National Assembly for Wales / Cynulliad Cenedlaethol Cymru
Health and Social Care Committee/ Y Pwyllgor Iechyd a Gofal Cymdeithasol

Public Health (Wales) Bill/ Bil Iechyd y Cyhoedd (Cymru)

Evidence from the Local Health Boards in Wales – PHB 02 / Tystiolaeth gan y Byrddau Iechyd Lleol yng Nghymru – PHB 02

Health and Social Care Consultation on the Public Health (Wales) Bill

Written evidence submitted by the Directors of Public Health on behalf of the Local Health Boards in Wales

30 June 2015

1. The Local Health Boards in Wales fully support the introduction of the Public Health (Wales) Bill as   an important opportunity to improve and protect the health and well-being of the population of Wales. We welcome this opportunity to submit views on the principles of the Bill.

Part 2: Tobacco and nicotine products

Restricting the use of nicotine inhaling devices such as electronic cigarettes in enclosed and substantially enclosed public and work places, bringing the use of these devices into line with existing provisions on smoking.

2. We support the restriction of nicotine inhaling devices, such as electronic cigarettes (e-cigarettes) in enclosed and substantially enclosed public and work places, bringing the use of these devices into line with existing provisions on smoking.

3. The concentrations of potentially harmful inhalants in e-cigarette vapour may be lower than that of cigarettes, however, they are still present and can still impact on involuntary bystanders, exposing them to greater than normal levels.^1,2 Levels also remain higher than found in nicotine inhalers and some brands have been shown to contain levels of cancer-causing agents, such as formaldehyde and acrolein, as high as that found in cigarette smoke.²

4. Many of these devices have not yet been tested by independent scientists and, where testing has taken place, wide variations in toxicity have been found.² For example, nicotine has been shown to increase HbA1c levels in established diabetics, and potentially to affect insulin-producing cells in the pancreas of foetuses following exposure in utero.^3,4 Nicotine may also increase cell division rates and exacerbate tumour growth.⁵

5. There may also be indirect risk from such devices and their refills which are not child protection packaged, if the device/refill is left unattended, dropped or discarded. The liquid is extremely toxic to young children if ingested or even if spilled onto skin, and often sold in attractive colours and flavours that appeal to young people/children such as ‘gummy bear’ or ‘bubble gum’. Exposure can cause cardiac effects. Figures from the UK and overseas report large increases in cases of accidental poisoning from contact with nicotine from these devices, with large proportions of the cases involving very young children.^6-8 The batteries from these devices are also very small and could cause serious damage if ingested by small children.

6. We consider that allowing use of e-cigarettes in places where smoking is banned will undermine and make more difficult enforcement of the smoking ban. The use of these devices is also highly likely to normalise smoking behaviour and undermine the public health progress made so far. While close observers may be able to detect the absence of smell or ash, those further away will not, for example in hospital settings across large concourses. Particularly with electronic nicotine delivery systems that are designed to look like cigarettes. This will send mixed messages to the public about smoking acceptance. Legislation would provide clarity and help ensure a consistent message across Wales. The burden of smoking on the NHS in Wales, means it is imperative that clear messages on the unacceptability of smoking on health site grounds are not compromised and made unenforceable.

7. Use of these devices can both create and maintain nicotine addiction. E-cigarettes may act as a gateway to the use of tobacco by appealing to young people in their design and colours. Evidence from studies in the UK and overseas suggests that e-cigarettes are being used by young people who have never previously used tobacco.^9,10 Anecdotal evidence also suggests that people are using the devices interchangeably with tobacco, with easy access to short term but unsustainable relief of nicotine withdrawal symptoms. In existing smokers these devices are likely to result in the reduction of cigarette use rather than in quitting, with dual use of e-cigarettes and cigarettes. The number of years spent smoking is considered to be of greater importance than intensity of smoking in causing negative health effects and therefore the benefits of dual use will be much lower than those of quitting completely due to the sustaining of an interchangeable habit.²

8. There is not yet evidence of the benefit of e-cigarettes to continuous long-term abstinence. Published rates suggest that they are less effective than NHS smoking cessation services.^11,12 Research on e-cigarettes as a gateway to cigarettes is still in train as studies take time and the use of nicotine inhaling devices is relatively new to the market. We strongly advocate the precautionary principle where there is a sound theoretical argument to support a risk to public health. It is important not to wait for confirmation of harm before taking action.

