There is no safe level of exposure to second-hand smoke
Following the spread of the COVID-19 pandemic around the world, 15 countries in the Eastern Mediterranean Region took a bold decision to ban waterpipe use temporarily in public places. This is in addition to the two countries that had already banned it previously, making the total number of countries that have banned waterpipe use in public places 17. Waterpipe use was identified as a possible means for the spread of COVID-19 due to its communal use, which involves the sharing of a single mouthpiece and hose, and customary use in social gatherings, which makes physical distancing impossible. The ban was strictly implemented, and violations were minimal due to active national inspection systems in different countries that monitor implementation. As countries now move towards less strict measures to control the spread of COVID-19, it is important to consider maintaining the ban on tobacco and waterpipe use, and e-cigarettes in all public places for public health reasons.
WHO recommends that countries comprehensively ban smoking in all indoor public places, and in other public places where possible [1], in line with Article 8 of the WHO Framework Convention on Tobacco Control and its Guidelines, as well as the MPOWER tobacco control policy package.
Suggested next steps during COVID-19 and beyond
In the context of COVID-19, tobacco, including waterpipe and e-cigarette use should remain banned in all public places. As countries start to relax COVID-19 lockdown measures, the following is highly recommended.
WHO Member States are invited to sustain the ban on waterpipe use and tobacco smoke in public places, in all indoor public places and outdoor public places, where possible, to protect public health.
The total ban on tobacco, including waterpipe and e-cigarette use should include health facilities, governmental and public buildings, restaurants and cafes, schools and educational facilities, universities, sports facilities, transportation, and private and public workplaces.
No designated smoking areas should be allowed.
A multisectoral approach must be followed in sustaining the ban, which should involve all relevant ministers and other organizations, where relevant.
Change the legislation, where needed, to make the ban of waterpipe use and smoking in public places permanent.
Put in place a mechanism that ensures monitoring and evaluation of the implementation.
Build on the enforcement mechanisms that worked well during the current ban of waterpipe use in public places.
Involve the public and raise awareness through mass media campaigns
Banning smoking and vaping in all their forms in all indoor public places is a legal obligation
The WHO Framework Convention on Tobacco Control (WHO FCTC) requires that tobacco smoking be banned in all indoor public places, and in other public places, where possible. All WHO FCTC Parties are requested to follow this direction. In the WHO Eastern Mediterranean Region, there are currently 19 Parties to the WHO FCTC.
Exposure to second-hand smoke kills over 1 million people every year, about 15% of the total number of deaths caused by tobacco use [2].
Tobacco use is a major risk factor for noncommunicable diseases, such as cancers, diabetes, lung disorders and cardiovascular disease. Tobacco use is also associated with increased transmission of, and mortality from, infectious diseases [3] [4] [5].
Exposure to second-hand smoke also imposes high economic costs from mortality, morbidity and loss of income from those exposed to tobacco smoke. A study done in the U.S. in 2005 estimated that exposure to second-hand smoke cost more than US$10 billion each year [6].
There is no safe level of exposure to second-hand smoke, which causes heart disease, chronic respiratory disease, several types of cancers and many other debilitating conditions. Even brief exposure can cause serious damage [7].
Novel tobacco and nicotine products should also be included in all smoke-free policies. This includes both heated tobacco products and e-cigarettes. There is clear guidance from the last session of the Conference of Parties that heated tobacco products are tobacco products and that all provisions of the WHO FCTC smoke-free policies should be applied. Like smoke from conventional cigarettes, emissions from heated tobacco products contain harmful toxicants [8]. This means that emissions from heated tobacco products, including second-hand emissions, still pose a health risk to people in public places. In addition, since heated tobacco products are tobacco products [9], obligations under the WHO FCTC still apply [10]. Parties to the WHO FCTC have an obligation to ensure that use of heated tobacco products is banned in all indoor public places, including workplaces, cafes and restaurants.
