Smoking e cigarettes in shops..

[Ghostrider]

I do not see where encouraging folk not to smoke is any of that. Thanks though. Telling folk is not the way forward really, hence it is always best to encourage. Sorry you do not like it.

 

Nah, Peat. The government in any of their various forms butting the hell out of dictating ever damn thing an individual can, and cannot do in their private lives, is the way ahead.

[shetlandpeat]

Then get used to it.  Though, you do have choices. But keep squealing though.

[Ghostrider]

Here you go Peat, you get used to it.....

 

[Colin]

 

Nah, Peat. The government in any of their various forms butting the hell out of dictating ever damn thing an individual can, and cannot do in their private lives, is the way ahead.

 

Yep, and if you submit to the hype and spin and believe everything they tell you, you've got no chance.

 

If the government really wanted to 'stamp out' smoking, they could do it very simply by putting tobacco products on prescription.  That should reduce the number of smokers to a small 'rump' within 1 generation.

 

It would also mean that smokers would (probably) have to undergo a medical every time they needed a repeat.

[shetlandpeat]

May be the case, it is after all a drug. The Gov could not just stamp it out, it would take a number of years, expensive court cases. Any how, the current PM is in league with the tobacco companies as he is with Fracking companies.

 

Still, it is still good to have e-cigs to try to prevent the Governments strangle hold on those who take this drug. Of course too, so I may have a better chance of meeting any great grand children before I pop of. I look forward to that.

[owre-weel]

Whit I want tae ken, is kin I git an e-pipe

[shetlandpeat]

Yes you can.

[shetlandpeat]

Recieved this the other day, it may be of interest to some.

 

As part of public health's commitment to supporting trained health advocates and health champions, I am attaching a briefing paper on illicit tobacco, e-cigarettes and shisha. As you may be aware, we are having weekly queries regarding e-cigarettes so public health has pulled together information to help partners respond to any queries.

 

Gulab .... at LCC

 

Tobacco and Nicotine Containing Products – Briefing Paper

 

What is Illicit Tobacco?

Illicit tobaccos includes cigarettes, hand-rolling tobacco (HRT) or niche products such as shisha, pan, gutkha and nass that have been smuggled, bootlegged or are counterfeit (fake). There are three types of illicit tobacco sources:

 

• Smuggling – This forms part of large scale organised crime and involves the illegal transportation, distribution and sale of genuine tobacco products. Legitimately manufactured tobacco products are diverted, usually in the wholesale distribution chain, thus evading payment of tax. The products are cheaper to the consumer, yet profits are still made throughout the supply chain from the manufacturer to the final supplier.

 

• Bootlegging – This is also a form of smuggling, often undertaken by the ‘white van man’. Tobacco products are purchased in continental countries with lower levels of taxation such as France and Belgium and illegally brought back into countries with higher rates of tobacco taxation such as the UK.

 

• Counterfeiting – This involves the illegal production of tobacco products from tobacco rejected by tobacco manufacturers. They are then covertly distributed and sold in order to avoid taxation. Counterfeit products are made from inferior materials to look genuine and can therefore be sold cheap to the consumer. Consequently vast profits are made throughout the supply chain. It is estimated that the profit margin on counterfeit cigarettes is greater than that attained from class A drugs (e.g. heroin, cocaine).

 

Impact on Health

Smoking is a major contributor to health inequalities, responsible for half the difference in life expectancy between deprived and more affluent communities^1,2. The taxation and price of tobacco is an influential factor in smoking population rates and an intrinsic part of tobacco control strategy. The World Bank estimates tobacco elasticity to be around -0.4 for developed countries, which means that a 10% rise in price leads to a 4% reduction in consumption³.

 

Evidence from Canada and Sweden has demonstrated an inverse relationship between levels of tobacco taxation and levels of smoking. Both countries experienced significant increases in smoking rates following tobacco tax reductions^4,5.

 

The UK tax on tobacco products including cigarettes, cigars and hand-rolled tobacco is the highest in the European Union. Around 77% of the price of a packet of premium cigarettes consists of taxation and the Treasury earned an estimated £12 billion in revenue from tobacco duties in 2011-2012⁶. This policy has been instituted to help to reduce smoking rates, especially among young people. However, illicit tobacco undermines the impact of taxation and other tobacco control measures such as raising the age of sale to 18 and pictorial health warnings on tobacco packaging.

