CC 2019-10-22_11a ECigarettes and Minor PossessionMEMORANDUM
TO: CITY COUNCIL
FROM: HEATHER K. WHITHAM, CITY ATTORNEY
SUBJECT: CONSIDERATION OF PROHIBITING THE RETAIL SALE OF
ELECTRONIC CIGARETTE PRODUCTS AND PARAPHERNALIA AND
PROHIBITING THE POSSESSION OF ALL TOBACCO PRODUCTS AND
PARAPHERNALIA BY PERSONS UNDER TWENTY-ONE
DATE: OCTOBER 22, 2019
SUMMARY OF ACTION:
Receive information regarding the prohibition of the retail sale of electronic cigarette
products and paraphernalia and a prohibition on the possession of all tobacco products
and paraphernalia by persons under twenty-one and provide direction to staff.
IMPACT ON FINANCIAL AND PERSONNEL RESOURCES:
There is no fiscal impact associated with this agenda item other than the cost in legal
services to perform research and prepare the item. There would be a fiscal impact if the
Council adopts an ordinance at a future meeting to prohibit the retail sale of electronic
cigarette products and paraphernalia and that fiscal impact will be analyzed at that time.
RECOMMENDATION:
It is recommended that the Council receive information on options related to prohibiting
the retail sale of electronic cigarette products and paraphernalia and the prohibition of the
possession of all tobacco products and paraphernalia by persons under twenty-one and
provide direction as to whether the Council wishes staff to return to the Council with a
draft ordinance.
BACKGROUND:
At the September 24, 2019 City Council meeting, Mayor Ray Russom requested that the
City Council consider banning the sale of electronic cigarettes in the City and asked that
staff prepare a report discussing options to be brought back to the Council for discussion
and consideration. Council Member George concurred.
Electronic cigarettes entered the marketplace around 2007, and since 2014, they have
been the most commonly used tobacco product among youth in the United States.
Electronic cigarettes are battery-operated devices, often designed to resemble a
cigarette, that deliver and emit a nicotine-containing aerosol. Electronic cigarettes are
considered electronic delivery devices and have many names. They are frequently
referred to as e-cigs, hookah pens, vapes and vape pens. ‘ Item 11.a. - Page 1
CITY COUNCIL
CONSIDERATION OF PROHIBITING THE RETAIL SALE OF ELECTRONIC
CIGARETTE PRODUCTS AND PARAPHERNALIA AND PROHIBITING THE
POSSESSION OF ALL TOBACCO PRODUCTS AND PARAPHERNALIA BY
PERSONS UNDER TWENTY-ONE
OCTOBER 22, 2019
PAGE 2
According to the Centers for Disease Control and Prevention ("CDC"), the number of
middle and high school students who reported being current users of tobacco products
increased 36%-from 3.6 million to 4.9 million students-between 2017 and 2018. This
dramatic increase, which has erased past progress in reducing youth tobacco use, is
directly attributable to a nationwide surge in electronic cigarette use by adolescents.
There were 1.5 million more youth electronic cigarette users in 2018 than 2017, and those
who were using electronic cigarettes were using them more often. Frequent use of
electronic cigarettes increased from 20 percent in 2017 to 28 percent in 2018 among
current high school electronic cigarette users.
The widespread use of electronic cigarettes by youth has significant public health
consequences. The Surgeon General has stated:
Most e-cigarettes contain nicotine- the addictive drug in regular cigarettes,
cigars, and other tobacco products. Nicotine exposure during adolescence
can harm the developing brain -which continues to develop until about age
25. Nicotine exposure during adolescence can impact learning, memory,
and attention. Using nicotine in adolescence can also increase risk for future
addiction to other drugs. In addition to nicotine, the aerosol that users inhale
and exhale from e-cigarettes can potentially expose both themselves and
bystanders to other harmful substances, including heavy metals, volatile
organic compounds, and ultrafine particles that can be inhaled deeply into
the lungs.
A copy of a Surgeon General Advisory regarding electronic cigarettes is attached to this
report.
As of June 9, 2016, California law prohibits selling, giving, or furnishing electronic smoking
devices to individuals under the age of 21, regardless of whether the electronic smoking
device contains tobacco or nicotine. This prohibition does not apply to active duty military
personnel who are 18 years or older, but the retailer must examine an identification card
issued by the United States Armed Forces to verify the purchaser’s age. Additionally, the
Arroyo Grande Municipal Code (“AGMC”) includes a provision prohibiting the sale of
tobacco products (including electronic cigarettes) to persons under twenty-one (AGMC
Section 8.36.020).
On August 27, 2019, the Council modified its smoking regulations to include electronic
cigarettes within its definition of cigarettes. The smoking of electronic cigarettes is now
prohibited wherever smoking is prohibited within the City of Arroyo Grande.
Item 11.a. - Page 2
CITY COUNCIL
CONSIDERATION OF PROHIBITING THE RETAIL SALE OF ELECTRONIC
CIGARETTE PRODUCTS AND PARAPHERNALIA AND PROHIBITING THE
POSSESSION OF ALL TOBACCO PRODUCTS AND PARAPHERNALIA BY
PERSONS UNDER TWENTY-ONE
OCTOBER 22, 2019
PAGE 3
As has been widely reported in the media, recently there have been a number of deaths
as well as potential cases of lung disease, related to the use of electronic cigarettes and
vaping. As a result, in early September, the governor of Massachusetts declared a public
health emergency and ordered a four-month ban on the sale of vaping products in the
state, which apparently is the first action of its kind in the nation by a state.
