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E-Cig Summit Debate - Are e-cigarettes a backward step in the fight against tobacco and smoking?

Chair: Okay, and I think in this panel you’ve met most of the speakers apart from Lorien Jollye, is that right? Who is a vaper and a member of the E-cigarette Consumer Association. Okay, so the question that was posed here, are E-cigarettes a backward step in the fight against tobacco and smoking? And again we are going to ask to the panellists to answer this in a couple of minutes and then we can open the floor to more questions. So I’m just going to do it in reverse order this way, so starting with Robert.

Prof. West: They’re a forward step, that’s pretty obvious.

Chair: So, forward step, great, that was short and sweet, that’s what I like. Number two, Lorien.

Lorien: I think my position’s going to be fairly clear, my experience is that I did smoke for 23 years through two pregnancies and multiple quit attempts. Each one failing miserably. And now I don’t smoke as is the experience of two members of my family, so no, in my opinion, there is no way they could be qualified as a step backwards.

Chair: Okay, thank you Lorien. Linda?

Linda: No, I think they are a step forward as well. I think you’ve heard from a couple of speakers, there is an important section of the public health community that didn’t feel comfortable attending this meeting today. They’re not here. And I think their view, for many of them, or some of them, think that long-term nicotine use is a bad idea. They believe people should stop using nicotine altogether. That’s not the conclusion we reached in the NICE tobacco harm reduction guidance. And then I think E-cigarettes potentially have an important role to play within that but we need to make sure that not only they are effective and safe, but also that, as I discussed earlier, our NHS and local authority colleagues can commission and use them appropriately and they won’t be able to do that unless there is some form of regulation.

Chair: Okay, Jean Francois. Thank you Linda.

Prof. Etter: Well, I think it’s a step forward and even more than that, there is a risk that many of the people worked in the field of anti-smoking are going to be just irrelevant, you know, they don’t understand and they been very slow to understand the importance of this and this huge change is just going to occur without them and worse, even in spite of them. They say that tobacco, that will be renormalised. There’s no evidence for that. Vaping, so I encourage it, vaping, not smoking. The gateway hypothesis? Well, for the moment it’s not proven. It may occur in the future if the industry targets kids so there’s a need to follow that and have appropriate rules to avoid this problem but for the moment it doesn’t occur. So it’s a revolution with or without the anti-smoking people.

Chair: Thank you. Deborah?

D Arnott: I would just like to follow what Linda said basically, and agree with Linda. I mean I think there is a great deal of concern about the risks of gateway effect and all the rest of it and concern also about addiction and I think we shouldn’t just deny the addiction point because actually being addicted is not necessarily a pleasant or an easy place to be, and these products are not going to be cheap. If people are going to addicted for their life, the whole of their lives, it’s going to cost money. So, I think we have to take all of that into account when we’re designing regulation. Potentially E-cigarettes are an enormous benefit. They are obviously, you know, there are quite a few people here in this room and Lorien’s one of them who’ve already benefited from that. What I’d like to see is regulation that ensures that the vast majority of smokers can benefit from them.

Chair: And Clive.

Clive: No doubt about it, it’s a hugely positive development, it will only get better over time as there’s more and more innovation. It’s a very interesting disruptive technology, it’s very disruptive to the tobacco industry. And providing the, you know, and the current incumbents cannot rely on their market shares of the nicotine market being protected, they’re going to face competition from what is basically a tech based industry with a very different active kind of user base than the ones that they’re used to so I think that’s good. I think it’s also very disruptive to the public health community actually. And I think Deborah uses this, so I just posted a response to a blog on Manchester University’s policy website, where people say, there are concerns using the passive voice. Actually, those concerns are voiced by a very narrow, very specific number of people who are professional engaged in this world who don’t like these developments. It challenges their model of tobacco control and public health, they tend to be people who have grown up with an anti, sort of corporate bias which they’ve, which they’ve honed on big tobacco and have been drawn into this for these reasons, but they are a very narrow group. And actually I don’t think they’re making particularly strong arguments. In many ways they’re sort of clutching at evidential straws or hypothetical risks to try to slow down these developments that they’re basically uncomfortable with. On nicotine addiction, I, you know, I’m very keen on vaping, but I’m not a vaper, and I never will be, but keen on it for its public health impact. To me an addictive drug that doesn’t really cause any harm to speak of is something that drops right down my list of concerns, to be honest. I suspect caffeine is addictive. I remember discussing this once with Anne over dinner and she was saying, “Of course, it’s better if people are completely nicotine-free,” and then we had a couple of glasses of red wine on the table which were enjoying while we were talking about this, and I think we both concluded it was no need for us both to be red wine free. Actually, there might be, you know, it might actually not be a bad thing if these things provide benefits and you know, functional advantages to things, so you should worry about it, the addictive side of it much less if there’s much less harm, and that’s the situation we’re in.

