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    This is an extract from the  response by Action on Smoking and Health to the consultation by the Committee of Advertising Practice and the Broadcast Committee of Advertising Practice.

    Relevant Facts

    The following are relevant facts about “electronic cigarettes” that should guide the final rules on how they are advertised.

     

    1.  Electronic cigarettes are not cigarettes in any meaningful sense, they are nicotine delivery systems that do not contain tobacco, where the nicotine is delivered orally to the user in the form of vapour rather than in the form of smoke. They are therefore much closer in kind to other non-tobacco licensed nicotine products, such as sprays, patches and gum, than they are to cigarettes.
    2. Nicotine is an addictive drug that can be toxic in relatively low doses. However, by far the greatest harm caused by cigarettes results from other toxic ingredients of cigarette smoke.
    3. Electronic cigarettes are therefore significantly less harmful than smoked tobacco, and are currently primarily used by smokers as an aid to cutting down on cigarette use or quitting smoking altogether.
    4. Nonetheless, advertising and promotion of products containing an addictive drug should always be subject to close supervision by regulatory authorities, since addiction undermines the principle of informed consent by adult consumers.

    ASH estimated that in 2013 there were 1.3 million current users of electronic cigarettes in the UK, and the number has continued to grow since then. This number is almost entirely made of current and ex-smokers; with perhaps as many as 400,000 people having fully replaced smoking with e-cigarette use.3 There is little evidence to suggest that anything more than a negligible number of never smokers regularly use the product. Research carried out for ASH also suggests that there is no current compelling evidence to suggest that young people are using electronic cigarettes as a “gateway” to smoking.3 However, this could change particularly if advertising and promotion of electronic cigarettes glamourises the use of these products and promotes their use to young people.

    Under the EU Tobacco Products Directive cross-border advertising of electronic cigarettes will be unlawful after the Directive comes into effect (likely in about mid-2016), unless they are authorised as medicinal products. This means that no TV, radio, electronic or print advertising will be allowed. The advertising permitted will essentially be limited to advertising which only has domestic reach such as billboard, bus and point of sale. The UK Medicines and Healthcare Products Regulatory Agency (MHRA) has said that it: “continues to encourage companies to voluntarily submit medicines licence applications for electronic cigarettes and other nicotine containing products as medicines”.

    This is an evolving market and it is highly likely that novel nicotine containing products, which do not fit within the category of ‘electronic cigarettes’ will enter the market. We therefore recommend that these rules cover all non-tobacco nicotine containing products, not just electronic cigarettes, so that they remain fit for purpose as the market evolves. This generic point applies to all the rules.

    As a general point the use of the descriptor ‘e-cigarette’ or ‘electronic cigarette’ has exacerbated general concern about these products and misunderstandings about what they are and their risk profile. Increasingly users themselves are referring to these products as ‘vapourisers’, their use as ‘vaping’ and users as ‘vapers’. We think it would be helpful if CAP required this terminology and prohibited the use in advertising of the words ‘e-cigarette’ or ‘electronic cigarette’ and descriptions of their use as ‘smoking’ and users as ‘smokers’. If this is not considered possible at the very least it should be required that the full term ‘electronic cigarette’ be used and not the shortened form ‘e-cigarette’ as this provides a clearer description of what they are.

    General Principles

    We therefore recommend that the revised set of rules adopted by CAP and BCAP following this consultation should be consistent with the following principles:

    1. Regulation of un-licenced electronic cigarettes and other nicotine containing products should be consistent with that for licenced products. For example, celebrity endorsement and free samples are not allowed for licenced nicotine containing products and should not be allowed for electronic cigarettes either.
    2. Electronic cigarettes and other nicotine containing products should not be advertised or promoted in ways that could reasonably be expected to promote smoking of tobacco products.
    3. As far as possible, electronic cigarettes and other nicotine containing products should be advertised as an alternative to smoking cigarettes or other tobacco products.
    4. Electronic cigarettes and other nicotine containing products should not be advertised in ways or through channels that could reasonably be expected to make them appealing to non-tobacco users.
    5. Electronic cigarettes and other nicotine containing products should not be advertised in ways or through channels that could reasonably be expected to make them appealing to children and young people.

