 Good morning and welcome to the 22nd meeting in 2015 of the Health and Sport Committee. I can ask everyone in the room, as I usually do at this point, to switch off mobile phones as they can often interfere with the sound system. I'll point out for those who haven't been with us in the past, that you will see officials and members using tablet devices, and that is instead of the hard copies of the papers. We have apologies this morning from the net miller for the records. Our first item on the agenda today is whether to agree to take item 7, a draft stage 1 report on carers Scotland bill in private and in private future meetings. The committee has also invited to agree to take the NHS board's budget scrutiny draft report in private future meetings. Can I have the committee's agreement that that would be the case? Thank you. We now move to agenda item number 2, health, tobacco, nicotine, et cetera care, Scotland bill, witnesses' expenses. Can I ask the members that they agree to delegate that onerous responsibility to me to arrange when it is necessary for the SPCB to pay those expenses under rule 12.43? Can we have the committee's agreement on that? Thank you. We now move to agenda item number 3, which is our first evidence session of the health, tobacco, nicotine, et cetera care, Scotland bill. Can I welcome to the committee Sheila Duffie, chief executive of Ash Scotland, Scottish Coalition of Tobacco. Thank you for your attendance this morning. Professor Linda Bald, Professor of Health Policy, University of Stirling, and Simon Clark, director of freedom organisation for the right to enjoy smoking, tobacco, forest, Andy Morrison, trustee, new, nicotine, alliance. Welcome to you all. Having any notification, we are going to make any presentation. Can we move to the first question and take it for there? I have got my first question from a committee member this morning. Richard Lyon to get started. Thank you. A number of months ago I was able to convince the committee to have a morning session on the NVPs, which are nicotine vapour products. What is your feeling on the suggestion that we look at ensuring that these are not sold to children and that they put an ace limit on it? And what is your opinion on the factor of advertising? Thank you very much for the question. I think there is almost universal acceptance that we need age restriction on nicotine containing products in terms of the responses to the consultation on this bill, but also to bring Scotland in line with the rest of the UK that were committed to introducing an age of sale limit of 18. There isn't really any reason why a never smoking child who has never used a nicotine product should start using nicotine. So I think even amongst the smoking and vaping community we see strong support for age of sale. So that's the first point. The second point is advertising, which is more difficult. My own view, I spent 17 years doing research on smoking cessation, helping people stop smoking, is that we still need some forms of e-cigarette advertising to encourage current smokers to switch to less harmful products. But I think the team who have drafted this bill have tried to strike a balance, still allowing point of sale, marketing or advertising while restricting some of the other channels that are not going to be covered by European legislation and might appeal to children. So we may have a longer discussion on that, but those are my starting thoughts on those two questions. I'll back that up as well. We don't want to see under 18s picking up these devices. However, we do have several issues with advertising. We feel that we shouldn't stifly advertising too much. We want responsible advertising to basically help fight against the tobacco products. We want to give e-cigarettes the leading edge over tobacco products and therefore would welcome the allowance of responsible advertising. Yes, I would just say again, like the other speakers, we'd be opposed to excessive restrictions on advertising free cigarettes. It makes sense to encourage people to switch from combustible cigarettes to electronic cigarettes, as long as people aren't forced to do so. Therefore, it seems to be counterproductive if you make those regulations in advertising and marketing too restrictive. In terms of age of sale, yes, clearly they should be restricted. I think there is perhaps an argument to be had as to whether that restriction should be 16 or 18. Up until a few months ago, we were familiar with the opinion that it should be 18. But as the more more evidence comes to the fore, we've seen in recent weeks Public Health England, the Royal Society of Public Health, saying that clearly e-cigarettes are a lot less potentially harmful than combustible cigarettes. It might be quite a courageous stance for the Scottish Government to take to actually say, well look, we need to create a clear marker between combustibles and electronic cigarettes and actually allow people to buy them at 16. Because you're always going to get some children who are going to experiment. That's never going to be stopped. At the moment, there are clearly a considerable number of children who experiment with traditional cigarettes at the age of 16 or 17. Maybe you want to make it, you know, nudge them towards e-cigarettes. There's no evidence that e-cigarettes are a gateway to tobacco. So it's not something we would specifically support an age limit of 16. But I think it's worth having that discussion. Because if you're allowing people to vote at 16, then maybe you should say, okay, they're old enough to make their own decisions about nicotine at 16. We would support the age restriction to 18 for consistency and because it's the international accepted age for protection. I have real concerns about the advertising. I think it's legitimate to want to make smokers aware of these products and to make them aware that tobacco is, on some estimates, 20 times more harmful. But I think potentially advertising could become a gateway for tobacco companies to reach young people and we must watch that carefully given their track record of exploiting advertising and marketing. This question is 16 and 18 and the growing idea that harm reduction is better than smoking cigarettes. If it's good for somebody at 19 to help them to get off tobacco, why isn't it good for somebody at 17 to be able to access e-cigarettes as a means of stopping smoking tobacco? I think you have to strike the balance between trying to support young people who are already using tobacco and giving access to a nicotine-containing product to children who have never smoked. It's a tricky decision about 16 and 18. The reason for cancer research UK and that's primarily why I'm here is on behalf of them. The reason we've supported the age of sale of 18 in our submission is, as Sheila said, largely for consistency with the rest of the UK and also internationally, where you see that that's the age of sale limit that's commonly being adopted. Also, I don't think that 16 or 18 is really the priority issue for this bill. There are other much trickier issues within it. Okay. Anyone else on that? No? Can I move on? Yes. Can I move on to my other question? I'm sure Mr Clark will come in on this one. In the bill is to regard smoking in hospital grounds. If you go to most hospitals standing outside, are people having a cigarette? Take, for instance, my own hospital near me, Wisher Hospital. Based on the regulations that the Government wants to introduce, you'd have to go outside the hospital, which would mean near enough a quarter, I've never measured it, but I would say about a quarter mile walk to the periphery of the hospital. I abhor people standing outside the hospital entrance. A number of years ago, we introduced non-smoking in public places, so basically people don't smoke inside buildings. Outside the building, would you agree, Mr Clark, that based on a notice on what you've submitted, would you agree or would you suggest that whilst you agree that smoking outside the building is wrong, that maybe 100 to 200 yards away there should be some form of shelter or whatever in order that people could go to an area to smoke, because at the end of the day there is, I believe, 20 per cent of the population still smoke. Going to a hospital can be quite