Chair: Okay, well thank you. Remarkable consistency then across the panel in terms of I think recognising that E-cigarettes are a positive forward step, if you like, but some caveats around regulation. And we might want to unpick some of those issues that have been raised such as addiction, gateway, and also the role of the tobacco industry in the discussion from the floor. So I’m now going to open it up for questions, please make sure your hands go right up so that we can try to identify you. It’s quite difficult with the microphones but has anybody got a microphone at the moment? Okay. Let’s go with the first question then. Thank you.

David Dorn: Okay, it’s David Dorn again from Vaper Trails, sorry, gob on a stick, it’s the way I am. I’ve been interested listening to this right the way through the day and a little confused. And the panel that I see before me now is representative of the organisations that I’m thinking of, which is the Royal College of Physicians, ASH and Cancer Research UK, who all seemed to be of one mind around about 2007 when they were calling for NRT to be removed from medicinal regulation and for there to be a kind of continuum of risk situation where there would be a nicotine regulatory authority rather than the MHRA dealing with everything as medicines. And it occurred to me that that would not be a bad idea, especially with regard to big tobacco becoming involved in the E-cig market and in the clean nicotine market because bit tobacco and its products then would be regulated by this nicotine regulatory authority which I think the Royal College of Physicians was very keen on and I recall reading, as I say, that Cancer Research and ASH was quite keen on it as well. I just wondered what the panel’s views were on that?

Chair: Okay, thank you. I don’t think the RCP ever called for NRT to be taken out of the medicines regulation but you are right in terms of people calling for a nicotine regulatory authority at a time when governments weren’t really interested in more bureaucracies. But anyway, does anybody want to pick that up? Robert and Clive.

Prof. West: I’m not representing Cancer Research UK, I should make that very clear. The reason for us, however, I was one of a number of people who thought that a nicotine regulatory authority would be a good idea. And the reason for that was in order to try to improve access to clean pure nicotine delivery systems relative to cigarettes. One of the things we haven’t talked about yet today is what in the context of E-cigarettes and improved nicotine delivery systems we do about tobacco. And I think we can move, maybe this is bold, it doesn’t seem bold to me. We can move to a situation where if smokers can get access to forms of nicotine that aren’t going to kill them, how come we can allow tobacco to be continued to be sold, marketed, still marketed, and kill many, large numbers of people, so I think one of the things we need to think about in terms of the regulation is the extent to which the advent of this new technology, instead of just looking at that, we can start to look at the other side of the coin.

Chair: Great, thank you, did you just want to?

Clive: Yeah, I think there’s an argument for having a sort of singular regulatory oversight here which did used to go under the name of a nicotine regulatory authority. And actually if you look at the way the Tobacco Products Directive is working you’ll see why. Basically the safest form of nicotine that’s under discussion in the Directive is the one with the hardest, most aversive, most burdensome regulation. Smokeless tobacco, which also as Antoine showed, very, you know, very, very beneficial from a harm reduction point of view, goes down two paths. One path is relatively lightly regulated, but if you put it in your mouth and suck it rather than chewing it is banned. Okay, so there’s a completely arbitrary distinction in smokeless tobacco. And then there’s potential to bring new tobacco product, heat not burn tobacco, so non-combustible where the nicotine is evaporated from the tobacco and inhaled, they seem to get the easiest ride of all in terms of access to the market, and I think that’s quite good actually. So one reason to have a consistent sort of regulatory approach to this, I don’t like the idea of new agencies particularly, but a consistent regulatory approach is to get rid of these sort of bizarre anomalies where there is completely different regulatory treatment between the different types of low risk alternative nicotine products to smoking. I mean the difference between all these products is much of a muchness in terms of risk, but in terms of the way they’re regulated, they’re hugely different. It makes the current arrangement in the TPD, and that’s really where my dog’s breakfast logo came from is basically a total mess. It’s completely incoherent. Particularly ridiculous to ban the product that is responsible for the best health tobacco-related health outcomes in the whole of Europe.

