 Good morning, and welcome to the 34th meeting on the health, social care and support committee in 2023. I've received no apologies for this meeting. The first item on our agenda is to ask Ruth Maguire to declare any interest relevant to the committee's re-mit. No interest to declare, thanks. Thank you, Ms Maguire, and welcome to the committee. The second item on our agenda is to decide whether to take item4 in private. The third item on our agenda is an evidence session on the public health impact of vaping. We will be hearing from representatives of Public Health Scotland, anti-smoking charities and academics with expertise in tobacco control and vaping. For this morning's session, I welcome to the meeting joining us remotely, Professor Emily Banks, head of the Centre of Epidemiology for Policy and Practice Australian National University, and visiting Professor in the Field Department of Population Health, University of Oxford. Professor John Britton, Emeritus Professor of Epidemiology, the University of Nottingham. With us here at committee, Sheila Duffy, chief executive of Ash Scotland and Dr Garth Reid, consultant in Public Health Scotland. We'll move straight to questions, and Ivan McKee. Thank you very much, convener, and good morning panel. I'd like to explore a bit about the issue of prevalence of vaping amongst young people, and we've certainly been given some data, which kind of sort of shows a picture, but to be honest, there's lots of different data points all taken from different cohorts at different times, asking different questions. I'd like to get your sense of what you think the data is telling us in terms of the prevalence of vaping amongst young people, what that looks like by different age cohorts, if you've got a sense of that, and also if there's any sense of how that is moving over time, is that increasing over time? So I don't know who wants to start. Will I start with that, and then maybe some of the other panel members might want to chip in. So in terms of children, as you say, there's no single survey which asks children about vaping every year, but we do have three representative surveys of 13, 15-year-olds, and we have those data since 2015. What they show, if I break it down into 13-year-olds and then 15-year-olds, so for 13-year-olds in 2015, 1% reported currently vaping, and then that's risen to 10% in 2022. There's then a similar picture for 15-year-olds with 2% reporting currently vaping in 2015, and that's risen to 25% in 2022. The biggest increases have been in the most recent years as well. So I think that really what we're seeing is that increase in youth vaping from a very slow level. In context, for adult vaping, what we're seeing is a flatter picture which varies around 5%. So it does seem to be that we've got a different picture between adults and children. I don't know if any of my colleagues would want to come in. No, you've given a comprehensive answer and all they feel you need to add to. Thank you very much. I suppose the following on from that, if you look at that in terms of the, which I believe is still a reducing number in terms of young people smoking, again you can clarify on that. Would the data suggesting that this is hard to know obviously in absolute terms but looking at those numbers, does that suggest that young people are moving from who would normally, who would perhaps in the past have smoked or vaping instead or do the number suggest that this is much more substantial than the reduction we're seeing over that time period in terms of young people smoking? So again, so what we're seeing in children is a much better picture in terms of smoking. So youth smoking has been dropping consistently for probably over a decade. So that's a really positive picture and that I think for 15 year olds that's dropped to about 4%. So we've got really low numbers of kids smoking and that's excellent. We want more of that obviously in public health. We want less kids to smoke and stopping kids starting smoking is an absolute priority. To go to your question though, if we've got 25% of 15 year olds vaping compared to 4% smoking, we're not seeing a picture there of just the smokers were switching. There's obviously a whole big group of kids who are taking this up who weren't smoking or I think that would be fair to say, hopefully the panel would agree. I don't know if you would, okay. Here is what percentage of 15 year olds were smoking in 2015 and I'm assuming it wasn't 25%. I'm assuming it was a lot less a lot less. Yeah, we could come back to the committee with things that figure about a lot less. No, thank you that because that would help to fill out that data picture. Are you comfortable that the data that has been that there's enough data being collected on this or is there a need for more data collection to give us a better picture? You could always have more data. I think that the the excellent thing about the Scottish Health Survey is that it's collected annually and I think that then that gives us this not real time picture but a really current picture of what's going on for adults in terms of their smoking, in terms of their vaping. I think in terms of for young people we don't have that picture anymore. So relying on these different surveys which are running in slightly different sort of sequences in order to make that data up as you said earlier. Okay and just to be clear when you talk about young people vaping is this have ever used it, occasionally use it, use it on a very regular basis? Current use, so current use of vaping. So the numbers of ever having tried would be higher than that. Right, so using it on a regular regular basis. Is there any breakdown beyond that in terms of characteristics of young people socio-economic background, gender, whether parents smoked anything like that? Yes, so the health and wellbeing census study has looked at this and there's some detail within that. So for example what we're seeing in youth vaping is that there's higher numbers of children across all of the different quintiles, all the different socio-economic groups who are vaping but unlike smoking there's actually sort of higher levels in so in with smoking we're seeing a picture where it's very socially patterned and really in the most deprived areas sadly we've got the highest levels of smoking in adults and in kids. We're seeing a flatter picture with vaping so there's more kids are vaping in more affluent areas compared to smoking if that makes sense. But it's still the same picture in terms of inequality. I don't have anyone else who wants to contribute to any of that. Sure. Just really wanted to say how pleased I am to be here speaking to you. I'd like to add first of all to support the comments made by my colleague Garthread and also to say that what we are seeing just looking at the data from Scotland but also seeing that more generally internationally is an increase in overall nicotine use in young people in teenagers. So it's not it's not a pattern consistent with people moving from smoking to vaping. It's more of a picture of continuing declines in smoking but actually quite rapid increases in vaping that exceed smoking prevalence and mean that there's an overall increase in nicotine use. The other comment about the differences in social patterning is also seen in other places that there's a more general distribution of use of e-cigarettes or vaping and less of a social gradient compared to smoking. That's really helpful. Thank you very much. Emma Harper. Thank you, convener. Good morning to everybody. Just to pick up on a question on Ivan McKee about data. So as a registered nurse, I understand that when somebody comes into the hospital through medical assessment unit, they are asked, do you smoke, yes or no, and if it's yes, then they're offered smoking cessation, can a pathway. So is that question extended to do you smoke or vape, yes or no, and then smoking cessation offered that way? And then also what do we do in paediatric admissions? Because it's kind of difficult to ask paediatric patients that question, especially if their mum or their dad are sitting there, like when they come in with a shortness of breath. The first thing we think is, well, that might be an asthma attack, but it might not be. It might be as a result of high doses of nicotine and vaping, for instance. Is that something that we're pursuing right now, because I understand that some health boards ask that question, but others don't? Yes, so this is an area that we're looking at at the moment, and it's sort of a live investigation. So I think in terms of your question, where it's not clear how consistently that question is being asked by health professionals, this is a relatively new and emerging issue. So I think that it is being recognised as being important more now in a clinical setting, but that's one of the things which we're investigating at the moment and one of the factors we would need to be confident about before we could publish official statistics on this, because we need to know how this is being handled clinically in that setting. So the MHRA, the Medical Health and Research Authority, have issued guidance for all healthcare professionals to ask consistently about