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Xand Van Tulleken: Hello and welcome to season four of public health disrupted with me, Xand van Tulleken. I'm a doctor, writer and tv presenter and at this point, my co host would normally leap in and say, and me, Rochelle Burgess. But I'm delighted to announce that Rochelle is a officially on maternity leave, enjoying time off with her wonderful new arrival. So we're really looking forward to having her back for season five in 2025. But in the meantime, it's just me.

This podcast is about public health. More importantly, it's about the systems that need disrupting to make public health better. So join us each month as we challenge the status quo of the public health field, asking what needs to change, why and how to get there.

The World Health Organisation highlights the tobacco epidemic as one of the greatest public health crises in history, claiming over 8 million lives annually. And over 7 million of these deaths stem from direct tobacco. Over 7 million of these deaths stem from direct tobacco use, while around 1.3 million are due to second hand smoke exposure among non smokers. The scale of the human and economic tragedy that tobacco imposes is shocking, and it's also preventable. In today's episode, our experts are going to be discussing the increasing political and public support for a smoke free generation, proposed legislative changes and their potential impact on smoking rates and improving the health of the public in the UK. We'll also be covering the alarming rise in vaping among children, current evidence on vape safety, their effectiveness in reducing smoking and their use by individuals who have never smoked, in fact, including me. so we'll get on to that.

Our first guest today is Professor Jamie Brown, Director of the ×î×¼µÄÁùºÏ²ÊÂÛ̳ Tobacco and Alcohol Research Group. Jamie's passion lies in smoking cessation research, driven by behavioural science. He co-leads a CRUK research programme aimed at understanding the factors influencing smoking, smoking cessation and vaping on a population level. With over 300 publications, Jamie has a particular focus on real-world monitoring and evaluation of national tobacco control policies, and smoking cessation treatments. He is a co-author of Theory of Addiction, co-Regional Editor at the journal Addiction and a sign-off Editor at Cochrane.

We’re also delighted to welcome our second guest, Hazel Cheeseman, who will soon become the chief executive of Action on Smoking and Health (ASH) on October 1. Hazel has extensive experience in health and social care policy both in the UK and internationally. Currently, she oversees ASH’s policy development work. With her background in health and housing policy, Hazel has specialized expertise in local government and local-level policy implementation. She also coordinates two coalitions focused on reducing health inequalities caused by smoking: The Smoking in Pregnancy Challenge Group and the Mental Health and Smoking Partnership.

Jamie and Hazel, you are two perfect guests to discuss this topic and public health in general. Thank you so much for being here. Jamie, can I start with you? Can you briefly explain the importance of the tobacco and vapes bill? What's being proposed? What's the impact going to be on smoking? How is it going to improve our health in the UK, if at all?