Chair: Okay, let’s take another question from the floor. Yeah?

Ruth Olding: Hi, I’m Ruth Olding, I work in public health in tobacco control and I just wanted to kind of have a voice for the people that help people smoking on two points. It’s more of an experience today, is that I support Linda’s point that we see a lot of smokers every year and I think if there is some regulation we can give access to those people who might not be able to afford those products and I support those products to help people stop smoking and give a cleaner form of nicotine and for the health benefits to be gained. But my experience today, it’s made me think about the second-hand smoke from these vapers, because this is the first time I’ve probably really been in a room where there’s been several people vaping. Very interesting and I came in this morning thinking, “I’m really going to keep an open mind here,” but I don’t like it. I have found it unpleasant and I’ve got a headache and that really makes me think, would I want to support, so there needs to be some thought about the regulation of whether it should be allowed indoors, and I certainly wouldn’t want to subject children to what I’ve been subjected to today. So that I would just like to make that point. Chair: Okay, thank you, Ruth. [Applause]

Lorien: Could I actually respond to that a little bit?

Chair: Yeah, Lorien, I was going to ask Amanda to, but.

Lorien: Sorry, but just briefly, I do understand exactly what you’re saying and we are always well aware that it is so ingrained in us as a society to feel aversion to smoke and naturally what we do very much resembles smoking so even is as a vaper, sometimes I see what I’m doing and without consciously thinking about it, I feel uncomfortable because that’s also my association. We’ve all become part of a society where smoking is absolutely deemed as inappropriate. So it is a natural response. It’s highly unlikely that you’re going to have, unless you’ve got an allergic reaction to propylene glycol, that you’re going to have a physical reaction. There’s every chance that it is an emotional response that we are conditioned to have and I am deeply sorry that you have been made feel uncomfortable but we can’t look at taking away an entire method of getting away from tobacco because unfortunately some people don’t like how it looks. [Applause]

Chair: Yeah, I think it’s a complex issue and I know some people just prefer to breathe in sort of clean air, so I guess what the point that Ruth’s making as much as possible is for people just to be aware that other people around them might not particularly want the vapour breathed all over them. Another person with the microphone there, Antoine had it here. Or would like it here.

Prof. Flahault: Yeah, perhaps it’s a good idea to have people who haven’t spoken yet?

Chair: Yeah. Antoine: So if – who’s got the microphone at the moment? Has he spoken?

Darren Johnson: Hi.

Chair: Okay, thank you.

Darren Johnson: Hi, it’s Darren Johnson here for RY4 Radio. It’s been really, really interesting today and I’d just like to thank the panel. I’ve actually learned a lot as well today, but interestingly enough on the top line of that subject about children, whilst I understand it’s important that we’re protecting children, you know, obviously for generations to come, I think none of us in the room are stupid. You’re never, ever going to stop a child from smoking. You’re never, that’s Page 92 of 102 just not going to happen. The only way that’s going to happen if you remove the product completely. Now, I don’t want that to happen but I think partially it’s down to the parents as well. Let’s not forget that. You know, I’m not a parent, but I think that there’s enough responsible parents out there to be able to educate their children but on another matter, if that is the case, this might sound a bit funny, but we teach children sex education in school. Children get science classes. Why aren’t the science teachers not educating the children about the dangers of tobacco? You know?

Chair: I hope they are.

Lorien: They are. [Laughter]

Chair: I do hope they are.

Darren Johnson: If that’s the case.

Chair: But point well taken. Does anybody want to respond to that?

Linda: Yeah, can I just answer that? Unfortunately in terms of giving children information straight up, there’s not a lot of evidence that that necessarily is effective in preventing them, for example, from starting smoking. But what we do know is important and works in preventing young people from starting smoking is the make sure that the adults around them are not using tobacco any more. And clearly these products may have a role to play in that. But we also need to make very sure as Deborah’s set out that we’re not advertising and promoting them in a way that makes them look as if they’re terribly appealing products to those children who might not have started using tobacco.

