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 Hywel Dda University Health Board – PHB 44 / Tystiolaeth gan Fwrdd Iechyd Prifysgol Hywel Dda – PHB 44

Hywel Dda University Health Board (HDdUHB) is committed to reduce the harm that smoking causes to individuals and to the population. The University Health Board’s three year vision is to “reduce smoking rates across Hywel Dda, so that its population enjoys better health and wellbeing; to ensure people live longer, healthier lives; and to reduce the impact of smoking related illness on quality of life.” (Draft HDUHB IMTP, 2015).  This can be achieved by:

· Preventing young people taking up tobacco use in the first place (smoking prevention)

· Implementing environmental measures to make non-smoking the norm across Health Board sites and across the population

· Supporting more smokers towards successfully quitting (smoking cessation)

These aspects of Tobacco Control are also addressed through the local  implementation of the Tobacco Control Action Plan for Wales (Welsh Government, 2012), and are embodied in the HDUHB 3 year Integrated Medium Term Plan (IMTP); County Foundations for Change Plans; Single Integrated Plans; Population health groups (Transforming Health Care Delivery Plans and the HDdUHB 10 pledges.

Part 2: Tobacco and Nicotine Products.

Do you agree that the use of e-cigarettes should be banned in enclosed public and workplaces in Wales, as is currently the case for smoking tobacco?

Hywel Dda University Health Board recognises many of the concerns relating to the use of e-cigarettes.  These concerns relate, primarily, to a lack of consistent evidence that does not, at this stage, provide a clear indication of harm.

In an effort to provide consistent messages relating to the smoking ban legislation to restrict the use of e-cigarettes in enclosed and substantially enclose spaces would be supported.  This would also ensure their use does not undermine prevention and smoking cessation interventions by normalising smoking behaviour

Hywel Dda University Health Board supports the position statement issued by Public Health Wales on electronic cigarettes which contains the advice that ‘their use should be prohibited in workplaces, educational and public places, to ensure their use does not undermine smoking prevention and cessation by reinforcing and normalising smoking.’ This is in line with previous advice from the British Medical Association which calls for ‘a strong regulatory framework to prohibit their use in workplaces and public places to limit second-hand exposure to the vapour exhaled by the user, and to ensure their use does not undermine smoking prevention and cessation by reinforcing the normalcy of cigarette use.

What are your views on extending restrictions on smoking           e-cigarettes to some non-enclosed spaces (example might include hospital grounds and children’s playgrounds)?

Hywel Dda University Health Board are in favour of extending current restrictions on tobacco smoking to include some non-enclosed spaces.  The current smoke-free legislation introduced in 2007 has been shown to be effective in terms of promoting health benefits for smokers and non-smokers through behaviour change and reduced exposure environmental exposure.

Hywel Dda University Health Board believes there are a number of issues to consider:

 E-cigarettes normalise smoking, as their use mimics this behaviour.

· The use of e-cigarettes in enclosed public places risks reversing the progress that has been made on implementing the smoking ban.

· The current best available evidence on e-cigarettes supports the prohibition of e-cigarettes from workplaces, educational and public places. This would ensure that their use does not undermine smoking prevention and cessation activity, by reinforcing and normalising smoking.

· Whilst there is limited evidence that e-cigarettes act as a gateway to conventional tobacco products, this risk remains. The main concern being that e-cigarettes appear to appeal to young people e.g. having pleasant tastes / flavours and being glamorised through advertising.  In addition, young people who are non smokers, but who start using e-cigarettes because they believe them to be safe, are likely to become addicted to nicotine and therefore may move on to use tobacco products. 

· There is little evidence of effectiveness of e-cigarettes in smoking cessation.

Hywel Dda University Health Board is committed to the health and wellbeing of its staff, patients and visitors. This means that staff, patients and visitors are not able to smoke on any of the hospital sites across Hywel Dda.  Hywel Dda University Health Board has a Smoke Free Policy, a copy of which is available at http://www.wales.nhs.uk/sitesplus/862/opendoc/194807

The policy is intended to promote the right of everyone to breathe smoke free air on all Health Board sites, and also recognises the responsibility of the Health Board to promote public health to all its employees, patients and visitors and act as an example of good practice. The smoke-free policy states that the use of electronic cigarettes is not permitted on Health Board sites (this would include vaping devices). This reflects concerns that:

· Use of e-cigarettes re-normalises smoking behaviours

· Use of e-cigarettes impacts on indoor air quality

· Use of e-cigarettes undermines the enforcement of the existing smoking ban.

E-cigarette products are currently unregulated, with unproven efficacy and safety. Therefore, continued use in public places not only risks causing confusion in terms of smoke-free legislation enforcement, but risks endorsing the use of e-cigarettes as a safe activity.

Do you have any views on whether restricting the use of                           e-cigarettes in current smoke-free areas will aid managers of premisis to enforce the current non-smoking ban?

Whilst the introduction of the HDdUHB smoke-free policy has seen some reduction in smoking on Health Board premises particularly amongst staff, the policy has proved to be extremely difficult to enforce with patients and visitors to Health Board sites, who continue to smoke on its premises as well as use e-cigarettes within enclosed hospital sites.  Evidence from other Health Boards suggest similar issues are being encountered.

