There is no impact to the General Fund as a result of accepting the report. Recommendations regarding the creation of any necessary educational materials, including signage, would be covered by existing resources within the Public Health Department.
REASONS FOR RECOMMENDATION
Santa Clara County has been a leader in protecting the health of its residents, children in particular, from the devastating consequences caused by tobacco use. In 2009, the Board expanded the County’s No Smoking Policy (Board Policy Manual, Section 3.47) to protect the health of all employees, clients and visitors from secondhand smoke exposure. The policy further restricted smoking inside county facilities, created a smoke-free campus at the Santa Clara Valley Medical Center, including all current and future Valley Health Centers, as well as increased the smoke-free zones surrounding County-owned and leased facilities.
In 2010, the Board adopted three tobacco prevention ordinances (Ordinance NS-300.832, NS-625.5, and NS-625.6) to reduce and prevent tobacco use, particularly among youth, and reduce exposure to secondhand smoke in public places, worksites, and in multi-unit residences. Under these ordinances, smoking is banned at the County Fairgrounds, County parks, in or within 30 feet of any outdoor service area, and all indoor and outdoor areas of motels and hotels. The Multi-Unit Residences Ordinance bans smoking in all units and common areas of all multi-unit residences, including apartments, condominiums and townhouses. The Tobacco Retailer Permit Ordinance requires all retailers in the unincorporated areas of the County to obtain and maintain an annual permit to sell tobacco products. The ordinance also restricts future retailers from operating in areas located within 1,000 feet of a school or 500 feet of an existing retailer. Adopting these ordinances helped to pave the road for 12 other cities in Santa Clara County to pass similar types of policy changes, impacting over 1.6 million county residents.
Unfortunately, the rapidly increasing use of e-cigarettes threatens to undo much of the social norm change around tobacco use that has largely resulted from policies like the ones implemented by the County. These policy measures could be undermined by the permitted use of e-cigarettes that produce a smoke-like aerosol in public as well as widespread, unrestricted advertising of such products in ways that have been restricted for cigarettes and other tobacco products for decades.
Children and adolescents are particularly vulnerable to the renormalization of smoking through the use of e-cigarettes. Youth are now witnessing smoking behaviors in public spaces that have been smoke-free for most, if not all, of their life. Youth are also being exposed to e-cigarette advertising on television, something that has been prohibited for decades for traditional tobacco products. The result is that youth are rapidly using e-cigarettes, which come in a variety of flavors, including cherry, grape and chocolate flavors, which cigarette companies have been prohibited from using in traditional cigarettes since 2009.
Despite the lack of regulation at the federal level, many communities across the United States and California have moved forward with prohibiting the use and sale of e-cigarettes in their jurisdictions. Over 100 cities and counties across the United States, including more than 40 counties and cities in California, have placed restrictions on the use of e-cigarettes.
The onset of tobacco use generally occurs before age 18; therefore, prevention of smoking initiation among children and adolescents is a powerful strategy for preventing much of the illness and mortality associated with tobacco use. If no action is taken, children would continue to be exposed to the use of e-cigarettes and secondhand aerosol, normalizing the action of smoking in public places that were previously smoke-free.
If no action is taken, seniors would continue to be exposed to the use of e-cigarettes and secondhand aerosol, normalizing the action of smoking in public places that were previously smoke-free. Observing smoking behavior can also be a trigger for people who are trying to quit smoking.
The recommended action will have no/neutral sustainability implications.
E-cigarettes are a class of electronic and/or battery-operated products designed to deliver nicotine, flavor and other chemicals through aerosol (commonly referred to as “vapor”) which is inhaled by the user. Most e-cigarettes are manufactured to resemble cigarettes, cigars and pipes, often with a light-emitting diode (LED) light at the tip that mimics the glow of a traditional cigarette.
According to a survey by the Centers for Disease Control and Prevention, the number of Americans who had ever used e-cigarettes quadrupled from 2009 to 2010, and 1.2 percent of adults, or nearly three million people, reported using e-cigarettes in the previous month. The United States Food and Drug Administration (FDA) has stated concerns about the safety of e-cigarettes, how they are marketed to the public, and that e-cigarettes can increase nicotine addiction among young people and may lead them to try other tobacco products, including conventional cigarettes, which are known to cause disease and lead to premature death. In addition, studies have shown that there are high levels of dual use among users of e-cigarettes and conventional cigarettes. Also of concern are the results of studies that found those who use e-cigarettes also smoke more conventional cigarettes than smokers not using e-cigarettes, and are much less likely to have stopped smoking.
Allowing the use of e-cigarettes in smoke-free areas undermines hard work done to de-normalize smoking behavior. The use of an e-cigarette in public is virtually indistinguishable from the use of traditional tobacco products in public, prompting possible confusion and concern by County employees and visitors of County facilities. In addition, the e-cigarette aerosol has not been proven safe for inhalation by bystanders.