vaping, and I think that's a really useful message, and I think that would really help. But we're looking at that right now with colleagues in hospitals, you say, and also GPs. I would also like to bring in the issue around the Scottish Government's health and wellbeing census that found that young people living in the most deprived areas are more likely to regularly vape than those in the least deprived areas. There is a risk that this could compound the existing health inequalities that already exist in Scotland. Is there a way we can make sure that the socioeconomic context and disparity in health outcomes is part of the evidence on chronic health harms of vaping going forward, and has this evidence featured so far? So what we see from the health behaviour in school-age children's survey in Scotland is that uptake, and with tobacco, there's a period of uptake that doesn't necessarily settle into regular use very quickly, but we are hearing reports of a huge rise in children and teenagers vaping of the easy availability of these highly-coloured, sweetie-flavoured, cheap products driving that rise in the last couple of years particularly. From the 2021 Scottish health survey data, we see that its current e-cigarette use is four times higher in SIMD1 areas compared to SIMD5, so in the more deprived areas. Jewel use with lit smoke tobacco is six times more common in the more deprived communities, so I would agree with you that this is a huge concern for widening inequalities and health inequalities. Can I just clarify something there? Because what Sheila has said, there seems to contradict both what Garth and Professor Banks had said about vaping being very much similar across socioeconomic groups. I was talking about the Scottish health survey, which is adult use. If you look at children who smoke in all deprivation categories, the rate of experimentation and use tends to be fairly similar, but if you fast forward a few years, there's a very clear disparity and inequality. Thanks for clarifying that. Thanks, convener. It's a helpful clarification. How do we monitor the links between vaping and certain health conditions? Should GPs, for example, or any medical professional, ask the patients if they vaping and record this as part of their medical records, for example, or is another way that this is being done or monitored or the data gathered? I think that's a really good question and this is what we're looking at. The advice is that all healthcare professionals should ask consistently about vaping and have that recorded. That would include GPs, obviously, as well. I think that it is really important that this information is collected clinically. No country has cracked this in terms of... Emily Banks might talk about the health harms later. It is a really new and emerging area, but I think that we've got the opportunity in Scotland to look at that and to look at clinical practice. The country is small enough that we can actually get the key people together to look at how we're going to tackle this together. I think that that's key and Scotland's got a really good track record of doing that. I'm really hopeful, although this is a real worry and a problem, that we can really look at this with clinicians. That's helpful. Has there been any data gathered about A&E presentations or people who have sought medical assistance due to concerns that may be linked to vaping? Is there any data that you know of? We've looked at the A&E data and there doesn't seem to be information that's coded as vaping-related disorder within A&E data. I think that shows you how new this issue is in terms of the uncertainty around quite a lot of the bits around it and also probably the inconsistent vaping histories that are being taken. Obviously, A&E is extremely busy and there's an awful lot of things which have to be done so we need to be mindful about how we do that in a way that's constructive and mindful of their other pressures as well. Thank you very much. Just also wanted to direct a question to Professor Banks for me. Your review of public health evidence published last year found evidence of acute harm such as seizure poisoning and nausea amongst others associated with vaping. Does the evidence show of these harms which we are seeing now are improved if and when a person stops vaping or is the damage potentially permanent and that these complications are persisting even after vaping is stopped? In our report, we found evidence of e-cigarette harms, particularly for non-smokers and for young people, and they included intentional and unintentional poisoning toxicity from inhalation, which can include loss of consciousness and potentially seizures, and also the less serious effects. Also, vaping is associated with lung injury, and that's predominantly because of tetrahydrocannabinol and vitaminy acetate, and then as we're going to talk about increased uptake of smoking, most of those things are acute and short term and will resolve once the person stops. The single most common and serious side effect for young people in non-smokers is actually addiction to nicotine, and that can be quite hard to kick, but once somebody stops and actually is past that addiction, although people can have lifelong cravings in general, that won't be long term. I think the exception there is, and the other issue we see is burns and trauma. If you can imagine burns and trauma, if you've got a serious burn and they have been deaths from exploding batteries, so those things can have lasting effects and lung injury can have lasting effects, but most of the effects that we see, including addiction, will resolve after the person ceases use. One of the major issues we identified in our review is actually uncertainty about a lot of the effects of electronic cigarettes, so we don't really know what they do to cancer, to cardiovascular disease, to reproductive health, so actually it's quite hard to say for some of them. If you don't know what the overall effects are then to say whether those effects are lasting or not, there's a lot of uncertainty. And you think it will be decades before that full time series is available to fully assess the life cycle on a human lifespan? Well, I'm optimistic that we do have an international community and national communities who are committed to finding out more about electronic cigarettes effects, so I think we can say that we probably will get more information much more rapidly than decades, but we do know from some exposures it can take decades before we know what they do, but I think we already know a lot more about e-cigarettes in this timeframe than, for example, we knew about smoking in the given timeframe, just because we actually understand a lot more about how to assess risk. I think Professor Britt, I'm going to do it. Oh sorry, please. Professor Britt? Can you hear me okay? Thank you and thanks for inviting me too. I'm sorry I couldn't send a message and to say I wanted to speak because for some reason I can't type into the message box so I had to wave my arm around, sorry. I just wanted to add a little bit of context to Professor Banks' comments there that the magnitude of the harm effects of e-cigarettes are unknown. She's quite right about that, but all of the early indications are that they're very modest. Since 2010, the MHRA, the UK Drug Regulator, has collected what are called yellow card reports on adverse effects from vaping, and that is where doctors fill in a report because they have just seen a patient with something that they think could have been caused by vaping. Now, not everybody does this. It's far from a complete reporting system. It does operate as a sentinel system, a bit like monitoring infectious disease. It tells you when something's happening. Since 2010, there have been five fatalities linked to vaping in the UK reporting on to the system and about a thousand adverse effects. By context, since 2010, about a million people have been killed by smoking. Whilst it is unequivocal that vaping is not harmless, it's the magnitude of these adverse effects is extremely small. Professor Banks also referred to acute lung injury caused by vaping tetrahydrocannabinol and vice-miniacitate, and that is true in an epidemic that broke out in the year before the pandemic in the United States, and that was a serious epidemic of major disease that killed hundreds of people. It was linked to the use of illicit cannabis vaping fluids produced illegally in a garage somewhere in middle America, and when the vitamine acetate was being used to cut the cannabis oil in the vaping fluids because the practice had become so popular there was a shortage of cannabis oil. There was vitamine acetate that was causing the illness. There is no vitamine acetate in nicotine vapes, and when the cause was identified, the epidemic disappeared. It isn't true to say that vaping causes major lung injury when we're talking about nicotine vaping and vaping licit contents. Sorry, Sheila. Did you just want to come in briefly on that, and then I'll come to that? If I may briefly, just to say that we have conclusive evidence that e-secret aerosol contains particulate matter of the kind that has been implicated in mechanisms like lung inflammation, DNA