Public Health England and NHS England are hosting three one-day events with a practical focus on the current challenges and how they can be met, discussing implementation of tobacco control interventions and how the NHS can make its contribution, to the benefit not only of millions of smokers but its own sustainability.
London – Tuesday 4 April
Leeds – Wednesday 26 April
Birmingham – Thursday 4 May
Smoking rates in England have been declining steadily in the general adult population in recent years (17%), falling further and faster among young people (8%). However, hidden behind this success is slower progress among certain population groups, including individuals with mental health problems and those on lower incomes. Large geographical variations also remain, including amongst women who smoke during pregnancy.
Smokers from all groups are likely to be high users of healthcare services, with significant financial and capacity related implications. Addressing this will be key to ensuring NHS sustainability.
Reducing smoking is key to ensuring NHS sustainability and with the new national CQUIN for addressing risky behaviours (alcohol and tobacco) and local Sustainability and Transformation Plans, there is a fresh impetus for collective action to reduce the health inequalities caused by smoking.
to explore opportunities for action across the local system to engage with smokers and support them to quit, tackling health inequalities and reducing the burden on the NHS and social care of smoking-related disease.
identify key areas for joint action to tackle smoking and reduce health inequalities
understand where smokers are accessing the healthcare system and how this impacts on primary and secondary care services
consider the ways in which healthcare professionals can integrate treatment for tobacco dependence into routine care and support smokers to quit
Who should attend?
local authority and NHS commissioners
CCG leads for acute care, mental health and maternity
healthcare and service providers
those with responsibility for managing: Commissioning for Quality and Innovation (CQUINS), delivery of Sustainability and Transformation Plans (STPs), implementation of the stillbirth reduction care bundle
regional strategic leads for health improvement and clinical networks
As part of on-going work in relation to tobacco harm reduction, Knowledge-Action-Change is organising a series of dialogues, to examine the often contentious issues that attach to the use of electronic cigarettes, or vaping, in workplaces, places of entertainment and public spaces.
The series entitled ‘How safe is vaping? Media coverage, dilemmas and solutions in work and social spaces’ will take place:
Why these dialogues now?
There is still a lot of debate between scientists and policy makers about the nature, use and safety of nicotine containing products. The media has produced a lot of stories about e-cigarettes, not all of them either accurate, or supported by scientific evidence. Nonetheless these stories have an impact and can influence peoples’ thinking and reactions on issues. This dialogue is a place where everyone can bring their concerns, air them and hopefully become better informed about the products and their use.
Most vapers are former smokers who have switched to this safer way to use nicotine. Professionals working in public health largely accept that this is a much safer form of behaviour – for users and those around them – but there remain concerns about the impact of their use in some circumstances and in this dialogue we aim to identify some of these and try to address them.
What are the dialogues?
These short events are designed to enable interactive discussion and debate – involving public health professionals, academics and scientists, policy makers, consumers, owners and managers of premises and members of the public – on a range of issues surrounding the increasing use of safer nicotine products (including e-cigarettes) as an alternative to smoking.
During each dialogue a panel of speakers, representing different interests, each make short presentations, addressing different issues relating to e-cigarette use. Q&A and discussion involving the audience follow the presentations.
The dialogues are filmed with the proceedings posted on the web, with the aim of providing information to those who might be interested in the subject and to assist those charged with making policy in having a cross-section of views to draw upon.
Previous dialogues: Knowledge-Action-Change has produced a number of dialogues to date and some of these can be viewed here.
Fears that “vaping” is a gateway to tobacco smoking are unfounded, shows a comprehensive review of available evidence on the harms and benefits of electronic or e-cigarettes and vapour devices, released today by University of Victoria’s Centre for Addictions Research of BC (CARBC) in a report called “Clearing the Air.”
Researchers surveyed the rapidly increasing academic literature on e-cigarettes and found evidence that vaping is replacing—rather than encouraging—the smoking of tobacco cigarettes among young people. The CARBC researchers identified 1,622 articles on the topic, of which 170 were relevant to their review. Evidence shows that tobacco use by youth has been declining while use of vapour devices has been increasing.
