State Laws Regarding Indoor Public Use, Retail Sales, and Prices of Electronic Cigarettes - U.S. States, Guam, Puerto Rico, and U.S. Virgin Islands, September 30, 2017.

Electronic cigarettes (e-cigarettes) are the most frequently used tobacco product among U.S. youths, and past 30-day e-cigarette use is more prevalent among high school students than among adults (1,2). E-cigarettes typically deliver nicotine, and the U.S. Surgeon General has concluded that nicotine exposure during adolescence can cause addiction and can harm the developing adolescent brain (2). Through authority granted by the Family Smoking Prevention and Tobacco Control Act, the Food and Drug Administration (FDA) prohibits e-cigarette sales to minors, free samples, and vending machine sales, except in adult-only facilities (3). States, localities, territories, and tribes maintain broad authority to adopt additional or more stringent requirements regarding tobacco product use, sales, marketing, and other topics (2,4). To understand the current e-cigarette policy landscape in the United States, CDC assessed state and territorial laws that 1) prohibit e-cigarette use and conventional tobacco smoking indoors in restaurants, bars, and worksites; 2) require a retail license to sell e-cigarettes; 3) prohibit e-cigarette self-service displays (e.g., requirement that products be kept behind the counter or in a locked box); 4) establish 21 years as the minimum age of purchase for all tobacco products, including e-cigarettes (tobacco-21); and 5) apply an excise tax to e-cigarettes. As of September 30, 2017, eight states, the District of Columbia (DC), and Puerto Rico prohibited indoor e-cigarette use and smoking in indoor areas of restaurants, bars, and worksites; 16 states, DC, and the U.S. Virgin Islands required a retail license to sell e-cigarettes; 26 states prohibited e-cigarette self-service displays; five states, DC, and Guam had tobacco-21 laws; and eight states, DC, Puerto Rico, and the U.S. Virgin Islands taxed e-cigarettes. Sixteen states had none of the assessed laws. A comprehensive approach that combines state-level strategies to reduce youths' initiation of e-cigarettes and population exposure to e-cigarette aerosol, coupled with federal regulation, could help reduce health risks posed by e-cigarettes among youths (2,5).

Low-Cost Air Quality Monitoring Methods to Assess Compliance With Smoke-Free Regulations: A Multi-Center Study in Six Low- and Middle-Income Countries.

INTRODUCTION: Many low- and middle-income countries (LMICs) have enacted legislation banning smoking in public places, yet enforcement remains challenging. The aim of this study was to assess the feasibility of using a validated low-cost methodology (the Dylos DC1700) to provide objective evidence of smoke-free (SF) law compliance in hospitality venues in urban LMIC settings, where outdoor air pollution levels are generally high. METHODS: Teams measured indoor fine particulate matter (PM2.5) concentrations and systematically observed smoking behavior and SF signage in a convenience sample of hospitality venues (bars, restaurants, cafes, and hotels) covered by existing SF legislation in Mexico, Pakistan, Indonesia, Chad, Bangladesh, and India. Outdoor air PM2.5 was also measured on each sampling day. RESULTS: Data were collected from 626 venues. Smoking was observed during almost one-third of visits with substantial differences between countries-from 5% in India to 72% in Chad. After excluding venues where other combustion sources were observed, secondhand smoke (SHS) derived PM2.5 was calculated by subtracting outdoor ambient PM2.5 concentrations from indoor measurements and was, on average, 34 µg/m(3) in venues with observed smoking-compared to an average value of 0 µg/m(3) in venues where smoking was not observed (P < .001). In over one-quarter of venues where smoking was observed the difference between indoor and outdoor PM2.5 concentrations exceeded 64 µg/m(3). CONCLUSIONS: This study suggests that low-cost air quality monitoring is a viable method for improving knowledge about environmental SHS and can provide indicative data on compliance with local and national SF legislation in hospitality venues in LMICs. IMPLICATIONS: Air quality monitoring can provide objective scientific data on SHS and air quality levels in venues to assess the effectiveness of SF laws and identify required improvements. Equipment costs and high outdoor air pollution levels have hitherto limited application in LMICs. This study tested the feasibility of using a validated low-cost methodology in hospitality venues in six LMIC urban settings and suggests this is a viable method for improving knowledge about SHS exposure and can provide indicative data on compliance with SF legislation.

