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 Dental Committee – PHB 56 / Tystiolaeth gan Bwyllgor Deintyddol Cymru – PHB 56


Public Health (Wales) Bill: Consultation questions

Tobacco and Nicotine Products

The Bill includes proposals to ban the use of nicotine inhaling devices, such as e-cigarettes, in enclosed spaces like restaurants, pubs and at work. Shops will also have to join a register for retailers of tobacco and nicotine products, and it will become an offence to “hand over” tobacco and e-cigarettes to anyone under the age of 18.

Question 1

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


We agree.


Just when smoking has become socially unacceptable it would be a retrograde step to permit use of nicotine inhalational devices to be used where smoking is not allowed. We acted to protect people from second hand smoke, we need to protect them also from second hand nicotine which is produced from these devices and exhaled by users. One aspect of the approach to regulation should be to permit use of these devices only where and when tobacco smoking is currently permitted.


Question 2

Do you believe the provisions in the Bill will achieve a balance between the potential benefits to smokers wishing to quit with any potential dis-benefits related to the use of e-cigarettes?




Smoking tobacco is a major cause of adverse health impact including oral health impact. Nicotine is addictive. Burnt tobacco carries additional harm. For the individual who cannot stop smoking e-cigarettes may be a less harmful alternative, but the better outcome would be to avoid individuals becoming nicotine addicts in the first place.


The advent of nicotine inhaling devices may assist those who are addicted to nicotine but are unwilling or unable to address their addiction to avoid the risks of inhaled tobacco, but to date evidence on this is weak.


While the evidence on young people using e-cigarettes is similarly weak at this stage we should also acknowledge that once the e-cigarette market is saturated there may be much more effort put into marketing e-cigarettes to young people which could become more effective.


Although it is beyond the scope of this Act ideally some thought should be given to the concentrations of fluids used and to the taxation of these to encourage a shift from higher to lower concentrations. There are parallels here to how we apply duty to alcohol products.  


Section 2 (2) refers to inhalation of nicotine via a mouth piece. It would seem wise to refer to a mouth piece or nose piece to reduce risk of some circumventing the intent of the Act.


Section 4 Offences. Subsections 5 and 6 refer to defences. It would be helpful if that Act made it clear that continuing to smoke/inhale after a person had been made aware that the premises/vehicle are smoke free negates any defence based upon lack of awareness. This would assist those charged under Section 5 to keep smoke-free premises smoke-free.


Question 3

Do you have any views on whether the use of e-cigarettes re-normalises smoking behaviours in smoke-free areas, and whether, given their appearance in replicating cigarettes, inadvertently promote smoking?


As was stated above, just when smoking has become socially unacceptable it would be a retrograde step to permit use of nicotine inhalational devices to be used where smoking is not allowed. We acted to protect people from second hand smoke, we need to protect them also from second hand nicotine which is produced from these devices and exhaled by users. Although some smokers believe they should be free smoke such freedom should not extend to imposing their smoke or exhaled e-cigarette vapours (including nicotine) on others.


Question 4

Do you have any views on whether e-cigarettes are particularly appealing to young people and could lead to a greater uptake of their use among this age group, and which may ultimately lead to smoking tobacco products?


With the moves of tobacco companies into the nicotine inhalational device marketplace comes the further risk of product design, device marketing, and development of flavours or other features intended to target the young and vulnerable.


We are still in the early stages on the introduction of these devices. When the market becomes saturated efforts to target non-users will become more creative and aggressive. Thus another aspect of the approach to regulation is to restrict sales to young people, and to restrict advertising, and of features such as flavouring.


Question 5

Do you agree with the proposal to establish a national register of retailers of tobacco and nicotine products?


The registration of those selling nicotine products and restrictions on sales to under 18’s are supported by Welsh Dental Committee.




Question 6

What are your views on creating a new offence for knowingly handing over tobacco and nicotine products to a person under 18, which is the legal age of sale in Wales?


The registration of those selling nicotine products and restrictions on sales to under 18’s are supported by Welsh Dental Committee.



Special Procedures

The Bill includes a proposal to create a compulsory licensing system for people who carry out special procedures in Wales. These special procedures are tattooing, body piercing, acupuncture and electrolysis. The places where these special procedures are carried out will also need to be approved.

Question 7

What are your views on creating a compulsory, national licensing system for practitioners of specified special procedures in Wales, and that the premises or vehicle from which the practitioners operate must be approved?


We support the proposal for compulsory national licensing of premises/vehicles and practitioners.


Recent events in Newport have highlighted the cross infection risks associated with some of these areas and the resulting large impact on public resources when incidents need investigation and follow up. Application of appropriate standards including licensing to protect the public during these activities seems entirely appropriate and necessary.



Question 8

Do you agree with the types of special procedures defined in the Bill?


In general yes.