“Fears of a gateway effect are unjustified and overblown,” says principal investigator Marjorie MacDonald. “From a public health perspective, it’s positive to see youth moving towards a less harmful substitute to tobacco smoking.”
Among their other observations, CARBC researchers found strong evidence that the vapour from e-cigarettes is less toxic than tobacco cigarette smoke. Vapour devices do not release tar, and vapour emissions contain only eighteen of the 79 toxins found in cigarette smoke, including considerably lower levels of certain cancer causing agents and volatile organic compounds (VOCs). Almost all substances tested were substantially lower, or not detected, in vapour devices compared to cigarettes.
In addition, vapour from electronic devices is airborne for less than 30 seconds compared to 18 to 20 minutes for tobacco smoke, substantially reducing the time of second-hand exposure.
Researchers caution, however, that some vapour devices may contain potentially concerning levels of metals and particulate matter, noting that there has been insufficient research regarding some significant carcinogens that may still be present.
Finally, they found encouraging evidence that vapour devices could be at least as effective as other nicotine replacements as aids to help tobacco smokers quit.
“The public has been misled about the risks of e-cigarettes,” concludes Tim Stockwell, CARBC director and co-principal investigator. “Many people think they are as dangerous as smoking tobacco but the evidence shows this is completely false.”
A media kit containing author photos, full report (for media only, not for publication), and an infographic is available on Dropbox. An executive summary is available here.
Connor  argues there is strong epidemiological evidence that alcohol causes cancer but highlights uncertainty about how this message may be understood by the ‘wider public’. We agree that there is public confusion and scepticism about public health advice on drinking, and that alcohol industry actors will seek to exploit this by ‘framing’ the debate in ways which further their commercial interests [2, 3]. However, there is also a pressing need to take into account the wider social context in which any new scientific evidence is introduced .
People have multi-factorial understandings of the causes of chronic disease which encompass family history, environmental factors, stress and luck, as well as behavioural factors such as smoking and drinking; these factors are perceived as interconnecting, rather than independent, and may become more or less salient at particular points in the life-course [5, 6]. Davison and colleagues [7, 8] argue that, in an iterative process similar to formal epidemiology, ‘lay’ epidemiologists extract information from mainstream health messages and observe patterns of illness and death among family, friends, acquaintances and those in public life to generate and reformulate hypotheses about ‘candidates’ for particular health problems. Gender, age and socio-economic status are also relevant here [9, 10]. Crucially, uncertainty is a key feature of lay epidemiology; some ‘candidates’ are observed to ‘do all the wrong things’ but live long lives (‘unwarranted survivals’: ‘the fat “Uncle Norman” figure who has survived into a healthy old age, despite extremely heavy smoking and drinking’) (, p. 682), while other people lead apparently ‘healthy’ lives but still suffer premature illness or death (‘anomalous deaths’). The ‘anomalous death’ of a relative is particularly important in undermining epidemiological evidence about risk factors for major diseases .
There are a number of reasons why the message ‘alcohol causes cancer’ may not fit easily with lay epidemiology. First, candidacy only indicates increased risk—not an inevitable outcome–so a message which emphasizes certainty rather than probability may be disregarded. Research investigating the acceptability of cancer warning messages among Australian drinkers  suggests that statements about alcohol leading to an ‘increased risk of cancer’ performed better than those which stated that alcohol ‘can cause cancer’.
Secondly, lay epidemiology encompasses an understanding of the different meaning of risk factors at the population and individual level: ‘most people have notions about what renders a person “a candidate” for a specific disease [incorporating “expert” epidemiological understandings of risk at the population level] whilst simultaneously understanding that life, health and death defy prediction at an individual level’ (, p. 445). Thus, simple health messages which focus exclusively upon behavioural risk factors at an individual level draw attention to ‘unwarranted survivals’ and particularly to ‘anomalous deaths’ in people’s social networks. The observation that behavioural change does not guarantee a reduction of risk at an individual level (mirroring epidemiological concerns about the ‘prevention paradox’) [11, 13] may therefore result in public scepticism.