This summer, several cities in California adopted prohibitions on the sale of electronic
cigarettes. The first was the City of San Francisco. In June, 2019 they adopted an
ordinance which prohibits:
…the sale by tobacco retail establishments of electronic cigarettes that
require, but have not received, an order from the Food and Drug
Administration (FDA) approving their marketing; and prohibiting the sale
and distribution to any person in San Francisco of flavored tobacco products
and electronic cigarettes that require, but have not received, an FDA order
approving their marketing.
The San Francisco ordinance was structured so that it would not be operative until six
months after its effective date. We understand that the electronic cigarette company Juul,
which is headquartered in San Francisco, is the backer of a referendum to repeal the
ordinance that is on the ballot for voters in a November 5, 2019 special election. A copy
of San Francisco’s ordinance is attached for reference.
The cities of Richmond and Livermore also adopted ordinances similar to San Francisco’s
this summer. Livermore’s ordinance has also been the subject of a referendum petition,
which was certified in early September by their City Council and will now go to the voters
in a March 2020 special election.
All three ordinances are structured in a way that relates to electronic cigarettes that have
not received premarket review by the FDA. As we understand it, rather than an outright
ban on electronic cigarettes, they are a prohibition against the sale of any electronic
cigarettes that haven’t been reviewed by the FDA to confirm that they are appropriate for
the protection of public health. Tobacco companies are required to report to the FDA for
premarket review any information concerning health risks, the components, ingredients,
additives, and manufacturing methods. So far, no electronic cigarettes have been put
through the review process that is required by federal law. Instead, the FDA has proposed
extending the deadline for electronic cigarettes to submit applications for premarket
review, which would mean electronic cigarette products will have been on the market for
15 years without the required public health review.
Item 11.a. - Page 3
CITY COUNCIL
CONSIDERATION OF PROHIBITING THE RETAIL SALE OF ELECTRONIC
CIGARETTE PRODUCTS AND PARAPHERNALIA AND PROHIBITING THE
POSSESSION OF ALL TOBACCO PRODUCTS AND PARAPHERNALIA BY
PERSONS UNDER TWENTY-ONE
OCTOBER 22, 2019
PAGE 4
In June 2018, a measure was placed on the ballot in San Francisco that was a referendum
of an ordinance that had been adopted by the San Francisco Board of Supervisors that
banned the sale of flavored tobacco products. The voters approved that referendum
measure, upholding the ordinance by a 68% vote. A number of other cities have banned
the sale of flavored tobacco. An article in the San Francisco Chronicle on November 29,
2018 noted that twenty-six California cities and counties have restrictions on the sale of
flavored tobacco products.
As reflected in the referendum challenges in San Francisco, retailers who sell tobacco
products often fight local bans and regulation. Such challenges are reportedly largely
funded by the tobacco industry. In addition, some opponents of electronic cigarette bans
assert that electronic cigarettes are a better alternative for traditional cigarette smokers
who are trying to quit smoking.
In addition, it might also be noted, that the City of Beverly Hills has gone a step further.
This summer, they adopted an ordinance that will ultimately prohibit (with very limited
exceptions related to cigar lounges and hotels), the retail sale of all tobacco products and
electronic cigarette paraphernalia in the City. That ordinance is structured to go into full
effect in January, 2021. As far as we are aware, they are the only city in the country to
outright ban tobacco products.
ANALYSIS OF ISSUES:
The City has the authority to adopt and enforce ordinances and regulations not in conflict
with general laws. Therefore, absent preemption by state or federal law precluding the
adoption of a local regulation, the City may adopt its own regulations as well as additional
requirements that supplement and do not conflict with state and federal regulations.
In 2003, California enacted the Cigarette and Tobacco Products Licensing Act to regulate
the sale of tobacco and tobacco products. Similar to a business license, the Act requires
every person selling cigarettes or tobacco products to the public in California to obtain a
license from the California Department of Tax and Fee Administration.
In 2009, the federal government enacted the Family Smoking Prevention and Tobacco
Control Act, which authorized the Food and Drug Administration to regulate the
manufacture, marketing, and distribution of tobacco products. The Family Smoking
Prevention and Tobacco Control Act authorizes the City to adopt local regulations
prohibiting the sale, distribution, possession, exposure to, access to, and promotion of, or
use of tobacco products, but does preempt the City from regulating tobacco product
standards, manufacturing, and labeling. With regard to advertising, the Family Smoking
Prevention and Tobacco Control Act prohibits the City from placing requirements on the
content of tobacco product advertisements. Accordingly, federal law grants the U.S. Food
Item 11.a. - Page 4
CITY COUNCIL
CONSIDERATION OF PROHIBITING THE RETAIL SALE OF ELECTRONIC
CIGARETTE PRODUCTS AND PARAPHERNALIA AND PROHIBITING THE
POSSESSION OF ALL TOBACCO PRODUCTS AND PARAPHERNALIA BY
PERSONS UNDER TWENTY-ONE
OCTOBER 22, 2019
PAGE 5
& Drug Administration authority to regulate all tobacco products and expressly preserves
the power of local governments to enact additional or “more stringent” regulations related
to or prohibiting tobacco sales. Since the California legislature has not fully occupied the
field of tobacco sales, California cities are free to implement any tobacco sales regulation
or restriction provided they do not involve the collection of taxes or the penal aspects of
tobacco sales to minors.
