It is unclear (to me at least) what form this evaluation will take and what decisions they could take.
On e-cigarette evidence updates
PHE will update their evidence report on e-cigarettes and other novel nicotine delivery systems annually until the end of the Parliament in 2022 and will include within quit smoking campaigns messages about the relative safety of e-cigarettes.
Evidence updates (see 2015 version) that cut through the detached academic activism and media clickbait about vaping are an important role for responsible government. I very much welcome this.
On risk communication
PHE will continue to provide smokers and the public with clear, evidence based and accurate information on the relative harm of nicotine, e-cigarettes, other nicotine delivery systems and smoked tobacco, to enable informed decision-making. This will include the publication of an assessment of the risks of nicotine addiction.
There is much to do to correct erroneous perceptions of risks of vaping and other nicotine delivery systems (see dramatic misperceptions documented in this ASH fact sheet). It is good that the government recognises its own role in supporting informed consumer choice with credible evidence-based advice on risks.
On medicalisation and treatment using e-cigarettes
The Medicines and Healthcare products Regulatory Agency (MHRA) will ensure that the route to medicinal regulation for e-cigarette products is fit for purpose so that a range of safe and effective products can potentially be made available for NHS prescription.
[Public Health England] will provide evidence based guidance for health professionals to support them in advising smokers who want to use e-cigarettes or other nicotine delivery systems to quit
The key issue here is the need for a positive approach by health and medical professionals – what they say needs to be realistic and patient-focussed. England already has good officially-blessed guidance on e-cigarettes for health professionals and it will be very helpful to have this routinely updated. Simplifying the medical licensing option is of lesser importance, but could provide some benefits within healthcare settings, but only as long as it remains an option.
On regulation for harm reduction
[The Department of Health] will, based on the evidence reviews undertaken by [Public Health England], review policy and regulation of nicotine delivery systems to provide an environment that facilitates smokers taking action to improve their health and the health of those around them, whilst minimising any risk of new nicotine addiction in children.
[The Department of Health] will monitor the impact of regulation and policy on e-cigarettes and novel tobacco products in England, including evidence on safety, uptake, health impact and effectiveness of these products as smoking cessation aids to inform our actions on regulating their use.
I hope and expect that this means the government will monitor for harmful unintended consequences of regulation, and respond accordingly. The words smokeless and snus do not appear in the document – but the ban on snus is one of the worst examples of harmful regulation.
On Brexit and reconsidering measures in the Tobacco Products Directive
Over the course of this Tobacco Control Plan, the government will review where the UK’s exit from the EU offers us opportunities to re-appraise current regulation to ensure this continues to protect the nation’s health. We will look to identify where we can sensibly deregulate without harming public health or where EU regulations limit our ability to deal with tobacco.
In particular, the government will assess recent legislation such as the Tobacco Products Directive, including as it applies to e-cigarettes, and consider where the UK’s exit provides opportunity to alter the legislative provisions to provide for improved health outcomes within the UK context.
The government will continue to embrace developments that have the potential to reduce the harm caused by tobacco use and as such we will consider if the current regulatory framework strikes the right balance, and whether there is more we can do to help people to stop smoking. We remain committed to a comprehensive and robust tobacco control strategy which protects the population of England.
Commendable! Though the flexibility to do anything unilateral will depend on the terms of the final post-Brexit trading arrangements between the UK and European Union. I wish we were trying to fix the TPD from within the European Union, and even more that our ministers and officials had not agreed to such a mess of pointless and incoherent regulation when the TPD was being negotiated at the end of 2013.
The new plan takes a more positive and enabling approach to tobacco policy than I would say is the norm. I believe this is the first coherent statement of government level support for embedding low-risk alternatives to smoking and the concept of tobacco harm reduction in a major policy paper anywhere in the world.
I haven’t yet done an in-depth look for any mad ideas in the plan. That’s for another time.