However the approach taken to define intimate piercing in the draft Bill excludes piercing within the oral cavity which appears to Welsh Dental Committee to be an inappropriate omission. The tongue is a highly vascular and sensitive organ, and the tongue and lips are frequently involved in intimate acts. Worryingly the tongue and floor of the mouth are sites from which a local haemorrhage or a locally spreading infection can rapidly threaten the airway. There are sufficient reports of adverse events both minor and major to suggest that intra-oral piercings should not be performed on anyone aged under 16.


Question 9

What are your views on the provision which gives Welsh Ministers the power to amend the list of special procedures through secondary legislation?


No views on this matter.


Question 10

Do you have any views on whether enforcing the licensing system would result in any particular difficulties for local authorities?


We believe it is appropriate for the local authority to have the proposed powers and trust that personnel who carry out this role will be appropriately trained and supported to enforce the provisions of the act



Intimate piercings

The Bill includes a proposal to ban intimate body piercings for anyone under the age of 16 in Wales.

Question 11

Do you believe an age restriction is required for intimate body piercing? What are your views on prohibiting the intimate piercing of anyone under the age of 16 in Wales?


The WDC believes it is correct to require an age restriction for intimate body piercing, and that intimate body piercing should not be performed on anyone who has not yet reached their 16th birthday.


Furthermore the WDC believes it is appropriate to obtain valid consent before carrying out intimate body piercing so that customers are fully aware of the potential risks. Customers should be provided with an opportunity to ask questions about the risks and be required to complete a written consent form.


Question 12

Do you agree with the list of intimate body parts defined in the Bill? Whether any other types of piercings (for example naval piercing, tongue piercing) should be prohibited on young people under the age of 16.


The WDC agrees with the list of intimate body parts, but want to see tongue piercing or any other intra-oral piercing added to the list. There are known risks associated with tongue piercing as detailed below and there are reports in the literature that tongue piercing is associated with sexual contact. We recognise that tongue piercing does not require the customer to undress, but we believe the oral cavity can be considered an “intimate area” and that tongue piercings on under 16’s is to some degree sexualisation of them.


The WDC believes that tongue piercing is a public health issue since it commonly leads to adverse effect locally in the mouth and more rarely systemically. Many patients attend for dental treatment following damage caused by tongue piercing, and we believe that including tongue piercing in intimate body piercing will contribute to improving public health


A brief review of the literature shows there are numerous studies in the UK and globally on the adverse effects of tongue piercing.  It is not possible to give accurate figures for the number of people with tongue piercings, but studies show the practice is most common among young people aged 16 to 24 and in some communities up to 50% of these young people will have a body piercing.


The data varies, but in 2 UK studies (including one in Cardiff) over 90% of the dentists surveyed had seen patients with tongue piercings, and about half had treated patients for complications arising from tongue piercing. About half of the patients had received advice about risks of piercing, but the advice was very limited and usually about pain and swelling


Complications of tongue piercing can occur immediately after the piercing, and then after healing. Reports consistently show approximately 90% or piercees will have immediate complications including pain, swelling, bleeding , nerve damage and infection. There are a small number of reports of severe spreading infection which has compromised the airway, putting life at risk.


Later complications commonly include –

·         Gingival (gum) recession

·         Bone loss around teeth near the piercing

·         Enamel chips / cracks and tooth fracture

·         Swallowing or inhalation of the barbell

·         Calculus formation around the barbell  increasing the risk of  infection

·         Tissue overgrowth causing the barbell to become embedded in the tongue

·         Split (bifid) tongue

·         Hypersalivation

·         Speech impediment

·         Metallic taste and allergic reaction to the metal


All of these complications can require treatment by the dental team, and may lead to tooth loss and soft tissue damage


There are reports of severe complications. While they may be very rare, they can be life threatening – in 2003 the UK Government debated the death of a Sheffield teenager following tongue piercing .

This is not the only case of death or of near fatality within Wales  or beyond .


Severe complications include –

  • Spreading infection which can compromise the airway
  • Endocarditis
  • Cerebellar abscess

·         As with all body piercing there is risk of infections such as Hepatitis B if strict cross infection control measures are not followed


There is evidence that people who have tongue piercing or other intra oral piercings are not fully informed of the risks beforehand, or provided with written advice on care of the piercing site. Dental teams are aware of many of the risks, but the evidence suggest they would welcome more information on advising patients about risks and care of the mouth after tongue piercing.”



Other comments

Question 19

Do you believe that the issues included in this Bill reflect the priorities for improving public health in Wales?


Given the extensive legislation covering many aspects which impact on public health these are appropriate issues.

Question 20

Are there any other areas of public health which you believe require legislation to help improve the health of people in Wales?


There are many issues which potentially impact upon the health of the people of Wales. Rather than legislate for everything a more balanced approach would be the requirement for Health Impact Assessment of policies and of both public and private planning applications.


Question 21

Are there any other comments you would like to make on any aspect of the Bill?