Thirdly, while smokers are currently viewed as ‘candidates’ for cancer, it appears that drinkers are not; lay people struggle to find an explanation for non-smokers who develop cancer and instead emphasize the unpredictability and randomness of the disease . Finally, it is important to explore how terms such ‘drinkers’ and ‘drinking’ might be interpreted by the wider public. While ‘smoking causes cancer’ draws on the commonly understood binary opposition between smokers and non-smokers, ‘drinking causes cancer’ may well be understood as comparing ‘heavy’ drinkers with ‘light’ or ‘moderate’ drinkers, rather than contrasting drinkers with non-drinkers. Qualitative research in the United Kingdom demonstrates that drinking is perceived as a routine activity associated with sociability, pleasure and relaxation and that heavy weekend drinking and drinking to intoxication are normalized; thus, drinking alone or choosing not to drink alcohol are behaviours which require explanation, not excessive drinking in general [13, 15-17]. In addition, people construct themselves as responsible, moderate drinkers and position other groups as the ‘problematic’ drinkers. For example, respondents in mid-life portray themselves as ‘experienced’ drinkers and younger people as irresponsible ‘problem’ drinkers , younger adults position older people, especially older women drinking heavily in public, as problematic , while younger middle-class women position working class women as vulgar and excessive drinkers . This suggests that ‘drinking causes cancer’ may be interpreted as ‘other people’s excessive drinking causes cancer’.
Connor demonstrates the strength of the evidence for alcohol consumption as a cause of cancer. Further research on how lay people conceptualize drinkers and drinking when assessing candidacy is necessary before this message can be communicated effectively to the public.
Declaration of interests
C.E. is a member of the Alcohol Research UK Grants Advisory Panel and has received research funding from Scottish Health Action on Alcohol Problems. S.M. has no competing interests to declare.
Thanks to Kate Hunt, Charlie Davison, Una Macleod and Graham Watt for previous conversations about lay epidemiology, and to Penny Buykx for useful suggestions for literature for this commentary.
A new WHO report fails to properly evaluate the evidence on e-cigarettes and could even undermine international efforts to reduce smoking, says a group of UK based academics.
UK academics are calling for better understanding of the potential benefits of e-cigarettes to reducing the smoking pandemic ahead of an international gathering of countries that have signed the World Health Organisation’s Framework Convention for Tobacco Control.
The 7th session of the Conference of the Parties (COP) of the Framework Convention on Tobacco Control (FCTC), a global public health treaty, will be held in Delhi, India from 7th-12th November 2016. At this meeting, Parties to the treaty (countries and other jurisdictions) will discuss whether similar policy measures recommended to reduce tobacco use should be applied to e-cigarettes.
In advance of the COP the World Health Organisation published a report about Electronic Nicotine Delivery Systems (ENDS) and Electronic Non-Nicotine Delivery Systems (ENDDS), also known as e-cigarettes. This aimed to summarise the evidence about these devices.
Academics from the UK Centre for Tobacco and Alcohol Studies, a UKCRC Public Health Research Centre of Excellence, have today published a robust critique of the WHO report setting out a series of concerns about the content of the document which, in their view, does not fairly represent existing evidence on e-cigarettes. Their critique examines each element of the WHO report and identifies flaws in the way the evidence is presented and problems with how the report could be interpreted, potentially encouraging countries to adopt excessive restrictions on e-cigarettes which could undermine efforts to reduce smoking.
The UKCTAS critique points to evidence set out in the recent Royal College of Physician’s’ report ‘Nicotine without Smoke’ and subsequent research which recognise that e-cigarettes are far less harmful than smoking and that smokers who find it difficult to stop should be encouraged to use them.
The WHO report fails to accurately present what is already known about e-cigarettes. In particular, it: positions e-cigarettes as a threat rather than an opportunity to reduce smoking; fails to accurately quantify any risks of e-cigarettes compared with smoking; misrepresents existing evidence about any harms to bystanders; discounts the fact that e-cigarettes are helping smokers to quit; does not recognise the place of some promotion of e-cigarettes to encourage smokers to switch to these less harmful products; fails to understand that the flavours in e-cigarettes are useful for people trying to stop smoking; mischaracterises the current e-cigarette market and appears to support very restrictive policies on e-cigarettes without including any good policy analysis. In addition, the WHO report does not acknowledge that significant restrictions on e-cigarettes could lead to unintended consequences, including increases in smoking.
