COVID-19 and beyond Banning the use of tobacco and e-cigarettes in public places WHO Library Cataloguing in Publication Data World Health Organization. Regional Office for the Eastern Mediterranean COVID-19 and beyond: banning the use of tobacco and e-cigarettes in public places / World Health Organization. Regional Office for the Eastern Mediterranean p. ISBN: 978-92-9022-400-6 ISBN: 978-92-9022-402-0 (online) 1. COVID-19 - prevention & control 2. Betacoronavirus 3. Disease Outbreaks 4. Tobacco Use – prevention & control 5. Vaping – prevention & control 6. Water Pipe Smoking – prevention & control I. Title II Regional Office for the Eastern Mediterranean (NLM Classification: WC 505) © World Health Organization 2020 Some rights reserved. This work is available under the Creative Commons Attribution-NonCommercial- ShareAlike 3.0 IGO licence (CC BY-NC-SA 3.0 IGO; https://creativecommons.org/licenses/by-nc- sa/3.0/igo). Contents Banning the use of tobacco and e-cigarettes in public places .................................. 1 Banning waterpipe use during the COVID-19 pandemic ........................................... 1 Maintaining bans on all tobacco use, including waterpipes and e-cigarettes, in public places during the pandemic and beyond ......................... 2 There is no safe level of exposure to second-hand smoke ....................................... 2 Heated tobacco products and e-cigarettes ................................................................ 2 Banning smoking in all its forms in all indoor public places is a legal obligation .............................................................................. 3 The status of smoke-free laws in the Eastern Mediterranean Region.................................................................................. 3 Enforcing a comprehensive ban on tobacco smoke in public places is possible............................................................................. 4 Economic losses related to a ban of tobacco smoke, including from waterpipe use, in public places are a myth ........................................ 4 Banning tobacco smoke in public places protects youth ........................................... 5 The expected reaction from the tobacco industry...................................................... 6 Recommended next steps during the COVID-19 pandemic and beyond ............................................................................................... 7 References ................................................................................................................ 8 Banning the use of tobacco Banning waterpipe use and e-cigarettes in public during the COVID-19 places pandemic WHO recommends that countries Following the spread of the COVID-19 comprehensively ban smoking in all pandemic around the world, 15 indoor public places, and in other countries in the WHO Eastern public places where possible (1), Mediterranean Region took the bold in line with Article 8 of the WHO decision to temporarily ban waterpipe Framework Convention on Tobacco use in public places. Added to the two Control (FCTC) and its Guidelines, as countries that had already banned it, well as the MPOWER tobacco control this brings the number of countries policy package. in the Region that have banned Exposure to second-hand smoke waterpipe use in public places to 17. kills over 1 million people every year, Waterpipe use has been identified comprising about 15% of the total as a possible means for the spread number of deaths caused by tobacco of COVID-19 due to its communal use (2). Tobacco use is a major risk use, which involves the sharing factor for noncommunicable diseases, of a single mouthpiece and hose, such as cancers, diabetes, lung and its customary use in social disorders and cardiovascular disease. gatherings, which makes physical Tobacco use is also associated distancing impossible. The ban was with increased transmission of, and strictly implemented, and violations mortality from, infectious diseases were minimal due to active national (3,4,5). inspection systems in countries to When tobacco is smoked in public monitor implementation. As countries places, both smokers and non- move towards less strict measures smokers breathe in the toxic to control the spread of COVID-19, constituents present in second-hand it is important that they consider smoke. Banning smoking in public maintaining the ban on tobacco and places (including waterpipe use) saves waterpipe use, and on electronic lives by protecting non-smokers from cigarettes (e-cigarettes), in public the harm of inhaling second-hand places for wider health reasons. smoke (6,7,8,9). COVID-19 and beyond Banning the use of tobacco and e-cigarettes in public places 1 Maintaining bans There are