Independent review of tobacco policy in England misses the point

The government has established a ‘smoke-free’ goal to reach 5% adult smoking prevalence in England by 2030. This represents a significant acceleration in progress (see chart above with linear trends). As a prelude to announcing a plan to achieve the goal, Ministers appointed Javed Khan OBE to head an independent review of tobacco policy to make recommendations for measures to meet the target and contribute to reducing health inequalities.

Here is what Dr Khan has come up with:

• Full report: The Khan review: Making smoking obsolete (9 June 2022)
• Summary: Making smoking obsolete: summary (9 June 2022)
• Press release: Independent review published to help meet 2030 smokefree target (9 June 2022)

These are recommendations to the government, not government policy. We have yet to see what the government will actually do and when it will get around to doing it.

In this blog, I set out an overview critique of the Khan programme and then look at each of the fifteen recommendations in more detail. Finally, a few words on what should be done.

A graphic summary of the Khan recommendations

Dr Khan’s review provides a summary graphic of his 15 recommendations in four parts.

Credit where some credit is due

This will be a critical review of Khan’s proposals, though hopefully also constructive. But despite the extensive criticism to come, I must stress that the thinking and insights that lie behind the Khan review are much better than the mainstream thinking you would see on tobacco harm reduction policy almost anywhere else in the world, notably in the United States, European Union or the World Health Organisation.

Khan and his team do at least recognise and value the concept of tobacco harm reduction and the great potential of vaping, even if their proposed policy package falls well short of maximising the opportunity. The review at least tries to engage with the evidence and gives due weight to the harm to adults caused by smoking and does not lose its mind over youth vaping.

Khan review: an overview critique

However, the recommendations fall far short of what is needed to meet the demanding target of reducing smoking in England to below 5% by 2030. But the review also takes the wrong approach overall.

I see three main overall failings:

First, it displays a wholly public sector mindset. The review ignores that most of the progress made in tobacco harm reduction has been made in the private sector through the interplay of consumer preferences and willing suppliers making and marketing appealing alternatives to cigarettes. That process could be greatly enhanced, and at negligible cost, by shaping the regulation of the market to favour consumer and producer migration to non-combustible smoke-free products. The report does little to implement better regulation to do this and nothing to exploit any Brexit opportunities to push back overly restrictive and evidence-free EU regulation, notably the ban on snus, counter-productive marketing restrictions, and indiscriminate and disproportionate regulation of vaping and heated tobacco products.

Second, it fails to make smoking the primary target. The Review offers a baseless recommendation to make the primary distinction in tobacco policy between tobacco and non-tobacco products.

As with snus, I have come to the conclusion that with such an array of tobacco-free alternatives already available (vapes, patches and gum) the primary distinction in government policy-making and regulation should be between nicotine products that do or do not contain tobacco.

Khan Review, Page 42

Why make this particular distinction? The better alternative would draw a distinction based on reduced harm (the actual purpose) and, therefore, make the primary distinction between combustible and non-combustible products. Khan’s illogical formulation screams out the influence of the anti-tobacco priorities of tobacco control activists at the expense of genuine public health objectives.

Somehow Khan manages to recognise that the strongest proof of concept for tobacco harm reduction is from snus in Scandinavian or Nordic countries – yet he asserts with only minimal argument that the EU snus ban should be retained in the UK. See Recommendation 8(ii) for more on this.

Also, he doubts the role of heated tobacco. Why? Even the endlessly hostile United States Food and Drug Administration deems the iQOS heated tobacco product “appropriate for the protection of public health” and allows the company to make reduced-risk claims about it.

It makes no sense to exclude these options: the 2030 smoke-free target is, correctly, framed by the government as a smoking target, not as a tobacco use target. Nor is it sensible for tobacco control activists or public health officials to second guess which tobacco harm reduction strategies will work for which users in which circumstances, and at what point in their transition from smoking to smoke-free. Consumers are best placed to make those decisions from the full range of smoke-free alternatives available to them. To meet the 2030 target, the government needs to go “all in” on tobacco harm reduction, not tie one arm behind its back by excluding important options.

Third, there is far too much punishment and coercion. Too much of Khan’s proposed agenda involves measures to hurt, restrict or humiliate smokers and to press them to stop smoking in response. The punitive agenda includes, for example, brutal tax increases, outdoor smoking bans, making purchasing more time-consuming, and new warnings designed to stigmatise and humiliate. For those who do not stop, these measures become policies that just add to the negative welfare effects and harms of smoking. Experience and good government suggest that major objectives need to be achieved as far as possible with the consent and support of those most directly affected. It is not the job of the government to batter citizens into behaviour change and it will fail if it relies too heavily on this approach.

The motivation behind the measures. Why does the review suffer from the three generic problems I list above? I would say that this is a review that marks out the comfort zone of the tobacco control activists who were extensively consulted for the review. The measures proposed are what that community finds agreeable: that being public sector paternalism, anti-tobacco activism, and punitive or coercive measures, all gilded by a fair amount of rent-seeking. But is pushing harder with this tired playbook really likely to work? I doubt it for two reasons. First, many of the recommendations will not be adopted by the government. Second, those that are adopted will not have that much impact.

Reasons why many recommendations will not be accepted. The review feels politically naive to me, as if it is unconnected to the reality of life in Britain today. It bases much of its proposed programme on: (1) increased public spending at a time of fiscal pain and public spending pressures; (2) tax rises that will hurt the poorest people in the middle of a cost of living crisis and do little to “level-up” life in poor communities; (3) an emphasis on public sector action to a government that is impulsively sceptical about the public sector; (4) denial of a single opportunity for a Brexit-based regulatory improvement, even though there are many; (5) extensive use of ring-fencing and top-down mandates to influence local government and NHS structures that are decentralised by design; (6) an eye-catching but absurd age-related proposal that infantilises adults and will fail due to its impracticality and libertarian opposition within the Tory party (and most of the country).

Maybe it would have been better to rely more on the engine of private sector innovation interacting with informed consumer choice, guided by risk-proportionate regulation and honest communications.

Update, 14 October 2022

The Guardian reports that Thérèse Coffey to drop smoking action plan, insiders say. If the report is true, it seems that Health Secretary Coffey is channelling the libertarian, tax-cutting, and pro-private sector instincts of the government, and the result is predictable (and as predicted above).

