Tattoos, Bans & Bogs - The Public Health Bill

The Public Health Bill is a wide-ranging law, prompting controversy over
a proposed ban on the use of e-cigarettes in indoor public spaces.
(Pic : BBC Wales)

Earlier this week, the Health Minister, Mark Drakeford (Lab, Cardiff West), introduced what's likely to be one of the most controversial and substantial laws of the Fourth Assembly, instigating one of those rare occasions where Welsh politics has made UK-wide headlines - not necessarily in flattering terms either.

Following a White Paper published in last April (Booze, Bans & Bogs), the Public Health Bill – Bill (pdf), explanatory memorandum (pdf) – is a wide-ranging law covering areas such as : e-cigarettes, tobacco sales, tattoos & piercings and public toilets. There's a handy summary of what's included from the Members Research Service In Brief blog, plus more detailed follow-up posts on specific areas of the Bill.

The Rationale

The overarching goal of the Bill is to respond to "new and emerging health challenges" and "put in place conditions that are conducive to good health, in which harms to health can be prevented". It's compared to legislative measures which introduced smoking bans in enclosed public places and compulsory use of seat belts. All this is in the face of improved life expectancies, but living longer doesn't necessarily mean "living healthier" and not everyone will live longer in the first place.

Around 5,450 people die from smoking-related diseases every year, costing the Welsh NHS an estimated £302million annually and the economy £90million in sickness and absence. It's said two-thirds of smokers start before age 18 and up to 40% of smokers start before age 16 (the legal smoking age). New EU directives have to be written into UK legislation by May 2016 which introduce a number of measures relating to tobacco, such as : packet size limits, increased size of health warnings on packets and further regulation of the electronic cigarette (e-cig/"vaping") market.

Likewise, the increased popularity of acupuncture, piercings and tattoos has prompted the Welsh Government to introduce new regulatory regimes and age-related restrictions. Customers are at risk of serious illnesses like blood-borne viruses if practitioners don't follow proper hygiene procedures, while an English study found that certain piercings have a notably higher reported rate of infection – tongue (50% higher incidence of complications), genitalia (45%) and nipples (38%).

Another delicate issue – which has been raised in the National Assembly a number of times – is the provision of public toilets (see also : Consult At Your Convenience - there'll be an update on this in the next few days). It has an obvious impact on public health, in particular amongst the elderly, disabled and parents of young children. Currently, public toilet provision varies between different local authorities and there's no statutory obligation for local authorities and community councils to provide them. The Bill aims to improve the planning process for toilet provision.

What exactly does the Public Health Bill propose?

Tobacco, Tobacco Retailers & E-Cigarettes

All tobacco and nicotine retailers will have to be registered, while
the age to buy e-cigs will be formally raised to 18.
(Pic : e-cigarettedirect.co.uk)

The Bill :

• Covers all forms of tobacco smoking and "nicotine inhaling devices" (e-cigarettes/vaping); regulations may be introduced to extend the provisions to other forms of "inhaling devices".
• Means all "workplaces" – defined as a premises where more than one person is employed or where members of the public will go to seek or retrieve goods and services - will become smoke-free premises.
• Gives Welsh Ministers the power to make regulations to designate another type of building a "smoke-free premises" or vehicle a "smoke-free vehicle", but also the power to designate certain buildings as exempt (i.e smoking rooms in hotels, members clubs).
• Places a duty on managers of smoke-free premises to display appropriate "no smoking" signs.
• Requires the registration of people operating as tobacco retailers ("tobacco" defined as including cigarette papers and "nicotine products" – including e-cigs).
• Amends the Children & Young Persons Act 1993 to extend restricted sale orders to nicotine products (effectively extending the age to buy e-cigs to 18).
• Makes it an offence to :
• Smoke tobacco or use an e-cigarette in a smoke-free premises or smoke-free vehicle (as outlined by regulations). Violators are liable to a fine of up to £200.
• Fail to prevent someone smoking or using an e-cigarette in a smoke-free premises or smoke-free vehicle. Violators are liable to a fine of up to £2,500.
• Fail to comply with signage regulations. Liable to a fine of up to £1,000.
• Sell tobacco/nicotine products without registration. Liable to an unlimited fine determined by magistrates.
• Sell tobacco/nicotine at a place other than the registered address (except movable stalls), or fail to give notice of a change of registered address. Fine of up to £500.
• Knowingly hand over tobacco or nicotine products to under-18s (sale or not). This includes internet and telephone sales. Fine of up to £2,500.

