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Assessing the potential impact of unintended consequences of a vaping ban in Wales

15, Jun, 2015

The explanatory memorandum[1] to the Welsh Public Health Bill – which bans vaping in public places – states the following:

“371. For the estimated one third of e-cigarette users whose source of nicotine is solely from e-cigarettes, it is considered that there would be a risk that some may relapse to smoking, given that the current advantage of being able to use their e-cigarette in enclosed public and work places would be removed.  In Wales, the Welsh Government estimates there are around 33,600 people whose only source of nicotine is from e-cigarettes, and it cannot be anticipated how many of these users would return to smoking as a result of a restriction on the use of e-cigarettes in public places. 

372. It is considered highly unlikely that all ex-smokers using e-cigarettes would return to smoking, particularly given that the Welsh Government workplace survey and CIEH hospitality survey indicate between around one third and a half of such premises already have voluntary bans on indoor e-cigarette use.  There are no studies currently available to measure the health effects of a current e-cigarette user returning to tobacco smoking following complete abstinence from tobacco. There is however a study which found that every smoker who quits smoking (long-term) gains an average of between 0.99 and 2.58 Quality Adjusted Life Years (QALYs) (discounted) depending upon the age of the individual. It could therefore be assumed for every ex-smoker using e-cigarettes who returns to tobacco smoking as a result of a new restriction on the use of e-cigarettes would lose the 0.99 to 2.58 additional years that they had gained from quitting smoking. This assumes that the health impact of moving from e-cigarettes to tobacco smoking is equivalent to moving from tobacco smoking to stopping smoking (albeit in reverse).

373. While it is not  possible  to  say  how  many  e-cigarette  users  would  start smoking  tobacco  products  again  as  a  result  of  extending  the  smoke-free requirements, the scale of the potential impact can be demonstrated using an  illustrative  example.  The current smoking prevalence rate amongst adults in Wales is 21%.  A relatively small increase in this prevalence rate to   21.1%   would   mean   an additional   2,450 people   smoking   tobacco products in Wales.  Based on the QALY gain/loss figures identified in the paragraph above, this equates to a reduction of between 2,400 and 6,300 QALYs.    Given  that  the  value  per  QALY  is  estimated  to  be  £60,000,  this represents  a  cost  of  between  £146  million  and  £380  million.   These calculations provide a hypothetical scenario only, and the likelihood and extent of any such impact occurring is not known at present.  However, the illustration does suggest that if the policy does result in some e-cigarette users switching to smoking, the potential impacts could be significant.   As such,  the  impact  of  the  policy  on  smoking  prevalence  should  be  closely monitored.” [Our emphasis.]

In and of itself, this is not a good argument for rushing ahead with a public spaces ban; rather it is an argument for being extremely careful before making policy. However, it also provides a basis through which some of the potential unintended consequences can be assigned an estimate of cost.

For example, the Welsh Government figures estimate 33,600 people whose only source of nicotine is electronic cigarettes. We think it’s highly likely that significant numbers of vapers might relapse to smoking. Despite the best efforts of Public Health and Tobacco Control, smoking is still considered normal – more so than the use of e-cigarettes. This means that if vapers are pushed out into smoking areas, peer pressure may well force them back into smoking.

If a public place ban is brought in, and this results in 10% of these people either relapsing to smoking or becoming dual users (given that in workplaces and social venues such as pubs, there will no longer be a convenience benefit to using e-cigs instead of smoking), we can make a few assumptions, and calculate the potential cost.

Using the lower estimate of QALY gain (0.99), to allow for a presumption that there is some risk inherent in the use of e-cigs, and the value of £60,000 for a QALY, we can calculate the following:

10% of 33,600 is 3,360

3,360 * 0.99 is 3,326 QALYs lost. This corresponds to a loss of £199 million in shortened lives (and without factoring in the significant costs to the NHS from treating smoking-related diseases).

If 20% relapse to smoking (either exclusively or dual use) the loss in QALY becomes 6,653 years, a cost of £399 million.

There is also the question of the effect on current smokers who might become complete switchers (either instantly or via a period of dual use). We think a vaping ban will lead to fewer people switching from smoking to vaping for several reasons including: 

  • that by treating vaping products in the same way as cigarettes, the Welsh public authorities send a message to smokers that there is no difference between the two, and there is therefore no health benefit to switching;
  • that by refusing to permit them indoors, smokers have no immediate benefits to switch, and that it therefore reduces the pressure vapers can apply to their smoking friends, particularly in social environments like pubs; etc.

If we assume that 0.1% of current smokers would become complete switchers per year but are deterred by this policy, this corresponds to around 2,450 people, per year; (this would of course diminish over time as smoking rates fall, but for simplicity of calculation this is ignored).

2,450 people remaining smokers per year have an annual QALY loss of 2,425 years, or £145 million. Over the course of 5 years this would amount to a loss of 12,127 QALY or £728 million.

0.1% of the smoking population might on the face of it seem like a lot, but it is worth bearing in mind that the numbers in the Welsh Government’s document are based on the survey data from ASH (UK). However, ASH (UK) has more recently produced a new set of data, allowing us to look at what has changed.

The Welsh Government used the Welsh population as a proportion of the UK as a whole (4.8%) to arrive at a figure of 100,800 total e-cig users, of which 33,600 were exclusive e-cig users, with the remainder being dual users. Applying the same logic to the more recent ASH data[2], this becomes 124,800 total, with 52,800 exclusive vapers. This shows an increase of 19,200 exclusive vapers between the 2014 and 2015 data sets.

It does not seem either excessive or unwarranted, therefore, to make the assumption that a mere 2,450 (12.7%) of these may be deterred if the value proposition of switching is significantly reduced, both by reducing the areas in which e-cigs can be used and reducing the perceived benefits of switching.

We remain convinced that the Welsh Government proposal is based on insufficient evidence, and has the very real potential to actually increase harm at a population level.

 

 

[1] http://www.assembly.wales/laid%20documents/pri-ld10224-em/pri-ld10224-em-e.pdf

[2] http://www.ash.org.uk/files/documents/ASH_891.pdf

Comments

It is interesting that,over 6 years after the BBC reported the use of ecigs,the impact assessment says only this in relation to harms the proposed legislation seeks to avoid

"Using the aggregate figures for costs and savings, Option 3 would therefore need to prevent a minimum of 36 people in Wales from taking up tobacco smoking over the five year period and a maximum of 237 for this measure to be cost neutral."

There is no attempt to estimate the number or cost of renormalisation or air pollutants,etc.This contrasts with the figures you analyse above which assess the potential harms of the legislation.

It is telling that they can't quantify the potential benefits of their proposal yet can quantify their potential harm - an odd state of affairs

The 36 - 237 people are to offset the estimated costs, which as you point out don't include the potential for keeping people smoking or driving them back to smoking, given in Table 7.12 (on page 118).

So in reality, this means that to be cost neutral, the bill must prevent smoking uptake by 36-237 more people than it sends back to smoking, or prevents from switching. Given that the mechanism by which people can be prevented from starting smoking by restrictions on ecigs is unknown and hypothetical, but the mechanism by which people can be deterred from e-cig use is obvious, this only makes matters worse.

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