Insiders also say there is “no chance” that recommendations to reduce smoking that the ex-Barnardo’s chief executive Dr Javed Khan made in a government-commissioned review will ever be acted on. They included raising the legal age of buying tobacco by a year every year and putting an extra £125m into efforts to encourage smokers to quit, possibly by imposing a new “polluter pays” levy on tobacco firms, and requiring sellers of tobacco products to have a license.

Quoted in The Guardian, 11 October 2022

End of update

A review of the Khan recommendations

Dr Khan makes 15 recommendations. Each is reproduced below with the summary paragraph (taken from the executive summary), a link to the appropriate page in the main report, and a brief commentary on each recommendation.

1. Spend more money

Recommendation 1. Urgently invest £125 million per year in interventions to reach smokefree 2030, and make smoking obsolete, addressing the health disparities smoking creates (critical intervention). Within this, invest an increase of £70 million per year into stop smoking services, ringfenced for this purpose, distributed according to prevalence data.

Khan Review, page 13

Value for money not assessed. The review bemoans cuts in funding for various forms of tobacco control activity and argues that the economic burdens of smoking are high and that reducing them would be good. But it does not show the proposed tobacco control expenditure is good value for money (VfM) and that the expected benefits would justify the costs. I don’t doubt that some interventions would meet a VfM test, but nothing is done to show that here. Nothing is done to show that progress was slower following reduced expenditure (it wasn’t) or that the interventions proposed would accelerate progress compared to not doing them or doing something else. Here’s a good example:

The results of disinvestment are stark. Since 2010, the number of people using stop smoking services reporting a successful quit attempt has fallen by 72%. From 380,000 people then to 105,000 now (reference 35).

Khan Review, page 16

Khan didn’t investigate why the footfall had fallen or how “disinvestment” had contributed to this or even what the disinvestment was. Was there a shortage of capacity or a shortage of demand? Had this intervention run its course with the smoking population? How does it reach people who don’t want to quit? These and other questions are further discussed under Recommendation 9.

It’s a common practice in public health to point at a large problem and then propose spending on interventions to address it as if the large problem, a priori, justifies the interventions. It does not. What matters is whether they work and their cost-effectiveness.

Ring-fencing and rent-seeking. Every interest group likes ring-fenced revenue for its favoured cause and its own profession, and that is evidently the case here. But that’s why governments generally avoid linking expenditure to a revenue source. In effect, such linkages mean governments end up spending their revenue on services that are not their highest priority (otherwise the ring-fence would be unnecessary). The review calls for ‘ring-fenced and targeted funding’ from central government. But this imposes central government priorities on local government or the decentralised structures of the NHS. It works against the principles of more localised decision-making. There is very little reflection on how this programme would work with decentralised decision-making in public service delivery.

Raising money by clobbering tobacco companies. The review proposes what it calls a “polluter pays principle” in which tobacco companies would be made to pay for the costs of either the programme Khan proposes or the healthcare burdens arising (depending on which paragraph you rely on).

Introduce a ‘polluter pays’ industry levy on profits from cigarette sales, which can directly fund the full range of comprehensive measures to help us reach smokefree 2030 and make smoking obsolete. This is my preferred option. […]

So, I am asking why should taxpayers have to pay for the health and other consequences of the tobacco industry’s lethal products?

Khan Review, page 18

Obviously, a raid on an industry with such a terrible reputation is an effortless crowd-pleaser. But is it right and would it work? There are various wheezes for shaking down the tobacco industry with a levy or extra corporation tax. The problem is that such charges have a way of ending up falling on consumers. An increase in tobacco duties is a better way and well-established way of doing that. When a tobacco industry levy was proposed in 2015, a government economics review concluded:

In particular, we believe that the crucial assumption that a significant proportion of the levy will be passed-on to consumers in the form of higher tobacco product prices as reasonable.

HM Treasury, Tobacco levy: Response to consultation, 2015.

A further complication is likely tax avoidance behaviours for which multinationals are justly infamous but required to do (lawfully) as part of their fiduciary duty to shareholders. Governments already have extensive tax-raising powers and it is typical in the UK for 80% of the price of a pack of cigarettes to be excise duties and VAT. Khan notes that £10 billion is raised from UK tobacco excise duties already. Isn’t that enough?

Other spending priorities. Even if it was possible to draw some money out of tobacco profits without the burden falling on consumers or the profits hiding abroad, why would the government spend it in the way envisaged by Khan? It could use any money raised to offset health and social care costs for people with smoking-related diseases, for example. I strongly support the Treasury’s default view on ring-fencing: spending measures should be based on their own merits and value for money. Revenue-raising and spending should not be linked.

Competition is a better idea. The review notes the obscene profit margins earned by some tobacco companies – I agree. But this arises through oligopoly and because cigarette retail prices are dominated by taxation and it is easy to raise underlying prices. I would prefer to see these margins come down because of competition from vaping and other products sold in a diverse competitive market. There is also room for tobacco excise tax reform, but I will not discuss that further here.

2. Increase age limits for a smoke-free generation

Recommendation 2. Raise the age of sale of tobacco from 18, by one year, every year, until no one can buy a tobacco product in this country (critical intervention). This will create a smokefree generation.

Khan Review, page 22

Impractical and pointless. This is basically an unworkable idea that will fail at the most cursory scrutiny. If age restrictions work, how is it that under-18s smoke today and have done so for many years? It will establish the conditions for tobacco to be traded illegally through older people selling to younger and for black marketeers to supply under-age adults. It creates a situation in 10 years whereby people will have to prove they are 28 rather than 27 to buy tobacco. Of course, all the usual comparisons about military service and other age of majority thresholds will be brought into play.

Wrong product focus. By referring to “tobacco” rather than “smoking”, Khan attempts to erect an unjustified barrier to quitting smoking using snus or heated tobacco products (HTPs may reach people who need a smoke-free product closer to the experience of smoking).

Wrong population focus. But there is an even greater problem with this. It is directed at an adolescent population for which smoking is increasingly a thing of the past (see ASH data). Those few who still want to smoke will smoke whatever the government says about age restrictions. The measure is an eye-catching but almost completely pointless distraction from addressing the more important adult smoker population.

Why would anyone waste political capital on such a bizarre but ineffectual measure?

3. Increase tobacco prices by 30%

Recommendation 3. Substantially raise the cost of tobacco duties (more than 30%) across all tobacco products, immediately. This includes increasing duty rates for cheaper tobacco products, such as hand rolled tobacco, so they are the same as standard cigarette packages. It also includes banning tobacco products at duty-free entry points.