 

It is estimated that nationally, one in fourteen manufactured cigarettes (7%) and around a third of hand rolled tobacco (35%) consumed are illicit⁷. Sales of illicit tobacco products in the UK deprives the exchequer of around £1.6 billion each year in lost revenue⁷, which could otherwise be used to fund health, education and other public sector services. However, the current economic downturn may exacerbate the consumption of illicit tobacco as more smokers take advantage of cheaper products.

 

Both smuggling and counterfeiting increase the availability of tobacco at less than half or a third of legal, duty paid products. Whilst a pack of 20 premium brand cigarettes e.g. Marlboro retail at £8.77 inclusive of tax, local intelligence has found that within Lancashire illicit cigarettes are routinely bought for just £3.00-3.50 (Trading Standards personal communication). Market activity is purposefully targeted to young people and those on low incomes in areas of deprivation who already experience significant health inequalities as a result of smoking⁸. This both maintains smokers in their habit and also encourages children and young people to initiate smoking. Research commissioned by ASH found that one in four of the poorest smokers buy illicit tobacco compared to one in eight of the most affluent⁹. The World Health Organisation (2008) state:

 

"Illicit trade in tobacco products contributes to the rise in tobacco consumption and poses a serious threat to health. By making cigarettes available at prices two to three times lower than in the shops, smugglers threaten to undermine global efforts to reduce smoking and save livesâ€

 

Research conducted in the North of England in 2011 highlighted that nearly one in five adult smokers (18%) had bought illicit tobacco, whilst rates among young people were even higher with one in two 14-17 year olds (46%) purchasing illicit products from street sellers, fag houses and even ice cream vans¹⁰. Similarly a Trading Standards study of 3,471 young people aged between 14-17 years old across Lancashire County found that 28% buy their cigarettes from other sellers such as neighbours, market stalls, car boots and ice-cream vans, a third (36%) bought cigarettes with health warnings in another language and a fifth (20%) had bought fake cigarettes¹¹. Purchasing of illicit tobacco was significantly higher among young people living in Ribble Valley, West Lancashire and Burnley¹².

 

National research has shown that four times more people die from the effects of illicit tobacco than from all illicit drugs combined¹³. Moreover, the researchers estimate that eliminating illicit tobacco use could lead to a 5% reduction in total cigarette consumption, resulting in 4,000 fewer premature deaths.

 

Electronic Cigarettes

Electronic cigarettes, or e-cigarettes, are battery-powered, nicotine delivery devices, which can be bought online, in retail premises, community pharmacists and pubs. They deliver oral doses of nicotine, typically combined with flavouring, to the user in the form of vapour that mimics the look and feel of smoking. Indeed, some products have an indicator light at the end, which glows during use to resemble a lit cigarette. Whilst no side-stream nicotine vapour is released from the device, it is blown out into the surrounding air as the user exhales.

 

The vapour is considered less harmful than cigarette smoke and is free of some of its damaging substances such as tar. However, nicotine is an addictive drug that can be toxic in relatively low doses. Although the long-term consequences of e-cigarette use on health are unknown, short-term side effects include mouth and throat irritation, vertigo, headaches and nausea¹⁴.

 

The availability, advertising and use of electronic cigarettes have increased significantly over the last couple of years, with an estimated 2.1 million users nationally in 2014^15,16. Although marketed as a healthier alternative to smoking, these products are unregulated and unlicensed in the UK and therefore their safety and efficacy remains undetermined¹⁷. As a consequence, devices have been shown to contain and deliver inconsistent levels of nicotine¹⁸ and harmful toxic compounds^19,20; there have been reports of cartridges leaking¹⁸ and house fires sourced to faulty battery chargers²¹. Between April 2013 and March 2014, Lancashire Fire and Rescue Service responded to six domestic fires caused by e-cigarettes across the County. They are currently undergoing thorough research by the UK's Medicines and Healthcare Regulatory Authority (MHRA) and will be licensed as medicines for public use in 2016.

 

Anecdotal evidence regarding a reduction in referrals to Stop Smoking Services over the last 18 months, suggests that electronic cigarette use may be averting utilisation of licensed smoking cessation products, such as nicotine replacement therapy (NRT) and retaining some people smoking when they otherwise would have stopped²².

 

Research regarding the clinical effectiveness of e-cigarettes as a stop smoking aid is limited. Laboratory reports have identified that they are inefficient nicotine delivery devices that only result in modest and unreliable increases in plasma nicotine levels²³. Another study in New Zealand, suggests that smokers who use e-cigarettes to try and quit smoking are at least as likely to succeed in quitting as those who use nicotine patches, however the authors concluded that ‘Uncertainty exists about the place of e-cigarettes in tobacco control, and more research is urgently needed to clearly establish their overall benefits and harms at both individual and population levels^24’.

