The County of Santa Clara
California

Report
71488

Consider recommendations relating to regulation of electronic smoking devices. (Public Health Department)

Information

Department:Public Health DepartmentSponsors:
Category:Report

Attachments

  1. Printout
  2. Proposed Findings - FINAL (This file has not yet been converted to a viewable format)
  3. Summary of Proposed Regulation of E-Cigarettes - FINAL (This file has not yet been converted to a viewable format)
  4. Resolution for Permit Fee - FINAL (This file has not yet been converted to a viewable format)
  5. Ord No 625 7 (Tobacco E-Smoking Restrictions Generally) - Final - CLEAN (This file has not yet been converted to a viewable format)
  6. Ord No 625 7 (Tobacco E-Smoking Restrictions Generally) - Final - REDLINE (This file has not yet been converted to a viewable format)
  7. Ord No 625 8 (Tobacco E-Smoking Restrictions in MUR) - Final - CLEAN (This file has not yet been converted to a viewable format)
  8. Ord No 625 8 (Tobacco E-Smoking Restrictions in MUR) - Final - REDLINE (This file has not yet been converted to a viewable format)
  9. Ord No NS-300 873 (Retailer Permits) - Final - CLEAN (This file has not yet been converted to a viewable format)
  10. Ord No NS-300 873 (Retailer Permits) - Final - REDLINE (This file has not yet been converted to a viewable format)
  11. Public Comment - Parcel Letter
  12. Speaker Form

Multiple Recommendations

Possible action:
a. Accept report relating to feasibility and timeline for incorporating regulation of electronic smoking devices into the current tobacco prevention and control ordinances.
b. Forward a recommendation to the June 10, 2014 Board of Supervisors meeting to adopt findings for Ordinances NS-625.7, NS-625.8, and NS-300.873.
c. Forward a recommendation to the June 10, 2014 Board of Supervisors meeting to adopt Ordinances NS-625.7, NS-625.8, and NS-300.873, relating to regulation of electronic smoking devices and tobacco products in the County unincorporated areas.
d. Forward a recommendation to the June 10, 2014 Board of Supervisors meeting to notice and hold a hearing to adopt a Resolution establishing fees for permits to be obtained by retailers of electronic smoking devices and/or tobacco products.

Body

FISCAL IMPLICATIONS

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, could be covered by existing resources within the Public Health Department.  Costs associated with the permitting of any retailers of electronic smoking devices alone will be covered through permit fees.  However, retailers that sell tobacco products and electronic smoking products and that already have a valid tobacco retailer permit will not be required to obtain another permit or pay another fee.

REASONS FOR RECOMMENDATION

Santa Clara County has been a leader in protecting the health of its residents, children and youth 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 to reduce and prevent tobacco use, particularly among youth, and reduce exposure to secondhand smoke. Under the Smoking Pollution Control Ordinance, smoking is banned in any enclosed structure owned or leased by the County; all enclosed and unenclosed places open to the public in the unincorporated areas of the County; and nearly all places of employment in the unincorporated areas of the County. (County of Santa Clara Ordinance Code, Div. B13, Ch. V (§ B13-79 et seq.).) The Smoking Pollution Control in Multi-Unit Residences Ordinance bans smoking in all units and common areas (other than designated smoking areas) of all multi-unit residences, including apartments, condominiums and townhouses. (Id. at Div. B13, Ch. VIII (§ B13-105 et seq.).) 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. (Id. at Div. A18, Ch. XXIII (§ A18-367 et seq).) The ordinance also, among other things, 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.

The rapidly increasing use of electronic smoking devices (referred to variously as electronic cigarettes, electronic cigars, electronic cigarillos, electronic pipes, electronic hookahs, electronic vapes, vaporizers, and otherwise) 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. Electronic smoking devices are a class of electronic and/or battery-operated products generally designed to look like and be used in the same manner as conventional cigarettes, cigars, and pipes, often with a light-emitting diode (LED) light at the tip that mimics the glow of a traditional cigarette.  They generally contain cartridges filled with nicotine, flavor and other chemicals, which are aerosolized or vaporized for inhalation by the user.