Khan Review, page 23

Hurting the poor with taxes. When you have a hammer every problem becomes a nail. Except this is a hammer that batters the poor through the ultra-regressive nature of tobacco tax – falling heavily on the most disadvantaged in society (or driving them into illicit trade). The question “how much tax is too much tax?” does not seem to have troubled Dr Khan. But it is something the Treasury considers carefully when it makes annual adjustments to tobacco excise duty. Khan does not present a convincing analysis to support his proposal.

He has looked at Australia and found it has higher taxes than the UK as if that is all the evidence he needs – without looking at the effects this has had in Australia.

To give an idea of the effect, Khan draws on a 2010 analysis using economic data from 1982-2009 to estimate that:

a 30% increase in price would reduce demand by around 12% in the short term

Khan Review, page 24

But he doesn’t draw the obvious conclusion from this…

On this basis, a crude calculation suggests total tobacco expenditure would rise by about 14% (1.30 x 0.88) and to the extent that it reduced the number of smokers (which is, after all, the point) this increased burden would fall on a smaller population of smokers – meaning average individual spend would rise by more than 14%.

So in a cost-of-living crisis and with the government’s commitment to “levelling up” (i.e. helping the poorest communities), Khan decides that what’s needed is a substantial transfer from one of the poorest subpopulations in society (smokers) to the Treasury via a highly regressive tax. I can’t see that flying.

The current UK tax raised on tobacco is £10.9 billion (OBR estimate 2022-23). If this also increases by 14% (a reasonable assumption if based on the numbers above), it would mean Treasury taking in an extra £1.5 billion, largely from people more likely to be suffering various forms of disadvantage. Amazingly, the Khan review doesn’t calculate any of this or consider the implications for poverty – or even why the Treasury doesn’t just jack up tobacco taxes in this way to raise money.

Assessment of impacts on poor smokers. Nothing in his analysis looks at how these measures would affect the household budget of a family living on benefits. Let’s help out here with a rough calculation comparing cigarette taxation to unemployment benefits (Universal Credit):

• A packet of 20 Mayfair budget cigarettes at Asda supermarket = £11.55
• Increase of 30% under the Khan proposals = £15.02
• Typical (median) cigarettes consumed per day = 10
• Smoke a half a pack of Mayfair (10) per day = £2,741 per year
• Universal Credit (UC) benefit for single person age over 25 = £334.91 per month
• Annual UC benefit for single person age over 25 = £4,019
• 10 Mayfair per day at Khan’s enhanced price = 68% of UC benefits

Half of all smokers smoke more than the median, so many would spend even more than shown in the calculation above. But the bigger point is that these costs are very large indeed compared to the incomes of the poorest in society. Many will manage around this by purchasing on the black market and/or using hand-rolled tobacco, but that probably just means the use of dated 1982-2009 estimates of elasticity are wrong. On the other hand, it might trigger more into switching to vaping (something that was not possible when the elasticities were calculated) – but Khan doesn’t explore the economics of this.

Wrong product focus. Again, Khan is indiscriminate about tax policy for tobacco products that have radically different risks in line with his acquiescence to anti-tobacco zealots rather than doing what’s right for public health.

Khan reaches straight for the punishment playbook of tobacco control with no analysis of the (intended) regressive economic effects or the unintended consequences. This policy should not be pursued.

4. (i) Retailer licensing

Recommendation 4 really contains two distinct recommendations, (i) retailer licensing and (ii) freezing the tobacco market:

Recommendation 4. Introduce a tobacco licence for retailers to limit where tobacco is available. The government should also ban online sales for all tobacco products, ban supermarkets from selling tobacco and freeze the tobacco market to stimulate innovation in tobacco-free alternatives.

Khan Review, page 25

There is a case for licensing retailers as part of an enforcement regime for age controls and selling lawfully compliant products, and other conditions for selling such products. It won’t make much difference to the 2030 target because smoking rates among youth are low and falling, and the 2030 target relates to adults.

But reducing availability? What does that even mean? As he puts it:

We need to make tobacco very difficult to buy. Retailers want this. Even most smokers want this.

Khan Review, page 26

Hurting people by taking their time. What this means is increasing time costs for people who smoke, and hoping that this quite arbitrary form of implicit non-financial burden adds to the pressure to make them quit. A punitive measure for smokers.

What sort of bureaucracy would determine which shops can and cannot sell tobacco, and what effect would this have on retailers? Under Khan’s regime, supermarkets (arbitrarily) would be barred from selling cigarettes with the following reasoning:

The government must ban supermarkets across the UK from selling tobacco products instore and online as soon as possible. I have spoken to several supermarkets and I know that they increasingly want customers to have the choice to make healthier decisions as part of their company’s vision.

Khan Review, page 27

But supermarkets can (and do) offer healthier alternatives (vapes etc) and the cigarettes are subject to display bans. If they have this concern for their customers, they could stop selling cigarettes if they wished.

More punishment. This sort of approach just seems the wrong way to go about achieving a smoke-free society – by harassing smokers and making their lives more difficult. Another example of Khan preferring punishment over the consent of the affected population.

4. (ii) Stop innovation in tobacco products

Tucked under recommendation 4 is a completely different proposition to retailer licensing: this is to freeze tobacco product innovation:

The government must freeze the tobacco market and not allow any new tobacco products to be introduced to the market.

Khan Review, page 27

An indiscriminate barrier to innovation. Again, this ignores the potential of smokeless and heated tobacco products to displace smoking. No good reason is given for this or any justification provided for stopping innovation in these products. The underlying reason is obvious: the review is distorted by a tobacco control priority to attack the tobacco industry rather than address smoking. But why deny, a priori, the potential of smoke-free tobacco products in meeting the smoke-free 2030 target? The chart below shows the effect of heated tobacco product introduction in Japan (Source Philip Morris International):

5. Illicit tobacco enforcement

Recommendation 5. Enhance local illicit tobacco enforcement by investing additional funding of £15 million per year to local trading standards. Give trading standards the power to close down retailers known to be selling illicit tobacco. Alternative tobacco products such as shisha need enhanced enforcement.

Khan Review, page 27

I agree with tackling illicit trade, but mainly for law and order reasons. Nothing here provides a justification for the £15 million annual expenditure he recommends or what public health results should be expected for that money. Given public health is the focus of his review, he should be able to connect the spending to a public health outcome. The history of illicit drug trade enforcement hardly inspires confidence and does not suggest it does much for reducing the total supply. No lessons are drawn from this experience. Khan has made a simplistic non-market assumption that the illicit supply chains will not simply respond to increased enforcement with the involvement of bigger villains and more organised crime, and supply and price will adjust to meet demand.

