Tobacco and vaping framework: roadmap to 2034

5. The First Implementation Plan

5.1 Developing actions on People

At the heart of the first implementation plan is how we support and inform people on how to stop smoking and the dangers posed to children, young people and non-smokers from vapes and other nicotine containing products.

There are two key areas that will be progressed during the first implementation plan under the banner of 'People':

• Improving cessation services and routes for support; and
• A media campaign to deter youth vaping.

These are critical to ensuring that individuals receive the help they require to stop smoking and also provide more information and guidance on the risks of vaping.

Improving cessation services

Cessation is key to ensure that smoking rates continue to decline and we need to ensure that there is no wrong door for support.

On the 26 September 2023, PHS published their review of cessation services in Scotland^[35].

This independent review made eight overarching themed recommendations:

• Improving national and local leadership:
  • including re-emphasising smoking as a public health priority nationally and locally; and establishing a group that supports the leadership of the Minister for Public Health and Women's Health in delivering against the commitment to reduce smoking rates;
• Setting and achieving new targets:
  • involving collaborative work among Scottish Government, NHS and other stakeholders to develop new three-year target(s); updates of Boards' smoking cessation services in line with the NICE guidelines; and updates to the performance management tools within the Outcomes Framework to improve monitoring;
• Improving smoker recruitment, retention and successful quits: NHS Boards and Community Pharmacy:
  • including promoting the need for services to engage with communities and third sector organisations; engaging with Healthcare Improvement Scotland to support Boards to develop quality improvement approaches; and reviewing and developing core training and establishing a national peer group for staff involved in smoking cessation;
• Improving smoker recruitment, retention and successful quits: NHS 24:
  • by exploring alternatives ways of engaging with the public and providing advice such as using a chatbot, reviewing the Scottish Care Information, allowing people to self-refer to their own local smoking cessation service, and signposting people looking to quit smoking at a local level;
• Improving data and referral systems:
  • by ensuring Boards can access detailed data to identify priorities for service improvement and achieving targets; and by strengthening and further integrating referral arrangements between smoking cessation services and primary and acute care;
• Improving workforce skills:
• through an agreed minimum standard for training across Scotland;
• Improving the promotion of cessation services:
  • by maintaining commitment to marketing in pharmacies and encouraging all Health Boards to use Quit Your Way branding); and
• Better understanding the role of vaping in cessation:
  • through a stakeholder roundtable on vaping in Scotland and by establishing a way forward that protects children and non-smokers, while also being cognisant that they are one potential route towards stopping smoking for adults who smoke).

An implementation group led by PHS and Scottish Government are working together with Health Boards on the recommendations made. They plan to update on a 6 monthly basis on progress and we would expect to see the impact from these recommendations being actioned during this first implementation plan.

Developing further maternity support

Working closely with Maternal Health we aim to capitalise on the unique opportunity pregnancy provides for women to stop smoking. Ensuring that women across Scotland can access the advice and support they need to quit is key and we will be working directly with Health Boards on solidifying these including working with chief midwives and PHS.

Pack inserts

Pack inserts are used internationally including in Canada and Israel, and are proven to encourage people to give up smoking.^[36] Pack inserts are placed inside the packaging of cigarettes and hand rolling tobacco and would contain positive messages to encourage people to quit and signpost them to advice and support. We will continue to work with the UK Government and other Devolved Governments and on the role of pack inserts to aid cessation attempts. This will include reviewing the results of the recently closed consultation (10 October)^[37] and deciding what action should be progressed.

Quit Your Way

Quit Your Way Scotland is an advice and support service for anyone trying to stop smoking in Scotland. It is available nationally for those who are ready to stop, are beginning to think about quitting, or are just looking for information.

Quit Your Way Scotland has no minimum age limit, and offers free on the phone advice or through webchat. The service is also supported by stop smoking information on the NHS inform website.

Quit Your Way Scotland is run by NHS 24 and is staffed by trained advisors.

The service can help by:

• talking through all the options available;
• referring on to free local NHS services;
• sending a free Quit Your Way Scotland quit pack;
• helping to plan to stop in a way that meets individual needs; and
• offering support and advice when trying to stop.

This service will continue and we will continue to work with NHS 24 over the development of resources to support cessation.

Marketing campaigns

We have listened to the concerns of parents, carers, schools and youth organisations that we need to provide more information around the risks and dangers of vapes. The speed at which these devices have entered our schools and young people's lives is concerning.

