That this House welcomes the Government’s ambition for England to be smokefree by 2030; notes the increasing disparities in smoking rates between the richest and poorest in society; further notes the effect of the covid-19 outbreak and the opportunities and risks provided by the reorganisation of public health on the UK’s ability to achieve this ambition; and calls on the Government to set out the further steps it plans to take to deliver a smokefree England by 2030.
I thank the Backbench Business Committee for granting this debate. I am also grateful to every Member who has given up their time to speak, especially the hon. Member for Strangford (Jim Shannon), who I believe has already had two questions and a speech today—and I suspect that he still has an Adjournment debate ahead of him.
This debate is on an issue that is close to my heart. I must declare an interest as a former chair of the Gateshead tobacco control alliance. As the prevention Green Paper acknowledged, achieving the smokefree 2030 ambition will be challenging, especially in deprived communities where smoking rates are higher. On current progress, Cancer Research UK estimates that these communities will not reach the 5% ambition until the mid-2040s. This is simply not acceptable. Indeed, in County Durham, adult smoking prevalence is 17% compared with 13.9% nationally. This rises to 27% among people in routine and manual occupations. On top of that, 16.8% of mothers smoked during pregnancy compared with 10.4% in England.
Smokers in the north-east lose around £600 million because of unemployment and reduced income due to smoking. For working smokers, weekly earnings are on average 6.8% lower than for non-smokers, equivalent to £1,424 less per smoker annually—and this, of course, was prior to covid-19, which is disproportionately harming the health of local economies of already disadvantaged areas. Helping smokers to quit will benefit not just their health and wellbeing but their incomes, helping to level up disadvantaged communities. Smoking is also responsible for half the difference in life expectancy between the rich and the poor. For every person who dies from smoking, another 30 are suffering from serious smoking-related diseases. Disturbingly, every week in England, almost 2,000 children take up smoking, two thirds of whom will go on to become regular smokers.
With 1,500 people dying from smoking-related diseases every week, there is no time to waste. The tobacco control plan published in 2017 was for five years, which comes to an end in 2022. It has already been overtaken by events and is no longer fit for purpose in the light of the ambition for England to be smokefree by 2030, the decision to abolish Public Health England, and the Government’s manifesto commitments to increase healthy life expectancy by five years by 2035 while narrowing inequalities. If a new tobacco control plan is to be put in place in a timely manner, it needs to be in development now. The Minister may remember that the last plan was published two years after its predecessor ran out of time. We need bold announcements from the Government on tough new measures, along the lines set out in the “Roadmap to a smokefree 2030”, which has been endorsed by the all-party group on smoking and health, if we are to achieve a smokefree 2030. Will the Minister confirm whether the Government are developing a new tobacco control plan, and if not consider doing so urgently? Will he further commit to publishing a new tobacco control plan in 2021, setting out concrete measures for delivering on the smokefree 2030 ambition?
Britain is a world leader in tobacco control, having driven down smoking rates by 60% since the start of this century. However, the Government’s decision to abolish Public Health England without a clear plan for the future risks undermining this hard-won progress. The success in tobacco control has been driven by combining national population level interventions with comprehensive actions at regional and local levels.
The national function is currently provided by a combination of the Department of Health and Social Care and Public Health England; what is crucial is not where the function sits, but that it has protected funding and continues to exist. Furthermore, while inequalities in smoking rates remain, where regional tobacco control programmes have been in place there has been a significantly higher rate of decline. Regional programmes, such as those led by Fresh in the north-east, provide an effective bridge between national and local activity and between local authorities and the NHS. The Government must publish a clear plan setting out the future of Public Health England’s health improvement and wider functions; that is crucial if we are to achieve the Government’s interlocking pledges not just to achieve a smokefree 2030, but to increase disability-free life years, reduce inequalities, improve mental health and reduce obesity and alcohol harm.
The covid-19 pandemic makes action to reduce smoking prevalence all the more urgent. Chronic diseases such as cardiovascular disease, respiratory diseases and diabetes account for about 89% of all deaths in the UK and are also linked to higher rates of mortality from covid-19. A robust and sustainable approach to health improvement is vital if we are to tackle the leading causes of chronic diseases, namely smoking, obesity and alcohol and drug abuse.
However, the impact of smoking is not limited to the UK. It is estimated that at least 8 million deaths around the world every year are linked to tobacco, more than for AIDS, tuberculosis and malaria combined. Over 80% of the more than 1 billion smokers in the world live in low and middle-income countries. In addition to the human cost, the impact on already overstretched health care systems puts a heavy economic burden on those countries, adding to the difficulties LMICs face in recovering from the global pandemic.
That is why we can all be proud that the UK, as a global leader in tobacco control, is providing funding via Official Development Assistance to support implementation of the framework convention on tobacco control in low and middle-income countries. The funding was £15 million over five years for the World Health Organisation’s FCTC 2030 project to support low and middle-income countries to implement tobacco control measures. The FCTC 2030 project has been very well regarded; however, funding is due to come to an end. Extending this funding will accelerate progress in ending the global tobacco epidemic, support FCTC 2030 beneficiary countries to recover from covid-19 domestically, and as the UK leaves the EU maintain our position and as a global leader on tobacco control.
This is a matter of development funding so it requires broader support than just from the Department of Health and Social Care, but the Minister’s support for the proposal would greatly facilitate the likelihood of success. Will the Minister therefore commit to supporting extending the UK’s funding for the FCTC 2030 project beyond 2021?
Aside from our international commitments, it is important that there is a focus within the UK at regional and local authority level. Smokers from deprived communities with higher smoking rates tend to be more heavily addicted than those from more affluent communities. Deprived smokers are just as motivated to quit as other smokers, but it is harder to succeed when people are more addicted, when smoking is more commonplace and when cheap, illicit tobacco is widely available.
Regional tobacco control programmes have been effective in tackling these disparities, as shown most clearly by the example of Fresh in the north-east, which is the longest-running and only surviving regional office for tobacco control. When Fresh was founded in 2005, smoking prevalence in the north-east was much higher than the average for England, at 29% compared with 24%, and the disparity was growing. Since then, the north-east has seen the greatest decline in smoking prevalence of any region, and smoking prevalence is now only a little higher than the England average. Smoking rates have also fallen faster among routine and manual workers in the north-east compared with in England as a whole. As a result, although the differential between routine and manual and professional workers declined in the north-east between 2012 and 2017, it has increased in England as a whole. The success and value of Fresh’s work is clear, and I commend it for its vital work in the region.
