Official Report: Minutes of Evidence

The Chairperson (Ms Kimmins): I welcome the Chief Medical Officer (CMO), Professor Sir Michael McBride, and, from the Department's health improvement policy branch, Bryan Dooley and Karen Oldham. Good afternoon. Thank you for your patience. We ran over time a wee bit. I invite you to make your opening remarks.

Professor Sir Michael McBride (Department of Health): Thank you for the invitation to attend this afternoon to brief you on the UK Government's tobacco and vapes Bill. As you know, the Department has already advised the Chair and Deputy Chair that the Bill has not yet been introduced at Westminster, so that restricts the detail that we can provide on the actual draft Bill at this point; it is going through the drafting stages. I want to emphasise that I will be happy to come back to provide a further briefing to the Committee when we have more detail on the Bill.

As we know, smoking kills. Fourteen per cent of the Northern Ireland population over 16 continue to smoke, which equates to 211,000 people. We know that many smokers want to quit but simply cannot due to an addiction to nicotine that started at a young age. We know that approximately two thirds of those who have ever smoked regularly started smoking regularly before the age of 18, and, across the United Kingdom, over 80% started before they turned 20. We also know that two thirds of smokers will die directly as a consequence of smoking and that smoking is a life-limiting addictive habit.

As you know, the Department's tobacco control strategy includes the objective of a tobacco-free society, and while we have made very good progress since that was published back in 2012, more work needs to be done. The Westminster Parliament is about to debate a Bill that, if passed, would produce enormous public health benefits. Minister Swann, with the unanimous support of the Executive, has sought our inclusion in that Bill, subject, of course, to Executive consideration and agreement.

The Bill's headline smoke-free generation measure will make it an offence for anyone who was born on or after 1 January 2009 to be sold tobacco products. That new law would have the potential to result, in time, in a generation who are free from the misery that tobacco addiction brings. In addition, we expect that the Bill will provide a number of regulation-making powers aimed at addressing the concerning increase in youth vaping that has been seen in recent years.

Why do we need such measures? Put simply, smoking increases the risk of 50 serious health conditions. For example, it accounts for 70% of lung cancer cases and one in four of all cancer deaths. Smoking impairs lung function and is estimated to cause nine out of 10 cases of chronic obstructive airways disease. Smoking substantially increases the risk of cardiovascular disease, heart attacks and strokes, and it increases the risk of premature birth and low birth weight. People with serious mental health conditions die 10 to 20 years earlier, and the biggest single factor in that is smoking.

Smoking is a major cause of health inequalities. In Northern Ireland, the incidence of lung cancer is two and a half times higher in the most deprived areas than it is in the least deprived areas. Smoking-attributable deaths in our most deprived areas are double those in the least deprived areas. In summary, smoking remains the UK's biggest preventable killer, resulting in 80,000 deaths a year in the UK and 2,000 locally. Over the last five years, approximately 12% of all deaths can be attributed to smoking tobacco.

In 2019-2020, Northern Ireland hospitals spent £218 million treating smoking-related conditions. In the same year, there were 38,617 smoking-attributable hospital admissions. The facts are clear. The World Health Organization (WHO) has stated:

As members will know, in January 2023, New Zealand was the first country to bring forward legislation restricting the sale of tobacco to anyone born after a specified date. While its new Coalition Government recently repealed those measures, we understand that that was due to taxation gaps rather than a concern about the effectiveness of the measures.

A review taken forward in 2022 by Javed Khan OBE recommended a smoke-free generation for England. Dr Khan referred to the proposal as a critical intervention. In his report, he said:

Critics may argue that the measures are an example of public health interference or nanny statism and that adults should get to choose. In response to that, I emphasise that the measures do not interfere with today's adult smokers; rather, they seek to reduce future access to tobacco for children currently aged 15 and younger so that they can break the cycle and avoid the generational harm that smoking brings. I cannot and do not believe that any of us wishes for our children or our grandchildren to have a choice to access an addictive product that will very likely end up killing them.

The consensus response to the consultation in Northern Ireland pointed to high levels of support for the measures — the highest across the UK — with 79% in favour of the proposals. I have heard pro-smoking commentators make comparisons with the legal age at which young people can do other things such as vote, drive a car, join the army or purchase alcohol, but none of those activities will kill two thirds of participants. Smoking poses a unique threat to public health and, in my professional view as Chief Medical Officer, undoubtedly requires the strongest of interventions.