Khan should also have recognised that illicit trade is a form of safety valve that reduces the exposure of poor and dependent smokers to extremely high prices – something he intends to increase (see the example under Recommendation 3 above). Tax policy and illicit trade should always be looked at together.

The case for tackling illicit trade is grounded in deterring lawlessness, but I doubt it will do anything to reduce smoking or meet the 2030 smoke-free target.

6. Change how cigarettes appear

Recommendation 6. Reduce the appeal of smoking by radically rethinking how cigarette sticks and packets look, closing regulatory gaps and tackling portrayals of smoking in the media.

Khan Review, page 30

The idea of printing warnings on individual cigarettes seems to have excited many in tobacco control. However, I really dislike this measure. I doubt it will offer any new or useful health or risk information to smokers. But that’s not its purpose or mode of action. The way this works is through mockery and humiliation – essentially a stigmatising measure designed to make smokers feel stupid and to force them to parade it as they smoke. I have no idea if it will be effective and the evidence provided to suggest that it would be effective is wholly inadequate. It just cites an RCP report (ref 69 in Khan), which in turn cites this (ref 160 in Chapter 5 RCP):

The perception among adolescents that an on-cigarette warning could deter smoking, and the high support for a warning on all cigarettes, warrants further research.

Moodie C, MacKintosh AM, Gallopel-Morvan K, Hastings G, Ford A. Adolescents’ Perceptions of an On-cigarette Health Warning. Nicotine Tob Res. 2017;19(10):1232-1237. [link]

…and this (ref 169 in Chapter 5 RCP):

Within every group there was mention of warnings on cigarettes potentially having an impact on themselves, others or both. Some, mostly younger groups, mentioned stubbing cigarettes out early, reducing consumption or quitting. The consensus was that they would be off-putting for young people, nonsmokers and those starting to smoke

Moodie C, O’Donnell R, Fleming J, Purves R, McKell J, Dobbie F. Extending health messaging to the consumption experience: a focus group study exploring smokers’ perceptions of health warnings on cigarettes. Addict Res Theory. 2019 Aug 29;28(4):328-334. [link]

These are studies of people asked to give their opinion on how they or other people would react to these warnings. They tell us little about how they would actually react (in terms of smoking behaviour). However, they are probably a better guide for how they would feel. The second source above provides good qualitative insights, but it really confirms that this would work by making people feel bad about themselves rather than by informing or empowering them.

So it’s another punishment or stigma-based measure. It may “work” as in affect behaviour, or it may not. I doubt it would have much impact after its ‘announcement effect’ had worn off. There is too little evidence here to assess actual behavioural responses (for example, economic choice experiments would be more revealing than opinions) or whether it would drive black markets, counterfeiting etc. But my concern is how it is supposed to work – by mockery and humiliation.

Tackle portrayals of smoking in the media? How? Who would be empowered to determine what was acceptable and what sanctions would be used?

7. Increase smoke-free places

Recommendation 7. Increase smokefree places to de-normalise smoking and protect young people from second-hand smoke. Strengthen smokefree legislation in hospitality, hospital grounds and outdoor public spaces. Local authorities should make a significant proportion (70% or more) of new social housing tenancies and new developments smokefree.

Khan Review, page 33

Smoking is already mostly banned where it counts. I was a bit surprised by this, given smoking is already banned throughout the UK in most indoor public places and workplaces. That is certainly the case where it would be justified to protect the health of workers (this is a legitimate justification in my view). So a new justification has been brought into play to expand the range of places where smoking bans might apply, and this justification has weaker ethical and political foundations. The justification is stated explicitly: “to de-normalise smoking”. This impressive-sounding technocratic term really just means “stigmatise”. It is a euphemism for policies designed to make people feel bad about themselves and to encourage people around them to feel hostility or disgust towards them. It has a weaker ethical justification because it is about regulating behaviour for the good of the regulated, not to protect third parties from harm caused by the regulated behaviour.

The recommendation here is to extend smoking bans to outdoor settings like pub gardens and pavement cafes, and to smokers’ shelters. I don’t believe there is a justification in this case for overriding the preferences of property owners and managers unless there is a material risk to bystanders. Together with harm reduction benefits, that is more or less the philosophical underpinning of the government’s reasonably liberal approach to vaping in public places.

Abuse of tenure. I think bans on smoking (or preferential selection of non-smokers) in social housing is another illiberal punishment-based policy, in which smokers are made to feel different about their home because of their tenancy status. A justification can be made on the basis that private landlords can impose such policies, so why not in public housing or social landlords? There are two problems here – should housing tenure be used as leverage to affect personal behaviours if these do not affect others outside the home (e.g. controlling nuisances like noise, aggressive dogs, or littering)? Even if we can justify addressing the smoking problem with measures like this, should the state use control over people’s housing to denormalise their personal behaviour at home? I’m uncomfortable with that degree of state intervention.

8. (i) Offer vaping as an alternative to smoking

Recommendation 8 contains multiple elements.

Recommendation 8. Offer vaping as a substitute for smoking, alongside accurate information on the benefits of switching, including to healthcare professionals (critical intervention). The government should accelerate the path to prescribed vapes and provide free ‘Swap to Stop’ packs in deprived communities, while preventing young people’s uptake of vapes by banning child-friendly cartoon packaging and descriptions.

Khan Review, page 36

Yes. This seems like a fine idea and there are several worthwhile proposals in this section. But why is vaping being “offered” rather than “chosen”? And why is the option to use a smoke-free tobacco product not to be offered, if that’s what the user thinks would work for them? Why not nicotine pouches – probably the safest of all forms of smoke-free recreational nicotine? This whole section is excessively focused on the public sector and ‘healthcare professionals’. But this reflects the tobacco control obsession with medicalising tobacco harm reduction. There are basically two quite distinct ways in which smoke-free products work for public health:

1. As an effective smoking cessation intervention – a kind of pimped-up NRT that replaces more of the smoking experience than just nicotine and is, therefore, more effective at managing the side effects of quitting smoking.
2. As a consumer alternative to cigarettes, in which pleasure, satisfaction, consumer appeal and branding play an important role. This is the market in action – with consumer choice and innovation as the dominant dynamics.