After the public health grant to local authorities was cut in 2015-16, the funding provided by local authorities for regional offices in the north-west and south-west was cut completely. Even in the north-east, funding has been significantly reduced. New funding streams are therefore needed. In addition, there are stop smoking services that act as a highly effective and cost-effective way of supporting smokers to quit. However, there is a stark inequity in the local authority offer to smokers across England. In some areas, stop smoking services have been scaled down or decommissioned altogether, whereas elsewhere local authorities have sustained or developed their services.
An Action on Smoking and Health and Cancer Research UK report published in January looked at the state of local stop smoking support and found that among the local authorities that still had a budget for stop smoking services, 35% had cut that budget between 2018-19 and 2019-20. That was the fifth successive year in which more than a third of local authorities had cut their stop smoking service budgets. Financial pressures caused by the cuts to public health funding and the wider pressures on local government finances are the major reason for that. The public health grant, which funds local authority tobacco control, has been cut by around a fifth in real terms since 2015-16, falling from £4 billion in ’15-16 to £3.2 billion now.
Analysis by the King’s Fund in 2018 found that wider tobacco control and stop smoking services were among the biggest losers in planned budget cuts and that these cuts have been accompanied by a 38% decline in the number of smokers setting quit dates at stop smoking services since 2015. Among pregnant women, the number setting quit dates has fallen by a fifth. This is one of the many failures of austerity, so will the Minister confirm that the Government will reverse the cuts made to local public health budgets to ensure that local authorities can play their part in delivering a smokefree 2030?
We must also recognise the value of social marketing campaigns, which have immediate impact, can be targeted with precision at disadvantaged smokers and can be highly cost-effective if carried out at a regional and national level. Such campaigns play a particularly important role in motivating smokers to try to quit. In 2016, Fresh worked with Smoke Free Yorkshire and the Humber to implement a hard-hitting quit smoking campaign aimed at raising smokers’ awareness of the links between smoking and 16 types of cancer and to trigger quit attempts, reaching millions of people. It is now thought to have been among the most successful quit campaigns to have ever been run in England in terms of awareness, attitudes and actions taken, with around 10% of people who saw it making a quit attempt—that is around 72,000 smokers. However, this regional activity is threatened by local authority budget cuts, which led to the decommissioning of the regional offices in the north-west and south-west. A smokefree 2030 fund imposed on the tobacco industry, as proposed in the Green Paper consultation, would provide vital funding for national and regional anti-smoking mass media campaigns.
Another important regional issue is the impact of illicit tobacco, which is concentrated in poorer communities. Cheap and illicit tobacco provides easier access to tobacco for children and reduces the incentive for adults to quit. In 2009, Fresh, along with colleagues in the north-west and Yorkshire and the Humber, established the North of England Tackling Illicit Tobacco for Better Health programme, originally with pump priming from a Department of Health grant. The aim was to increase the health of the population by reducing smoking prevalence; reducing the availability of illicit tobacco, therefore keeping real tobacco prices high; developing infrastructure to aid information sharing, identification of illicit markets and enforcement action; reducing the demand for illicit tobacco through campaigns raising awareness of the issue; engaging with relevant health and community workers; and finally, regularly monitoring smokers’ attitudes and behaviour to measure the effectiveness of the programme.
Between 2009 and 2019, the illicit market share declined by a third in the north-east from 15% to 10%, and enforcement was enhanced. That compares with the national market share of illicit tobacco in 2018-19 and of manufactured cigarettes, with a share of 34% for hand-rolled tobacco. Elements of the original north of England programme have been sustained by Fresh in the north-east, including insight-led demand reduction programmes. Fresh now leads the national Illicit Tobacco Partnership, supported by ASH and other partners. However, the 2013 National Audit Office recommendation that this approach be rolled out nationally has not yet been adopted, while essential regional activity to tackle illicit tobacco and reduce smoking among children and young people has been put at risk by cuts to public health grants since 2015-16. Does the Minister agree that regional activity to get illicit tobacco off our streets should be sustainably funded?
Finally, I would like to raise the regulation review. While we await the Government’s response to the prevention Green Paper consultation, I hope the Minister can tell us what has happened to the Government’s response to the consultation on the Nicotine Inhaling Products (Age of Sale and Proxy Purchasing) Regulations 2015, which closed in September last year. A response to that consultation was due last December, and almost a year on, there has been no word from the Government about when it will be published. The Government are also required to review the Tobacco and Related Products Regulations 2016 and the Standardised Packaging of Tobacco Products Regulations 2015 by May 2021. They should set out the timetable for the consultation process for both sets of regulations as soon as possible. We are therefore awaiting the Government’s response to two consultations and the launch of two more, which need to be reported by the end of the financial year. Can the Minister confirm when the Government will deliver on all four of those?
I recognise that I have posed a lot of questions, and I thank the Minister and the House for their time. However, those are questions that need to be asked and answered if we are to achieve the smokefree 2030 ambition that is shared right across the House.
May I start by congratulating my hon. Friend the Member for City of Durham (Mary Kelly Foy) on securing this debate and on her introductory speech? I am going to start in time-honoured speaking fashion by telling you, Minister, what I am going to ask you, and then elucidating on that—
Sorry. I will start by telling you, Madam Deputy Speaker, what I am going to be asking the Minister and then perhaps expanding on that. First of all, Minister, I will be asking you about the tobacco control plan, which my hon. Friend has already referred to. If we are going to achieve the smokefree by 2030 ambition, that needs to happen quickly, and I will be asking you what you can do—
Sorry, Madam Deputy Speaker. I am getting carried away.
I will be asking the Minister what he will be doing to ensure that vital maternity safety programmes, such as the saving babies’ lives care bundle, can get back on track. I will be asking him what he will do to develop a national strategy for reducing rates of smoking in pregnancy among women from disadvantaged communities, learning the lessons from the areas where the greatest declines have been seen in smoking in pregnancy. I will be asking him how he will ensure that mental health trusts are required to implement National Institute for Health and Care Excellence guidance and that the Care Quality Commission is directed to assess that when it carries out its inspections. Finally, I will be asking him what steps he will take to ensure that smokers with mental health conditions receive evidence-based advice about switching from smoking to vaping.
I want to elaborate a little further on those issues. As a result of comprehensive action at national, regional and local levels, significant progress has been made over the years on bringing down smoking rates in England. The 2019 prevention Green Paper’s commitment to make England smokefree by 2030 was an appropriately ambitious and welcome commitment to continuing this important mission. However, a year on from the end of the Green Paper consultation, we have yet to see the Government’s response or their promised and much-needed further proposals, which would enable us to meet the 2030 ambition.