On December 17, 2013, the Board directed the Public Health Department to report through the Health and Hospital Committee on the feasibility and timeline for incorporating regulation of electronic smoking devices into the County’s current tobacco prevention and control ordinances and policies, and report on impacts to external stakeholders. On March 25, 2014 the Board approved a resolution amending the County’s No Smoking Policy (Board Policy Manual, Section 3.47) and Santa Clara Valley Health and Hospital System’s No Smoking Policy (Policy #810.1).  Together, these policies prohibit the use of electronic smoking devices 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; all unenclosed places within 30 feet of any operable doorway, window, vent or other opening into such a building; and all County vehicles.  The County policy also prohibits the sale of tobacco products and electronic smoking devices on County-owned and -operated property.

Electronic smoking devices are currently unregulated by the federal government, and few restrictions exist at the state level.  In 2010, the U.S. Court of Appeals for the D.C. Circuit held that the Food and Drug Administration (FDA) could regulate e-cigarettes as a tobacco product under the Family Smoking Prevention and Tobacco Control Act. The FDA could, therefore, require the e-cigarette industry to follow the same regulations that guide the tobacco manufacturing process, including: ingredient listing, good manufacturing practices and advertising restrictions.[1] The FDA just recently issued a proposed rule on April 24, 2014, establishing its authority to regulate electronic smoking devices. Consistent with currently regulated tobacco products, under the proposed rule, makers of electronic smoking devices would, among other requirements: 1) Register with the FDA and report product and ingredient listings; 2) Only market new tobacco products after FDA review; 3) Only make direct and implied claims of reduced risk if the FDA confirms that scientific evidence supports the claim and that marketing the product will benefit public health as a whole; and 4) Not distribute free samples. In addition, under the proposed rule, the following provisions would apply to electronic smoking devices: minimum age and identification restrictions to prevent sales to underage youth; requirements to include health warnings; and prohibition of vending machine sales, unless in a facility that never admits youth.[2] California law, by contrast, merely prohibits anyone from selling or otherwise providing electronic cigarettes to minors (Health and Saf. Code, § 119405) and prohibits certain online and mobile marketing and advertising of e-cigarettes to minors (Bus. & Prof. Code, § 22580, subd. (a), (b), and (i)(17)).

In the absence of government oversight, manufacturers and retailers have advertised their products as a healthy, safe alternative to cigarettes.[3] Furthermore, the electronic smoking device industry advertises through multiple media platforms such as television, magazines and social media sites – practices that the tobacco industry has not been allowed to engage in for many years.[4] Electronic smoking device companies are also marketing electronic smoking devices as smoking cessation devices3, and yet, despite these aggressively marketed claims, no electronic smoking device company has submitted an application to market electronic smoking devices as either smoking cessation aids or reduced risk products to the FDA.

The current lack of regulation and widespread availability of electronic smoking devices have contributed to increasing social acceptance of electronic smoking devices and dangerous perceptions that these products are safe or safer than conventional tobacco products.  Children and adolescents are particularly vulnerable to the renormalization of smoking through the use of electronic smoking devices. Youth are now witnessing smoking behaviors in public spaces that have been smoke-free for most, if not all, of their lives. Youth are also being exposed to electronic smoking device advertising on television, something that has been prohibited for decades for traditional tobacco products. An April 2014 Congressional Report investigating the marketing practices of nine of the largest electronic cigarette manufacturers, found that all nine of the companies were using various marketing practices to appeal to youth.[5] These practices, many of which were self-reported by the companies, include sponsoring youth-oriented events such as music festivals, and handing out free product samples at as many as 348 events between 2012-2013.5 The result of all this is that youth are rapidly turning to electronic smoking devices. A Centers for Disease Control and Prevention (CDC) study showed that, in 2011, 4.7% of all high school students had tried electronic smoking devices and that, in 2012, that number increased to 10.0% of all high school students.[6] Electronic smoking devices and other unapproved nicotine delivery products have a high appeal to youth due to their high tech design and availability in child-friendly flavors like cotton candy, bubble gum, chocolate chip cookie dough and cookies and cream milkshake.4,5 The FDA has raised concerns that electronic cigarettes, including but not limited to flavored electronic cigarettes, can increase nicotine addiction among young people and may lead youth to try conventional tobacco products.[7]