Alongside the publication of this Framework we are launching our first marketing campaign, to inform both young people and those who interact with young people, on the dangers of vapes. This campaign uses current knowledge and understanding as well as international approaches to support our messaging.

We know that this work needs to be supported by the information that children and young people receive in school. Work will continue on the development of wider school resources to complement this information.

Our annual pharmacy campaign^[38] will continue to run to support current smokers to help them to make informed choices on the best way to quit that meets their own circumstances.

Engagement

We know that it is not possible nor realistic for Scottish Government to do this on our own and we will continue working across the UK Government on 4-nation approaches as well as working and developing relationships with our third sector stakeholders.

The actions on people are summarised in Table 3.

5.2 Developing actions on Product

As well as supporting and informing individuals, it is important that we address issues in relation to cigarettes, vapes and other nicotine products directly. These products are not harm free and we are committed to taking further action including working on a UK-wide basis on proposals including within the Smoke Free Generation consultation.

There are two key areas that will be progressed under the banner of 'Product' within the first implementation phase:

• Restrictions on the age of sale:
  • we will consider responses to the consultation on age of sale for tobacco^[39] and whether legislation should be brought forward; and
  • we will consider if the age of sale of vapes should also increase and if so consult on proposals.
• Further restrictions on vaping:
  • we will consider responses to the current consultation on restrictions on the sale of vapes^[39]and whether legislation should be brought forward; and
  • continue to progress the outstanding regulations from the 2016 Act that were consulted on in 2022.

Age of sale of tobacco

Tobacco use is the world's single most preventable cause of death and disease^[40].

Countries around the world have adopted different approaches to tobacco control, reflecting the unique cultural, social and economic contexts in which they operate.

Some countries have sought to increase the age at which tobacco products can be purchased. For example, in 2019 the USA introduced a federal minimum age of sale of tobacco products from 18 to 21 years.^[41] Singapore progressively raised the age at which individuals could buy cigarettes from 18 to 21 between 2019 and 2021, with recent discussions to increase this further.^[42]

More countries are looking to raise the age of sale to prohibit the next generation from smoking. New Zealand^[43] and Malaysia^[44] passed Tobacco-Free Generation laws respectively in 2022 and 2023 that would prohibit smoking for anyone born on or after 1 January 2009 in New Zealand and on or after 1 January 2007 in Malaysia.

The Khan Review specifically noted: 'The short term impacts for raising the age of sale of tobacco are already proven. When the age of sale was increased from 16 to 18 in 2007, it led to a 30% reduction in smoking prevalence for 16 and 17 year olds in England. Evidence from the US showed that when the age of sale was increased from 18 to 21, the chance of a person in that age group smoking decreased by 39%'.^[26]

It is much easier to never start smoking than it is to give up an addiction. It is important as part of our 2034 ambition that we create the conditions to stop children from ever starting. This is why, with the UK Government and the Devolved Governments and Administrations we are consulting on raising the age of sale of tobacco^[45].

Prohibiting the sale of tobacco products to anyone born on or after 1 January 2009 (and also from purchasing tobacco products, in Scotland) will affect children who are turning 14 or younger in 2023. Setting this date will mean the change in the law would come into effect in 3 to 4 years' time from January 2027, when this group of children turns 18.

Our next steps will be to review the responses to the consultation when it closes at the start of December 2023 to determine whether legislation should be brought forward on increasing the age of sale.

Age of sale of vapes

Vapes have a role to play in smoking cessation, but we know that children and young people are using these devices. Children and young people may not fully understand the risks and implications of using these devices or be able to make informed decisions. Many of them contain nicotine and, as with tobacco, it is much easier to never start than it is to give up an addiction.

The current UK-wide consultation is currently focused on raising the age of sale of tobacco only. As part of the first implementation plan we will consider whether any potential raise in age of sale of tobacco should be introduced alongside an increase in the age of sale of vapes. Any change to the age of sale of vapes would require consultation before introduction.

Legislative restrictions on vapes

The Health (Tobacco, Nicotine etc. and Care) (Scotland) Act 2016 ("the 2016 Act") created restrictions on purchase and sale of vapes in Scotland e.g. restrictions on sales to under 18's^[46], as well as regulation making powers to further restrict the advertising and promotion of NVPs, including restrictions on advertising, brand-sharing and sponsorship, free distribution or nominal pricing of NVPs.

