Article Text

Workplace smoke-free policies that allow heated tobacco products and electronic cigarettes use are associated with use of both these products and conventional tobacco smoking: the 2018 JASTIS study
  1. Yanakawee Siripongvutikorn1,
  2. Takahiro Tabuchi2,
  3. Sumiyo Okawa2
  1. 1 Osaka University Faculty of Medicine Graduate School of Medicine, Suita, Japan
  2. 2 Cancer Control Center, Osaka International Cancer Institute, Osaka, Japan
  1. Correspondence to Dr Takahiro Tabuchi, Cancer Control Center, Osaka International Cancer Institute, Osaka 541-8567, Japan; tabuti-ta{at}mc.pref.osaka.jp

Abstract

Objectives Heated tobacco products (HTPs) and electronic cigarettes (e-cigarettes) are rapidly gaining popularity, especially in Japan. However, at the time of the survey (2018), there was no national legislation banning HTPs or e-cigarette use in the workplace. The objective is to examine the current situation for workplace smoke-free policies which ban the use of HTPs/e-cigarettes and the associations of such rules with the use of HTP and e-cigarette as well as conventional cigarette smoking.

Methods An internet-based self-reported questionnaire survey was conducted in 2018 as a part of the Japan Society and New Tobacco Internet Survey study. 5646 eligible employees aged 15–72 years were analysed. Proportions and adjusted rate ratios for HTP and e-cigarette use were calculated according to covariates, using Poisson regression models. Those who reported HTP or e-cigarette use within 30 days were defined as current user of the products.

Results In workplaces which prohibited smoking indoors but permitted the use of HTPs/e-cigarettes, the rate ratios of HTP use was 2.19 (95% CI 1.57 to 3.06), e-cigarette use was 3.86 (95% CI 1.97 to 7.57) and combustible cigarette use was 1.67 (95% CI 1.19 to 2.34) when using workplaces which also prohibited HTPs/e-cigarettes as a reference category.

Conclusions Workplaces that allow HTP/e-cigarette use indoors were associated with higher rate for HTP and e-cigarette users, and for combustible cigarette smokers. National legislation banning tobacco should be enforced and also cover HTPs and e-cigarettes in order to avoid renormalisation of smoking and nicotine addiction.

  • electronic nicotine delivery devices
  • non-cigarette tobacco products
  • public policy

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Introduction

Recently, heated tobacco products (HTPs) and electronic cigarettes (e-cigarettes) have been rapidly gaining popularity in Japan and worldwide.1 2 In an internet survey conducted in 2015, it was estimated that 22.1% of Japanese adults were current combustible cigarette smokers, 6.6% had ever used HTPs such as IQOS, Ploom TECH and glo or e-cigarettes and 1.3% had used them in the previous 30 days.3 Japan became the only country where a national roll-out of IQOS had occurred, and Japan’s worldwide share of IQOS sales was 96% in October 2016.4 IQOS users increased from 0.3% in 2015 to 0.6% in 2016, 3.6% in 2017 and up to 6.9% in 2018.2 5

Smoke-free policies are one of the key mediators in tobacco control.6 National-level legislative smoking bans in countries such as Australia, England and the USA have proven to be effective in reducing smoking rate and the burden of secondhand smoke (SHS)-related disease.6 7 SHS exposure is one of the most prevalent and preventable risk factors for many health outcomes, including respiratory, cardiovascular and neoplastic diseases.8 Globally, approximately 35% of non-smokers have been exposed to SHS in a number of different places,9 with workplace reported to be a major area where such exposure occurs.10 The WHO Framework Convention on Tobacco Control recommends complete workplace smoking bans in order to reduce workplace SHS exposure.11 In Japan, however, partial smoking bans were approved in 200312 and are now widespread.13 At the time of the survey (2018), there was no national legislation banning HTP or e-cigarette use in the workplace. Moreover, most private workplaces have adopted their own smoke-free policies.14

HTPs and e-cigarettes have been marketed to consumers as less hazardous products than combustible cigarettes, and as means to evade smoke-free policies.15 Although detailed reports of long-term side effects are still pending, respiratory tract irritation, impaired pulmonary function and various health risks have been reported by several studies.16 17 A previous study found that about 30% of adult Japanese had ever used e-cigarettes in restaurants and/or workplaces where combustible tobacco smoking is not allowed.18 The use of HTPs or e-cigarettes in places where conventional tobacco smoking is prohibited could potentially renormalise tobacco use, sustain the dual use of such products and tobacco, maintain nicotine addiction and complicate the enforcement of smoke-free policies.19–21

Considering the growing use HTPs and e-cigarettes worldwide and their adverse health effects, close monitoring of the situation is necessary. To the best of our knowledge, only two studies have examined e-cigarette restriction in the workplace.22 23 However, there have still been no studies which include restrictions on HTPs. Therefore, the objective of this paper is to examine the current situation for workplace smoke-free policies which cover HTP/e-cigarette use and the association of such rules with the rate of their use. The results of this study will provide relevant information for policymakers to establish explicit smoke-free rules covering HTP and e-cigarette use.