According to a survey by the CDC, the number of Americans who had ever used electronic smoking devices quadrupled from 2009 to 2010, and 1.2 percent of adults, or nearly three million people, reported using electronic smoking devices in the previous month.[8] In addition, studies have shown that there are high levels of dual use among users of electronic smoking devices and conventional cigarettes.8,[9]

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[10] 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[11], and immediate adverse physiologic effect after short-term use that are similar to some of the effects seen with tobacco smoke.[12] A recent CDC study found the number of calls to poison centers involving e-cigarette liquids containing nicotine rose from one per month in September 2010 to 215 per month in February 2014.[13] Because there is little control or regulation of electronic smoking devices 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.[14] A 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.[15]

The FDA has determined that since there is virtually 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.1 Electronic smoking device packages do not supply any warnings about possible adverse effects on health comparable to FDA-approved nicotine replacement products or conventional cigarettes[16]; and the World Health Organization does not consider electronic smoking devices to be a legitimate therapy for smokers trying to quit tobacco[17] as there is no scientific evidence that electronic smoking devices can help smokers to quit smoking.

Electronic smoking devices contain and emit propylene glycol, a chemical that is used as a base in the electronic smoking device solution and is one of the primary components in the aerosol emitted by electronic smoking devices. Even though propylene glycol is FDA approved for use in some products, the inhalation of vaporized nicotine in propylene glycol is not. Some studies show that heating propylene glycol changes its chemical composition, producing small amounts of propylene oxide, a known carcinogen.[18] Existing studies on electronic smoking devices’ vapor emissions and cartridge contents have found a number of dangerous substances including chemicals known to the state of California to cause cancer,[19] such as formaldehyde, acetaldehyde, lead, nickel, and chromium.[20],[21]  Additionally, studies have found the presence of PM2.5,  acrolein, tin, toluene, and aluminum, 20,21,[22],[23] which are associated with a range of negative health effects such as skin, eye, and respiratory irritation,[24] neurological effects,[25] damage to reproductive systems,24 and even premature death from heart attacks and stroke.[26]  Such substances appear to be contained in and emitted from electronic smoking devices, regardless of whether the cartridges contain nicotine.

For all of the foregoing reasons, local regulation is needed. Many communities across the United States and California agree and have moved forward with prohibiting the use and sale of electronic smoking devices 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 and sale of electronic smoking devices.[27],[28]

In addition, the Public Health Department recommends a prohibition on retailers’ use of vending machines for the sale of either electronic smoking devices or tobacco products, as well as a prohibition on retailers’ use of self-service displays of electronic smoking devices in retail locations other than vape shops.  A requirement for face-to-face transactions (i.e., no vending machine sales or self-service displays), are a proven strategy for reducing minors’ access to tobacco products, as they require assistance from the store merchant, and prevent shoplifting of tobacco products.[29],[30]

CHILD IMPACT

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 electronic smoking devices and secondhand aerosol emitted from electronic smoking devices, normalizing the action of smoking in public places that were previously smoke-free.

SENIOR IMPACT

If no action is taken, seniors would continue to be exposed to the use of electronic smoking devices and secondhand aerosol emitted from electronic smoking devices, 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.

SUSTAINABILITY IMPLICATIONS

The recommended action will have no/neutral sustainability implications.

BACKGROUND

This section will: 1) Describe how the Public Health Department worked with internal and external stakeholders in developing the proposed recommendations; 2) Outline the proposed changes to each of the County’s tobacco prevention and control ordinances and the scientific findings and rationale for regulation; 3) Provide a summary description of current research including what is less known, and requires additional research; and 4) Describe the timeline and next steps regarding implementation, should the recommendations be approved.

This section addresses issues that were raised at the March 25, 2014 Board of Supervisors meeting, including the request to address areas of state law not previously covered by County policy and ensuring sufficient outreach is conducted with various stakeholders including businesses, tobacco retailers, Stanford University, County Youth Task Force, and multi-unit residence landlords, owners and tenants.

Public Outreach and Stakeholder Engagement:

Since March 25, 2014, the Public Health Department convened two meetings with internal stakeholders, including representatives from Department of Environmental Health and County Counsel. Outreach was also conducted with the Tri-County Apartment Association, Stanford University, County Parks, County Sheriff’s Office, and the County Youth Task Force, as was requested by the Board of Supervisors. Additionally, letters were mailed to all businesses (tobacco retailers, restaurants, bars, worksites, hotels/motels, etc.) and multi-unit residences (apartments, townhomes, condos) in the County unincorporated areas outlining the proposed changes to the current tobacco prevention ordinances, and soliciting any feedback on the proposed changes. 

