National
Assembly for Wales / Cynulliad Cenedlaethol
Cymru
Health
and Social Care Committee/
Y Pwyllgor Iechyd a Gofal Cymdeithasol
Public Health (Wales) Bill/ Bil Iechyd y Cyhoedd (Cymru)
Evidence from Ash Wales – PHB 48 / Tystiolaeth gan Ash Cymru – PHB 48
Consultation on the Public Health (Wales) Bill – response from ASH Wales
ASH Wales is the only public health charity in Wales whose work is exclusively dedicated to tackling the harm that tobacco causes to communities. Further information about our work can be found at http://www.ashwales.org.uk/
We are engaged in a wide range of activities including:
· Advocating for tobacco control public health policy
· Undertaking tobacco control research projects
· Training young people and those who work with young people to provide factual information about the health, economic and environmental effects of smoking
· Engaging young people and professionals working with young people through the ASH Wales Filter project
· Bringing health information and advice to the heart of the community
We also oversee the Wales Tobacco or Health Network (a network of over 300 individual members) and the Wales Tobacco Control Alliance (an alliance of 35 voluntary and professional bodies in Wales), providing forums for sharing knowledge and best practice.
ASH Wales has no direct or indirect links with, and is not funded by, the tobacco industry.
Smoking prevalence and electronic cigarette (e-cigarette) usage in Wales
Based on 2014 Welsh Health Survey data the percentage of the adult (age 16 and over) population in Wales categorised as a smoker is 20%, with this figure greater for males (22%) than females (19%).1 In terms of numbers of smokers, this equates to approximately 518,000 adults in Wales currently smoking. Smoking is the largest single cause of avoidable early death in Wales. In 2010, around 5,450 deaths in people aged 35 and over were caused by smoking2, and about half of all life-long smokers will die prematurely as a result of their habit.3
In terms of e-cigarette usage, ASH UK reports that an estimated 2.6 million adults (aged 18+) in Great Britain currently use e-cigarettes.4 Based on the most recent population data for Wales this equates to approximately 129,000 e-cigarette users (aged 18+) in Wales∆.
Consultation questions
Part 2: Tobacco and Nicotine Products
· Do you agree that the use of e-cigarettes should be banned in enclosed public and work places in Wales, as is currently the case for smoking tobacco?
We believe any proposal to ban e-cigarettes in enclosed public and work places in Wales should be evidence based. The law to prohibit smoking in enclosed public places was implemented to protect people from exposure to tobacco smoke and thus reduce the toll of ill-health and premature death caused by second-hand smoke. A comprehensive review of the most up-to-date evidence on e-cigarettes commissioned by Public Health England concludes “EC [e-cigarette] use releases negligible levels of nicotine into ambient air with no identified health risks to bystanders”.5 In an article published in 2012, McAuley et al6 analysed pollutant concentrations from e- and tobacco cigarettes, and showed that the e-cigarette vapour was found “to pose a significantly lower risk than cigarette smoke under the same testing conditions”. Other authors have pointed out that the levels of toxins contained within e-cigarettes are comparable to conventional nicotine replacement products, rather than tobacco products.7
Before taking steps to regulate we believe policy makers should review all existing evidence and appraise the views of experts in the field. This is vital in order to make sure that any proposed measure would have a positive impact on public health. There is at present no clear evidence to suggest that including e-cigarettes under the Smokefree Premises regulations would benefit the health of the public in a similar way to the smokefree legislation currently in operation. Some people have argued that because there is still much that is unknown about the health impact of using e-cigarettes that the precautionary principle should be applied, i.e. to warn against their use until we can be sure of their safety. However, there could be a public health risk in doing so, since smokers are clearly using the devices to help them reduce their consumption of tobacco and/or to quit smoking altogether.5,8 To be precautionary it is necessary to take all effects into account of both over regulating and under regulating. It could be equally argued that under regulation is a precautionary approach for instance.
The National Institute for Health and Care Excellence (NICE) has developed guidance on a harm reduction approach to smoking.9 NICE’s recommendations aim to inform how best to reduce the illness and deaths attributable to smoking through a harm reduction approach. As part of this guidance, NICE supports the use of licensed nicotine containing products (NCPs) to help smokers cut down, for temporary abstinence and as a substitute for smoking, possibly indefinitely. NICE guidance cannot recommend the use of unlicensed nicotine containing products. However the guidance is clear that using an e-cigarette is likely to be less harmful than smoking. ASH Wales supports a harm reduction approach to tackle smoking.
