Should e-cigarette use be included in indoor smoking bans?

540 Bull World Health Organ 2017;95:540–541 | doi: http://dx.doi.org/10.2471/BLT.16.186536 Perspectives Electronic nicotine delivery systems, also called e-cigarettes, are devices that vapourize liquid, typically comprising nicotine, propylene glycol, glycerine and flavourings. Switching from smoking tobacco cigarettes to using e-cigarettes – known as vaping – may reduce user harm, by supporting quitting or acting as a lower risk substitute. However, the degree of harm reduction is uncertain. Governments that are considering poli- cies to restrict vaping should consider the optimal regulation of e-cigarette products, including defining where vaping may occur. Here, we explore some of the arguments for and against extending indoor smoke-free laws to also cover vaping. Arguments for vaping First, allowing vaping in indoor public places may encourage smokers to switch to vaping, by making it relatively more attractive as vaping would be allowed where tobacco smoking is not. Some e- cigarette users have voiced this potential benefit of normalization of vaping when arguing against any bans on public vap- ing.1 Nevertheless, we are not aware of any clear evidence supporting this argu- ment as an important driver for smok- ers switching to vaping. Other factors, such as health reasons or the lower cost of vaping, seem to be more important for switching from smoking to vaping. Furthermore, if vaping indoors does actually normalize vaping for smokers, then logic would suggest it might also normalize vaping for non-smokers. Second, allowing vaping in indoor public places where smoking is not per- mitted could minimize any discomfort that e-cigarette users may experience from nicotine withdrawal when being in such settings. However, evidence sug- gests that this discomfort is fairly mod- est. For example, in a survey conducted among exclusive e-cigarette users in the United States of America, only 12% (124 of 1034) reported finding it difficult to refrain from vaping in places where they were not supposed to.2 Arguments for prohibiting vaping First, at a distance, smoking and vaping may look similar to some people, since both activities produce visible clouds exhaled from people’s mouths after they have drawn on a cigarette or device. Some e-cigarette users admit to this similarity, e.g. some cite visual similarity as a reason why they do not vape around people who are eating.1 Given such simi- larities, permitting indoor vaping might renormalize tobacco smoking in smoke- free indoor environments and may lead smokers to query: if vaping is permitted, why is smoking not allowed. Renormal- ization of tobacco smoking would be particularly problematic if it increases the risk that children become suscep- tible to or initiate smoking. Indeed, some research suggests that children may misperceive vaping as smoking.3 Nevertheless, the authors of this study speculated that “once these products are more common and the purpose of them is known, seeing people use them should normalize quitting behaviour.”3 A second argument is that close exposure to vaping among people who have recently quit smoking or vaping might trigger them to relapse to smok- ing. For example, an experimental study among young-adult tobacco smokers reported that exposure to a video show- ing vaping significantly increased their urge to smoke as well as their desire for tobacco cigarettes and e-cigarettes.4 Similarly, another experimental study found that exposure to the e-cigarette cue but not the tobacco cigarette cue also significantly increased desire to smoke an e-cigarette.5 Evidence suggests that many smok- ers support smoke-free areas, because this helps encourage them to quit.6 It seems plausible that this reasoning would also apply to e-cigarette users, who wish to either constrain the level of their vaping or to quit vaping and may therefore favour indoor areas be- ing vape-free. Third, passive exposure to e-cig- arette vapour might lead to adverse health effects according to a systematic review of 16 studies.7 A 2016 report from the World Health Organization (WHO)8 also concluded that second- hand aerosols from e-cigarettes are a new air contamination source for hazardous particulate matter (PM). The levels of some metals, such as nickel and chromium, in second-hand aerosols are not only higher than background air, but also higher than second-hand smoke. Furthermore, compared to background air levels, PM1.0 and PM2.5 in second- hand aerosols are 14–40 times and 6–86 times higher, respectively. In addition, nicotine in second-hand aerosols has been found to be between 10–115 times higher than in background air levels, acetaldehyde between two and eight times higher, and formaldehyde about 20% higher.8 The report suggested that the increased concentration of toxicants from second-hand aerosols over back- ground levels poses an increased risk for the health of all bystanders, espe- cially those with pre-existing respiratory conditions.8 As a result of the report, WHO recommends to Parties of the Frame- work Convention on Tobacco Control (FCTC) that they consider prohibiting by law the use of e-cigarettes in indoor spaces or at least where smoking is not permitted.8 Furthermore, the Interna- tional Agency for Research on Cancer9 now considers particulates such as PM2.5 to be carcinogenic. These data seem to support the case for fairly strong pre- cautionary arguments for governments to protect the public from involuntary exposure to second-hand aerosols. Fourth, regardless of the potential health risks, some people find second- hand aerosols from nearby vaping to be a nuisance, since the e-cigarettes Should e-cigarette use be included in indoor smoking bans? Nick Wilson,a Janet Hoek,b George Thomsona & Richard Edwardsa a Department of Public Health, University of Otago, Mein St, PO Box 7343, Wellington, 6021, New Zealand. b Department of Marketing, University of Otago, Dunedin, New