Despite our national progress, smoking remains the leading cause of preventable illness and death in England. Each year, smoking kills more people than obesity, alcohol, drug misuse, HIV and traffic accidents combined. Smoking is a particular challenge in my constituency of Blaydon, where 17.4% of adults smoke, compared with 15.3% across the north-east and 13.9% nationally. Smoking costs Blaydon £1.8 million every year, largely as a result of NHS treatment costs, lost productivity due to ill health and premature death caused by smoking. For communities such as Blaydon, achieving the smokefree 2030 ambition will be tough, but it remains essential for the health and wellbeing of our community. However, analysis by Cancer Research UK finds that on current trends, disadvantaged communities such as my own will not become smokefree until the mid-2040s. This rate of progress is not acceptable and not affordable for our most deprived communities.
For the sake of clarification, there are very few people present and the hon. Lady is making important points, so, just for once, I am not putting her under any time pressure.
As you say, Madam Deputy Speaker, this is an important issue.
I return to my point about developing a national strategy for reducing rates of smoking in pregnancy among women and the disadvantaged communities they come from. What does the Minister plan to do to ensure that those reductions are seen and that there is a continued decline in smoking in pregnancy?
Let me turn to smoking and mental health. The last tobacco control plan for England was widely welcomed for including a specific focus on smoking and mental health. With such high rates of smoking in the community and such little progress in reducing rates, this focus was long overdue. Progress has been made since the plan was published, with mental health trusts being set a target: to implement smokefree settings, in line with NICE guidance on smoking, by 2018.
However, despite that, an ASH survey commissioned by Public Health England to look at trust implementation found the following:
“Staff behaviour often enables smoking, with staff accompanying patients on smoking breaks every day in 57% of trusts.
In 55% of trusts, patients were not always asked if they smoked on admission.
Only 47% of trusts offered the choice”
of stop smoking medications
“in line with NICE best practice”.
The impact of covid-19 is likely to have further hindered the implementation of NICE guidance. The Mental Health and Smoking Partnership, a coalition of leading mental health and physical health charities, has raised concerns that some trusts have been rolling back what smokefree policies they had put in place. There are concerns that the Care Quality Commission is not assessing the implementation of NICE guidance on smoking in a consistent way, with trusts receiving conflicting messages on implementation from different parts of the system. Another question I ask the Minister is whether he will ensure that mental health trusts are required to implement NICE guidance PH48 and that the CQC is directed to address this when it carries out inspections.
It is a pleasure to follow the hon. Member for Blaydon (Liz Twist), who I have been questioned by many times. Thinking about today’s debate, I remember in early summer 2017, when I was standing down there at the Dispatch Box answering Health questions, being pressed by my then shadow, the lovely lady the hon. Member for Washington and Sunderland West (Mrs Hodgson), on when I was going to publish the long-awaited tobacco control plan, which, as the hon. Member for Blaydon reminds us, was due to be out in December 2015. Rather to the surprise of my shadow that day and my officials sitting in the box, I said that it would be out “before the summer recess” and, true to my word, it was.
That was an early lesson for me in how to focus minds in the civil service, because I have never seen them move so fast, but more importantly, it set out some of the key ambitions for us to hit by 2022. The prevention Green Paper a few years later then set the course for England to be smokefree by 2030. I stand by the ambitions, both in the plan and in the Green Paper, 100%, and I believe with all my heart that they are completely achievable, but we will have to get our skates on, as has been said by the first two speakers, the hon. Members for City of Durham (Mary Kelly Foy) and for Blaydon. We will have to be very bold and make the most of one of the rare opportunities afforded to us by the covid pandemic.
I want to make just a few points today. On public health reorganisation, I have previously raised my concerns in the House about the future of Public Health England’s work to tackle issues such as smoking, obesity, inequality and air quality after the new National Institute for Health Protection comes online. I have no issue with the desire to take the health protection functions out and create the new institute based on the German model—it makes a lot of sense, and I have said so to the Health Secretary in public and in private. My concern is about the health prevention parts of Public Health England. On 1 September, I asked the Secretary of State whether he was considering bringing Public Health England’s expertise and significant experience in this area back into the Department. When I was travelling abroad representing the Government and I needed briefing on these issues, I always knew that there would be somebody who knew infinitely more than me inside Public Health England. I do not want to see that wasted.
For the second time today, it is a pleasure to follow the hon. Member for Winchester (Steve Brine), given the knowledge he has of all the subjects we have covered in this debate and the last one. I thank him for his contribution when he was Minister, too. It is always good to see him in his place.
I congratulate the hon. Member for City of Durham (Mary Kelly Foy) on what I think may be the first debate she has led in the Chamber. If it is, I say to her, “Well done and congratulations.” We look forward to many more contributions from her in this place. I was glad to add my name to the request to the Backbench Business Committee for this debate, and to work alongside the hon. Lady to highlight some of these issues.
I believe that freeing smokers from the tyranny caused by their addiction, and the damage it causes to their health and wellbeing, is an issue not just of health but of human rights. I am my party’s spokesperson for health and human rights, and this debate covers both those issues.
This issue is close to my heart, as I know it is for speakers in all parts of the House. Public health policies, which are the responsibility of the devolved nations, have a key role to play in tackling smoking, but so do the Government in Westminster and this debate. I am pleased to see the Minister in his place. He and I have been good friends for a long time, and I look forward to his response because I know it will be positive.
I want to refer quickly, if I may, to the Northern Ireland Department of Health tobacco control strategy, which was implemented in 2012. It was clear that the Northern Ireland Assembly was trying to direct its action at children and young people, disadvantaged people, and pregnant women and their partners who smoked. A review of that strategy undertaken earlier this year found that Northern Ireland has met its target of ensuring that a minimum of 5% of the smoking population accesses smoking cessation services annually, but there is still a group of people who continue to smoke. I am conscious that people have freedom of choice, but we hope that they take note when we present them with the health issues.
Order. The hon. Gentleman promised me that he would no longer address the Minister, but would take to addressing the Chair, in the way one is supposed to in this place. He speaks in this Chamber more than any other Member, and he knows that he must not address the Minister. I cannot understand why he persists in doing it.
Thank you, Madam Deputy Speaker. I will certainly endeavour to get that right.
