Meeting:	Health, Housing and Adult Social Care Scrutiny Committee
Meeting date:	23/04/2024
Report of:	Peter Roderick, Director of Public Health
Portfolio of:	Executive Member for Health, Wellbeing and Adult Social Care

Scrutiny Report: Update on Vaping in York

Subject of Report

1. E-cigarettes, devices which deliver nicotine-containing flavoured vapour through electronically heating liquid, have been commercially available for around 15 years, and their use (henceforth, ‘vaping’) has rapidly grown as a trend.

2. It is estimated that of 9.1% of adults vape in the UK, 20.5% of children aged 11-17 have tried vaping and 7.6% are currently vaping (ASH 2023). Vaping presents society with a public health challenge. On the one hand, it has shown to be highly effective at helping existing smokers to quit the use of a product that kills half of its lifetime users (the cigarette). On the other, there are concerns around the take-up of vaping amongst non-smokers, particularly children and young people. Thus, we are in the strange position of recommending vaping to one section of the population (smokers) and discouraging its use in another section of the population (children and young people).

3. This report updates committee members on the latest trends, research, local developments and national policy on vaping, in order for them to take a view on our approach in York.

Policy Basis

4. Ending smoking in York is a key part of our local public health strategy; it is the focus of the Tobacco Control Plan 2020-2025, and is Goal 3 of the Joint Health and Wellbeing Strategy 2022-32.

Recommendation

5. Scrutiny committee are recommended to note and comment on this report.

Background

Trends in smoking and vaping nationally and in York

6. Smoking prevalence has fallen steadily since a high in the 1960s when up to half the male population smoked in the UK. Currently, an estimated 12.7% of the population smoke, and in York this is significantly lower at 8.7%. This equates to around 14,500 smokers in the city.

7. The secular trend in smoking in York shows a steady decline over the last decade, with rates approximately halving:

8. However, the current trajectory of smoking prevalence reduction will not, nationally, reach the target of a ‘smokefree generation’ by 2030, defined by the WHO as having national prevalence rates below 5%.

9. The harms of smoking are manifold and result, for instance, in around 1,450 hospital admissions and around 200 deaths per year in York. These harms are in some ways ‘baked in’ to population health within the foreseeable future due to historical smoking patterns (for instance lung cancer incidence rates typically lag behind smoking rates by around 20-30 years). However, reductions in smoking prevalence also have short-term positive benefits (e.g. in-year reductions in acute admissions for exacerbation of asthma), as well as medium-term positive benefits (e.g. reductions in 2-5 year rates of strokes and heart attacks) and long-term positive benefits (e.g. reductions in incidence of over 15 type of cancer).

10. The electronic delivery of nicotine has been around for decades, particularly through Nicotine Replacement Treatment (NRT) devices used in stop smoking services (for instance inhalators). However e-cigarettes which heat and vapourise flavoured nicotine-containing liquid have been commercially available for around 10-15 years.

11. The most solid evidence on trends in vaping comes from Action on Smoking and Health (ASH), who have been running YouGov surveys since 2013. In 2023 they estimated that 4.7 million adults vape in the UK, 9.1% of the population. 2.7 million (56%) of these vapers are ex-smokers,1.7 million (37%) are current smokers, and 320,000 are never smokers (1.1% of never smokers are current vapers, and 6.7% of current vapers are never smokers).

12. The ASH Smokefree GB Youth Surveys 2013-23 suggests that 20.5% of children aged 11-17 have tried vaping, with 11.6% of them having tried it once or twice, and 7.6% currently vaping either less than once a week (3.9%) or more than once a week (3.7%) (ASH 2023):

13. The ASH survey also demonstrates a number of trends in children and young people’s vaping, including:

- A plateaued vaping rate in children and young people at the end of last decade, rising in the years following the pandemic

- Greater rises in experimentation with vaping (trying once or twice) and much smaller rises in those regularly vaping

- An age gradient both for ‘ever’ and ‘current’ vaping, with older ages (16-17 year olds and 18 year olds) more likely to have done either than younger ages (11-15 year olds).