Finally, the researchers point out that the WHO briefing is based on four unpublished papers which are still undergoing peer review, which does not allow for open, transparent scrutiny of the evidence. This does not, therefore, provide a good basis for policy making and risks undermining rather than promoting the aims of the FCTC, which is a treaty that was designed to help countries reduce smoking rates and save lives.
Tobacco companies want to sell you cigarettes – today, tomorrow and for the foreseeable future. Whether you’re at the tobacco counter or out with friends, glitzy cigarette packaging is a really important part of their sales pitch. Tobacco companies are aware of this. It’s why they are so opposed to their cigarettes being put in plain packaging.
But why would these organisations lobby against plain packaging? On looking into these opposition groups, our recent research gives a clear answer. Opponents of plain packaging tend to have links to the tobacco industry. So much so that three-quarters of organisations identified in our study had financial links to tobacco companies.
Perhaps we shouldn’t be surprised. Decades of research into political activity by the tobacco industry has shown that “third parties” are used to campaign against tobacco-control policies. Health advocates are aware of this. In 2005, the World Health Organisation’s Framework Convention on Tobacco Control committed the countries that signed the convention to protect tobacco policy from interference by the tobacco industry and, crucially, groups linked to them. In response, in 2011, the UK government committed to publishing details of any policy meetings with tobacco companies and the Department of Health routinely requests disclosure of tobacco industry links. So far so good. In doing so, the UK sets a strong example.
Third party interference
But our research shows how “third party” opposition to tobacco control policies extends tobacco industry interference beyond this realm of government. In a three-year period which included the 2012 government consultation on plain packaging, 88% of research and 78% of public communications opposing plain packaging were carried out by organisations with financial links to tobacco companies (see figure 1). And public and retailer campaigns funded by tobacco companies to mobilise opposition to plain packaging generated 98% of the more than 420,000 negative postcard and petition submissions to the consultation.
In this way, ideas and arguments that come from tobacco companies and their research spill into public spaces. Once there, they can influence the public and political mood on life-saving tobacco control policies and create a misleading impression of diverse and widespread opposition. This is known in the world of political science as “conflict expansion”. And the potential effects are significant. When widespread, these “third party” activities can work to delay and even prevent policies: it took four years to get from consultation to implementation in the UK.
This wouldn’t be so serious if organisations and tobacco companies were open about their relationships. But, in many cases, links were not easy for the research team to detect. Of 150 examples of public communications, less than 20% explicitly acknowledged tobacco industry connections. And, while academics and research consultants tended to clearly report funding sources, “third parties” promoting their research in press releases, news stories and letters to government, frequently did not.
If they were open about their financial relationships with tobacco firms, business and civil society organisations would give the public, politicians and officials the opportunity to scrutinise their arguments and evidence in context. In the case of plain packaging, a lack of openness masked these links and lent credibility to claims that the policy lacked evidence and would increase the trade in illicit cigarettes – claims which have been shown to be unfounded by both peer-reviewed research and by the High Court in Britain. Now, as more countries move to introduce plain packaging, “third party” transparency remains an issue.
In order to help countries guard against tobacco industry interference, awareness can be raised of the effects of their activities on public and political debates. And steps could be taken to make their relationships with tobacco companies clearer. A compulsory register of tobacco companies’ memberships, political activities and associated spending would be a strong first move.
There is strong global commitment to addressing the problem of tobacco industry interference. Parties to the framework convention meet in India in November amid concerns about this issue, and the message to the tobacco industry from the WHO is clear: “The world understands who you are and what you do, and is determined to stamp out the global plague which you do so much to spread.”
New research released today shows no evidence that e-cigarettes are a ‘gateway’ for young people to start smoking. The annual survey, by tobacco control campaign group, ASH Wales Cymru, questioned more than 830, 11 to 18 year olds across Wales.