damage and a subsequent risk of lung cancer, and a lot of the evidence we have is from air pollution, but it tells us to be wary about saying these things. I think if you make a comparison with tobacco, smoked tobacco absolutely agree with Professor Britton about the relative harms, but if you make a comparison with not using anything and breathing fresh air and people who initiate particularly as young people, I think there are huge question marks that we should not be complacent about. If you think about tobacco, it was popularised by being given free to the troops around the time of the First World War, but from the 1920s to the 1950s, some doctors were actively recommending patients to smoke because of the short-term benefits and weren't aware of the long-term harms, so I think we need to just keep that caution in mind. Thank you. I think Professor Banks wanted to come back in on this point too. Thank you very much. I think it's really, really important that we do pay attention to both the nature of the harms that have been identified and their magnitude, so I think the first thing to say is, and obviously I served for seven years as the chair of the advisory committee on safety of medicines for Australia, so I'm very familiar with the reporting systems, and I think they're very important for medicines and for particular adverse events that doctors will see that they can link to a specific exposure. They are more problematic when you are looking at a moderate increase in risk, so if you wanted to say, well, is regular vaping in young people linked to increased asthma risk, that's going to be difficult for a doctor to link cause and effect in front of them. I would say that we know that addiction to nicotine is a serious harm for young people and it tends to, because the brain is plastic at that age, addiction in youth tends to set the scene for and increase the risk of addiction later in life, and we know that 52.1% of the e-cigarette users who were 11 to 17 in the most recent ASH survey said that they had moderate to extremely strong urges to vape, so, and we certainly hear plenty of case reports of addiction, and I think that we underestimate addiction. I know my kids say, oh, I'm addicted to chocolate or I'm addicted to this particular television programme, but if you are addicted to, particularly nicotine is a highly addictive substance, you're going through a cycle of withdrawal and craving and irritability before you satisfy that urge, and you can be going through that many, many times a day because nicotine is quite rapidly metabolised. So we have kids who have difficulty sitting through a lesson or sitting through a meal with a family who are experiencing addiction, and so I think we have to be careful about what we can know from reporting systems and where we need other kinds of data, but also to appreciate the breadth of health effects that nicotine and the other things in e-cigarettes can have. A more technical point regarding the Ivali outbreak which peaked in September 2019, which Professor Britton spoke of, it was absolutely largely attributed to illicit substances in vapes, but in the CDC reports, one in eight cases was actually linked to reported use of standard vapes, and we've certainly seen intermittent cases of lung injury where there were not illicit substances indicated, but it's obviously not of the magnitude of the Ivali outbreak, which caused 68 deaths and of 2,800 hospitalisations. Good morning to panel members. Can the witnesses provide an overview of the strength association between nicotine, brain development and mental health problems? Professor Banks, do you want to come in first and then we'll go to Professor Britton? Well look, I'd be quite happy for Professor Britton to go first actually, because I've spoken quite a bit just then and then I'm happy to speak. Okay, thanks. There is evidence that particularly from animal models that exposure to nicotine during brain development leads to evidence of adverse effects when in mature animals. In humans, nearly all of the available evidence is derived from studies of smokers, so we know that smokers have impaired cognitive development. There is the theory, as Professor Banks has alluded to, that that might set the scene for greater preliction to other addictions in late life, but studies of pure nicotine in humans are pretty few and far between and extremely difficult to disentangle statistically the effect of vaping from the concurrent or preceding effect of tobacco smoke. I agree entirely with the earlier comments that what we're seeing or you're seeing in Scotland and we're seeing in England and elsewhere in the world is a big increase in young people vaping who would not otherwise have smoked and I think that needs to be addressed, but nevertheless the majority of people who vape regularly were smokers or are at very high risk of becoming smokers if they don't vape and come from families where people do or did smoke, so it's very hard to separate out the effects of vaping nicotine in those human populations, so I would say that the risks of future mental health disease as the question asked are more theoretical than real and are, though I'm not writing them off, but are more theoretical than real, but if they did exist would be unlikely to be substantially different from the status quo of about 20 years ago when smoking was so much more common. Would you like me to add to that now? So absolutely, it's one of the difficulty series disentangling what is a nicotine related issue and what is a smoking related issue, all we do know is that nicotine itself is highly addictive and that e-cigarettes particularly the nicotine salt products are capable of delivering nicotine very high concentrations very rapidly and we are seeing nicotine addiction in children. I think we do have clear evidence that nicotine addiction in childhood predisposes to nicotine addiction in later life, that's part of why the tobacco industry and related industries are targeting aggressively targeting children and adolescents in their marketing to create those lifelong customers. We do also know from reports among children that they are experiencing issues with addiction to e-cigarettes. We also know that there's a lot of distress and actually stigma related to becoming addicted to e-cigarettes because the idea is that you will just use this highly addictive product socially and it's seen as failure among some people to become addicted to it. We also know that there's a close and complex relationship between nicotine addiction and mental health problems where there will be people who will say well I'm vaping to relieve mental health problems but we also know that addiction creates mental health problems and that particularly cessation of smoking but I think we're getting more evidence on vaping can improve mental health so I think there are things that we do know but I think there's also the issue of a lot of long-term uncertainty and I think one thing that's important to remember with e-cigarettes is that when people inhale the aerosol or emissions from an electronic cigarette they're generally getting nicotine but they're also getting the products of the e-liquid which includes propylene glycol, vegetable glycerine and usually flavouring and other additives and the latest analyses of just four brands of e-cigarettes are between 900 and 2,000 distinct chemical entities many of which are unknown and a number of which are known and are hazardous so it's not just about the nicotine there's a lot of other products other emissions and particulate matter in what is being inhaled. Professor Britton, as a respiratory consultant are you seeing an increase in the number of young patient and as a result of vaping and how are you presenting? Well I should say I'm a former respiratory consultant I did 30 years of it but I am retired from that and I was an adult physician during my time of working which therefore finished in 2020 I didn't see a single admission of anybody who was in hospital because they vaped and we very actively recommended smokers smokers who come to hospital with lung disease who are still smoking are hardcore smokers and we would very much encourage any method of quitting smoking albeit conventional medicines or electronic cigarettes because I have to say that electronic cigarettes were by far the most widely used in children there in the UK certainly in England there have been anecdotal reports of increasing admissions of children excuse me and one or two very serious cases of lung disease which have been written up in the literature again there is a big problem that at least some of those people were smokers and have come into hospital with diseases that can certainly but with lung infections that are certainly more common than smokers but could also have been triggered by vaping but the numbers remain very small they are growing but they are very small and could I just come back on one other point sorry about the the content of toxins in vapour I agree with Professor Bounce there's a lot of stuff there and we analysed the first year of reporting of emissions that were registered with the MHRA from 2016 to 17 so by law vape retailers and suppliers sorry