     

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    When the UK Government abandoned its proposal to introduce minimum unit pricing for alcohol in July 2013, it argued there was a lack of concrete evidence that the policy would reduce the harm caused by alcohol without penalising responsible drinkers. In research published in the Lancet, the Sheffield Alcohol Research Group show minimum unit pricing avoids penalising moderate drinkers on low incomes and would contribute to the reduction of health inequalities.

    Minimum unit pricing (MUP) sets a threshold below which a unit of alcohol cannot be sold to consumers. Under a 45p MUP a pint of beer containing two units would need to cost at least 90p and a bottle of wine containing 9 units at least £4.05. Since heavier drinkers typically pay less per unit for their alcohol than moderate drinkers, and of course buy more units in the first place, this means that heavier drinkers would be affected the most by MUP.

    The impact of MUP on the poor

    In our new research, we explore the impact of MUP on those with low incomes who may be more likely to buy cheap alcohol. In particular we were interested in claims the policy could be particularly regressive by targeting drinks bought by the poor. To investigate this, we constructed a model of the relationship between MUP, people’s alcohol spending and consumption and the health risks associated with that consumption.

    We separated the population into moderate, hazardous and harmful drinkers and found moderate drinkers in the lowest income group bought very little alcohol for less than 45p per unit – less than one unit per week on average. When we estimated how much their consumption would reduce under a 45p MUP, we found it would drop by just 4 units per year – approximately 2 pints of beer. As this income group was the least likely to drink and most likely drink at moderate levels if they did so, this suggests the overwhelming majority of those on low incomes would not be substantially affected by MUP.
    Among heavier drinkers the picture was different. For harmful drinkers, a 45p MUP was estimated to have a large effect which varied substantially by income. For the lowest income group consumption would fall by 300 units per year among the 5% who are harmful drinkers, compared to 34 units in the highest income group of whom 8% are harmful drinkers.

    Reducing health inequalities

    Even though harmful drinkers with lower incomes are the group likely to be affected most by MUP, this does not necessarily mean the policy is regressive. To understand its full implications we need to look at its success in achieving MUP’s primary aim – reducing alcohol-related harm.

    For reasons which are unclear, those with lower incomes appear to suffer greater risks of harm from their drinking than those with higher incomes. The combined effect of the bigger risks and bigger consumption reductions means low income groups would be by far the biggest beneficiaries of the policy in terms of health improvements. A 45p MUP is estimated to lead to 860 fewer deaths and 29,900 fewer hospital admissions due to alcohol per year and routine or manual worker households would account for over 80% of these. On this measure, the policy can be argued to be strongly progressive.

    Minimum Unit Pricing

    Model-based estimates of policy effects are, of course, subject to uncertainty and we take account of this by using different assumptions and inputting alternative data to see what the range of plausible effects might be. Although the size of the effects varied under these scenarios, the key findings remained the same and give us greater confidence in our conclusions.

    Effectiveness and fairness

    We consistently find, across a wide range of plausible scenarios, no support for the UK Government’s concerns that minimum unit pricing would penalise responsible drinkers. This is because the estimated effects on this group are negligible, even in the lowest income groups. Instead, the policy targets those at greatest risk of harm – heavier drinkers on low incomes. As such, the benefits of the policy are also concentrated on this group.

    The reduction of health inequalities, including those generated by alcohol consumption, is an explicit aim of the Government’s public health policy. Our research shows minimum unit pricing would make an effective contribution to reducing such inequalities by particularly reducing the harm caused by alcohol in lower socioeconomic groups. It also challenges perceptions about levels of drinking among the poorest in our society and raises important questions about how we judge the fairness of public health policies.

    This BMA info graphic is based on the lowest proposed unit price of 40p. The BMA believes the minimum price should be no less than 50p per unit.

    Dr John Holmes, Sheffield Alcohol Research Group

    This article first appeared in Healthier Scotland – The Journal Published by Socialist Health Association Scotland March 2014

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