- significant growth in awareness of promotion of e-cigarettes, with only 20% of children and young people reporting not seeing vapes being advertising

- The three most common reasons given by children and young people for vaping have remained fairly consistent, and are in order, ‘just to give it a try’, ‘other people use them, so I join in’, and ‘I like the flavours’

- A large leap around 2021 in the proportion of vapes children and young people are using which are disposable – now around two thirds of all vapes

14. It is illegal to sell a vape to someone under the age of 18, and thus someone has broken the law (either through sale or proxy purchase) when a child vapes. The three most common methods of obtaining a vape reported in the ASH survey are, in order, ‘I buy them from a shop’, ‘purchased from friends or other informal source’ and ‘given’.

15. Another trend evident across smokers (of all ages) is around the perception of health harm. As the next section of this report demonstrates, vapes are significantly less harmful to health than cigarettes, however perceptions of harm amongst smokers have shifted in recent years and the majority of smokers now incorrectly believe that e-cigarettes are a lot more, more or equally as harmful as cigarettes (see graph). This has potentially damaging consequences for the usefulness of vapes as smoking quit aids.

Analysis

Current state of the evidence on the health impact of vaping

16. As an emerging and popular product, e-cigarettes have been subject to a large amount of scientific scrutiny to measure their potential harmful effect on the body. This research can demonstrate a great deal, but by definition does not yet include the types of study which stretch over decades and ascertains long term trends in health harm, or studies which are particularly good at picking up rare and unexpected events.

17. Globally, different approaches have been taken to public health advice on the health impacts of vaping. UK health agencies, for instance Public Health England and its successor the Office for Health Improvement and Disparities, NICE, the British Thoracic Society, the Royal College of General Practitioners, the Royal College of Physicians, the Royal College of Obstetrics and Gynaecology and the Royal College of Midwives, have generally concluded that compared to smoking a cigarette, vaping is 95% less harmful to human health, and as such it should be recommended to smokers as a valuable quit aid. This position has been reinforced by a series of evidence reviews on the international literature regarding vaping, published by Public Health England (later OHID) – the most recent is included as a background paper.

18. Internationally, for example the World Health Organisation (WHO) and Centre for Disease Control (CDC) have however been more cautious and while recognising vapes as far less harmful to health than tobacco, have not recommended their use so strongly.

19. ASH have produced a document ‘Addressing common myths about vaping: Putting the evidence in context’, which takes a number of common myths around vaping and answers them with the most up to date science and evidence. This is summarised below:

- ‘MYTH: Vaping nicotine is more harmful than smoking tobacco’ – there are 75,000 deaths from smoking each year versus 5 deaths related to vaping products in the last 12 years. Since 2016, the UK have prohibited the use of any ingredient in nicotine containing e-liquid that poses a risk to human health in heated or unheated form. There are over 70 years of evidence of the harms of smoking while vaping has only been around for 16 years, so we cannot yet be precise about the long-term risks of vaping. However, the most recent independent review of the evidence commissioned to inform the government’s policies and regulations published in 2022, concluded that vaping poses only a small fraction of the risk of smoking.

- ‘MYTH: Vaping is more addictive than smoking’ – how addictive a product is depends upon its design and mode of use. Cigarettes carry the highest risk of addiction as they are designed to facilitate the inhalation of nicotine-laden smoke deep in the lung. People addicted to nicotine because of smoking who switch to vaping may remain addicted, but they are reducing their risks of relapsing back to smoking which is far more harmful. The method of acquiring nicotine from a vape is different to that from smoking, so one draw on a vape will result in less nicotine than the same on a cigarette. Therefore, to receive the same total amount of nicotine, a vape needs more draws than a regular cigarette, which can give the perception of “more addiction”.