There is no clear evidence to support the hypothesis that the use of e-cigarettes serves to renormalise smoking behaviour or act as a gateway to tobacco products among young people. In terms of renormalisation, the 2015 report commissioned by Public Health England states “there is no clear evidence to date that EC [e-cigarettes] are renormalising smoking, instead it’s possible that their presence has contributed to further declines in smoking, or denormalisation of smoking”.5 With regards to e-cigarettes acting as a gateway to smoking among young people the report found no evidence of this during their comprehensive review leading them to conclude “Whilst never smokers are experimenting with EC [e-cigarettes], the vast majority of youth who regularly use EC [e-cigarettes] are smokers. Regular EC [e-cigarettes] use in youth is rare”.5 The existing evidence base suggests the situation is no different in Wales specifically. For instance, studies by ASH Wales10 and Moore et al11, which were based on a cohort of young people living in Wales, found regular use of e-cigarettes to largely be confined to tobacco smokers, with use among never smokers rare.
Furthermore, it is worth noting that the uncertainty regarding the impact of e-cigarettes, and in particular the debate around banning the use of e-cigarettes in enclosed public and work places, has the potential to shift public opinion of e-cigarettes. ASH UK runs an annual survey on e-cigarette use among adults and young people in Great Britain. Between 2013 and 2015 the number of adults who wrongly considered e-cigarettes to be as harmful as conventional cigarettes increased from 6% to 20%.4 Given the potential benefits of e-cigarettes as a smoking cessation tool this represents a worrying trend since it is important for the public not to get the wrong impression of the dangers of e-cigarettes.
ASH Wales therefore recommends that any decision to ban the use of e-cigarettes in enclosed public and work places in Wales should be delayed until additional evidence is forthcoming. In the meantime ASH Wales recommends that premises continue to be allowed to make decisions for themselves on whether or not to permit the use of e-cigarettes, although we recognise that there may be environments where the use of these devices is inappropriate, such as schools for example. ASH UK have provided a briefing on the issues that organisations need to consider in relation to permitting use of e-cigarettes on their premises.12 ASH Wales recommends that Public Health Wales disseminates responsible guidance such as this to businesses and other organisations.
· What are your views on extending restrictions on smoking and e-cigarettes to some non-enclosed spaces (examples might include hospital grounds and children’s playgrounds)?
We are in favour of extending the current restrictions on tobacco smoking to include some non-enclosed spaces, such as hospital grounds and mental health units. We additionally support the introduction of voluntary smoking bans in places like playgrounds, school gates and beaches. We consider this to be an important development that will serve to further denormalise smoking as an activity in communities across Wales as well as protect members of the public from the damage to their health caused by inhaling secondhand smoke. The current smokefree legislation, introduced in the UK in 2007, bans smoking in virtually all enclosed and substantially enclosed public and work places. These regulations have been shown to be effective in terms of initiating health benefits for smokers/non-smokers and changes in smoking related attitudes and behaviour.13 Furthermore, the extension of smoking bans to include non-enclosed public places has also been shown to be effective. For instance, following the parks and beaches in New York City (NYC) becoming smokefree in 2011 Johns et al found the trend in the frequency of NYC residents noticing people smoking in local parks and beaches decreasing significantly over the six quarters after the law took effect, leading the authors to conclude that their results provide population-level evidence that suggest the law has reduced smoking in parks and on beaches.14 Furthermore, there is strong public support in Wales for an extension of the smoking ban to include additional non-enclosed spaces. According to a 2015 YouGov survey commissioned by ASH Wales 54% of respondents agree that smoking should be banned in communal recreational spaces such as parks and beaches.15
In contrast, we are not in favour of restricting the use of e-cigarettes in some non-enclosed spaces. As per our answer above, we do not believe sufficient evidence currently exists to warrant banning the use of e-cigarettes in enclosed public and work places, and hence we also feel it is too early to consider banning e-cigarettes in non-enclosed spaces.
· Do you believe the provisions in the Bill will achieve a balance between the potential benefits to smokers wishing to quit with any potential disbenefits related to the use of e-cigarettes?
We feel at present that the provisions in the Bill are weighted too heavily in favour of protecting the public from the potential disbenefits associated with the use of e-cigarettes, to the detriment of the potential benefits accrued by smokers resulting from the use of e-cigarettes as a smoking cessation tool.