It has been a concern among health professionals since the rapid emergence of e-cigarettes that they would ‘renormalise’ smoking and act as a ‘gateway’ towards tobacco for young people.
Of the young people who reported using both e-cigarettes and tobacco cigarettes at some point, 90% had used tobacco first, suggesting the absence of any ‘gateway’ theory. The report confirms e-cigarette use is confined to current smokers or ex-smokers and they are rarely used among ‘never’ smokers.
It also showed more than 30% of the e-cigarette users had quit smoking altogether. Reasons for using e-cigarettes varied from taste, to friends using them, to wanting to know what they were like.
Young people from the poorest parts of Wales were 25% more likely to have used an e-cigarette compared to their counterparts in the least deprived areas of the country.
This was the first time the Welsh Health Survey had looked at e-cigarette use. It revealed that 6% of over 16’s stated they currently use an e-cigarette – 140,000 of the Welsh population. Use among never smokers was negligible at 0.06%.
Suzanne Cass, Chief Executive of ASH Wales:
“For the third year in a row our research confirms young people are not using e-cigarettes if they’ve never smoked before.”
“E-cigarettes can contain highly addictive nicotine and there is no need for young non-smokers to use the devices. We are pleased to see these latest results confirm that e-cigarettes are being used as a smoking cessation device, similar to nicotine patches or gum and at the moment are not acting as a gateway towards tobacco. E-cigarette users are now reducing the harm to their bodies caused by poisonous and cancer-causing tobacco smoke.”
Professor Linda Bauld from the University of Stirling and UK Centre for Tobacco and Alcohol Studies:
“There is a lot of confusion about the relationship between e-cigarettes and smoking in young people. Surveys from other countries do keep claiming there is a link despite youth smoking rates continuing to fall in the countries where these studies take place. This new data from Wales should reassure people that although young people are experimenting with e-cigarettes, we are not seeing regular use in never smokers. Meanwhile, youth smoking rates in Wales continue to decline, which is key to preventing cancer and other diseases that smoking causes.”
Ruth Coombs, Head of British Heart Foundation (BHF) Cymru:
“We are pleased that latest ASH Wales Cymru findings highlight encouraging trends to show that young people in Wales are not turning to e-cigarettes as a way to start smoking but rather as a way to reduce harm caused by intake of tobacco by cigarettes.”
In terms of awareness of e-cigarettes, a large majority of respondents (90.7%) were aware of e-cigarettes. When stratified by age and gender the awareness of e-cigarettes remained extremely high. As many as 88.5% of respondents under the age of 13 were aware of what an e-cigarette is.
The most common sources of finding out about e-cigarettes were: seeing strangers using them in public (45.9%), reading or hearing about them on the internet or social media (42.6%), being told about them by friends (42.5%), and seeing them or hearing about them in the media (42.5%). By contrast only a very small proportion of respondents found out about e-cigarettes from a youth worker (3.3%) or health professional (3.0%).
The majority of respondents (68.6%) have never used an e-cigarette, with 13.7% only using an e-cigarette once and just 10% currently using an e-cigarette. A higher percentage of males reported currently using e-cigarettes every day (6.8%) relative to females (2.2%).
Respondents from the most deprived parts of Wales were far less likely to have never used an e-cigarette (48.6%) relative to respondents located in the least deprived areas of the country (75.4%).
The vast majority of never smokers have also never used an e-cigarette (88.9%), with a further 8.2% only ever having tried an e-cigarette once. Just 0.6% of never smokers currently use e-cigarettes regularly (i.e. more than once a week).
The main reasons for using e-cigarettes for the first time were to see what they tasted like (48.7%), because friends were using them (40.1%), and for a bit of fun (30.7%). 22.1% of respondents cited using e-cigarettes to reduce their intake of tobacco cigarettes.
The vast majority of respondents (90.3%) who had used e-cigarettes and smoked tobacco cigarettes reported starting to smoke tobacco cigarettes first.
Of the respondents who had used e-cigarettes and smoked tobacco cigarettes at some point (n = 172) 25.0% smoked fewer tobacco cigarettes since starting to use e-cigarettes, with 34.3% of respondents ceasing to smoke tobacco cigarettes altogether.