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 Bevan Foundation – PHB 69 / Tystiolaeth gan Sefydliad Bevan – PHB 69




145a High Street

Merthyr Tydfil

CF47 8DP




4th September 2015



Dear Chair,


Evidence on the general principles of the Public Health (Wales) Bill




1.    The Bevan Foundation develops ideas to make Wales fair, prosperous and sustainable. It is a registered charity and is independent of government, any political party or line of thought.  We welcome the opportunity to submit a response to the Committee’s inquiry. We have also submitted evidence as part of a group led by Tenovus Cancer Care.

2.    Our submission addresses your specific questions on smoking and e-cigarettes and on toilets, and your general questions on the approach taken in the Bill.


Smoking and e-cigarettes


3.    Our research on smoking cessation in Wales[1] argued that the end to the downward trend in smoking amongst the population as a whole and the high prevalence and upward trends in smoking amongst the least well-off require a new approach to smoking cessation. This would involve:

a.    Regarding smoking as an addiction not a lifestyle choice.

b.    Active intervention by a wide range of health professionals to support quitting.[2]

c.    Active use of a range of quit aids to reflect smokers’ circumstances.[3]

d.    Creating a no-smoking culture and environment particularly amongst groups at greatest risk of smoking.

4.    The use of e-cigarettes in enclosed public places is a minor issue compared with the scale of the smoking problem, and we are not convinced that a ban is the right focus for public health in Wales.

5.    The rationale for the 2007 ban on smoking in enclosed public places was to reduce the harm from second-hand smoke, and for this reason it has had high levels of compliance.  The Bill’s proposals change the rationale of a ban: we are not aware of evidence that second-hand e-cigarette vapour causes harm, and it is hard to see how smoking conventional or e-cigarettes in open public spaces e.g. a hospital car park harms others.

6.    Indeed, the evidence suggests that e-cigarettes are less harmful to the user than smoking, and the evidence that their use ‘normalises’ smoking is weak. As an NRT product (albeit unregulated at present) e-cigarettes can help with quitting especially for those who do want to engage with smoking cessation services.

7.    We understand the wish to be cautious about the use of a new nicotine device, but believe that the resources involved in implementing and enforcing a ban would be better used on promoting more effective stop smoking support.

Provision of Toilets

8.    We welcome the inclusion of public toilets in the Bill. Access to toilets is a much neglected issue of importance to everyone but especially children, older people and people with certain health conditions.

9.    We are concerned that the proposed requirement for each authority to prepare and publish a toilet strategy adds to local authorities’ paper mountain without resulting in the provision of more toilets. Instead, we suggest that the Bill is less cautious and places a direct requirement on public and private bodies alike to provide and maintain public toilets in places open to the public, such as shopping centres, bus stations, sports venues and town centres. The requirement could be proportionate to footfall, e.g. one toilet per X visitors.

10.There should be an explicit requirement that toilets are accessible to disabled people and are open for specified hours.  


Priorities for public health

11.Wales has one of the least healthy populations in the UK, with high levels of smoking, obesity and alcohol misuse. A Public Health (Wales) Bill is a unique opportunity to tackle the underlying environmental and behavioural causes of poor health in an innovative way which meets Wales’ needs. 

12.We would like to see the Bill take a coherent and broad approach to promoting public health, bringing together action to address all the key challenges. 

13.The Bill should include the general principles that underpin the Welsh approach to public health, and should:

a.    Recognise that poor public health is much more than ‘lifestyle choice’ – it is caused by structural problems in the economy and society, including low income, low levels of education, poor housing, and unregulated promotion of unhealthy products and services.

b.    Recognise the deep inequalities in health associated with socio-economic group, gender, age, ethnicity and disability.[4]

c.    Ensure the infrastructure for healthy living is available e.g. adequate housing, access to affordable and nutritious food, access to sport facilities.

d.    Combine positive incentives for good health behaviours with restrictions on others.

e.    Be willing to innovate and test new interventions.  

Other areas of public health

14.  There are many other areas of public health that are critically important, including:

a.     Nutrition (including obesity)

b.    Alcohol and substance misuse

c.     Damp, cold and over-crowded housing

d.    Physical inactivity

e.     Sexual health

15.  These issues are arguably more important than where people use e-cigarettes and we would welcome their inclusion in a comprehensive Public Health (Wales) Bill.

Yours sincerely

Victoria Winckler



Minister for Health and Social Services

Deputy Minister for Health

Chief Medical Officer

[1] Bevan Foundation (2013) Hitting the Quit Target: Smoking and Low Income Groups.

[2] Accessing help to quit can involve several separate steps which lose smokers en route - intervention should occur immediately a smoker indicates they want to quit. 

[3] The preferred approach of nicotine replacement therapy (NRT) plus group support is not appropriate for all quitters. Other methods (e.g. prescription medicines or multiple NRT) are slightly less effective but are very much better than no support at all or repeated failures with the preferred method.  

[4] Bevan Foundation (2015) Social Justice Briefing: Inequalities in Health.