Gay: Shuttering Public Health England Bad for Public Health

The axing of Public Health England could have a lasting negative impact on public health.

By George Gay

Reading through the U.K. Vaping Industry Association’s (UKVIA) Aug. 28 statement on “the transferal of responsibilities from Public Health England [PHE] and the future of harm reduction,” I was reminded why the UKVIA has been successful in advancing the interests of vaping and, in doing so, encouraging smokers to switch to a less risky form of nicotine consumption.

In the face of a move by the U.K. government that conceivably could cause a significant setback to vaping, the association refused to engage with the negative. It did what it had to do; it accentuated the positive by performing a well-choreographed verbal sword dance while mentioning only in passing that the blades on the floor could deprive it of a few toes and perhaps much else.

The UKVIA statement was in response to an announcement by the government that, at the end of March, it was to axe Public Health England, an executive agency of the Department of Health and Social Care, and transfer some of its responsibilities, but not its smoking prevention and some other obligations, to a new organization, the National Institute for Health Protection (NIHP). PHE has for a long time supported the use of vaping as a method of helping smokers quit their tobacco habit, and its declarations that vaping is at least 95 percent less risky than is smoking have been widely and confidently quoted in recent years; so the government’s announcement was a significant and potentially negative development.

The UKVIA acknowledged this risk in passing but concentrated on encouraging the government to ensure that the transition of responsibilities from the PHE to other agencies was as smooth as possible. It began its statement, issued under the name of its director, John Dunne, by saying it would like to place on record its thanks for PHE’s considerable contribution to harm reduction and smoking cessation in recent years.

“The independent and progressive stance taken by PHE has undoubtedly improved the health of the nation and saved lives,” it said. “In particular, PHE’s support of vaping as a vital harm reduction tool ensures an admirable legacy of falling smoking rates in the U.K., with all of the associated benefits to public health and the NHS [National Health Service]. PHE’s evidence-based approach provided many adult smokers with the reassurance they needed to explore the full range of smoking cessation options available to them.”

Deflecting attention

Let’s halt the statement there for a moment because I’m sure that a lot of readers will be wondering why PHE is being axed when it has done such a good job. Well, as is mentioned above, PHE’s responsibilities go beyond smoking prevention, and part of its remit has required it, along with other agencies, to engage in the fight against the coronavirus pandemic and the resulting Covid-19 disease outbreak. And since the U.K. government has proved to be scarily incompetent in the face of the coronavirus pandemic but a dab hand at shifting the blame for its incompetence onto others, PHE, one of the more publicly recognizable health agencies, was always going to be at risk.

On Aug. 28, The Guardian, in a leader column, described the decision to abolish PHE during a pandemic as reckless, adding that it was part of the government’s strategy of casting about for scapegoats for its failings during the pandemic. The leader was headed: “[Prime Minister Boris] Johnson’s donkeys have failed the frontline workers they lionized.”

The Guardian wasn’t alone in condemning the government’s action. On Sept. 2, a piece by the newspaper’s health policy editor, Denis Campbell, described how Britain’s doctors and public health experts had warned the prime minister that the abolition of PHE would damage the fight against obesity, smoking and alcohol misuse. “More than 70 health organizations have written to Boris Johnson outlining their fears about last month’s controversial decision to axe PHE, which prompted claims it was an attempt by ministers to deflect attention from their own failings over the coronavirus crisis,” Campbell wrote.

Rearranging the deck chairs

There was no way that the UKVIA was going to be drawn into this dispute and, in its statement, it merely noted that many of PHE’s responsibilities would be overseen by the newly formed NIHP, “which will take a lead role in safeguarding the U.K. from novel health risks.

“The UKVIA completely acknowledges the need for new ways of working in combatting modern challenges and supports the government’s prioritization of public health,” the association said.

“It is further reassuring that Secretary of State for Health and Social Care Matt Hancock confirmed his ongoing commitment to health improvement while announcing the NIHP’s formation. This is a commitment which the UKVIA shares and thoroughly supports.”

You can see the UKVIA’s point. I mean, we are where we are, and there is little point in trying to reason a government with an 80-seat majority out of a position into which it seems not to have reasoned itself. But there is no reason not to have a parting shot, and I think the Liberal Democrats’ health spokesperson, Munira Wilson, had the situation nailed when, according to Campbell’s piece, she said: “Now is not the time to rearrange the deck chairs.”

One of the dangers as I see it is that the government made its decision to axe PHE without having thought through what should happen to all of PHE’s responsibilities, including its role in preventing smoking. In other words, it was rearranging the deck chairs without any idea of where to put many of them; so the worry must be that some will wind up overboard as jetsam.

And it was clear that the UKVIA too was concerned about this aspect of the government-announced changes. “To protect the many successes of vaping in U.K. public health, as well as empowering further positive change in the future, it is vital that this progressive, evidence-based culture continues,” the association’s statement said. “Whenever responsibilities are transferred, there is a risk that invaluable institutional knowledge and memory is lost. This would be to the detriment of the U.K.’s millions of smokers and vapers and cannot be allowed to happen in this case.