9. The companies that produce these devices are using many of the advertising, promotion and sponsorship approaches used by the tobacco industry, and there is currently open advertisement of products which closely resemble cigarettes. The same promotions which make the devices appeal to smokers, may also make them attractive to children and non-smokers.² Research by the North Wales Public Health Team found that use of e-cigarettes is widespread among 11-12 year-old girls and that the girls were often attracted by the range of flavours available.¹³

10. The Local Health Boards of Wales would also support the extension of restrictions to some non-enclosed spaces such as hospital grounds and children’s playgrounds. Enforcement of the voluntary ban on NHS premises has proven difficult and time consuming, requiring employment of additional staff specifically to enforce such bans. Legislation would send a clear message around smoking being prohibited in these areas and make consistent enforcement easier. It is important that the additional support needed to enforce such bans is adequately resourced.

Creating a national register of retailers of tobacco and nicotine products.

11. We support the creation of such a register which is in line with the Tobacco Control Action Plan for Wales. A register would help to enforce legislation on the display of tobacco products and tackle underage sales by helping Trading Standards Officers to easily identify retailers and check compliance with regulations. A recent survey in England showed that nearly half of young smokers (44%) reported being able to purchase tobacco from retail premises despite the ban on the sale of tobacco products to those under the age of 18.¹⁴

12. Smoking is also increasingly concentrated in less affluent areas, where many may purchase smuggled or fake tobacco products at reduced cost. This has the potential to undermine tobacco control measures, encourage higher consumption, and deprive small businesses in these areas of legitimate trade.

Prohibiting the handing over of tobacco or nicotine products to people under the age of 18.

13. The Local Health Boards of Wales support prohibition of the handing over of tobacco or nicotine products to those aged under 18 years. The rapid rise in internet shopping could offer an easy way for young people to circumvent age restrictions. There is currently a lack of safeguards against children purchasing cigarettes through the internet. There should be consistency in the control of the sale of restricted products across all outlets, physical or virtual.

Part 3: Special procedures

Creating a mandatory licensing scheme for practitioners and businesses carrying out ’special procedures’, namely acupuncture, body piercing, electrolysis and tattooing.

14. We support the creation of a mandatory licensing scheme for both practitioners and businesses carrying out ‘special procedures’. This Bill also presents an opportunity to regulate the administration of the following procedures: body modification (to include stretching, scarification, sub-dermal implantation/3D implants, branding and tongue splitting), injection of any liquid into the body e.g. botox or dermal fillers, dental jewellery, chemical peels, and laser treatments such as used for tattoo removal or in hair removal.

15. Such a register would be beneficial in recognising legitimate practitioners and businesses and help to regulate these procedures in Wales. It would help to ensure a consistent approach to regulation across Wales. Suitable resources would need to be made available to realise and sustain the benefits of such a register. We also advocate national guidance with a maximum and minimum cost threshold for registration. The ability to amend the list of procedures through secondary legislation would also provide flexibility to incorporate new procedures with the potential to cause harm in the future.

16. The current legislation does not adequately protect the public and these procedures have the potential to cause harm if not carried out safely. In a recent look back exercise in Wales, nine people were identified as needing hospital admission due to severe Psuedomonas aureaginosa infection, eight of whom required surgical intervention (including incision, drainage, reconstruction and stitching), following body piercing at a tattoo and body piercing premises. The individuals needed weeks of hospital treatment and follow-up care, and some are permanently disfigured. More minor problems for other clients included swelling and trauma around the site, scarring, local skin infections, and allergic reactions which were more prevalent. A lack of good hygiene and infection control can lead to blood poisoning (sepsis) or transmission of blood-borne infections through contaminated equipment, such Hepatitis B, Hepatitis C or HIV.