 

Furthermore, the World Health Organisation has recommended that ‘Until such time as a given electronic nicotine delivery system is deemed safe and effective and of acceptable quality by a competent national regulatory body, consumers should be strongly advised not to use any of these products, including electronic cigarettes’²².

 

In view of the dearth in consistent medical evidence and long term population level surveillance to support how e-cigarettes can be used to reduce or stop smoking, they should therefore not be used as a cessation tool²². The Department of Health recommends that the best way to stop smoking is through a Stop Smoking Service who provide free face to face support and offer licensed, regulated stop smoking medicines on prescription. This method is proven to be four times more successful at helping people quit long term²⁵.

 

Electronic Cigarette Use among Young People

Children learn their behaviour from adults and if young people see smoking as a normal part of everyday life, they are more likely to become smokers’ themselves²⁶. Electronic cigarette devices replicate smoking. In addition to creating confusion and undermining compliance with smokefree policies, they also normalise smoking behaviour for children and young people.

The British Medical Association has stated that the use of e-cigarettes ‘normalises smoking behaviour and they shouldn’t be marketed to appeal to non-smokers particularly children and young people’.

 

Certainly, adolescence has been identified as a significant time for the development of risk-taking behaviour including initiation of alcohol, tobacco and drug use²⁷. This could also extend to experimentation with e-cigarettes. A 2013 Trading Standards Survey with 3,471 young people aged 14-17 years across Lancashire County highlighted that more than one in four (27%) had bought or tried electronic cigarettes¹¹. Use was greater among males (31%) and among young people living in Rossendale (36%), Hyndburn (35%), Burnley (35%), Preston (33%) and Pendle (32%)¹². This could potentially facilitate a lifelong addiction to nicotine and provide a route into smoking conventional cigarettes^28-32. Indeed, a significant proportion of those who had tried electronic cigarettes (39.9%) were non-smokers (6.8% of 2,144 who had never smoked tobacco and 33.7% of the 688 who had tried smoking and not liked it)³³.

 

Furthermore, e-cigarette marketing strategies such as the availability of a wide range of flavourings, brightly coloured designs and celebrity endorsement are focused to appeal towards a youth audience¹⁵. A recent qualitative research study of 45 young people aged 13-17 years in Cheshire and Merseyside highlighted that e-cigarette use was driven by the choice of flavours, available designs and opportunity to customise devices to reflect individuality³⁴.

 

In response to these concerns, the Government announced its intention to implement legislation to ban sales of e-cigarettes to young people aged under 18 years within the Children and Families Act 2014 in 2015³⁵. Additional regulation, including restrictions on the advertising and promotion of e-cigarettes to children, could also be introduced at a national level³⁶, whilst the revised EU Tobacco Products directive will also require regulation on e-cigarette nicotine concentration, health warnings and declaration of additives¹⁶.

 

However, in view of the relative novelty of e-cigarettes, levels of awareness regarding the potential health risks and the proposed future regulation remain low, particularly amongst young people, with many reporting access to these products via family members, older friends or strangers outside shops³³.

 

This identifies a need to increase knowledge levels of the forthcoming legislation with young people under 18 years of age, retailers and adults in order to facilitate compliance and prevent proxy purchasing via training and information provision.

 

Shisha

The use of niche tobacco products, such as shisha, pan, gutkha and nass³⁷, remain a concern in communities in Lancashire. The 2013 Trading Standards Survey with 3,471 young people aged 14-17 years across Lancashire County¹¹ showed that on average, nearly one in five (18%) had bought niche tobacco, with escalated use in Ribble Valley (50%) and West Lancashire (44%)¹².

 

Shisha water pipes, also known as hookahs, narghiles, or hubble-bubble pipes have been used for smoking tobacco in the Middle East and parts of Africa and Asia for centuries³⁸. The wide range of terms used is reflective of the different types of tobacco or herbs used in the water pipe.

 

Within the water pipe, smoke is created by placing heated coal on pierced aluminium foil over a mixture of tobacco or herbs, honey and fruit flavours, and passed through a water bowl before being inhaled through a hose^39,40. It is usually smoked collectively by two or more people for 45-60 minutes⁴¹ and it is estimated that a typical one-hour session involves inhaling 100-200 times the volume of smoke inhaled with a single cigarette⁴². The quantity of tobacco used can vary greatly between different mixtures and non-tobacco herbal variants are also available⁴³.