In 2018, there was an explosion of new video on demand services, such as Netflix and Amazon Prime, which are particularly popular among young people. Ofcom’s on demand programme service rules, governing video on demand services such as Netflix, have no rules at all on smoking. The use of video on demand continues to grow, so this problem will only get worse. Is the Minister prepared to look at that issue and address it?
The licensing of tobacco retailers is another issue that I spoke about in 2018 that bears raising again. In Northern Ireland, since 6 April 2016, retailers have been obliged to register with the tobacco register of Northern Ireland; the deadline for doing so was 1 July 2016. It built on similar schemes in Scotland and Wales. In 2018, we implemented a track-and-trace scheme that required every retailer to have an economic operator identifier code. That system was required by the EU tobacco products directive, but the Government have confirmed that it will continue after we leave the EU. Can the Minister confirm that all nations in the UK will continue to implement a retail register scheme? Will he ensure that officials at Her Majesty’s Revenue and Customs talk to their opposite numbers in Northern Ireland, Scotland and Wales about their experience of the retail register scheme, and the lessons to be learned about it from the devolved Administrations?
Are the tobacco control regulations on e-cigarettes delivering on the twin goals of helping smokers to quit and protecting children from taking up smoking—objectives supported by all parties and all nations of the United Kingdom of Great Britain and Northern Ireland?
There is a concerning loophole in our regulations: while it is illegal for e-cigarettes to be sold to children under 18, according to advice from trading standards, it is not illegal to give them out as free samples to anyone of any age. Could the Minister give us direction on that? How can we ensure that things are done correctly? I hope the Minister is aware of the article in The Observer in October that highlighted that a supplier working on behalf of British American Tobacco was caught handing out samples from BAT’s popular e-cigarette brand to a 17-year-old without carrying out any kind of age check. That contravenes the spirit, if not the letter, of the regulations. Given the importance of balancing the needs of smokers against any impact on young people, it is vital that a review of these regulations is undertaken. Will the Minister set a timeline for just that?
It is a pleasure to speak in such an important debate. I represent one of the less healthy constituencies in the country, but we could remove half of our health inequalities by being a smokefree community. That is what is at stake here. I therefore commend my hon. Friend the Member for City of Durham (Mary Kelly Foy) for securing the debate, which I understand is her first through the Backbench Business route, and congratulate her on her speech. She set out the challenge very well. The point she made about the current trajectory getting us there only by the mid-2040s was absolutely right. She also did the Minister an extraordinary favour in essentially laying down a tobacco control plan in her speech for you, Minister—sorry, Madam Deputy Speaker; I will never do that again. The Minister could clip my hon. Friend’s speech directly from Hansard and turn it into a tobacco control plan overnight. I think we are almost there, so I hope to hear positive noises from the Minister when it is his turn.
My hon. Friend the Member for Blaydon (Liz Twist) also made a strong case. I was particularly struck by the points made about smoking in pregnancy and with regard to those with mental health issues. We know from Pareto’s law that on any great journey the last 20% takes as much energy as the first 80%, and that is definitely the case with smoking cessation, so we will have to take a granular look at which groups are still disproportionately affected and target resources specifically in a way that works for them.
I was cheered when I saw the name of the hon. Member for Winchester (Steve Brine) on the call list. As he is a former public health Minister, I knew he would have an awful lot of insight to share from his time developing the previous tobacco control plan. His story certainly made me laugh. I agree with him wholeheartedly on a number of issues, particularly when he said that we should get our skates on. I agreed with his points about Public Health England, which I will expand on soon. The case for keeping everything in one place is profound and compelling; I completely agree.
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The last tobacco control plan was two years late, as we have heard. It should have been published in 2015, and it was delivered in the summer of 2017 only because of the commitment of the then Health Minister, the hon. Member for Winchester (Steve Brine), who I am pleased to say has just joined us. The tobacco control plan that he introduced included the ambition for a smokefree generation, and now that the Government have committed to deliver this by 2030, the pressure is on. Our current tobacco control plan is set to run out in 2022, leaving an eight-year gap in which, according to Cancer Research UK, the rate of smoking prevalence decline must be 40% faster than our current trajectory if our nation is to meet the 2030 tobacco control plan commensurate with the scale of the ambition to be smokefree by 2030.
I shall turn now to the NHS long-term plan. The successful delivery of the plan is essential to the achievement of the smokefree 2030 ambition. The plan published in January last year sets out welcome commitments to tackle smoking in the NHS. By 2023-24, NHS-funded tobacco dependence treatment will be offered to all hospital in-patients who smoke; all pregnant smokers and their partners, too, if they smoke; and all long-term users of specialist mental health and learning disability services who smoke.
The evidence is clear of the benefits this will bring, both to smokers and to the NHS. Smokers are 36% more likely to be admitted to hospital and smoking is responsible for almost 500,000 admissions each year in England. One hospital patient in four is estimated to smoke. The increased demand that smoking places on NHS treatment capacity translates into an enormous financial burden. Each year, smoking costs the NHS around £2.6 billion, including avoidable secondary care costs estimated at £890 million a year. The cost in the north-east to the NHS is around £132.3 million a year, with smoking in Blaydon alone responsible for around £300,000 of that. Across the north-east, it is estimated that implementing the long-term plan commitments at just 40% coverage, as is aimed for by the end of 2021-22, would deliver net savings of nearly £12 million to the NHS in the north-east.
In the north-east, progress towards implementation of the long-term plan’s commitments on smoking is well under way. Treating tobacco dependency is one of two key priorities for the north-east and north Cumbria integrated care system population health and prevention work stream. To focus efforts across the region, a dedicated north-east Smokefree NHS/Treating Tobacco Dependency Task Force was established in 2017. The taskforce has provided strategic direction, developing regional resources and facilitating partnership working with all stakeholders, including NHS trusts, local authority tobacco commissioners, Public Health England and primary care.
As of April 2020, all NHS trusts in the north-east had achieved smokefree NHS status by implementing updated smokefree NHS policies and pathways to identify and treat smokers from admission, in line with national guidance. Across the north-east, trusts have established good links between hospitals and community stop-smoking services funded by local authorities to ensure treatment started in hospital is continued after patients leave hospital. Trusts are training staff to build capacity. They have also signed the NHS smokefree pledge as a clear and visible way to show commitment to helping smokers to quit and to providing smokefree environments.