Trends in children's exposure to second-hand smoke in the INMA-Granada cohort: an evaluation of the Spanish anti-smoking law.

The smoke-free legislation implemented in Spain in 2006 imposed a partial ban on smoking in public and work places, but the result did not meet expectations. Therefore, a more restrictive anti-smoking law was passed five years later in 2011 prohibiting smoking in all public places, on public transport, and the workplace. With the objective of assessing the impact of the latter anti-smoking legislation on children's exposure to second-hand smoke (SHS), we assessed parent's smoking habits and children's urine cotinine (UC) concentrations in 118 boys before (2005-2006) and after (2011-2012) the introduction of this law. Repeated cross-sectional follow-ups of the "Environment and Childhood Research Network" (INMA-Granada), a Spanish population-based birth cohort study, at 4-5 years old (2005-2006) and 10-11 years old (2011-2012), were designed. Data were gathered by ad-hoc questionnaire, and median UC levels recorded as an objective indicator of overall SHS exposure. Multivariable logistic regression was used to examine the association between parent's smoking habits at home and SHS exposure, among other potential predictors. An increase was observed in the prevalence of families with at least one smoker (39.0% vs. 50.8%) and in the prevalence of smoking mothers (20.3% vs. 29.7%) and fathers (33.9% vs. 39.0%). Median UC concentration was 8.0ng/mL (interquartile range [IQR]: 2.0-21.8) before legislation onset and 8.7ng/mL (IQR: 2.0-24.3) afterwards. In the multivariable analysis, the smoking status of parents and smoking habits at home were statistically associated with the risk of SHS exposure and with UC concentrations in children. These findings indicate that the recent prohibition of smoking in enclosed public and workplaces in Spain has not been accompanied by a decline in the exposure to SHS among children, who continue to be adversely affected. There is a need to target smoking at home in order to avoid future adverse health effects in a population that has no choice in the acceptance or not of SHS exposure-derived risk.

Reduction in hospital admissions for acute coronary syndrome after the successful implementation of 100% smoke-free legislation in Argentina: a comparison with partial smoking restrictions.

BACKGROUND: Several studies have shown a decrease in acute coronary syndrome (ACS) admissions after the implementation of 100% smoke-free legislation. However, no studies have been conducted in developing countries. METHODS: We conducted a time series analysis of ACS hospital admissions in Santa Fe province and Buenos Aires city, Argentina. In 2006, Santa Fe implemented a 100% smoke-free law and Buenos Aires implemented a partial law with designated smoking areas and exceptions. Age-standardised ACS admissions rates were compared before and after the implementation of the laws in each district. Smoking prevalence, compliance with legislation and exposure to secondhand smoke (SHS) was also assessed in both districts. RESULTS: In Santa Fe an immediate decrease in ACS admissions was observed after implementation (-2.5 admissions per 100,000, p=0.03; 13% reduction), compared with no change in Buenos Aires city (rate ratio Santa Fe vs Buenos Aires: 0.74, 95% CI 0.63 to 0.86, p≤0.001). In Santa Fe, the immediate effect was followed by a persistent decrease in admissions due to ACS (-0.26 admissions per 100,000 per month). Smoking prevalence did not change significantly in either district during the same period. In both districts, there was a reduction in self-reported SHS exposure, with a trend towards lower exposure in Santa Fe province. No other comprehensive tobacco control interventions were implemented during the study period. CONCLUSIONS: A 100% smoke-free law was more effective than a partial restriction law in reducing ACS admissions. An immediate effect was followed by a sustained decrease in ACS admissions. Smoke-free initiatives can be also effective in decreasing acute coronary events in developing countries.

Secondhand smoke exposure in bars and restaurants in Guatemala City: before and after smoking ban evaluation.