Professor Jamie Brown: Hello, thanks for your kind introduction and very much for, having me on as well. Great pleasure to be here. so, in answer your question, first of all, I think, it's helpful to set the scene for the UK a little as well, I think, to understand the urgency and seriousness of the situation. So you mentioned global figures, but there are also still about 6 million adults smoking in the UK and each year about 76,000 people die from, smoking. Smoking is also responsible for about half the difference in healthy life expectancy between rich and poor in the UK. and as a result, as you can imagine, smoking puts enormous pressure on our, ah, NHS and social care system. It's a big financial impact due to lost productivity, with, I think, estimated cost to the UK economy in 2023 being about 55 billion. So the last government decided that allowing all these preventable deaths was completely unacceptable and had this ambition for the country to be smoke free by 2030. and that means overall smoking prevalence being less than 5%. Unfortunately, that ambition wasn't going to be realised on the current trajectory. Prevalence is still about 13% of the adult population and has been recently declining by only about 0.5% each year. In fact, a bit less the last year or two, probably, which means we'd have completely missed that ambition with business as usual, which is why the tobacco and vapes bill was so important and had the potential to be one of the most significant public health interventions for a generation. As she said, at the core of the bill was, making it illegal to sell tobacco products to anyone born on or after the 1 January 2009, which would have effectively created a smoke free generation by continuously raising the minimum age for legally purchasing tobacco. so I think in 2027, you did need it to be 19 to purchase and then 20 in 2028. And so on, now we have some excellent evidence that increases, in the minimum age of sale from 16 to 18 in the UK and also, from the US, where in certain places it went up to 18 to 21. And that substantially reduced m smoking prevalence in children and young people. and we saw that, including from some of our own cruk funded research. So, I think that kind of evidence base provides good reason to expect this measure to have a similar impact. unfortunately, I think, as everyone will now know, due to the snap election, the bill didn't pass into law. it had passed. A second reading, was scrutinised effectively in committee and would almost certainly have passed by summer recess if we hadn't had that snap election. However, labour backed the bill, in opposition and again in its manifesto. And last week, action on smoking and health. Hazel and her colleagues did a wonderful job in coordinating a letter published in the BMJ, signed by over 1400 health experts, that really urged our new government to put the reintroduction of this bill at the front and centre of its, immediate priorities. So we're at a critical juncture right now, but I think all the signs are positive, but we're watching closely. and then I think one final word is that, ah, the last government also now, announced substantial additional funding for our world leading stop smoking services and to restore substantial funding for really visible mass media campaigns to motivate quit attempts among smokers. And we really need all these measures. So it's not just about going for a smoke free generation. We need to get the effect of all these policies working in synergy to really get the country back on track for a smoke free future and avoid those 76,000 deaths a year that smoking cause the tobacco and vapes bill, as its name suggests, also proposes some new regulation for vaping. and I do also support those elements of the bill. There has been a recent increase in youth vaping across the UK and as a result, the current regulation of e cigarettes is probably no longer adequate and needs to be strengthened, to achieve and balance two objectives. So one, obviously curb this underage, vaping, increase and minimise uptake among adult never smokers. But also, secondly, and importantly, minimise the risk that policy changes will discourage substantial number of adult smokers from using them to quit smoking. so the original bill proposed a number of different powers which could be used flexibly and I think the ones that would most effectively balance these two, objectives would be things like stronger powers to regulate displays of e cigarettes that we all see in corner shops and supermarkets and so on, their retail packaging and the product appearance and the label description, the flavours of apes. from the evidence of similar measures on smoking, we can expect those sorts of policies to make a real difference in reducing, vaping uptake, while hopefully doing much less to discourage adults from using them to quit.

Xand Van Tulleken: It's such an interesting, balance that you're trying to strike. So essentially the dilemma you're describing, if I've got this right, is that smoking is so terribly dangerous that if vapes are, ah, important to help people stop there, shouldn't be discouraged from using them. And yet vaping is not entirely safe and potentially does also lead to smoking. So there's a strange two way street that requires some pretty, pretty delicate regulation. my personal experience, I should say, is that having been a never smoker, I met my wife, she was vaping and somehow, I mean, falling in love does all sorts of odd things to your brain, but I started vaping along with her and suddenly I was walking along, sort of puffing away on a blue razz, vape and then had to quit at age sort of 43, which was a completely bizarre experience, but I just fell into it, and that's, that journey is the one that you don't want people taking while maintaining access for smokers. Have I got that balance right?

Professor Jamie Brown: Absolutely. From my perspective.

Xand van Tulleken: So the issues that Jamie raises about vaping, ah, are increasingly obvious to everyone. I think youth vaping has tripled in the last three years. And how do you see the increases in vape use among non smoking young adults will be affected by the new legislation? Is there going to be a growing market for illicit cigarettes? How does that challenge, how do you sort of deal with that black market phenomenon. Can you talk me through youth vaping and illicit cigarettes?

