What to Do about E-Cigarettes

Employers are struggling to determine how e-cigarettes fit in with their smoke-free or tobacco-free workplace policies. Smoking-cessation expert Ken Wassum offers advice for effective e-cigarette-policy communication.

Friday, August 22, 2014
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In the past few decades, cigarette smoking has been largely de-normalized, depending on the region in which people live. People have become used to seeing fewer smokers in most public areas.

Yet, cigarette smoking remains the leading preventable cause of death in the United States, according to the Surgeon General Report in 2010. Ten years ago, many experts in the field of tobacco control felt that the development of a safe form of pulmonary delivery of nicotine could spell the end of combustible tobacco and its deathly impact.

As if on cue, the electronic cigarette (e-cigarette or e-cig) entered the picture in 2006. E-cigarettes differ from regular cigarettes in that what is inhaled is a vapor composed of water, nicotine, and propylene glycol instead of smoke. Since then tobacco control experts have struggled to understand if and how e-cigarettes will impact efforts to reduce smoking-related morbidity and mortality.

E-cigarettes are challenging the scientific community to think about the relative harm of different tobacco products and how to advise the public moving forward. Unfortunately, this doesn't help employers, who are trying to figure out how e-cigarettes should be considered in the context of smoke-free campus policies. Employees who use e-cigarettes want to know if they can use them at work, and employers have to decide whether to let them.

Employers are asking:

*     Should they allow e-cigarette use at work since inhaling vapor does not have the health risks associated with inhaling smoke?

*     If so, should they even encourage e-cigarette use as an alternative to smoking, or as a quitting aid?

*     What if they have tobacco-free policies in place? Should they make an exception?

*     How can employers communicate their policies on e-cigarettes?

Conflicting Messages Create Uncertainty

Many employers justifiably feel a bit overwhelmed about all the conflicting information they are hearing and reading about e-cigarettes. It seems like every few days, there are new conflicting reports about them on TV, the web, radio, and print media.

On one day, there may be an article about exploding e-cigarette batteries or how a patient on oxygen set himself on fire while using an e-cigarette. Then another day, there may be an article on a study that shows how e-cigarettes can help smokers quit. Discussions about the study may dominate the media for a period of time, and suddenly, there may be a new report about nicotine poisonings.

Those in support of the products argue that smokers should be offered e-cigarettes as a tool to quit smoking traditional cigarettes, while those who are unconvinced, argue that e-cigarettes should not be offered until there is evidence-based proof that they are safe and effective. E-cigarettes are currently marketed as a safe alternative to traditional cigarettes, but that may not last for much longer.

The Food and Drug Administration announced April 24 that it deems e-cigarettes to be within their jurisdiction to regulate, along with cigars, hookah tobacco (flavored tobacco smoked via a water pipe), and some dissolvable tobacco products not already being regulated.

What to Say in E-Cig Workplace Policies

At this time, there is insufficient evidence to support the safety of long-term use of e-cigarettes or whether they are effective in helping smokers quit traditional cigarettes. Both safety and effectiveness are standard measures that need to be demonstrated in order for a treatment, such as the FDA-approved nicotine replacement therapy patches, to be adopted by tobacco-treatment professionals.

It is unlikely that anyone in the tobacco control community would argue against the premise that e-cigarettes are unlikely to cause the same amount of damage to the body as traditional cigarettes. The question is whether e-cigarettes will cause damage that is new and different from that caused by traditional cigarettes. Many advocate for a harm-reduction approach that would use e-cigarettes as a tool in the process of quitting tobacco.

Until more is known about e-cigarettes, it would not be wise for employers to advocate their use. Workplace policies should reflect the following rationale:

*   E-cigarette use should not be encouraged as a way to quit smoking until there is good empirical evidence that they are effective and safe as a quitting tool. Current research has led to evidence-based cessation treatment approaches that have proven to be highly cost-effective. Whether e-cigarettes are a tool that can be added to existing treatments has yet to be determined. Well-designed randomized control trials are needed to provide that information.