Estimates in England show that smoking costs the economy about £17 billion a year, whereas the tax raised in duty revenue is approximately £10 billion a year. The British Heart Foundation recently estimated that the cost of tobacco to society here in Northern Ireland is £400 million annually. Every penny spent dealing with tobacco-related harms is entirely avoidable and represents a huge opportunity cost to our health service and a financial cost to taxpayers. The costs of smoking to our economy and wider society are unacceptable. The costs to our health service are unacceptable. The human costs of smoking to families and people in Northern Ireland are simply unacceptable. We now have a groundbreaking opportunity, subject to the Assembly's consideration of the Bill in due course, to change that for the next generation.

I will move quickly to vaping, because I am conscious of members' time. Vaping rates amongst young people here continue to rise. Data from the recent young persons behaviour and attitudes survey showed that one fifth of young people have used an e-cigarette at least once. Those in older age groups are more likely to have reported ever using, with findings ranging from 6% of those in year 8 to 44% of those in year 12. Overall, e-cigarette use among young people rose from 5·7% in 2016 to 9·2% in 2022. However, amongst year 12 pupils, the growth in reported use is particularly concerning: 11·7% to 23·6%.

We know that e-cigarettes may have a role in helping some people to quit smoking, but the long-term harms of continued use are unknown. The Institute of Public Health recently took forward a rapid review of evidence on behalf of the Department. It is still in draft form, but we will share that with the Committee in due course. Early findings confirm that vaping acts as a gateway to tobacco smoking among young people. That substantiates my view and advice as Chief Medical Officer that measures to address the appeal of those products to children are justified.

According to the World Health Organization, consumption of nicotine in children and adolescents has deleterious impacts on brain development, leading to long-term consequences for brain development and, potentially, to learning and anxiety disorders. The UK Command Paper raised concerns about some of the other components and ingredients of vapes, which, when heated, can produce toxic compounds. The long-term health impacts of inhaled colours and flavours are unknown, but they are unlikely to be beneficial. In addition, there are growing concerns about the significant social and educational harms of vaping, with increased numbers of post-primary-school children at risk of disciplinary action, including suspension, as schools attempt to deal with the numbers vaping on school premises.

The UK Government announced that the Bill will include regulation-making powers to restrict flavours, packaging and point-of-sale displays of nicotine and non-nicotine e-cigarettes. They have indicated an intention to bring forward legislation that would enable regulation across the UK. Any subsequent regulations of that nature would, of course, be subject to further consultation. The UK Government also intends to address legal loopholes in relation to non-nicotine vapes and distribution. The exact detail of the regulation-making provisions will be shared with the Committee once the Bill is finalised, which we expect to be imminently.

Support for the proposed vaping measures in the consultation was highest in Northern Ireland, with 75·6% of respondents in Northern Ireland supporting a restriction on vape flavours and 85·3% supporting a restriction on the display of vapes. The measures are aimed primarily at protecting young people by addressing the unacceptable and increasingly blatant marketing of those products to children.

It is our expectation that the Bill will be introduced at Westminster imminently. Following that, a legislative consent memorandum will be laid before the Assembly, and a copy of the Bill made available to the Health Committee as soon as possible to inform its consideration and report. As I said at the outset, I shall be happy to return to the Committee and give a further detailed briefing at that time.

We have a once-in-a-generation opportunity now. I ask for the support of the Committee as this proceeds through the Assembly by legislative consent motion.

The Chairperson (Ms Kimmins): Thank you. That was comprehensive and probably answered some of the questions that we had thought of. The pace at which this can be introduced will cause concern in respect of the ability of Members and the Assembly to look at it in detail. There will probably be more questions once it is published.

I would like to understand a wee bit more about what engagement the Minister has had with the British Government on the matter. Has there been any engagement with the Southern Government? Coming from a border community, I am very conscious of the fact that, in areas that are within a walking distance of a couple of minutes of each other, there could be two very different sets of rules and regulations. We want to try to align as best we can and to have those discussions. Have you any information around that?

Professor Sir Michael McBride: I will make a few introductory comments, and then Karen or Bryan can perhaps pick it up.