Hazel Cheeseman: yeah, absolutely. And I think, you know, to go to the theme of the podcast, you know, this new legislation effectively phasing out the sale of tobacco to the next generation, I mean, this is a really highly disruptive policy. We're talking about really changing our approach to how we think about smoking in this country. It's not a case of whittle it down, whittle it down. It's like no, no, at some point in the future we will not have smoking in this country. Let's ask ourselves the question, how quickly can we get there? Do we have to wait for the kind of sell through period, as it were, as people age out of being able to purchase tobacco? Or can we get these 6 million smokers, the people that are still smoking in this country, to quit quicker and really see the end of smoking in much, much shorter order? And so I think it's important to think about vaping in that context. So will the phasing out of the sale of tobacco cause an increase in youth vaping? I'd be interested to know what you think, Jamie, or an increase in vaping among never smokers? I think that's an interesting question, to explore. But in the immediate term, the regulations which are proposed around, you know, limiting the marketing, around vaping products, the way they're sold in shops, etcetera, will be really important for reducing what we've seen in increases in youth vaping. Now the expectation would be that that would curb that increase in youth vaping quite rapidly. But then as we have this new population of young people that cannot legally be sold tobacco, the modelling suggests that we'll see a very big drop in smoking in that age group and it's already very low, you know, record very single digits in that those 15 year olds who will be impacted by this policy, but it's not zero. And so we do need an alternative product available for these people who are going to never legally be able to be sold tobacco to help them manage, their addiction to nicotine. And vaping is probably part of that answer. And then on the point about illicit tobacco, I think it's unlikely that it will pose a particularly big problem for the illicit market. when the age of sale went from 16 to 18, which was removing the ability to be legally sold tobacco from, from a group in a population that could already be legally sold it didn't have any impact on illicit sales, particularly. And the way that we've seen over time, regulations come in the tobacco, and the tobacco industry says, oh, well, that will cause an increase in, illicit tobacco, from point of sale, display prohibitions, to standardised packaging, taxation, whatever it might be. it's not the case. It doesn't happen, because the thing that stops illicit tobacco coming into your country is having a proper enforcement strategy that is well implemented internationally, domestically and locally. So there's no reason to think that the illicit market will be a problem. But we will have to remember that there is going to be this small group in the population that will have a nicotine addiction and that will require some kind of support.

Xand Van Tulleken: It's so interesting that you began with how disruptive this is. And as you're describing it, I mean, I think it hadn't even quite sunk in for me that this is actually an attempt to completely eradicate one of the biggest public health problems in the world. I'd love to ask you a bit more about industry and the opposite you're going to face. My processed food, my brother does a lot of work on that and on formula milk, and is just relentlessly attacked by industry scientists to the point where a lot of. It's all horrible. and I would imagine you face, I done like two tweets on tobacco and got threatened with lawsuits immediately and the whole thing was a terribly adverse experience As a follow up, what, opposition you're going to face from industry. You're talking about, taking away an entire product from entire generation. They're going to push back quite hard, aren't they? Or is the battle over for the UK, for the tobacco industry?

Hazel Cheeseman: Do you think so? I think tobacco is in a different place from where, say, food policy is, or alcohol policy, where food industry, alcohol industry, they are seen as a legitimate part of the debate by the media, by politicians, by the public to some extent. whereas with tobacco, that argument is largely over. we have an international framework, a treaty that the UK is a party to, which says that tobacco industry should not be part of the policymaking process, and the UK has done quite a good job of holding that up. So it's not quite the same as what you see in these food and alcohol industry spaces. perhaps that's where we were, perhaps a couple of decades ago. But that's not to say that the industry isn't, on manoeuvres, because you're right, this is existential for the industry. If it happens in the UK, our big economy, a kind of world leading country, of course you would expect to see this policy being adopted elsewhere. And we see the industry marching their forces in terms of employing lobbying groups, finding front organisations who will take the message forward for them, because nobody really wants to take a meeting with Japan tobacco or british american tobacco, but perhaps they'll take a meeting with another group that isn't so explicitly linked to the tobacco industry. and then we've also seen that kind of regulatory chill that they always deploy around the world, writing legal letters to the Department of Health, etc, etcetera. Expect to see more of that. I can't see this going through a process where there wouldn't be, probably some legal challenge, however baseless, that would end up being. One of the things that we've seen them pushing very hard on is a carve out for one of the products which is owned by the tobacco industry, which is seen as a harm reduction product by the tobacco industry, although perhaps less so by the public health sector, which is this heat not burn, products. And these are still tobacco products. They are less harmful than smoking, but they're probably a bit more harmful than vaping. And, they've been looking for loopholes. Can we get a loophole in the law? And any kind of loophole is going to undermine, the effectiveness of this law going forward.

Xand Van Tulleken: I know you work on addiction across multiple things and without alcohol as well. Do you see the successes of tobacco spilling into, food, alcohol and other, I guess what I would call commercial, illnesses?