Chair: Okay.

Linda: So those are the two points.

Chair: Thank you Linda. I’m particularly keen to get people who haven’t yet had a chance to speak. I can see Elsa’s got the microphone, could you just stand up for a minute if you haven’t yet spoken and wait, wait, wait, wait, one minute, just for the rest, for the people who haven’t yet spoken and have a question so we know where to direct the microphones next. Okay, can you, people with the microphones, can you see those people standing up and get the microphones to them? Elsa, thank you.

Elsa Wright: Thank you, Elsa Wright, director of Fresh. We have a number of big tobacco companies present today and they are evidently interested in this new market of electronic cigarettes and supporting light touch regulation to be proportionate to harm. Can we on this basis therefore assume that they will be more accepting of the need for tougher regulation of their lethal smoked tobacco products to reduce children taking up smoking or are they going to continue to deny, delay and derail any effective public health measures we try to take? Thank you. Chair: Great question, perhaps, would anybody from the tobacco industry in the audience like to stand up and. (Laughter)

Chair: Steve Stotesbury? Yeah, Steve Stotesbury was here wasn’t he? Go on, answer that question. I mean, it’s a very valid point.

Steve Stotesbury: Er, yeah, Steve Stotesbury, Imperial Tobacco.

Chair: Thank you.

Steve Stotesbury: Well, I don’t know what regulations we’re trying to block that the speaker.

Elsa Wright:: Standardised packaging. [Laughter]

Elsa Wright: If you just realised you were blocking it, perhaps that’s helpful. [Laughter]

Steve Stotesbury: Well, I. Look I. [Laughter]

Steve Stotesbury: I think you.

Chair: Next question.

Steve Stotesbury: Yeah. (Laughter)

Steve Stotesbury: No, I’m, look I’m happy to say, you know, would any commercial entity want to see a regulation that deprives them of their trademarks? You know, there is a health warning on the pack. It’s pretty clear, it’s also evident that that has had an impact on smoking prevalence. Now I think people get the message, it just seems, you know, a totally disproportionate measure on what is a legal product.

SPEAKER: So the answer is no, Elsa?

Chair: Yeah, and we can probably take that from that. It’s a legal product that kills, you know, one in two of its regular persistent users when used in the way intended.

Clive: That’s a disproportionate. It’s disproportionate. Which impacts, I’m not going to defend him here.

D. Arnott It doesn’t sound disproportionate to me.

Clive: But no, but Debs, the impacts of the product isn’t particularly in dispute. The question is whether that, whether the benefits associated, the health benefits associated with that measure justify the other costs which they say affect them, so, you know, hard to defend these guys, but actually what he’s saying here is is this proportionate, not anything goes.

Chair: Okay, I think it’s proportionate, but anyway, Elsa, did you want to comment on that? Because your question was slightly different. SPEAKER: … packaging is … Chair: Yeah. SPEAKER: … trying to take … (inaudible 6:07:46) -

Chair: Type of? SPEAKER: Going on so it’s. Chair: You name it. SPEAKER: That’s just want it (inaudible 6:07:51) -

Chair: Anybody else from the tobacco industry want to answer or we’ll move on to the next question. I know you’re not from the tobacco industry Martin. Okay, let’s move onto the next question. Has somebody got the microphone? Thank you.

Alicia Forry: Yes, thank you. My name is Alicia Forry, I’m with Canaccord Genuity which is a financial services firm. And my question’s about the final bullet, what dangers are there in tobacco industry involvements in the E-cig markets? We’ve heard about the tobacco industry’s history, their communications to the public, and we also know that E-cigarettes appeal primarily to smokers and now tobacco companies are obviously moving wholeheartedly into the Ecigarette space so I’m curious about what the expert panel thinks about this transition and I’m curious, I don’t know whether tobacco companies are currently allowed to sell other nicotine replacement therapy products like patches or gums, is that allowed? And if it is not, why should they be allowed to sell E-cigarettes?

Chair: Yeah, go on.