Elsewhere, progress has not been so heartening, and it is clear that the funding and focus promised by the long-term plan are much needed. An audit of smoking cessation advice and services in NHS acute hospitals, published earlier this year by the British Thoracic Society, concluded that there is poor adherence to national standards and slow progress in identifying and treating smokers. In fact, in many cases the situation is worse than at the time of the last audit in 2016. One smoker in two is not asked whether they would like help to quit. Only one hospital in three has a hospital-funded smoking cessation practitioner, compared to one in two in 2016. Referral to hospital smoking cessation services is available in only four out of 10 hospitals. In 2016, the figure was more than half.
Progress on the long-term plan’s commitments has also not been immune from the impact of the covid-19 pandemic. Early implementation sites chosen to stress test the new tobacco dependency treatment pathways set out in the long-term plan were due to start in April, but this had to be delayed until last month. With winter approaching, and the risk of co-circulation of covid-19 and seasonal flu looming, there is a real risk that work to deliver the long-term plan’s commitments on smoking could be derailed. If we are to achieve the smokefree 2030 ambition, addressing smoking where contact with smokers is greatest is an opportunity that must not be missed
Let me turn to smoking in pregnancy. The Minister is as concerned as I am about this issue, on which there is too little progress. This needs to be a major focus of the next tobacco control plan. Ensuring that more pregnancies are smokefree not only protects the baby as it grows and reduces the risks of complications such as stillbirth and miscarriage; it also gives children the best start in life. NHS England has included addressing smoking as a key part of the initiative to reduce stillbirth and neonatal deaths through its saving babies’ lives care bundle, which is designed to encourage trusts to implement evidence-based measures to improve the safety of pregnancies. However, as with other aspects of NHS activity, this work has been undermined by the impact of covid-19, with a key aspect—carbon monoxide breath tests for all women—currently suspended. I understand that there are also reports from local authorities’ stop-smoking services that fewer pregnant women are being referred for them for support by maternity services. What will the Minister do to ensure that those vital maternity services get back on track as a matter of urgency?
Despite work in the NHS, progress has not been made anywhere near swiftly enough. There are big variations in the performance of different parts of the country. In a soon-to-be published analysis, Action on Smoking and Health finds that rates of smoking in pregnancy have increased in the past five years in a third of clinical commissioning groups, while declines have been seen in less than half, or 44%. It is therefore hardly surprising that the Government seem so unlikely to achieve their ambition of reducing rates to 6% by 2022. In the north-east, we continue to have some of the highest rates of smoking in pregnancy in the country. These are driven by high levels of disadvantage in the region, but, unlike in some regions where rates have even increased, rates in the north-east have fallen in the past five years, from 17% in 2016 to 15% in 2020. Progress has been driven by the regional tobacco programme in the north-east and by the work of NHS England, Public Health England and local government.
The Minister might be interested to hear that a recent analysis by The Times found that areas of the country that were likely to have seen big drops in rates of smoking in pregnancy were also more likely to have implemented financial incentive schemes to support pregnant women to quit. Evidence on the effectiveness of these schemes has been accumulating for many years; they have been shown to increase quit rates when implemented alongside evidence-based quit support. Such incentive schemes are in place in Greater Manchester and South Tyneside. Madam Deputy Speaker, I can see you looking at the clock, so I shall press on.
Action in mental health in-patient settings is only the tip of the iceberg; most smokers with a mental health condition will never have an in-patient stay. The NHS long-term plan has committed to implement a universal smoking cessation service in mental health settings. A promising area for support in the community, and via primary care, is improving access to psychological therapies services, which were established in 2008 with the ambition of scaling up access to talking therapies. About 1 million people with depression and anxiety access IAPT services each year. It is estimated that about 28% of people with depression and anxiety smoke. Quitting smoking has also been found to improve depression, with the same effect as taking antidepressants, so there is a major opportunity to improve both mental and physical health by integrating smoking cessation support into IAPT services. Research by the University of Bristol is under way to explore the integration of support for smokers with these talking therapies, and the early findings are positive. Individual local services, such as Talkworks in Devon, have also started to explore the potential of integration. However, smaller-scale pilots, although important, miss the big opportunity to reach many thousands each year with additional support.
E-cigarettes are a major opportunity to help more smokers to quit, particularly those with high levels of dependency, common among smokers with a mental health condition. E-cigarettes have been shown to help smokers successfully quit at greater rates than traditional nicotine replacement therapies and to be popular quitting aids. Despite the need among smokers with mental health conditions and the potential for e-cigarettes to save many lives, the attitude towards e-cigarettes within mental health services remains varied. Two excellent examples of good practice in mental health trusts can be found in my region, where the Cumbria, Northumberland, Tyne and Wear NHS Foundation Trust and the Tees, Esk and Wear Valleys NHS Foundation Trust both offer e-cigarettes to their patients as a treatment option, alongside the provision of nicotine replacement therapies. Those trusts have shown not only leadership in treating tobacco dependency and implementing national guidance, but real pragmatism on vaping, which could save the lives of many smokers with mental health problems who may not otherwise be able to quit smoking.
Unfortunately, that pragmatism is not found nationwide, and in many trusts the restrictions placed on vaping are not dissimilar to those placed on smoking. Such inconsistency is also seen in staff attitudes towards e-cigarettes. New unpublished data gathered by ASH found that 46% of mental health nurses and 66% of psychiatrists had received no training on e-cigarettes. As a result, many are uncertain about the role of e-cigarettes in supporting smokers in their care. So I reiterate the last of my questions: what steps will the Minister take to ensure that smokers with mental health conditions receive evidence-based advice about switching to vaping? This is an important issue that requires persistence and detailed attention. I look forward to the Minister’s positive responses to these proposals.
I note that the Department has now established a programme of work to pick through this. The snappily titled population health improvement stakeholder advisory group has been formed and there are some notable names on there, such as Seema Kennedy, who was my successor as Public Health Minister; Professor Helen Stokes-Lampard, formerly of the Royal College of General Practitioners and now chair of the Academy of Medical Royal Colleges; Professor John Newton from Public Health England; Dr Jenny Harries, whom many of the public will be familiar with as deputy chief medical officer; and Professor Paul Cosford, emeritus medical director of Public Health England and a truly excellent official—one of the best I ever worked with. There are some good people on there.
On balance, I would restate my call for the Department to recover these functions, and I refer the Minister to a pretty comprehensive piece of work published just this week by Policy Exchange, examining how a new deal for public health can build a healthier nation. It calls for the creation of a new institute for health improvement housed in the Department of Health and Social Care, reporting directly to Ministers and the chief medical officer, for a new funded national mission to improve the health of the nation. There is a lot of sense in that, and I recommend the report to the Minister.