- ‘MYTH: Disposable vapes deliver as much nicotine as 50 cigarettes’ – Cigarettes generally contain 10-15mg of nicotine per stick, which is 200-300mg per 20 pack. A vape with the highest legal level of nicotine (20 mg/ml) and size (2ml) contains 40mg of nicotine. It is worth noting that most vapers use vape liquid with around 1-3mg/ml of nicotine.

- ‘MYTH: Vaping is a proven gateway into smoking’ - If vaping were a gateway into smoking at population level, as vaping increased smoking rates would be expected to show a reduced rate of decline or start to increase. To the contrary between 2010 and 2021 when e-cigarette use grew rapidly from a low base in England, smoking rates among children continued to fall at least as rapidly as previously, which does not support the gateway hypothesis at population level.

- ‘MYTH: Nicotine damages brain development in young people’ - NRT is on the World Health Organisation list of essential medicines because there is good evidence of efficacy, safety and comparative cost-effectiveness. NRT is licensed by the MHRA for smoking cessation, not just by adults but also by young people from age 12 upwards, pregnant women and people with cardiovascular disease.

20. It is important to recognise that e cigarettes are tightly regulated in the UK, with the use of any ingredient in nicotine containing e-liquid that poses a risk to human health in heated or unheated form prohibited. The Tobacco Products Directive, which came into force in the UK in May 2017, restricts vapes to 2 millilitres of e-liquid with a nicotine strength of 20mg per millilitre or under in any single product, a much lower nicotine threshold than elsewhere in the world.

21. The harms of vaping compared to not vaping are only a fair comparison if the individual is not an existing smoker. If they do smoke vaping has been shown to be the most effective quitting aid, and the Smoking Toolkit Study (an ongoing series of monthly surveys of the adult population of England) has shown a clear association between changes in population rates of quitting smoking and prevalence of e-cigarette use after adjusting statistically for a range of potential confounding factors. If the association is causal, then the use of e-cigarettes in quit attempts appears to have helped in the region of 30,000 to 50,000 additional smokers to successfully quit each year in England since 2013. In the words of the Chief Medical Officer, “If you smoke, vaping is much safer; if you don’t smoke, don’t vape.”

Smoking and vaping trends amongst children / young people in York

22. The School Health and Wellbeing Survey was commissioned by City of York Council Public Health. This is the second large scale survey on the health and wellbeing of children and young people in the city carried out between 2021 - 2024.

23. The latest survey took place between November 2023 and January 2024 and included questions on vaping and smoking. Five year groups across all publicly funded schools in York were invited to participate: years 4 and 6 in primary schools and years 8, 10 and 12 in secondary/sixth form schools. Altogether we heard from 2,956 children and young people in the city.

24. In 2023 a quarter of children and young people in York aged 12-17 years had tried vaping, up from around a fifth in 2021. The majority report experimentation having only tried an e-cigarette once or twice (9%) and 3% report using e-cigarettes every day. There are no noticeable differences between boys and girls.

25. Most primary school children say that they have never used an e-cigarette (71%) or heard of e-cigarettes (19%). None reported using e-cigarettes every day. Around a quarter of young people aged 12-17 years said that they ‘don’t know why’ they vape and 32% said that they use/used an e-cigarette ‘just give it a try’. ‘I like the flavours’ was the reason given by 11% of young people in York.

26. Most secondary/sixth-form children in York wrongfully believe that vaping is ‘about the same’ (42%) or ‘more harmful’ (17%) compared to smoking cigarettes. However, despite this the number of children and young people vaping in the city continues to rise. Most primary school children say that ‘I don’t know’ (42%) if vaping is more or less harmful than smoking.

27. The majority of young people in York say that they are given vapes by friends or that they buy them from friends, relatives or someone else. Disposable (non-rechargeable) vapes are the most frequently used (33%). However most young people aged 12-17 years say that they don’t know what type of vape they use most often (44%).