OBJECTIVE: In February 2009, Guatemala implemented a comprehensive smoking ban. We assessed air nicotine levels in bars and restaurants 6 months after the ban (post-ban) and compared them with levels found in 2006 (pre-ban). METHODS: Exposure was estimated by passive sampling of vapor-phase nicotine using samplers (n=50) placed for 7 working days in 10 bars and 11 restaurants in Guatemala City. Air nicotine was measured by gas chromatography, and the time-weighted average concentration in µg/m(3) was estimated. Employees answered a survey about smoke-free workplaces (n = 32) and compared with pre-ban (n = 37) results. RESULTS: Nicotine was detectable in all bars pre- and post-ban. In restaurants, it was detectable in all pre- and 73% post-ban. Median nicotine concentrations in bars significantly decreased from 4.58 µg/m(3) (IQR, 1.71, 6.45) pre-ban to 0.28 µg/m(3) (IQR 0.17, 0.66) post-ban (87% decrease). In restaurants, concentrations significantly decreased from 0.58 µg/m(3) (IQR, 0.44, 0.71) to 0.04 µg/m(3) (IQR 0.01, 0.11) (95% decrease). Employees' support for a smoke-free workplace increased in the post-ban survey (from 32 to 81%, p < 0.001). CONCLUSION: Six months after the implementation of a smoke-free law in Guatemala, nicotine levels were significantly decreased in bars and restaurants and workers' support for the law substantially increased.

Secondhand tobacco smoke in bars and restaurants in Santiago, Chile: evaluation of partial smoking ban legislation in public places.

OBJECTIVE: To compare air nicotine concentrations according to the smoking policy selected by bars/restaurants in Santiago, Chile before and after the enactment of partial smoking ban legislation in 2007 (establishments could be smoke free, have segregated (mixed) smoking and non-smoking areas, or allow smoking in all areas). METHODS: The study measured air nicotine concentrations over 7 days to characterise secondhand smoke exposure in 30 bars/restaurants in 2008. Owner/manager interviews and physical inspections were conducted. RESULTS: Median IQR air nicotine concentrations measured in all venues were 4.38 (0.61-13.62) µg/m(3). Air nicotine concentrations were higher in bars (median 7.22, IQR 2.48-15.64 µg/m(3)) compared to restaurants (1.12, 0.15-9.22 µg/m(3)). By smoking status, nicotine concentrations were higher in smoking venues (13.46, 5.31-16.87 µg/m(3)), followed by smoking areas in mixed venues (9.22, 5.09-14.90 µg/m(3)) and non-smoking areas in mixed venues (0.99, 0.19-1.27 µg/m(3)). Air nicotine concentrations were markedly lower in smoke-free venues (0.12, 0.11-0.46 µg/m(3)). After adjustment for differences in volume and ventilation, air nicotine concentrations were 3.2, 35.5 and 56.2 times higher in non-smoking areas in mixed venues, smoking areas in mixed venues and smoking venues, respectively, compared to smoke-free venues. CONCLUSIONS: Exposure to secondhand smoke remains high in bars and restaurants in Santiago, Chile. These findings demonstrate that the partial smoking ban legislation enacted in Chile in 2007 provides no protection to employees working in those venues. Enacting a comprehensive smoke-free legislation which protects all people from exposure to secondhand smoke in all public places and workplaces is urgently needed.

Reduction of secondhand tobacco smoke in public places following national smoke-free legislation in Uruguay.