also high economic costs on all tobacco use, that result from the mortality, morbidity and loss of income that results from including waterpipes exposure to second-hand tobacco and e-cigarettes, in smoke. A study done in the United public places during the States of America in 2005 estimated that exposure to second-hand smoke pandemic and beyond costs more than US$ 10 billion each A comprehensive ban on all tobacco year (17). smoke, including waterpipe use, in all indoor public places, indoor Heated tobacco products workplaces and public transport should and e-cigarettes be maintained because tobacco smoke Novel tobacco and nicotine products in any indoor place seriously harms should also be included in all smoke- the health of the tobacco user and all free policies. This includes both heated those exposed to tobacco smoke (10). tobacco products and e-cigarettes. Research shows that banning tobacco use in public places has reduced There is clear guidance from the the prevalence of tobacco use by last session of the Conference of 2.5%–15% over five years in various Parties to the WHO FCTC that countries of the Region (11). heated tobacco products are tobacco products and that all provisions of the There is no safe level of WHO FCTC on smoke-free policies exposure to second-hand should be applied. Like smoke from smoke conventional cigarettes, emissions from heated tobacco products contain More than 7000 chemicals have been harmful toxicants (18). This means identified in second-hand smoke, of that emissions from heated tobacco which 250 are known to be harmful to products, including second-hand health and more than 50 are known to emissions, pose a health risk to people cause cancer (12,13,14,15). There is in public places. In addition, since no safe level of exposure to second- heated tobacco products are tobacco hand smoke, which causes heart products (19), obligations under the disease, chronic respiratory disease, WHO FCTC still apply (20). Parties to several types of cancers and many the WHO FCTC have an obligation to other debilitating conditions. Even brief ensure that the use of heated tobacco exposure can cause serious damage (16). COVID-19 and beyond 2 Banning the use of tobacco and e-cigarettes in public places products is banned in all indoor public Convention are requested to comply places, including workplaces, cafes with this requirement. In the WHO and restaurants. Eastern Mediterranean Region, there are currently 19 Parties to the WHO Emissions from e-cigarettes are also FCTC. harmful to both users and non-users. These emissions typically contain The status of smoke- nicotine, which is addictive, and other free laws in the Eastern toxic substances, some of which are known to cause cancer and other Mediterranean Region health conditions (18,21). Use of Currently, seven countries in the e-cigarettes also increases the risk Eastern Mediterranean Region of heart disease and lung disorders have successfully passed laws that (22,23,24). Second-hand aerosol comprehensively and permanently from e-cigarettes has been shown ban tobacco smoke in all indoor to be a source of air contamination public places, including workplaces, with particulate matter and contains cafes and restaurants. Enforcement significantly higher levels of many of this policy, however, remains a big harmful chemicals than background challenge in the Region. Countries that air levels (21). Given these health have banned tobacco use in public risks for both users and non-users, places include Afghanistan, Egypt, use of e-cigarettes should be Islamic Republic of Iran, Lebanon, comprehensively banned in all indoor Libya, Pakistan and Palestine (25). public places. This has been made Many other countries have introduced clear by WHO, including in a report to partial bans on tobacco smoke in the Conference of Parties to the WHO public places. FCTC in 2016 (21). A lack of enforcement of smoke-free Banning smoking in all its laws is a common issue in the Eastern forms in all indoor public Mediterranean Region, with large places is a legal obligation numbers of youth reporting exposure to second-hand smoke in public places The WHO FCTC requires that tobacco despite the adoption of smoke-free smoking be banned in all indoor public laws. For instance, although Egypt places and in other public places, has banned smoking in all indoor where possible. All Parties to the public places, 55% of youth reported COVID-19 and beyond Banning the use of tobacco and e-cigarettes in public places 3 being exposed to second-hand smoke Economic losses related to in these areas. Youth exposure to a ban of tobacco smoke, second-hand smoke is also high in several other countries that have a including from waterpipe similarly comprehensive ban, including use, in public