traumatic. You're in to see your relation who may have severe health problems, not related to smoking, and you come out and you want to have a cigarette. So would you suggest in your submission, would you suggest that somewhere within the hospital grounds there should be a shelter or something set out up outwith the entrance to the hospital? Well, thank you for raising that issue, because it's something we feel very, very strongly about. As you've said, going to hospital as a patient or a visitor can be a very stressful experience. It's also quite stressful for many members of staff, and to ban smoking on all hospital grounds, we think is totally inhumane. It's totally vindictive. It's petty, far pettier, actually, than banning smoking in pubs, because at least people can still go outside. We're still firmly against the current comprehensive smoking ban, but to extend it to the entire hospital site, we think is absolutely outrageous. I totally accept that when you go to a hospital, having people standing around the entrance is not a nice site. It's not particularly nice for people who are walking past them, although I do think that's often exaggerated. But you've got to look at it from a patient's point of view. I'm thinking of patients who are not just in for one or two days, but patients who might be in for eight or nine weeks. There might be somebody, for example, an elderly person who's in for a hip replacement. They might be in hospital for eight or nine months, have very limited mobility. They're being told that they cannot go outside and smoke anywhere on the hospital grounds. For a lot of those people, a lot of patients in hospital having the odd cigarette is a comfort factor there. It's something they actually look forward to. To nidon that right to have a cigarette anywhere on hospital grounds is totally and utterly wrong. I think it's going to be quite expensive to enforce. We've read newspaper reports in recent months in Scotland of a lot of people simply ignoring smoking bans on hospital grounds, but that's fine for people who are mobile and can go outside. But what about people who are immobile? I had a call recently from the daughter of a woman aged 67 suffering from dementia who was at a psychiatric hospital in Edinburgh. Lots of other patients were able to go outside, but because she was suffering from dementia, she couldn't go out on her own. It was unsafe. The staff were being threatened with disciplinary action if they took pity on her and took her outside. There's a long history of staff taking people outside so that they can have a smoke. That's what they want to do. But now those same staff are being threatened with disciplinary action. So you might have somebody who has a fantastic record of 20, 30 years working for the NHS who could find themselves penalised in some way, maybe even lose their job because they've taken pity on a patient, taken them outside for a smoke. That has to be wrong. Just going back to your specific point, yes, I don't see why hospitals can't have smoking shelters, but if they turn around and say, well, we can't actually afford them, I would say, well, what is wrong with, as you say, smoking 100 yards away from the building? I wouldn't put a particular limit on it. I think this is something where people have to show a bit of common sense. So, yes, let's not have people smoking around the entrance, but anywhere else on hospital grounds for heaven's sake, they're not putting anybody else's health at risk by lighting a cigarette in the open air. Why should they be forced off hospital grounds, to walk, as you say, a quarter of a mile, perhaps onto a busy main road, and one item we put into our submission, which I totally accept is an isolated case. But about eight years ago, there was a nurse who in, I believe it was a hospital in Essex who was forced off hospital grounds to have a smoke, and she was murdered. Now, I'm not saying that that is going to be a regular occurrence, but I think it's something that we have to bear in mind, when you are putting people potentially at risk by forcing them further and further away from hospital grounds just to light a cigarette in the open air. I think it's totally wrong, and as I said, I think it's totally not inhumane, and it goes against the so-called caring NHS. Yeah, thanks. We need to, you know, we've got a limited time, and we need to be concise in our questions and concise in our responses. Please, anyone else, in response to the perimeter of smoking, Sheila? Sorry, I should have made a declaration of Scott 2015 declaration for the record that I and my organisation have no formal or informal financial or in-kind links to tobacco companies. Their representatives are vested interests. Apologies for not making that first. I would note just for the record that dementia tobacco use smoking is a very high-risk factor for all forms of dementia. I think that the aim in Scotland is to put tobacco out of mind and out of fashion, and as part of that, of course, you have to be compassionate with people who are used to smoking and who may have a physical addiction, and the NHS is very good at offering all forms of support to people to try and manage that, and that's important as part of any proposed restrictions. Anyone else? I would just like to say that the new nicotine alliance has delighted that e-cigarettes have not been brought to this part of the legislation, in other words, they are not going to make it a law the same as cigarettes. However, we are a little bit disappointed that some of the NHS buildings have decided to ban e-cigarettes on their grounds, along with tobacco. We've had some evidence about that. I think that there is a general consensus that better with an e-cigarette is this contradictory? Do people feel that it's a bit contradictory in terms of the banning e-cigarettes alongside tobacco and on and around? Does it not send the wrong message? I think that we had evidence in the past if you treat people with an e-cigarette the same as you would someone smoking, then you're sending the wrong message here. Does it actually harm her actions in trying to get people to reduce the smoking? I think that the bill that is currently drafted in relation to hospital grounds is very clear that e-cigarettes are not included in that in terms of the enforcement and the penalties that will follow with that. I think that that's absolutely right. I'm very clear that we shouldn't have banned e-cigarette use in NHS grounds in Scotland. I think that the health board's decision was wrong on that because, as you say, it sends the message that e-cigarettes are smoking and that potentially they are as harmful as smoking. Fortunately, that bill doesn't include e-cigarettes in the grounds provisions. I think that that's key. Also, just to state for the record, the bill encouragingly doesn't include any suggestions of banning e-cigarette use uniformly indoors in Scotland. In other words, it doesn't propose extending smoke-free legislation indoors to cover e-cigarettes. Again, in contrast to Wales, that is the right decision because we just do not have the evidence of health harm from second-hand vapour the way we did second-hand smoke. Is that a view that's supported by everyone as there are variations in that view from the witnesses here this morning? Yes. It's not an agreement, but we would like to see the Scottish Government work with partners to issue guidance on policies as appropriate for indoor use of NVPs. Anyone else? Mr Clare? Now I think it would be ludicrous to ban the use of e-cigarettes in hospital grounds. Is there anywhere that we differ from the fact that I'm also against a ban on use of cigarettes in hospital grounds? Colin Kear? Thank you, convener. It's really actually a clarification of something that was said by Mr Morrison in the opening question, which was this statement of responsible advertising that you mentioned. I'm a bit of a, maybe it's just me, but how do we get a definition of what is responsible advertising? What is it? How do we define it? Talking about not targeting children, not glamourising the e-cigarette even, basically to make sure it's aimed at smokers, and that's all. Aimed at current smokers to get them off cigarettes or to give them an opportunity to get off cigarettes. We