Emissions from electronic cigarettes are also harmful to both users and non-users. These emissions typically contain nicotine, which is addictive, and other toxic substances, some of which are known to cause cancer and other health conditions [8] [11]. Use of e-cigarettes also increases the risk of heart disease and lung disorders [12] [13] [14]. Second-hand aerosol from electronic cigarettes has been shown to be an air contamination source for particulate matter and contains significantly higher levels of many harmful chemicals than background air levels [11]. Given these health risks for both users and non-users, use of electronic cigarettes should be comprehensively banned in all indoor public places. This has been made clear by WHO, including in a report to the Conference of Parties to the WHO FCTC in 2016 [11].
It is a public health ‘must’ to maintain the ban on all tobacco smoke, including waterpipe use, in public places during COVID-19 and beyond
More than 7000 chemicals have been identified in second-hand smoke, of which 250 are known to be harmful to health and more than 50 are known to cause cancer [15] [16] [17] [18].
Exposure to second-hand smoke kills over 1 million people every year, about 15% of the total number of deaths caused by tobacco use.
Fundamentally, a comprehensive ban on all tobacco smoke, including waterpipe use, in all indoor public places, indoor workplaces and public transport should be maintained because tobacco smoke in any indoor public place seriously harms the health of the tobacco user and all those exposed to tobacco smoke [19].
When tobacco is smoked in public places, both smokers and non-smokers breathe in the toxic constituents present in second-hand smoke.
Banning smoking (including waterpipe use) saves lives by protecting non-smokers from the harm of inhaling second-hand smoke [7] [20] [21] [22] [23].
The status of smoke-free laws in the Eastern Mediterranean Region
Currently, seven countries in the Eastern Mediterranean Region have successfully passed laws that comprehensively and permanently ban tobacco smoke in all indoor public places, including workplaces, cafes and restaurants. Enforcement of this policy, however, remains a big challenge in the Region.
Countries that banned tobacco use in public places are [24]:
Afghanistan
Egypt
Islamic Republic of Iran
Lebanon
Libya
Pakistan
Palestine
Many other countries, however, have introduced only partial bans on tobacco smoke in public places.
A lack of enforcement of smoke-free laws is a common issue in the Eastern Mediterranean Region, with large numbers of youth reporting exposure to second-hand smoke in public places despite the adoption of smoke-free laws. For instance, although Egypt banned smoking in all indoor public places, 55% of youth reported being exposed to second-hand smoke in these areas. Youth exposure to second-hand smoke was also high in several other countries that have a similarly comprehensive ban, including Afghanistan (35%), Islamic Republic of Iran (38%) and Pakistan (38%).
Enforcing a comprehensive ban on tobacco smoke in public places is possible
Recent national efforts in the Eastern Mediterranean Region to ban waterpipe use in public places, including in cafes and restaurants, in light of COVID-19 show that with strong support from all relevant national authorities – a multisectoral approach – and effective public awareness campaigns, smoke-free policies can be enforced successfully.
The public only benefits from a comprehensive ban on tobacco smoke in indoor public places when the policies are fully complied with, which requires effective enforcement.
Passing smoke-free legislation is not enough. Its proper implementation and adequate enforcement require relatively small but critical efforts and activities. Over time, once a high level of compliance is achieved, smoke-free laws become self-enforcing [1]
Economic losses related to a ban of tobacco smoke, including waterpipe use, in public places is a MYTH
Comprehensively banning tobacco smoke, including waterpipe use, in public places does not lead to economic losses.
Evidence from countries where comprehensive smoke-free legislation has been implemented and enforced shows that these policies have a neutral or positive impact on businesses [1] [25]. This contradicts the tobacco industry’s claims that these policies economically harm businesses and the hospitality industry.
Implementing smoke-free policies is a very cost-effective tobacco control policy. In fact, in its recent review of policies for the prevention and control of noncommunicable diseases, WHO assessed that eliminating exposure to second-hand tobacco smoke in all indoor workplaces, public places and public transport should be classified in the highest category as a ‘best buy’. It is a highly effective intervention with a cost effectiveness analysis ≤ 100 international dollars per daily-adjusted life-year averted in low- and middle- income countries [26].