28. In 2023 90% secondary/sixth-form children in York have not smoked a cigarette, rising to 95% of primary school children. Like with vaping, the majority report experimentation having only tried cigarettes once or twice. Less than 1% say that they smoke more than 6 cigarettes a week. This is similar to the 2021 survey when 10% of 12-17 year olds said that they had used cigarettes and most did not smoke regularly. Most young people in York say that they are given cigarettes by their friends.

29. A fifth of secondary/sixth form children report living with an adult who smokes, rising to 24% of primary school children. This is similar to the 2021 survey which found that around a quarter of children and young people in the city were living with an adult who smoked.

30. 100% of secondary/sixth-form children who took part in the survey said that they did not know where to get help to stop smoking or vaping, despite having a youth stop smoking and vaping offer within the CYC Health Trainer service.

31. Based on the above findings, as well as national evidence presented in this paper, the public health approach to vaping in York has two separate strands:

· the offer / advice to smokers, which does incorporate support to use vapes as quit aids;

· and the offer / advice to our children and young people, where we seek to discourage vaping, minimise the advertising and marketing of vapes, and work in partnership to reduce vaping rates over the next years.

Local work on smoking and vaping through the CYC Health Trainers

32. The Council’s Health Trainer service sits as part of the Public Health department. The service offers free, 1-1 support and guidance to residents of York on how to effectively quit smoking. At present, the service offers 4 weeks of Nicotine Replacement Therapy or e-cigarettes, alongside behavioural support to enable a successful quit attempt.

33. The service sees good outcomes, with 75% of residents who set a “quit date” going on to successfully quit 4 weeks later. This is a national standard for measuring quit effectiveness of stop smoking services in England. In 2022/23 245 residents set a quit date, with 184 successfully quitting (75.1% quit rate). For Q1-Q3 of 2023/24 225 residents set a quit date, with 170 successfully quitting (75.6% quit rate). We have the fourth best quit success rate in England.

34. The health trainer service is a person centred, behaviour change offer, where the focus is on facilitating behaviour change and being user led to meet their outcome goals. As such, service users are given advice on the different nicotine replacement devices, and encouraged to utilise the device they think will work best for them. In some instances this is solely NRT or solely and e-cigarette, or in others it may be a combination of NRT and e-cig (using a NRT patch to provide a background level of nicotine, alongside the e-cigarette as a secondary device to control cravings).

35. In 2022/23, 52% of quit attempts used NRT only, 31% used NRT and e-cig, 16% e-cig only and 1% used no nicotine device. In terms of quit success, e-cig only users were most successful 83% achieving a 4-week quit, then NRT & e-cig combined with 80% success, then NRT only with 74% success.

36. Included at Annex A is a feedback form from a stop smoking service user, a 77 year old man from the north of the city named Ollie. He highlighted that he had tried to quit before, but was unsuccessful as he couldn’t get to grips with the NRT, quickly re-lapsing and returning to smoking. He was delighted to try an e-cig and was able to successfully quit smoking using the device.

37. Across the Health Trainer service, using an e-cigarette is seen as a means to support a successful quit attempt from smoking cigarettes. The long-term goal is to also stop using the e-cigarette, by slowly reducing the strength of the nicotine e-liquid and then coming off the e-cig altogether. This is where the behavioural support offered by the health trainers is vital, to help smokers understand the habits and behaviours they have formed, alongside the addiction (to nicotine).

38. In response to local concerns about increases in children vaping, the service has a dedicated offer to support 12- to 17-year-olds to stop vaping. The team will offer NRT if required, but most often it is the behaviour change support alone that is required. The service works will all secondary schools across York, alongside the council’s Healthy Child Service School Nurses.

39. As a further additional support for schools, a resource pack has been created which includes postcards, posters, letters and presentations. The resources can be placed across the school, with the letters sent home to parents and the presentation is designed to be used by teachers within PHSE lessons. The Health Trainer service manager has worked closely with school leaders to promote the support available to schools, including the distribution of printed materials to each secondary school in York. The service regularly attends both school leader and pastoral leads meetings.