17. There is some older evidence that procedures such as piercing are a risk factor for hepatitis, though actual occurrences may be rare.^15-17 A recent review suggests there is a significant risk of transmission through piercing and tattooing procedures which are not done under sterile conditions, such as at home or in prison.¹⁸ However, in our view, the risk of transmission is the same in professional parlours where sterile conditions and infection control measures are not in place. Scarring from complications following such procedures can also have long-term psychological impacts.^19-21 Anecdotal evidence suggests that localised infections associated with such procedures are often seen in GP practices and Accident and Emergency departments, particularly following tongue piercings. All of the nine cases identified in the look back exercise self-presented to healthcare, often multiple times.

18. We would like this Bill to go further by requiring those registering to undertake such procedures to meet national standardised training where criteria of competency will have been met, hygiene standards, and age requirements and by ensuring that they have no criminal background that would make them unsuitable to undertake special procedures (e.g. Child Protection – CRB checks). We would advise that registration should include mandatory proof of identity of the practitioner. These measures would ensure that they have the knowledge, skills and experience needed to perform these procedures.

Part 4: Intimate piercing

Introducing a ban on the intimate piercing of people under 16 years old.

19. We support the introduction of a ban on the intimate piercing of those aged under 16 years, as relates to those body parts defined in the Bill. This will aid in protecting the public and ensure a clear and consistent message across Wales. The recent look back exercise in Wales demonstrates that intimate piercing is not uncommon in this age group and we welcome the outlawing of intimate piercing irrespective of parental consent. We would encourage mandatory proof of age for any client undergoing a special procedure. It should be noted with concern that girls as young as 13 had undergone nipple piercing in the recent Gwent look-back exercise.

Part 5: Pharmaceutical services

Changing the way Health Boards make decisions about pharmaceutical services by making sure these are based on assessments of pharmaceutical need in their areas.

20. We welcome the opportunity to help support healthier lives by basing our decisions on pharmaceutical services on the needs of the community. Expanding pharmaceutical services in community pharmacies offers a great opportunity to strengthen existing relationships with communities, improve access, and NHS capacity. Provision of a national template would help to ensure these assessments are carried out in a consistent way across Wales.

21. Pharmacies have been shown to be effective at delivering enhanced services such as smoking cessation, harm minimisation in substance misuse, flu vaccination, and emergency hormonal contraception.^22,23 Currently, the majority of pharmacy time is spent dispensing prescriptions and providing advice on medicines. We believe the legislation proposed in the Public Health (Wales) Bill will encourage existing pharmacies to adapt and expand their services in response to local needs. The risk of another contractor making a successful application to join the pharmaceutical list in their area, if they fail to respond to need will be an effective incentive. This can help to ensure services are available where needed.

22. We also believe that undertaking and incorporating such assessments of need will help to improve the planning and delivery of pharmaceutical services in Wales by making them more integrated and aligned with wider health needs assessment and service planning.

Part 6: Provision of toilets

Requiring local authorities to prepare local toilets strategies for the provision of, and access to, toilets for public use, based on the needs of their communities.

23. The Local Health Boards of Wales see that there is a need for accessible public toilets and feel these are an important community amenity, particularly for older people, those with disabilities, and families with children. In addition an estimated 14 million British people have a bladder control problem, while 7.5 million have a bowel control problem.²⁴

24. Without adequate public toilets some people may feel unable or reluctant to leave their home for periods of time, which can lead to a lack of mobility, worsening health, and isolation.²⁵ Accessible public toilets contribute towards an age-friendly community reflecting the aging population in Wales. Whilst there is a lack of research evidence on the health benefits of accessible public toilets, this is supported by professional opinions and public surveys.