Let me dwell for a moment on the word “funded”. I do not think—the record will show that I was always lukewarm at best on this idea—that the Government should proceed with the idea of ending the ring fence of the public health grant. I think it would be a mistake. That should be kept. It should be measured much more tightly and, if anything, I think it should be increased to help our directors of public health to do what works towards smokefree 2030. I am not making unfunded spending commitments. The prevention Green Paper, which I helped to draft and still think is a very credible piece of work, talks about the principle of making the polluter—that is, the tobacco firms—pay, as has been done in France and in the United States, and we should progress that to create a smokefree 2030 fund. I would be grateful if the Minister could reassure me that the Government are at least considering this option and what it might look like in practice.
The Government’s ambition for what we call “smokefree” is for a smoking prevalence in England of 5% or less in the next 10 years, but, as we have heard, significant action is clearly needed if we are to achieve this. The rate in Winchester, which I represent, may be 8.3%, but the national average is 14.1%, so there is a way to go. Smoking remains the biggest single cause of preventable death in our country today, and it is a leading cause of health inequalities. The issue is also one of inequality. About one in four people in routine and manual occupations smoke—about two and a half times more than people in managerial and professional occupations—and this gap has widened significantly since 2012, according to the Office for National Statistics. The inequalities are also geographic, as we have heard.
As a Conservative Member, I see becoming smokefree as a vital step towards delivering our manifesto pledges on extending healthy life years by five by 2035, reducing inequalities across the board, and, as the Prime Minister calls it, levelling up every part of our country. However, as the Green Paper concluded, this is an extremely challenging ambition for any Government. The all-party group on smoking and health has recommended a new tobacco control plan focusing on delivering the 2030 ambition, and that is an eminently sensible suggestion. Given how long it takes to get a tobacco control plan, even when making promises at the Dispatch Box, has the Minister commissioned officials to start work on renewing the TCP to set a course for the smokefree ambition? I think that Ministers will be doing that, with smoking prevalence going in the right direction, albeit not fast enough to meet our agreed ambition, but also off the back of the opportunity afforded to us by the by the pandemic.
The University College London smoking toolkit indicates that the pandemic has been a driver of quitting among smokers across all social groups, with the highest rate of people stopping smoking seen in the past 30 years. That is the good news. However, we cannot be complacent. Although it is true that many people have quit, there are signs that some have relapsed into smoking. In particular, there are worrying signs among the 18 to 24-year-old group that smoking rates may be increasing again and have certainly stopped declining.
Turning to the alternatives, the UK has long been a leader in traditional tobacco control measures such as the use of taxation, as we hear at Budget time; the smoking ban, which was a great credit to the Blair Government; plain packaging; readily available smoking cessation services; and numerous tobacco harm reduction policies using less harmful alternatives to smoking. I was often criticised in office both for promoting e-cigarettes too much and for not promoting them enough as an alternative. That suggested to me that I may have had the balance about right, but I will go further. Data from the ONS tells us that over half of smokers in this country want to quit and that, on average, smokers try some 30 times or more before giving up successfully. Of those who are successful, only 2% quit through stop smoking services, and over 40% use an e-cigarette. However, while many have quit using vaping, the fact remains—we cannot deny this—that nearly half of smokers in Britain have tried vaping but did not stick with it. On top of that, the figures now show that the number of vapers is falling, while some 1.3 million vapers have not fully made the switch and still continue to smoke at the same time.
Since the early 2000s, tobacco policy in the UK has been driven by the European Union through the tobacco products directive. That is about to change. May I therefore ask the Minister to speculate, as I know Ministers love to do, on what opportunities Brexit brings to advance our leading role as a tobacco harm reduction advocate? We may be leaving the political structures of the European Union, but I sincerely hope that we are not leaving our leadership role in this area when many countries around the world look to see what the UK does.
Our prevention Green Paper pledged—as, indeed, did I when in office—to
“run a call for independent evidence to assess further how effective heated tobacco products are, or are not, in helping people quit smoking and reducing health harms from smoking.”
The Government said that the call for evidence would be announced in summer 2020. Of course, we all understand why that has slipped, but I wonder if we might get a reaffirmation today, because recent word, including a parliamentary written answer on 21 September to my hon. Friend the Member for Broxbourne (Sir Charles Walker), who I know wanted to speak today, said that the Government would merely
“consider looking at this at a later date”.
It is imperative that the Government recommit to holding that call for independent evidence as soon as possible, so that the effectiveness of heated tobacco products can be assessed and smokers can have confidence that they are switching to a less harmful alternative.
I say that because there is growing evidence that adult smokers’ misperception of the risks surrounding vaping may be preventing them from transitioning to less harmful alternatives. Last month the excellent UK charity Action on Smoking and Health, otherwise known as ASH, which campaigns against smoking and is run by Deborah Arnott, published survey data showing that vaping in the UK had stagnated as a percentage of the total smoking population, after year-on-year growth. The charity blamed what it called
“unfounded concerns about the relative safety of e-cigarettes”
as a likely cause.
Given that public health authorities in the UK actively support and champion vaping as an alternative to smoking, that statistic shows how damaging inaccurate media coverage can be. To maximise the public health benefits of e-cigarettes, I think regulations should be risk-proportionate and reflect the scientific evidence base on the relative harms of cigarette alternatives and their potential for harm reduction. For example, when this Parliament’s Select Committee on Science and Technology, chaired so ably by my right hon. Friend the Member for Tunbridge Wells (Greg Clark), reviewed the scientific evidence on e-cigarettes, it recommended that the Government should move to a
“risk-proportionate regulatory environment; where regulations, advertising rules and tax/duties reflect the evidence on the relative harms”
of vape products compared with combustible cigarettes.
The UK Government have invested a lot of resources to understand the science behind these products, which I think has informed the pragmatic and progressive approach that successive Governments have taken to vaping regulation over many years. The results have been impressive, suggesting that it would be a strong regulatory model for other countries to consider. Given competing public health priorities, of course I appreciate that it is not as simple as it sounds, but I believe we should dedicate sufficient time and resource to understanding the science around vape products and their potential to improve public health. That is why I would like us to recommit to what it says in the Green Paper that I partly wrote.
Will the Government consider increasing the age of sale from 16 to 21? That could be a useful tool in the toolbox. ASH has suggested that the Government should consult on that as a means of reducing youth uptake. The call has been backed by more than 70 organisations, including Cancer Research UK, the British Heart Foundation and the Royal College of Physicians. I think it is well worth considering.