Methods

Data

We conducted a cross-sectional study using internet-based self-reported questionnaires during January–March 2018, as a part of the Japan Society and New Tobacco Internet Survey (JASTIS) study.24 Participants were drawn from the registers of Rakuten Insight, one of Japan’s largest internet research companies which maintains a pool of 2.3 million panellists covering all social categories (eg, education level, housing tenure and marital status) defined by the census in Japan.25 The survey panel consisted of people recruited initially through services managed by the research agency group. At the time of registration, they were required to provide information such as sex, age, occupation and place of residence and to agree that they would participate in different research surveys.

Participants

In 2018, 9111 respondents participated in the study. After exclusion of respondents who showed unnatural discrepancies (eg, respondents who always chose the same number in an entire set of questions; n=189), non-workers (ie, students, retired people, housewives/husbands and jobless; n=2727) and those whose workplace smoke-free policies were unknown (n=549), 5646 respondents remained for analysis.

Measures

Workplace smoke-free policies

Workplace smoke-free policies are defined as shown in figure 1.

Figure 1

Workplace smoke-free policies. Policy I: smoking prohibited indoors; policy I-1: combustible cigarettes, HTPs and e-cigarettes are all prohibited indoors; policy I-2: combustible cigarettes are prohibited indoors, but HTPs and e-cigarettes are allowed indoors; policy I-3: combustible cigarettes are prohibited indoors, but no rules are administrated for HTPs and e-cigarettes indoors; policy II: smoking room/corner available; policy II-1: HTPs/e-cigarettes must be used only in the smoking room/corner indoors; policy II-2: HTPs/e-cigarettes can be used outside of the smoking room/corner indoors; policy II-3: no rules administrated for HTPs/e-cigarettes outside of the smoking room/corner; policy III: smoking allowed indoors. HTP, heated tobacco product.

First, participants were asked about their workplace smoke-free policies. Options were (A) ‘smoking prohibited indoors’, (B) ‘smoking room available’, (C) ‘smoking corner available’, (D) ‘smoking allowed indoors’, (E) ‘none of the above (eg, non-workers)’ and (F) “I do not know”. Those whose workplace smoke-free policies were unknown (those who chose E or F; n=549) were excluded from the analysis as mentioned earlier.

Next, we defined smoke-free policies (indicated in italics) as follows. (A) ‘Smoking prohibited indoors’ was defined as policy I. Participants in policy I were asked for further detail about their smoke-free policies and had to choose from : (1) ‘combustible cigarettes and HTP/e-cigarettes are all prohibited indoors’—defined as policy I-1; (2) ‘combustible cigarettes are prohibited indoors, but HTPs/e-cigarettes are allowed indoors’—defined as policy I-2 and (3) ‘combustible cigarettes are prohibited indoors, but there are no rules for HTPs/e-cigarettes indoors’—defined as policy I-3. (B) ‘Smoking room available’ and (C) ‘smoking corner available’ were grouped together and defined as policy II. Participants in policy II were asked for further detail about their smoke-free policies, and had to choose from (1) ‘HTPs/e-cigarettes must only be used in the smoking room/corner indoors’—defined as policy II-1; (2) ‘HTPs/e-cigarettes can be used outside of the smoking room/corner indoors’—defined as policy II-2 and (3) ‘no rules for HTPs/e-cigarettes outside of the smoking room/corner’—defined as policy II-3. (D) ‘Smoking allowed indoors’ (assuming that combustible cigarettes, HTPs and e-cigarettes are all allowed) was defined as policy III.

Current use (use in the previous 30 days)

Participants were asked about their current use (use in the previous 30 days) of each product (IQOS, Ploom TECH, glo and e-cigarettes) in the survey. Respondents who answered ‘yes’ to the question, “Have you used the following products in the previous 30 days?” (options: IQOS, Ploom TECH, glo, e-cigarettes (with nicotine), e-cigarettes (without nicotine) and e-cigarettes (not sure whether with/without nicotine)) were defined as current users of the designated product.26 27 Current users of any of the following products—IQOS, Ploom TECH or glo—were defined as HTP current users. Current users of any type of e-cigarette product were defined as current e-cigarette users. Combustible cigarette smoking status was categorised into current smoker, former smoker and never smoker. Dual users were defined as current combustible cigarette smokers who had concurrently used any HTPs or e-cigarettes in the previous 30 days.