don't want to encourage any non-smokers to be children, adults, whatever. How would you go about that? This is the thing that's all very well-seen, responsible advertising. It's the definition, obviously, you're trying to get around, but obviously not everybody's going to necessarily agree with how to do it. This is the thing. The one thing that gets me is always been how do you make sure people understand what responsible advertising is? I can't answer that question. In which case, how could we accept there is? I certainly enjoy this conversation, but that isn't a conversation. You need to allow some of the others who may wish to respond to your initial question about how important the bill sees the role of advertising and what its target is, Professor Ball. Obviously, the Advertising Standards Authority has already put some restrictions in place on e-cigarette advertising, and they adjudicate, so people complain, as you will know, and they can look at the advertising and come to a decision about whether it's irresponsible or not. I do take the point that it's difficult to differentiate whether marketing, for example, reaches a child or is a responsible advert and it only appeals to an adult. That's actually quite difficult to do. I think that's why again the team have been very careful in terms of the bill allowing the point of sale advertising to continue, because you could argue that giving people information about the products at the point of sale and making some effort to continue the appeal of those products to current smokers is still needed. Removing the other forms of advertising, the giant billboards, et cetera, that might glamourise products, but still providing that information, I think, is really important. I do think that the bill tries to strike the right balance on this issue, a very tricky issue. Anyone else? Nothing with marketing and promotion. I think that we have to be careful that we don't make e-cigarettes promoted purely as a medicinal product, because the reason that e-cigarettes have been so popular with a lot of smokers is because they see them as a recreational product, not a medicinal product. It's true that a lot of users are using them to cut down or quit smoking, but there's also the pleasure aspect to vaping using e-cigarettes. If you turn all e-cigarette advertising into essentially lights of pharmaceutical advertising, there's a danger that you'll actually drive a lot of potential consumers away and you won't attract smokers because they'll see it as a medicinal product, which is frankly less attractive than if it's promoted as an attractive recreational product. So we have to be very, very careful here. Colin, do you wish to go? No. Mike, please, and then Richard. Thank you, convener. My question I suppose is more specifically for Professor Bald, and I just wonder if you're aware of any evidence that cold turkey is a kind of method for cessation is efficacious. Does that work? Okay, so if you look at the evidence globally, the vast majority of smokers who stop smoking do it in precisely that way. They do it unaided, it's will power alone, and that may be because that's how they decide to do it. They're not informed about the alternatives or they're not available in some countries. But we know that that's probably the worst way to stop in terms of your chances of success. So if you look at the evidence again globally, the best way for somebody to stop smoking is a combination of two things. Using a stop smoking aid like nicotine replacement therapy, champics or indeed potentially cigarettes, and then having support to stop from a nurse, a doctor, somebody trained, even the quit line to help them stop. If you combine those two things, our studies have shown you're about four times more likely to be successful than if you use will power. But I would say it's very important to give people choice and if people decide that they're going to throw away their pack of cigarettes tomorrow or not touch them again, and that's the way that works for them. Great, we have to give lots of routes in. Can I take it then that you're not in favour of a kind of imposed cold turkey solution then? No, I mean, again, all the years I've spent in this field, I've seen for pregnant women, people with mental health problems, whatever, lots of different groups, different things work for different individuals. So we need to make sure that there are many routes out of tobacco as possible. What aspects of this? We need to, like the other witnesses who are here not to witness our proceedings, give them an opportunity if they want to ask, because there are... In terms of the... Apologies, convener, understood that Professor Bowd was the authority in this aspect of... We have a panel of witnesses. Apologies. We need to give them time if they wish to. Some of them are looking to me wanting in, so it's just to give them a full experience. Shirley-Dee, you want to respond? Or anyone else want to respond? I agree with what Professor Bowd said. I agree as well, but I think you'll find with electronic cigarettes that the great thing about electronic cigarettes is the diversity of the product. It's not a one-size-fits-all. Not like a nicotine patch where you slap the nicotine patch on. If it works, it works. If it doesn't, it doesn't. The same with the gum. If it works, it doesn't. Electronic cigarettes. It's strange of these devices out there and you can mix and match and so forth and everyone will find a solution. I've not known one person come to me that said, oh, I don't like these and I've not been able to change that device in some way, shape, or form and within a week or so he stopped smoking. So electronic cigarettes for me is the way to go. Is there any wider evidence on that in terms of the use of different types of devices? Would you like to comment on that, Professor? It's a new area. We're seeing new studies published all the time. We've got two, very briefly, two randomised control trials that show using very old devices that e-cigarettes are about as effective as a nicotine patch for stopping smoking. Those are the trials. A more recent study showing that people who stopped smoking using electronic cigarettes in the UK were 60 per cent more likely to be successful in stopping smoking than will power alone or buying nicotine replacement therapy and then finally a really interesting new study which differentiated as Andy's saying between the basic cigillite the ones that look like cigarettes and what we call tank devices, later generation that showed that the tanks were more effective in helping people to stop because they allow people to vary the amount of nicotine that's in there they're more effective in delivering nicotine so I do agree with Andy that the different devices have different effectiveness and from a research perspective actually we need to study this in the longer term and see what works best for folk. Mike. Thank you, convener. Bring it just back to the bill. Are you concerned that there are aspects of this bill then in prohibiting smoking in hospital grounds which could be seen as a kind of imposed cold turkey solution and that may actually engender a very negative response in terms of taking forward the agenda and encouraging people to stop through more efficacious methods so is this bill running the risk of actually having a contrary purpose to that which Sheila Duffie would like to see Smoke Free Scotland by 30, 20, 34 or whatever it is? I think it very much depends how you do it I think you have to communicate with people you have to offer them support and you have to take them with you and that was the real success of Scotland's indoor public places legislation Forgive me I've heard this answer before and I've read it in the written evidence I don't quite see how that gels with saying to people we've heard some descriptions of people who have just visiting a very sick relative they're traumatised or somebody who's just had very bad news from their consultant or whatever who's a smoker who's instinct is to light a cigarette to help them cope with whatever and you're saying yes we're offering you a long term cessation treatment but you're banned from smoking for the next half a mile or whatever or in terms of patients who are inpatients who are banned