I reassure the Committee that there has been extensive engagement at Chief Medical Officer level between myself and my counterpart in the Republic of Ireland and between the four UK Chief Medical Officers. We, collectively, support this as an important policy opportunity from a public health perspective. There has also been extensive engagement between the respective policy teams, including meetings between the policy teams in the South, Scotland, Wales, England and Northern Ireland. There has been very effective engagement. Indeed, there has been effective ministerial engagement. There is determination on the part of Ministers to seek to progress this, subject to consideration, by legislative consent motion in their jurisdictions, so as to take it forward on a UK-wide basis.

Do you want to add to that, Karen?

Ms Karen Oldham (Department of Health): Yes. I would point out that conversations around this predate the return of the Assembly. The consultation exercise was launched in October, at which stage we were involved in discussions with the UK Government at official level. The permanent secretary agreed to our being included in that consultation, with the caveat that the taking of decisions would be subject to the return of the Assembly.

Since then, with the return of the Assembly, we have been working at pace to update our Minister, because the Bill is getting to the stage of being finalised, when we need to make our intent and wishes known. Our Minister has been engaging with the UK Government on several levels, through both correspondence and, in the past couple of weeks, meeting the Secretary of State for Health and Social Care to discuss the matter.

We have close working relationships with the South, too, at official level. We meet officials there regularly and know that they face challenges that are similar to ours. In fact, they had a consultation that closed in early January. We met them a few weeks ago to discuss where they were with that. They have not published the outcome of the responses to their consultation, but it looked at very similar issues to ours, including age of sale and vape flavours. There are a few different aspects to their consultation, but there is definitely a lot of overlap, so we are aware of parallels and similarities.

You made a point about border communities. We do not know exactly what the Republic of Ireland will do with its consultation. If it were to take on a slightly different model — some people have discussed raising the age of sale to 21, and there has been an appetite for that among some of the stakeholders in the South — I do not think that that would be the end of the world, because the smoking initiation age is in the late teenage years. Therefore, if someone living in Newry was not legally able to buy cigarettes there, and the South had moved their age of sale to 21, there would still be that benefit because, by the time a person gets past 21, the age of initiation has largely passed.

The Chairperson (Ms Kimmins): It is good to know that those discussions are happening. I would just hate to think that we were doing all of this in isolation. Something that will be beneficial to the health of our public is key. It is important that we align on it where we can, because we live on one island.

I have one or two other questions, and I know that other Committee members will have some. As you highlighted through your figures, Michael, the increase in youth vaping is shocking; it is snowballing. For all the reasons that you outlined, vaping is very attractive, but it is also very addictive, and that is very concerning. What engagement has there been with young people on that, if any?

Professor Sir Michael McBride: There has not been any direct engagement with young people. There has been extensive engagement with the Public Health Agency (PHA), youth groups and schools, particularly on vaping. As some Committee members may have picked up this morning, the PHA has launched a series of leaflets and posters about youth vaping, as well as an information sheet to empower parents to have discussions about vaping with their children. There will be further engagement.

Ms Oldham: This is not specifically in relation to the consultation or these particular proposals, but, early last year, the Public Health Agency carried out research in post-primary schools, which included surveys of over 7,500 post-primary children, focus groups with young people and interviews with staff.

The analysis is happening in stages, but we have some preliminary results that include the significance of flavours in attracting young people to vaping. There has been quite a bit of engagement, and that analysis is under way, but that has helped to inform the series of resources that Michael referred to that have been published today.

Mrs Dillon: I have a quick point, because you have answered most of my questions. I think that there is an opportunity here. You talk about the Public Health Agency's leaflets, but, let us be honest, most of those young people are not reading them: that is the reality. A lot of their parents do not necessarily know that they are vaping. I declare an interest as the mother of a 15-year-old daughter, who, thankfully, hates it, as do I, and I detest smoking. My interest is declared. In all seriousness, there is an engagement piece to be had with young people, and it is not necessarily a piece for the Department.

There is an opportunity to work with schools. You mentioned disciplinary action. Schools have choices and do not always make the right ones. Disciplining children in those circumstances is not always the right thing to do. Children are also suspended from school for having certain haircuts and wearing jewellery, and that is not necessarily the right action to take. This is the wrong Committee for that conversation, but I make the point that there is an opportunity to engage directly with schools, educational establishments, the Education Authority and youth services that have direct contact with young people and can engage with them in a way that is meaningful to them. Colin will know more about that than most of us.

