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The availability, marketing and use of electronic cigarettes or nicotine vapourisers is subject to a range of regulations across different countries, varying from the prohibition of sales and use, to little or no regulation.1 The most common approach adopted in countries that permit some use of e-cigarettes has been to adapt existing laws or frameworks designed for tobacco products to include e-cigarettes. This can include extending bans on tobacco advertising to e-cigarettes, applying the same age of sale laws or taxing e-cigarettes like tobacco.2 In some jurisdictions including many Canadian provinces and US states, existing smoke-free public places laws have also been amended to include e-cigarettes, so that vaping is prohibited wherever tobacco cannot be used—including enclosed public places, workplaces and some outdoor areas. But is this the right approach, and is it supported by research evidence?
In the UK, a country with 2.8 million vapers (and 9 million smokers), policymakers have taken the decision not to legislate to ban e-cigarette use in all public places and workplaces.2 This is the case in all parts of the UK (Scotland, Wales, England and Northern Ireland) despite different approaches to considering the issue and different regulatory frameworks. In England and Scotland in particular, decisions have been taken by governments that extending smoke-free laws to include e-cigarettes is neither desirable nor necessary to protect the health of the population.
The reasons for this are complex but relate to at least three issues. First, and most importantly, is exposure to e-cigarette vapour harmful to bystanders? Second, what is the role of e-cigarettes in reducing smoking rates and how might public and workplace bans help or hinder this? Third, what are the views of key stakeholders?
Discussion of these three issues in the UK has been informed by the state of the evidence gathered in our own country and further afield.
Is e-cigarette vapour harmful to bystanders?
Legislation prohibiting smoking in workplaces and public places was introduced in the UK and other countries on the basis of scientific evidence that secondhand smoke was harmful to bystanders.3 Article 8 of the Framework Convention on Tobacco Control was developed from this evidence of health harms and sets out how smoke-free laws should be implemented.
Studies examining the effects of passive exposure to e-cigarette vapour on bystanders were summarised in a recent Royal College of Physicians report ‘Nicotine without smoke: tobacco harm reduction’.2 The report concluded that, to date, there was no evidence that passive exposure was likely to cause significant harm to bystanders. E-cigarette users exhale vapour (an aerosol) which usually contains nicotine but there is no evidence that passive exposure to this exhaled nicotine can cause harm. Exhaled nicotine can be deposited on surfaces, but at extremely low levels and no mechanism has been proposed by which these deposits could be ingested in doses that could cause physical harm.
How could a ban on e-cigarettes in indoor places affect smoking?
We believe that potential benefits accrued from permitting e-cigarettes in some workplaces and public places outweigh concerns that allowing use might ‘normalise’ a behaviour similar to smoking, undermining the gains that have been made by smoke-free laws. There is no evidence that e-cigarettes are renormalising tobacco smoking. Regular use of e-cigarettes by never smokers, including children, is minimal despite misleading headlines driven by studies that only examine ever or recent use.4–6 The evidence shows that in the UK, US and other countries where e-cigarette use among young people have risen, levels of tobacco use have fallen. To date the fear that e-cigarettes will create a new generation of either regular nicotine users or smokers remains unfounded.
In relation to adult smokers, current evidence suggests that e-cigarettes are unlikely to be as effective for smoking cessation as the combination of intensive behavioural support and licensed pharmacotherapies offered by well-established smoking cessation services.7 However, a challenge in the UK as well as elsewhere is that many smokers do not access these types of services. Indeed in the UK, more than 10 times as many people use e-cigarettes to stop smoking as access services. Even with moderate effectiveness, therefore, their promise for smoking cessation may be in their reach and popularity. Yet a significant barrier to uptake of these less-harmful products is public perception that they are dangerous. Smokers in the UK and elsewhere increasingly believe vaping is as risky as smoking—with this misperception rising year on year. These misperceptions influence usage.8 Prohibiting the use of e-cigarettes in all places where smoking is banned is likely to promulgate the misleading message that e-cigarettes are just as harmful as smoking and therefore could deter switching from smoking to vaping.
What are the views of stakeholders?
A third important consideration on indoor e-cigarette regulations is the views of key stakeholders. Employers may be concerned about any risks from vaping either to users or bystanders, and opinions on acceptability, etiquette and enforcement are also relevant. A recent study9 in Great Britain suggested that public support for prohibiting vaping in indoor public places had increased over recent years. However, this and studies from other countries found that respondents with more accurate knowledge about the relative risks of e-cigarettes, smoking and nicotine were less likely to support such a policy. Public agencies in the UK have therefore consulted on new regulations governing e-cigarettes—including the provisions in Scotland's Health (Tobacco, Nicotine, etc, and Care) Act and through Public Health England's online discussion with stakeholders about a framework for the use of e-cigarettes in enclosed public places and workplaces.10 The Public Health England consultation in particular proposed draft principles for policies and practice that provided the basis for feedback from public health professionals, business owners, agencies and the public. What emerged was a consensus that national legislation was unlikely to strike an appropriate balance of risks and benefits when there was no ‘one size fits all’ solution. The resulting framework,11 launched in July 2016, contains five principles to help guide a vaping policy appropriate for individual organisations. These were: make a clear distinction between vaping and smoking; ensure policies are based on evidence of harm to bystanders; identify and manage risks of uptake by children and young people; support smokers to stop smoking and stay smoke free; and support compliance with smoke-free laws and policies. This framework allows different organisations (a nursery, or a factory or warehouse, which are very different working environments) to make their own decisions about where and when vaping is allowed indoors or in outdoor public spaces.
The evidence to date does not support a policy to prohibit e-cigarette use in enclosed public places and such policies could have significant unintended consequences by sustaining the use of smoked tobacco. In addition, if and when vapour products with a medicinal license become available, it will be important to allow their use indoors, just as asthma inhalers, which dispense a drug and propellants into the atmosphere, can be used indoors. It remains important, however, to continue to research the impact of exposure to e-cigarette vapour on bystanders and of policies where implemented, to ensure that evidence continues to inform practice in this area.
Competing interests PH has provided consultancy for and received research funding from manufacturers of stop smoking medications. The other authors have no competing interests.
Provenance and peer review Commissioned; internally peer reviewed.