Consistent with the state Cigarette and Tobacco Products Licensing Act and the federal
Smoking Prevention and Tobacco Control Act, the City licenses tobacco retailers and
regulates the sale of tobacco products (reference AGMC Chapter 8.38). These
regulations could be extended to include prohibitions on the sale of electronic cigarettes
and paraphernalia.
It is important to keep in mind that courts have not yet reviewed citywide bans on
electronic cigarette or tobacco sales, so there is still uncertainty as to whether a court
would uphold these types of bans if challenged. Accordingly, if the City chooses to enact
a ban on the sale of electronic cigarettes and paraphernalia, there could be legal
challenges, which could be underwritten by tobacco industry interests. Any such legal
challenges would need to be appropriately defended, which could result in substantial
litigation expenses.
Lastly, when the legislature changed the legal smoking age from eighteen to twenty-one
in 2016, they also repealed an existing law (Penal Code 308(b)), which made it illegal for
individuals under eighteen to purchase, receive or possess tobacco products. Therefore,
under State law, it is illegal to sell or give tobacco to individuals under twenty-one, but it
is not illegal for individuals under twenty-one to use or possess tobacco products. This
has eliminated a tool previously used by law enforcement to deter individuals under the
legal smoking age from smoking.
Business and Professions Code Section 22964 expressly authorizes local jurisdictions to
adopt stricter standards than those set forth in State law, providing that “[t]his division
sets forth minimum state restrictions with respect to the legal age to purchase or possess
tobacco products and does not preempt or otherwise prohibit the adoption of a local
standard that imposes a more restrictive legal age to purchase or possess tobacco
products. A local standard that imposes a more restrictive legal age to purchase or
possess tobacco products shall control in the event of any inconsistency between this
division and a local standard.”
If the Council is interested, staff could also explore the possibility of adopting an ordinance
prohibiting the purchase, use or possession of all tobacco products by persons under
twenty-one. However, staff has not explored the legislative intent behind the legislature’s
Item 11.a. - Page 5
CITY COUNCIL
CONSIDERATION OF PROHIBITING THE RETAIL SALE OF ELECTRONIC
CIGARETTE PRODUCTS AND PARAPHERNALIA AND PROHIBITING THE
POSSESSION OF ALL TOBACCO PRODUCTS AND PARAPHERNALIA BY
PERSONS UNDER TWENTY-ONE
OCTOBER 22, 2019
PAGE 6
decision to repeal the prohibition on possession of tobacco products by those under the
legal smoking age. In addition, ChangeLab Solutions, which is a nonprofit organization
that provides legal information on matters relating to public health and has developed
model ordinances to help California cities and counties limit tobacco use and unwanted
exposure to secondhand smoke, including electronic smoking devices and cannabis,
strongly recommends against adoption of such ordinances. In their Model
Comprehensive Tobacco Retailer Licensing Ordinance, ChangeLab Solutions notes the
following regarding local ordinances regulating possession of tobacco by persons under
the legal smoking age:
Any jurisdiction that currently penalizes underage youth who purchase, use,
or possess Tobacco Products or Tobacco Paraphernalia should repeal
such penalties. ChangeLab Solutions and other leading tobacco control
organizations strongly recommend against the adoption or enforcement of
laws penalizing youth who purchase, use, or possess Tobacco Products or
Tobacco Paraphernalia (commonly referred to as “Youth PUP Laws”).
Evidence demonstrates that well-enforced laws targeting Tobacco Retailers
provide greater public health benefits than Youth PUP Laws. Moreover,
studies show that Youth PUP Laws only minimally affect tobacco use, and
prioritizing enforcement of other tobacco control laws can more effectively
reduce youth access to Tobacco Products. Finally, Youth PUP Laws raise
significant equity concerns because their enforcement often
disproportionately affects youth of color.
In addition, with only having performed a limited search, staff was unable to locate a city
that has adopted such a prohibition.
ALTERNATIVES:
The following alternatives are provided for the Council’s consideration:
1.Direct staff to proceed with preparing and bringing forth an ordinance
prohibiting the retail sale of all electronic cigarette products and paraphernalia
and provide direction on the prohibition of possession of tobacco products and
paraphernalia by persons under twenty-one;
2.Direct staff to proceed with preparing and bringing forth an ordinance
prohibiting the retail sale of all electronic cigarette products and paraphernalia
until they are approved by the FDA and provide direction on the prohibition of
possession of tobacco products and paraphernalia by persons under twenty-
one;
3.Receive information and direct staff to take no further action at this time; or
4.Provide other direction to staff.
