Banning the use of tobacco and e-cigarettes in public places COVID-19 and beyond © World Health Organization 2020 Some rights reserved. This work is available under the Creative Commons Attribution-NonCommercial- ShareAlike 3.0 IGO licence (CC BY-NC-SA 3.0 IGO; https://creativecommons.org/licenses/by-nc- sa/3.0/igo). WHO Library Cataloguing in Publication Data Names: World Health Organization. Regional Office for the Eastern Mediterranean Title: COVID-19 and beyond: banning the use of tobacco and e-cigarettes in public places / World Health Organization. Regional Office for the Eastern Mediterranean Description: Cairo: World Health Organization. Regional Office for the Eastern Mediterranean, 2020 Identifier: ISBN 978-92-9274-433-5 (pbk.) | ISBN 978-92-9274-434-2 (online) Subjects: COVID-19 - prevention & control | Betacoronavirus | Disease Outbreaks | Tobacco Use – prevention & control | Vaping – prevention & control | Water Pipe Smoking – prevention & control Classification: NLM WC 505 This publication was originally published under ISBN: 978-92-9022-400-6, 978-92-9022-402-0 Contents Banning the use of tobacco and e-cigarettes in public places .................................. 1 Banning waterpipe use during the COVID-19 pandemic ........................................... 1 Maintaining bans on all tobacco use, including waterpipes and e-cigarettes, in public places during the pandemic and beyond ......................... 2 There is no safe level of exposure to second-hand smoke ....................................... 2 Heated tobacco products and e-cigarettes ................................................................ 2 Banning smoking in all its forms in all indoor public places is a legal obligation .............................................................................. 3 The status of smoke-free laws in the Eastern Mediterranean Region.................................................................................. 3 Enforcing a comprehensive ban on tobacco smoke in public places is possible............................................................................. 4 Economic losses related to a ban of tobacco smoke, including from waterpipe use, in public places are a myth ........................................ 4 Banning tobacco smoke in public places protects youth ........................................... 5 The expected reaction from the tobacco industry...................................................... 6 Recommended next steps during the COVID-19 pandemic and beyond ............................................................................................... 7 References ................................................................................................................ 8
COVID-19 and beyond Banning the use of tobacco and e-cigarettes in public places 1 Banning the use of tobacco and e-cigarettes in public places WHO recommends that countries comprehensively ban smoking in all indoor public places, and in other public places where possible (1), in line with Article 8 of the WHO Framework Convention on Tobacco Control (FCTC) and its Guidelines, as well as the MPOWER tobacco control policy package. Exposure to second-hand smoke kills over 1 million people every year, comprising about 15% of the total number of deaths caused by tobacco use (2). Tobacco use is a major risk factor for noncommunicable diseases, such as cancers, diabetes, lung disorders and cardiovascular disease. Tobacco use is also associated with increased transmission of, and mortality from, infectious diseases (3,4,5). When tobacco is smoked in public places, both smokers and non- smokers breathe in the toxic constituents present in second-hand smoke. Banning smoking in public places (including waterpipe use) saves lives by protecting non-smokers from the harm of inhaling second-hand smoke (6,7,8,9). Banning waterpipe use during the COVID-19 pandemic Following the spread of the COVID-19 pandemic around the world, 15 countries in the WHO Eastern Mediterranean Region took the bold decision to temporarily ban waterpipe use in public places. Added to the two countries that had already banned it, this brings the number of countries in the Region that have banned waterpipe use in public places to 17. Waterpipe use has been identified as a possible means for the spread of COVID-19 due to its communal use, which involves the sharing of a single mouthpiece and hose, and its customary use in social gatherings, which makes physical distancing impossible. The ban was strictly implemented, and violations were minimal due to active national inspection systems in countries to monitor implementation. As countries move towards less strict measures to control the spread of COVID-19, it is important that they consider maintaining the ban on tobacco and waterpipe use, and on electronic cigarettes (e-cigarettes), in public places for wider health reasons. COVID-19 and beyond Banning the use of tobacco and e-cigarettes in public places2 Maintaining bans on all tobacco use, including waterpipes and e-cigarettes, in public places during the pandemic and beyond A comprehensive ban on all tobacco smoke, including waterpipe use, in all indoor public places, indoor workplaces and public transport should be maintained because tobacco smoke in any indoor place seriously harms the health of the tobacco user and all those exposed to tobacco smoke (10). Research shows that banning tobacco use in public places has