1. As a smoking cessation intervention. The review raises the idea of using vaping starter packs to engage people in deprived communities (an intervention that would be best done in partnership with good vape shops) and again raises the idea of GPs prescribing vaping products that have been licensed as medicines, something that always excites the press and tobacco control community. All this is welcome, though the barriers to achieving medicine licensing are likely to constrain this option, as they have so far, to a small number of products made by large firms (so far none are available). Yet, it seems possible to navigate around this requirement, as Khan describes the Salford Swap to Stop scheme:

The support provided included advice and guidance on stopping smoking and how to use the vapes. An evaluation found that the cost per quit of using vapes is significantly lower than the standard stop smoking service offer, and number of quits increased by nearly three-fold. Offering and promoting free vapes significantly increased demand for stop smoking services, particularly in the most deprived quintiles.

Khan Review, page 41

I don’t really see what prescribing would add to a scheme like this or why Khan recommends pouring £70 million per year into standard stop-smoking services (see Recommendation 9) if this Swap to Stop approach is “significantly lower” cost per quit. Perhaps the right way is to establish schemes like this and have GPs make referrals, as they can do with exercise classes, for example.

Khan also makes welcome recommendations on addressing misinformation about vaping and reinforcing clinical guidance that supports healthcare professionals recommending vaping:

The government must provide accurate and consistent information to healthcare professionals on vaping, to promote the benefits of switching to vaping and to dismantle longstanding myths. The government should launch a vaping facts website similar to New Zealand’s Vaping Facts website, which has been incredibly useful at dispelling these myths.

The Cochrane Review on e-cigarettes for smoking cessation found that like for like, vapes are as effective for smoking cessation as licensed medicines, with no greater risk of adverse effects (reference 81). We need to take a scientific approach and stick to the evidence. Clinicians should follow NICE guidance on stopping smoking, which states that “healthcare professionals can recommend vaping devices, as a means to help patients stop smoking” (reference 82).

Khan Review, page 39

2. As a consumer alternative to cigarettes. The Khan Review is overwhelmingly focussed on the role of vaping as a smoking cessation intervention and does far too little to strengthen the consumer proposition, though there are a couple of welcome exceptions.

Rebalance regulations on promotion. The government should modify advertising rules so vapes can be promoted as a less harmful product, particularly on the products themselves, and should allow vape shops to support campaigns like Stoptober. Smokers need to see more messages that switching to vapes is hugely beneficial to their health.

Reduce VAT on vaping devices in line with other nicotine products. Most people vape to quit smoking and to help them stay off tobacco. This will give people an added incentive to switch.

Khan Review, page 40

This is the right sort of thinking, but comparatively rare in the Khan Review.

8. (ii) Maintain the European Union ban on snus

While snus offers tobacco companies a useful alternative to cigarettes, it offers little that is new to smokers in the UK. Given the range of tobacco-free alternatives that we already have readily available in the UK, I have not been persuaded that snus adds additional value.

Khan Review, page 41

There is a ‘tell’ in this statement. He starts by mentioning snus as if the important concern is whether it is a benefit to tobacco companies rather than focussing on the benefit to smokers or public health. You just can’t get away from the obvious priority given to hurting tobacco companies over public health implied in such statements. This has led to the baseless position described above in which they regard the key policy distinction to be between tobacco and non-tobacco rather than between combustion and non-combustion – a position for the comfort of tobacco control activists rather than to serve public health.

The irony of this absurd position is that Khan lists the evidence for the effectiveness of snus in reducing smoking.

I understand that:

• snus is a tobacco product and its use carries risks, but is far less harmful than smoked tobacco

• smokers switching completely to snus can reduce their exposure to harmful chemicals (reference 84)

• snus can be effective for smoking cessation

• in some countries, such as Norway, snus use has all but replaced tobacco smoking among young adults (reference 85, 86)

Khan Review, page 41

Ignore all that evidence. Yet despite this encouraging analysis, he determines that this is the wrong way to quit smoking. He draws on an argument that smokers to not switch to smokeless tobacco in the United States (Jackson, et al. 2021). That’s a kind of non-sequitur because snus obviously has displaced smoking where it is available in Western Europe. But also the United States suffers from extreme misperceptions about the relative risks of smokeless tobacco and smoking. Only 13% think smokeless is safer than smoking and the vast majority are wrong or confused:

Waste of legislative time? A further, desperate, argument is that it would not be worth the legislative time. But if there is to be legislation for the future tobacco control plan then it is a minor incremental change to remove the retained EU legislation that bans snus. If the government wanted to do more on regulating smokeless tobacco, it should focus its attention on South Asian traditional tobacco recipes. Note that legislation that rolls back baseless European Union regulations is appealing to the current government: because it is a Brexit opportunity.

There is also a basic liberal argument. Even if only a few thousand people in the UK wish to use snus, why stop them by banning the product? Why not have the safest tobacco products on the market alongside cigarettes for those who want them?

9. Spend on stop-smoking services

Recommendation 9. Invest an additional £70 million per year into ‘stop smoking services’, ringfenced for this purpose. The government should commission an update to existing quality of service standards guidance and build the provision of good quality stop smoking support across the country. The government should also ensure that any national helpline complements existing local (and national) virtual offers of support. Employers should follow National Institute for Health and Care Excellence (NICE) guidance on stopping smoking to support their employees to quit.

Khan Review, page 42

I would expect some diagnosis of why the footfall in stop-smoking services was declining before a recommendation to pump in a lot of money. Over ten years, the number of persons setting a quit date at stop-smoking services in England has fallen by 88% (see chart below). Why? We are not told.

The assumption made by Khan is that the problem is supply and austerity-driven declines in spending on these services, but he provides no data to show that access to such services is at the heart of the problem. It could work the other way around… funding was cut because footfall declined and the funding trend is not even given.

Possible reasons for the decline. First, supply is one possible contributory explanation – affecting both the availability and quality of such services. But it is not the only possible explanation. What if the problem is that only a subset of smokers is interested enough and sufficiently willing and able to follow this particular path? That subset would be the ones already motivated to quit, with time to devote to receiving behavioural support and counselling, and an inclination to put themselves in a ‘treatment’ relationship with a provider. It is quite possible that these services worked through the stock of smokers for whom they were an appropriate fit and then ran short of potential users. Alternatively, what if many of the potential ‘patients’ at these services were those for whom vaping offered a better and more practical alternative – i.e. vaping as a drop-in replacement for their smoking and these potential users chose to vape instead? Or suppose the repeated failures to quit with established medical aids ultimately discredited these services among many smokers? Or did the dogmatic refusal to embrace vaping on the part of many (not all) services degrade trust in their advice?