Research shows that banning tobacco use in public places can reduce the prevalence of tobacco by 2.5%–15% in five years in different countries of the Region [27].
Banning tobacco smoke in public places protects youth
Internal analyses by the Tobacco Free Initiative at the WHO Regional Office for the Eastern Mediterranean on the results from the Global Youth Tobacco Survey show that as the exposure of youth to second-hand smoke in indoor public places increases, the prevalence of current youth tobacco smoke also increases (Figure 1).
At the same time, country-level analyses of the results from the Global Youth Tobacco Survey show that the exposure of youth to second-hand smoke in public places increases their likelihood of becoming cigarette smokers in the future [28].
In Tunisia, youth who are exposed to second-hand smoke in outdoor public places are 2.3 times more likely to become cigarette smokers.
In Qatar, youth who are exposed to second-hand smoke in outdoor public places and enclosed public places are 3.2 and 1.7 times more likely to become cigarette smokers, respectively.
In Morocco, youth who are exposed to second-hand smoke in enclosed public place are 2.3 times more likely to become cigarette smokers.
In Bahrain, youth who are exposed to second-hand smoke in outdoor public places and enclosed public places are 2.3 and 1.5 times more likely to become cigarette smokers, respectively.
In Djibouti, youth exposed to second-hand smoke in outdoor public places are 1.6 times more likely to become current cigarette smokers.
In Egypt, youth who are exposed to second-hand smoke in outdoor public places and enclosed public places are 2.5 and 2.0 times more likely to become current cigarette smokers, respectively.
In Yemen, youth who are exposed to second-hand smoke in outdoor public places were 2.3 times more likely to become current cigarette smokers.
These findings are in line with analyses of the results from the Global School Health Survey in Lebanon, which show that youth who witness someone smoking in their presence are 2.8 times more likely to become cigarette smokers [29].
The expected reaction from the tobacco industry
Governments need to remain vigilant to the efforts of the industry to interfere in health policy. The tobacco industry is highly likely to:
undermine smoke-free laws.
promote designated smoking areas and alternatives for comprehensive tobacco smoke bans.
push for the ban in some, but not all, public places.
seek exemptions for e-cigarettes and heated tobacco products from the ban
The industry is currently seeking to create the false impression that e-cigarettes and heated tobacco products are safe alternatives to smoking and that using these products in public places is not harmful for non-users.
In line with the WHO Framework Convention on Tobacco Control, all tobacco control policymaking including policymaking regarding smoke-free policies, laws and enforcement, should be protected from the interests of the tobacco industry. This means that the tobacco industry, or any of its representatives, front groups and affiliated organizations, should be excluded from the setting, implementation or enforcement of smoke-free policies [30].
References
[1] World Health Organisation, WHO Report on the Global Tobacco Epidemic, Geneva, 2009.
[2] Global Burden of Disease 2017 Risk Factor Collaborators, Institute for Health Metrics and Evaluation, "Global, regional and national comparative risk assessment of 84 behavioural, environmental and occupational, and metabolic risks or clusters of risks for 195 countries and territories, 1990–2017: a systematic analysis," 2018.
[3] 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, The health consequences of smoking: 50 years of progress - A report by the Surgeon General, Atlanta, 2014.
[4] K. Lonnroth and M. Raviglione, "Global epidemiology of tuberculosis: prospects for control," Seminars in Respiratory and critical care medicine, vol. 29, no. 5, pp. 481-91, 2008.
[5] L. Han, J. Ran, Y. Mak, L. Suen, P. Lee, J. Peiris and L. Yang, "Smoking and Influenza-associated Morbidity and Mortality: A Systematic Review and Meta-analysis," Epidemiology, vol. 30, no. 3, pp. 405-417, 2019.
[6] D. Behan, M. Eriksen and Y. Lin, "Economic effects of environmental tobacco smoke," Society of Actuaries, Schaumberg, IL, 2005.
[7] International Agency for Research on Cancer, Tobacco Control, Volume 13: Evaluating the effectiveness of smoke-free policies, Lyon, 2009.
