Martin Dockrell, Tobacco Control Programme Lead at Public Health England (PHE), considers how vaping is changing thinking on smokefree policies.
“I only smoke at work. At home and with friends, I always vape”.
That is not the kind of thing you expect to hear from a colleague at PHE, but it is exactly what I was told when I visited one of our sites to discuss changes to our smokefree policy.
That is a problem, because when PHE, RSPH and others agreed our consensus statement on e-cigarettes, we said: “The public health opportunity is in helping smokers to quit, so we may encourage smokers to try vaping but we certainly encourage vapers to stop smoking tobacco completely.”
When PHE was first established, we adopted a temporary policy treating e-cigarettes as if they were smoked tobacco. After some careful thought and consultation however, we changed our policy. In contrast to the conclusive evidence of harm to bystanders from exposure to secondhand smoke, there is no evidence of harm from exposure to secondhand e-cigarette vapour and the risks are likely to be extremely low.
We wanted to make sure our own policy aligns with the advice we give to others, so now both smoking and vaping are prohibited indoors, but on PHE operated premises, vaping is permitted in the grounds but smoking is not.
A key plank of PHE’s position is that vaping is not the same as smoking. You might prohibit both but you shouldn’t treat them as if they are the same, and this was a ruling of a recent Employment Tribunal.
But not everybody agrees, and in the US, smokefree legislation has often been extended to include vaping. At a meeting with staff, one of the smokers had explained to me that our original policy meant that he had to go all the way off-site and, if he had to do that, the only way he would get the dose and duration of the nicotine he craved was to smoke.
Many will think “or he could just quit” and that is fair enough, but in effect he had quit. He only smokes when policies make it too inconvenient to vape. It was an interesting lesson in the unintended consequences of health policies.
I was recently reading a review of literature on outdoor smoking. The evidence of measurable exposure was stronger than I had expected and we know that there is no safe level of second hand smoke. However, the evidence that these policies actually deliver health gain is not so strong.
When England’s smokefree law first came in some said that we might simply displace smoking into homes and so do more harm than good. Fortunately, the evidence showed the reverse as more homes went smokefree. It seems England’s smokers said to themselves “I want to protect my children at least as much as I protect my work mates”, and now most smokers in England live in smokefree homes. But we should never be complacent about unintended consequences.
Smokefree policies have had a measurable impact on health but outdoor bans do not seem to deliver similar health benefits. The main health benefits of smokefree outdoor policies are likely to be from reduced youth uptake resulting from the “denormalisation” of smoking but this is hard to measure and harder still to tie to individual policies.
I was talking to a foreign civil servant on a study visit to London as he drafted national smokefree legislation. “I think it is likely that we will permit smoking rooms in public buildings. We have been so successful in getting smokers not to smoke outdoors we need to have somewhere for them to smoke”.
There is a certain logic in confining smoking to rooms where only smokers are harmed, but it does not square well with the evidence on effective smokefree laws. In practice when you allow smoke indoors, it is very hard to confine it only to the lungs of smokers.
But it got me thinking. What if our smokefree parks meant that parents who smoke (often the most disadvantaged) became less likely to take their children to the park? What if making the outdoor areas of council estates smokefree meant that more people smoked inside?
In the long term, the only answer is to evaluate policies rigorously, being open to learn from what went wrong as well as what went well. In the shorter term, we can anticipate some of the risks and design our policies to take account of them. It is plausible that policies that prohibit smoking but permit vaping encourage more smokers to switch.
By permitting vaping in the park but not smoking, smokers might be more inclined to try vaping. Once they have started vaping, they might then feel more able to make their homes smokefree.
Will it work? We will only know if we try it and test it thoroughly. After all, that consensus statement closed with an important pledge: “There is no circumstance in which it is better for a smoker to continue smoking – a habit that kills one in every two and harms many others, costing the NHS and society billions every year. We will continue to share what we know and address what we don’t yet know, to ensure clear, consistent messages for the public and health professionals.”