*   E-cigarettes should not be encouraged as a harm-reduction approach to smoking, but smokers inclined to switch should not be discouraged from doing so. Some experts suggest that the risk of e-cigarette use is far less than the use of traditional combustible tobacco and only slightly higher than NRT products that are recognized as being very safe. One e-cigarette ingredient, propylene glycol, is considered by the FDA to be "generally recognized as safe." However, just as the true health implications of daily cigarette smoking were not understood until many years after they were first commercially marketed in the early 20th century, there is currently not enough information about the long-term health effects of e-cigarettes to encourage such a switch.

*   E-cigarette use should not be allowed in any locations where use of traditional tobacco products (cigarettes, cigars, pipes and smokeless-tobacco products) is not permitted. While e-cigarettes do not technically produce "smoke," they do produce a vapor or aerosol that contains exhaled nicotine, flavoring compounds and other chemicals. Until long-term exposure to these ingredients is proven to be safe, non-smokers should not have to be exposed to second-hand vapor. Another reason for banning e-cigarettes in smoke-free locations is that it is very difficult to determine from a distance whether a person is smoking a traditional tobacco cigarette or an e-cigarette. This requires those in charge of enforcement to approach individuals for a close inspection, which can result in awkward situations and needless ambiguity.

How to Communicate E-Cigarette Policies

Companies with smoke-free or tobacco-free policies in place who decide to ban e-cigarette use can easily add an e-cigarette section to their existing policies. Most companies who have these policies in place can draw upon their previous experience when deciding their e-cigarette strategies. The following considerations may be helpful for employers as they develop communications about their policies regarding e-cigarettes in the workplace:

*     Develop a policy that clearly lays out expectations and consequences. Communicate the policy very clearly and state the rationale for why e-cigarette use is being banned on company property. Be clear about how the policy will be enforced and whether there will be any punitive actions taken toward employees who do not comply with the policy.

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*           Develop messaging that presents the policy as a positive change meant to create a safe, clean and healthful environment. Make sure all communications and promotions present the new policy as a benefit that ensures a healthy workplace for everyone. Be clear that the policy is not meant as punishment to employees who use any type of tobacco.

*     Develop a communication and promotion strategy. Determine the best methods for communicating within the organization, both with employees and management. Consider the demographics of the workforce and determine the most effective way to reach employees. Plan on using a number of different communication modalities, including:

*     Email campaigns that provide links to the policy and other supporting documentation on the internal employee website;

*     Visually appealing promotional materials like flyers, table tents and posters that can be hung on the walls and left in break rooms;

*   Promotional materials like postcards mailed to home addresses;

*   Videos of company leaders talking about the policy, the purpose and the rationale;

*         Emails by the CEO and other leaders explaining the new policy; and

*         Town-hall meetings or any other methods that align with the company culture.

*     Create a communication timeline that includes a period of time (six months to a year) to prepare employees for the change. A best practice for implementing any tobacco use policy is communicating about it way in advance to ensure that all employees are fully aware of the policy and consequences of non-compliance. The timeline should include a calendar for all communications, including promotions, leading up to the implementation date.

*     Offer  and communicate about access to a tobacco-cessation program to assist all smokers who want to quit, including those who only smoke e-cigarettes. Often, when employers implement smoke-free and tobacco-free policies, they offer financial or other incentives to quit smoking and/or access to a smoking cessation program as much as a year in advance to increase awareness. Employers who already have a smoking cessation program should make sure the program offers help with quitting e-cigarettes.

Without solid empirical research, including longitudinal studies that can provide clear answers on both the safety of e-cigarettes and their effectiveness in helping smokers quit, employers should not feel uncomfortable making a decision to ban e-cigarette use in office settings. Their main concern should be making sure that their employees understand the rationale behind their decision - the lack of research and the need to make decisions that are in the best interest of all employees.

Ken Wassum is director of clinical and quality support for the Quit For Life ® Program, a tobacco-cessation program provided by Alere Wellbeing and the American Cancer Society. He is past president of the Association for the Treatment of Tobacco Use and Dependence and previously served on its board of directors.


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