As we say about all these things, doing what we have always done and expecting different outcomes is foolhardy. We need different ways to engage with young people to find out why they vape. We have said that it has attractive smells and tastes — all of which I find disgusting — but some young people choose not to vape. Why do some young people choose to do it? The only way to find that out is to have the conversation with them. Some of that can be done through the schools and some through the other educational establishments and services that deal with young people. It is worth having those conversations, because there is another piece to it. The Committee will look at what is published, but my position is to test them. That is a personal position not a party position.

Professor Sir Michael McBride: You make a very valid point about engagement with young people. There is a significant behavioural science piece as to what underlines young people's choices and decisions. I was once young myself, believe it or not, and we know that young people tend to stress-test boundaries and to experiment. The difficulty is that, if you experiment with nicotine vapes, you become, as you correctly said, addicted. Taking an enforcement and disciplinary approach to an addiction is most likely not the most effective way forward. I agree with you. There is already good engagement between the Public Health Agency and education authorities and other bodies. Obviously, it will be very important that we continue to progress those relationships.

Mrs Dillon: Helping them to understand that is probably the approach. It is not about telling schools what to do or how to do their own business, but it is about educating them as well.

Miss McAllister: Thank you for the briefing so far. It is an opportunity that we should take, and I look forward to seeing a non-smoking generation. I hope that I will live long enough.

On the Bill's content, I appreciate the broad outline that you gave in the presentation and the papers, but there is one area that I want to explore. For example, Northern Ireland Chest Heart and Stroke (NICHS) advocates for enforcement. That might not strictly be for the Department of Health, but, in preparation for the upcoming Bill, is enforcement as it currently stands enough? In my constituency office, I deal with so many parents who are so sick of standing in shops arguing with the people behind the counter about selling to underage young people. It is about getting councils to enforce it. It takes a long time. We have had successful outcomes in my constituency in very few cases, despite the volume of complaints that we receive. What work is happening on the enforcement side in preparation?

Professor Sir Michael McBride: You raise an important point, and I will probably want to pick up with Bryan on some of the detail of it. I reassure you that councils sit on the tobacco control strategy and are full members of that. Obviously, you know that the environmental health teams in district councils are responsible for enforcement in Northern Ireland, so they are aware of, insofar as we are aware of it, the objective of the Bill and are supportive of that. Once we know the actual detail of the Bill, such as the operational impacts, we will engage further with councils in considering what impact that will have on the current resources, for instance, that they have available for enforcement. Enforcement is a really important point, and I also get that correspondence, as the Department does, on concerns about enforcement. The Public Health Agency funds, through the Department, test purchasing officers, who will try to stress-test whether or not retailers who are registered on the tobacco register are actually complying with issues around displays, legislation, age of sale, etc.

Miss McAllister: Can you send them my way?

Professor Sir Michael McBride: I do not currently have details on the number of fixed penalty notices or fines issued. Karen, do you know?

Ms Oldham: I think that we have some details on the fixed penalties over the last six months. I was not sure whether you were talking about the tobacco or vaping side of things.

Miss McAllister: Both.

Ms Oldham: The number of offences detected in relation to tobacco has dropped, whereas the number of vaping offences has risen quite sharply. You mentioned Northern Ireland Chest Heart and Stroke, and I think that I am right in saying that that body is an advocate for a register for retailers of e-cigarettes, and, whilst we have no immediate plans to do that and that will not be addressed through this legislation, that is something that, domestically, we might explore in due course. We have that register for tobacco, and some of the councils say that it helps them.

One of the challenges with vaping is that there is such a variety of retail outlets for these things. It can be all kinds of unusual businesses that sell them. That has been raised by our stakeholders. One advantage of the measures in this Bill is that the aim is to reduce that marketing and tackle that marketing of the products towards young people. We hope that, in time, there will be less attraction there and, therefore, less test purchasing, etc needed in the future.

Miss McAllister: Thank you. I will maybe examine a bit more the PHA and the test samplers who go in, because all of us are getting so much correspondence about vapes, in particular, and shops selling them to children in uniform who look really young. It is deeply frustrating, so I look forward to seeing this.

Mrs Dodds: I have two very quick questions. I am a little bit concerned about being asked to look at a Bill or to support an LCM on a Bill with very little time for scrutiny. It is important that we get as much information as possible as quickly as possible. You mentioned the response to the consultation from Northern Ireland. Do we know specifically how many responded from Northern Ireland?