Professor Jamie Brown: Yeah, really good question. I think so, to an extent. But you also have to remember they're all different too. So there are some parallels, but there are also unique, features to each that requires you not to necessarily just transfer wholesale the approach. But I think one really key lesson, with tobacco that, ah, when we're occasionally asked about other areas that I'm always keen to make clear is that need to take a real systems approach. So I think where we've had success in tobacco is where countries have taken a really comprehensive approach. So it, hasn't just been about doing one thing or one thing at a time, it's been with tobacco. We've taken so many different approaches and tried to hit so many different levers. So it's not just tax, it's not just mass media campaigns, it's not just stop smoking services, it's not just plain packaging, it's trying to do them altogether. And so you

Professor Jamie Brown: get a real synergistic effect from these different policies. And we see that in terms of when rates were coming down in the UK and when they weren't, it's when we had lots of policies working together in concert. Because quite often, if you approach it in isolation, if you just run the mass media campaigns, but you don't have the support to help people or you don't have alternative products, you don't get anywhere near the same bang for your buck or effect. So I think that's one big lesson for, other areas. It's really approaching it from that system's perspective and trying to hit across things rather than just taking a very piecemeal.

Xand Van Tulleken: Approach, I think that's really fascinating. I think one of the things that helps industry thrive is confusion among the general public. I think you see that with food and lots of other products, and with booze as well. I mean, the idea that a glass of wine a day may be good for you has been enormously beneficial for the alcohol industry. so hazel can you just tidy up the current evidence around vape safety? how useful they are to quit smoking. Should you then quit your vape as well? they're used by non smokers, non, nicotine vapes.

Hazel Cheeseman: I shall do my best, but I would say that the last report that public Health England, ah, commissioned on this, or ohid, I suppose we should now call, was a thousand pages long. so I'll do my best to summarise.

Hazel Cheeseman: what's interesting, because what is often said is, oh, we don't have enough evidence about the harms m, from vaping products, but we do actually have at least a thousand pages worth of evidence. so, you know, there are things that can be said. I think the first thing is to start with, smokers. So the most valuable, thing, that an e cigarette can play in our public health, to improve public health, is as an alternative to smoking. And the evidence that vaping is less harmful than smoking is really, you know, the jury is not out on this. It is very clear that vaping is less harmful. the cancer causing chemicals that we find, in cigarettes are either not present in liquid, vape or vapour, or they're present at much lower levels. the various things that we know are damaging from tobacco smoke, ah, by and large either are not found or are found at lower levels. But of course that doesn't mean that these products are risk free. So if they are helpful in terms of, helping people stop smoking. And again, the evidence is really clear on this, that they are as good as any other medication that we have available to help smokers quit. And in fact they're probably better than nicotine replacement therapy. Or certainly the evidence, points to the fact that they are better than nicotine replacement therapy and helping, people to stop smoking. but there is this group of people who have never smoked before who are using them and of course the use among young people there are still questions to ask about just what the impact might be. If you were to vape, and you never would have smoked for decades and decades, what might the health harms be from, vaping over that long period of time? and we don't have the answers to that. But on a precautionary basis, on the basis that you're inhaling something into your body that you need not, you know, probably it's best avoid it. If you are not a smoker, you wouldn't go back to smoking. If you stopped vaping, then the advice would be to not vape and to find your way out of that vaping product on a precautionary basis. Not because we've got bucket loads of evidence that it will cause cancer, or it will cause cardiovascular conditions, or it will cause respiratory problems, but because it might, and on that basis you should avoid it.

Hazel Cheeseman: Jamie, on the nicotine point, I think it would be good to talk about. There are an awful lot of misperceptions around nicotine, as a drug and what its impact has.