Effectiveness of these services. Similar concerns relate to the claims about the effectiveness of these services. There are two points to consider. First, the people who attend such services to the point that they are ready to set a quit date are already a subset of the smoking population, but not a representative subset. Is there something about their motivation or dependence that means that success is more likely than among the general population (i.e. there is a kind of cream-skimming at work)? Second, the effectiveness doesn’t matter much if the reach is poor. The perfectly effective smoking cessation service that no one wants to use has no public health impact.

Current funding and trends. Bizarrely for a spending proposal, Khan does not report the current expenditure on stop-smoking services or local tobacco control or its trend. For that, we can refer to the Local Government Association:

Councils currently spend around £75 million on Stop Smoking Services and £11 million on Tobacco Control. 

LGA, Progress towards the Government’s smokefree ambition, House of Commons, 26 April 2022 [here]

Oh, wait… so they are already spending more than the proposed extra £70m funds? What is to stop local authorities from freeing up their own resources and funding the services from the new central pot? And that is already a quite large budget, given there are options to switch to vaping at no cost to the public sector.

Cost-effectiveness. Khan reports that:

the top 20% of SSS in England last year (measured by number of successful quits per 100,000 smokers) spent an average of £23 per local smoker to achieve those quits. The remaining 80% of SSS spent £13 per smoker (reference 95).

Khan Review, page 43

But spending per smoker is an ‘input’ measure, not a measure of cost-effectiveness. It’s 10 years since I had civil service accounting officer responsibilities, including ensuring value for public money. But if I was doing it today, I’d start with a crude estimate of cost-effectiveness. I’d do that simply by dividing the total spend (£75m) by the desired outcome, in this case, the number of 4-week quits (the definition of ‘successful’ used here). The SSS data show 4-week quits to be 105,403 in 2020/21. Dividing these together, I’d come up with £419 per quit.

Then start asking more difficult questions:

• How useful is a 4-week quit as a benchmark of success and how does this translate to long-term smoking cessation and health outcomes (e.g. QALYs)?
• How many would quit anyway in the counterfactual world in which these services did not exist? So what would the service ‘additionality’ be?
• Would this cost per quit meet NICE cost-effectiveness thresholds?
• Would we be better off keeping the money and sending smokers off to a vape shop or giving the money to GPs?

I am not against these services, far from it. But I don’t think it is possible to justify spending an additional £70 million per year on an assumption that the problem with them is inadequate supply and funding. These are additional things to consider:

• Could better smoking cessation interventions be delivered within NHS and, in particular, via general practice for the equivalent money?
• Could better integration between the health care system and vape shops or pharmacies be better value for money?
• Should specialised smoking cessation services concentrate on particular hard-to-reach or disadvantaged sub-populations and take form in different settings (e.g. in mental health, homelessness)

Khan’s review showed no imagination about the future of specialised stop-smoking services and his recommendations do not provide a reliable guide for government policy and spending.

10. Spend on a national mass media campaign

Recommendation 10. Invest £15 million per year in a well-designed national mass media campaign, supported by targeted regional media. This should be nationwide, direct smokers to support and dismantle myths about smoking and vaping.

Khan Review, page 47

Communicate, but creatively. Yes, it would be useful to have the authority of the government backing truthful communications and myth-busting about smoking and vaping. It is also a good idea to motivate people to quit smoking. But this recommendation focuses on spending £15 million per year on a “national mass media” campaign. It follows the basic impulse of this review to spend money rather than think imaginatively about how to deliver results in straightened circumstances.

Yes, it is true that public spending on anti-smoking campaigns has decreased.

But here are two issues. First, is there any analysis to show the trend in smoking was adversely affected by the precipitous reduction in anti-smoking campaign spending? If there is, none was presented in the Khan Review. The review just referred to international evidence on mass media campaigns. But even this evidence is pretty weak. This is what the Cochrane Review has to say:

Tobacco control programmes that include mass media campaigns may change smoking behaviour in adults, but the evidence comes from studies of variable quality and scale and often occur in an environment where there are other influences on smoking, making it hard to isolate the effects of the media campaign itself. No consistent patterns by age, education, ethnicity or gender were found.

Cochrane Review, Mass media interventions for smoking cessation in adults, 2017

Strangely, this systematic review was not cited.

The second issue is, once again, the Khan Review’s public sector focus. It is quite possible that total anti-smoking mass media went up if you include private sector expenditure by vaping companies entering the market and growing through the 2010s. Smokers are their target market and switching is their goal.

Spending proposals in dire fiscal circumstances. The problem is that spending pledges in the medium term will face the hurdle of already established Spending Review budgets and ongoing intense pressure on the public finances. So anyone proposing more spending should probably impose the discipline of saying what they would defund in the health budget to achieve it.

I’m not opposed to a mass media campaign in principle, but why not let communications professionals design a multifaceted and cost-effective campaign with options for spending larger sums if available? That would at least be resilient against budget constraints.

Low-cost government communications. I would start by asking how much could be achieved without any significant spending. For example, what could be done with statements from the Chief Medical Officer, Chief Nursing Officer and important figures in the health care professions, like the NHS Chief Executive? Could the government be more proactive about correcting well-publicised nonsense in newspapers? Could it do more to work with health and medical journalists (reverse the hostility of the BMJ and Lancet)? Should it operate an extensive fact-checking system (outsourced to specialists) for the benefit of journalists and healthcare professionals and other communications intermediaries? Could the NHS resources on vaping and tobacco harm reduction be further developed and be made more prominent (Khan proposes this in Recommendation 8). Could hospitals and primary care settings be used for better NHS-branded public information on vaping?

Leverage commercial communications. Could the government leverage the communications of private sector entities (e.g. vape or tobacco companies) by authorising the use of a range of generic statements about tobacco harm reduction and vaping in commercial communications? What about allowing these companies to advertise on TV, the internet or other media banned under the European Union Tobacco Advertising Directive or Tobacco Products Directive as a Brexit dividend? Once it is understood that advertising for vaping functions as anti-smoking advertising, much more “free” media becomes possible. Would it be possible to amend the information available at the point of sale and engage supermarkets? Khan does propose advertisers should be able to claim that vaping is less harmful than smoking in Recommendation 8.

