National Assembly for Wales / Cynulliad Cenedlaethol  Cymru
Health and Social Care Committee / Y Pwyllgor Iechyd a Gofal Cymdeithasol


Public Health (Wales) Bill / Bil Iechyd y Cyhoedd (Cymru)


Evidence from UK Faculty of Public Health – PHB AI 05 / Tystiolaeth gan Cyfadran Iechyd y Cyhoedd y DU – PHB AI 05

Catherine Hunt

Second Clerk

Health and Social Care Committee

National Assembly for Wales


01 October 2015


UK Faculty of Public Health comments to the National Assembly for Wales on the general principles of the Public Health (Wales) Bill


About the UK Faculty of Public Health


The UK Faculty of Public Health (FPH) is committed to improving and protecting people’s mental and physical health and wellbeing. FPH is a joint faculty of the three Royal Colleges of Public Health Physicians of the United Kingdom (London, Edinburgh and Glasgow). Our vision is for better health for all, where people are able to achieve their fullest potential for a healthy, fulfilling life through a fair and equitable society. We work to promote understanding and to drive improvements in public health policy and practice.


As the leading professional body for public health specialists in the UK, our members are trained to the highest possible standards of public health competence and practice – as set by FPH. With 3,300 members based in the UK and internationally, we work to develop knowledge and understanding, and to promote excellence in the field of public health. For more than 40 years we have been at the forefront of developing and expanding the public health workforce and profession.




FPH welcomes the opportunity to provide oral evidence before the Health and Social Care Committee of the National Assembly for Wales in relation to the Public Health (Wales) Bill, with a particular focus on electronic cigarettes. To compliment Professor Alan Maryon-Davis’ oral evidence before the Committee, I am pleased to attach below some brief headline messages in relation to this important area of legislation, which address some of the Committee’s central concerns.


FPH wishes to underscore at the outset that it is a signatory of the recent consensus statement on electronic cigarettes by Public Health England and eleven other UK Public Health organisations[1], and we are accordingly in strong agreement that:


o   The evidence suggests that the health risks posed by electronic cigarettes are relatively small by comparison with smoking

o   We must continue to study the long term effects and provide clear factual information

o   We must reassure the 1.1 million electronic cigarette users who have stopped smoking that electronic cigarettes are less harmful that cigarettes

o   We may encourage smokers to try electronic cigarettes, but should encourage them stop smoking cigarettes completely

o   Electronic cigarettes are the most popular tool, but local stop smoking services the most effective

o   We must encourage those who want to use ecigs to quit to seek local stop smoking services

o   In the UK regular electronic cigarette use is almost exclusively confined to young people who smoke, and youth smoking prevalence is continuing to fall – we will continue to research and closely monitor this.

o   We have a responsibility to provide smokers with info and tools to help them quit completely

o   As a sector we will share what we know and address what we don’t, to ensure clear, consistent messages


FPH further highlights four principal concerns, which make a powerful case for strong regulation of unlicensed electronic cigarettes, and for MHRA regulation of licensed electronic cigarettes:


o   The tobacco industry uses ecigs to promote cigarettes and gain access to policy makers

o   Ecigs may be a ‘gateway‘ to smoking among young people and current non-smokers

o   The efficacy of ecigs as smoking cessation aids remains uncertain

o   The safety of ecig has not been scientifically demonstrated


Accordingly, the ideal regulatory framework should prevent initiation among youth and other non-tobacco users and protect bystanders. It should maximise product safety and enable current smokers who would not or cannot otherwise quit to move to electronic cigarettes. In keeping with the aims of the consensus statement, the ideal framework should reassure the 1.1 million electronic cigarette users who have stopped smoking that electronic cigarettes are less harmful that cigarettes.


FPH notes that regulations already agreed under the 2014 TPD will come into force in 2016. These stipulate that electronic cigarettes can either be regulated as medicines (and then subject to the same marketing controls as medicines) or as consumer products (and then subject to the same marketing controls as tobacco).


FPH recognises the advantages of this approach, in particular the marketing controls it puts on electronic cigarettes. FPH is concerned about the high levels of marketing and exposure (e.g. through use in public places) that young people will be exposed to between now and 2016. As such it further welcomes the proportionate approach that the Welsh Government has outlined within the Public Health (Wales) Bill, which compliment the TPD and allow the achievement of the aims of the consensus statement. FPH further recommends that:


o   Comprehensive controls on marketing in line with the TPD urgently be implemented

o   Unlicensed products should be subject to the same comprehensive and binding marketing controls as tobacco products so that they cannot be marketed or advertised

o   Marketing controls should include bans on sponsorship of sports clubs/ events, events targeting young people, product placement, flavours appealing to youth and celebrity endorsement

o   No advertising or use should ‘re-normalise/glamourise‘ smoking and undermine prevention

o   All products, whether licenced as medicines or consumer products, should be required to carry a health warning clearly indicating the addictive nature of nicotine and detailing ingredients and their safety, and also encourage smoking cessation, with links to the NHS Smokefree website

o   Outlets selling electronic cigarettes should provide information on the dangers of smoking, the addictive nature of nicotine and encourage cessation

o   Until further information is available on effectiveness as a quit product, smokers should be Informed that the most effective means of quitting is via the NHS stop smoking service

o   Age of sale legislation on e-cigarettes should be actively enforced

o   A ban on use in public places should be introduced in order to protect bystanders

o   Products must be consistent in quality and deliver nicotine as effectively and safely as possible

o   Independent data on exclusive and ‘dual use‘ by socioeconomic status should be collected

o   Studies must be in place to detect any small changes in youth smoking rates in a timely manner


In light of evidence showing how the tobacco industry intends to misuse its claimed interest in harm reduction, the FPH stresses that full weight should be accorded to Article 5.3 of the Framework Convention on Tobacco Control.