Covariates

We converted variables of participant characteristics to categorical variables: sex (men, women), age (15–19, 20–29, 30–39, 40–49, 50–59, 60–72 years), education (high school or below, college, university or above), marital status (married, never married, widowed/divorced), being a current alcohol drinker (yes/no to the question “Have you drunk alcohol in the previous 30 days”) and self-rated health status (good, normal, poor).

Statistical analysis

The proportions and 95% CIs of rate of product use (HTPs, IQOS, Ploom TECH, glo, e-cigarettes and combustible cigarettes) were calculated according to characteristics, including sociodemographics and workplace smoke-free policy. The rate ratios (RRs) and their 95% CIs for each product use, according to each workplace smoke-free policy, were calculated using multivariable regression models.28 29 RRs were used instead of OR because most of the outcomes were not rare (>10%).30 As covariates, we included tobacco smoking status and other sociodemographic factors.

Probability values for statistical tests were two tailed; p<0.05 was considered statistically significant. All analyses were performed using Stata/SE V.13.1.

Results

Characteristics of study participants are shown in table 1. Of total baseline subjects, 60% were male, mean age±SD was 45.0±12.3 years, 51% were never smokers, 28% were former smokers, 22% were current smokers and 11% were current HTP/e-cigarette users. Among current HTP users, 66% (n=359/543) were dual users (using both HTPs and combustible cigarettes). Among current e-cigarette users, 79% (n=106/135) were dual users. Of participants whose workplaces prohibited smoking indoors, 2% (n=60/3126) reported that HTP/e-cigarette use was allowed indoors. Of participants whose workplaces provided a smoking room/corner, 4% (n=95/2218) reported that HTP/e-cigarette use was allowed indoors, outside of the smoking room/corner.

Table 1

Basic characteristics of study subjects

Table 2 shows the proportion and RRs of HTP, e-cigarette and combustible cigarette use according to characteristics under smoke-free policies which include restrictions on HTPs/e-cigarettes. Workplaces with smoke-free policies which exceptionally allowed HTP/e-cigarette use indoors had significantly higher rates for HTP and e-cigarette use, and for combustible cigarette use, compared with when HTPs/e-cigarettes were subject to the same restrictions as those applied to combustible cigarettes (policy I-2>policy I-1 and policy II-2>policy II-1). On the other hand, workplaces which allowed combustible cigarette smoking indoors (policy III) did not show a high rate for HTP or e-cigarette use, though it did for combustible cigarette smoking.

Table 2

Proportions and prevalence ratios of tobacco and tobacco-like product use according to characteristics under workplace smoke-free policies with HTPs/e-cigarettes concerns

The rates of HTP and e-cigarette use were 28.3% and 11.7%, respectively, in workplaces with policy I-2 (vs 8.1% and 1.6%, respectively, with policy I-1); 34.7% and 20.0%, respectively, in workplaces with policy II-2 (vs 16.1% and 3.4%, respectively, with policy II-1) and 9.9% and 2.0%, respectively, in workplaces with policy III. Meanwhile, the rate of combustible cigarettes was 35.0% in workplaces with policy I-2 (vs 19.0% with policy I-1); 45.3% in workplaces with policy II-2 (vs 30.1% with policy II-1) and 31.5% with policy III.

For comparison, table 3 shows the proportion and RRs of HTP, e-cigarette and combustible cigarette use under smoke-free policies without rules for HTP/e-cigarette use (conventional rules). The RRs for HTP and e-cigarette use were 2.19 (95% CI 1.57 to 3.06) and 3.86 (95% CI 1.97 to 7.57) for policy I-2; 2.02 (95% CI 1.56 to 2.63) and 5.32 (95% CI 3.17 to 8.93) for policy II-2, with respect to policy I-1 (table 2). However, RRs for HTP and e-cigarette use were only 1.22 (95% CI 1.05 to 1.41) and 1.41 (95% CI 1.00 to 1.98) for policy II, with respect to policy I (table 3). The RR for combustible cigarette use was 1.67 (95% CI 1.19 to 2.34) for policy I-2; 2.28 (95% CI 1.81 to 2.88) for policy II-2, with respect to policy I-1 (table 2). However, the RR for combustible cigarette use was only 1.31 (95% CI 1.19 to 1.46) for policy II, with respect to policy I (table 3). Separated results for HTPs and/or e-cigarettes, IQOS, Ploom TECH and glo did not largely differ from the results for total HTPs (online supplementary tables S1 and S2). As for additional information, proportion of workplace smoke-free policies according to the types of workplace is shown in online supplementary figure S1.