manufacturers and suppliers have to submit analysis of vape content to the MHRA now it's their own analysis nobody checks it we have no idea how reliable these numbers are they could be made up for I know but if we take them as face value as as as reasonable and valid we found that there was a very wide range of chemicals in vape and in vapour itself but with adjustment when we estimate the concentration of most of those contents in the low after inhalation of the vapour the levels of those constituents were typically below european standards for occupational health so there is a lot there but their levels are very low we have no idea what long time exposure to those things will mean and I suspect though it will mean that in 50 years time we'll be seeing some cases of lung cancer and pulmonary fibrosis and COPD and heart disease caused by vaping but whereas lung cancer cases are currently in the tens of thousands I would expect the numbers of those cases to be in the tens or the hundreds at most but there so there is a wide range of toxicants in the vapour but their levels are typically not exclusively but typically very low we've had comments made about elicit substances in vapes and that being a product of harmful outcomes for people who are using vapes has been put to me before that some vapes been sold in the UK of nicotine levels in them which exceed the legal limit and do the panel have any knowledge of this how can we monitor product safety more robustly and strength and regulation and particularly imported vape products from from china for example at the sea professor of britain and maybe then we'll go to this stuff here thanks you're right that elicit vapes are getting into the UK some of them contain very high levels of nicotine that in and of itself if the vapes are being used by smokers may not be such a bad thing the 20 milligram upper limit in the european directive of 2014 always struck me as an arbitrary level but in terms of what we do to stop it I would say we enforce the laws that we already have in place these products shouldn't be on the market at all to be on the market they should have registered the product with the mhra if they haven't registered with the mhra it's a legal product and it's illegal to sell it to people so it is illegal to sell vapes to people aged under 18 it is illegal to sell vapes that aren't registered with the mhra these are elicit products so asking what we can do my first answer would be to police what is on the market and close down those retailers and suppliers that are not registering their products and then beef up our trading standards to make sure that sales to children don't happen I think there's a where this leads is the possibility of somehow prohibiting vaping producing vapes and that is a policy that Australia has gone down the route of and Professor Banks may differ but it seems to me that vaping levels among children in Australia are not remarkably lower than they are in the UK despite that the products are illegal so I think it comes down to policing and enforcing compliance with law rather than thinking about what else we could do we've got laws we're just not enforcing thank you so I would agree elicit is an issue and is a problem I have heard from the society of chief officers of trading standards Scotland that they are aware of a regularly used route for elicit products coming into Scotland that come from the republic of Ireland through Belfast to kenrair ending up in the north of England and there is no easy mechanism at the moment for controlling that because trading standards don't have the powers that please have and HMRC apparently don't deal with elicit e-cigarettes in the way that they do deal with elicit tobacco so I think we need to join up some of the enforcement that we have on the question of elicit though I would say elicit is always the go-to argument for tobacco companies against any meaningful health regulation and the fact that an elicit product may or may not kill you faster than a legally sold product does not reassure someone in Europe described it as jumping out of the 23rd floor of a tower block rather than the 21st so I note that the e-cigarettes are a range of products they're not one thing they are four or five different types of devices some of them modified in different ways they are there are over 30 000 eliquids registered on the mhra site and as professor britain said they're not tested they are just informed as to what's in them and then they can be legally sold the fda decided that wasn't good enough and they decided that they would look at and scrutinise what could be legally sold they had 6.7 million applications for authorisation so far they have authorised only 23 and none of those has flavourings so I think we need to be clear that this is not a pharmaceutical medicinal product because nowhere in the world is there positive medicinal product that is an e-cigarette professor britain if there's a bank sorry I wanted to back him thanks I think that I would support that often it's about if you're talking about illicit trade and illicit products the main thing to do in that situation is better enforcement and enforcement is critical there um I'd like to note that in Australia e-cigarettes are legal on prescription so unless you're thinking you know antibiotics are prohibited um e-cigarettes are not prohibited in Australia they are available on prescription and in addition um the current statistics are that use among 15 year olds is lower in Australia than in many other parts of the world but we do have a problem with enforcement we have the same we have similar issues in terms of enforcement and so while we have the regulations in place we are now working to enforce those regulations and I think I think it's also important to note that many of the issues that we see with e-cigarettes um are actually similar between those products that are legally available and those that are illicit in that they largely relate to nicotine and then they relate to the products of heating, propelling, glycol, vegetable glycerin and flavours to a high temperature and inhaling them we do know that the higher concentrations particularly of the nicotine salt products um can be you know are probably more are more addictive particularly to young people and I think the other thing that's probably worth talking about is that where you have open and refillable systems there's an a recognised issue with um illicit drugs um being you know they're being used to deliver illicit drugs including opioids um so it's it's not just about um illicit nicotine products but it's also about other illicit substances Dr Ravita first name is just to say that the uh so I agree with the point about tougher controls absolutely I think that's that's a really good point is also just to note for the committee that the mhra so the regulatory authority for medicines is got a yellow card system and so it and what you can use that for is if there's any products which um there's any concerns about that look to be illegal then they've got this surveillance system that um again what certainly all healthcare professionals should use so we can send the link to that but I think that's a really useful function that they provide as well as trading standards so these things work together with the the different types of surveillance yep so just a point of clarification so I think in Australia the government has followed through on what was in this consensus statement which said these products are of interest to health in so far as they could help smokers move away from lit smoke tobacco and in Australia this is not a positive medicinal prescription it is a check that people have the chance to be fully advised of the options available to them for quitting smoking before they are then allowed to buy cigarettes which are not then regarded as permitted as recreational products in the way that they are here the risk of particulate inhalation um there are some products that have no nicotine that might be perceived as risk free as a result of having no nicotine do you still regard there being risks associated with that then I'm not sure the particulates are linked with the nicotine to be honest right and um a lot of the products that are advertised as nicotine free when tested in various studies have been found to contain nicotine and some of the illicitly sold products when tested haven't been found to contain what they were notified as containing so I think there's an awful lot of unknowns this if there's no other comments thank you Emma Harper just to pick up quickly around um she'll will know that Dr Jonathan Coots came to the lung health cross party group and I'm the co-convener of that and we presented about vaping especially with young people and so in terms of thinking about um the way it's targeted and and you know I'm really concerned about a whole raft of new interstitial lung diseases and I can say that as I've got close links with our nurse consultant in respiratory medicine um Phyllis Murphy who happens to be my sister so we've explored the whole issue around um future lung ill health for young people and Dr Jonathan Coots talks about how um the alarming rise from 3% to 43% in