Early E-Cigarette Ban Reignited Seattle-King County's Effort to Snuff Out Tobacco Smoking

Seattle-area businesses were concerned in 2010 when suddenly people—particularly youth—seemingly lit up in and outside stores, snubbing a well-respected ban on public and workplace smoking.

“We got a lot of complaints,” recalls Scott Neal, Tobacco Prevention Program Manager at Public Health - Seattle & King County. As it turned out, e-cigarettes were becoming a trend. For example, e-cigarette use now eclipses tobacco use by youth, according to the CDC. But e-cigarettes did not fall under public smoking bans, and Seattle businesses wanted local health officials to take the lead.

“We knew e-cigarettes were addictive because of their nicotine,” says Neal. Will they transition young users to tobacco? “We don’t know, but that’s a concern,” he notes. Between e-cigarettes’ nicotine content and that, “kids were being able to buy these things pretty easily.”

Neal says department officials worked with the King County Board of Health on the ban on electronic smoking devices and unapproved nicotine delivery products, which the Board unanimously passed the ban in 2010.

In 2010, when electronic cigarettes were little more than novelties, King County, home to Seattle, Washington, restricted their sale and use, along with nicotine electronic juices and other unapproved nicotine delivery devices. In doing so, Seattle became the first big-city jurisdiction to: 1) prohibit the sale of e-smoking devices to those under 18; and 2) ban the devices in restaurants and other public places and workplaces, mirroring tobacco smoking restrictions already in place. 

The ban aims to prevent youth from nicotine addiction and preserves county public spaces as fully smoke free. Use of e-cigarettes is slightly lower among middle and high school students in King County versus the rest of the state (see box). Just as important, the e-cigarette ban represented something even bigger for Seattle public health officials—it jump-started a moribund effort to reduce tobacco use in the county.      

After seeing smoking rates drop in half over the decade ending in 2007, officials at Public Health – Seattle & King County watched smoking rates flatten for several years. State tobacco funding shriveled from about $29 million a year in 2008 to less than $1 million in 2014. Turning to grants to help fill the void, officials feared they may be rejected, as smoking rates in King County were among the lowest in the nation—only 10 percent of adults smoked.

“A closer examination of the data revealed that King County had the most extreme smoking disparities of the 15 largest metropolitan counties in the country,” says Scott Neal, Tobacco Prevention Program Manager at Public Health - Seattle & King County. The smoking rate for black adults in the county—more than one in five smoked—was double that of whites, while King County adults in low-income households were three times more likely to smoke than high-income adults. Nearly 20 percent of lesbian, gay, bisexual or transgender adults were smokers. And by 2010, smoking among local youth became common, with one in four 12th graders using cigarettes or other tobacco products.  

While the e-cigarette ban potentially could have a spillover effect on tobacco rates, local health officials won several grants in a strategy to address smoking among vulnerable populations. Grants from the CDC Communities Putting Prevention to Work, a national initiative to prevent chronic disease and promote health through policy, systems and environment changes, allowed county health officials to collaborate with others to snuff out smoking. As a result, health officials have:

· Seen all local housing authorities and many low income housing providers implement smoke‐free policies, creating nearly 14,000 smoke‐free units. Now, officials are looking to expand smoke-free policies to market-rate housing complexes. “Any exposure to second-hand smoke is bad,” says Neal, adding that most high-end apartment operators already ban smoking. But for any smoke-free policy to work, Neal says, tobacco users need access to cessation programs. To that end, officials are working with local health plans to standardize cessation benefits.

· Made inroads integrating tobacco treatment in publicly funded mental health and substance abuse agencies. Forty‐seven provider agencies, representing more than 100 different publicly funded treatment sites in King County have implemented tobacco screening and treatment policies. Nearly all provider agencies have tobacco‐free campus policies. People who have a mental health and/or substance abuse disorder use tobacco up to four times more than the general population, so inroads among provider agencies is crucial.

· Taken other steps to target smoking among youth and young adults, including leading the effort to get the county and 13 area cities to adopt tobacco-free parks’ policies. Health officials also are working with the many college, university and technical campuses in King County to adopt tobacco-related policies. Currently, about half have some policy in place. As 95 percent of smokers start before age 25, and as the tobacco industry targets this age group, says Neal, de-normalizing smoking on campus is essential in preventing future tobacco-related death and disease.

While health officials continue to target the root of some of the county’s smoking-related disparities, Neal says it’s also time to step up efforts on e-cigarettes as their overall use has jumped both locally and nationally. For example, the CDC reports e-cigarette use tripled among youth between 2013 and 2014. As of spring 2015, the Obama administration had not finalized e-cigarette restrictions [1, 2]. 

Because of the dramatic increases in e-cigarette use among youth, the health department is looking into potential strategies that will reduce youth access and use of these addictive products.  Now that recreational marijuana is legal in Washington, the health department also is considering how this impacts the use of tobacco and e-cigarettes.  “Many e-cigarettes can now be refilled with liquid marijuana so it’s difficult to tell exactly what people may be vaping in their e-cigarettes and that adds a layer of complexity to the situation,” says Neal.

Several other BCHC jurisdictions have also passed laws to regulate e-cigarettes, including: BostonChicagoLos AngelesMinneapolisNew YorkPhiladelphiaSacramento, and San Francisco.