Table 3

Proportions and prevalence ratios of tobacco and tobacco-like product use according to characteristics under workplace smoke-free policies without HTPs concerns

In general, use of HTPs was higher among male, married and younger participants. Nevertheless, being a current smoker showed the strongest association with HTP and e-cigarette use.

Discussion

To the best of our knowledge, this is the first study to examine present smoke-free policies in workplaces, including restrictions on HTP and e-cigarette use in addition to conventional smoke-free policies and to investigate their influence on HTP, e-cigarette and conventional tobacco smoking status.

In our study, 2% of respondents in workplaces which prohibit smoking indoors, and 4% of respondents in workplaces which provide a smoking room/corner reported that their workplace permitted use of HTPs/e-cigarettes indoors. These percentages were similar to those found in a previous study of e-cigarette use in the UK.21 Although the number of workplaces which permit HTP/e-cigarette use might be relatively low in the present study, the existence of such policies itself indicates that tobacco-control efforts of smoke-free policies are already being evaded.

In July 2018, the Health Promotion Law was revised for smoke-free regulation in Japan. For schools, hospitals and government offices, tobacco use, including both combustible cigarettes and HTPs, has been prohibited indoors since July 2019. For general offices, factories and restaurants (exceptions are made for restaurants smaller than 100 m2), tobacco use is allowed in two types of designated tobacco rooms: (i) tobacco rooms for any tobacco product: smoking is the only activity permitted in the room and (ii) tobacco rooms, especially for HTP use: eating/drinking and other activities besides HTP use are permitted in the room. These rules will be enforced from April 2020.31 Regarding e-cigarettes, there is still no national legislation prohibiting their use at present. The only restriction applies to ‘nicotine-containing’ liquid cartridges, which cannot be purchased in Japan according to Pharmaceutical Affairs Law.32 In other words, HTPs and e-cigarettes are regulated differently from combustible cigarettes, despite WHO’s suggestion that these products should be subject to the policy and regulatory measures applied to all other tobacco products.33 34

As many people around the world, including the Japanese, might perceive HTPs and e-cigarettes as safer alternatives to conventional combustible cigarettes,35 Japan’s national legislation which provides exemptions for HTPs and e-cigarettes will lead to further misperception. Such a situation will undermine social norms that discourage tobacco smoking and make enforcement of smoke-free policies more complicated.19–21

Workplace smoke-free policies are associated with smoking behaviour

In workplaces which prohibited smoking indoors but permitted the use of HTPs/e-cigarettes, the rate of HTP use was 2 times, e-cigarette use was nearly 4 times and combustible cigarette use was 1.7 times higher than workplaces which also prohibited HTPs/e-cigarettes. On the other hand, workplaces which allowed combustible cigarette smoking indoors did not show a higher rate for HTP or e-cigarette use. Although these findings were based on a cross-sectional survey and should be interpreted carefully, the following possibilities can be suggested.

First, HTPs and e-cigarettes may be used as substitutes for combustible cigarettes. A study conducted in 2015 reported that current smokers were more aware of HTPs and e-cigarettes than never smokers.3 The proportions of current smokers were higher in workplaces which exceptionally permitted HTP/e-cigarette use. Therefore, it is plausible that HTPs and e-cigarettes are being used instead of combustible cigarettes at work when combustible cigarettes are banned.

Second, people may be encouraged to use HTPs and e-cigarettes in workplaces which do not ban their use. It is known that smoke-free policies and social environments are critical factors that influence tobacco product use.6 36 Previous studies have suggested that living in an environment surrounded by smokers increases the risk of an individual becoming a smoker themselves. Therefore, workplaces which allow HTP/e-cigarette use are also likely to encourage a person to start using HTPs and e-cigarettes. This result was in line with a previous study in the USA, which reported that workplace e-cigarette restriction was associated with less likelihood of e-cigarette use.25 Due to the new Japanese legislation which will permit HTP use in special areas separated from conventional cigarette smoking in 2020,31 it is likely that such areas designated for HTP use will increase and further promote the use of HTPs.

Restrictions on HTP/e-cigarette use should be included in tobacco rule classification for proper monitoring of current tobacco situation

The rate of HTP, e-cigarette and combustible cigarette use varied greatly among subgroups within policy I and policy II after restrictions on HTP/e-cigarette use were taken into account. This result suggests that restrictions on HTP/e-cigarette use should be included in tobacco rule classification, in order to monitor current tobacco situation effectively.