from smoking and absolutely prohibited from doing so with a real practical problem in terms of being able to smoke but yet you're saying that you really want to offer long term cessation No I'm talking about short term management in terms of habit and if there's a physical addiction that's the kind of support that we need to be offering people but I think it is a real myth and it's one that the tobacco companies perpetuate that smoking relieves stress and if you look at the research actually there's an inverse relationship and former smokers and never smokers report better wellbeing and less stress than current smokers Well let's leave that argument aside there's people wanting to answer your question you've got a range of people a range of views here they all want to participate Sorry convener I was just mindful of the fact that you've told us throughout this meeting that we're short of time Well you have had more than your fair share Mr Mackenzie but we will there are people on the panel who want to respond to your question The hospital grounds element this bill is complex I think that those of us working in the field would agree that having smoking in the very place where people go to get well even if it's an outside, slightly outside the building is not compatible with the NHS we're spending millions of pounds trying to treat smoking-related disease so that's the first principle but I guess the second principle is that when you look at what we know internationally about how to make new smoke-free policies work even if they include the grounds they need three things they need a good policy they need good enforcement and they need good communication with the public about what they're for and why it's happening now those may be issues for the regulations rather than for the legislation but I do think they're important things to keep in mind and if we are going to go down this route I slightly disagree with Sheila I don't think we're actually doing enough in the NHS to offer people alternatives to help them deal with their nicotine withdrawal or forced to not be allowed to smoke including in the grounds I think we could do a lot more actually on that Thank you Anyone else? I just repeat what I said earlier I think it's totally wrong to ban smoking in all hospital grounds I think it is inhumane I understand why hospitals don't want to appear to encourage people to smoke but we're living, we've got to be pragmatic about this we've got to live in the real world not some utopian smoke-free world where there's a great many people enjoy smoking and they get comfort from it particularly in stressful situations like hospitals Professor Ball to the next stage you believe that this bill and this process here and the implementation the expected implementation of this bill confirms those three key elements that you mentioned I think that the way the bill is drafted tries to strike the right balance but I do think that the specifying exactly what the perimeter around the buildings is going to be how that's enforced all those aspects are very important we learn that from smoke-free and my understanding is that those are aspects for the regulations the specificity of that rather than the bill itself so I'm pointing out that's going to be challenging for my reading it's not clear who's going to enforce although I welcome this in principle it's not clear who's going to enforce this extension of smoke-free it really shouldn't be a one-size-fits-all regulation on smoking outside because NHS hospital grounds vary enormously in size so surely it should be left to the chief executive or the people who are administering that particular hospital to make their own decisions no one else thank you now have Rhoda, followed by Richard thank you going back to e-cigarettes and how they compare with ordinary cigarettes I think that everyone is clear that they are more healthy but a couple of comments some of the evidence we received and I'm sorry I can't remember was that only one brand of e-cigarette has been approved as nicotine replacement therapy and that's not available is that the case? it's not actually an e-cigarette there's a device called Vogue it's more like an asthma inhaler that's made by Nicol Venture a branch of a British American tobacco that has been granted a medicinal licence in the UK but it's not yet come to market but it's not really an e-cigarette but that's the only one we have electronic cigarettes that are available as medicines anywhere in the world those licence medicines it seems to me that one way around all of this if it is so successful in dealing with nicotine addiction then therefore it surely should be registered as a medical device and I've always been a little concerned about the reluctance of those who are making e-cigarettes to have them registered and I hear yes of course that's better if you market them as recreational devices but that also appeals to non-smokers if you do that surely if we're talking about smoking cessation and the addiction to nicotine surely it would be better that they were treated totally differently rather than being sold as recreational products try start? I think that Andy and the sport are here I think the main problem with medicinal regulation apart from the cost of making the companies jump through hoops to get this through all the various stages that have got to go through is that it is not a one size fits all you could have a medical device but it would be about as effective as any other form of NRT like some people get on with Kiwi patches some don't if you've only got the one type of device then it basically it's just not good enough the way electronic cigarettes work is because of that diversity we need to keep the diversity we need to keep the development of the product going forward we started off with cigillites just a couple of years ago the little ones that look like cigarettes and I showed you a couple of seconds ago what we're on to now we're on to really really powerful devices that are very very effective and that's been consumer driven I don't think that if you're going to put it through a medical process to get what the end product is it's just not going to be it's not going to cut it at the end of the day it will do for some people but if you keep it as a consumer product let the consumers drive the the innovation then it's working an awful lot better that way an issue slightly out with this bill because the European Tobacco Products Directive which is intended to come in next spring will introduce a two tier system where those devices that can chain 4ml of nicotine will have to go through down the medicinal licensing route and the other products will be allowed to remain as consumer products so that already exists it's been a very difficult journey in the UK we recommended the committee that I chaired at Nice almost three years ago now that there be medicinal e-cigarettes but the MHRA process is so cumbersome and complex that very few companies have been willing to put forward a device for medicines regulation including the pharmaceutical industry who have not been interested so the only one that's come through is this single tobacco industry funded device so we kind of have a system which is very complex and disincentivises it at the moment but then we also have European legislation which is going to make this a requirement so this is going to change and I guess this bill which focuses on the wider issues around e-cigarettes will just have to take into account that changing context and actually Linda knows a lot more about it than I do but I think we've got to make this leap away from seeing nicotine itself as harmful Public Health England only in the last couple of weeks has declared quite authoritatively that nicotine is no more harmful than caffeine nicotine of course is very closely associated with the tobacco so people leap to this conclusion that nicotine itself is harmful but we've got to get away from that and see nicotine itself is not a bad thing and perhaps Linda could add to that a bit well we know a survey that the Royal Society for Public Health did earlier this month about 90% of non-smokers in the UK believe that nicotine is harmful and 75% of smokers believe it's harmful yet we provide nicotine replacement