Piercings, Tattoos & Other "Special Procedures"

For his or her pleasure.
(Pic : via epubbud.com)

The Bill :

• Defines a "special procedure" as : acupuncture, electrolysis (laser hair removal), tattoos and body piercings.
• Defines "intimate piercing" as a piercing of the genitalia (including the mons pubis and perineum aka. "gooch"), bellybutton, breasts or buttocks.
• Requires any individuals performing "special procedures" to be licenced. Licences will be issued by local authorities. Individuals can be licenced to perform more than one special procedure. It appears as though licences will last for three years from date of issue. Healthcare professionals are exempt.
• Requires Welsh ministers to issue regulations on mandatory licensing criteria (i.e. record-keeping, premises, display of licences), which may include giving local authorities the power to withhold licences until a premises has been inspected.
• Gives local authorities the power to revoke licences if licence holders fail to meet licensing criteria, or if their non-compliance presents a risk to human health. They can also issue stop notices and remedial action notices for the licence holder to undertake.
• Makes it an offence to :
• Perform special procedures without a licence, continue in contravention of a stop notice or remedial action notice, make a false statement etc. Liable to a fine of up to £1,000.
• Perform an "intimate piercing" on, or make an arrangements for an intimate piercing on, a person aged under-16. Liable to a fine of up to £2,500. Medical procedures are exempt.

Pharmaceutical Services

The Bill amends the NHS Wales Act 2006 to :

• Change the process by which local health boards approve providers of NHS pharmaceutical services by placing a duty on local health boards to assess pharmaceutical needs in their respective areas.
• Introduce a "control of entry" test for prospective NHS pharmaceutical providers to ensure they'll meet the needs identified in the assessment.
• Give local health boards the power to remove providers from the approved list if they continuously breach terms and conditions of service.

Public Toilets

Local authorities will have to properly plan public toilet provision.
(Pic : South Wales Evening Post)

The Bill :

• Places a duty on local authorities to prepare both a local toilets strategy - which assesses the need for public toilets in their area - and a statement setting out how the local authority intends to meet those needs. The strategy must be published within 12 months of the first local authority elections following the commencement of the Act.
• Includes baby changing facilities and disabled changing facilities within the definition of "toilet".
• Gives Welsh Ministers the power to issue guidance on the toilet strategy itself.
• States that local authorities and community councils "may", but not "must", provide public toilets – though provision has to match the toilet strategy.
• Grants local authorities the power to make bylaws regarding the conduct of people using public toilets.

How much would a Public Health Act cost?

There's an estimate that the Act (as it stands) would have a net cost to the Welsh Government of £455,300 between 2016-17 and 2020-21 and £1.82million to local authorities over the same period based on the preferred options.

The estimated cost to the public and work places with regard the tobacco and e-cigarette restrictions is £8.82million over the five year period, and around £1.35million to the e-cigarette industry over the same period.

The E-cig Ban Justification

The Welsh Government and public health bodies might feel they're doing the right thing despite
the lack of hard evidence, but the public are unlikely to take kindly to the "nanny statism".
(Pic : yourassembly.org)

As the most controversial and high-profile aspect of the Bill is the proposal to extend a ban on smoking in enclosed public places and workplaces to e-cigarettes, it's worth looking at the Welsh Government's argument in a bit more detail.

• Some "flavours" of the vapour liquid used in e-cigarettes might appeal to children and young people, and flavoured tobacco products are disproportionately used by young people. Vaping re-normalises smoking behaviour and undermines smoking bans, making it harder "to challenge perceptions that smoking is normal behaviour". There's limited evidence which suggests that using e-cigs as a teenager (14%) makes them more likely to take up smoking than non-users (2%) so e-cigs might act as a "gateway" to smoking.
• Many users use e-cigarettes as a partial, not complete, replacement for smoking (aka. "dual users"). This is considered a harm reduction approach in cases where smokers are unwilling to quit smoking completely; however, even low levels of smoking convey substantial health risks. The long-term health impacts of vaping are currently unknown. It's also said the quality of evidence that suggests vaping is an effective and safe replacement for smoking is "low", despite studies and expert opinion pointing in that direction.
• There are restrictions on advertising e-cigs and they also come with nicotine addiction health warnings. Despite this, there are few public bans on the use of e-cigarettes in line with World Health Organisation advice. A ban on their use in public wouldn't impact their use as a tool in getting smokers to quit, with the aim to, "balance the potential benefits to smokers wishing to quit with any potential dis-benefits related to the use of e-cigarettes".
• Local health boards and Public Health Wales support the proposal. A narrow majority of public responses were against the proposal (271 of 525 responses) and the response from the third sector (notably including the British Heart Foundation and Cancer Research UK) is described as "mixed" - though I would argue mostly against.