In general, HTP and e-cigarette use is higher among male, married and younger participants. The higher use in males is thought to be associated with conventional tobacco smoking status. Higher use in married people can be related to SHS consideration towards other family members, and the belief that HTPs and e-cigarettes are less harmful.5 Finally, HTP and e-cigarette use is higher among younger people than in older age groups. On the other hand, combustible cigarette use is higher among older people and lower in younger age groups. This is possibly because HTPs and e-cigarettes were introduced to the market in recent years, while combustible cigarette history dates back much further. Thus, the younger generations have become targets for HTPs and e-cigarettes, while older generations were already more familiar with combustible cigarettes.

Limitations

This study has several limitations. First, the results were obtained through a self-reported internet questionnaire survey. Although the polling company aims to achieve representativeness, the distribution of the population might be imperfect. As the information was self-reported, we excluded respondents with discrepancies or inconsistencies in their answers. However, since the true effects and implications of HTP/e-cigarette use are unknown, we could not confirm the validity of the exclusion. Second, the data were collected from a mainly Japanese population, while smoke-free policies may differ from country to country. Proper interpretation is needed in relation to the restrictions in each country. Nevertheless, we believe that the trends of HTP/e-cigarette use according to workplace smoke-free policies observed in this study are largely generalisable. Third, as HTPs look like e-cigarettes, some people might have mistaken them for each other and selected both e-cigarettes and HTPs, leading to overestimation. Fourth, the data were not weighted to population, and therefore the results might differ from the actual proportions. Finally, this is a cross-sectional study. We observed the associations between workplace smoke-free policies and rate of HTP, e-cigarette and conventional tobacco product use. However, we cannot surmise whether smoke-free policies led to the smoking habits, or the smoking habits of the population in each group led to the smoke-free policies, or both.

Conclusion

Although HTPs and e-cigarettes are prohibited in most workplaces where combustible cigarettes are banned, a few have exceptionally permitted HTP and e-cigarette use. This could indicate that smoke-free policies are already being disrupted by the emergence of HTPs and e-cigarettes. We found that workplaces where HTP/e-cigarette use was exceptionally allowed were associated with a significantly higher rate of HTP/e-cigarette use and of combustible cigarette smoking. Considering the growing worldwide use and the potential adverse health effects of these products, close monitoring of the situation is necessary. Finally, national legislation banning tobacco should be enforced and this should also cover HTPs and e-cigarettes in order to avoid renormalisation of smoking, encouraging the dual use of such products and sustaining cigarette and nicotine addiction.

What this paper adds

What is already known on this subject

  • In Japan, there was no national legislation banning heated tobacco products (HTPs) or electronic cigarettes (e-cigarettes) in the workplace; consequently, most private workplaces have adopted their own smoke-free policies.

What important gaps in knowledge exist on this topic

  • Despite the growing use of HTPs and e-cigarettes, there have been no studies on the current application of workplace smoke-free policies which include restrictions on HTP/e-cigarette use and the association of such rules with the rate of their use.

What this paper adds

  • HTPs and e-cigarettes are prohibited in most workplaces where combustible cigarettes are banned.

  • However, a few have exceptionally permitted HTP and e-cigarette use, which were associated with a significantly higher rate of HTP and e-cigarette use and of combustible cigarette smoking.

Acknowledgments

The authors would like to thank Dr Julia Mortimer for her English-language editing.

References

Supplementary materials

  • Supplementary Data

    This web only file has been produced by the BMJ Publishing Group from an electronic file supplied by the author(s) and has not been edited for content.

Footnotes

  • YS and TT contributed equally.

  • Contributors TT had full access to all of the study data and takes responsibility for the integrity of the data and the accuracy of the data analysis. Study concept and design: YS, TT. Acquisition of data: TT. Analysis and interpretation of data: all authors. Drafting of the manuscript: YS. Critical revision of the manuscript for important intellectual content: YS, TT, SO. Statistical analysis: YS, TT. Study supervision: TT.

  • Funding This work was supported by Health Labour Sciences Research Grants (H26-junkankitou-ippan- 023 and H28-junkankitou-ippan-002), and Japan Society for the Promotion of Science (JSPS) KAKENHI Grants (15K19256; 18H03062).

  • Competing interests None declared.

  • Patient consent for publication Obtained.

  • Ethics approval The study was reviewed and approved by the Research Ethics Committee of the Osaka International Cancer Institute (no. 1412175183).

  • Provenance and peer review Not commissioned; externally peer reviewed.

  • Data availability statement Data are available on reasonable request. The JASTIS data can be accessed via the corresponding author, TT, on reasonable request.

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