therapy to pregnant women and the reason we've allowed that since 2005 is because nicotine is delivered in a cleaner form is not, as Simon says, is not a harmful drug and certainly the harm caused by tobacco is the 4,000 other chemicals and combustible tobacco, not the nicotine so it is this tricky issue and it probably contributes to some of the public misunderstanding about the relative risks of e-cigarettes versus tobacco cigarettes because as soon as people hear the word nicotine they think that it's potentially damaging not risk free but certainly as an alternative tobacco far far safer Yes, Rhoda, go on. Just on that point I think it's widely understood that that's the case but nicotine is highly addictive surely it's not a good thing to be addicted to something. Nicotine is as addictive as people are making out it's certainly addictive within cigarette smoke but I think we're beginning to find out now that on its own it's not that addictive it's about as addictive as caffeine and I've noticed that I've gone through the process of switching from tobacco to vaping I've just come off a four and a half hour flight from Madeira and not once did I have the feeling that I want to tear my hair out because I can't have a cigarette I did have my vaping gear on me but it never bothered me in the slightest that I couldn't vape on the plane Nicotine in nicotine replacement therapy isn't dependence forming people don't get hooked generally on NRT or use it in non smokers there's about half a percent of the population in the UK who are never smokers say they use nicotine replacement therapy if it was attractive more would use it we're also seeing that with e-cigarettes nicotine yes is dependence forming but it's primarily in tobacco it's dependence forming and we think that it's some of the other constituents in tobacco that work with the nicotine to really hook people in the cigarette within e-cigarettes the evidence we're seeing now is that people are not as reliant on the nicotine in the e-cigarette as they are when they're smoking but again we need longer term studies to really understand that relationship in e-cigarettes I welcome Andy's experience and I think that is the experience of many people using NVPs but we also have to recognise that cigarettes are as addictive as they are because they've been consciously engineered by tobacco companies over a number of years and with a lot of investment and we have to recognise the strong footprint that companies have in the NVP market which is likely to become stronger after the tobacco products directive regulations take effect I suppose that it takes us to another aspect of this in terms of the register of those who would be selling I'll say e-cigarettes that they would need to again register I think is on the same basis as someone who was selling tobacco there would be the consequences of selling to under 18s would be similar to selling tobacco to under it seems a bit disproportionate if we apply it, the bill suggests that we should be applying the same sort of restrictions and penalties there and would that be disproportionate given the discussion that we just had there that we're not dealing with as an addictive product We would like to see a totally separate register but I understand that that may be a costly process it would be I've had notification from the Scottish Government that they are facing part of it we'll try to distinguish between NVPs and tobacco we would like to see it totally separate but if it's not possible then I've certainly made it very clear that I don't think it should be the same register I can see that the idea of a register is useful for enforcing giving trading standards a tool to enforce the underage sales issue which we've all agreed is important but I don't think it should be the same register as tobacco and certainly it shouldn't be presented as the same register because they're not the same products we need to do much more to get rid of tobacco from Scottish society and definitely not focus on trying to get rid of e-cigarettes because they potentially will save lives for some people I think there have been two advantages to having a register of those retailing tobacco and one is that enforcement officers know who's selling it where and can engage and educate and the other is that we can it's access for academics to see how things change now this is a very fluid emerging changing market and I think that data would be very helpful but I agree with the points that Linda made that for it to look different when a retailer is going in to register may help just to distinguish the products Richard Simpson Yes, the rule 8 in the advertising standards association is marketing communications must not encourage non smokers or non nicotine users to use e-cigarettes so you know if they're so safe and they're completely harmless then you know why have we got that restrict restrictions on this at all I mean it seems to me that we need to recognise the cultural history of cigarettes that they started off as something that was apart from King James it was thought to be very reasonable and was promoted as improving health and you know my father is a GP who smoked said it was good for the lungs courage the lungs to exercise we'd been through this once this is a very new area we really don't know and I do understand that there are some studies in the states already suggesting that the consumption of nicotine by this method not by patches or other methods but by this method is not entirely free from harm and I wonder if Linda could tell us if there's any research on that but also if the others could comment on whether this is a reasonable restriction and I suppose my last bit on the restrictions is should the advertising within a certain distance of schools be actually banned in order to not encourage youngsters to take this up The reason why I welcome some restrictions on advertising is precisely for that there are no good reasons why a never smoking child should start using these products and we all actually agree on that point because nicotine may still is still dependence forming certainly it is in cigarettes the other aspect of course is an inequality why should kids spend their money on these devices if they don't need them so we do have to protect children from uptake and I think that's why some of the idea around restricting advertising is important what will happen in the future and how they evolve Sheila's already highlighted that I agree there's a range of questions so I think what we're seeing here is an attempt to balance risk and benefit not prohibit current smokers from accessing these products but we're also trying to keep an eye on the protection and responsibility that we have it says it all for me, it's proportionate to risk the question is what the risk is we just don't know do we, do we know I mean it's so new are there any studies at all on the harm with the types of research Richard that we have, the lab based studies that have tried to look at the constituents in these cigarettes what you find is that they don't have tobacco-specific nitrosamines that you know are carcinogenic but they do have very low levels of some of the harmful toxins that we've seen in tobacco like lead and cadium acetaldehyde but at very, very low levels so I'm not saying they're risk free but they're certainly far, far less harmful than tobacco I think we can be relatively confident about that there are questions about going on in detail about as you know long term use inhalation into the lungs long term exposure we know about propylene glycol but we maybe don't know about some of the other constituents but these are more research questions I think if we are too restrictive we potentially miss a public health prize which is people switching but I agree it's not straight forward so we need some, we need good research really the last bit of my question chair oh sorry what that a wee bit because Linda mentioned earlier that what's the difference it's claimed to me that Lehmann of giving a nicotine patch to a pregnant woman than using an e-cigarette Richard will correct me if I'm wrong as one of the clinicians in the room basically it's pharmaceutical grade nicotine in the nicotine patch it's the method of delivery that has been rigorously