the number of teens using e-cigarettes you know that's reversed a lot of the work to eliminate nicotine exposure and the inaddiction so I'm interested in how concerned are you about about whether it's illicit or not this is about exposing young people directly to nicotine which is going to cause them harm I think I'm very concerned because of the massive rate of uptake we have seen and heard reported since about autumn 21 and it's driven by products that are marketed pretty much entirely at children through bright colours, sweetie flavours, the way they're designed, the price point, the availability we've got twice the failure rate of underage sales for e-cigarettes as we do for tobacco according to scots and that's about 20% failure and they are highly addictive the disposables which have driven this massive uptake among children are pretty much universally at the highest permitted level of nicotine for the UK and they use nicotine salts which are smooth on the throat and make it easier to use and therefore to become addicted and they're in sweetie flavours which have their own concerns about health harms and my experience is the pediatricians are extremely concerned and are warning us that they feel that there are huge risks here and we should be getting on top of this massive rise in youth uptake Do you want me to carry on with it? So when looking at again it's Jonathan Cootsie's work a lot of the companies quote the research by not at all at 95% e-cigarettes are 95% safer than standard cigarettes but that study was 12 invited people that took part in this study so it wasn't peer reviewed it wasn't really I suppose those and two of the people that participated in this study had financial links with the vaping industry can you job by memory Sheila about that 95% argument that e-cigarettes are 95% safer? I think it is probably irrelevant because it was in the early days of cigillikes and there have been so many more iterations and devices since then it was considered at the time of the Scottish consensus statement and universally rejected by the panel which included people with a range of views because it was felt to be methodologically and scientifically unsound and Professor Coots gave a very comprehensive explanation of that and also unhelpful because it gives the impression that e-cigarettes are safe and while we know that let's smoke tobacco is lethal and will reliably kill between half and two thirds of its consumers when use long term is intended that is not an excuse for therefore encouraging people to think that e-cigarettes are safe when we know that there are serious current concerns and huge question marks for the long term health and then I brought up smoking cessation earlier about questions for people admitted to hospital and things like that do you think that the fact that the colours that you're talking about in the sweetie flavours and everything is that an inhibitor then to cessation of nicotine devices and how do we I guess support a better transition to have people move away from cigarettes and I know people say yeah we use e-cigarettes as a to help smoking cessation but where do you feel we are now when it comes to the flavours and the colours and the way and the way that that's been used to I suppose encourage people to pick up e-cigarettes so we know that we have products which are available on NHS prescription free to people in Scotland who want to quit the evidence I've seen is not yet a clear endorsement for e-cigarettes to quit for everyone it it it pertains I think to a very narrow slice of smokers who may find them helpful but the commercial impetus and the argued the marketing and promotions that are behind these devices are absolutely driving their uptake where people might previously have used nicotine replacement therapy which is pretty much in the same ballpark of effectiveness I think the absolute goal that we haven't fully explored yet is how we strengthen people's motivation their readiness to quit and and their ability to quit and the environments that support those quit attempts and that's what we're hearing from low income communities in Scotland that cigarettes are highly addictive highly habit-forming e-cigarettes feel pretty addictive also people want to move away from that addiction and they want to move away to be free from it and is there a danger that like I suppose that a flavour ban could also deter adult smokers from making a switch to vapes I mean should I know it's very complicated how we encourage people to stop smoking but I mean if we banned flavours would that not help people stop smoking I think we've heard arguments for flavours when we thought about alcolpops in the past and the question is who are these flavours mainly being targeted at and if you look at some of the names of the flavours that are out there you know blue lemonade and sort of you know it's sweetie flavours it's part of the marketing so New Zealand's actually restricted its flavours to the flavours only that are available in tobacco. Denmark's banned all flavours because they've said it's too much of an added health risk and if you want to get off tobacco the flavour now isn't a particular plus for you so why wouldn't moving to something flavourless be acceptable and I think again we're getting into the is it a recreational product is it a medicinal option most medicines are only flavoured very carefully and for good reason. Professor Britton was looking to come in as was Professor Banks. Okay if I go first I mean I'll preface what I'm going to say by a statement again that I think the rise in vaping in adolescents people who would not otherwise have smoked is an issue and needs to be addressed and there are ways that we could think about going for that and incidentally just in relation to Sheila's earlier comment or question about why HMRC don't get involved in illicit supplies of e-cigarettes as I understand it they get involved in tobacco because there's an excise duty on it and they don't want to lose the excise duty there's no excise duty on vape so there's no interest in in policing their import there were a number of things there that I wanted to come back on you asked about nicotine and pulmonary fibrosis there is to my knowledge no evidence linking nicotine inhalation with pulmonary fibrosis pulmonary fibrosis is a very rare condition which is increased in smokers but to a very in in terms of numbers is very small so I wouldn't focus a risk on pulmonary fibrosis but I would say interstitials lung disease not pulmonary fibrosis and I was really talking about nicotine it's the other inhalational bits that are in there like these other components okay no that that's fine that's fine but that's not nicotine sorry and you said you were worried about the association between nicotine and you said interstitial lung disease which results in pulmonary fibrosis at chronic on cessation I think Sheila is right that the Cochran reviews and the NYS review and in fact the MHRA's 2010 determination that anything that contains nicotine is likely to be an effective stock smoking aid mean that e-cigarettes are about as effective as combination nrt or varenicline which is the best of the non nicotine drugs the difference with e-cigarettes is that they are available over the counter as a consumer product so a smoker who has probably tried to stop smoking umpteen times and failed and doesn't want to put his or her head up over the parapet and say look I'm going to try again and I'm probably going to fail doesn't have to make it public doesn't have to go to a GP or a pharmacist to get help they just walk into a shop and make a discrete choice for themselves and that population reach of a consumer product eclipses the population reach of the services that we've been promoting so hard for 30 years so it's not just a matter of efficacy it is has to do with population reach and the reach of e-cigarettes is much greater than other stop smoking products the final thing about the flavours is that it's if you the ash data for the UK apart from other sources suggest very strongly that smokers find unflavoured nicotine and even tobacco flavoured nicotine there's a non smoker I find this very hard to believe they find it intolerable to inhale and flavours are what make it tolerable so you are right if you say if we ban flavours we will discourage the use of e-cigarettes by smokers who are absolutely right it's what is wrong is the kind of marketing that Sheila has alluded to which makes these flavours attractive to children if we look at what's on current cigarette packs in England and in sorry in the UK and in Australia it's the name of the brand and one descriptor in a single standard font on a plain background if we do that with flavours and they become generic flavours orange vanilla whatever smokers will still be able to access them but children won't be bombarded with attractive images akin to the alcohol problem that's all I wanted to say thank you okay thank you I was going to just mention nhs quit your way is a one thing that has been taken forward obviously but I think does there need to be a revision in how we promote and support people to quit smoking and nhs quit your way as part of how we help people