Zealand. Correspondence to Nick Wilson (email: nick.wilson@otago.ac.nz). (Submitted: 12 October 2016 – Revised version received: 26 December 2016 – Accepted: 6 January 2017 – Published online: 28 April 2017 ) Bull World Health Organ 2017;95:540–541| doi: http://dx.doi.org/10.2471/BLT.16.186536 541 Perspectives Vape-free indoor areasNick Wilson et al. can include strong flavours and leave pungent odours. While such nuisance concerns do not appear to have been quantified in surveys, we note that the 2016 vaper-friendly Global Forum on Nicotine conference, actually banned participants from vaping in certain indoor areas due to the nuisance that aerosol clouds caused.10 Fifth, a law aiming to achieve high compliance needs to be readily under- standable to people who vape and those around them, hence a law restricting smoking should support a smoke-free encompasses vape-free approach. Ex- emptions that permit vaping in some indoor smoke-free settings (e.g. certain workplaces, restaurants or pubs) but not others, may risk generating confusion. The problems with a lack of simplicity have been illustrated by jurisdictions that have adopted complex smoke-free laws (e.g. exemptions for some types of small pubs/bars, permitting smoking rooms and defining half an indoor area smoke-free). Simplicity might also fa- vour citizen-led promotion and enforce- ment of the law by reducing confusion between a cloud of vaped aerosol at a distance and a cloud of cigarette smoke. Conclusion Considering the above arguments col- lectively, we believe that, from a public health perspective, central and local governments should adopt regulations that effectively determine that all des- ignated indoor smoke-free areas are also vape-free areas. We note that this approach is being implemented by many jurisdictions, with vaping being banned in enclosed public spaces, such as bars, restaurants and other workplaces, in 25 countries.11 This approach is also recom- mended in the 2016 WHO report to the Parties of the FCTC.8 Nevertheless, further research on the risks of using e-cigarettes is still desirable.12 Research is needed to determine whether smoke-free out- door areas should also be vape-free or not, as the issues differ somewhat from indoor public spaces (e.g. greater dilution of second-hand aerosols outdoors). An important perspective is wheth- er a society is considering vaping as a permanently acceptable activity or as a temporary way to provide nicotine for people giving up smoking and transi- tioning to be nicotine-free. If public health policies are based on the latter perspective, it may be unwise to adopt any policy permitting indoor vaping areas, since that could suggest vaping should be a permanently allowed activ- ity. Furthermore, governments wanting to encourage smokers to shift to vaping might be better advised to evaluate the potential of other strategies, such as differential prices, that is, via high tobacco taxes and untaxed e-cigarettes. A potential advantage of price instru- ments over vape-free policies is that price instruments might be more easily and quickly adjusted via tax changes than changes to the legal designation of vape-free areas. ■ Competing Interests: None declared. References 1. Farrimond H. E-cigarette regulation and policy: UK vapers’ perspectives. Addiction. 2016 Jun;111(6):1077–83. doi: http://dx.doi.org/10.1111/ add.13322 PMID: 26802864 2. Yingst JM, Veldheer S, Hammett E, Hrabovsky S, Foulds J. Should electronic cigarette use be covered by clean indoor air laws? Tob Control. 2017 Mar;26 e1:e16–8. doi: http://dx.doi.org/10.1136/tobaccocontrol-2016-053074 PMID: 27596227 3. Faletau J, Glover M, Nosa V, Pienaar F. Looks like smoking, is it smoking?: children’s perceptions of cigarette-like nicotine delivery systems, smoking and cessation. Harm Reduct J. 2013 11 18;10(1):30. doi: http://dx.doi. org/10.1186/1477-7517-10-30 PMID: 24238406 4. King AC, Smith LJ, Fridberg DJ, Matthews AK, McNamara PJ, Cao D. Exposure to electronic nicotine delivery systems (ENDS) visual imagery increases smoking urge and desire. Psychol Addict Behav. 2016 Feb;30(1):106–12. doi: http://dx.doi.org/10.1037/adb0000123 PMID: 26618797 5. King AC, Smith LJ, McNamara PJ, Matthews AK, Fridberg DJ. Passive exposure to electronic cigarette (e-cigarette) use increases desire for combustible and e-cigarettes in young adult smokers. Tob Control. 2015 Sep;24(5):501–4. doi: http://dx.doi.org/10.1136/ tobaccocontrol-2014-051563 PMID: 24848637 6. Nagelhout GE, Zhuang YL, Gamst A, Zhu SH. Do smokers support smoke- free laws to help themselves quit smoking? Findings from a longitudinal study. Tob Control. 2015 May;24(3):233–7. doi: http://dx.doi.org/10.1136/ tobaccocontrol-2013-051255 PMID: 24415730 7. Hess IM, Lachireddy K, Capon A. A systematic review of the health risks from passive exposure to electronic cigarette vapour. Public Health Res Pract. 2016 04 15;26(2):e2621617. doi: http://dx.doi.org/10.17061/phrp2621617 PMID: 27734060 8. Electronic nicotine delivery systems and electronic non-nicotine delivery systems (ENDS/ENNDS). Geneva: World Health Organization; 2016. Available from: http://www.who.int/fctc/cop/cop7/FCTC_COP_7_11_EN.pdf?ua=1 [cited 2017 Apr 25]. 9. Hamra GB, Guha N, Cohen A, Laden F, Raaschou-Nielsen O, Samet JM, et al. Outdoor particulate matter exposure and lung cancer: a systematic review and meta-analysis. Environ Health Perspect. 2014 Sep;122(9):906–11. PMID: 24911630 10. Global Forum on Nicotine. GFN 2016 vaping policy. London: Knowledge Action Change; 2016. Available from: https://gfn.net.co/venue-city-2016/ vaping-policy [cited 2016 Oct 4]. 11. Kennedy RD, Awopegba A, De León E, Cohen JE. Global approaches to regulating electronic cigarettes. Tob Control. 2016 Nov 30;tobaccocontrol-2016-053179. doi: http://dx.doi.org/10.1136/ tobaccocontrol-2016-053179 PMID: 27903958 12. Combes RD, Balls M. On the safety of e-cigarettes: “I can resist anything except temptation”. Altern Lab Anim. 2015 Dec;43(6):417–25. PMID: 26753944