E-Cigarette Use in Enclosed Areas of Restaurants and Bars
Existing North Carolina Regulation: Public Use
In North Carolina, e-cigarettes are considered a tobacco product (NC GS §14-313(4)), therefore, many places considered to be tobacco-free also prohibit the use of e-cigarettes. In Orange County, this includes venues such as 100% Tobacco-Free public schools, county buildings and vehicles, and UNC athletic facilities. In addition, several other public and private places have prohibited use such as the Chapel Hill Library.
Proposed Orange County Board of Health Rule
In January 2016, the Orange County Board of Health reviewed the emerging evidence on the risks of secondhand e-cigarette aerosol exposure and decided to develop a proposed rule to prohibit use in enclosed areas of bars and restaurants. There was a public comment period and a public hearing on the proposed rule in April 2016. The Board has reviewed the emerging research on this issue, received input from over 150 individuals with over 80% supporting the proposed rule, and heard from more than a dozen people at the public hearing. To base their decision on the most rigorous review of public health research available, the Board has decided to schedule its vote on the proposed rule after the Surgeon General issues his report on the health effects of electronic cigarettes later this year.
- Online Survey - Closes April 24, 2016 - Click here to take the online survey
- Telephone Message Line - Closes April 24, 2016 - (919) 245-2480
- Email - Closes April 24, 2016 - Send your comments via email to firstname.lastname@example.org
- U.S. Mail - Closes April 24, 2016
- Public Hearing - Wednesday, April 27th at 7:00 PM
Location - Orange County Health Department 300 West Tryon Street Hillsborough, NC 27278 - 2nd Floor Meeting Room
Electronic cigarettes, also called e-cigarettes, vaporizers, and hookah pens, are electronic devices that produce a smoke-like aerosol (commonly referred to as vapor). This aerosol typically contains nicotine, propylene glycol and/or vegetable glycerin, chemical flavorings, and may have additional contaminants. E-cigarettes vary widely in terms of product design and manufacturing.Use Trends
E-cigarettes have become a popular alternative to combustible cigarettes among adults who smoke. Surveillance data suggest that among adults, approximately 15% of current smokers and 22% of recent former smokers currently use e-cigarettes (CDC NCHS, 2015). However, a concerning trend has emerged among youth in Orange County. Local data show that 37% of high school students have ever used an e-cigarette and 18% used an e-cigarette in the past 30 days (YRBS, 2015). Although use of combustible cigarettes and overall tobacco use have been dropping for many years, overall tobacco use and corresponding nicotine addiction began to increase with the introduction of e-cigarettes and other vapor products. Click here for more information about youth tobacco use.
The research is inconclusive on whether e-cigarettes are an effective cessation tool. One systematic review found that using an e-cigarette with nicotine may help adults who smoke cut down on the amount they smoke and did not find evidence that short-term e-cigarette use was associated with health risk; due to the limited number of studies available, however, the authors noted that confidence in these results is low (McRobbie, et al., 2014). However, heavy smokers who significantly reduce their smoking, and even those who smoke just 1-4 cigarettes per day, may not reduce their risk of premature death (Tverdal & Bjartveit, 2006; Bjartveit, 2005).
The Surgeon General has recognized that in combination with rigorous surveillance and aggressive strategies to end combusted tobacco use – e-cigarettes could help complement “end game” strategies by allowing complete nicotine substitution among cigarette smokers (US DHHS, 2014). A recent systematic review found that, as currently being used, e-cigarettes are associated with a significantly less likelihood of quitting among people who smoke compared to those who do not use e-cigarettes (Kalkhoran & Glantz, 2016).
E-cigarettes are not currently marketed as therapeutic devices and are therefore not regulated by the Federal Drug Administration (FDA) as cessation products, although the FDA has proposed to extend its authority to cover e-cigarettes as tobacco products (FDA website).
In general, studies are limited and do not yet prove the safety or efficacy of these devices, although research continues to emerge.