BACKGROUND: Smoke-free legislation eliminating tobacco smoke in all indoor public places and workplaces is the international standard to protect all people from exposure to secondhand smoke. Uruguay was the first country in the Americas and the first middle-income country in the world to enact a comprehensive smoke-free national legislation in March 2006. OBJECTIVE: To compare air nicotine concentrations measured in indoor public places and workplaces in Montevideo, Uruguay before (November 2002) and after (July 2007) the implementation of the national legislation. METHODS: Air nicotine concentrations were measured for 7-14 days using the same protocol in schools, a hospital, a local government building, an airport and restaurants and bars. A total of 100 and 103 nicotine samples were available in 2002 and 2007, respectively. RESULTS: Median (IQR) air nicotine concentrations in the study samples were 0.75 (0.2-1.54) microg/m(3) in 2002 compared to 0.07 (0.0-0.20) microg/m(3) in 2007. The overall nicotine reduction comparing locations sampled in 2007 to those sampled in 2002 was 91% (95% CI 85% to 94%) after adjustment for differences in room volume and ventilation. The greatest nicotine reduction was observed in schools (97% reduction), followed by the airport (94% reduction), the hospital (89% reduction), the local government building (86% reduction) and restaurants/bars (81% reduction). CONCLUSION: Exposure to secondhand smoke has decreased greatly in indoor public places and workplaces in Montevideo, Uruguay, after the implementation of a comprehensive national smoke-free legislation. These findings suggest that it is possible to successfully implement smoke-free legislations in low and middle-income countries.

Informing effective smokefree policies in Argentina: air quality monitoring study in 15 cities (2007-2009).

OBJECTIVE: To evaluate indoor air pollution in hospitality venues in Argentina. MATERIAL AND METHODS: PM2.5 levels were measured in a convenience sample of venues in 15 cities with different legislative contexts following a protocol developed by Roswell Park Cancer Institute. RESULTS: 554 samples were collected. Across all 5 smoke free cities the mean PM2.5 level was lower during daytime vs. evening hours, 24 vs. 98 PM2.5 respectively (p=.012). In the three cities evaluated before and after legislation, PM2.5 levels decreased dramatically (p<0.001 each). Overall, PM2.5 levels were 5 times higher in cities with no legislation vs. smoke free cities (p<0.001). In cities with designated smoking areas, PM2.5 levels were not statistically different between smoking and non-smoking areas (p=0.272). Non-smoking areas had significantly higher PM2.5 levels compared to 100% smoke free venues in the same city (twofold higher) (p=0.017). CONCLUSIONS: Most of the participating cities in this study had significantly lower PM2.5 levels after the implementation of 100% smoke free legislation. Hence, it represents a useful tool to promote 100% smoke free policies in Argentina.

Informing effective smokefree policies in Argentina: air quality monitoring study in 15 cities (2007-2009) / Políticas efectivas de ambientes libres de humo de tabaco en Argentina: estudio de monitoreo de calidad del aire en 15 ciudades (2007-2009)

Objective. To evaluate indoor air pollution in hospitality venues in Argentina. Material and Methods. PM2.5 levels were measured in a convenience sample of venues in 15 cities with different legislative contexts following a protocol developed by Roswell Park Cancer Institute. Results. 554 samples were collected. Across all 5 smokefree cities the mean PM2.5 level was lower during daytime vs. evening hours, 24 vs. 98 PM2.5 respectively (p=.012). In the three cities evaluated before and after legislation, PM2.5 levels decreased dramatically (p<0.001 each). Overall, PM2.5 levels were 5 times higher in cities with no legislation vs. smokefree cities (p<0.001). In cities with designated smoking areas, PM2.5 levels were not statistically different between smoking and non-smoking areas (p=0.272). Non-smoking areas had significantly higher PM2.5 levels compared to 100 percent smokefree venues in the same city (twofold higher) (p=0.017). Conclusions. Most of the participating cities in this study had significantly lower PM2.5 levels after the implementation of 100 percent smokefree legislation. Hence, it represents a useful tool to promote 100 percent smokefree policies in Argentina.