We agree that it is important to ensure the health of the public is safeguarded at all times, and that given the fact e-cigarettes are still relatively new it is necessary to be cautious with regards to the potential health risks. However, at present the majority of evidence does not suggest that e-cigarettes are particularly harmful to health. Whilst e-cigarettes do contain some carcinogens and toxicants these are at much lower levels than those observed in tobacco smoke, and as such e-cigarettes are widely regarded as being much safer than tobacco cigarettes. A number of studies have not reported any significant adverse effects on health of e-cigarettes. As part of a Cochrane review McRobbie et al looked at whether it is safe to use e-cigarettes as a smoking cessation aid.16 None of the studies found that smokers who used e-cigarettes short-term (for 2 years or less) had an increased health risk compared to smokers who did not use e-cigarettes. As part of a systematic review appraising existing laboratory and clinical research on the potential risks from e-cigarette use, Farsalinos and Polosa concluded that the currently available evidence indicates that e-cigarettes are by far a less harmful alternative to smoking.17 Furthermore, in a study of the levels of selected carcinogens and toxicants in the vapour from e-cigarettes Goniewicz et al found the levels of the toxicants were 9 - 450 times lower than in cigarette smoke18, whilst according to the 2015 report commissioned by Public Health England e-cigarette use is around 95% safer than smoking.5
A related concern surrounding e-cigarettes is that they may become a new form of nicotine addiction. However, there is an emerging body of evidence which suggests that at present e-cigarettes are not currently as addictive as tobacco cigarettes given the other constituents of tobacco smoke enhance the addictiveness of nicotine. According to Guillem et al compounds present in tobacco smoke may combine with nicotine to produce the intense reinforcing properties of cigarette smoking that lead to addiction.19
In contrast to the relative lack of evidence in terms of the adverse impact on health of e-cigarettes, there is a growing body of evidence suggesting that e-cigarettes are increasingly being used for smoking cessation purposes. In England, since the third quarter of 2013 a higher percentage of smokers have tried to stop smoking using e-cigarettes compared to any other popular smoking cessation aid. Indeed, by the last quarter of 2014 approximately 15% more smokers used e-cigarettes as a means to give up smoking relative to over-the-counter NRT.20 Research is also becoming available signifying the effectiveness of e-cigarettes as a smoking cessation aid. In 2014 Brown et al undertook a cross-sectional population study aimed at assessing the real-world effectiveness of e-cigarettes when used to aid smoking cessation.8 Among the findings of the study was that e-cigarette users were more likely to report abstinence than either those who used NRT bought over-the-counter or those who used no smoking cessation aid.
Given the above, plus the fact that restrictions on the use of e-cigarettes reinforces the belief that the products are as risky as tobacco cigarettes in the public consciousness, we feel it is necessary to take more time to assess the relative benefits and disbenefits associated with the use of e-cigarettes. We consider this to be the best option as opposed to regulating on the basis of insufficient evidence, as is currently the case in relation to the Public Health (Wales) Bill. If there was a ban on using e-cigarettes in all enclosed public places, users could be less inclined to use them which could result in more of them reverting back to smoking. Prohibition would also increase the likelihood that vapers and smokers would effectively be required to share the same spaces. This not only undermines quit attempts but would also expose users of e-cigarettes to second-hand smoke. Before regulation of this nature proceeds, it needs to be clear that the harms to others outweigh the benefits to those who are using e-cigarettes for harm reduction or cessation purposes, as otherwise there is a risk that the regulation in question could harm public health by making a potential avenue for smoking cessation less attractive to current smokers.
· Do you have any views on whether the use of e-cigarettes renormalises smoking behaviours in smoke-free areas, and whether, given their appearances in replicating cigarettes, inadvertently promote smoking?
To date, there has been very little research based upon the question of perception of e-cigarettes and whether or not they can be argued to normalise, or indeed denormalise, the act of smoking. E-cigarettes are distinct from tobacco products. Whilst the early version of e-cigarettes were designed to look like the tobacco equivalent this tends to be no longer the case with current developments in e-cigarette design meaning that most devises now look more like pens as opposed to conventional cigarettes. Furthermore, e-cigarettes lack the most distinctive characteristic of smoking – its smell (which travels rapidly) – plus they do not produce ash. It is therefore difficult to see how any confusion between the products could be sustained for long. Indeed, the 2015 report commissioned by Public Health England reviewing the most up-to-date evidence in relation to e-cigarettes states “there is no clear evidence to date that EC [e-cigarettes] are renormalising smoking, instead it’s possible that their presence has contributed to further declines in smoking, or denormalisation of smoking”.5
In fact emerging evidence suggests that the advent of e-cigarettes is playing a role in the observed reduction in smoking prevalence. According to Professor Robert West the number of smokers in England estimated to have quit in 2014 who would not have quit if e-cigarettes had not been available is 20,340.21 This appears to be borne out by further evidence from the Smokers’ Toolkit study which revealed that people attempting to quit smoking without professional help are about 60% more likely to report succeeding if they use e-cigarettes than if they use willpower alone or over-the-counter nicotine replacement therapies.8
· Do you have any views on whether e-cigarettes are particularly appealing to young people and could lead to a greater uptake of their use among this age group, and which may ultimately lead to smoking tobacco products?