There are seven FDA-approved smoking cessation medications, including nicotine patches, gum, and lozenges, also known as Nicotine Replacement Therapy (NRT). Orange County provides free NRT, while supplies last, to adults who live or work in the county and participate in eligible smoking cessation counseling. Click here for more information.Health Risks
An emerging body of research on e-cigarettes suggests that emitted aerosol may contain potentially harmful chemicals in addition to nicotine. Although there are likely fewer toxins in e-cigarette aerosol than in smoke from lit tobacco products (Goniewicz et al., 2013), the aerosol may be harmful, especially for more vulnerable populations. Research on the acute health impacts e-cigarettes is limited, and there is no adequate research on the long-term health effects.
- Injury: Lithium batteries, which are used in many e-cigarette devices, carry an inherent risk of flame and explosion that are currently not well marked on product packaging and which can cause significant injury among users (Colaianni, et al. 2016; Jablow & Sexton, 2015).
- Nicotine Poisoning: Take caution in handling nicotine refill solutions, or “e-juice”, as there is a risk of nicotine poisoning when it comes in contact with the skin or when ingested, especially among children (AAPCC website).
- Nicotine Exposure: The evidence is sufficient to caution children and adolescents, pregnant women, and women of reproductive age because of the potential for fetal and adolescent nicotine exposure to have long-term consequences for brain development. (Surgeon General Report, 2014)
- Flavors: Several chemicals commonly used as flavorings in e-cigarettes, such as diacetyl and cinnamaldehyde, have known associations with respiratory disease. Studies demonstrate that the level of exposure through inhaling e-cigarette aerosol may be of toxicological concern. (Allen, et al. 2015; Behar, et al. 2014; Farsalinos, et al. 2014; Lerner, et al. 2015; Tierney, et al. 2015; Rowell, et al. 2015; Sussan, et al. 2015)
- Propylene Glycol: Propylene glycol is generally considered a low toxicity compound and is widely used in many products. However, occupational exposures have led to acute ocular and upper respiratory irritation, cough, reduced lung function, and chronic work-related wheezing and chest tightness. (Wieslander, et al. 2001; Varughese, et al. 2005)
- Acute Health Effects: Limited research on adverse short-term effects include increased airways resistance and respiratory irritation and cough, particularly among individuals with asthma. (CDC NIOSH, 2015; Vardavas, et al. 2012; McConnell, et al. 2015)
- Secondhand Exposure: Research demonstrates the potential for secondhand exposure to e-cigarette aerosol through biomarkers of nicotine exposure, as well as through studies done in controlled indoor conditions. (Balbé, et al. 2014; Thornburg, et al. 2014; Thornburg, et al. 2016)
- Vulnerable Populations: For ethical reasons, there is limited research on the human health effects of secondhand aerosol exposure among vulnerable populations. Research in mice, however, suggests that chemicals in e-cigarettes may exacerbate asthma and that there is potential for e-cigarette aerosols to affect development of neonates. (Lim & Kim, 2014; McGrath-Morrow, et al. 2015; Wu, et al. 2014)
Variability in e-cigarette emissions makes it very difficult to assess risk. In addition, users sometimes mix and use their own e-liquid, rather than one commercially available, which is challenging to simulate in toxicological studies and other research. (Cheng, 2014)Regulation: Sale and Packaging
There is currently no federal legislation with respect to labeling or packaging of nicotine refill solution, although North Carolina law requires child-resistant packaging (NC GS §14-401.18A). In this state, minors are not allowed to purchase e-cigarettes (NC GS §14-313(b)), although online purchasing is allowed (NC GS § 14-313(b2)) and research suggests that minors can easily buy the products online (Williams, et al. 2015). North Carolina levies an excise tax on vapor products at the rate of five cents (5¢) per fluid milliliter of consumable product (NC GS §105-113.35).For more information:
Annotated References - April 2016
Presentation to the Orange County Board of Health by Jonathan Thornburg, Ph.D., Director of Exposure and Aerosol Technology at RTI International - E-Cigarettes and Vapor Products: The State of the Science
CDC Letter of Evidence on Electronic Nicotine Devices - http://www.tobaccopreventionandcontrol.ncdhhs.gov/Documents/CDC-LetterofEvidenceonElectronicNicotineDeliverySystemsNorthCarolina-April2015.pdf
North Carolina Department of Health and Human Services - Electronic Cigarettes Fact Sheet
Synopsis of Electronic Nicotine Devices Information from 2012 and 2014 Surgeon General's Reports
Electronic Nicotine Device Systems: Key Facts CDC Office of Smoking and Health
American Association of Poison Control Centers (AAPCC). E-Cigarettes and Liquid Nicotine. Available at: http://www.aapcc.org/alerts/e-cigarettes/. Accessed March 30, 2016.