25. We consider that it is, however, important to recognise the strain already placed on local government services and that there will be an opportunity cost when prioritising services with limited resources. The preparation of a local strategy may not result in improved provision and accessibility without adequate resources to implement such a strategy.

Other comments

Food standards

26. The Local Health Boards of Wales are disappointed that regulation of food standards in settings such as pre-school and care homes are not included in the Public Health (Wales) Bill. Food standards can make an important impact on public health. Good nutrition in very young children is essential for future growth development and health, while poor nutrition in care homes is likely to undermine their health and well-being and increase the chances of the need for health services intervention.

27. We strongly are persuaded that this aspect could be strengthened so that there is no missed opportunity to place mandatory food standards on all food or drink supplied by or procured for settings directly controlled, commissioned or inspected by public sector organisations. Over 300,000 people are currently employed in the public sector in Wales. Offering healthy choices as the norm to them, and the public they serve, could make a significant contribution to the adult obesity problem.

28. The risk of many chronic conditions, in particular coronary heart disease, obesity, diabetes and some cancers, is increased by poor diet and diet-related disease has been estimated to cost the NHS around £6 billion a year. The cost of obesity alone has been predicted to reach £49.9 billion per year by 2050 by the Foresight report.²⁶ Wales faces some of the biggest challenges in the UK, with the Child Measurement Programme reporting prevalence of overweight or obese children to be 26% in reception year.²⁷

29. Maintaining food standards, particularly in health settings such as hospitals which seek to keep people well, can inform and influence the public’s perception of what foods are considered acceptable and healthy. The public sector caters for some of the poorest and most vulnerable people in society. Catering Standards for Food and Fluid Provision for Hospital Inpatients, and the All Wales Hospital Menu Framework standards ensure patients receive adequate nutrition to assist with their recovery whilst in hospital, but there is much work needed to make sure that healthy and balanced meals and food are offered to all those accessing the restaurants (including staff, patients and visitors). Mandated criteria for the provision of only healthier retail items in hospital restaurants and outlets would help hospitals in Wales to fulfil their responsibility for improving the health of the population they serve.

30. We would welcome the extension of the Welsh Government’s Health Promoting Hospital Vending Directive into other public sector settings, such as Local Authority premises including leisure centres and community centres, and feel that there is also a need to introduce food standards into the wider private sector.

Further comments

31. We consider that it is important the Public Health (Wales) Bill contains a commitment to progressing health in all policies which may impact on the health and well-being of the people of Wales. We believe that this would raise the profile of public health in society, increasing awareness and knowledge of important public health issues across government departments and in all sectors.

32. Minimum unit pricing for alcohol is not included in the Public Health (Wales) Bill and we are aware of current testing of Scotland’s decision to include this. We feel it is highly important that this is taken forward in the future when the position is clarified. There is a strong evidence base for a link between alcohol affordability and levels of harm and until this prudent initiative is implemented alcohol-related morbidity, mortality and cost will continue to impact on society.

References

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3. McCulloch P, Lee S, Higgins R et al. (2002). Effect of smoking on hemoglobin A1c and body mass index in patients with type 2 diabetes mellitus. J Investig Med. 50(4): 284-7.

4. Bruin JE, Gerstein HC, and Holloway AC (2010).Long-Term Consequences of Fetal and Neonatal Nicotine Exposure: A Critical Review. Toxicol Sci. 116(2): 364–374.

5. Davis R, Rizwani W, Banerjee S, et al. (2009). Nicotine promotes tumor growth and metastasis in mouse models of lung cancer. PLoS One 4(10): e7524.

6. Jame Meikle (2014). E-cigarette poisoning figures soar as vaping habit spreads across UK. Available online at: http://www.theguardian.com/society/2014/apr/14/e-cigarette-poisoning-figures-soar-adults-children [accessed 25th June 2015]

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