Item 11.a. - Page 6
CITY COUNCIL
CONSIDERATION OF PROHIBITING THE RETAIL SALE OF ELECTRONIC
CIGARETTE PRODUCTS AND PARAPHERNALIA AND PROHIBITING THE
POSSESSION OF ALL TOBACCO PRODUCTS AND PARAPHERNALIA BY
PERSONS UNDER TWENTY-ONE
OCTOBER 22, 2019
PAGE 7
ADVANTAGES:
This item provides the Council with information regarding the potential prohibition of the
retail sale of electronic cigarette products and paraphernalia and facilitates a discussion
of whether or not to adopt an ordinance prohibiting their sale. A prohibition would prohibit
access to electronic cigarettes in the City of Arroyo Grande, which could be a benefit to
public health.
DISADVANTAGES:
There are no disadvantages identified with the discussion of prohibiting the sale of
electronic cigarette products and paraphernalia. A prohibition would prohibit the sale of
electronic cigarettes in the City of Arroyo Grande, which could expose the City to legal
challenge and some have argued would limit access to a less harmful smoking alternative
to the regular cigarette.
ENVIRONMENTAL REVIEW:
No environmental review is required for a discussion of options related to prohibiting the
retail sale of electronic cigarette products and paraphernalia.
PUBLIC NOTIFICATION AND COMMENTS:
The Agenda was posted at City Hall and on the City’s website in accordance with
Government Code Section 54954.2.
ATTACHMENTS:
1.San Francisco Ordinance
2.Surgeon General’s Advisory on E-cigarette Use Among Youth
3.Correspondence from Tenet Health Central Coast Received by the City on October
10, 2019
Item 11.a. - Page 7
ATTACHMENT 1
Item 11.a. - Page 8
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FILE NO. 190312 ORDINANCE NO. 122-19
[Health Code -Restricting the Sale, Manufacture, and Distribution of Tobacco Products,
Including Electronic Cigarettes]
Ordinance amending the Health Code to prohibit the sale by tobacco retail
,'
establishments of electronic cigarettes that require, but have not received, an order
from the Food and Drug Administration (FDA) approving their marketing; and
prohibiting the sale and distribution to any person in San Francisco of flavored
tobacco products and electronic cigarettes that require, but have not received, an FDA
order approving their marketing.
NOTE : Unchanged Code text and uncodified text are in plain Arial font.
Additions to Codes are in single-underline itczlics Times New Roman font .
Deletions to Codes are in s1.rikethrm1gh italics Times ,¥-cw Reme,nfon.t.
Board amendment additions are in do ub le-underlin ed Arial fo nt.
Board amendment deletions are in &b=-ikethrou§h /\ria l font.
Asterisks (* * * *) ind ic ate the omission of unchanged Code
subsections or parts of ta bles.
Be it ordained by the People of the City and County of San Francisco:
Section 1. Findings.
(a) Despite progress in reducing smoking, tobacco use is still the leading cause of
preventable death in the United States. Tobacco kills more than 480,000 people in this
country annually-more than AIDS, alcohol, car accidents, illegal drugs, murders, and
suicides combined. And beyond this large, impersonal statistic , are countless human beings,
whose lives are forever devastated by the irreparable loss of a loved one caused by tobacco
use, and the inevitable rupture of family that follows such a loss. And that is to say nothing of
the huge financial costs tobacco use places on our health care system, and the constraints on
productivity it imposes on our economic system.
Supervisors Walton; Peskin; Fe wer, Safai , Ye e , Bro wn
BOARD OF SUPERVISORS Page 1
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(b) Electronic cigarettes (or "e-cigarettes") entered the marketplace around 2007, and
since 2014, they have been the most commonly used tobacco product among youth in the
United States. The dramatic surge in youth e-cigarette use ("vaping") is no accident. E-
cigarettes are frequently marketed in a variety of flavors with obvious appeal to youth, such as
gummy bear, cotton candy, and fruit punch. As of 2017, researchers had identified more than
15,500 unique e-cigarette flavors available online. In addition, e-cigarette companies have
effectively used marketing strategies, including celebrity endorsements, slick magazine
advertisements, social media campaigns, paid influencers, and music sponsorships, to reach
youth and young adults. A 2016 study found that 78.2% of middle and high school students-
20.5 million youth-had been exposed to e-cigarette advertisements from at least one source,
an increase from 68.9% only two years before, in 2014.
(c) According to the Centers for Disease Control and Prevention ("CDC"), the number
of middle and high school students who reported being current users of tobacco products
increased 36%-from 3.6 million to 4.9 million students-between 2017 and 2018. This
dramatic increase, which has erased past progress in reducing youth tobacco use, is directly
attributable to a nationwide surge in e-cigarette use by adolescents. There were 1.5 million
more youth e-cigarette users in 2018 than 2017, and those who were using e-cigarettes were
using them more often. Frequent use of e-cigarettes increased from 20 percent in 2017 to 28
percent in 2018 among current high school e-cigarette users.
(d) The widespread use of e-cigarettes by youth has significant public health
consequences. As stated by the Surgeon General, "Most e-cigarettes contain nicotine -the
addictive drug in regular cigarettes, cigars, and other tobacco products. Nicotine exposure
during adolescence can harm the developing brain -which continues to develop until about
age 25. Nicotine exposure during adolescence can impact learning, memory, and attention.