D Arnott: Well, in fact, RJ Reynolds actually bought up an NRT company, I’m not sure they’ve done very much with it, but there’s nothing to stop them, but I think it makes it even more important that the regulation is appropriate to make sure that for example, they’re not using E-cigarettes to promote smoking because as you can see from the history, actually that’s in their interest because cigarettes are much more addictive, they’re much more profitable, they’re cheap as chips to make, much cheaper than E-cigarettes and so, you know, I think that’s the point, but no, they, just because they’re tobacco companies doesn’t mean they can’t own, you know, Philip Morris used to own food companies and they can own any other company they want.

Chair: Okay, can I just ask those people again who are trying to get to raise a question who haven’t yet spoken?

Amanda: Anne, we’ve got two.

Chair: And we’ve got two, great.

Amanda: One there and a lady here, and another gentleman there that haven’t spoken.

Chair: Thank you Amanda.

Erik Bloomquist: Oh, good afternoon. Erik Bloomquist from Berenburg. I was wondering if you could comment on an element of regulation not addressed so far today which is taxation and how do you propose, or what do you think is the optimal way to approach taxation of E-cigarettes given some governments are starting to move into relatively aggressive taxation which would seem likely to reduce adoption of these products? Thank you.

Chair: Thank you. Sorry, did you say your name? I?

Erik Bloomquist: Erik Bloomquist, Berenburg.

Chair: Okay. Thank you. Who wants to address taxation of E-cigarettes? Yeah, okay.

Linda: Well, I mean, I’ll make a start. I mean one of the benefits of having a regulated product, as you know, that the licenced nicotine products currently in the market have benefited from a lower level a VAT for example, which we’ve regarded as helpful, so I think if we have safe and effective products then we shouldn’t be using, we should have lower forms of taxation on those products so that they’re accessible and affordable for people who want to use them. That would be the first step. But certainly I don’t have any evidence about existing taxation regimes in relation to E-cigarettes in the UK or elsewhere that, you know, are not currently regulated.

Chair: Thank you and I think Lorien and.

D Arnott: And it is a significant difference, in the UK, NRT is over the counter, it currently attracts 5% VAT compared to 20% for most, for other consumer products. And if E-cigarette companies get their products licenced they will be in the same position.

Chair: Lorien, did you want to make a point?

Lorien: I did, yeah. Just to speak on, kind of on behalf of the community in that respect, we don’t want any special kind of treatment with these products. It certainly wouldn’t be reasonable to put any further tax on them than is already there unless it was a small amount as I saw on one of the slides earlier, and the idea of putting a small amount of tax on to further and fund research, that would be perfectly reasonably. However, to put huge taxes like on tobacco would be unreasonable because as it stands there is no proof that these cause the kind of illnesses that the NHS have to support and need extra funding for. In terms of going back down the other way to 5% tax, that again, that isn’t something that we’re asking for. We’re not asking for anybody to fund this. This is our habit, it’s what we enjoy doing, it is a pleasure as much as it is to drink alcohol or drink coffee or buy clothes or shoes or whatever it is you like. Chocolate which tends to be my case. This is choice thing and we don’t want special treatment. It. We don’t cost anybody anything. And I would like people to bear that in mind. For the thousands of hundreds of, however many there are of us who have completely given up tobacco, we have not cost anybody for that. We are not spending any time in our doctors’ surgeries, we are not having to go to visit smoking cessation nurses, we’re not having to go into pharmacies, this is all off of our own backs, this is completely self-funded and we’ve managed to achieve something that most all of us where failed at by the NHS itself with their own services. We’ve not cost a penny.

Chair: Okay. [Applause]

Clive: You just said it all basically, I mean very eloquently put. I mean, just one quick thought about this. You know, there’s a limit to how much you can tax these products or how much you can raise the cost of them because if they start to get more expensive than cigarettes and they’re some way off that, you’ll lose a lot of the incentive to switch. So, things that increase the costs or increase the tax, basically we will squeeze the margins that are available for the manufacturers, we’ll close down the rate of growth and innovation in the market, it would be wholly counterproductive to do that and if, too bad if you’re losing tobacco tax revenue, just find it somewhere else. You don’t have to turn to the nearest thing that looks roughly the same.

Chair: Okay, thank you. Let’s take the next person with the mic please.