Professor Jamie Brown: I think there are a lot of harm perceptions in the wrong way about nicotine, which, you know, the main thing with nicotine is when delivered, particularly by a cigarette, it's incredibly addictive. That's the main problem with nicotine. it's not necessarily really health harming, on its own. And we kind of have that evidence from lots of people have used, nrt in the very long term, having quit smoking and carried on using that, we also have data from, particularly Sweden, Scandinavia, where snooze use, is very prevalent and replace cigarette smoking. And we see what effects that kind of comparatively had, on, lung cancer rates, for example. where there might be a bit of harm from nicotine is if people have, existing cardiovascular issues, then there's some evidence that, that may exacerbate it. But, you know, the real problem with smoking, as I'm sure you'll know, most of our listeners will know, is all the other stuff you get from smoking, not necessarily the nicotine. The nicotine is just the bit that keeps you doing the smoking. And likewise in vaping, insofar that there are going to be problems from it, it will be from the other excipients, arising from the vapour, as opposed to nicotine itself. and Hazel did, a really beautiful job of summarising a very difficult, or complicated evidence base. But what I might just add, because I think it's, you know, it boils, it distils it all down into, a really nice point, is that, you know, Chris Whitty, the chief medical officers for England's consistent advice, which is if you smoke vaping as much less harmful, if you don't smoke, don't vape, and that's it. But, you know, we have been also tracking relative harm perceptions of cigarettes and e cigarettes in England for about ten years now. I know Hazel and Ash have a survey where they look at that too. but what we've seen is that the proportion of smokers who do believe that vaping is less harmful than smoking has steadily dropped from about 40% in 2014 to now, less than 20% in 2024 with more than 65% believing vaping is equally or even more harmful than smoking. So that's a great tragedy. So you have this uncertainty there, but we don't have that uncertainty with smoking. You know, remember that figure of 76,000 people a year still dying from smoking, and worse still during that ten year period? We've also collected really high quality evidence that these are a really effective way for people to quit that lethal smoking that they're doing. And we have that from randomised trials. I think the latest Cochrane review included seven different trials, about two and a half thousand participants, and found it to be better than NRT, which is in itself a really effective medication for quitting smoking. we have over a hundred trials of that, comparing it to placebo. and we also, in England. We've got excellent observational, real world epidemiological data on, smoking rates and vaping rates. And we can be pretty confident now that, e cigarettes have probably been helping people, about 30 to 50,000, smokers each year quit smoking over and above what we could have expected in their absence. And we can kind of make those estimates using kind of some time series, some causal inference type methods. So yeah, we know from the trials, we know from the real world studies, these are really effective ways for people to quit smoking, but smokers are really sceptical about whether they're any better.

Hazel Cheeseman: If I just to follow on Jamie's point, I think those misperceptions have, I think, two big concerns. First, that smokers, might not use them as a quitting aid, that they might be put off from trying them when they could be really beneficial. And second, that when people are using them with, cigarettes, if they don't understand that they are sufficiently different from, smoking, that they continue to dual use. And that's really problematic because any amount of smoking is damaging, to your body. You know that for one cigarette is enormously harmful. If you smoke more, then the harm grows. But the big kind of step up in harm is from zero to one cigarettes. So it's a problem if people don't understand that these products are much less harmful, and if they switched

Hazel Cheeseman: all of their consumption of nicotine to those vaping products, that they're doing their health a massive favour.

Xand Van Tulleken: The very clear message is smoking is by very long way the most dangerous thing you can do, and anything to stop people smoking of the kind of range of options you've discussed is really important, and we should take great care in, emphasising the dangers of that. Is there much danger of people starting vaping and then moving on to tobacco if they think that vaping is the same level of dangerous tobacco? Or is that not a route that you see very much?

Hazel Cheeseman: I think given the state of public understanding, I think that is a real risk is the fact that these teenagers don't really perceive their smoking and vaping behaviours to be that different, they're just sort of all part of the same thing is really very worrying, given that these are very, very different activities in terms of their impact on your body.

Professor Jamie Brown: I think it's possible, that concern, and it is something that has obviously occurred to public health researchers and something that's been extensively researched, there are two types of evidence on this. We've got longitudinal studies, and they consistently show that people who start vaping, particularly young people, they start vaping, you follow them up a period later, they are much more likely to be smoking than people who've never tried them. So that does show you that happens even though with epidemiology you're trying to adjust for, lots of factors that would make people more liable to try both, there's still probably that kind of unmeasured confounding. So, those studies are kind of limited up to that point. But then the other kind of avenue of evidence is if you study populations and look what happens to the overall rates in populations of smoking and vaping at the same time. One goes up or the other goes down. because then that kind of deals with that individual level confounding a bit more then what you've tended to see. and we published a recent paper on this in England, which tends to show, smoking declines are most pronounced in kind of age groups, with the largest increases in vaping. So where vaping has gone up, smoking has actually gone down. So on an individual level, you're more likely. But how it works out at the aggregated level, we haven't really seen substantial gateway effects into smoking. What I would say in England, and I think that was part of your previous question as well, is that what we didn't see for a long time either was a gateway into nicotine use or a gateway into inhaled nicotine use. So we were just seeing use by people who probably otherwise would have become, smokers. But what we have seen, I think, since kind of mid 2021, which is around the time that these kind of disposable devices became very popular, is we have seen probably a bit of a recruitment into people who may otherwise not have used any kind of inhaled nicotine. And, that's changed the game slightly, and is of a bit of a concern. But it comes back to that balancing point, because it's also true that at the time we've seen these increases, we've also seen the fastest declines in vaping. So it's a thorny issue that it needs careful and balanced regulation, I think, of the type we've already discussed.

