Sir, we read with interest the 'Perspectives' feature published on the occasion of the ten-year anniversary of the smoke-free legislation in England.1 We enjoyed reading the personal views of dental professionals on this topic, including those who were working before and after the smoke-free legislation came into effect. It was very encouraging that they all advise patients to stop smoking and warn them of the negative impacts of smoking on oral health.

However, there is a clarification to the article that we think is important to make. The feature states that 'The smoking ban has since been extended to cover the use of electronic cigarettes'. This is incorrect. The smoking ban was introduced, after much debate, on the basis of well-established evidence of the harms of second-hand smoke, which is not the case for electronic cigarettes (e-cigarette) vapour. There are voluntary restrictions on the use of e-cigarettes, but the smoke-free legislation does not cover e-cigarettes anywhere in the United Kingdom (UK). Indeed, Public Health England (PHE) and Action on Smoking and Health (ASH) have produced useful guidance on this, which encourages organisations to develop evidence-based policies to the benefit of public health.2,3

Many NHS organisations have followed this guidance with e-cigarette use being allowed in some NHS grounds and in certain circumstances inside buildings (eg single occupancy bedrooms in inpatient mental health settings).

The feature also mentioned the role of e-cigarettes in smoking cessation on several occasions and this has been previously discussed in a BDJ letter earlier this year, which highlighted that e-cigarettes have been effective in helping smokers in England to quit.4

With respect to the standardised packaging of tobacco (SPoT), the UK was the second country in the world to introduce this, after Australia. The move was evidence-based with government commissioned systematic reviews of over 50 studies5,6 and an independent review7 concluding that SPoT would 'lead to a modest but important reduction [in smoking] over time'. It is important to put SPoT into context; it's not going to single-handedly eradicate smoking, but it is an important component of a comprehensive tobacco control strategy, and may be particularly important for youth smoking prevention. Interestingly, the strength of the tobacco industry's (failed) legal challenges to SPoT, in the UK, indicate their views on the potential impact to their business.8

Pictorial health warnings are also an important tool in a comprehensive tobacco control strategy. To date, more than 100 countries have passed legislation implementing this highly cost-effective tool.9

In a recent review, the UK ranked 14th globally for its warning size of 65% of the packaging's front and back surface (along with all other EU countries).9

Finally, surveys of the public perception of harm from e-cigarettes (and nicotine replacement therapy) indicate increasingly negative views, with only 13% of people (in 2017) considering e-cigarettes to be a lot less harmful than smoking.10 Some of this is attributed to misconceptions around perceived harm from nicotine, which although highly addictive is 'not a significant health hazard' on its own delivered in forms other than combustible tobacco.11 There are clearly mixed views amongst dental professionals and over the coming years we need to continue to develop the evidence base to best inform our patients and ourselves.