On 3 February 2022, the Scottish Government published a consultation seeking views on our proposals to make regulations under the 2016 Act.

A total of 757 validated responses^[47] were received to the consultation and the vast majority were from individuals. Organisations that submitted a response included local government, health organisations, the tobacco industry, the vaping sector, and other organisations (e.g. those that sell tobacco and vaping related products).

The themes from the consultation responses can be categorised broadly into the following areas:

• Need to raise awareness of the benefits of vaping as one option around smoking cessation;
• Need to provide accurate, person-focused information around cessation;
• Impact of packaging, flavouring and content on the appeal of vaping;
• Views on the alignment with current tobacco legislation;
• Role of specialist retailers; and
• Need to adequately support current enforcement routes such as Trading Standards.

As part of the first implementation plan we will continue to develop the proposals presented in the 2022 consultation to support the further restriction of vapes in Scotland.

The current UK wide consultation^[45] also seeks views on a range of further restrictions on vapes, which include:

• restricting flavours;
• regulating point of sale displays;
• regulating packaging and presentation;
• considering restricting the supply and sale of single use vapes;
• whether regulations should extend to non-nicotine vapes; and
• taking action on the affordability of vapes.

We will continue to work with the UK Government and other Devolved administrations over the development of any potential legislation from this consultation.

Price

We know that price can be a critical factor in people starting to smoke and also starting to vape so it is important that this is considered alongside the impact on individuals who regularly use these products.

We also know that the tobacco industry has significant profits. In 2018, the world's largest cigarette manufacturers made pre-tax profits of over USD$55million, which means they are likely to be highly critical of any changes in price.^[48]

There is currently a significant difference in price between vapes and tobacco products, in part because vapes are only subject to VAT, whereas tobacco has VAT and duty (at least a £7.87 duty on a packet of 20 cigarettes). Smoking is three times more expensive than vaping^[49]. This price differential is important, as it can encourage smokers to switch from cigarettes to vapes.

However, the current price of vapes combined with the look and feel of these devices means that they can and do appeal to children, young people and non-smokers.

In 2023, the majority of respondents to UK Government's youth vaping call for evidence (64%) said price increases would reduce the demand for vapes. ^[50] Thirty-six per cent of respondents said vapes are affordable and within the average child's buying power and that price has a significant impact on the appeal of vapes, with a further 22% stating that single-use vapes specifically are affordable.

A quarter of respondents thought there was a risk that price increases may have a negative impact on smoking cessation progress, given the use of vapes as an aid to quit smoking. Eleven per cent of respondents stated that the price differential between vapes and cigarettes increased the appeal of vaping.

Work is at a very early stage over an exploration of additional levers that could be used to drive behaviour change in Scotland. This includes looking at options such as the introduction of minimum and maximum prices of tobacco and vaping products, and price changes to roll your own tobacco.

The first implementation plan will review how price could be used as a lever and also how any price lever could impact inequalities, where we know the price rises can disproportionately affect those in areas of higher deprivation.

It would not be within devolved competence to introduce a new duty on vapes, in line with one option mentioned in the smokefree generation consultation. We will continue to work with the UK Government on policy proposals that may arise following the consultation but would welcome this proposal to increase duty.

Enforcement

Ongoing work by Trading Standards officers in Scotland testing sellers of tobacco and vapes has found that 1 in 8 premises visited sold cigarettes, and 1 in 5 sold vapes to an under 18 volunteer.^[51] These levels are simply too high and show that more needs to be done to ensure compliance especially given the increasing rates of children and young people vaping.

Trading Standards Officers work in partnership with the Scottish Government to monitor and support sellers, who need to comply with regulations associated with the retail sale of both tobacco and vaping products. Officers work with young (under-18) people locally and in tightly controlled test purchase situations to check that sellers are abiding by the law by asking for proof of age where appropriate and refusing to sell to children. Those found to be selling to under-18s can be issued with fixed penalty notices or even be banned from selling these products.

Enforcement is critical to ensuring that tobacco and vaping products are sold legally. All retailers have a responsibility to ensure that they are complying with the law.

We will continue to work with Trading Standards officers in Scotland on enforcement and investigate ways in which this can be improved as part of the first implementation phase, which will include investigating opportunities to look at online sales.