stop smoking absolutely I mean I think you know you can see in the discussion today that a lot of the evidence is emerging a lot of the things are contested with different opinions and I think if we focus on things like cessation it's sort of too late so we need to focus on prevention we need to turn off the drivers that are actually causing kids to start vaping and to start smoking and so we know that these are things around price so you know if products are dirt cheap then kids will be able to afford them also the availability of products as well so if you can get them in every shop that the kids go to and it's easy to to get hold of them that's going to drive kids to use them too and these are not products for children kids know that because it's illegal so kids are having to go out their way to get hold of these so we do need to have more enforcement but we need to also just think about the broader drivers and to make sure that we're addressing them so there might be differences of opinion around flavours but I think actually there'll be a lot of agreement on some of the other drivers you know as John was talking about in terms of you can have flavours but you can't call it child names that children are going to find appealing the same with the colours there's no reason that these products need to be the colour that they are that it's going to be appealing to children if you look back pre-pandemic if you can remember that far back it feels like a lifetime ago but at that point what these products looked like was they were black and they were chrome and they were big and they were quite technical you had to know how to use them now these products are small and they are brightly coloured and they are very cheap and they're in every shop and so it's easy for kids to hold them in their hands that it's easy for them to conceal them in their pocket so I think in terms of what we can do I think if we get hung up on some of the things we don't agree on and some of the problems I think that distracts us away from some of the things we can do and I think that that we're proposing having a round table on e-cigarettes including Emily and it'd be great if John could be part of that as well and Sheila where we look at what we can do actually in Scotland and Scottish Government as well and that so bringing together all the different stakeholders to look at how we move forward on this because I think when we if we do that there'll actually be a lot of things that we do agree on it's very easy to get distracted into fighting about differences on the little bits of evidence and for talking about sensation I think it's too late and then just finally I think we have to always remember to focus on tobacco control and tobacco and tobacco smoking because that is the thing that is still killing 8,000 people every year in Scotland so we need to make sure that anything we do on e-cigarettes complements and builds on what we've done on tobacco. Ruth Maguireann. Just a brief supplementary and I would acknowledge everything you've said there Dr Reid about the importance of prevention but I suppose something that Professor Britton said there about the population reach and the sort of lack of stigma around adults I know we're specifically talking about children, adults being able to go in and buy these vapes does that not maybe tell us more about how we have to approach the cessation and health for adults that's not really a pro vaping point is it that's maybe something for us to reflect on about how we how we provide assistance to citizens to make choices that are healthier for them absolutely and I think that so the quit your way approach which was mentioned earlier I think is a really good example of person centered care so Luke asks the person who's wanting help and putting them at the centre of that I suppose journey and asking them how they want to quit so we within that would want to have some of the longest standing evidence promoted first that people have talked about already so NRT patches and gum behavioural support but I think if people want to use an e-cigarette to quit then the view at the moon in Scotland is that that we would not turn people away and they'd be unable to do that because we want to have a person centered care approach as opposed to saying oh well we're not going to do that for you and we know better and so it's really about putting the person at the centre thank you thanks I believe professor banks wants to come in on this point thank you I would 100% support what's just been said in that I think what happens often when we think about tobacco control people go immediately to products for individuals to see smoking but actually the things that are really the most effective for tobacco control are if you consider broadly what we're trying to do which is to reduce smoking uptake and increase cessation and reduce harms then we and and also once you get to a lower smoking prevalence happily where we are trending towards in Scotland it's increasingly driven by young people not taking up smoking and the measures that work at the population level are those measures like price bans on advertising plane packaging health warnings smoke free spaces going hard as possible on those and those motivate people to quit as well as reducing uptake individual smoking cessation is actually a relatively small part of of that and I understand that it's you know that that for people who deal face to face with those individuals it's very meaningful but if we're looking at a population level those broader drivers are actually in many ways more important and and so when we actually look at those um and we ask people who have quit smoking successfully what they did the majority actually quit unaided so so actually the the number who actually need a specific thing to help them quit smoking is is not the majority of smokers um and then there are approved products available and as as we've heard varenical and you know a lot the things that are and that are actually appropriate there so we have to be careful that we don't magnify the importance of things like e-cigarettes and then we have to say in this situation we look at our population in Scotland I think we're looking at about 15% or fewer current daily smokers in the whole population which means 85% of the population are not current daily smokers so we've got that picture of the population and we have to look after both of those groups of people um and if we have a product that is harmful for for the 85% and beneficial for a minority of the 15 or so percent we have to think very carefully how we're going to tread the balance there and quite often it's being portrayed that if you do anything to reduce availability of e-cigarettes for smokers um that is a really big problem and we can't do measures that will actually protect young people um that might disadvantage smokers and I think we we as a community we're everyone's struggling with this um but but it's often brought into you know that we have an industry that is very interested in in aggressively marketing these things to young people and it's kind of a bit of a Trojan horse or across between a Trojan horse and Pandora's box like a Trojan or Pandora's horse or something but brought into the community saying this will help adults to quit and when you open it up outcomes bubble gum flavored vapes that are being used by children in the toilets and and that's not what any community wants and we also know that internationally there's a lot of variation in how people are dealing with it uh 35 countries don't have e-cigarettes available as consumer products and that covers about 41% of the world's population a further 25% or more of the world's population are in countries that heavily restrict flavors and that actually includes China which is only allowing tobacco flavored e-cigarettes for its internal market but it also includes the Netherlands it also includes Finland so it's not out of the question to try and get think about that balance and what balance you want to strike thank you in jillian mckay thanks convener um just to build on what we've we've just heard from from professor banks of i've hosted a couple of round tables on vaping and parents and professionals raised concerns about flavors and price promotions and how they're being marketed to children and actually how those things interlink in terms of of marketing to children as well from a very quick look through a vaping selling website which which incidentally also only took one click of a button that says yes i'm 18 to get access to it in the first place flavors like rainbow orange gummy bear grape gummy bear prime which any parent watching will know how popular that soft drink is with with children and young people vimple crush of course which is a brand of juice often given to children super mix which shares its name with haribo sweets and there are even even christmas flavor special editions popping up there are also multi buy offers and cash back offers on the disposable vapes so to what extent does the panel believe that a ban on disposable vapes would make a difference to children and young people and stop some of this marketing so i think we saw the rise in children's