 

Within the BME community, shisha provides a central activity at social gatherings such as weddings or in the home with friends and family⁴⁴. However, it is now increasingly being used in Western countries and over recent years there has been a rise in the popularity of commercial shisha bars and lounges, which serve as safe, alcohol-free environments for young people to socialise with the opposite sex⁴⁵. The British Heart Foundation has documented a 210% increase in the number of shisha bars operating in the UK over five years, from 179 in 2007 to 556 in 2012⁴⁶. Locally, there are currently three premises operating in Preston, although there could be more functioning illegally underground.

 

Although shisha users may not identify themselves as smokers, or indeed realise that they are smoking tobacco⁴⁵, research has demonstrated that shisha smoking can result in nicotine levels equivalent to ten stick cigarettes among daily users⁴⁷, and there is growing evidence of nicotine addiction and dependence among regular water pipe users^48,49.

 

The upsurge in the popularity of shisha bars has therefore facilitated a route into tobacco use and potential addiction for young people^50,51, in addition to creating other regulatory issues including: non-compliance with the smokefree legislation; fire and safety hazards; nonconformity with health warnings and tobacco packaging requirements^52,53; illegal sale of tobacco to under 18’s; and use of illicit, non-duty paid tobacco.

 

The Global Youth Tobacco Survey, which involved more than 500,000 13-15 year olds internationally, found an increase in tobacco use attributed to water pipes in 33 of the 97 participating sites⁵⁴. On a national level, it is estimated that 8% of school children smoke water pipes⁵⁰. However, data from the 2013 Trading Standards Survey with 3,471 young people across Lancashire illustrates that locally one in five (21%) of 14-17 year olds have tried or experimented with shisha smoking¹¹. Rates are higher in Preston (32%), Pendle (30%), Hyndburn (30%) and Burnley (29%)¹².

 

Impact of Water Pipe Smoking on Health

Shisha smoking is increasingly seen as an emerging threat to public health and safety, both locally, nationally and beyond. The World Health Organisation states⁵⁵:

 

‘Using a water pipe to smoke tobacco poses a serious potential health hazard to smokers and others exposed to the smoke emitted’ and ‘second-hand smoke from water pipes is a mixture of tobacco smoke in addition to smoke from the fuel, and therefore poses a serious threat for non-smokers.’

 

Water pipe smoking produces high levels of toxic compounds including tar, nicotine, heavy metals such as arsenic and beryllium, carbon monoxide and carcinogens e.g. polycyclic aromatic hydrocarbons (PAHs) from the burning coals^47,56,57. Herbal varieties also contain significant levels of toxic chemicals with the exception of nicotine.

 

Consequently, research suggests that water pipe smoking is associated with many of the same risks as cigarette smoking including:

 

• Increased heart rate and blood pressure^58-60

• Carbon monoxide poisoning^61-65

• Impaired lung function^66,67 and development of chronic obstructive pulmonary disease (COPD) ⁶⁸

• Bladder, throat and oesophageal cancer⁶⁹

• Infertility⁶⁹

 

The communal sharing of water pipes also carries the additional risk of transmission of infectious diseases such as tuberculosis and hepatitis^70,71.

 

However, there are common misconceptions among water pipe users that it is less harmful to health than smoking conventional cigarettes. A survey of 282 members of the BME community in Lancashire in 2013 highlighted that the majority of shisha users did not realise that the product being smoked usually contained tobacco and nicotine, and many also thought that the water bowl within the pipe filtered out the harmful substances from the smoke prior to inhalation⁴⁵.

 

This lack of awareness highlights the need to develop and disseminate clear and consistent messages regarding the addictive nature and health harms caused by shisha use, the risks associated with secondhand shisha smoke and carbon monoxide exposure both in commercial venues and recreationally within the home. Research indicates that shisha users welcome such information⁴⁵ and those in receipt of it are more likely to want to quit⁵¹.

 

In addition, proprietors and employees of commercial shisha venues and those hosting BME events such as weddings also require training to ensure they are fully informed and compliant with the relevant regulatory legislation regarding: smokefree premises; tobacco packaging, duties and trade marks; and point and age of sale, including the legal consequences of contravention.

 

Paper prepared by Jo McCullagh

Public Health Specialist – Tobacco Control and Stop Smoking Services

Adult Services, Health and Wellbeing Directorate

May 2014

Joanne.McCullagh@lancashire.gov.uk

 

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