德莫斯研究所-无烟无火：英国电子烟政策的新愿景

SMKEWITHOUTFIRECEDAWSON2OpenAccess.Somerightsreserved.OpenAccess.Somerightsreserved.Asthepublisherofthiswork,Demoswantstoencouragethecirculationofourworkaswidelyaspossiblewhileretainingthecopyright.Wethereforehaveanopenaccesspolicywhichenablesanyonetoaccessourcontentonlinewithoutcharge.Anyonecandownload,save,performordistributethisworkinanyformat,includingtranslation,withoutwrittenpermission.ThisissubjecttothetermsoftheCreativeCommonsByShareAlikelicence.Themainconditionsare:•Demosandtheauthor(s)arecreditedincludingourwebaddresswwwdemosco.ukicenceAfullcopyofthelicencecanbefoundat/licenses/by-sa/3.0/legalcodecometoaskforpermissiontousethisworkforpurposesotherthanthosecoveredbythelicence.DemosgratefullyacknowledgestheworkofCreativeCommonsininspiringourapproachtocopyright.TofindoutmoregoWearegratefultoJuulLabsfortheirsponsorshipofthisprogrammeofresearchourfindingsandanalysisremainfullyindependent.PublishedbyDemosNovember2022©Demos.Somerightsreserved.15Whitehall,London,SW1A2DDT:02038783955hello@demos.co.ukwww.demos.co.uk3CNTENTSEXECUTIVESUMMARYPAGE4THEPROBLEMPAGE6SMOKINGINTHEUK:FACTSANDMYTHSPAGE7ENCOURAGESMOKERSTOSWITCHPAGE9REDUCINGHEALTHINEQUALITIESPAGE12PREVENTINGYOUNGPEOPLEFROMTAKINGUPVAPINGPAGE13PROTECTINGCONSUMERHEALTHANDSAFETYPAGE16CONCLUSIONPAGE184EEXECUTIVESUMMARYIn2019,theGovernmentsetoutalaudable,ambitiousgoal.By2030,theirstatedambitionisforEnglandtobeentirelysmoke-free,withtheCabinetOfficeandDHSCissuinganultimatum“forindustrytomakesmokedtobaccoobsoleteby2030,withsmokersquittingormovingtoreducedriskproductslikee-cigarettes.”Achievingthisaimwouldpreventdeathandtobaccorelateddisease,primarilyamongstthemosteconomicallyvulnerablemembersofsociety.SmokingremainstheleadingpreventablecauseofillnessandprematuredeathintheUK,andisaprimarydriverofhealthinequalityinEngland.rsetomissthistargeteintheUKisjustoverandfalling,buttherecentKhanreviewonsmokefreepoliciespredictsthat,onourcurrenttrajectory,around7%oftheUK-over4.8millionpeople-willstillsmokein2030.1UrgentchangeisneedediftheGovernmentisgoingtoreachitssmoke-freegoal,reducehealthinequalitiesanddiminishthedevastatingimpactssmokinghasonpeople’slives.E-cigarettescouldbeakeytoolinencouragingthischange;thereisagrowingbodyofevidencesuggestingtheyareeffectiveinincreasingquitratesinsmokers,andpeoplewhousee-cigarettestoquitsmokingaretwiceaslikelytobesuccessfulthanpeoplewhouseothernicotinereplacementproductslikepatchesorgum.2,3However,thecurrentregulatoryframeworkismakingitdifficulttoencouragemoresmokerstoswitch,whilefailingtoaddressmisinformationaroundrisk,preventcounterfeitgoodsreachingconsumers,anddiscourageunderagepeoplefromvaping.majorityofproductscontainnicotine-ahighlyaddictivesubstancethatcanharmyoungpeople’sdevelopingbrains.Illicite–cigaretteproductsarealsogettingontothemarketwithnon-compliantnicotinelevelsanddangerous,counterfeitbatteries,puttingHealthEnglandestimatesthate-cigarettesare95%lessharmfulthantraditionalcigarettes,anditisvitalweareabletodispelmisperceptionsthatvapingarmfulastobaccosmokingbyreachingsagesWealsoneedtomakee-cigarettesamoreappealingandaccessibleoptionforsmokersfromthemostdeprivedcommunities.dstandsachanceofbeingsmokefreeby2030,weneedaneffectiveregulatoryframeworkthatstopsyoungpeopletakingupvapingandcracksdownonnon-compliantproducts,butwithoutdeterringadultsmokersfromswitching.DrawingonresearchfromtwopreviousDemosreports-MythsandMisinformationandE-cigaretteRegulationsin2022-thispapersetsoutamethodthroughwhichthiscarefulbalancemightbestruck.Wehaveidentifiedfourpillarsofe-cigarettepolicywherechangeisurgentlyneededtoimprovepublichealth:gsmokerstoswitch1Khanreview:.uk/government/publications/the-khan-review-making-smoking-obsolete/making-smoking-obsolete-summary.Smokingpopulationin2030basedonONSforcastsforpopulationgrowth,retreivedfrom.uk/peoplepopulationandcommunity/populationandmigration/populationprojections/bulletins/nationalpopulationprojections/2020basedinterim#:~:text=The%20population%20of%20the%20UK,69.2%20million%20in%20mid%2D2030.2https://www.nhs.uk/live-well/quit-smoking/using-e-cigarettes-to-stop-smoking/#:~:text=A%20major%20UK%20clinical%20trial,such%20as%20patches%20or%20gum.3Seee.g.Hartmann-Boyceet.all(2021)ElectroniccigarettesforsmokingcessationCochraneDatabaseofSystematicReviewsIssue9.RetrievedAugust2022from/cdsr/doi/10.1002/14651858.CD010216.pub6/full5Reducinghealthinequalities•PreventingyoungpeoplefromtakingupvapingProtectingconsumerhealthandsafety6THETHEPROBLEMIn2022,smokingcontinuestotakeaserioustollonthehealthoftheUK.Smokingrelatedillnessanddeathnotonlyhasdevastatingconsequencesforsmokersandtheirfamilies,butalsoputsoverwhelmingpressureontheNHSWemustaddressthis,andurgenteffortsareneededtogetmoresmokerstoquitifsmokingratesaretofall.verasDemoshashighlightedinMythsandMisinformationandE-cigaretteRegulationsin2022,misperceptionsaroundtherelativeharmsofvaping,restrictiveadvertisingregulationsandsocioeconomicinequalitiesareplacingseriousbarriersonthepathtoasmoke-freeEngland.Tacklingtheincorrectbeliefthate-cigarettesareequallyormoreharmfulthansmokingiskeytoovercomingthesebarriers.Ina2022pollconductedbyDemos,48%ofrespondentsjudgedthefalsestatement“Thenicotineintobaccocigarettesisthechemicalwhichcausesmostofthecancer”tobetrue;only26%correctlyidentifieditasfalse.Thesemisperceptionsaffectsmokersconfidenceintryingalternativestosmoking.4Regulatorychangeisneededtogiveusmoreopportunitiestopromotevapingtosmokersasalessharmfulnicotinealternative,withoutencouragingnon-smokers,especiallyyoungpeople,tousee-cigaretteproductsThisisaclearandgrowingrisk-despiteagerestrictions,thelatestdatashowsthat16%ofchildren11-17havetriedvaping,anincreasefrommberrisestoforyearolds.WeurgentlyneedinnovativeregulatorychangeandnewsmokingcessationpoliciestotackletheseissuesInthepagesthatfollowwewilllayoutasetofpolicyrecommendationsforhowtheGovernmentandregulatorybodiesmightencourageadultsmokerstoswitchandmakee-cigarettesmoreaccessibletosmokersfromlowsocioeconomicgroups,withoutincreasingtheirappealtoyoungpeople,orleadingtoamarketfloodedwithnon-compliantproductsattractedbyanewregulatoryapproach.4https://demos.co.uk/wp-content/uploads/2022/05/myths-and-misinformation.pdf7SMOKINGSMOKINGINTHEUK:FACTSANDMYTHSSmokingremainstheleadingpreventablecauseofillnessandprematuredeathintheUKwithanestimated191,900deathsattributedtosmokinginEnglandintheyears2017to2019.5Accordingtothelatestdata,13percentofadultsintheUKsmoke.6ItremainsoneofthemaincausesofhealthinequalitiesinEngland;smokingalonecontributestoabouthalfofthegapinhealthylifeexpectancybetweentherichestandthepoorest.7ONSdatasuggestsnearlyaquarterofthoseonincomeslessthan£10,000arecurrentsmokers,comparedwithjustover10%ofthoseonincomesover£40,000.Further,Demos’ownresearchfoundsmokersfromlowersocioeconomicgroupsarelesslikelytobeplanningtoquitthantheirmoreaffluentcounterparts.8Tacklingsmokingshouldbothbeamajorpublichealthpriorityandamajorpriorityinthelevellingupagenda.Althoughe-cigarettescanbeaneffectiveandrelativelysafetoolforthosewishingtoquitsmoking,ysmokersaswellasthewidergeneralpublicholdinaccurateviewsaboutnicotine,leadingtoapoorunderstandingoftherelativeharmcausedbyvapingincomparisontosmoking.TherearethreedressmythsinthisNICOTINEISNOTACARCINOGENThecancercausingcomponentoftraditionalcigarettesisthechemicalsfoundinthesmokeandweverDemosresearchfoundthatofonsmokersbelievethatitstineincigarettesthatcausescancerThisisleadingpeopletobelievethate-cigarettesarejustasorevenmoreharmfulthantraditionalcigarettes.CIGARETTESAREAROUND20TIMESASHARMFULASE-CIGARETTESmokingbutonly18%ofsmokersand10%ofthewidergeneralpublichavecorrectharmperceptions.11AsurveybyActiononSmokingandHealth(ASH)alsofoundthatofsmokersbelievevapingismoreorequallyasharmfulastraditionalcigaretteswhileafurther22%saidtheydon’tknowwhattherelativeharmsare.12Smokersfromlowersocioeconomicgroupsaremorelikelytohavethesemisperceptionsourresearchfoundthatpeoplewhodon’twork(55%vs44%ofthosewhoareworking)aremorelikelytoincorrectlybelievethatnicotineisthemaincancercausingchemicalincigarettes.135PublicHealthEngland.LocaltobaccocontrolprofilesforEngland:shortstatisticalcommentary,July2021.PHE,2021.Availableat:https://.uk/government/statistics/local-tobacco-control-profiles-for-england-july-2021/local-tobacco-control-profiles-for-england-short-statistical-commentary-july-2021#:~:text=There%20were%20an%20estimated%20191%2C900,period%20(2017%20to%202019).6OfficeforNationalStatistics.AdultsmokinghabitsintheUK:2021.ONS,2022.Availableat:.uk/peoplepopulationandcommunity/healthandsocialcare/healthandlifeexpectancies/bulletins/adultsmokinghabitsingreatbritain/2021(accessed08/01/2023)7.uk/sites/default/files/ALUK_clearing_the_smoke_report.pdf8https://demos.co.uk/wp-content/uploads/2022/05/myths-and-misinformation.pdf9https://demos.co.uk/wp-content/uploads/2022/05/myths-and-misinformation.pdf10PublicHealthEngland.E-cigarettesaround95%lessharmfulthantobaccoestimateslandmarkreview.PHE,August2015.Availableat:.uk/government/news/e-cigarettes-around-95-less-harmful-than-tobacco-estimates-landmark-review(accessed11/08/2022)11https://demos.co.uk/wp-content/uploads/2022/05/myths-and-misinformation.pdf12.uk/uploads/Use-of-e-cigarettes-vapes-among-adults-in-Great-Britain-2022.pdf?v=166186595913Mackenzie,PandDawson,A.MythsandMisinformation:Mappingthebarrierstosmokingcessationandtheuptakeofnicotinealternatives.Availableat:https://demos