experimentation and use directly as a result of disposables or limited use e-cigarettes before that it was mainly adults there was some experimentation but very little and that was for about seven years so i would say these products are responsible for children's uptake a massive rise in children's uptake and we have an opportunity in scotland to address that we also have an opportunity to recognise that these are uniquely dangerous environmental products because there are very few throwaway electronic products and most of them i would say do not have toxic chemical soap sponges plastics metals particulates and tiny electronic components and lithium batteries which is a further health risk and health hazard so i think the scottish parliament has the opportunity to move fast on limited use disposable e-cigarettes and other countries like france and netherlands ireland are very interested in doing so i think it also has a unique opportunity to lay the regulations before this committee to enact legislation that was debated and passed by the scottish parliament that would allow for shutting down the colourful bright displays in shops the billboard and bus shelter advertising the free samples and sponsorship and brand sharing so those are two things i think this committee could consider recommending back and the other one is is more frequent and better data so we actually can understand what's happening and how things can change i agree with shillers points on that i think that so laura young has done really excellent work shining a light on this issue to do with disposables and the environmental damage that they're doing so i think that there's two reasons to look at disposables as shillers said so one is that children are using these and then the other part is the environmental damage that they're doing so i think that they're two really strong pillars to to support that i think as well though the there's no magic bullet here that's going to reduce youth vaping so we need to have a combination of approaches so if you look at your website that you're on there and the price of the disposables i would guess would be the cheapest product if you go and look at the tanks on it they'll be more expensive so we need to make sure that disposables are if there's a ban which i would support as well for for those reasons but it's part of a broader package of measures that's also going to tackle these other drivers and if we leave them still in place then it's unlikely that disposables on the run and that legislation would be successful the pervasiveness of marketing and product placement is also something that's been raised the advertising standards authority website says that ads for nicotine containing a cigarettes not licenses medicines are prohibited on on demand television and newspapers magazines on the internet and emails and in text messages but in reality product placement on tv shows people using them in youtube videos on instagram vaping in twitch streams is all exposing young people on top of that the number of shops that i'm sure we've all seen with windows full of vapes signs on doors advertising that they have vapes back in stock when back in the day that used to be that they had pokemon cards back in stock which is definitely showing my age it means it repeated exposure for young people is something that's happening every day as they walk around their their local environment does the panel believe that more could be done to limit this exposure and do we need to see social media companies in particular taking action to make sure that there is either a content warning and that nicotine products are being used in some of these videos or that actually it's against the community guidelines at all to be able to use them on twitch streams or in youtube videos i think that would be an excellent thing to do and so i think again it's this combination so i think marketing is one of the key things to tackle as well and there might be some areas where the scottish parliament you know could legislate on it but there might be other areas that i think with marketing that might be done at a uk wide level so i think it is important to work you know across the different countries to make sure that we can try and protect children you know there's no reason why we should have advertising of vapes with in content that is designed for children i think so i don't think anyone would want to to see that so i would support that and i think that the idea of plain packaging or displays as well is part of that picture too so and part of that is about the denormalisation of these products so they're not something in which children are thinking are products for them so i think that that we need to sort of send that message to children we've done that through the fact that they're illegal but then they're everywhere and they're very cheap so you can pick them up with pocket money prices so children pick up on these cues so i think we need to make sure that we're being consistent in our messages to to our children that's great can i ask you to be very brief we have not a lot of time left and a lot of members who still want to ask questions professor banks oh so um i would agree that um the disposable high concentration nicotine salt products have been clearly attributed to the they've clearly driven youth use and the US surgeon general and the canadian health authorities have said the same thing but they are we are seeing really quite aggressive marketing of these products to children and bands need to be quite creative to stay ahead of the industry and the ways that they are getting around a lot of these so i would also support scotland not only um really thinking about how to restrict advertising but really keeping abreast of the tactics that industry is using to market them and thinking about how to maintain innovation in regulation alongside the innovation of industry thank you er test week thank you convener um a question for Sheila duffie if i may um the branding and sales tactics for single use vapes is prolific compared to cigarettes today and it's now these which are clogging the drains and littering town centres so i'd ask you to comment on that please i think you're absolutely correct i think we are seeing the tobacco industry playbook playing out with these cigarettes they are very carefully targeting young people including through targeted social media and influencers that we will never see unless we know someone of the target age group um but i also think we need to think ahead because uh as professor bank said the industry is constantly reinventing itself and innovating it's very hard to keep up we're seeing a rise in concerns about nicotine pouches targeted at young people we're seeing snus which it cannot be legally sold in this country turning up uh among and used among influencers of young people thank you and a follow-up question Sheila duffie in your opinion should the sale of vapes be brought in line with cigarettes and hidden behind the counter we would support that because what we're healing from enforcement officers is that clear category regulation makes them it makes it easier for them to do their job thank you thank you thank you i know we're tight for time and we have discussed i'm interested in regulation in the link with public health which um professor bank spoke about um but we have also talked about in the marketing section the sort of heavy influence from the industry um and i just want to be clear in terms of where we're going in the Scottish Parliament with public health and the way we should be going you know are there undue influences from the tobacco companies or similar companies um around our public health um intentions if people are aware of anything like that sure duffie thanks so i would say very definitely we are seeing tobacco companies bouncing the messages that favour commercial addictive health harming products and their whole portfolio of products including cigarettes because the predominant pattern we see in scotland is dual use with 42 of vapers also dual using with tobacco and i think what's new in my experience working in this field is the huge rise in kind of third party influencing through so called consumer groups but they are massively funded they operate internationally and through third parties who are funded by tobacco companies but it isn't always apparent where that funding is coming from so i think we're going to have to think through and adapt because it isn't just as straightforward as tobacco companies thank you anybody else dr ed noy thank you i degree with that and i think you know article 5.3 of the framework convention for tobacco control which is about making sure that the tobacco industry isn't influencing political decision making and legislation is one of the cornerstones of of public health and a really good example of making sure that we are not influenced by tobacco industry so i think that that is a really is a really positive and important thing sorry i should have added that at 10 o'clock today the tobacco industry interference index was published it's run among 90 countries in the world the UK has always been exemplary started off in first place in year one in years