I think one thing is we all have our priors about what we might expect to see, but England is in the really privileged position of having really excellent vaping and smoking surveillance. and we will be able to provide pretty rapid indication of the extent to which new policies are achieving these goals. We're not going to be needing to wait five years. We do have much better surveillance. I think that would be a real advantage. And, I know Chris Whitty, when he was giving evidence on this bill, was saying, the fact that they're planning for the regulations to have a degree of flexibility to allow you to kind of recalibrate the policies as the data shows you. I'm sure it's probably informed a little bit by his experience with COVID You tweak things as you get new data and you update things. yeah, I think that's going to be a really important part of, the UK approach to vaping and smoking regulation over the next five years.

Xand Van Tulleken: Really fascinating. And probably all health policy should have some metrics of success attached to them that they can be evaluated on and adjusted and, you know, have, a more sort of experimental feel the thing we hear from politicians a lot is that the public don't want a nanny state. They don't want to be told what to do. And that's the reason why there's so much in action around, diet related ill health and many other public health issues. So from your point of view, is that the case? I mean, is it true that the public supports smoking regulation more than they support other kinds of regulation? And if so, what could be done about that?

Hazel Cheeseman: I'll kick us off. I mean, I think it's wrong from the political narrative that, the public do not support action on these leading causes of poor health is just wrong from the polling data. and the thing that needs to change is this kind of political status quo, this public don't want it, And actually, I think smoking is quite instructive. Yeah, smoking policies definitely have higher levels of support than interventions in other areas, but that's also because we've been having this debate for 60 years about the harms from smoking. Most people know that smoking causes cancer. Most people know that smoking causes a whole range of cardiovascular diseases. but perhaps, less good understanding about the direct relationship we're seeing between, say, unhealthy foods and alcohol to, to those same sorts of conditions. Yet even so, you still have, you know, above 50% support for a lot of these measures. And I was looking back at the levels of public support for, comprehensive smoke free legislation. So when we banned smoking in pubs it was in 2004, in May 2004, 51% of the public supported that comprehensive ban on smoking in public places. And then by December 2005, it was up at 66%, and then following implementation, it went to 81%. So the public support for these things grows as they are implemented, and it grows through having a debate. So what happened between 2004 and 2005, we had a big public debate about the harms from second hand smoke, why comprehensive smoke free legislation was proportionate and people understood it, changed their minds once it was implemented. They saw it was great. Support went up and up and up. And I think, politicians have to get braver about having these debates with the public about why these measures are needed. Because plainly the story of, smoking policy is that as you regulate, as you show bravery, as you have the debate with your population, the population come with you. And as I say, I think to a large extent they are already there on things like limiting sports sponsorship, using things like the sugar levy and things like that to make unhealthy products more expensive. but support will grow if politicians seize the opportunity to have the debate with the population.

Xand Van Tulleken: The thing that extends across all of public health is that idea of policy leading debate and kind of courageously, providing leadership to encourage people to think differently and change minds. I mean, otherwise you end up, not making any changes at all. That's fantastically helpful.

Professor Jamie Brown: I was just going to add one point. I mean, I've got almost nothing to add because it's such a brilliant answer, but just to explicitly draw out that not only does the public debate kind of change minds and the support grows, and also you have the direct impact of, for example, the smoke free legislation. But probably what we also saw in terms of the first year impact in some of our data was that, having the public debate in itself acts as a behaviour change intervention because you're suddenly having a, month or two or however long it is, talking about how harmful it is, how harmful smoking is to people around you and so on. And, and that provides a real kind of motivation and drive for people more effective than some more contrived or abstract campaign. So it's actually second order. You get two levels. You get big impact to the intervention you're discussing and you probably get an impact from that debate itself.