[8] World Health Organisation, Novel and emerging nicotine and tobacco products: Health effects, research needs and provisional recommended actions for regulators, Cairo, 2020.
[9] Conference of Parties to the WHO FCTC, "FCTC/COP8(22): Novel and emerging tobacco products," 2018.
[10] World Health Organisation, "WHO/NMH/PND/17.6: Heated tobacco products (HTPs) information sheet," 2018.
[11] World Health Organisation, "FCTC/COP7(11): Electronic Nicotine Delivery Systems and Electronic Non-Nicotine Delivery Systems (ENDS/ENNDS)," 2016.
[12] J. Gotts, S. Jordt, R. McConnell and R. Tarran, "State of the Art Review: What are the respiratory effect of e-cigarettes?," British Medical Journal, vol. 366, no. l5275, 2019.
[13] T. Alzahrani, I. Pena, N. Temesgen and S. Glantz, "Association between electronic cigarette use and myocardial infarction," American Journal of Preventive Medicine, vol. 55, no. 4, pp. 455-61, 2018.
[14] T. Wills, I. Pagano, R. Williams and E. Tam, "E-cigarette use and respiratory disorder in an adult sample," Drug and Alcohol Dependence, vol. 194, pp. 363-70, 2019.
[15] National Toxicology Program, U.S. Department of Health and Human Services, 14th Report on Carcinogens, 2016.
[16] World Health Organisation, Don't let tobacco take your breath away: Choose health not tobacco, Geneva, 2019.
[17] World Health Organisation, World No Tobacco Day 2018: Tobacco breaks hearts - choose health. not tobacco, Geneva, 2018.
[18] Scientific Committee on Tobacco and Health, UK Department of Health, Secondhand Smoke: Review of evidence since 1998, 2004.
[19] A. Hyland, M. Travers, C. Dresler, C. Higbee and K. Cummings, "A 32-country comparison of tobacco smoke derived particle levels in indoor public places," Tobacco Control, vol. 17, no. 3, pp. 159-65, 2008.
[20] S. Haw and L. Gruer, "Changes in exposure of adult non-smokers to secondhand smoke after implementation of smoke-free legislation in Scotland: national cross sectional survey," British Medical Journal, vol. 15, no. 335, p. 549, 2007.
[21] M. Pickett, S. Schober, D. Brody, L. Curtin and G. Giovino, "Smoke‐free laws and secondhand smoke exposure in US non‐smoking adults, 1999-2002," Tobacco Control, vol. 15, no. 4, pp. 302-307, 2006.
[22] P. Goodman, M. Agnew, M. McCaffrey, G. Paul and L. Clancy, "Effects of the Irish smoking ban on respiratory health of bar workers and air quality in Dublin pubs," American Journal of Respiratory and Critical Care Medicine, vol. 15, no. 175, pp. 840-5, 2007.
[23] D. T. Levy, J. A. Ellis, D. Mays and A. Huang, "Smoking-related deaths averted due to three years of policy progress," Bulletin of the World Health Organisation, vol. 91, no. 7, pp. 509-518, 2013.
[24] World Health Organisation, WHO Report on the Global Tobacco Epidemic, 2019, Geneva, 2019.
[25] M. Scollo, "Review of the quality of studies on the economic effects of smoke-free policies on the hospitality industry," Tobacco Control, vol. 12, no. 1, pp. 13-20, 2003.
[26] World Health Organisation, WHO Report: "Best buys" and other recommended interventions for the prevention and control of noncommunicable diseases, 2017.
[27] World Health Organisation, "Effects of meeting MPOWER requirements on smoking rates and smoking-attributable deaths for the Member States and Territories of the Eastern Mediterranean Region," 2018.
[28] World Health Organisation , “Global Youth Tobacco Survey,” 2020.
[29] World Health Organisation, U.S. Centers for Disease Control and Prevention, Lebanon Global School Health Survey, 2011.
[30] Conference of Parties to the WHO FCTC, WHO FCTC Guidelines on the Implementation of Article 5.3, 2008.