two and three it was in fourth and then third place we're still not bad but we've plummeted to 21st place we are not protecting health policy as effectively as we used to and that really does need to be addressed thank you thank you can be there thank you and we'll go to sandish gohani thank you and just to declare my interest as a practicing NHS GP um a couple of quick questions if i may professor britain um i'm listening to what's being said do you think vaping is safe no i don't think and i don't think any serious academic or practitioner who's taken any interest in vaping would say otherwise it's definitely not safe it's just not as harmful as smoking absolutely i couldn't agree more about how it is safe and smoking but it's not safe but i wonder if a lot of people think that it's safe and i think the the prime minister has spoken about wanting to to stop 14 year olds from smoking going forwards um and that's something that i very strongly support is this something that we should be looking to introduce for vaping um i think it's a really good question um and difficult because um insofar as vaping is is an alternative to smoking and a way out of smoking um and i well i i would like to take issue with with professor bank's comment that most people quit without any help at all because far more of them would quit if they did use help and e-cigarettes our help so i wouldn't want to cut off access to e-cigarettes for smokers i think in the first place we could do a great deal more to stop adolescent never smokers from using vapes by making them less attractive to look at putting them out of sight putting excise duty on disposable vapes and take stock but bringing in a minimum age i don't know whether that would work or not to be honest nobody knows whether it'll work for tobacco either but i'm very pleased that Rishi Sunak has taken the plunge and is following that policy because it makes sense and if i could ask um Sheila from ash um right now if you were to vape where you're sat um you would be advised that you're not allowed to vape but you're not actually breaking the law so so my question is should we bring in regulation um that basically puts tobacco and vape in the same piece of legislation for everything so we we categorize it the same in law i think in terms of uh clean air in public spaces personally i would say the move at European level and the evidence suggests we should be looking at safe spaces smoke and aerosol free environments and that would include heated tobacco products as well as e-cigarettes and lit smoke tobacco products my question was specifically about legislation should we put vaping at the same as as cigarettes and tobacco i think it would be helpful to have category legislation for all tobacco and related products it would be helpful for enforcement um i would recognise that tobacco is by far the most lethal product and one of the ways New Zealand's dealing with this as well as a rising prohibition on on sale to young people is by mandating only nicotine free combustible tobacco products so as to take away from the addiction that people experience with tobacco and also massively reducing the number of outlets selling tobacco products which i think is supportive for people who are trying to quit thank you and finally just um professor i'm sorry dr read um my big concern when it comes to some vaping is that there's sort of a subgenre of vaping with big huge clouds going out into the air because that's something that people think they like doing or they there's lights on on the product themselves but i'm also concerned that when i walk past shops just as as you heard jillian mckay say but you walk past a shop and i actually have walked past a shop which is a sweet shop and it's selling vapes or vapes are put next to the sweets um and i can't think that a smoker necessarily will want to go to a sweet shop to buy their vapes but but my my question to you is should we be absolutely clamping down on these type of things because if we want vapes to be there for people to stop smoking as a smoking cessation aid then why do we need to to have all of the other things that that i've just described and thank you absolutely agree and i think that having vapes at a children's eye level is not by mistake and so i think that there's no reason to to have these products available in every shop and there's no reason for these for you know for that so i think i absolutely agree with you i think that you could have a similar to the display ban that we've got for tobacco to put vapes out of sight would be part of again denormalising the product and also so that children are not being exposed to them and seeing them because they're really appealing colours and they're really as as we've sort of heard today and also the names that are used for these products are names which will be really appealing to children as you as you read out there some of them are products which almost exclusively are used by children so and again these things are not a mistake these are really intentional acts so i think we need to be intentional in what we do to protect children so i think it's a having a combination of approaches but i would absolutely support a display ban like that or putting them out of sight i think actually we might want to consider do we really need to have all of these retailers selling these products or not if they are for smoking cessation and that's something which they've obviously considered in australia and decided to put them on prescription but i think it's thinking about well what do we want to have in scotland and to make sure that we act and i don't think it's a case that we're limited in what we can do that if we do anything it'll put smokers off i think that that's slightly misleading so i think that there will be actions that we can take which are positive like i think a display ban without putting off people who do want to use the product to quit which i think is is a good thing thank you all of the panel members this morning have contributed a lot of helpful suggestions to the committee for things that could be done to either reduce the use of all vapes the availability of vapes and discourage children and young people from uptaking vapes is there anything else that the panel would wish to bring to the committee's attention that they think it would be helpful to ask the scotland Government to do in terms of helping to reduce vaping usage particularly in children and young people i think those measures for me would be ones which would be really worth considering but i think we should do that you know together with experts learn from what's happened in australia and other countries as well so i think it's about having that collaborative approach and that is one of the good things that we've sort of got in scotland and some other countries there's been a really divisive issue which has sort of pulled public health community apart and that hasn't happened in scotland we've got sort of consensus statement which is now you know quite a few years old pre-plan pandemic but i think that's again a template to follow in terms of working to try and address this so i think of those measures were and were put and put up for discussion and in that expert group there might be other things which would come out and i think that because it's a rapidly growing field we need to really you know be quite flexible in our own approach to tackling it particularly around things like you know marketing and so we need to think about how we can work with for example UK government to do with that Professor Banks you wanted to come in on this thanks um one of the main things i would say is it's very very important that we maintain our really strong action against conventional tobacco and that whatever we're doing about e-cigarettes we're not getting distracted and and we have considered this quite extensively in australia and one of the things we think is it's appropriate to think of them together um that that it's that it's not one or the other but that we should be really going as hard as possible on both um there just is a risk i think that people will because vaping so new that they'll get that you'll put more emphasis on that and and industry's done a very good job of making us you know think that tobacco isn't such a big problem anymore but in fact it is you know causes eight point seven million deaths a year and as we said many thousands in scotland so i think the main thing is for everybody to maintain um and the the emphasis on tobacco control and go as hard as they can at the same time as controlling e-cigarettes thank you thank you very much to the panel for joining us i think all of the committee have found this a really interesting and informative session and will help us certainly in the development of our thinking going forward taking on board your point there professor banks about vaping and tobacco in its entirety so thank you very much to you for your attendance today our next meeting will be holding the first oral evidence session as part of our inquiry into health and care in remote and rural areas followed by a session with the women's health champion and that concludes the public part of our meeting today