.co.uk/project/myths-and-misinformation-mapping-the-barriers-to-smoking-cessation-and-the-uptake-of-nicotine-alternatives/(accessed11/08/2022)8THEPUBLICAREASKINGFORCHANGEDemospollingconductedinMay2022foundthat85%oftheUKthinktheGovernmentshouldacttoreducehealthinequality,witholderparticipantsespeciallylikelytoseethisasimportant.1431%ofthecountryfeltthatsmokingcessationwasoneofthetopthreemeasuresthegovernmentshouldprioritise,afterhelpwiththecostoflivingandhealthyeating.ngcessationshouldnotbeseenasanelectoralliability.ThesemisperceptionsarenotonlyabarriertotheUK’sgoalofbecomingsmokefreeby2030,butalsotonarrowingthegapinhealthylifeexpectancyofthepoorestandrichest.Addressingthesemyths,andencouragingpeopletostopsmoking,willtakeaconcertedeffortfromgovernment,regulatorsandthehealthsystem,butnswhichcoulduschangeandgetusbackontracktobeingsmoke-freeinthenexteightyears.Weexplorethesebelow.14/drive/u/0/search?q=myths%20and%20misinformation9EENCOURAGESMOKERSTOSWITCHTheTobaccoandRelatedProductsRegulations(TRPR)andCAPcoderegulationsshouldbemodifiedtoallowmessagespromotinge-cigarettesaslessharmfultobetargetedatadultsmokers,forexamplethroughinsertsincigarettepackets.Effortstotacklemythsaroundthehealthrisksofvapingneedtobeacceleratedifwewantpeopletoswitch.TheDepartmentofHealthandSocialCare(DHSC)shouldmodifyTRPRregulationthatprohibitsinsertsandadditionalmaterialsintobaccocigarettepackaging,toallowconsistent,governmentapprovedmessagingtopromotee-cigarettesasalessharmfulalternativeandmessagesthatencourageswitching.15stedTheUKsScienceandTechnologyCommitteehascalledformoretargetedcommunicationontherelativeharmsofe-cigarettestobedirectedtowardssmokers,andsuggestedpackinsertsmightbeaneffectivemethod.InCanada,itisalegalrequirementfortraditionalcigarettepackstocontaininsertswithsmokingcessationinformation.16A2015evaluationofthispolicyfoundthatsmokerswhoreadinsertsweremorelikelytomakequitattemptsthanthosethatdidn’t.17Anotherwaythismessagingcouldbeeffectivelytargetedisthroughemail.Thisiscurrentlyblockedinofe-cigarettesonline,andtheCommitteeofAdvertisingPractice(CAP)doesnotallowe-cigaretteretailerstoprovidepromotionalinformationtocustomers.18Adjustingtheseregulationstoallowfore-cigarettestobepromotedtoadultsonlineasanalternativetosmokingcouldbeeffectiveiningmessagestoreachmoresmokersincludingthosenotactivelylookingtoswitch,whileminimisingtheriskofyoungpeoplebeingexposedmessagesTRPRandASAshouldbemodifiedsoinformationpromotinge-cigarettesaslessharmfulalternativescanbeproactivelytargetedtowardssmokers.TheGovernmentshouldallowmoreagegatedadvertisingchannelstoshowmessagesthatpromotevapingasalessharmfulnicotinealternativeforsmokers.Inordertoencouragesmokingcessation,itwon’tbeenoughtotargetsmokersalonethereisaneedtotackleharmmisperceptionsamongthegeneralelvesAsDemosssinformationaboutsmokingandvapingfromfriendsandfamilyThismeansitiscrucialthatsmokers’friendsandfamilyhaveanaccurateunderstandingoftherelativeharmsofvapingsotheycanbeinabetterpositiontoencouragesmokerstoswitchandalsoavoidactivelydiscouragingthem.E-cigaretteadvertisementsonTVthatpromotemessagesabouttherelative“healthfulness”of15.uk/