tested in terms of safety and efficacy the difference with e-cigarettes if we leave aside the nicotine which I don't think we really need to worry about in e-cigarettes it's the other constituents in the e-cigarettes and the way that the device delivers nicotine to the body that may have some risks we're not seeing really any evidence of that at the moment but there's propylene glycol there's flavourings that you will have heard of in terms of questions about potentially the impact of use but when the contrast is with smoking where we know so clearly what the harm is I do believe that we can be confident about far lower risk Sheila I think Richard is absolutely right we do not have good long-term knowledge yet about the effects of NVP products and I think there are some concerns when you are taking things in through the lungs or through the stomach it's a slightly different agency and I think to me these things are fairly obviously not as dangerous as tobacco but as we said that doesn't make them completely safe and there have been one or two flavourings that there have been immediate risks attached to such as butterscotch dacitals and cinnamon and particularly when you heat them at high temperatures in a factor that's coming in so I think this is probably one to watch very carefully but I agree with Linda that tobacco is undoubtedly dangerous incredibly dangerous and that is something that we have to keep our eyes on throughout this how does it impact on tobacco use Andy is going to respond to that as well just with reference with reference to the flavourings problems the consumers are actually dealing with these kind of problems as they happen as soon as a problem is identified that stuff gets off the market straight away and it's replaced with something that's more acceptable so yeah, the risk is probably 95% less there is room for improvement but again the devices are improving as we go along we've now got heat protection in the devices in that you can't heat it to the temperature that's going to start producing formaldehydes and so forth so with it still being a consumer driven product we are addressing these problems as we go along there will be other problems that will come up but it's certainly not going to be anywhere near the scale of the problems caused by smoking combustible tobacco is there anything one of the things that concerns me is the tobacco industry are buying up VPNs and they're not doing it for the good of our souls they're doing it on a profit based motive and good luck to them in that and then that's their job but what's to stop them actually putting in the back-in the additives that previously addicted people strongly you know, given that we're saying that nicotine consumed by this method as others is maybe less addictive than tobacco what is to stop them actually creating the market strengthening their market by adding in some of the additives that they've added in before I absolutely agree with you they are very effective at getting around whatever restrictions are put in their way and they have huge resources behind them the European Tobacco Products Directive is requiring both for the consumer product for the consumer product primarily not the medicinal product which will have to go through the licensing route for contents to be clearly described for the development of the devices and what the different constituents in them are to be more clearly labelled and it's actually a very complex document what they're going to have to declare now whether that will deal adequately with that issue or not I don't know but that is part of the EU TPD thank you anyone else Andy? I can also tell you, the tobacco industry products are useless they are absolutely hopeless no seasoned vapour would bother with the tobacco company products that they're putting on they just don't cut the ice so to speak and maybe that's deliberate, I don't know it could well be deliberate from the tobacco company's point of view they don't want them to work so generally speaking anyone that knows enough about vaping will not buy one of these tobacco products and they're few and far between to tell the truth Sheila's going to respond as well there you go so you give them a chance they will respond I share Andy's concern that tobacco companies may consciously try to dominate the market and that their products are likely to be less effective in delivering what people want and that they will be trying to encourage dual use rather than cessation because they make more profit from combustible tobacco products anyone else? well I'm not here as you know to represent the tobacco industry but I think that's a load of nonsense that they're going to produce a product that nobody wants what a load of nonsense I mean look at it this way the tobacco companies have a lot of money to put into research and development e-cigarettes will get better and better and looking at it from the outside I would have thought that nobody's in a better position to pour money into research and development than the large tobacco companies but so I'm not here to defend them going back to Richard's initial point I just wanted to say that the implication of what he was saying is that we should live in a risk free world well we don't live in a risk free world and I think the important thing is to give the consumer as much information as possible about the health risks of tobacco the health risks of using e-cigarettes or any other consumer product ultimately it comes down to a word that Linda used a bit earlier choice let the consumer make their choice based on an informed choice based on all the available information it's their choice it shouldn't be the choice of politicians to decide how they're going to live their lives as I was told we've got Dennis now please as a politician who's concerned about health and wellbeing of everyone in our society do you think his bill strikes the balance for instance do we have within the bill enough there for the exemptions to be flexible enough say within health boards to have areas designated as potentially a smoking area because it is seen as it is the preferred route for that person's health and wellbeing albeit maybe going through a cessation programme or whatever but maybe due to mental illness psychiatric conditions it is felt that we need those specific areas within the health boards the enforcement aspect that we're talking about is proportionate I seem to think that perhaps sometimes enforcing can be overzealous I wonder if you have any points with reference to the bill taking on the professor's aspect of policy enforcement and information Professor maybe you would like to start I mean I guess I feel more strongly about the e-cigarette elements of this legislation and feel more able to speak to the evidence on that than the hospital grounds issue which I said earlier I think is a tricky complex issue I do think the way this I think the principle of a smoke free area around a hospital is very important and the power to enforce that in an effective way which is what this bill tries to do is very important but just to state again that I think the crucial thing to get that balance right complex but do you feel that in the interests of a person's overall health and wellbeing if it is determined that that the patient should be permitted to continue to smoke there should be a designated area and mainly within the I'm talking about significant mental health or psychiatric conditions I can't see that it would ever be able to be argued that smoking tobacco is in the interests of anyone's health I think we need to look at what that smoking is doing for that person and what can be offered and it may be for example in cases of mental health issues that some form of NBP could be an acceptable alternative as it has been for a number of smokers with respect we're talking about wellbeing rather than health and a lot of patients immediate wellbeing may actually be helped by being allowed to have a cigarette outside a psychiatric hospital or a standard NHS hospital and I can't repeat myself enough I think it's petty vindictive and inhumane to say to people no you cannot have a cigarette anywhere on hospital grounds that's totally and utterly wrong and that's where I think the bill does go too far What