What about using the cigarette or vaping pack as a platform for communications? The review ignores the option to change negative warnings on vaping packs into effective risk communications to encourage switching on vaping products. Nor does it consider the use of NHS-branded cigarette pack inserts to communicate directly with smokers. With Brexit, the EU rules that govern vaping and smoking warnings can be amended to suit the UK’s approach to harm reduction – but these options are not even considered by Khan.

11. Prioritise prevention in the NHS

Recommendation 11. The NHS needs to prioritise prevention, with further action to stop people smoking, providing support and treatment across all its services, including primary care (critical intervention). First and foremost, the NHS must meet its existing commitments in the Long Term Plan. Healthcare professionals should use every ‘teachable moment’ to deliver ‘very brief advice’ on quitting, and this should form part of revised core training curriculums. The NHS should invest to save, committing resource for this purpose and incentivise its services to implement the NICE guidance on stopping smoking. All hospitals must integrate ‘opt-out’ smoking cessation interventions into routine care. Hospital trusts should report on progress towards implementing these measures in their annual reports and have a named lead. The NHS must ramp up its messaging on stopping smoking.

Khan Review, page 52

The idea that prevention is better than cure is hardly a new insight. Nor is this the first time that someone has thought of having the NHS more engaged in reducing smoking. In fact, there is already a set of smoking cessation incentives built into the performance management regime for the NHS. Back in 2014, I wrote a post on “Doctors, smoking and money“, in which I estimated that about £88 million of incentive payments were already going into smoking cessation, and questioned whether we were getting a decent return on this public money.

Better analysis is needed to change practice in the NHS. Instead of the repeated exhortations that the NHS ‘must ensure’, ‘needs to’ and ‘should do’ the various things advocated by Khan, I would have expected an analysis of what the current system is doing and why it isn’t working as well as Khan would like. This would be a starting point on which to build some substantive recommendations. Instead, Khan’s review mainly reverts to the generalities of the 2019 NHS Long Term Plan.

Newsflash: doctors are economic agents. Motivating providers gets down to understanding the economic behaviours of the individuals and institutions involved. That doesn’t mean looking at their pay, but a more subtle analysis that looks at how the urgent trumps the important in healthcare settings and the misalignment of the costs and benefits of prevention (large hospital savings arising from spending on primary care preventative interventions). I don’t have time to update my 2014 analysis, but what is the point of making a recommendation on NHS performance and incentives if you don’t start with a detailed analysis of what the system is already supposed to do? If you want to wrestle with a complex organisation like the NHS you really need a high-resolution view of how the centre can influence decentralised structures and how the incentives play out in practice, not just on paper.

12. Support for pregnant women to quit

Recommendation 12. Invest £15 million per year to support pregnant women to quit smoking in all parts of the country. The NHS should provide treatment at every stage. The government needs to create a national funding pot for evidence-based financial incentives to support all pregnant women to quit. There should be a ‘stop smoking midwife’ in every maternity department to provide expert support and advice at the front line.

Khan Review, page 57

The concerns about this are almost the same as with Recommendation 11. The case for pregnant women not smoking before, during and after pregnancy is strong. But the question is how to achieve it, especially in a decentralised system for allocating resources – and especially if there is to be a centrally allocated budget for incentive schemes. In this case, it is not clear to whom Khan is directing his recommendations – NHS Trusts, Integrated Care Systems or the government? There is an eye-catching proposal for a £15 million incentive scheme involving shopping vouchers for successful quitting.

The government should create a national funding pot of £15 million to support all pregnant women to quit. There is strong evidence that women who receive incentives (in the form of shopping vouchers on condition of carbon monoxide verified abstinence) are 2.5 times more likely to quit (reference: Cochrane Review).

Khan Review, page 60

Pilot first. It is way too soon to commit to a £15m incentive scheme for operation in real life rather than in the trials reviewed by the Cochrane team. This is the sort of measure that should be done as a pilot to iron out perverse incentives (becoming a smoker briefly to collect on the vouchers) and cost-effectiveness outside a trial setting (i.e. with less motivated staff).

To his credit, Khan does endorse the findings of the Royal College of Midwives regarding vaping as a harm reduction strategy in pregnancy:

The NHS should offer safer alternatives to smoking. The Royal College of Midwives says “E-cigarettes [vapes] contain some toxins, but at far lower levels than found in tobacco smoke. If a pregnant woman who has been smoking chooses to use an e-cigarette (vaping) and it helps her to quit smoking and stay smokefree, she should be supported to do so” [RCM position statement]

Khan Review, page 60

13. Tackle smoking and mental health

Recommendation 13. Tackle the issue of smoking and mental health. Disseminate accurate information that smoking does not reduce stress and anxiety, through public health campaigns and staff training. And make stopping smoking a key part of mental health treatment in acute and community mental health services and in primary care.

Khan Review, page 62

Again it is a laudable aim to address smoking in people with mental health problems. But why the emphasis on denying the potential modulating benefits of nicotine? There is good evidence that nicotine does control stress and anxiety. In a major 2009 paper, Professor Neal Benowitz, a global authority on nicotine, states:

In humans, nicotine from tobacco induces stimulation and pleasure, and reduces stress and anxiety. Smokers come to use nicotine to modulate their level of arousal and for mood control in daily life. Smoking may improve concentration, reaction time, and performance of certain tasks.

Benowitz, N. L. (2009). Pharmacology of Nicotine: Addiction, Smoking-Induced Disease, and Therapeutics. Annual Review of Pharmacology and Toxicology, 49, 57. [link]

Confidently asserting something that is manifestly wrong will fail a reality check and degrade trust among the affected population. This is unlikely to help. It will also tend to overweight abstinence approaches compared to harm reduction with continuing nicotine use in the preferred approach for people with mental health problems.

Dr Khan appears to have given up on the complexity of tackling this problem and resorts to:

We must offer effective smoking cessation treatment within acute and community mental health services and in primary care.

Khan Review, page 63

Yes, but how would this happen? Why doesn’t it happen already? What are the institutional and cultural barriers? Why is money proposed for other ideas, but not for this?

14. Make use of the new NHS Integrated Care Systems

Recommendation 14. Invest £8 million to ensure regional and local prioritisation of stop smoking interventions through ICS leadership. ICS and directors of public health must set, and annually report against, clear targets to reduce smoking prevalence in their areas and commission services to allow that reduction to be achieved. The government should set up a support fund to which ICS can bid for funding to support regional collaboration and partnership.

Khan Review, page 64

On 1st July 2022, forty-two new Integrated Care Systems (ICSs) replaced 108 Clinical Commissioning Groups as the bodies primarily responsible for spending the NHS budget and delivering community health.