Objetivo. Evaluar la polución ambiental del sector gastronómico en Argentina. Material y métodos. Se midieron los niveles de partículas respirables (PM2.5) en una muestra por conveniencia de establecimientos de 15 ciudades con diferente legislación, siguiendo un protocolo del Instituto de Cáncer Roswell Park. Resultados. Se recolectaron 554 muestras. En cinco ciudades libres de humo (CLH) la media de PM2.5 durante el día fue baja y menor a la observada durante la noche, 24 vs. 98 PM2.5 respectivamente (p=.012). En las tres ciudades evaluadas antes y después de la legislación, las PM2.5 disminuyeron drásticamente (p<0.001 cada una). Las PM2.5 fueron cinco veces mayores en ciudades sin legislación comparadas con CLH (p<0.001). En ciudades con restricción parcial, no hubo diferencia significativa entre las PM2.5 en el sector fumador y no fumador (p=0.272). Los sectores no fumadores tuvieron niveles PM2.5 significativamente más altos comparados con los lugares 100 por ciento libres de humo de la misma ciudad (p= 0.017). Conclusiones. La mayoría de las ciudades participantes en este estudio tuvieron niveles PM2.5 significativamente más bajos tras la implementación de leyes pro ambientes 100 por ciento libres de humo de tabaco, por lo que representa una herramienta útil para promover legislación 100 por ciento libre de humo en Argentina.

Factors associated with total restrictions on smoking at work and at home: a study among populations in multiple US states and the US Virgin Islands.

This study investigated factors associated with smoking restrictions in the workplace and at home in order to better understand the effects of workplace smoking restrictions. Data from the 2006 Behavior Risk Factor Surveillance System were analyzed. Multiple logistic regression was used to determine independent risk factors for potential smoking exposure at work and at home. The population potentially exposed at work were more likely to be young, male, low-income, Latino adults without college degrees or health insurance; they were also more likely to be a current or former smoker and be at risk for heavy drinking. Our study also investigated self-reported restrictions at home and found significant disparities between populations. We conclude that men, Latinos, and young adults are more likely to live in a home with a smoking ban, but are disproportionately exposed to risks at work, presumably against their preferences. Workplace smoking restrictions in 2006 offered unequal protection.

Philip Morris involvement in the development of an air quality laboratory in El Salvador.

BACKGROUND: The tobacco industry has organised research institutions to generate misleading data on indoor air quality, including second-hand smoke exposure and health effects. OBJECTIVES: To describe tobacco industry involvement in the organisation and financial support of an air quality research laboratory in El Salvador. METHODS: Tobacco industry documents on the internet were systematically searched from August 2007 to February 2008 for air quality studies undertaken in El Salvador, and laboratory personnel were interviewed. RESULTS: Philip Morris sought to establish a network of air quality laboratories throughout Latin America. In El Salvador, in 1997, through Tabacalera de El Salvador (a subsidiary of Philip Morris) and the Salvadoran Foundation for Economic Development (FUSADES), the industry organised an air quality research laboratory. FUSADES was part of the industry's Latin American Scientific Network, which consisted of doctors hired as consultants who would send air samples from their research to FUSADES. Philip Morris Scientific Affairs personnel hired LabStat, a Canadian-based laboratory, to provide technical assistance to FUSADES (train and assist the laboratory in air quality measurements). In addition, the Washington-based HMS Group successfully implemented a plan to upgrade the laboratory and obtain international certifications. HMS Group also assisted in searching for sustainable funding for FUSADES, including seeking funds from international aid for Hurricane Mitch. CONCLUSION: Air quality studies that have used the FUSADES laboratory should be carefully interpreted, given the support that this laboratory received from Philip Morris.

Secondhand smoke: facts and lies.

Mexico ratified the Framework Convention for Tobacco Control in 2004 and is obligated to move forward with implementing its provisions, including Article 8 (Protection from exposure to tobacco smoke). The country has already faced opposition from the tobacco industry. This paper addresses industry tactics against tobacco control, describing the general strategies that have been pursued and the evidence relevant to combating these strategies. The approaches taken by the industry in an effort to discredit the scientific foundation for promoting smokefree environments, the efforts by the industry to propose ventilation of indoor spaces and separation of smokers from nonsmokers as an effective alternative to smokefree places, and finally, the strategy of raising fear of economic losses on the part of the hospitality industry and thereby gaining this sector as an ally in campaigning against smokefree policies are considered. As reviewed in this article: 1) There is scientific consensus on the adverse effects of inhaling SHS; 2) Only smokefree places fully protect nonsmokers from inhaling SHS; and 3) Smokefree policies do not bring economic harm to the hospitality industry.