Using nicotine in adolescence can also increase risk for future addiction to other drugs. In
Supervisors Walton; Peskin; Fewer, Safai, Yee, Brown
BOARD OF SUPERVISORS Page2
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addition to nicotine, the aerosol that users inhale and exhale from e-cigarettes can potentially
expose both themselves and bystanders to other harmful substances, including heavy metals,
volatile organic compounds, and ultrafine particles that can be inhaled deeply into the lungs."
(e) And while there is some evidence that the use of e-cigarettes by adults may
support smoking cessation under certain circumstances, a 2018 National Academy of
Sciences, Engineering, and Medicine report concluded that there was moderate evidence that
e-cigarette use in fact increases the frequency and intensity of cigarette smoking in the future.
(f) In addition, there is a growing body of research concluding that there are significant
health risks associated with electronic cigarette use. For example, daily e-cigarette use is
associated with increased odds of a heart attack. And the American Lung Association has
warned that the inhalation of harmful chemicals through vaping may cause irreversible lung
damage and lung disease.
(g) To reduce the burden of tobacco use, the City and County of San Francisco (the
"City") licenses tobacco retail establishments. (Health Code Article 19H). In 2017, to address
the appeal of flavored tobacco products to youth, the City enacted Ordinance No. 140-17,
prohibiting tobacco retail establishments from selling flavored tobacco products. As a result of
the referendum process, the ordinance was placed before the voters, who approved the
ordinance in June 2018 (Proposition E) by a majority of 68.39%.
(h) Notwithstanding these efforts, San Francisco's youth still access and use tobacco
products. According to the most recent Youth Risk Behavior Survey for which local data are
available, in 2017, 16.7% of San Francisco's high school students had tried smoking, 25%
had used an electronic cigarette (or "vaped"), and 7.1 % reported current e-cigarette use,
which is defined as use on at least one day in the past 30 days.
(i) Among San Francisco high school students who reported currently using electronic
cigarettes, 13.6% reported that they usually purchased their electronic cigarette products in a
Supervisors Walton; Peskin; Fewer, Safai, Yee, Brown
BOARD OF SUPERVISORS Page 3
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store. The remaining 86.4% reported that they obtained them from places other than the
City's licensed tobacco retail establishments, including friends, other social sources, and
internet e-cigarette vendors.
U) To protect the public, especially youth, against the health risks created by tobacco
products, Congress enacted the Family Smoking Prevention and Tobacco Control Act
("Tobacco Control Act") in 2009. Among other things, the Tobacco Control Act authorized the
U.S. Food and Drug Administration ("FDA") to set national standards governing the
manufacture of tobacco products, to limit levels of harmful components in tobacco products
and to require manufacturers to disclose information and research relating to the products'
health effects.
(k) A central requirement of the Tobacco Control Act is premarket review of all new
tobacco products. Specifically, every "new tobacco product"-defined to include any tobacco
product not on the market in the United States as of February 15, 2007-must be authorized
by the FDA for sale in the United States before it may enter the marketplace. A new tobacco
product may not be marketed until the FDA has found that the product is: (1) appropriate for
the protection of the public health upon review of a premarket tobacco application; (2)
substantially equivalent to a grandfathered product; or (3) exempt from substantial
equivalence requirements.
(I) In determining whether the marketing of a tobacco product is appropriate for the
protection of the public health, the FDA must consider the risks and benefits of the product to
the population as a whole, including users and nonusers of the product, and taking into
account the increased or decreased likelihood that existing users of tobacco products will stop
using tobacco products and the increased or decreased likelihood that those who do not use
tobacco products will start using them. Where there is a lack of showing that permitting the
Supervisors Walton; Peskin; Fewer, Safai, Yee, Brown
BOARD OF SUPERVISORS Page 4
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sale of a tobacco product would be appropriate for the protection of the public health, the
Tobacco Control Act requires that the FDA deny an application for premarket review.
(m) Virtually all electronic cigarettes that are sold today entered the market after 2007,
but have not been reviewed by the FDA to determine if they are appropriate for the public
health. In 2017, the FDA issued Guidance that purports to give electronic cigarette
manufacturers until August 8, 2022 to submit their application for premarket review. The
Guidance further purports to allow unapproved products to stay on the market indefinitely,
until such time as the FDA complies with its statutory duty to conduct a premarket review to
determine whether a new tobacco product poses a risk to public health. In March 2019, the
FDA issued draft guidance in which it considered moving the premarket application deadline
up by one year for certain flavored e-cigarette products. It is not known when, if ever, this
narrow adjustment will become final or will take effect.
(n) By the time e-cigarette manufacturers will be required to submit their premarket
review applications, e-cigarettes will have been on the market for fifteen years without any
FDA analysis of their safety and alleged benefit. If current trends continue, six million more
youth in the United States will begin using e-cigarettes between now and then. Until such
time as the FDA fulfills its statutory duty to conduct premarket reviews of new tobacco
products, a generation of young people will become addicted to tobacco, resulting in an
entirely preventable increase in the burdens and tragedies associated with tobacco use. San
Francisco is not content to wait until then before addressing, for its residents, what appears
from the evidence to be a major public health crisis that is going unattended.