Jo Luxmore: Hi. I’m Jo Luxmore, I’m also from the public health community. My question really is both around addiction and regulation. I’m responsible for commissioning some of the cessation services in England and we are finding now that people are accessing service who are addicted to E-cigs. And they are obviously seeking the advice of health professionals to help them wean off the addiction, but without the regulation in place at the moment, because we’re an NHS service it’s difficult for us to provide that support. So my question is, without regulation, how do propose we do support people become addicted to these products in the future?

Chair: Okay. Clive, your hand was up first. And then we’ll.

Clive: But this is a problem of the health establishment’s own making basically that it said rather than take sort of, you know, sensible humane judgements about advice that we give to people given what products from the market, there was there, you know, thou shalt not use E-cigarette products if they’re not licenced. So this is a consequence of guidelines that, you know, denied the solution itself as a licenced produced, whereas actually there are many sort of public health specialists. I’m just thinking at the moment of Lynne Koslowski at Buffalo State University of New York. Very sort of, just try it. Use these products. They can’t be remotely as bad as cigarettes. If they work for you, brilliant. And why we couldn’t have just had straightforward advice like that instead of something that was extremely risk averse, but raised a barrier to attempting a different approach to quit unnecessarily in my view and as I say, I think it’s a problem of the NICE guidance, it’s a problem of the health establishment’s own making.

Chair: I think the question was actually around the...

D Arnott: I don’t think that answered the question.

Chair: E-cigarette users. Would anybody like to offer?

Clive: I thought it was like we can’t recommend this product?

Chair: No, no, no.

Clive: Because they’re not licenced.

D Arnott: No, no. Sorry. Clive that is wrong.

Chair: Treatment of addicted E-cigarette users, so does anybody want to try and address that? Linda?

Linda: There’s nothing to stop somebody who works for the NHS Stop Smoking services giving people information about E-cigarettes, and if they choose to encourage them to continue to use them, along with the treatment that’s available, that’s fine, we know that’s happening in practice, so the guidance doesn’t prevent them from doing that Clive. I think the issue about you’re seeing people coming to you who are using E-cigarettes and would prefer to stop using them, how do you support them? That’s a difficult challenging issue. I’m hearing the same thing from colleagues in Scotland. We have no protocols for that at the moment. However, the services and the services are not funded to do that, but the services do help people come off other forms of licenced nicotine products, and at the moment I think that’s the only approach you could take would be to adopt a similar model until as Robert very helpfully said, we need the studies that he was describing which are just around day to day effectiveness.

Chair: Robert, do you want to come in?

Prof. West: Well, I think there’s a bit of an issue because the reason that the NHS Stop Smoking services are there because, because they come under the NICE threshold for a cost per quality adjusted life/year gained, and the reason they do that is because even though the success rates aren’t massive, cigarette smoking’s so incredibly dangerous that you don’t have to be tremendously effective to be very, very cost effective as a way of saving lives. I don’t think, and I’m pretty sure that providing NHS support for people to come off Ecigarettes would come under the NICE threshold to be quite honest, which is £20,000, £20-30,000, so I think that is an issue when you consider, you know, that the, all the things that the NHS needs to do. You know, I can understand the concern of someone who’s, you know, someone comes to you and they want help with coming off an electronic cigarette or any other form of nicotine and you want to help them, but just bear in mind that everything that we do in the NHS we do at the cost of something else we do in the NHS and to be honest given what we know about the safety and risk of nicotine I doubt whether that would ever come under the threshold.

D Arnott: But can I just add something because actually I think while, you know, we certainly say to people, “If you carry on using, whether it’s medicinal nicotine or E-cigarettes for the rest of your life, it’s much, much less harmful than smoking”. The number of times I’ve had smokers say to me, “I don’t want to be addicted,” and I think that’s something we have to recognise that an awful lot of smokers don’t want to be addicted and sometimes their worry about E-cigarettes is that it will just carry on the addiction and that’s why a lot of smokers try and quit as they call it, cold turkey, and I think, you know, we have to be recognised that that is actually how people feel and not say, “Oh well, you shouldn’t worry about it,” because actually they do and they have a right to worry about it.

Chair: Okay, quick Jean Francois and then.