Secondhand smoke: facts and lies / Humo de segunda mano: hechos y mentiras

Mexico ratified the Framework Convention for Tobacco Control in 2004 and is obligated to move forward with implementing its provisions, including Article 8 (Protection from exposure to tobacco smoke). The country has already faced opposition from the tobacco industry. This paper addresses industry tactics against tobacco control, describing the general strategies that have been pursued and the evidence relevant to combating these strategies. The approaches taken by the industry in an effort to discredit the scientific foundation for promoting smokefree environments, the efforts by the industry to propose ventilation of indoor spaces and separation of smokers from nonsmokers as an effective alternative to smokefree places, and finally, the strategy of raising fear of economic losses on the part of the hospitality industry and thereby gaining this sector as an ally in campaigning against smokefree policies are considered. As reviewed in this article: 1) There is scientific consensus on the adverse effects of inhaling SHS; 2) Only smokefree places fully protect nonsmokers from inhaling SHS; and 3) Smokefree policies do not bring economic harm to the hospitality industry.

En 2004 México ratificó el Convenio Marco para el Control del Tabaco y está obligado a implementar sus disposiciones, incluidas el Artículo 8 (Protección contra la exposición al humo de tabaco); esto ha generado oposición de la industria tabacalera. En este artículo se describen las tácticas de la industria para contrarrestar el control del tabaco, sus principales estrategias, y también se presentan las evidencias relevantes para combatirlas. Además, se describen las acciones emprendidas por la industria en el esfuerzo por desacreditar el fundamento científico de la promoción de ambientes libres de humo de tabaco, y su propuesta de usar sistemas de ventilación en espacios interiores y la de separación de áreas para fumadores y no fumadores, como alternativas efectivas a la creación de ambientes libres de humo de tabaco. Por último, las tabacaleras también han creado temor a las perdidas económicas para la industria restaurantera, ello con el objetivo de hacer de este sector un aliado en la lucha contra las políticas de ambientes libres de humo de tabaco. Este artículo concluye que: 1) existe un consenso científico sobre los efectos adversos para la salud causado por la exposición al humo de tabaco; 2) los ambientes libres de humo de tabaco son la única forma de proteger a los no fumadores de la exposición a humo de tabaco; 3) las políticas de ambientes libres de humo de tabaco no afectan económicamente a la industria restaurantera.

[Comments on studies of industrial and non-industrial environments in Brazil: a comparative approach]. / Considerações sobre estudos de ambientes industriais e não industriais no Brasil: uma abordagem comparativa.

Air quality in industrial environments has been studied since the second half of the 20th century. Well-documented results show that exposure to chemical pollutants through their consumption, production, and storage can damage workers' health. New research focusing on non-industrial environments has shown unexpected correlations between air quality and health effects. Artificial ventilation systems have been related to health-related complaints and a high rate of absenteeism. Symptoms related to air quality in non-industrial environments are recognized by the World Health Organization and encompassed under the so-called sick building syndrome (SBS). In Brazil there are few studies comparing indoor air quality and health. The present study is intended to map the studies already conducted in Brazil in order to encourage further research in this area, due to its importance for public health.

Ambientes climatizados, portaria 3.523 de 28/8/98 do Ministério da Saúde e padrões de qualidade do ar de interiores do Brasil / Indoor air quality, Act 3,523 of the Ministry of Health and Brazilian standards for biological indoor air contaminants

O artigo analisa criticamente a portaria 3.523 de 28/8/98 do Ministério da Saúde, com ênfase na questão dos contaminantes do ar e suas conseqüências para a saúde em ambientes climatizados. É feita, ainda, uma revisão concisa sobre as infecções hospitalares e as áreas hospitalares em que a transmissão por via aerógena pode ser importante, sendo necessários sistemas de ventilação especial. Os padrões de partículas, mais precisamente os biológicos, são considerados de forma detalhada, destacando-se os contaminantes microbianos mais comuns, as diferenças entre países dos Hemisférios Norte e Sul e as questões relativas à metodologia utilizada em sua análise. Conclui-se que não há, no momento, elementos para uma definição de padrões de partículas biológicas no país