reduced the prevalence of tobacco use by 2.5%–15% over five years in various countries of the Region (11). There is no safe level of exposure to second-hand smoke More than 7000 chemicals have been identified in second-hand smoke, of which 250 are known to be harmful to health and more than 50 are known to cause cancer (12,13,14,15). There is no safe level of exposure to second- hand smoke, which causes heart disease, chronic respiratory disease, several types of cancers and many other debilitating conditions. Even brief exposure can cause serious damage (16). There are also high economic costs that result from the mortality, morbidity and loss of income that results from exposure to second-hand tobacco smoke. A study done in the United States of America in 2005 estimated that exposure to second-hand smoke costs more than US$ 10 billion each year (17). Heated tobacco products and e-cigarettes Novel tobacco and nicotine products should also be included in all smoke- free policies. This includes both heated tobacco products and e-cigarettes. There is clear guidance from the last session of the Conference of Parties to the WHO FCTC that heated tobacco products are tobacco products and that all provisions of the WHO FCTC on smoke-free policies should be applied. Like smoke from conventional cigarettes, emissions from heated tobacco products contain harmful toxicants (18). This means that emissions from heated tobacco products, including second-hand emissions, pose a health risk to people in public places. In addition, since heated tobacco products are tobacco products (19), obligations under the WHO FCTC still apply (20). Parties to the WHO FCTC have an obligation to ensure that the use of heated tobacco COVID-19 and beyond Banning the use of tobacco and e-cigarettes in public places 3 products is banned in all indoor public places, including workplaces, cafes and restaurants. Emissions from e-cigarettes are also harmful to both users and non-users. These emissions typically contain nicotine, which is addictive, and other toxic substances, some of which are known to cause cancer and other health conditions (18,21). Use of e-cigarettes also increases the risk of heart disease and lung disorders (22,23,24). Second-hand aerosol from e-cigarettes has been shown to be a source of air contamination with particulate matter and contains significantly higher levels of many harmful chemicals than background air levels (21). Given these health risks for both users and non-users, use of e-cigarettes should be comprehensively banned in all indoor public places. This has been made clear by WHO, including in a report to the Conference of Parties to the WHO FCTC in 2016 (21). Banning smoking in all its forms in all indoor public places is a legal obligation The WHO FCTC requires that tobacco smoking be banned in all indoor public places and in other public places, where possible. All Parties to the Convention are requested to comply with this requirement. In the WHO Eastern Mediterranean Region, there are currently 19 Parties to the WHO FCTC. The status of smoke- free laws in the Eastern Mediterranean Region Currently, seven countries in the Eastern Mediterranean Region have successfully passed laws that comprehensively and permanently ban tobacco smoke in all indoor public places, including workplaces, cafes and restaurants. Enforcement of this policy, however, remains a big challenge in the Region. Countries that have banned tobacco use in public places include Afghanistan, Egypt, Islamic Republic of Iran, Lebanon, Libya, Pakistan and Palestine (25). Many other countries have introduced partial bans on tobacco smoke in public places. A lack of enforcement of smoke-free laws is a common issue in the Eastern Mediterranean Region, with large numbers of youth reporting exposure to second-hand smoke in public places despite the adoption of smoke-free laws. For instance, although Egypt has banned smoking in all indoor public places, 55% of youth reported COVID-19 and beyond Banning the use of tobacco and e-cigarettes in public places4 being exposed to second-hand smoke in these areas. Youth exposure to second-hand smoke is also high in several other countries that have a similarly comprehensive ban, including Afghanistan (35%), Islamic Republic of Iran (38%) and Pakistan (38%) (26). Enforcing a comprehensive ban on tobacco smoke in public places is possible Passing smoke-free legislation is not enough. The public only benefits from a comprehensive ban on tobacco smoke in indoor public places when the policies are fully complied with, which requires effective enforcement. The proper implementation and adequate enforcement of bans requires relatively small but critical actions. Over time, once a high level of compliance is achieved, smoke-free laws become self-enforcing (1). Recent national efforts in the Eastern Mediterranean Region to ban waterpipe use in public places, including in cafes and restaurants, in light of COVID-19, show that with strong support from all relevant national authorities – a multisectoral approach – and effective public awareness campaigns, smoke-free policies can be enforced successfully. Economic losses related to a ban of tobacco smoke, including from waterpipe use, in public places are a myth Comprehensively banning tobacco smoke, including waterpipe use, in public places does not lead to economic losses. Evidence from countries where comprehensive smoke-free legislation has been