about with regard to enforcement do you think we would have the appropriate guidance and information to enable enforcement officers to carry out I suppose their duties within so that we'll continue in the hospital grounds Well the problem is in terms of enforcement A it's going to cost money you may be have to employ tobacco control wardens you may have to put in CCTV cameras I mean we've even heard of some hospitals putting in a sound system so that if the CCTV camera catches somebody lighting up in the bushes a big voice comes out of the ether and says put that cigarette out I mean this is a ridiculous way surely to run a hospital surely hospitals have far better things to do and we did a recent poll through populars and we asked people what their priorities were for hospitals and I have to say tackling smoking came last in a list of 10 issues there were other issues that were far more important to the public like reducing A&E waiting times and general waiting times having more doctors and nurses these are far more important issues than whether somebody lights a cigarette on hospital grounds and just aren't the other thing on enforcement is that this has made a statutory offence and somebody tries to stop somebody smoking on hospital grounds what are they going to do if it's a visitor you can order them off the premises if it's a patient what's going to happen are they going to be ordered off the premises or are they going to be manhandled we're getting into very difficult areas here if you try and physically stop somebody smoking on hospital grounds that could be seen as assault so let's be careful we've got a very dangerous route here The NHS boards in Scotland have unanimously taken the decision already to make their grounds smoke-free in line with the Scottish Government's last tobacco control strategy which had that as an objective within it I think this bill tries to provide the basis for actually enforcing that in other words giving that voluntary decision that they've taken teeth and that's my understanding of what the spirit of this is if it proceeds there are a number of countries other countries other than the UK who've successfully implemented smoke-free hospital grounds and I think there's potentially a great deal that we could learn from them what are those countries that you're well in both prisons and hospitals Canada is a good example to look at some states in Australia or other other places and also parts of Scandinavia where you see good examples and grounds Sheila, did you want to come in? Just briefly to say that you've got polling that we commissioned last year showed that 73% of Scottish adults supported the proposal that smoking should end in hospital grounds No one else Richard Lyle Can I come back and Mr Clark can you stay back on this one I'd like the other three witnesses to come in and get real on this bill At the end of the day I agree that smoking outside a hospital people shouldn't do it shouldn't litter the place shouldn't crowd and sometimes you have to 4 o'clock try again to visit a loved one try to get by people who are standing there puffing away but can I say that there may be a flaw or an opportunity in this bill The Scottish Government writes in policy on the bill that has chosen the option that it will ban smoking around buildings but would allow exceptions to the ban to be made in regulations It states that this option complements existing smoke free policies which will take a balance more realistic, more compassionate and safe approach I must smoke it I agree that people shouldn't smoke outside the hospital but should we not make it the point that Mr Clark has been quite forceful on and the point that I am trying to make is maybe a 100-200-yard radius within the hospital entrance that people should be able to smoke there If I go into Wisha car park at the hospital my wife doesn't want me to do this by the way and I don't do it now I can smoke my car you can't do anything about that and I am maybe within the cartilage of the hospital grounds I am in the hospital grounds but I am in my own car so we won't even go there but the point is should it not be that within a 100-200-yard radius or 300-yard radius the point you made earlier on Professor all these notices are up in hospital grounds now don't smoke they are totally ignored what I want is to have a situation on both sides that we respect people do still want to smoke but we respect that people who don't want to smoke and in order to ensure that people don't crowd an entrance that people should respect that and move away from the entrance have a designated area don't even put up, don't spend money sheltered by the way but have a designated area that people can exercise let's be honest about it their human right to do as they wish to have a cigarette and I like the three other three witnesses apart from I know what Mr Clark would come back and say it for half an hour I've went on long enough can ask the three witnesses should we not have a 200-yard radius of people smoke they call for smoke free hospital grounds and the policy for smoke free hospital grounds didn't come from my organisation Ash Scotland that came from clinicians and hospitals who I think have seen the pain caused to people's lives and people's families by diseases caused by tobacco so I think the magnitude of this epidemic which is responsible for the early deaths of some 13,000 adults in Scotland every year to me it seems that the enforcement in a defined perimeter will address some of the concerns that you've raised and is a good starting point I suppose the danger in creating areas for smoking is that you are seen to be acknowledging and permitting something that is so damaging to people's lives anyone else Richard anyone else I'd rather not talk about smoking quite well again I have to get real one in three people have cancer or get cancer and a lot of people I've had a lot of friends who have died with cancer that have never smoked you know we honestly I want to see this bill work I want to ensure that what's happening in hospitals doesn't but we have to get real you know why bring in something that if I walked down Circe Hall Street and I dropped my cigarette end I can face a £60 fine but I think it's up to £80 now I'm not sure I accept that but if I'm going to a hospital to see a loved one and we see people I've seen it during the time that I worked with NHS out of our service for two and a half years trying the loved one had just died and the first thing they did was to open this cigarette packet shaking and having a cigarette to calm themselves down now if we're going to turn around and say we're anti smokers well let's do away with smoking let's lose the millions of pounds that the Government gets in tax right if you want to do away with smoking do away with smoking right we have to get real we have to convince people we convince people not to smoke inside premises because it's harmful people now accept that we've got to we need to get to the question the question it seems to be focusing on is enforcement we already have health board policy that's being ignored we have a collection of not just clinicians who are treating people as a consequence of many times of a lifetime of smoking but we've got a vulture and people visiting the hospital and having to go through a lot of people smoking in the entities to our hospital that's what my case work reflects so we've got a Government bill that seeks to do that do we need to are we going too far to to find people in hospital grounds who are who who smoke in hospital grounds are in areas where they're clearly not allowed to should we be finding them on the spot we're just to come back to the point I made earlier there's no point having these current restrictions if they're not if they don't work I mean it makes a mockery of the time, money and effort spent in the signage and everything else and the spirit as Sheila said the reason the push for this has come from clinicians and others who do not want that big group of people around the periphery of the building, the litter all the other things associated with that so by saying let's have at least some of the grounds covered by a smoke free policy that's enforceable and has penalties associated with it we can successfully