Professor Sir Michael McBride: Yes. Northern Ireland made up 4·5% of the total UK responses, so we punched well, well above our weight, such was the level of public interest. The number was over —.

Ms Oldham: It is 1,221.

Mrs Dodds: That is significant.

Ms Oldham: It is. That is exactly right. We punched well above our weight in terms of the responses, and the support for the measures is also significantly higher in just about all the areas from Northern Ireland.

Mr Bryan Dooley (Department of Health): There was significant promotion when the consultation came out to make sure that stakeholders were aware. I think that they wrote to the Department of Education, and parents were informed as well to see if they could provide their opinion.

Mrs Dodds: I do not have an issue with the Bill's aim or objective. I want to see how the Bill works and to see its content. You may have said this and I missed it — forgive me if so — but will there be regulations in terms of the vapes themselves in the Bill? In other words, I mean the content of vapes. I remember doing a lot of work in the European Parliament on the tobacco issue, and it left vaping completely regulation-free. Will there be regulations in the Bill around vaping, what you can put in vapes and the impact of flavours in vapes, for example, that encourage more people to do it more often? Will there be something about that in the Bill?

Ms Oldham: Flavours and packaging restrictions were some of the things that were consulted on. The commitment is to explore that further. There was quite a lot of support from Northern Ireland for restrictions around flavours. There were concerns amongst some of our stakeholders about the impact of heating those flavours along with the other contents that can be in vapes. I am not sure whether anything else covers any of the other chemicals, but, certainly, flavours form a big area of concern at the minute.

Mrs Dodds: Finally, the Bill has not made it out of the machine yet. Do we understand when the Bill will make it out of the machine? Given the very short time that this Parliament has to run, what is your honest assessment of anything being done in relation to the Bill? [Inaudible.]

Mrs Dodds: Maybe that question is too political.

Professor Sir Michael McBride: It is above my pay grade. The word that we are hearing consistently is "imminent". It is expected imminently. There is a high level of commitment to it from Health Ministers across the UK and, as you understand, the Prime Minister. There is a very significant public commitment right across the United Kingdom, and, particularly, significant support for it in Northern Ireland. I hope that there will be sufficient time to introduce the Bill and have it work its way through the parliamentary process and for the Bill to be fully and comprehensively considered and scrutinised by the Northern Ireland Assembly. I hope that we have an opportunity to be on the right side of history in this matter and that we can look back on it in five or 10 years as a potential tipping point in relation to our commitment to having a generation of individuals free from addiction to tobacco.

The Chairperson (Ms Kimmins): The ban on smoking indoors was a huge change. I remember seeing the change as an 18-year-old at university. At the start, people probably were quite reluctant about it, but it is just the norm now. That played a part in reducing the number of people who smoke as well. Anything that moves us in that direction will be —.

Professor Sir Michael McBride: We were looking at some of those statistics before we came to the meeting. When the age of sale was increased in 2008 —

Ms Oldham: It was 2008 here, yes.

Professor Sir Michael McBride: — you saw exactly that point. When we introduce legislation, it basically has a significant downward pressure on the number of people who take up smoking. Legislation matters. Policy is important. Legislation is really important in this space, and we can demonstrate that. I do not have the figures in front of me but —.

Mr Dooley: It decreased illicit activity among 16- to 18-year-olds by about a quarter.

Mr Donnelly: Thank you for the presentation. Anything that reduces the number of people who smoke is absolutely a good thing, and, certainly, we will support it.

I have seen the posters from the Public Health Agency. It is quite [Inaudible.]

It is a good image; it is a strong image of a smoke plume and a hand on a young person's shoulder. It is quite gripping, and, hopefully, that image will get around as much as possible.

People do not appreciate how addictive nicotine is, and that is part of the issue. Initially, when vapes came out, they were seen as the safer choice for smokers. That was a good thing, because it would stop people inhaling combustible tobacco. However, they have now moved into a space where they are being marketed almost as sweets — with pineapple, strawberry and cola flavours and bright colours. When you walk into a newsagent's shop now, there is a wall of the things.

Mrs Dodds: There are shops devoted to them.

Mr Donnelly: Absolutely, yes. There are shops devoted to them. It is crazy how, apparently, completely unregulated it is, for something that is very addictive and, seemingly, marketed directly at young people to get them early and make them lifelong customers. What research has been done into the long-term harms of vapes? Obviously, it is a relatively new product, but is there any research that we can look at and say, "These are the harms that are attributable to this"?