Actions on product are summarised in Table 4.

5.3 Developing actions on Place

The third dimension to our Framework is the role of place.

Review of Smoke-free spaces

On the 5^th September 2022 it became illegal to smoke within 15m of a hospital building.^[52] This built on restrictions on wider smoke free bans that were focused on internal spaces.

As part of the first implementation plan we will review the effectiveness of the hospital ban to understand the impact of this policy and wider policy options that could be implemented such as the broader approach that Wales introduced in 2021, which included smoke-free hospital grounds and playparks.^[53]

Developing the Tobacco and NVP register for Scotland

Scotland is the only country in the UK with a tobacco and NVP register^[54] and we want to make sure that this resource is future proofed to allow for any potential developments in tobacco control. All sellers of tobacco and vapes need to be registered to legal sell their products. It is an offence to sell and not be registered on the system. The tobacco register is maintained by the Scottish Government and is currently free to register. It is used by Trading Standards Officers in Scotland when undertaking enforcement and anyone can search the database.

The current register has been in place for 10 years and the platform it is hosted on has room for improvement. We are working with CivTech^[55] to develop a platform that could be used for more effective enforcement and retailer training.

Working in partnership with Trading Standards Officers we will development an information module to support retailers on compliance with age of sale of tobacco and vaping products, which has been shown to be a growing problem since the pandemic.^[56] It is expected that this would be hosted on the new platform that is currently being developed.

As there are currently no conditions on the current tobacco and NVP register, any information and training would need to be voluntary. The effectiveness of both the module and any associated impact on compliance will be monitored within the first implementation plan to determine next steps.

It is hoped that by providing support and training to retailers on the register we can increase compliance with age of sale and reduce this access point for underage sales of vapes and tobacco.

Actions on place are summarised in Table 5.

5.4 Improving Transparency

Scottish Government is signed up to the World Health Organization Framework Convention on Tobacco Control (WHO FCTC)^[57]. Under Article 5.3 of the WHO FCTC, we have a legal obligation "to protect these policies from commercial and other vested interests of the tobacco industry in accordance with national law" when setting and implementing public health policies with respect to tobacco control.

The FCTC defines the tobacco industry as "tobacco manufacturers, wholesale distributors and importers of tobacco products". This includes, but is not limited to:

• organisations or individuals with commercial or vested interests in the tobacco industry;
• those that receive funding from the tobacco industry;
• those that work to further the interests of the tobacco industry, including organisations with directors from the tobacco industry;
• tobacco growers;
• associations or other entities representing any of the above; and
• industry lobbyists.

The WHO guidelines for implementing Article 5.3 are applicable to government officials, representatives and employees of any national, state, provincial, municipal, local or other public or semi/quasi-public institution or body within the jurisdiction of a Party, and to any person acting on their behalf.

This will be underpinned by actions in Table 6.

5.5 Improving Accountability

It is important that the work of the Framework is overseen by a governance board.

Unlike previous action plans progress will be monitored by a strategic oversight group and three focused workstream governance groups (Figure 10). Each oversight group will meet at least six monthly to monitor progress, hearing from the working groups within their theme on progress and report back to the overarching strategic oversight group. This will ensure that the working groups, which will meet more frequently, progress actions with input from their lead oversight group.

The membership and reporting mechanisms will be developed within the first six months of the first implementation plan.

In the first full year of the framework (post Autumn 2023) the key focus under accountability will be on developing further indicators that could be used to monitor progress against the framework to supplement the four key indicators set out earlier in section 4.1.

As noted one priority area will be around improvements to data showing smoking and vaping prevalence in childhood given the 4-year reporting cycle of the HSBC survey.

These supplementary indicators will be reported on as part of the biennial reporting cycle of the plan as described in section 4.2. A working group is being specifically convened to progress this.

The benefit of this approach will be to allow us to monitor and understand areas where further actions are required to ensure we meet the 2034 target and the biennial reporting on the progress of the Framework.

This work on accountability will be underpinned by actions in Table 7.

5.6 Providing Support

The final strand of this implementation plan recognises that, for the framework to be successful, we must continue to support our wider partners.

This continues the work from previous plans and reaffirms our commitment to work collaboratively with a wide range of stakeholders to ensure we continue to make progress on our 2034 target.

These continuing commitments are summarised in Table 8.