Section 2. The Health Code is amended by adding new Article 19R, consisting of
Sections 19R.1 through 19R.5, to read as follows:
Supervisors Walton; Peskin; Fewer, Safai, Yee, Brown
BOARD OF SUPERVISORS Page 5
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ARTICLE 19R: PROHIBITING THE SALE OF ELECTRONIC CIGARETTES LACKING FOOD
AND DRUG ADMINISTRATION PREMARKET APPROVAL
SEC. 19R.1. DEFlNITIONS.
For purposes of'thi.s Article l 9R, the following terms have the following meanings:
"Director" has the meaning set forth in Hea lth Code Section 19H2.
"Electronic Cigarette" has the meaning set forth in Section 30121 of the California Revenue
and Taxation Code, as m.av be amended from time to time.
"Establishment" has the meaning set forth tn Health Code Section 19H2.
"New Tobacco Product" has the meaning set forth in 21 U.S.C. § 387;(a)(J ). as may be
ame'71.ded fr om time to time.
SEC. 19R.2. SALE OR DISTRIBUTION OF ELECTRONIC CIGARETTES LACKING
FOOD AND DRUG ADMINISTRATION PREMARKET ORDER OF APPROVAL PROHIBITED .
The sale or distribution by an Es tablishment of an E lectron ic Cigarette is prohibited where ·the
Electronic Cigarette:
(a) ls a New Tobacco Product.-
(b) Requires premarket review under 21 U.S. C. § S87i, c1s mav be aniended from time to time;
(c) Does not have a premarket review order under 21 U.S.C. § 387i(c)(l)(A)(i), as may be
amended from time to time.
SEC. 19R.3. ADMINISTRATIVE REGULATIONS.
The Director may adopt rules, regulations, or guidelines for the implementation lmd
enforcement of this Article l 9R.
Supervisors Walton; Peskin; Fewer, Safai, Yee, Brown
BOARD OF SUPERVISORS Page 6
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SEC. 19R.4. ENFORCEMENT.
The Director maven.force Section 19R.2 tinder Articles 19 et seq. ofthe Health Code , including
but not limited to Article 19H
SEC. 19R.5. NO CONFLICT WITH FEDERAL OR STATE LAW.
Nothing in this Article J 9R shall be interpreted or applied so as to create any requirement,
power, or duD, that is preem.pted by federal or state law.
Section 3. Article 19H of the Health Code is amended by adding new Section 19H .14-
3, to read as follows:
SEC. 19H.14-3. CONDUCT VIOLATING HEALTH CODE ARTICLE 19R
(PROHIBITING THE SALE OR DISTRIBUTION OF ELECTRONIC CIGARETTES LACKING
FOOD AND DRUG ADMINISTRATION PREMARKET ORDER OF APPRO VAL).
(a) Upon a decision by the Director that the Permiltee or the Permittee 's agent or em ployee
has engaged in anv conduct that violates Health Code Section 19R.2 (Sale or Distribution of Electronic
Cigarettes l ac/cin,g Food and Drug Administration Premarket Order o(Approval Prohibited), the
Director mav suspend a Tobacco Sales permit as set forth in Section 19H.19.
OJ) The Director shall commence enforcement under this Section 19H 14-3 bv serving either a
notice of co rrection under Section J 9H.21 or a notice o{initial determination under Section 19 H. 22.
Section 4. The Health Code is hereby amended by adding new Article 19S, consisting
of Sections 19S.1 through 19S.6, to read as follows:
Supervisors Walton; Peskin; Fewer, Safai, Yee, Brown
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ARTICLE 19S. PROHIBITING THE SALE AND DISTRIBUTION OF TOBACCO PRODUCTS
IN SAN FRANCISCO
SEC. 19S.1. D EFINITIONS.
For purposes o[this Article J 9S. the [allowing terms have the [allowing meanings:
"Characterizing Flavor" has the meaning set forth in Health Code Section 190. 2.
"Cigarette" has the meani)igsetforth in Health Code Section J9Q.2.
"City II means the Cit.v and County o(San Francisco .
"Cons titit ent '' has the memfing set forth in Health Code Sect.ion 190. 2.
"Director" nU3rtns the Director o(Healt.h , or th e Dire ctor's designee.
"Distinguis h.ab le" hru the meaning set forth in Health Code Section J 90.2.
"Distribute" or "Distribution" means the transfer. by any Person other than a co mm on ca rri er ,
o[a Tob_acco Product at anv point from the place o(J.Ylanu[acture or thel'eafter to th e Person who sells
the Tobacco Product to an individual /0r personal consumptton .
"Electronic Cigarette" has the meaning set forth in Section 30121 ofthe California Revenue
and Taxation Code, as may be amended from time to time.
"Flavored Tobacco Product" has the meaning set forth in Hea lth' Code Section 190.2.
"Labeling" has the meaning set forth in fleal{h Code Section l 9Q. 2.
"New Tobacco Produl1" has the meaning set forth in 21 US. C. § 387i(a)(J), as may be
amended fron1 . time to time.
".Packaging" has the meaning set forth in Health Code Section 190. 2.
"Person" has the meaning set f'orth in Health Code Section 19H.2.
"Sell," "Sale," an.d "to Sell" mean any transaction where, for any considera_tion, ownership of'
a Tobacco Product is transferred from one Person to another, including but not limited to any transfer
oftitle or possession for consideratio n, exchange. or barter, in any manner or by any means.