Prof. Etter: Yes, about the addictiveness of E-cigarettes, it’s not very well documented for the moment, I have data in about 1,000 long-term users of E-cigarettes and I’m currently analysing these data comparing the addictiveness to E-cigarettes to the addictiveness of cigarettes and also I’m comparing this long-term users to long-term nicotine gum users and they are very different. Long-term use of Ecigarettes is I think much less related to addiction than long-term use of gums and more to pleasure. But, certainly some users transfer their addiction from tobacco to E-cigarettes and they are addicted. Is it a problem? Is it a public health problem if they are to toxic? I’m not sure. There’s also some moral preferences, some people would prefer others not to be addicted to nicotine but if there is no health, negative health impact then it’s more of a moral question and they should, these arguments should be put forward under their real name. Moral preferences, not public health. And also just one more minute. And I also think that current E-cigarettes are not addictive enough. [Laughter]

Chair: Okay. Jean Francois: Okay? They are not effective enough, they do not deliver. [Applause]

Chair: Okay, who.

Jean Francois: They do not deliver nicotine quickly enough and more people would switch to E-cigarettes if they delivered nicotine properly.

Chair: Okay. Who’s next with the mic I think?

Martin Dockerell: Martin Dockerell.

Chair: Martin Dockerell from?

Martin Dockerell: Martin Dockerell from Action on Smoking and Health. I want to address the normalisation, renormalisation question. It seems to me that renormalisation is a problem about confusion between real smoke cigarettes and what we call electronic cigarettes. It’s because E-cigarettes were designed to look like smoking because that was their, that’s been the secret of their success. They’re white, originally white tubes, glowing red tip, produce vapour. That has caused a great deal of confusion both among the public and among the public health community would the panel agree that this extremely welleducated and articulate audience has a duty to explain to the public and to the public health community continually the difference between electronic cigarettes and real cigarettes?

Chair: Anyone want to develop?

Clive: I, oh sorry, you go.

Lorien: No, it’s much quicker, it’s quite quick. Firstly, I don’t hold, yes, you’re right, absolutely of course that the public health do have, should have it in their remit to be continually explaining the difference and not be dragging down the reputation of electronic cigarettes as they so often do. However, the note I would like to pick up on, anybody who is alive today who is able to make a decision for themselves, so any adult and really probably children from about the age of 10, are well aware for the past six years it has been completely unacceptable to smoke in a public place. In most cases now it is unacceptable to smoke near a public place. There are no grey areas. Everyone knows that is the situation. So if you were in a restaurant or you’re in an office, or you’re in a pub or in a shopping centre, and you see vapour emitting from somebody’s mouth, you know that is not a cigarette. Nobody’s going to suddenly go, “Oh, did they change the law this morning?” It has been in place for long enough and that is how, and that is how children are growing up in that environment. They already know the difference. The idea that we’re going to, we, whether using a device like this or something that looks like a cigarette is suddenly going to make everybody think it’s okay to smoke inside again is nonsense. We are far more intelligent than that. [Applause]

Chair: Okay, thank you. [Applause]

Chair: Right, we’re running out of time so what I suggest is the few people who we’ve sort of indicated will speak if you could ask your questions and then I’ll ask thepanel for any final comments which an incorporate your answers. Jane.

Jane Landon: Hi, Jane Landon from the UK Health Forum. Earlier today someone talked about marketing and advertising as information to consumers and I think that Deborah’s slide show did a lot more than that, that it’s about appeal and it’s making the product attractive and sexy and two things, one we’ve heard also that the tobacco industry are moving into the E-cigarette market, and secondly that advertising regulation is itself self-regulatory. Would a medicines regulatory environment alter what you could or couldn’t say in terms of marketing and advertising of E-cigarettes? Chair: Yeah, I think, yes, I think is the answer to that, but please feel free to incorporate it in your.