Hazel Cheeseman: And it's absolutely to be hoped that this phasing out of the sale of tobacco would have that impact. Because if you're telling your population, God, this stuff's so harmful. We've got to phase out the sale of it to, to our children, those people that are still smoking. It really makes you ask a question to yourself about why you're still doing that.

Xand Van Tulleken: there is a real benefit to successful legislation being passed because it shows lawmakers that they can actually make a difference. And so much of work as an MP and as a lawmaker is so incredibly frustrating. So few policies get enacted or do anything that if you can get a big win on a massive public health issue, it actually gets politicians to care about health. Maybe we could do something about other diseases as well. I don't know if you. That feels to me like another disruptive element where there'll be mp's m going, oh, I never thought we could improve anyone's health.

Professor Jamie Brown: Well, and, we published a paper in thorax about this and that point I said earlier, but smoking rates were steadily coming down as education and stuff, but we started not doing very much. And in the nineties, you really saw this plateau, the prevalence of smoking stopped coming down in England, across the nineties and then in two thousands, when labour had this first really comprehensive, smoking kill strategy, you suddenly saw them accelerating again. So it's not just seeing the win in terms of, the legislation, but actually seeing that direct impact. You're talking about evaluation before. But you can beautifully see this kind of s shaped curve where government in action, rates of smoking plateau, all these additional deaths, you have this great big action, lots of legislation like smoke free, etcetera, suddenly they start coming down again.

Xand Van Tulleken: can I finally ask you about what things have disrupted your thinking? We ask everyone this, it might be a piece of art or musical poetry or anything, really. Hazel, can I start with you? What have you got? A thing that sort of shook you up and disrupted you?

Hazel Cheeseman: Well, I was thinking about this and thinking about what, led me into the work that I do. And I was in Las Vegas when I was 21, maybe I won't say what year, this sort of world of like excessive commercialism, like everybody is selling you something everywhere you go. And I went to an exhibition at the Bellagio of Andy Warhol,

And that sort of juxtaposition between coming from, outside in Las Vegas, sell, sell and then this very much. There's a kind of theme, isn't there, in the Andy Warhol, the marketing, etcetera. The sense in which you are in a world in which people are selling you things all the time. I felt I took that away from that, exhibition at the Bellagio.

Despite his work, there wasn't anybody else there, just me.

Xand Van Tulleken: Yeah, it's good. But if he checked, if he got one person into public health, then that's a huge win. That's really cool. Yeah. No, I mean amazing commentary on the marketing and. I think the commercial influence and commercial genetic illness in public health is still, I think, quite under emphasised. that's really, that's a lovely story. I won't ask you more about your trip to Las Vegas. Jamie, what about you?

Professor Jamie Brown: well, in the spirit of being disruptive, I'm going to answer a slightly different question and answer topically and probably a bit more authentically for me. So rather than the kind of art. Ah, musical poetry. I'm a massive football fan, specifically a massive Tottenham fan. Now, I quite vividly remember the first time I ever saw Harry Kane play football for Tottenham and I thought he was absolutely rubbish. As a good friend of mine regularly reminds me, the first text I ever sent him about Kane after one of his first games in the Europa league was that, I thought he was just a slower, shorter, worse version of Peter Crouch. And my exact words were probably not quite so polite. and I believed it for a while until eventually I decided he was probably the best player I've ever seen play for Tottenham. So how did that disrupt my thinking relative to my science? Well, two things, very salient reminder, of updating your beliefs as the evidence accumulates and changes and not being afraid to admit you're wrong and change your position. And secondly, I try to keep in mind the importance of not rushing to judgement when you've got a very small, uncertain amount of information to inform your position. I think both those, perspectives have served me pretty well while, studying e cigarettes over the last ten years or so.

Xand Van Tulleken: Oh, I love that. Look, both of you, that is enormously kind of you to take so much time, and I think helpful. Helpful personally, for lots of people listening, and, extremely valuable in terms of all the work you're doing. So very, very good luck

Hazel Cheeseman: Thank you.

Professor Jamie Brown: Thanks very much