The Tri-County Apartment Association has not taken an official position on the regulation of electronic smoking devices but conducted outreach with their members to solicit input on the County’s proposal. Stanford University conducted outreach with various campus stakeholders.

Currently there are 24 tobacco retailers permitted in the County unincorporated areas, of which nine (9) currently sell electronic smoking devices. At this time, staff have not identified any retailers that sell electronic smoking devices but do not sell traditional tobacco products in the unincorporated areas. Should there be any new retailers of electronic smoking devices, the permit fee would be the same as the fee for sellers of traditional tobacco products ($425 annually). Retailers with current tobacco retailer permits who are also selling electronic smoking devices would not be required to obtain any additional permit or pay any additional fee.

Additionally, the Public Health Department-coordinated youth tobacco prevention coalition, Community Advocate Teens of Today, is conducting educational presentations and discussions with youth organizations, including city-run Youth Advisory Commissions, the County’s Youth Task Force and Santa Clara County Office of Education, to further explore this issue and its impacts on youth in our county.

Finally, per request by the Board of Supervisors, the Public Health Department has conducted initial outreach to the Planning Department to further understand current and potential regulatory mechanisms, such as conditional use permits, as it relates to advertising of electronic smoking devices. The proposed changes to the County ordinance would require any retailers that sell electronic smoking devices to comply with the current regulation of not covering more than 15% of windows and clear doors with any type of ads or signs, which applies to sellers of traditional tobacco products. The Department of Environmental Health checks for compliance of this provision on an annual basis. Earlier this year the Public Health Department conducted preliminary observations in tobacco retail stores countywide, including unincorporated areas, and has found that advertising practices for electronic smoking devices mirrors those of traditional tobacco products. The Public Health Department, if requested, will continue to keep the Board informed as additional research is conducted on this issue.

Proposed Changes

See attachment “Proposed Regulation of Electronic Smoking Devices” for a detailed description of the proposed changes to each of the three Santa Clara County No-Smoking Ordinances. In summary, the proposed changes are to prohibit the use of electronic smoking devices wherever tobacco use is currently prohibited by state or local law, with the exception of private units of multi-unit residences.  Additionally, any business that sells electronic smoking devices would be required to obtain a local retail permit, if they do not already have a valid Santa Clara County Tobacco Retailer Permit, and abide by certain requirements in order to maintain that permit. A summary of the current evidence, including areas where more research is needed, it outlined for each ordinance below. A separate document [“Ordinance Findings”], outlines the findings that provide the rationale for the recommendations.

Smoking Pollution Control and Smoke-free Multi-Unit Residences Ordinances

Summary of Related Research: Studies of electronic smoking devices demonstrate a lack of standards for electronic smoking devices, discrepancies between stated nicotine levels in e-cartridges and actual content levels, and wide variability in electronic smoking device constituents and toxicants. The studies examining what is in electronic smoking devices, including their component parts, are limited by the selection of a handful of products examined (from the hundreds on the market). Long-term health impacts are unknown at this stage because the products and their use are very new and evolving rapidly. However, early studies indicate that electronic smoking devices pose potential dangers for users, as well as for non-users who passively inhale these chemical vapors. At minimum, these studies show that electronic smoking device aerosol contains nicotine, ultrafine particles and low levels of toxins that are known to cause cancer. The thresholds for human toxicity of potential toxicants in electronic smoking device aerosol are not known, and the possibility of health risks to primary users of the products and those exposed passively to the product emissions must be considered. Given the unknown public health impacts and the current lack of regulation, the Public Health Department recommends a precautionary approach in regulating the use of electronic smoking devices, until their safety is conclusively established.