Local work on smoking and vaping by CYC Public Protection

40. During 2023, Public Health funded the CYC Public Protection team to develop a retailer vaping scheme. The team visited all known vaping retailers in the city, be that specialist vape shops, supermarkets or smaller independent retailers such as newsagents.

41. The scheme was designed to remind retailers of their responsibilities under legislation for the correct age of sale of vapes and to check for potentially illicit vapes that were for sale.

42. In November 2023, Trading Standards Officers visited 8 premises in the city with underage volunteers to ensure that advice on refusing children was being followed. Only one premises sold vapes to a child (14 year old) and a prosecution is pending.  

43. In March 2024, due to intelligence gathered via the retailer scheme, the Public Protection team seized over 1,000 illegal vapes worth over £13,000. This seizure was only from two shops within the city, and highlights that there is further work to do on clamping down on the sale of illegal vapes in York. 

44. The Tobacco and Vapes Bill described below contains a number of new measures on vapes, which will lead to greater responsibilities for local trading standards department to enforce in this area.

Recent national policy – the Tobacco and Vapes Bill 2024

45. The Bill, under primary legislation, will make provision about the supply of tobacco, vapes and other products, including prohibiting the sale of tobacco to people born on or after 1 January 2009; and to enable product requirements to be imposed in connection with tobacco, vapes and other products. It will do this by:

· making it an offence to sell tobacco products to those born on or after 1 January 2009, thereby phasing out the sale of tobacco products while not stopping anyone who currently legally smokes from being able to do so. This will mean anyone who turns 15 or younger in 2024 will never legally be sold tobacco products

· amending existing legislation to make it an offence for anyone over 18 to purchase tobacco products on behalf of those born on or after the 1 January 2009 (proxy purchasing)

· supporting the enforcement of the new measures by requiring retailers to update the current age of sale notices (or warning notices), so that any retailer that sells tobacco will need to state clearly that ‘It is illegal to sell tobacco products to anyone born on or after 1 January 2009’

· ‘On the spot’ fines of £100 to be introduced to clamp down on underage sales of tobacco and vaping products

46. The Bill also has secondary legislation relating to reducing the appeal of vaping to children. It will do this by:

· restricting vape flavours

· requiring plain packaging

· controlling how vapes are displayed in shops

47. The government has also committed to ban the sale and supply of disposable vapes from April 2025 under separate environmental legislation.

48. The Bill has had its first reading in Parliament on 20 March 2024, and it’s seconding reading on 16 April 2024. There are several further stages it must go through such as Committee and Report, before it moves to the third reading and MPs can vote on the legislation, before it then goes on the House of Lords.

49. Additionally, in the Spring Budget, the government announced it was introducing a new duty on vaping and increasing tobacco duty from October 2026. A 12-week consultation on the policy design and technical details was launched at the end of March. The proposed vaping duty rates will be:

· £1.00 per 10ml for nicotine free liquids

· £2.00 per 10ml on liquids that contain 0.1-10.9 mg nicotine per ml

· £3.00 per 10ml on liquids that contain 11mg or more per ml.

Contact details

For further information please contact the authors of this Report.

Author

Name:	Peter Roderick
Job Title:	Director of Public Health
Service Area:	Public Health
Telephone:
Report approved:	Yes
Date:	09/04/24

Name:	Phil Truby
Job Title:	Public Health Specialist Practitioner Advanced
Service Area:	Public Health
Telephone:	07767 318091
Report approved:	Yes
Date:	09/04/24

Background papers

Action on Smoking and Health [ASH] myth buster - https://ash.org.uk/uploads/Addressing-common-myths-about-vaping-ASH-brief.pdf

OHID: Nicotine vaping in England: 2022 evidence update main findings

Nicotine vaping in England: 2022 evidence update main findings - GOV.UK (www.gov.uk)

Tobacco and vapes bill - https://bills.parliament.uk/bills/3703/publications

Health trainers vaping resources - https://www.york.gov.uk/HealthTrainersToolkit#vaping

Annex

Annex A – Stop Smoking service user feedback – Ollie.