Conclusions

Plans for a minimum unit price for alcohol and nutritional standards in parts
of the public sector which provide meals have been dropped or postponed.
(Pic : The Guardian)

The vaping controversy aside, the Bill is a bit of a damp squib, even disappointing.

The first thing to note is that a proposal to introduce minimum per-unit pricing for alcohol has been dropped (see also Vice Nation : Alcohol I – Our Drinking Culture). The explanatory memorandum says the Welsh Government want to pursue the issue separately from this Bill – that might mean joint EnglandandWales regulations similar to the recent smoking ban in cars (Assembly Bans Smoking in Cars With Kids).

Secondly, another policy proposal dropped from the Bill is the introduction of nutritional standards in schools, care homes and hospitals. The Welsh Government say they'll deal with this through secondary legislation/regulations. Considering obesity should be one of the most serious public health concerns at present (Hard Graphed & Fat of the Land : More work needed on childhood obesity), it's disappointing there's little reference to it in a public health law. The Minister did say in his plenary announcement he was working with organisations to see if legislative measures on things like physical activity and mental health are appropriate.

On e-cigs, there's an unofficial social contract between society and legislators in any liberal democracy that if you're going to ban or restrict something, there has to be hard evidence that it causes harm to others. Welsh Labour - and occasionally other parties in the Assembly - simply don't understand this and are all to eager to rush towards knee-jerk bans in order to protect the public from ourselves "for our own good" - what I've previously called a socialist paternalism.

There's no question that the vaping industry requires proper regulation – such as restricting sales to over-18s and regulating ingredients - but any public use ban should be conditional on evidence that it has an equivalent "passive effect" as smoking. Although I'm not blasé enough to say vaping is 100% safe, or that a nicotine addiction is a good thing, that evidence simply doesn't exist (yet).

The Health Minister himself is quoted as saying that the Welsh Government "are not waiting for proof of harm", which for a government that often prides itself on pursuing "evidence-based policy" is a pretty damning statement. It's an open invitation to lawyers and the Supreme Court as well as straight-up poor law-making. Under "precautionary criteria" the Welsh Government could justify banning, or restricting the use of, a whole host of things, like caffeinated drinks, driving, veganism, certain sex acts - or even the intimate piercings included in the Bill.

Why would someone who's thinking of giving up smoking move to less-damaging e-cigs if they're going to be restricted in the same manner as tobacco? That's why this proposal has caused such a split amongst health organisations. If it comes down to a choice between 1) people sustaining/treating a nicotine addiction through vaping, or 2) developing lung cancer or COPD through tobacco smoking, you've got to go for option one (harm reduction) as the least-worse option while smoking remains legal. It has to remain attractive enough to switch from cigarettes, which means permitting vaping indoors (or, preferably, restricting it to a designated room).

On the rest of the measures, they're largely common sense, although I can't really comment on the pharmaceutical changes as it's a bit technical. What I will say though is that it's disappointing that there'll be no duty placed on local authorities to provide public toilets.

As much as there's been an explosion in the popularity of tattoos,
there's also been an explosion in the number of awful tattoos.
(Pic : via imgur.com)

With regard tattoos, I'm not a fan; a vast majority (clichéd roidhead tribal tattoos, kanji, logos, "arse antlers") are horrendous, though professional tattoos can, and do, look amazing.

Similarly, if someone's going to pierce a vulva, anus (why? I don't want to know....), scrotum or give you a Prince Albert I'd bloody well expect them to have gone through some sort of formal training or licensing procedure. A stringent licensing system makes sense, but a question has been raised previously by Keith Davies AM (Lab, Llanelli) - of all people - whether hairdressers should require "special procedure" licensing too? Whilst a bad haircut won't make you ill, it can be as damaging or embarrassing as a bad tattoo and hairdressers routinely use hazardous chemicals.

One thing I will point out – I'm sure if I've noticed it AMs will too – is that electrolysis specifically refers to hair removal, so the Bill doesn't appear to cover laser tattoo removal while both tongue and lip piercings aren't included as "intimate piercings". These are glaring omissions and potential loopholes.

Also, you've got to assume that the licensing process, inspections etc. will be undertaken by local authority environmental health departments, which have come under immense strain as a result of local government cuts. Will there be extra ring-fenced funding for them?