“The UKVIA therefore calls upon the custodians of PHE’s former responsibilities, in the event that they are indeed reallocated, to continue their positive approach towards harm-reduction technologies. Independent reviews, studies and statements, all focused on facts rather than hearsay, have been a cornerstone of a successful British vaping industry which supports adult consumers to make a positive change for their health.

“The UKVIA will continue to do its utmost to ensure that adult smokers and vapers have access to the high-quality products they need as well as the reliable information and advice needed to empower their choices. Assistance in this regard from public health bodies is vital to ensuring that the positive potential of vaping is not squandered in the U.K. We look forward to engaging constructively with all public health partners.”

Hoping for the best

I have no idea how this will pan out because there is much going on in the U.K. at the moment that will impinge on health issues. The U.K. government is in the process of breaking—I use the word with care—its final bonds with the EU and trying to sell off the last of the family silver—the NHS—to the highest bidders as part of a trade deal with the U.S., though it remains to be seen whether any nation will want to sign a deal with a country that, as this piece was being written, was openly talking about breaking international law so as to renege on part of the Brexit withdrawal agreement signed by Johnson in January with the EU.

In part of his story, Campbell quoted Wilson as describing the axing of the PHE as “nonsensical.” She is right of course, but only if you assume that the aim of the government is to improve public health, and nothing I have observed in the actions of the government would lead me to believe that it is particularly interested in such munificence. I would guess that if the work of the PHE in supporting vaping and, therefore, smoking reduction, is continued, it will be down to luck, not to the deliberate actions of the government.

Whatever happens, all is not lost in the U.K. vaping sector. The UKVIA is used to navigating the choppy waters of vaping rules and regulations. In March, it wrote to the government asking that specialist vape shops be allowed to stay open during the coronavirus lockdown and requesting support for the industry during and after the crisis was over. It made the point that because such shops had bucked the trend of high-street attrition, and because they provided much-needed specialist advice, they were the source of economic and health benefits to the communities they served.

The UKVIA won the backing of Sir Kevin Barron, former MP and honorary fellow of the Royal College of Physicians, and further argued that closing vape stores would be a potentially counterproductive move that could place further strain on the already overstretched NHS. Due to the stress caused by the coronavirus pandemic, vapers who could not access their specialist stores and the advice available there were at risk of falling back onto cigarettes, which were more readily available.

On this occasion, the UKVIA was not successful, in part I would guess because the government would have taken the view that closing specialist shops would not have prevented vapers from obtaining their products, or at least substitutes for their usual products, in the food and corner shops that were allowed to stay open, and, for those with internet access, via online suppliers.

But though it was not successful, the UKVIA again chose not to embrace the negative. While continuing to lobby the government to review its decision on vape stores, it switched its focus to keeping its members informed about their obligations under government guidelines and the opportunities still open to them, such as online or home delivery services in the case of retail outlets. And following a report in a national newspaper that a vape shop owner had been arrested by police after keeping their retail outlet open despite the government directive, the association issued another note urging vape stores to adhere to government guidance to remain closed during the current lockdown.

“We understand that we are talking about people’s livelihoods here, but it is paramount that the industry follows the government guidance,” said Dunne. “We have to wait until we get the green light to reopen.”

And the green light was triggered on June 15, at which point the UKVIA praised the U.K.’s vaping businesses for the responsible approach they had taken during the 10-week lockdown. In a statement issued at the time, the association said it believed that the entrepreneurial spirit that had seen many vaping companies transform their business models overnight would mean they would be well placed to bounce back.

“The response from the industry to the challenging conditions has been both staggering and exemplary,” Dunne was quoted as saying. “I know that our members that make up a large share of the vaping market have been working around the clock to provide online and home delivery services to the 3.2 million vapers across the country.”

And this strategy has apparently worked for both vapers and vaping businesses. Feedback from UKVIA members indicates that few stores closed permanently because of the lockdown. Overall, demand is said to have stabilized, though it is probably inevitable that some vapers will have returned to smoking, either temporarily or permanently. Part of that demand has almost certainly shifted permanently to different supply streams.

Many retailers saw big increases occur in their online sales, and it must be assumed that at least some vapers who discovered home delivery services during lockdown will stay with such services. It is difficult to know how this will pan out over the long term, but there are reasons to be positive. The sorts of services offered by high-street retailers have probably appealed mainly to novice vapers, and with about 3 million vapers and 7 million smokers in the U.K., the potential for recruiting more vapers to high-street shops must be high.

Having said that, the uptake of vaping in the U.K. has slowed in recent years and, for reasons that will be familiar to readers of this magazine, it is proving harder to persuade large numbers of smokers to move to vaping. Concerns around this situation can be discerned in at least two of the UKVIA’s four strategic objectives: to reassure smokers about vaping so they continue to see vaping as the best way to quit their smoking habit and to give confidence to existing vapers about vaping so that they don’t go back to smoking or other alternative ways to break their former smoking habit.

Another objective is to heighten the understanding among the political/public health community of the positive impact that vaping has had, and continues to have, and highlight the potential adverse impact of vapers returning to smoking and smokers not transitioning across. This brings us back to the beginning of the story by raising the question of whether the realization of this objective will be made more difficult if the UKVIA has to start afresh with a new public health body.

This story can be found in Issue 5, 2020 of Vapor Voice.