Recent figures suggest that the awareness and usage of e-cigarettes among young people in Wales and Great Britain as a whole is increasing.10, 22 We consider this finding to be concerning and are keen to see young peoples’ use of nicotine minimised as much as possible.
It is important to note however that the evidence collected so far about young people and e-cigarette experimentation and usage from a number of countries has not yet demonstrated any ‘gateway’ effect, that is non-smokers taking up e-cigarettes, much less progressing to conventional tobacco products. Writing in a report on e-cigarette marketing commissioned by Public Health England, Bauld, Angus and de Andrade note that ever use is concentrated among young people who smoke. They also state that they “could not identify any evidence to suggest that non-smoking children who tried e-cigarettes were more likely then to try tobacco.”23 A recent ASH Wales survey of young people across Wales also suggested that e-cigarettes are not currently acting as a gateway to smoking among non-smokers. Regular use by never smokers was negligible at 0.16%. Of those respondents who reported using both e-cigarettes and tobacco cigarettes at some point (n=84), 98% had first used tobacco cigarettes suggesting the absence of any gateway theory.10 A survey commissioned by ASH UK found that in 2014 of those who had never smoked a cigarette 99% reported never having tried an e-cigarette and 1.5% reported having tried them “once or twice”. They found negligible evidence of regular e-cigarette use among children who have never smoked or have only tried smoking once. In addition, only 1% of those who had never smoked thought that they would try an e-cigarette soon.22 Research conducted in the United States aimed at identifying the beliefs that predicted subsequent e-cigarette use also found that a relatively small number of (baseline) never smoking respondents reported ever using an e-cigarette (2.9%) when compared with (baseline) former smokers (11.9%) or (baseline) current smokers (21.6%).24 Findings in a survey conducted among young people (15-24 year olds) in Poland also returned similar results with regard to non-smokers. Whilst around one-fifth of respondents reported having tried an e-cigarette at some point, this dropped to 3.2% among those who had never smoked a cigarette. This percentage fell even further, to 1.4%, when asked if they had used an e-cigarette in the previous 30 days indicating that for many non-smokers who had tried one, this had not led to long-term use.25
On balance therefore, from the evidence currently available on the issue of young people and e-cigarettes, the majority of the data shows that ever cigarette use is concentrated among current and former smokers with negligible evidence of never-smokers trying e-cigarettes, much less progressing to regular use of e-cigarettes, let alone tobacco products. Although ASH Wales recognises the need to continue monitoring the situation and enhancing the evidence base in this area.
· Do you have any views on whether restricting the use of e-cigarettes in current smoke-free areas will aid managers of premises to enforce the current non-smoking regime?
Whilst recognising the concerns about enforcing the Smoke-free Premises regulations, we are unaware of any evidence to suggest that the regulations are being consistently undermined by the use of e-cigarettes in public places, i.e., causing people to use tobacco products illegally. Consequently, ASH Wales does not feel that an outright ban on the use of nicotine containing devices (e- cigarettes) in enclosed public places under the existing regulations is warranted. As noted above, vaping is not smoking and we believe it is inappropriate to place non-combustible nicotine delivery devices under smokefree legislation.
There may be some uncertainty regarding how businesses appropriately deal with e-cigarettes, and, in particular, whether they are able to adopt and enforce bans themselves. For this reason we feel there is a clear need to provide education and clear guidance for businesses so that they are fully informed about e-cigarettes and what their rights and responsibilities are. ASH UK have provided a briefing on the issues that organisations need to consider in relation to permitting use of e-cigarettes on their premises12 and we should be adopting similar guidance in Wales.
· Do you agree with the proposal to establish a national register of retailors of tobacco and nicotine products.
We agree with the proposal for a national retail register of retailors of tobacco and nicotine products. We would favour retailors of tobacco to be on a separate register from retailors of nicotine products given these are very different products.