Concerns have been raised by staff who have no wish to become involved in a confrontation with someone who is smoking on the hospital site. A series of policy ‘policing options’ therefore has been explored such as a  Community Safety Accreditation Schemeand Local Authority officers policing sites, however it is only the littering aspect of tobacco use that currently is able to be enforced and not the act of smoking on Health Board premises. 

It should be made clear therefore with the introduction of legislation that smoking is not permitted on Health Board sites. Hywel Dda university Health Board would therefore welcome the prospect of legislation in this area in order to ensure that this issue is taken seriously by staff, patients and visitors alike.

Do you agree with the proposal to establish a national register of retailers of tobacco and nicotine products? And do you believe the establishment of a register will help protect under18’s from accessing tobacco and nicotine products?

A retail register is an important step towards reducing the number of young people in Wales who become smokers.  The introduction of a registration scheme will help prevent underage sales and sales of illegal tobacco. Creating a tobacco retail register will provide Trading Standards with the authority needed to tackle the problem of under-age sales.

Hywel Dda University Health Board agrees that this action would help prevent access to tobacco products by children and would therefore support local and national initiatives outlined in the Welsh Government Tobacco Control Action Plan.

We therefore believe that a register will help bring a more co-ordinated approach to tobacco control and would increase the accountability of retailers. A register should also support the enforcement of current measures, for example, extend the display ban to small/independent retailers.

Do you believe the proposals relating to tobacco and nicotine products contained in the Bill will contribute to improving public health in Wales?

Smoking places a significant burden of illness on the health of the population of Wales, the effects of which place an unprecedented demand on Health and Social Care services across community, primary care and secondary care; and on the services provided by its partner organisations across statutory and voluntary sectors.  The full impact of tobacco use on the health of individuals, communities and the population, and its impact on health services is wide-reaching.  While overall death rates from smoking are falling, it still continues to be the largest single preventable cause of ill-health and premature death, therefore, measure proposed in the Bill with continue to support prevention and cessation.

HDdUHB believe that the proposals to establish an national register of tobacco and nicotine retailers, strengthening the Restricted Premises Order and prohibiting access to tobacco/nicotine products to those under the age of 18 years will contribute to improving public health in Wales

Part 3: Special Proceedures

Hywel University Health Board believes that the current information, regulation and enforcement in relation to the procedures listed in the Bill does not protect the public effectively. Much of the legislation and regulation in this area is both inconsistent and fails to reflect a range of recent developments in tattooing and body piercing etc, many of which are invasive and similar to minor medical procedures. These procedures have the potential to cause harm, if they are not carried out safely e.g. risk of blood borne viruses and infection.

If these procedures were carried out in a healthcare setting, there would be a clear expectation that patients would be provided with clear information about risks and benefits and that clinicians would undertake them in a safe way.

Do you believe the proposals relating to special procedures contained in the Bill will contribute to improving public health in Wales?

Hywel Dda University Health Board believes that a National Special Procedures Register should be introduced so that there is a consistent approach across Wales. This would help to ensure that the public are better informed and protected from harm, specifically reducing the risk of blood borne viruses.

Part 4: Intimate Piercing

HDdUHB agree that intimate piercing of anyone under the age of 16 should be prohibited.

Part 5. Pharmaceutical Services:

As the NHS shifts towards upstream interventions and moves away from the current ‘illness’ model, the wider contribution community pharmacy can make beyond supply of medicines will become increasingly important.

It would be appropriate for Health Boards to consider applications on all the services proposed by the applicant that are included in the Health Board Pharmaceutical Needs Assessment. Proposed services outside of those identified through a needs assessments should not be considered during the application process, unless there is compelling evidence of benefit. Where an application is approved on the basis of addressing specific unmet pharmaceutical need, approval of the contract should be conditional on delivery of these services, consideration should be given to appropriate timescales for conditional offers and sanctions available to the Health Board should the contractor fail to deliver required services.

Local Health Boards should be allowed to invite community pharmacies in their areas to provide specified services to meet identified pharmaceutical needs.  Where those pharmacies are unable to do so adequately the Health Board should be allowed to invite additional pharmacies to become established to provide pharmaceutical services provided the Health Board acts reasonably in terms of the service(s) required and the specified timescale for introduction of the service(s). 

Part 6: Provision of Toilets

Adequate provision of and access to toilets for public use is an important public health and equality issue as it has a disproportionate impact certain population groups such as families with young children, older adults and disabled people. 

A lack of public toilets results in certain groups feeling anxious about going out. Older people, for example, may be reluctant to leave their home or may reduce fluid intake unless reassured that they will have access to public toilets. Poorly designed, located and inadequately maintained public toilets can also discourage public use.

Hywel Dda University Health Board support placing a duty on Local Authorities to develop a strategy for the provision of toilets for public use. However, whilst recognised as an important public health issue its prioritisation needs to be balanced against the demands of other service provision.  Therefore it would seem appropriate to incorporate this as an assessment of need as part of the next round of needs assessment for the single integrated plan/wellbeing plans.

Clara Greed, “Taking Stock: an Overview of Toilet Provision and Standards” (paper presented at the World Toilet Conference, Belfast, September 2005), p 14.

Help the Aged “Nowhere to Go: Public Provision in the UK”, March 2007, p5.

Nowhere to go in Wales, Help the Aged in Wales (now Age Cymru), 2009.