Tobacco Retail Permit Ordinance

Summary of Related Research: Youth use of electronic smoking devices is increasing and many of those youth are using both traditional tobacco products and electronic smoking devices. The number of stores selling electronic cigarettes is rapidly increasing in the County and California, as is the amount of advertising and marketing of these products in stores, on television and online. The dangers of nicotine are well documented in the literature and are particularly hazardous to children, adolescents, pregnant women, and nursing mothers. The number of poisonings due to exposure to electronic smoking device liquids containing nicotine has been rapidly increasing. While their long-term health effects remain largely unknown, early studies indicate that electronic smoking devices pose potential dangers for users, as well as for non-users who passively inhale these chemical vapors. Given the unknown public health impacts and the current lack of regulation, the Public Health Department recommends a precautionary approach in regulating the sale of electronic smoking devices, particularly to protect children and youth from access and exposure to these products.

Timeline and Next Steps:

Should the Board approve the proposed changes to the County Ordinances, the Smoking Pollution Control and Smoke-free Multi-Unit Residences would take effect after 30 days and the Tobacco Retailer Permit changes would take effect after 60 days. The Public Health Department will work with internal and external stakeholders including the Department of Environmental Health, County Parks, Stanford, Tri-County Apartment Association, and the County Sheriff’s office on implementation, including posting signage and notifying businesses, multi-unit residence owners and residents. Public Health Department will provide signage to owners and managers of the impacted locations.

The Public Health Department plans to continue to outreach to cities and school districts in the County to share the research and models that were developed to address this issue and further protect the public’s health across all areas of the County.

CONSEQUENCES OF NEGATIVE ACTION

Failure to accept the report would 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.


[1] U.S. Food and Drug Administration. “Regulation of E-Cigarettes and Other Tobacco Products.” FDA. April 25, 2011. Available at: http://www.fda.gov/NewsEvents/PublicHealthFocus/ucm252360.htm 

[2] U.S. Food and Drug Administration. “FDA proposes to extend its tobacco authority to additional tobacco products, including e-cigarettes.” April 24, 2014. Available at: http://www.fda.gov/NewsEvents/Newsroom/PressAnnouncements/ucm394667.htm

[3] Grana, R and Ling, P M. (2014). “Smoking revolution: A content analysis of electronic cigarette retail websites. Am J Prev Med 46(4): 395-403.

[4] Grana, R; Benowitz, N; Glantz, S. “Background Paper on E-cigarettes,” Center for Tobacco Control Research and Education, University of California, San Francisco and WHO Collaborating Center on Tobacco Control. December 2013.

[5] U.S. Congress, Senate and House of Representatives Report. “Gateway to Addictions?: A survey of popular electronic cigarette manufacturers and targeted marketing to youth. April 2014. Available at: http://democrats.energycommerce.house.gov/sites/default/files/documents/Report-E-Cigarettes-Youth-Marketing-Gateway-To-Addiction-2014-4-14.pdf

[6] Corey, C., Johnson, S., Apelberg, B., et al. (2013). “Notes from the Field: Electronic Cigarette Use Among Middle and High School Students - United States, 2011- 2012.” Morbidity and Mortality Weekly Report

[7] U.S. Food and Drug Administration. “Consumer Updates: E-Cigarettes Questions and Answers” Available at: http://www.fda.gov/forconsumers/consumerupdates/ucm225210.htm

[8] King, B., Alam S., Promoff, G., et al. (2013). “Awareness and Ever Use of Electronic Cigarettes Among U.S. Adults, 2010-2011.” Nicotine and Tobacco Research, doi: 10.1093/ntr/ntt013, 2013.

[9] Regan AK, Promoff G, Dube SR, Arrazola R. (2013). Electronic nicotine delivery systems: adult use and awareness of the ‘e-cigarette’ in the USA. Tob Control. 2013 Jan;22(1):19-23.

[10] The Health Consequences of Smoking: Nicotine Addiction, a report of the Surgeon General (1988), available at http://profiles.nlm.nih.gov/NN/B/B/Z/D_/nnbbzd.pdf

[11] The Health Consequences of Smoking: Nicotine Addiction, a report of the Surgeon General (1988), available at http://profiles.nlm.nih.gov/NN/B/B/Z/D_/nnbbzd.pdf

[12] Vardavas CI, Anagnostopoulos N, Kougias M, Evangelopoulou V, Connolly GN, Behrakis PJK. Short-term Pulmonary Effects of Using an Electronic Cigarette. CHEST. 2012;141(6):1400-1406. Doi:10.1378/chest.11-2443.