We welcome the measure as an important initial step towards reducing the number of young people in Wales who become smokers or start using e-cigarettes, and consider it to be both workable and proportionate. Evidence from Scotland suggests that the register has been useful as a means of improving proactive communication to retailors in terms of what their responsibilities are. However, from an enforcement point of view the retail register in place in Scotland appears to be less successful. There have been very few prosecutions and the register doesn’t improve the ability of enforcement officers to tackle illicit tobacco outside legitimate retailors. For this reason we view the proposal to establish a national retail register in Wales as a first step towards a positive licensing scheme, which is what we would like to see adopted for tobacco in the same way it is applied to alcohol. Such a scheme would mean tobacco retailors have to meet certain conditions to gain a licence to sell tobacco, with the potential to suspend, revoke or vary the conditions of a licence. We believe a positive licensing scheme would initiate more effective enforcement than a retail register, affording enforcement officers more powers to address tobacco being sold outside the legitimate retailors.
· Do you believe the establishment of a register will help protect under 18s from accessing tobacco and nicotine products?
Yes. The establishment of a national register of retailors of tobacco and nicotine products will hold retailors more accountable for their actions if caught partaking in underage sales and will make it easier for them to be monitored and tracked over time. This is important since evidence from the North East of England in 2013 showed that young smokers (14-15 year olds) are significantly more comfortable than their adult counterparts in purchasing illegal tobacco. 30% of 14-15 year olds were buyers of illegal tobacco, making them twice as likely as adult smokers in having purchased illegal tobacco.26 We believe under 18s will be afforded additional protection from a positive licensing scheme however and would support the introduction of such a scheme to replace the retail register in the long term.
· Do you believe a strengthened Restricted Premises Order regime, with a national register, will aid local authorities in enforcing tobacco and nicotine offences?
Yes. This will act as a greater deterrent to any retailors tempted to breach the new requirements. It is important however that following any changes the regime is easy to enforce plus there should be clear guidance for enforcement officers and magistrates on how to implement the changed regime.
· What are your views on creating a new offence for knowingly handing over tobacco and nicotine products to a person under 18, which is the legal age of sale in Wales?
We believe that this measure would be in line with the commitment demonstrated by other legislative steps, such as the vending machine ban, point of sale display bans and the introduction of a retail register, to limit as far as possible the access of young people to tobacco/nicotine products.
We would support the proposal to prevent under-18s receiving delivery of tobacco/nicotine products in principle, as unintentionally or not, allowing under-18s to receive delivery of tobacco/nicotine products blurs the message that is being developed on the issue of proxy purchasing. If an under-18 is the only person present to receive a delivery, even if ordered by an adult, there would be no way of preventing them accessing the goods delivered, whether they were intended for their consumption or not. However, before this offence is created we believe it is important to ensure that there is evidence that this issue is a problem. All decisions of a regulatory nature such as this needs to be evidence based.
· Do you believe the proposals relating to tobacco and nicotine products contained in the Bill will contribute to improving public health in Wales?
We believe the proposals to establish a national register of retailors of tobacco and nicotine products, strengthening the Restricted Premises Order regime and prohibiting the handing over of tobacco and/or nicotine products to a person under the age of 18 will each contribute to improving public health in Wales.
However, we are concerned that the proposal to place restrictions on the use of nicotine inhaling devices such as e-cigarettes in enclosed public and work places may serve to damage public health in Wales. There is a clear risk that this regulation will reduce uptake of e-cigarettes among current adult smokers who may otherwise have sought to use the device in an attempt to quit tobacco smoking or harm reduce. ASH Wales therefore recommends that any decision to ban the use of e-cigarettes in enclosed public and work places in Wales should be delayed until additional evidence is forthcoming.
Other comments
As we have stated we believe there are several components of the Public Health (Wales) Bill that will serve to improve public health in Wales. However there is a risk that such positive aspects of the Bill will be overshadowed by the debate surrounding the proposal to ban the use of e-cigarettes in enclosed public and work places. For this reason we recommend that this specific proposal be removed from the Public Health (Wales) Bill, if only temporarily, so that it can be debated separately at a later date. This will allow for a more considered debate to be had and more evidence from experts to be heard. By introducing a longer timeframe to consider the e-cigarette proposal there will be an opportunity for more evidence to be forthcoming to inform the debate and given the current uncertainty regarding the issue of whether e-cigarettes act as a gateway to tobacco products among young people and/or renormalise smoking as an activity such a stoppage for reflection is most welcome.