In conclusion, we should keep the ambition. We have never been short on the ambition, across the last Government, the coalition Government and this Government. We should tighten and update the plan, to bring it in line with the ambition in the Green Paper. We should stick to what we know works and be honest enough to say what does not. We should fund the directors of public health on what does work, and I have given a suggestion as to where I think that can happen. There is a lot riding on getting this right. A lot of people’s lives depend on us getting this right, and we need to do so for their benefit and for that of the next generation, so that another generation of young people is not weaned on to the damaging lifestyle that smoking can lead to. I have given a few ideas and look forward to hearing the Minister’s response at the end of the debate.
That target was achieved, but we are not hitting our targets at population level. There was a target to reduce the smoking rate among manual groups from 31% to 20% by 2020. That rate still lingers around 27%, so that target has not been met. There was also a target to reduce smoking during pregnancy from 15% in 2010 to 9% by 2020. To date, however, that rate has barely declined, so we have hit problems in Northern Ireland. At the time of speaking, the rate is 14%, so we have reduced it by only one percentage point. Let us be very clear: smoking when pregnant puts babies at risk of avoidable harm, including stillbirth, premature birth and birth defects.
We seem to have done better on the target for 11 to 16-year-olds. I am really quite encouraged by that. There has been a reduction from 8% in 2010 to 4%. The target was 3%, so we are one percentage point shy of it, but what we have done there has been quite dramatic. Children who live with smokers are almost three times more likely to take up smoking than children from non-smoking households, which creates a generational cycle of inequality, with smoking locked into disadvantaged communities.
Will the Minister make contact—he probably has—with the Northern Ireland Assembly, and particularly the Health Minister, Robin Swann, to see what has happened there? I feel that we can feed off each other regionally in Administrations, to our advantage. If something is being done right in England, we want to know about it in Northern Ireland, and the same applies in Scotland and Wales.
The disadvantaged communities worst affected by smoking have also been hit hardest by the coronavirus pandemic. Smoking is a leading risk factor for all sorts of things, such as cardiovascular disease and chronic obstructive pulmonary disease, which have been identified by Public Health England as being associated with worse outcomes from coronavirus. When households stop spending money on tobacco, it can lift them out of poverty, and it increases the disposable income available to spend in local communities rather than lining the pockets of the transnational tobacco firms.
Those inequalities are a problem not just for Northern Ireland but in every part of the United Kingdom. The answer is more action at population level through Government interventions that support people, particularly in disadvantaged communities. I believe that the time is right for the Department of Health and Social Care to publish a new tobacco control plan that addresses UK-wide issues as well as those relating just to England—I believe that we should be doing this across the four regions—and provides solutions to the threats posed by Brexit as well as delivering on the opportunities.
Smoking on screen is an issue close to my heart; we have to find some way of addressing it. Smoking is rarely portrayed in an unattractive manner, or associated with negative consequences. Guidelines on smoking have been established by the communications regulator, Ofcom, but they are often not rigorously applied. The UK Government and Ofcom have committed to working with the British Board of Film Classification to ensure a consistent approach across the piece. On the tobacco control plan, I said in 2018:
“A clear causal link has been established between smoking initiation among young people and smoking on screen in the entertainment media. The impact is down to the amount of smoking that young people see, not whether it is glamorised or not.”
Young people may feel, sometimes unconsciously, that smoking is normal, and that we should all be doing it. However, its depiction is linked to greater risk of smoking uptake. In that earlier debate, I asked:
“Will the Minister ask his colleagues who are responsible for the regulation of film and TV in the Department for Digital, Culture, Media and Sport to work with the Department of Health and Social Care, and press Ofcom and the British Board of Film Classification to ensure that their codes effectively tackle the portrayal of smoking in films and television programmes that are likely to be seen by children?”—[Official Report, 19 July 2018; Vol. 645, c. 685.]
At the time, the Minister briefed that Ofcom and the BBFC were dealing with the issue; quite clearly, Minister, that has not happened to the extent that we would like.
The hon. Member for Strangford (Jim Shannon) seems to have perfected the art of being in multiple places at once, speaking in both Westminster Hall and here very quickly but with characteristic force and insight. I particularly liked the way he characterised this as a social justice issue, which is locked into communities. I relate to that from my home experience. I hope the Minister will address the point on e-cigarettes, which seems like a loophole that none of us would be particularly enthusiastic about.
Earlier this year, the all-party parliamentary group on smoking and health invited me to speak at a roundtable to discuss the next steps to secure the ambition, which I share with the Government, for England to be smokefree by 2030. Both the Under-Secretary of State for Health and Social Care, the hon. Member for Bury St Edmunds (Jo Churchill)—she is responding to the Westminster Hall debate—and I highlighted the importance of cross-party working if we are to deliver that ambition. I want to reiterate that sentiment today. I thank the chair of the all-party group, the hon. Member for Harrow East (Bob Blackman), for inviting me to that event and acknowledge his tireless work in this space. I think it is only the nature of proceedings that has stopped him from contributing; I have no doubt he will be watching.
As the Minister said in our exchanges relating to tobacco last Tuesday, we can all be proud of the shared record of successive Governments over the last two decades in reducing smoking. I say everything in that context. We have a high degree of consensus in wanting to be smokefree by 2030, with that ambition shared by all. That was featured in the Government’s prevention Green Paper last year, which promised to build out a comprehensive approach. It has been a year since the consultation on the Green Paper closed, and we are still awaiting the Government’s response and the further proposals they promised, which are expected in January. Given that each day nearly 300 children start smoking, we cannot afford further delay, so the Minister ought to lay out a commitment on the timing of that response when he has his opportunity today.
In my city of Nottingham—colleagues have drawn on their examples from around the country, so I hope they will allow me to do so as well—21% of adults smoke, compared with 14% nationally. The figure is 29% among those in routine and manual occupations. One in six mothers smoked during pregnancy, compared with one in 10 nationwide, and smoking costs the people of our city about 75 million quid, £11.5 million of which comes in the form of NHS spending, which of course is under such pressure due to covid.
This is a social justice issue. It does impact on all communities, but not on all communities equally, and then, within this pandemic, has a compounding and knock-on effect on pandemic outcomes. The prevalence of smoking-related diseases—whether heart disease, respiratory diseases or diabetes—has undoubtedly impacted on the severity of the impact of covid on communities, especially ones like mine. Public Health England has identified these diseases as being very strongly associated with worse outcomes from covid. Of course, as we go into winter, with normal winter pressures and covid-related winter pressures, smoking puts extra pressures on our NHS. Again, there is much at stake for us.