UK Faculty of Public Health response to the Health and Social Care Committee’s key concerns


1)      The potential role of e-cigarettes in smoking cessation/harm reduction

There is some evidence that electronic cigarettes (eCigs) may have a role as an aid to tobacco smoking cessation (Bullen RCT, Cochrane Review). However, this evidence is limited and further RCTs are required to assess their effectiveness with confidence, as are trials examining long-term safety, which is so far largely unknown.


2)      The risks of e-cigarette use normalising smoking behaviour and the gateway effect (e-cigarettes leading to tobacco smoking). Acknowledging the current lack of evidence around this, is the Bill’s approach a proportionate one.


FPH supports the Welsh Government’s proposal to ban vaping in enclosed public spaces for several reasons, including:


a)    The toxic effects of eCig aerosols on bystanders are poorly understood, but clearly greater than zero.

b)    The nuisance effects are undisputed; some people find the vapour unpleasant or disconcerting

c)    The majority of vapers are cognisant of other people’s comfort, and promote an “etiquette code” to avoid causing discomfort. But many do not.

d)    Use of ‘cigalikes’ in public spaces will send powerful signals renormalising the appearance of smoking. This would be particularly undesirable with regard to the normalising effect on children.

e)    Use of eCigs in pubs, sports stadia and other public spaces risks undermining current smoke-free legislation. There are reports that some individuals have used a lit cigarette, then briefly substituted it with an eCig when challenged by a staff member, then returned to a lit cigarette when no longer under direct scrutiny.


3)      The risks of e-cigarette use normalising smoking behaviour and the gateway effect (e-cigarettes leading to tobacco smoking). Acknowledging the current lack of evidence around this, is the Bill’s approach a proportionate one.


FPH supports the Welsh Government’s proposal to regulate eCigs, particularly reflecting the concerns over a potential gateway effect. The gateway effect splits into two separate but related issues:


i.        Will marketing, role models and peer pressure result in children commencing eCigs who would otherwise not? The answer is yes; it is clearly not zero.


ii.        Of those children who use eCigs regularly, (many of whom will develop nicotine addiction), what proportion go on to be regular users of lit cigarettes who would not otherwise have done so? The answer is it is too early to say, but the evidence to date suggests that this could be a significant proportion.


The gateway effect is therefore real, but remains to be quantified in different subgroups of the child population. This transition is already being reported in teenagers in North America. We await data from the UK.


4)      Any evidence of an increased risk of harm from e-cigarettes for certain vulnerable people, e.g. those with asthma or respiratory illnesses, babies, pregnant women?


The risks would need to be considered separately for active vapers and passive vapers (breathing the invisible vapour in an enclosed space). We do not have specific and current information/knowledge about this issue.


With regard to asthma and respiratory symptoms, clinical experience in respiratory medicine would suggest that both active and passing vaping could be an aggravating factor. With regard to pregnant women and babies, there is evidence that nicotine is harmful. We lack evidence on the effects of substances in eCig propellants.

5)      In relation to workplaces that are also private dwellings (homes), does the Bill strike the right balance between a) the right of people to smoke/use e-cigarettes in their own homes, and b) the health benefits that might be seen as a result of restricting the use of e-cigarettes as well as tobacco in the home? Evidence about the effects of third hand tobacco smoke and residual vapours from e-cigarettes that is relevant to this context would be useful.


It would seem sensible to focus on protecting bystanders from secondary vape inhalation in enclosed PUBLIC spaces. Restrictions on vaping clearly should not exceed the current restrictions on smoke from lit cigarettes.


6)      To what extent will improved regulation under the EU Tobacco Products Directive address witnesses’ concerns about the quality, safety and labelling of products?


The TPD will provide a solid basis for regulation but does not address all our concerns.


7)      What might be the impact of the Medicines and Healthcare Products Regulatory Agency (MHRA) approving any e-cigarettes as medicinal products? How should this be dealt with under the Bill?


As with any pharmacological substance being marketed for a medicinal purpose (e.g. as a quitting aid) this can provide reassurance on safety.


8)      Is further action needed to reduce the risks of e-cigarettes appealing to children/young people? Can the Bill be strengthened in this regard, or would it require a different approach? 


FPH believes that there should be no marketing of eCigs to the general public. Only targeted messages to individual smokers via leaflets etc. in smoking cessation clinics and similar settings should be permitted.


9)      The provision to extend the ban on smoking and e-cigarette use to additional, non-enclosed, places (such as hospital grounds/children’s playgrounds as intended by the Minister).


FPH supports this proposal, as a logical step to address and minimise the risk of eCigs threatening to re-normalise the smoking process.


10)    The provision to exempt certain premises or parts of premises (this could be in relation to smoking and e-cigarettes, just smoking, or just e-cigarettes).


Exemptions would undermine the principle and the practice of the legislation. FPH strongly opposes any exemptions. For the same reasons that smoke-free exemptions were opposed by the majority of topic experts, and the totality of Public Health organisations.



For detailed evidence, please refer to:


·         FPH’s policy statement on electronic cigarettes:


FPH is also happy to provide further detailed evidence in relation to any specific matter as required.

[1] Public Health England, Joint statement on e-cigarettes by Public Health England and other UK public health organisations, September 2015,