In terms of other areas of public health that require legislation to help improve the health of people in Wales we support the extension of the current smokefree legislation to include a ban on smoking tobacco in some non-enclosed spaces, such as hospital grounds and mental health units. We are also in favour of the introduction of voluntary smoking bans in places like playgrounds, school gates and beaches. We consider these proposals to be an important development that will serve to further denormalise smoking as an activity in communities across Wales as well as protect members of the public from the damage to their health caused by inhaling second-hand smoke.
References
1 Welsh Government (2015). Welsh Health Survey 2014.
2 Public Health Wales NHS Trust / Welsh Government (2012). Tobacco and health in Wales.
3 ASH (2014). Smoking statistics: illness and health.
4 ASH (2015). Use of electronic cigarettes (vapourisers) among adults in Great Britain.
5 McNeill A, Hajek P et al (2015). E-cigarettes: an evidence update – A report commissioned by Public Health England.
6 McAuley TR., Hopke PK., Zhao J. and Babaian S. (2012). Comparison of the effects of e-cigarette vapor and cigarette smoke on indoor air quality. Inhalation Toxicology, Vol 24 (12): pp850-857.
7 Cahn Z. and Siegel M. (2011): “Electronic cigarettes as a harm reduction strategy for tobacco control: A step forward or a repeat of past mistakes?” Journal of Public Health Policy, Vol 32 (1): pp16-31.
8 Brown J, Beard E, Kotz D, et al. (2014). Real-world effectiveness of e-cigarettes when used to aid smoking cessation: a cross-sectional population study. Addiction, 109; pp1531-1540.
9 National Institute for Clinical Excellence (NICE). (2013). Tobacco: harm-reduction approaches to smoking.
10 ASH Wales (2015). Young people and the use of e-cigarettes in Wales.
11 Moore G, Hewitt G, Evans J, Littlecott HJ, Holliday J, Ahmed N, Moore L, Murphy S, Fletcher A (2015). Electronic-cigarette use among young people in Wales: evidence from two cross-sectional surveys. BMJ Open, 5.
12 ASH (2014). Will you permit or prohibit electronic cigarette use on your premises? Five questions to ask before you decide.
13 Bauld, L. (2011). The impact of smokefree legislation in England: Evidence review.
14 Johns M., Farley SM., Rajulu DT., Kansagra SM., Juster HR. (2014). Smoke-free parks and beaches: an interrupted time-series study of behavioural impact in New York City. Tobacco Control.
15 YouGov for ASH Wales. Total sample size was 1,002 adults. Fieldwork was undertaken between 26th February to 12th March 2015. (in press).
16 McRobbie H, Bullen C, Hartmann-Boyce J, Hajek P. (2014). Electronic cigarettes for smoking cessation and reduction. Cochrane Database of Systematic Reviews, Issue 12.
17 Farsalinos KE. and Polosa R. (2014). Safety evaluation and risk assessment of electronic cigarettes as tobacco cigarette substitutes: a systematic review. Ther Adv Drug Saf, Vol 5(2); pp67-86.
18 Goniewicz ML, Knysak J, Gawron M, Kosmider L, Sobczak A, Kurek J, et al. (2013). Levels of selected carcinogens and toxicants in vapour from electronic cigarettes. Tobacco Control. 23 pp. 133-139.
19 Guillem K, Vouillac C, Azar MR, Parsons LH, Koob GF, Cador M, and Stinus L. (2005). Monoamine Oxidase Inhibition Dramatically Increases the Motivation to Self-Administer Nicotine in Rats. The Journal of Neuroscience. 25(38).
20 West R, Brown J, Beard E. (2015). Trends in electronic cigarette use in England. www.smokinginengland.info/latest-statistics
21 West R. (2015). Estimating the population impact of e-cigarettes on smoking cessation and smoking prevalence in England.
22 ASH (2015). Use of electronic cigarettes among children in Great Britain.
23 Bauld L., Angus K. and de Andrade M. (2014). E-cigarette uptake and marketing: A report commissioned by Public Health England.
24 Choi K. and Forster JL. (2014): “Beliefs and Experimentation with Electronic Cigarettes. A Prospective Analysis Among Young Adults”, American Journal of Preventive Medicine, 46 (2): pp175-178.
25 Goniewicz ML. and Zielinska-Danch W. (2012): “Electronic cigarette use among teenagers and young adults in Poland”, Pediatrics, 130 e879; doi:10.1542/peds.2011-3448.
26 NEMS Market Research (2013). North East Illicit Tobacco Survey. NEMS Market Research.