Professor Sir Michael McBride: In my introductory comments, I made reference to the WHO's position in relation to the evidence in terms of the brain development of young people, in particular, and the possibility of that being linked to learning problems and difficulties and anxiety disorders. It is true that smoking and using e-cigarettes is less harmful than smoking tobacco, as you indicated. My position on this and my advice has always been precautionary, in that two fifths of smokers have successfully used e-cigarettes to quit smoking; others, unfortunately, substitute. If, indeed, e-cigarettes have any place, it is only in the short term to help smokers who are addicted to tobacco to quit. There is, however, emerging evidence of potential harm from e-cigarettes. Again, as I said, it is not firm evidence at this point.

Ms Oldham: A lot of the evidence has been contradictory or is not quite in a place yet where we can say firmly that it causes x, y and z. Northern Ireland Chest Heart and Stroke published some information or evidence recently in relation to potential impacts on cardiovascular systems and so on. In the short term, nicotine raises blood pressure and heart rate and does things like that. A lot of the concerns around vaping, in particular, are to do with inhaling hot vapour and the potential harms that go with that, as well as the flavours and the things that we talked about earlier. It is still very much a developing evidence base, but it is right to make the point that, while the long-term evidence is not there, we seem to have enough evidence to show that it is significantly less harmful than tobacco, because the tar in tobacco causes such a significant impact.

Professor Sir Michael McBride: As members will know, the absence of evidence does not mean that there is an absence of harm. Therefore, we need to adopt a precautionary approach.

Mr Chambers: My party fully supports and welcomes the Bill. It will remove a lot of ambiguity around the sale of vapes and the long-term damage that they do. We have moved on a lot from the days when a child could walk into some shops, push a few pennies over the counter and buy a single cigarette, and that is a very good thing. Sometimes, as well, we overlook the impact of the inhalation of smoke on a non-smoker in an enclosed space. I am reminded of the tragedy of Roy Castle, the performer who died. He never smoked a cigarette in his life, but he died from lung cancer, induced by the smoke that he inhaled in the clubs that he performed in over the years.

You gave us a very stark figure. There has always been a myth that the Government are being a bit hypocritical given the amount of tax that they take in: they tell people to stop smoking, but they want the tax. The figure that you gave us of a cost of £17 billion to the health system, while the tax take is £10 billion, kills that myth.

We have all seen the tangible outworking of the ban on smoking in public places and in works vehicles and so forth. When you go into public places now, it is great not to come out with the smell of smoke on your clothes.

Has any research been done? You mentioned that sales are falling. Has any research been done on the medical outcomes of that? Maybe that is very difficult to tie down.

Professor Sir Michael McBride: I cannot point to any specific benefits, at this point, in terms of deductions from the incidence of cardiovascular disease —

Mr Chambers: There are bound to have been.

Professor Sir Michael McBride: — strokes or heart attacks, etc. The difficulty is that it would be quite complex to untangle that. As an ageing society, we are all living longer, and that is a really good thing. However, the problem is that we do not necessarily always live longer, healthier lives. In an ageing population, you will have increased prevalence of cerebrovascular disease, strokes, etc. Certainly, there is no doubt, given the direct harms — think of the strong evidence around lung cancer and chronic obstructive airways disease — that, if we can stop the next generation of young people becoming addicted to tobacco, we should see a tangible impact on a wide range of conditions — more than 50 — that I mentioned in my introductory comments. That would not only be advantageous for the health of the population; it would be advantageous in terms of the focus of the health service and, for the taxpayer, would ensure that we do not spend the money that we currently spend in tragically dealing with the health consequences of smoking tobacco.

Mr Chambers: There may be a bit of work to be done on consistency. Nuala pointed out that, in her area, the council is maybe not as active in enforcing the regulations on smoking. In my constituency, Ards and North Down Borough Council has a very robust programme. You will get a letter from the council. You may say, "Well, they are giving a pre-warning", but, sometimes, that pre-warning is a good thing. The letter will state that a sample is being conducted over the next, say, four months and outline the consequences if you are detected selling tobacco to underage people. The staff member and the shopkeeper will be fined, and that is a good weapon for a retailer to use with the staff to make sure that they check everybody's ID. I think that, if a retailer is caught out — I may be wrong here — on two occasions, they can lose their licence to sell tobacco products. That is a good weapon as well. I think that, in the Department, there is a bit of work to be done to look at which councils produce the best models and which ones are not really doing that.