Allen, J. G., Flanigan, S. S., Leblanc, M., Vallarino, J., Macnaughton, P., Stewart, J. H., & Christiani, D. C. (2015). Flavoring Chemicals in E-Cigarettes: Diacetyl, 2,3-Pentanedione, and Acetoin in a Sample of 51 Products, Including Fruit-, Candy-, and Cocktail-Flavored E-Cigarettes. Environmental Health Perspectives.
Ballbé M, Martínez-Sánchez JM. (2014). Cigarettes vs. E-Cigarettes: Passive Exposure at Home Measured by Means of Airborne Marker and Biomarkers. Environmental Research. 135:76–80.
Behar RZ, Davis B, Wang Y, Bahl V, Lin S, Talbot P. (2014). Identification of toxicants in cinnamon-flavored electronic cigarette refill fluids. Toxicol In Vitro 28: 198–208.
Bjartveit, K. (2005). Health consequences of smoking 1-4 cigarettes per day. Tobacco Control. 14(5):315-320.
Cheng T. (2014) Chemical Evaluation of Electronic Cigarettes. Nicotine & Tobacco Research. 23:ii11–7.
Colaianni, C. A., et al. (2016). Injuries Caused by Explosion of Electronic Cigarette Devices. Eplasty. 16:ic9.
Centers for Disease Control and Prevention. National Center for Health Statistics. (2015). National Health Interview Survey Data Brief No. 217. Available at: http://www.cdc.gov/nchs/products/databriefs/db217.htm. Accessed March 28, 2016.
Centers for Disease Control and Prevention. National Institute for Occupational Safety and Health. (2015). Comments of the National Institute for Occupational Safety and Health to the Food and Drug Administration (FDA) in response to Establishment of a Public Docket; Electronic Cigarettes and the Public Health Workshop Docket No. FDA—2014—N—1936 Cincinnati, Ohio. Available at: http://www.cdc.gov/niosh/topics/flavorings/pdfs/comment_from_the_national_institue_for_occupational_safety_and_health_niosh.pdf. Accessed March 28, 2016.
Farsalinos, K. E., Kistler, K. A., Gillman, G., & Voudris, V. (2014). Evaluation of Electronic Cigarette Liquids and Aerosol for the Presence of Selected Inhalation Toxins. Nicotine & Tobacco Research, 17(2), 168-174.
Federal Drug Administration. Public Health Focus: Electronic Cigarettes (e-Cigarettes). Available at: http://www.fda.gov/NewsEvents/PublicHealthFocus/ucm172906.htm. Accessed March 30, 2016.
Federal Drug Administration. FDA 101: Smoking Cessation Products. Available at: http://www.fda.gov/forconsumers/consumerupdates/ucm198176.htm. Accessed March 30, 2016.
Goniewicz ML, Knysak J, Gawron M, et al. (2013). Levels of selected carcinogens and toxicants in vapour from electronic cigarettes. Tobacco Control (Published Online First). doi:10.1136/tobaccocontrol-2012-050859.
Jablow, L. M. and Sexton, R. J. (2015). Spontaneous Electronic Cigarette Explosion: A Case Report. American Journal of Medical Case Reports. 3(4):93-94.
Kalkhoran, S., & Glantz, S. A. (2016). E-cigarettes and smoking cessation in real-world and clinical settings: A systematic review and meta-analysis. The Lancet Respiratory Medicine. 4(2):116-128.
Lerner CA, Sundar IK, Yao H, Gerloff J, Ossip DJ, McIntosh S, Robinson R, Rahman I. (2015). Vapors produced by electronic cigarettes and e-juices with flavorings induce toxicity, oxidative stress, and inflammatory response in lung epithelial cells and in mouse lung. PLoS One 10:e0116732.