"Tobacco P1·odu.ct" has the meaning set forth in Health Code Section 19H.2.
Supervisors Walton; Peskin; Fewer, Safai, Yee, Brown
BOARD OF SUPERVISORS Page 8
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SEC. 19S.2. PROHIBITION ON SALE OR DISTRIBUTION OF TOBACCO PRODUCTS.
(a) No Per.·011. shall Sell or Distribute anvFlavored Tobacco Product to a Person in San
Fta:ncisco. There shall be a rebuttable presumption that a Tobacco Product, other than a Cigarett.e,. is
a Flavored Tobacco Product ifa. mo.n.ufacturer or any o[th.e manufacturer's a gents or em.plovees, irt
·the course of their (lgency or emplovment, has made a statement or claim directed to consumers or to
the public that the Tobacco Product has or produces a Characterizing.Flavor. including, but not
limited to, text, co lor, and/or images on the product 's Labeling or Packagiiig that are used to explicitlv
or implicitly communicate that the Tobacco Product has a Characterizing Flavor.
(b) No Person shall Sell or Distribute an Electr'onic Cigarette to ci Person in San Francisco
whei-e the Electronic Cigarette:
(1) ls. a New Toba cco Pi·oduct ,·
(2) Requires premarket review under 21 U.S.C. ,S 387i, as may be amended from time
to time; and
(3) Does not have a premarket review order under 21 US.C. {i 387/(c)O )(A)(i), as mav
b-e amended 6·om lime to lime.
SEC. 19S.3. ADMINISTRATIVE REGULATIONS.
The Diredor may adopt rules, regulations, or guidelines for th e implementation of this Article
SEC.19S.4. ENFORCEMENT.
(ci) Violations o[this Artide 19S or o(anv rule or regulation issued tinder this Article shall be
punishable by administrative fines i1nposed pursuqnt to administrative citations. Administrative Code
Chapter I 00 "Procedure8 Governing the Imposition o{Administi•ative Fines,,, as amended from time. to
Supervisors Walton; Peskin; Fewer, Safai, Yee, Brown
BOARD OF SUPERVISORS Page 9
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time, shall go ·vern the issuance cmd enforcem.ent o(adtninistrat.ive citations, and cv /L ection a:nd review
o{admtm:str"tive fine s , to enforce this Article and any rule or regulation adopted pursuant to th.is
Article.
(h) The CiiyAttornev may at any time institute civil proceedings for 1'.niunctive and monetary
relie(including civil penalties, against any Person fbr violations o(this Article l 9S, without regard to
whether the Director has assessed or collected administrative penalties.
(c) At any tim e. the Director mav refer a ca se to the City Attomev 's Office for civil
enforcement, but a referral is not required for the City Attorney to bring a civ il action under subsection.
(d) Anv Person that violates any provision of'th is Anicle 19S sh.all be subiect to iniwictive
relief and a civil penalty tn cm amount n:ot to exceed $1,000 for each. violation , whdi penalty shall be
assessed and recovered in a civil action hrought in the name of'the people o[the City and County o[
San. Francisco by-the City A ttornev in anv co ur t o[com.petent iurisdiction. In assessing the amount of
the civil penalty, the c0urt shall co nsider any one or more o(tlrn relevant circumstances presented by
any of th e pa.rties to the case, including but not limit ed to, the following: the nature and seriousness of'
the misconduct giving rise to the violation, the nwnber of violations, the persistence of the misconduct,
the length o[time over which the misconduct occurred, the wr:llfidness o[lhe 1nisconduct, and the
de[enclan.t's assets, liabilities , and net worth.
{e) The Citv n1a y recover 1-e asonable attorneys' fees and costs for civil actions brought
pursuant to this Section 19S. 4.
(/) Remedies under this Section 19S.4 are non-exclusive and cumulative to all other remedies
available at law OF equity.
SEC.19S.5. NO CONFLICT WITH FEDERAL OR STATE LAW.
Supervisors Walton; Peskin; Fewer, Safai, Yee, Brown
BOARD OF SUPERVISORS Page 10
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Nothing in this Article 19S &hall be interpreted or applied so as to create any requirement,
power, or dutv that is preempted hv federal or state law.
SEC. 19S.6. SEVERA BILTTY.
If'ahv section. subsection . sentence, clause, phrase, or word of'this Article l 9S, or any
application thereof to any person or circumstance, is held to be invalid or unconstitutional by a
decision of a court o[competent luris·cliction, such decisio n shall not affect the validity o[the remaining
portions or applications of the Article. The Board o(Supervisors hereby declares that it would have
passed this ordinance and each and every section, subsection, sentence, clause, phrase, and word not
dec lared invalid or unconstitutional without regard to whether any other portion ofthis Article or
application thereof wou ld be subsequently declared invalid or unconstitutional.
Section 5. Effective and Operative Dates.
(a) This ordinance shall become effective 30 days after enactment. Enactment occurs
when the Mayor signs the ordinance, the Mayor returns the ordinance unsigned or does not
sign the ordinance within ten days of receiving it, or the Board of Supervisors overrides the
Mayor's veto of the ordinance.