Integrated care systems (ICSs) are partnerships of organisations that come together to plan and deliver joined up health and care services, and to improve the lives of people who live and work in their area.

Source: NHS England

These decentralised “place-based” commissioning bodies are immensely powerful in the NHS, controlling more than two-thirds of the NHS budget (~£80 billion). They also have a substantial degree of devolved autonomy by design. So it just isn’t that easy to make them do something. So when Khan says something like the following:

The arrival of ICSs presents an opportunity that must be seized. ICSs bring together the NHS, local authorities, primary care and the voluntary sector, working interdependently to improve population health. As local system leaders are responsible for improving population health, they should be held to account for achieving smokefree 2030 targets.

Khan Review, page 64

…the question everyone should ask is “how and why?”. By what mechanism does central government impose priorities on decentralised decision-makers regarding the allocation of funds? Similarly, when the government sets up decentralised decision-making and resource allocation, how does this system internalise national priorities and by what mechanism, if any, are these bodies held accountable for national smoking targets. None of this is articulated in the Khan Review.

Recommendations 11-14 are all part of the same challenge: how does Whitehall incentivise the labyrinthine NHS and local government services structures to work towards a national goal when the policy intention is to decentralise prioritisation and resource allocation?

15. Spend on research and data

Recommendation 15. Invest £2 million per year in new research and data. The government should invest in an innovation fund to support the commissioning of new research, data and monitoring of impact at all levels. This will provide improved and accessible information to identify effective evidence-based interventions that should be rolled out. The government must also commission further research on smoking-related health disparities, particularly on ethnic disparities and young people.

Khan Review, page 64

If money is going to be spent above and beyond that allocated by the standard research funding mechanisms, then it should focus on work that has the highest policy and delivery relevance (i.e. a direct return to the public). In my view, this would emphasise:

• Evidence synthesis – the series of E-cigarette evidence reports of Public Health England have been invaluable in providing a basis for policy and practice
• High-resolution data – the Smoking Toolkit provides high-quality and timely insights into changes in the patterns of tobacco and nicotine use
• Attitudes – the ASH/YouGov surveys provide excellent insights into motivation and behaviour change.
• Targetted sub-populations – smoking is increasingly a condition of various forms of disadvantage and such groups are often hard to reach or hard to influence.
• Policy evaluation and cost-effectiveness – a more rigorous system for assessing policies both introduced in the UK and overseas. There is a profound lack of independent and objective assessment of policies.
• Post-publication peer review, replication and challenge – though vast in scale, the tobacco control research community appears to be missing the normal corrective and challenge functions that are integral to open science.

How to meet the 2030 smoke-free target

The New Nicotine Alliance (a consumer group for which I am an unpaid adviser) has suggested twenty policy proposals to meet the target – essentially by going “all-in” on tobacco harm reduction – helping people switch to less harmful products and also to avoid the harms created by tobacco policy itself (financial pain, restrictions, stigma).

It is not my aim to repeat the case for these policies here. You can read the arguments for these policies on the NNA website and by accessing the full PDF submission.

Principles to underpin a smoke-free strategy

I’d like to draw on two quotes about the right approach to meeting the 2030 target. I raise these because they contrast with the dominant approach adopted by Javed Khan:

First, a view on why going all-in on tobacco harm reduction is likely to be the best way to achieve the 2030 goal:

Maximal tobacco harm reduction is the only way to meet the 2030 goal

In our view, the key strategy for attaining smoke-free status, especially in individuals and communities where smoking is deeply entrenched, is switching from high-risk smoked products to low-risk smoke-free products. The reason is simple: this is a more straightforward pathway to follow for many smokers because it does not demand the user gives up nicotine or many of the sensory or behavioural aspects of smoking. Yet switching is likely to reduce health risk by 95% or more. Switching from cigarette smoking to these new products provides three main benefits: (1) an improvement in long-term health outlook and life expectancy; (2) a rapid improvement in wellbeing and fitness; and (3) substantial household budget savings due to the high cost of cigarettes.

Second, a reflection on the appropriate relationship between those affected and the government and the policies it imposes:

Smoke-free policy must have the support of those most affected

There has been sustained public support for smoking-reduction policies. However, policymakers should pay particular attention to those most affected by policies to achieve the Smoke-free 2030 ambition and be mindful of the effects on those who continue to smoke (still 2-3 million people even if the policy succeeds). It is essential that ministers carefully consider the policy-induced harms of imposing measures like taxes, restrictions and campaigns that may make people who smoke feel stigmatised. As far as possible, the 2030 target should be achieved with the consent of those affected, using all available insights and levers to convince those most reluctant to stop smoking, but without causing them significant harm. That suggests a different approach to the traditional toolkit of tobacco control will be needed to reach the hardest-to-reach fairly and proportionately. A central premise of our proposals is that ambitious public health targets should, as far as possible, be met with measures that rely on the consent and informed choices of those affected. The measures we propose should appeal to hearts and minds rather than making smokers feel alienated and punished.

Twenty proposals to meet the 2030 smoke-free target

These proposals overlap with Khan’s review, but the emphasis is far more on making the private sector mechanisms for tobacco harm reduction work better by removing counterproductive regulation. Please see the detail in the submission.

1. Lift the EU-imposed ban on snus
2. Remove the 20mg/ml limit on the strength of nicotine e-liquid
3. Replace excessive and inappropriate warnings on vaping products
4. Replace excessive and inappropriate warnings on non-combustible tobacco products
5. Replace partial bans on vape advertising with controls on themes and placement
6. Replace blanket bans on advertising of low-risk tobacco products with controls
7. Limit plain packaging to combustibles but control themes on smoke-free packaging
8. Require NHS inserts in cigarette packs to encourage switching to smoke-free products
9. Allow commercial inserts in cigarette packs to promote smoke-free products
10. Amend the leaflet requirement in vaping products
11. Drive motivation to switch with improved risk communications
12. Eliminate pointless restrictions on tank and refill container sizes
13. Take a principled approach to flavoured smoke-free products
14. Introduce consumer protection regulation for modern oral nicotine pouches
15. Use fiscal policy to support the transition to smoke-free alternatives
16. Allow use of smoke-free products in public places
17. Impose well-designed age restrictions
18. Strengthen healthcare and public health system response
19. Allow prescribing of e-cigarettes on a trial basis and engage with vape shops
20. Use science and evidence to underpin the strategy