While the original e-cigarette companies were competing with conventional cigarette companies, all the major cigarette companies are now in the e-cigarette business. E-cigarettes are evolving rapidly and being marketed like cigarettes were in the 1950s and 1960s, including advertising on television and radio, with celebrities serving as spokespersons for e-cigarette brands. E-cigarette manufacturers and retailers are also making unproven health claims about their products by asserting that they are safe or safer than traditional cigarettes and that they can be used as an aid to smoking cessation. Despite these aggressively marketed claims, no e-cigarette company has submitted an application to market e-cigarettes as either smoking cessation aids or reduced risk products to the FDA.
The FDA has not yet issued any regulations regarding e-cigarettes and these products are available for purchase in this County. The FDA has determined that since there is no regulation of electronic cigarettes, consumers have no way of accurately knowing the doses of nicotine that they are inhaling when using these products; and, the FDA has warned the public about the potential health risks of using electronic cigarettes and has found carcinogenic chemicals and toxic ingredients in some electronic cigarettes. An FDA laboratory analysis found that e-cigarettes contain carcinogens and toxic chemicals such as diethylene glycol, an ingredient used in antifreeze. Because there is little control or regulation of e-cigarette products, the amount of nicotine inhaled with each “puff” may vary substantially, and testing of sample cartridges found that some labeled as nicotine-free in fact had low levels of nicotine. A recent study published in the European Respiratory Journal found that e-cigarette users get as much nicotine from e-cigarettes as smokers usually get from tobacco cigarettes.
The Surgeon General has found that the chemical nicotine is a powerful pharmacologic agent that acts in the brain and throughout the body and is highly addictive, and the use of nicotine may cause or contribute to cardiovascular disease, complications of hypertension, reproductive disorders, cancer, gastrointestinal disorders, including peptic ulcer disease and gastro esophageal reflux, and immediate adverse physiologic effect after short-term use that are similar to some of the effects seen with tobacco smoke.
E-cigarette packages do not supply any warnings about possible adverse effects on health comparable to FDA-approved nicotine replacement products or conventional cigarettes; and the World Health Organization does not consider e-cigarettes to be a legitimate therapy for smokers trying to quit tobacco as there is no scientific evidence that e-cigarettes can help smokers to quit smoking.
Recommendations and Next Steps:
Since December 17, 2013, the Public Health Department has convened two meetings with internal stakeholders, including representatives from Department of Environmental Health, County Counsel and the County Executive’s Office. Additional conversations were conducted with Employee Services Agency, Employee Wellness and the Health and Hospital System Administration. The internal stakeholder group worked together to review existing County polices and ordinances where regulations of e-cigarettes could be incorporated. Furthermore, the work group reviewed the current research and efforts across the county, state and nation prior to making the recommendation. Key highlights include:
· In 2012, the California State Legislature took up Senate Bill 648 (Corbett), which would restrict the use of e-cigarettes in any area where smoking is currently prohibited.
· Currently, e-cigarettes may not be legally sold to minors in California. However, no other current regulations impact the sale or use of e-cigarettes in the County.
· In April 2011, the Food and Drug Administration (FDA) announced that it intends to regulate e-cigarettes as a tobacco product; however, no actions have been taken to date.
The work group determined that there are two tobacco prevention and control policies that affect internal County policies and facilities: the Board’s No-Smoking Policy and the Santa Clara Valley Health and Hospital System No-Smoking Policy. These policies currently prohibit smoking within any enclosed structure owned or leased by the County, all current and future County-operated health facilities and clinics, extending at least as far as the property line, and at all unenclosed places within 30 feet of any operable doorway, window, vent or other opening into such a building. Smoking is also prohibited in all County vehicles.
1) Pending the Board’s approval, the County’s No-Smoking Policy (Board Policy Manual, Section 3.47), would be amended to include (1) a definition of smoking that incorporates use of electronic smoking devices (2) a prohibition on selling tobacco products and electronic smoking devices on County owned and operated property; and (3) amendment of no-smoking signage to include the prohibition on use of electronic smoking devices.
2) Pending the Board’s approval, the SCVHHS No-Smoking Policy (SCVHHS Policy 810.1), would be amended in conformity with the changes proposed to the County’s No-Smoking Policy.
These amendments would prohibit the use of any electronic smoking device (as it is would be defined in our policy), including use with other substances—e.g., cartridges that do not contain nicotine but nevertheless may contain other harmful ingredients (e.g., propylene glycol) and addictive ingredients like lobeline.
The amended draft SCVHHS policy was reviewed by the SCVHHS Executive Management Group.
The internal work group plans to continue to work together to review tobacco prevention and control ordinances, collect data, and conduct public outreach related to the inclusion of electronic smoking devices in regulations affecting external stakeholders. The plan is to report back on the recommendations at the Health and Hospital Committee meeting on August 13, 2014.
CONSEQUENCES OF NEGATIVE ACTION
Failure to accept the report will result in the Committee not receiving the information requested, and result in no change to existing policies, leading to an inability to act upon this critical public health issue.
· SCVHHS Policy 810 1 attch A (2) (DOCX)
· SCVHHS Policy 810 1 - 2 14 14 clean_DRAFT (DOC)
· Board Policy Resolution -- E-Cigarettes - 2 14 14 clean_DRAFT (DOCX)