Prof. West: Can I just by a very brief comment on this Anne, because I think, yeah, I mean Deborah put up those adverts and kind of implied that this was a bad thing. And in therefore under a medicines regulatory regime, or her preferred regulatory regime, these things wouldn’t be allowed. But if you go back to what I’ve been trying to say is that the key thing here is to build up the appeal of these product so people, and you’re quite right, it’s more than, advertising is much more than conveying information. You know, we don’t, adverts in Britain at least aren’t public service announcements. They’re about creating a kind of, a buzz, an excitement and I actually thought some of those adverts that she showed were quite good in the sense that they created a compelling, you know, from an advertisers point of view, a compelling value proposition which, you know, if you don’t feel there’s any buzz or any attraction or there’s any strength in the brand, then why are you going to motivated to switch? I’d be very surprised if anyone who isn’t already a smoker or vaper would be touched by anything like that, they’d just go, “What’s all this about?” So, I think we’ve got to careful here that when we, and it was kind of slightly revealing to me that we’ve got you know, when we talk about what we mean in practice, we mean get rid of all the sexiness in the adverts and have information about rational choice, which is what the medicines regulation sort of thing is supposed to be. But to really do the public health thing you need some buzz about these products.

Chair: Okay, we are running short of time. I see somebody’s got the microphone, I know Konstantinos has got it, so we’ll take two very small points and then I’ll give final wrap up.

SPEAKER: I think it’s been an incredibly interesting afternoon and is, Deborah it seems like we all want the same thing. We want to improve these product to actually be the best addictive electronic cigarette product. It is a kind of incredible that on a side we want to improve the addictiveness of these tools and on the other side we want to fight addictiveness. It’s not going to happen because that’s exactly the beauty of the electronic cigarette and on taxation, if I may.

Chair: Just quickly.

SPEAKER: Taxation has been introduced in Italy, it’s been a very destructive move. It’s created a lot of people to return to back to smoking as a matter of fact.

Chair: Okay. Not long.

SPEAKER: The real issue there is the conflict of interest of the governments. Governments make a lot of money from tobacco and in Italy alone in 2012 there’s been a cut in the consumption of tobacco of 8%. It’s never been seen before. Not all the anti-smoking campaign over 20, 30 years were able to achieve that. So we really need to take this into account, you know, the conflict of interest of our governments.

Chair: Thank you very much.

SPEAKER: When it takes to regulation.

Chair: And then Konstantinos did you have a final, very short, comment? [Laughter]

Dr. Farsalinos: One comment for Mrs Bauld. I absolutely agree with you that nicotine should be eliminated, that’s the ideal thing. With your colleagues I mean. But let’s be realistic, I’m a clinical doctor, I ask patients every day to stop smoking. It doesn’t make it more feasible than it really is. So I think and I agree with the rest, with all the panel that we must be realistic and we must provide all these people with something that is feasible, that is less addictive compared to what they are currently doing. I have a question for the Electronic Cigarette Consumer Association. Do you believe and do you promote informed decisions by consumers and do you support that the consumers should apply pressure to the manufacturers and the retailers in order to provide evidence about their safety of their products, that they’re products are tested and what’s inside and what is the role of a consumer association in educating users from this?

Chair: Okay. Lorien, do you want to quickly address that?

Lorien: Yeah, no, sure. Yes, consumers absolutely have a right to know what’s in these fluids and certainly on the face of things and quite often it’s a very simple list of ingredients. Any consumer group or any group of consumers should have the right to know what they are eating, drinking, smoking, driving, whatever it is. And certainly in this market, it is still very young, and we do still have a lot to learn, what happens when we vaporise food flavours because obviously that wasn’t their original intention. These are all things we have to learn, but the key word in all of this is the word “safer”. We’re not asking for 100, we’re not asking for drinking water here, we are asking for something that’s safer than what we were doing beforehand. We don’t need it to be sterile and clinical, we don’t need it to give us a perfect nicotine dosage every time. We don’t need it to regulate exactly how we use the device. We want it to be safer and I think that’s probably what’s most important.

Chair: Okay, thank you. I know you also addressed a question at Professor Bauld but I don’t think we’ve got time because we’ve got about 30 seconds to wrap up, so I hope that you’ve got something from the day, I hope it’s caused you to reflect. I would like to thank you very much from the floor for your questions, I’d also like to thank all the speakers and the panellists for your contributions today. Thank you very much. [Applause]

Chair: And a thank you as well, please, to Amanda from Smooth Events, and the EC Forum and please do fill in your questionnaires before you go. Your evaluation forms. Thank you very much.