implemented and enforced shows that these policies have a neutral or positive impact on businesses (1,27). This contradicts the tobacco industry’s claims that these policies economically harm businesses and the hospitality industry. Implementing smoke-free policies is a very cost-effective tobacco control policy. In fact, in its recent review of policies for the prevention and control of noncommunicable diseases, WHO assessed that eliminating exposure to second-hand tobacco smoke in all indoor workplaces, public places and public transport, should be classified as the highest category of ‘best buy’ (28). COVID-19 and beyond Banning the use of tobacco and e-cigarettes in public places 5 Fig.1 Correlation between youth exposure to second-hand smoke in indoor places and prevalence of youth tobacco use (R2 = 0.46, p < 0.01) 35 30 25 20 15 10 5 0 Exposure to second-handsmoke in enclosed public places (%) 30 40 50 60 Pr ev al en ce o f c ur re nt y ou th a ny to ba cc o us e (% ) Oman Pakistan Afghanistan Morocco Islamic Republic of Iran Qatar United Arab Emirates Sudan Djibouti Bahrain Iraq Gaza Strip Yemen Kuwait Jordan Tunisia West Bank Egypt Banning tobacco smoke in public places protects youth Analysis of the results of the Global Youth Tobacco Survey shows that as the exposure of youth to second- hand smoke in indoor public places increases, the prevalence of current youth tobacco use also increases (Fig.1). At the same time, country-level analyses of the results of the survey show that the exposure of youth to second-hand smoke in public places increases their likelihood of becoming cigarette smokers in the future compared to those who are not exposed (26): • In Bahrain, youth who are exposed to second-hand smoke in outdoor public places and enclosed public places are 2.3 and 1.5 times, respectively, more likely to become cigarette smokers. • In Djibouti, youth exposed to second-hand smoke in outdoor public places are 1.6 times more likely to become current cigarette smokers. COVID-19 and beyond Banning the use of tobacco and e-cigarettes in public places6 • In Egypt, youth who are exposed to second-hand smoke in outdoor public places and enclosed public places are 2.5 and 2.0 times, respectively, more likely to become current cigarette smokers. • In Morocco, youth who are exposed to second-hand smoke in enclosed public places are 2.3 times more likely to become cigarette smokers. • In Qatar, youth who are exposed to second-hand smoke in outdoor public places and enclosed public places are 3.2 and 1.7 times, respectively, more likely to become cigarette smokers. • In Tunisia, youth who are exposed to second-hand smoke in outdoor public places are 2.3 times more likely to become cigarette smokers. • In Yemen, youth who are exposed to second-hand smoke in outdoor public places are 2.3 times more likely to become current cigarette smokers. The expected reaction from the tobacco industry Governments need to remain vigilant to the efforts of the tobacco industry to interfere in health policy. The tobacco industry is highly likely to: • try to undermine smoke-free laws; • promote designated smoking areas and alternatives for comprehensive tobacco smoke bans; • push for the ban in some, but not all, public places; • seek exemptions for e-cigarettes and heated tobacco products from any bans. The industry is currently seeking to create the false impression that e-cigarettes and heated tobacco products are safe alternatives to smoking and that using these products in public places is not harmful for non- users. In line with the WHO FCTC, all tobacco control policy-making, including regarding smoke-free policies, laws and enforcement, should be protected from the interests of the tobacco industry. This means that the tobacco industry or any of its representatives, front groups and affiliated organizations should be excluded from the setting, implementation and enforcement of smoke-free policies (29). COVID-19 and beyond Banning the use of tobacco and e-cigarettes in public places 7 Recommended next steps during the COVID-19 pandemic and beyond In the context of COVID-19, tobacco use, including waterpipe and e-cigarette use, should remain banned in all public places. As countries start to relax COVID-19 lockdown measures, the following approaches are recommended. 1. Bans on waterpipe use and tobacco smoke in all indoor and outdoor public places should be maintained where possible, to protect public health. 2. Bans on tobacco use, including waterpipe and e-cigarette use, should include health facilities, governmental and public buildings, restaurants and cafes, schools and educational facilities, universities, sports facilities, transportation, and private and public workplaces. 3. No designated smoking areas should be allowed. 4. A multisectoral approach should be followed in maintaining bans, involving all relevant ministries and other organizations. 5. Legislation should be changed, where needed, to make bans on waterpipe use and smoking in public places permanent. 6. A mechanism should be put in place to monitor and evaluate the implementation of bans on tobacco use in public places. 7. Enforcement mechanisms should be built upon those that have worked well during the current ban of waterpipe use in public places. 8. Mass media campaigns should be undertaken to raise awareness and engage the public in support of bans on tobacco use in public places. 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