Ms Oldham: We recently had an audit completed by the Northern Ireland Audit Office on smoking measures. One of its recommendations is about developing quality standards on enforcement. That is something that we will have to look at with the PHA in due course.

Mr Chambers: I think that that would be useful.

Mr Dooley: The other point that you made, about second-hand smoke, was very interesting. Some studies have found that we should maybe focus more on that area than on outdoor smoking. You have children and young people who are basically hostages at home inhaling tobacco smoke.

Professor Sir Michael McBride: That is why, in all this, there has to be balance in terms of the potential unintended consequences. Exposure to second-hand smoke in an outdoor area — a park or whatever — is not ideal but is lower risk. We have research available to us from the University of —

Ms Oldham: Stirling.

Professor Sir Michael McBride: — which makes that very point. We need to be conscious of the health inequalities impacts. If you restrict smoking in too many outdoor places, what happens is that you potentially run the risk of exposing young children whose parents smoke to increasingly higher levels of smoking in the home, which obviously carries a much greater risk. In all this, there is a need for balance and proportionality as we progress.

Mr Chambers: Thank you.

The Chairperson (Ms Kimmins): I have a very quick question, before I bring in Nuala. This is probably not something that you can answer today, but I am interested to know more about vape fumes. They hang about, and you see them for a while after someone has used a vape. I am very interested to find out a bit more about the impacts of second-hand vaping. It is possibly even more harmful than cigarette smoke. It lingers for a long time. I do not know whether it is to do with its density or what it is, but it is something that I always notice, and I often wonder about the potential harm for anybody in the area. Vaping is almost a wee bit more acceptable in public spaces than smoking, so people are not as cautious around that.

Professor Sir Michael McBride: Again, we can update the Chair on that.

The Chairperson (Ms Kimmins): It would be interesting.

Professor Sir Michael McBride: There is some research on that, from Cancer Research UK, for instance. There is some preliminary data suggesting that it is much less harmful, certainly, than being exposed to second-hand tobacco smoke. It is not likely to be harmful, but, again, there is no definitive evidence in that space either, hence the need for caution.

The Chairperson (Ms Kimmins): I go back to the point that you made, Michael, about children and whether, particularly where there are people who have maybe moved to vaping because they are trying to get away from cigarette smoking, there is potential for harm, especially in enclosed settings.

Miss McAllister: I am not contradicting what you are saying, but the point that restricting smoking in more public places might drive it indoors made me think of smoking on hospital premises. Forgive me if that was asked about when I was out of the room, but where are we on having no smoking outside a hospital and in its vicinity? I am talking about having a smoking ban around the hospital area and not just moving people away from the door a wee bit and the smoke goes in the windows anyway. If you are talking about prevention, what about people in hospital?

Professor Sir Michael McBride: I will maybe give you a personal anecdote, which is illustrative of some of the challenges there. Bryan, do you want to pick up the issue of hospital premises?

Mr Dooley: There are policies in trusts where they can restrict it, but we do not have the regulation in relation to that.

Professor Sir Michael McBride: I have had those conversations with individuals smoking on hospital premises in my former roles and responsibilities over the years. All trusts have policies in place about smoking on their premises. Those have been there since 2006, when the legislation was introduced. Much more can be done in that space.

The conversations that I have had with individuals have been useful. I had a conversation with someone who was smoking outside a building, and they said that they had terminal lung cancer and were smoking because they had a short number of months left. I remember that conversation with that lady vividly. I spoke to her every day then as I met her as she was smoking her cigarette outside the cancer centre. Similarly, I have had conversations with individuals who were smoking on hospital premises when they had a relative in intensive care.

In all this — it is back to the issue around schools and the addiction to nicotine — we always need to have balance. Absolutely, health should be signposting the way ahead, and hospitals should be signposting and leading the way, whether it is healthy eating, encouraging exercise and supporting employees, or on smoking. We just also need to be mindful of the human aspects of this, particularly people who have an addiction to tobacco and when they are stressed. We need to be empathetic in how we approach it.

The Chairperson (Ms Kimmins): Thank you all for coming today. It has been very helpful. I am sure that we can pick up this conversation in the coming weeks. We appreciate you coming today. Thank you.

Professor Sir Michael McBride: Thank you very much for your consideration.