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 Welsh Medical Committee – PHB 102 / Tystiolaeth gan Bwyllgor Meddygol Cymru – PHB 102
This Bill is welcome, though much diminished from the ambitious but overwhelmingly supported green and white papers.
The individual sections are sensible and reasonable.
It is regrettably noticeable that the legislation makes no suggestion as to how evaluate the effect of the Bill once it is enacted. Since the doctors and all health other professionals are being required to provide evidence of its effectiveness, it is a strange omission that legislation with the associated public cost implications has no such requirement to provide evidence of its effectiveness.
If not contained in the face of the bill it would be a welcome improvement if the regulations contained a mechanism by which the effectiveness or otherwise of the legislation will be assessed (outcomes sought and by when would be the minimum.)
If this were to be done then Wales once more will be leading the UK in this aspect of health legislation.
In relation to special procedures the harm caused by unsafe piercing practices has been ignored for too long. And this Bill should help prevent an avoidable epidemic of liver disease including malignancy linked to infection.
The approach proposed for handing Tobacco products to children is again sensible and reasonable, and merely refines the current situation to correct the inconsistencies that have emerged with changes in technology and social patterns.
The ENDS or e-cigarette aspect is the most controversial. It is curious how a product that has never been tested for therapeutic use, and is currently (and correctly) unlicensed for this use is being promoted by its manufacturers as a recreational product. But promoted in the media as a therapeutic aid! The comments by PHE have received wide publicity and some assembly members have used this as evidence to reject the proposal. This would be a tragedy.
Similar argument about reduced toxicity were used in the past to support the release of Heroin as a substitute for Laundanum, and more recently Bruphenorphene for Heroin.
Careful reading of the PHE report does not advance good quality evidence that ENDS help people stop smoking, even in therapeutic controlled environments. The history of the development of ENDS suggests this was not the intended use. It was developed in China as a safer product to the growing dependence of large sections of the workforce on cigarettes. By transferring the sales to ENDS the growth in addiction would hopefully be accompanied by reduced increase in harm. Thus the intention was not to reduce smoking or tobacco consumption or Nicotine addiction but to make it less harmful. If the UK was still in a Tobacco Growth stage, then this would have some validity. However, after 400 years, the UK has moved to reduce the harms tobacco causes and has made big strides in reducing tobacco consumption. This has been despite the efforts of Tobacco companies to outmanoeuvre those seeking to protect public health. That companies who have made fortunes over the years from selling products that kill when used in the manner intended should seek to maintain their viability by diverting in to less harmful products is to be expected, but the product is still not safe in unrestricted use. (95% less dangerous than the major cause of premature death in Wales)
That a recent paper1 from the peer reviewed journal JAMA reported a cohort study in adolescent children confirmed that the concerns that E-cigs are associated with increased uptake of burning tobacco products has debunked the theory that there is no gateway effect. (There was a threefold increase in combustible tobacco use in those who used E-cigs compared to their peers who did not after 12 months follow up.)
That does not mean that in a therapeutic setting they may not have use, when a licensed product has been developed, tested and approved then trials will demonstrate its effectiveness or otherwise in use in the real world.
Such a study is being undertaken and until that has been reported it would be premature to add a recreational product to the list of treatments the NHS has to supply.
I trust the Welsh Assembly will support the Welsh Minister and support this bill in all its parts, perhaps with the addition of an evaluative section, to ensure we continue to reduce the burden of ill health borne by the current and future populations of Wales, and so reduce the drain that ill health places on both social and economic prosperity of those AM's represent. The alternative is to ensure future generations are condemned to life that is both less pleasant and shorter than could be achieved.
Dr Mark Temple
GMC reg number 2488589
Reference List
(1) Leventhal AM, Strong DR, Kirkpatrick MG. Association of electronic cigarette use with initiation of combustible tobacco product smoking in early adolescence. JAMA 2015; 314(7):700-707.