In the covid context, I think we would all be encouraged by the rise in quit attempts and the success rates during the pandemic so far. Again, however, we know that that is not distributed equally. It tends to be older smokers in disadvantaged communities who are quitting in high numbers, not so much younger smokers. It is impossible not to think about the fact that the feeling going into a second lockdown is very different from going into the first. In the first lockdown people talked about ways in which they might improve their lives. I think I was going to re-learn French—I never did—but whether it was banana bread or committing to quit smoking, lots of people used that time very constructively. I worry about the impact of this second one, because there is definitely not the same level of optimism, if optimism is the right word. There will be people who quit six or so months ago who are feeling the pressure at this point, because quitting smoking is really hard. To those people, I think we would all send our solidarity and hope that they can keep going the course, because they are doing a brilliant thing for themselves and for their families.
I am greatly concerned by the Government’s decision to axe Public Health England in the middle of a pandemic. It seems a very odd thing to do. Certainly, without a clear plan for what the future of the health improvement work of PHE is going to be, it risks undermining the progress we have made on smoking and across all other types of health promotion issues. The success on smoking has been driven by a robust national strategy, strong regional delivery and effective, evidence-based local action. I think that is a really good model for smoking cessation and for all other areas of health improvements. I would be very keen to hear the Minister address the issue of when we are going to see an options paper for the future of PHE—I hope he will do so—but I also hope that he will commit to that model and be clear about how public health stakeholders are going to be able to contribute their views and expertise.
I am slightly surprised to have to say this, but, again, it would be good to hear a clear commitment, much in line with what the hon. Member for Winchester said, that the Government believe that this a national-level leadership role and that these functions ought to be together in one place. Whether that is in the Department, as the hon. Gentleman says, or stand alone, as they are currently, they should be in one place, taking a national lead and then providing support for the regional delivery and the effective local action. That has really worked so far, and I do not know why we would not want to do that. I would say to the Minister, as I have said to the Minister for public health—the Under-Secretary of State for Health and Social Care, the hon. Member for Bury St Edmunds—that if the Government come to a sensible place on this, we will not run political victory laps. There is no value in that to anybody. I think we just need to get it done.
It is impossible to talk about Public Health England without relating it to public health cuts, which both my hon. Friends the Members for Blaydon and for City of Durham did. I know these very well; prior to this election, I was the custodian of Nottingham’s public health budget for three years. Extraordinary cuts to local government, particularly in the poorest communities, have meant diminished public health services, but particularly smoking cessation services. After we have paid for demand-driven services such as drugs and alcohol or sexual health, there is not an awful lot left. I am not sure that the point the hon. Member for Winchester made about the public health grant ring fence is meaningful. I understood it and I agreed with it, but I think that, as a fence, it has a lot of holes. If we looked up and down the country, we would see a lot of public health spending by name that we would not necessarily consider to be public health by discipline. We need to reflect on the impact of those cuts, because they only create greater financial losses for us later, and I will come to that shortly.
Analysis by the Health Foundation shows that nearly £1 billion a year is required to reverse the real-terms per capita cuts, and that an extra £2 billion a year would be needed for adequate investment in the most deprived communities, and that is before the pandemic struck. I am very concerned that virtually all of our local authorities will have to draw up some sort of in-year budget to deal with covid costs. The promise was made by the Ministry of Housing, Communities and Local Government that those costs would be met. That is clearly now not going to happen, so, again, will those cuts come from public health budgets? That is something that we should all be very concerned about, because, as the King’s Fund characterises them, they are the falsest of false economies. The cuts have damaged not only stop smoking service provision, but all sorts of other provisions, such as health visiting, sexual health clinics and others, and they are storing up problems for our future. I hope the Minister, when he has his opportunity to speak, will confirm whether the upcoming spending review will include an uplift to the public health grant given to local authorities.
Similarly, it would be good to hear a recommitment to national level quitting campaigns, because in their heyday—2008-09—public spending in this area was in the tens of millions. It is not anymore and PHE’s budget for anti-smoking campaigns, including Stoptober, which was estimated in 2012 to have generated an additional 350,000 quit attempts in England—a fantastic figure—has fallen substantially now to £1.8 million, which is a quarter of what it was six years ago. Again, these things work. The Department clearly recognises that, and we should recognise the work that PHE did with Action on Smoking and Health during the pandemic on “Today is the Day” campaign, which was targeted at those communities where rates are the highest, including the City of Nottingham, and we are grateful for it. Therefore, those things work and I hope that we can hear a recommitment in due course.
Just to finish, how do we get to being smokefree by 2030? Following the prevention Green Paper, the Smokefree Action Coalition, which includes ASH, Cancer Research, the British Heart Foundation and the Royal College of Physicians, launched the roadmap to smokefree 2030, which is a really good read and was endorsed by all sorts of leading public health organisations and the all-party group. It also has some great recommendations that the Government should engage with, so will the Minister share his reflections on that important document? We do have to come to a position on the issue of the levy on tobacco companies. We should recognise the work that is being done by tobacco companies to reformulate to safer alternatives, but it is still a very profitable industry.
I was going to pull my punch on what I was going to say on this and leave it quite broad, but as other colleagues have been braver than me, I thought that I had better be a bit braver, too. I do not like hypothecated taxes. If we start opening the door to hypothecated taxation, we will never fund unpopular things ever again, as we will just increasingly create a tax regime that fits around that. Nevertheless, a smokefree fund is attractive and could be a way to try to improve funding for public health grant services. Therefore, again, if the Minister has a preferred way forward on that, I think that we could seek to find a political consensus on it, because we know that it would be a challenging thing to do, but it could also be a very important thing to do.
I am conscious that the sector has told us what it thinks it needs, so now it is time for us to reflect on that and that has to be through, as a matter of urgency, a new tobacco control plan. Again, I hope that we will hear from the Minister on that. There is no room now for flapping and no room for the two-year gap that we saw previously; we must get on with this because, on the current trajectory, we will not make it. I hope the Minister will commit to that as a matter of urgency.
In conclusion, this is a shared goal and it is a significant prize. There are weaknesses in our current approach that we must address now. If we do so and we act decisively, we will make one of the biggest public health breakthroughs that we have made in our nation’s history, so let us grab this moment.