[13] Chatham-Stephens, K, Law, R, Taylor, E, et al. (April 2014). “Notes from the Field: Calls to Poison Centers for Exposures to Electronic Cigarettes — United States, September 2010–February 2014” Morbidity and Mortality Weekly Report

[14] FDA and Public Health Experts Warn about Electronic Cigarettes (July 22, 2009), available at www.fda.gov/NewsEvents/Newsroom/PressAnnouncements/ucm173222.htm.

[15] Etter, J.F. and Bullen, C. (2011) Saliva cotinine levels in users of electronic cigarettes. European Respiratory Journal. Vol 38, 1219-1220.

[16] FDA and Public Health Experts Warn about Electronic Cigarettes (July 22, 2009), available at www.fda.gov/NewsEvents/Newsroom/PressAnnouncements/ucm173222.htm.

[17] World Health Organization, Press Release, “Marketers of electronic cigarettes should halt unproved therapy claims” (September 19, 2008), available at www.who.int/mediacentre/news/releases/2008/pr34/en/index.html

[18] Henderson, TR; Clark, CR; Marshall, TC; Hanson, RL; & Hobbs, CH. “Heat degradation studies of solar heat transfer fluids,” Solar Energy, 27, 121-128. 1981.

[19] State of California Environmental Protection Agency, Office of Environmental Health Hazard Assessment, Safe Drinking Water and Toxic Enforcement Act of 1986. (2013) Chemicals known to the State of California to cause cancer or reproductive toxicity. Available at: http://oehha.ca.gov/prop65/prop65_list/files/P65single091313.pdf

[20] German Cancer Research Center. (2013). “Electronic Cigarettes - An Overview” Red Series Tobacco Prevention and Control. Available at: www.dkfz.de/de/tabakkontrolle/download/Publikationen/RoteReihe/Band_19_e-cigarettes_an_overview.pdf.

[21] Goniewicz M, Knysak J, Gawron M, et al. Levels of selected carcinogens and toxicants in vapour from electronic cigarettes. Tob. Control. 2013;1:1–8. Available at: http://www.ncbi.nlm.nih.gov/pubmed/23467656.

[22] Williams, M., Villarreal, A., Bozhilov, K., Lin, S., & Talbot, P. (2013). Metal and silicate particles including nanoparticles are present in electronic cigarette cartomizer fluid and aerosol. PloS one, 8(3), e57987. doi:10.1371/journal.pone.0057987

[23] Schober W, Szendrei K, Matzen W, et al. (2013). Use of electronic cigarettes (e-cigarettes) impairs indoor air quality and increases FeNO levels of e-cigarette consumers. Int. J. Hyg. Environ. Health. Available at: http://dx.doi.org/10.1016/j.ijheh.2013.11.003

[24] Agency for Toxic Substances and Disease Registery (ATSDR). (2008). Toxic Substances Portal. Available at http://www.atsdr.cdc.gov/substances/index.asp

[25] State of California Environmental Protection Agency Office of Environmental Health Hazard Assessment. (n.d.). Chronic Toxicity Summary: Toluene. CAS Registry Number: 108-88-3. Available at: http://oehha.ca.gov/air/chronic_rels/pdf/108883.pdf

[26] Environmental Protection Agency. (2012). Particle Pollution and Health. Available at: http://www.epa.gov/pm/2012/fshealth.pdf

[27] American Lung Association in California, the Center for Tobacco Policy and Organizing. (2013). Local Policies on the use of Electronic Cigarettes. Available at: http://center4tobaccopolicy.org/wp-content/uploads/2013/11/Local-Policies-on-Use-of-E-Cigs-Nov-2013.pdf

[28] American Lung Association in California, the Center for Tobacco Policy and Organizing. (2013). Tobacco Retailer Licensing and Electronic Cigarettes. Available at: http://center4tobaccopolicy.org/wp-content/uploads/2013/08/E-cigarettes-in-TRL-8.9.13.pdf

[29] Caldwell MC, Wysell MC, Kawachi I. (1996). Self-service tobacco displays and consumer theft. Tob Control.5:160–161.

[30] Lee RE, Feighery EC, Schleicher NC, Halvorson S. (2001). The relation between community bans of self-service tobacco displays and store environment and between tobacco accessibility and merchant incentives. Am J Public Health.91(12):2019-21.