government/uploads/system/uploads/attachment_data/file/978513/tobacco-packaging-guidance-great-britain-april-2021.pdf16/ntr/article-abstract/17/7/870/102611317/ntr/article-abstract/17/7/870/102611318.uk/static/uploaded/545851fd-cd02-4b1b-a3d950d3886a438d.pdf19Mackenzie,PandDawson,A.MythsandMisinformation:Mappingthebarrierstosmokingcessationandtheuptakeofnicotinealternatives.Availableat:https://demos.co.uk/project/myths-and-misinformation-mapping-the-barriers-to-smoking-cessation-and-the-uptake-of-nicotine-alternatives/e-cigarettesincomparisontotraditionalcigarettes,havebeenfoundtomakesmokersmoreinterestedintryinge-cigarettesthane-cigaretteadsthatdon’tpromotethismessage.20TheGovernmentshouldexpandthelistofadvertisingchannelsonwhichgovernmentapprovedswitchingmessagescanbepromotedsomorepopularformsofmedia,likeTV,canbeusedtoresponsiblypromotevapingasalessharmfulsmokingalternative,andcontainhealth-focusedmessagingencouragingsmokerstoswitch.ModifyingCAPregulationswillnotonlyallowthesesmokersbutalsotheirpossibleAgainthisapproachisactivelybeingdiscussed.TheKhanreviewhascalledforadvertisingregulationstobemodifiedsomoresmokerscanseee-cigarettesbeingpromotedaslessharmfulproducts.21Modifyingadvertisingregulationsisnotwithoutrisk-unliketargetedmarketing,non-smokerswillbeexposedtotheseadvertisements.ItiscrucialthereforethatexistingASAregulationswhichprohibite-cigaretteadvertisementsappealingtonon-smokersarestrictlyenforced,withstrongpenaltiesfornoncompliance.Thepromotionoftheseswitchingmessagesshouldalsoberestrictedtoage-gatedadvertisingchannelstopreventchildrenseeingtheseadvertisements.TheOfficeforHealthImprovementsandDisparities(OHID)shouldinvestinpublicinformationcampaignsthatpromotee-cigarettesasalessharmfulsmokingalternative,andretailersshouldbeallowedtosupportthesecampaigns.eratethenumberofsmokersmakingattemptstoquit,theOHIDshouldincreasethenumberofyearlysmokingcessationcampaignsthatpromotee-cigarettesasalessharmfulsmokingalternative.Currently,theStoptobercampaignrunsonceayearandgivessmokersa“challenge”toquitin28days.Througharangeofmediaplatforms,likesocialmediaandradio,thecampaignpromotesmessagesonthehealthandfinancialbenefitsofquittingwhilehighlightingdifferentquittingtools-thecampaignhighlightede-cigarettesasasmokingcessationaidforthefirsttimein2017.22Thecampaignhasmakingquitattemptswith2.3millionsmokersmakingquitattemptssincethecampaignbeganin2012.23Muchofthissuccesscanbeattributedtotheuniquebehaviouraleconomicsandpsychologicalinsightsthatunderpinthecampaignwhichaimtomaximisethelikelihoodofsmokerschangingtheirbehaviour.24ThesecampaignsneedtohappenmorethanjustonceayeariftheGovernmentistogetmoresmokerstoquit.ASAregulationscurrentlyprohibite-cigaretteretailersfromprovidingcustomerswithpromotionalinformationone-cigarettes,preventingthemfromsupportingGovernmentsmokingcessationcampaigns,despitethesecampaignsthemselvespromotinge-cigarettesasalessharmfulsmokingalternative.Toincreasereach,shopssellingvapingproductsshouldbeallowedtosupportandpromotecampaignstotheircustomers.Retailersareavaluable,untappedsourceofsmokingcessationinformation-researchbyUKVIAfoundthatspecialistvapeshopsarethemainsourceofadvice(49%)forsmokerslookingtoquit.25TheGovernmentcannotcontinuetomissopportunitiestoreachsmokerswithswitchingmessages.TheOHIDshouldcreatea‘vapingfacts’websitesohealthprofessionalshavetheknowledgetheyneedtocorrectlyassessrisks.cessationplan,anditisvitalthattheyhaveanaccurateunderstandingoftherelativeharmsofsmokingalternatives.A2015studyfoundthatthetyofsmokersratedphysiciansasthemosttrustworthysourceofinformationontherelativehealthrisksofvapingincomparisontosmoking.26TheOHIDshouldcreateavapingfactswebsite,includingfactsontherelativeharmsofvapingandworktopromotethistohealthprofessionals.bytheKhanreviewandhasbeenpioneeredinNewZealand,27wherevapingfacts.health.nzprovidesbalancedanddetailedinformationontherelativeharmsofvapingand20/content/23/suppl_3/iii3121.uk/government/uploads/system/uploads/attachment_data/file/1081366/khan-review-making-smoking-obsolete.pdf22/article/news/stoptober-campaign-backs-e-cigarettes-for-the-first-time#:~:text=The%20annual%20Stoptober%20campaign%20is,of%20the%20risk%20of%20cigarettes%E2%80%9D.23.uk/government/news/smokers-encouraged-to-take-part-in-stoptober-as-they-report-smoking-more-during-pandemic24/pmc/articles/PMC3929003/25https://www.ukvia.co.uk/first-time-vapers-value-specialist-advice-in-helping-them-quit-conventional-cigarettes/26/science/article/pii/S221133551500148527.uk/government/uploads/system/uploads/attachment_data/file/1081366/khan-review-making-smoking-obsolete.pdfnicotine,andoffersadviceonusinge-cigarettesasatooltoquitsmoking.TheNHShasstartedtodevelopasimilarwebsite,however,thereisscopeforittoprovidemoretailoredinformationandadviceforhealthprofessionals.28AsimilarwebsiteintheUK,promotedthroughNHSEngland,couldhelphealthwhilesupportingpatientstryingtoquitsmoking.adequatelytrainedandencouragedtofollowthe2021NICEguidanceonprovidingadviceone-cigarettestosmokers.ThelatestguidancefromTheNationalInstituteforasaneffectivecessationoptionandrecommendsthathealthprofessionalsandthoseprovidingstop-smokingservicesofferadvicetopatientsonusinge-cigarettestoquit.29TheKhanreviewhasurgedtheNHStoincentiviseitsservicestoimplementtheNICEguidanceonstoppingsmokingsohealthprofessionalscanbettersupporttheirpatientswhosmoke.30Providingclinicians,includingdoctors,nursesandpharmacists,withtrainingonthisguidancecouldfurtherhelphealthprofessionalsbetterassesstherelativerisksofvapingandmakethemmorelikelytoperceivee-cigarettesasalegitimatetooltohelpsmokersquit.GovernmentshouldworkwithMHRAtofindwaystomakeamedicinallylicensedvapeproductavailableassoonaspossiblewithoutcompromisingonsafetyHavingecigarettesavailableonprescriptionisalsolikelytohelpsmokerstoswitch,particularlythosefromlowersocioeconomicgroups.Amedicallycertifiedproductmayreassuresmokersaboutthesafetyofe-cigarettes,aswellasmakingthemavailabletothoseentitledtofreeNHSprescriptions.Weknowpriceisakeyfactorinsmokingbehaviour:researchfromtheUniversityofOxfordfoundthatokerspreferecigaretteswhentheyarecheaperthantheirusualtobaccocigarettes,suggestingthatthecomparativelylowcostofe-cigarettesmakesthemmoreappealingtosmokers.35TheGovernmentshouldworkwiththeMHRAandindustrytocertifymedicinallylicensedvapingproducts,allowinghealthprofessionalstoprovidee-cigarettestosmokersonprescription.Healthprofessionalsareunderstandablymorelikelytofeelconfidentencouragingtheirpatientswhosmoketoswitchiftheycanprescribethemaproductthathasgonethroughrigoroussafetychecks.31WhiletherearenomedicallyapprovedvapingproductscurrentlyavailableintheUK,theGovernmenthasannouncedplanstobecomethefirstcountrywithNHSprescribede-cigarettes.32TheMRHAhasalsoexpressedaninterestincertifyingproductsformedicaluseandhasencouragede-cigarettecompaniestoapplyforamedicallicence.33,34The28FortheNewZealandvapingfactswebsitesee:Vapingtoquitsmoking,VapingFacts.Availableat:https://vapingfacts.health.nz/vaping-to-quit-smoking/(Accessed:January10,2023)andfortheNHSwebsitesee:(nodate)NHSchoices.NHS.Availableat:https://www.nhs.uk/better-health/quit-smoking/vaping-to-quit-smoking/(Accessed:January10,2023).29.uk/guidance/ng209/chapter/Recommendations-on-treating-tobacco-dependence#support-to-stop-smoking-in-secondary-care-services30.uk/guidance/ng209/chapter/Recommendations-on-treating-tobacco-dependence#support-to-stop-smoking-in-secondary-care-services31/analysis/is-an-e-cigarette-a-medical-device/32/article/news/uk-medicines-regulator-to-approve-e-cigarettes-for-medical-use33Kent,C.Englandcouldbegintoprescribee-cigarettesasmedicalproducts.MedicalDeviceNetwork,October2021.Availableat:https:///analysis/is-an-e-cigarette-a-medical-device/(accessed11/08/2022)34.uk/government/uploads/system/uploads/attachment_data/file/1081366/khan-review-making-smoking-obsolete.pdf35https://www.ndph.ox.ac.uk/news/study-suggests-how-to-make-e-cigarettes-more-appealing-to-reluctant-tobacco-quittersREDUCINGREDUCINGHEALTHINEQUALITIESIntegratedCareSystems(ICSs)shouldmakesmokingcessationakeystrategicaimwithafocusonreducinghealthinequalitiesbetweensmokers.IntegratedCareSystemsarecurrentlybeingestablishedacrossEngland,withtheaimofbringingtogetherstakeholdersataregionalleveltostrengthencollaboration,improveoutcomesandreducehealthinequalities.Thesegroupsshouldmakesmokingcessationakeystrategicaimwithafocusonreducinghealthinequalitiesbetweensmokers.GreatercollaborationbetweenNHSservices,localcouncilsandcommunitygroupswillhelptocreateabetterunderstandingofthesocioeconomicdisparitiesthatexistamongsmokersinregardstosmokinguptake,willingnesstoquit,andsuccessfulquitattempts.Thiscollaborationshouldalsohelpfindareaswherethesedisparitiescanbeaddressed.Encouragingtheuseofe-cigarettesasoneofseverallessharmfulnicotinealternativesshouldbeakeypartofthisstrategy,withaparticularfocusonunderstandingandaddressingthesocioeconomicbarrierstoswitching.Demospollingsuggeststhatsmokersfromlowsocioeconomicgroupsaremorelikelytobelievemythsabouttherelativeharmsofnicotineandvaping.36Therefore,akeyaimhereshouldbetotacklemisperceptionssurroundinge-cigarettesbyensuringthatallsmokershaveequalaccesstoaccurateandreliableinformationontherelativeharmsofvaping,andmakingthisinformationavailablefromawiderangeoflocalndorganisationsLocalauthoritiesshouldworkwithstopsmokingservicestoextendtheprovisionoffreeSwaptoStoppacksindeprivedcommunitie