Lim HB, Kim SH. (2014). Inhalation of e-cigarette cartridge solution aggravates allergen-induced airway inflammation and hyper-responsiveness in mice. Toxicol Res 30: 13–18.
McConnell R, et al. (2015). Electronic-Cigarette Use and Respiratory Symptoms in Adolescents. Society for Research on Nicotine and Tobacco 2015, PA6-4 (Presentation).
McGrath-Morrow SA, et al. (2015). The effects of electronic cigarette emissions on systemic cotinine levels, weight and postnatal lung growth in neonatal mice. PLoS One 10: e0118344.
McRobbie, H., Bullen, C., Hartmann-Boyce, J., and Hajek, P. (2014). Electronic cigarettes for smoking cessation and reduction. Cochrane Database of Systematic Reviews. 12:CD010216.
Rowell, T. R., Lee, S., and Tarran, R. (2015). Select E-Cigarette Flavors Alter Calcium Signaling Cell Viability And Proliferation in Lung Epithelia. American Thoracic Society International Conference Abstracts.
Sussan TE, Gajghate S, Thimmulappa RK, Ma J, Kim JH, Sudini K, Consolini N, Cormier SA, Lomnicki S, Hasan F, Pekosz A, Biswal S. (2015). Exposure to electronic cigarettes impairs pulmonary anti-bacterial and anti-viral defenses in a mouse model. PLoS One 10: e0116861.
Thornburg, J., Malloy, Q., Cho, S-H. Studabaker, W., and Lee, Y. O. (2014). Exhaled Electronic Cigarette Emissions: What’s Your Secondhand Exposure? RTI Press. Available at: https://www.rti.org/pubs/secondhand_exposure_to_electronic_cigarette_emissions.pdf. Accessed March 28, 2016.
Thornburg, J. (2016). E-Cigarettes and Vapor Products: State of the Science. Presentation to Orange County Board of Health on January 27, 2016. Available at: https://youtu.be/0HNqLcl7iBo. Accessed March 28, 2016.
Tierney, P. A., Karpinski, C. D., Brown, J. E., Luo, W., & Pankow, J. F. (2015). Flavour chemicals in electronic cigarette fluids. Tobacco Control. TC Online First. 10.1136/tobaccocontrol-2014-052175.
Tverdal, A., & Bjartveit, K. (2006). Health consequences of reduced daily cigarette consumption. Tobacco Control, 15(6), 472-480.
U.S. Department of Health and Human Services. (2014). The Health Consequences of Smoking: 50 Years of Progress. A Report of the Surgeon General. Atlanta, GA: U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, National Center for Chronic Disease Prevention and Health Promotion, Office on Smoking and Health.
Vardavas CI, Anagnostopoulos N, Kougias M, Evangelopoulou V, Connolly GN, Behrakis PK. (2012). Short-term pulmonary effects of using an electronic cigarette: impact on respiratory flow resistance, impedance, and exhaled nitric oxide. Chest 141: 1400–1406.
Varughese, S., Teschke, K., Brauer, M., Chow, Y., van Netten, C., & Kennedy, S. M. (2005). Effects of theatrical smokes and fogs on respiratory health in the entertainment industry. American Journal of Industrial Medicine, 47, 411–418.
Wieslander G, Norback D, Lindgren T. (2001). Experimental exposure to propylene glycol mist in aviation emergency training: acute ocular and respiratory effects. Occup Environ Med 58: 649–655.
Williams RS, Derrick J, Ribisl KM. Electronic Cigarette Sales to Minors via the Internet. JAMA pediatrics. 2015;169(3):e1563-e1563.
Wu Q, Jiang D, Minor M, Chu HW. (2014). Electronic cigarette liquid increases inflammation and virus infection in primary human airway epithelial cells. PLoS One 9: e108342.
Youth Risk Behavior Survey (YRBS)– Preliminary Data. (2015). Phone communication with Scarlett Steinert, Chapel-Hill Carrboro City Schools, on February 23, 2016.