implement that so I think that's the spirit of it but the point I would make is the detail of how big that perimeter is exactly what that involves is an issue for the regulations and I don't think it's straightforward and there's a the other side Richard of this is I notice in hospitals just as I see sometimes with pubs and clubs that people are outside the building but not stop smoking and I see staff members now out on the street outside the hospital perimeter having a cigarette before they're going to work and I've come back to that question about actually dealing with this under you mentioned earlier as well as the punitive measures that they have because those staff certainly face punitive action if they smoke on-ground they can be disciplined they can be sacked, dismissed etc but about that gap that you mentioned about about the support that health boards give to staff members and indeed patients who may be in for a short or medium term about what alternatives can be given to them and supported in them when they have an addiction so we have nice guidance which doesn't directly apply to Scotland on smoking cessation in acute mental health and maternity hospitals and my understanding is the pathway that recommends is not widely implemented in Scotland so there's much more we could do to give people other products like nicotine containing products to help them deal with withdrawal and use those if they want when they're going outside as well so those are licensed products much more we could do but I also think importantly there is a place for NVPs in this as well that's why it's so important not to ban nicotine e-cigarette use in NHS grounds because an alternative for a staff member of course is not just a nicotine patch it's an e-cigarette as well so I do think those alternatives and that support are really crucial have we any other questions thank you convener I was home to get to this point earlier and it seems to me to be fundamental to the question that the legislation is trying to address is there any evidence to suggest that passive smoking in the open air presents a tangible health risk can I come in sorry Linda they're not if you're far away from the smoker it doesn't if you're a very close proximity to the smoker you're going to get that side stream drift the way you would indoor so that's why we don't want any environments including some outdoor environments where people are close to smokers and can be impacted by that side stream drift which is important I'm not aware that there's any evidence that lighting up in the open air is harmful to anybody even if you're standing quite close to them because as soon as you light up in the open air it's massively diluted even a tiny little bit of wind is going to blow it away I do think people are now very very precious about walking past somebody in the street of there smoking a cigarette quite often it's not the smoke that's bothering them it's the smell we can't go around banning things because we don't like the smell of it but what's happened I think since the smoking ban came in is that people are now very sensitive to even a whiff of smoke in a way that they weren't before because they were used to it so now people sort of complain if they have to run the gauntlet of going past smokers outside hospitals I agree with Richard I think basically we shouldn't have people smoking directly outside the entrance to a hospital but when people use terms like running the gauntlet of people smoking outside I don't know what world they're living in I'm a non-smoker, I've never smoked and honestly in my average day now I can't think of when I'm actually exposed to somebody lighting a cigarette in the open air. If I'm walking down the street I'm not even aware that they're smoking or if I was I could just move around them it's complete enough nonsense as long as you're on your feet and you're mobile then I really don't see what the problem is I understand why smoking is banned in outdoor stadiums because if you're in a seat and you can't move then yes even if you're in the open air it's not very pleasant being stuck right next to somebody who's smoking and that would actually go for vaping as well blowing clouds of vapour into your face when you're in an open concourse on a sports stadium you can move I think we'll get the point Mr Clark Sheila, do you want to contribute to this? There is I don't think exposure to tobacco smoke would be the main argument in this case there are limited examples where you don't have airflow where you've got open windows and smoke is drifting in where it could be a concern That's been one point of that because I've heard that argument used quite a lot smoke drifting in through windows I've not been in a hospital ward where somebody's been smoking outside I have been in a hotel and people have been standing outside smoking and I tell you it's not smoke drifting into my window that's the problem, it's them chatting too loudly so you can't get to sleep the idea that smoke is drifting into people's windows when they're smoking outside I'm sorry again, this is just hyperbole It does upset some people going back to my case the sick kids there are people outside where the children are very seriously ill smoking below the window they might be chatting as well and smoking in the window so people are affected at different levels I just throw that in I agree with Sheila the main rationale for that is not around health harm from second hand smoking but there are definitely studies that look at drift of smoke between an outdoor smoking area and an outdoor eating area where they have been able to measure whether people are exposed to that when they're in close proximity to the outdoor smoking area so there is some data, it does happen but the main arguments are not so much the health harm arguments but the other arguments around taking tobacco out of society, less visibility children's exposure etc beer gardens one of the things that has been researched in Australia and I think also anyone who walks from Waverley has to go through a cloud of smoke within 20 yards of the Waverley station every morning when you come down from Parliament if you're an asthmatic I have to say Mr Clark then I think it isn't the smell it is actually the smoke that actually causes problems so I think that your arguments are overly strong I think Mike I just wondered then and just to tease out this area that yes and I can accept that in certain circumstances there will be a health argument to be made about passive smoking if it's concentrated I just wondered though if there's been an analysis, I mean Dr Simpson mentions walking down from Waverley station and vehicles have been largely excluded from Waverley station because of the the air quality and air quality is a problem in Edinburgh generally and what I'm interested in is a scientific risk based approach to this so what and perhaps she'll answer this in terms of your concerns about the risks to health through passive smoking and open air how does that compare with the health risk due to poor air quality in a lot of our cities as a result of traffic fumes so that we can get a sense of proportion over this issue right, well I would say there are specific examples for example Victoria hospital where the windows tilted and people smoking directly outside by the building the smoke was going into the maternity ward if you're asking me about vehicle pollution there is a study I'm aware of I would have to look up the details and send it to the committee but there is a study that compares vehicle exhaust with tobacco smoke so that we can test it no, good the bill the bill of course doesn't propose to ban smoking in open public areas it stops short of any of that not yet I hear from the hecklers beside me but we'll see a lot of revisionism going on this morning if we've got no other questions from the committee can I extend the committee's thanks for your attendance here this morning the whole time you've given and the oral and written evidence that we've received, thank you very much indeed we're suspended at this point and as previously decided we will be going into private session with the exclusion of Richard Simpson who's got us he can stay for the first bit so I think we're the first two is it? yeah