(b) This ordinance shall become operative six months after the effective date.
Section 6. Severability . If any section , subsection, sentence, clause, phrase , or word of
this ordinance, or any application thereof to any person or circumstance, is held to be invalid
or unconstitutional by a decision of a court of competent jurisdiction, such decision shall not
affect the validity of the remaining portions or applications of the ordinance. The Board of
Supervisors declares that it would have passed this ordinance and each and every section,
subsection, sentence, clause, phrase, and word not declared invalid or unconstitutional
Supervisors Walton; Peskin; Fewer, Safai, Yee, Brown
BOARD OF SUPERVISORS Page 11
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without regard to whether any other portion of this ordinance or application thereof would be
subsequently declared invalid or unconstitutional.
Section 7. Undertaking for the General Welfare. In enacting and implementing this
ordinance, the City is assuming an undertaking only to promote the general welfare. It is not
assuming, nor is it imposing on its officers and employees, an obligation for breach of which it
is liable in money damages to any person who claims that such breach proximately caused
injury.
APPROVED AS TO FORM :
DENNIS J. HERRERA , City Attorney
( ')
By : -l ) h l ( \ ( :u ·: l
ANNE PEARSON
Deputy City Attorney
n:\leganalas2019\1900441\01345951.docx
SupervisorWalton, Peskin, Fewer, Safai, Yee, Brown
BOARD OF SUPERVISORS Page 1
Item 11.a. - Page 20
City and County of San Francisco
Tails
Ordinance
City l-!all
1 Dr , Carlton B . Goodlett Place
San Francisco, CA 94102-4689
File Number: 190312 Date Passed: June 25, 2019
Ordinance amending the Health Code to prohibit the sale by tobacco retail establishments of
electronic cigarettes that require, but have not received, an order from the Food and Drug
Administration (FDA) approving their marketing; and prohibiting the sale and distribution to any
person in San Francisco of flavored tobacco products and electronic cigarettes that require, but have
not received, an FDA order approving their marketing .
June 07, 2019 Public Safety and Neighborhood Services Committee -RECOMMENDED
June 18, 2019 Board of Supervisors -PASSED ON FIRST READING
Ayes : 11 -Brown, Fewer, Haney, Mandelman, Mar, Peskin, Ronen, Safai, Stefani,
Walton and Yee
June 25, 2019 Board of Supervisors -Fl NALLY PASSED
Ayes : 10 -Brown, Haney, Mandelman, Mar, Peskin, Ronen, Safai, Stefani, Walton
and Yee
Absent: 1 -Fewer
File No . 190312
London N. Breed
Mayor
City 1111d County of S1111 Francis co Page 1
I hereby certify that the foregoing
Ordinance was FINALLY PASSED on
6/25/2019 by the Board of Supervisors of
the City and County of San Francisco.
fr; Angela Calvillo
Clerk of the Board
Date Approved
Printed at 11:00 am 011 6/26/19
Item 11.a. - Page 21
ATTACHMENT 2
Item 11.a. - Page 22
Surgeon General's Advisory on E-cigarette Use Among
Youth
I, Surgeon General of the United States Public Health Service, VADM Jerome Adams, am emphasizing the importance
of protecting our children from a lifetime of nicotine addiction and associated health risks by immediately addressing the
epidemic of youth e-cigarette use. The recent surge in e-cigarette use among youth, which has been fueled by new
types of e-cigarettes that have recently entered the market, is a cause for great concern. We must take action now to
protect the health of our nation's young people.
KNOW THE RISKS. TAKE ACTION. PROTECT OUR KIDS.
The E-cigarette Epidemic Among Youth
Considerable progress has been made in reducing cigarette smoking among our nation's youth. 1 However, the
tobacco product landscape continues to evolve to include a variety of tobacco products, including smoked,
smokeless, and electronic products, such as e-cigarettes. 2 E-cigarettes are designed to deliver nicotine,
flavorings, and other additives to the user via an inhaled aerosol.2
E-cigarettes entered the U.S. marketplace around 2007, and since 2014, they have been the most commonly
used tobacco product among U.S. youth. 2 E-cigarette use among U.S. middle and high school students increased
900% during 2011-2015, before declining for the first time during 2015-2017.3 However, current e-cigarette use
increased 78% among high school students during the past year, from 11. 7% in 2017 to 20.8% in 2018.4 In 2018,
more than 3.6 million U.S. youth, including 1 in 5 high school students and 1 in 20 middle school students,
currently use e-cigarettes.4
E-cigarette aerosol is not harmless.2 Most e-cigarettes contain nicotine -the addictive drug in regular cigarettes,
cigars, and other tobacco products.2 Nicotine exposure during adolescence can harm the developing brain -
which continues to develop until about age 25.2 Nicotine exposure during adolescence can impact learning,
memory, and attention.1•2 Using nicotine in adolescence can also increase risk for future addiction to other
drugs.1 ·2 In addition to nicotine, the aerosol that users inhale and exhale from e-cigarettes can potentially expose
both themselves and bystanders to other harmful substances, including heavy metals, volatile organic
compounds, and ultrafine particles that can be inhaled deeply into the lungs.2
Many e-cigarettes also come in kid-friendly flavors. In addition to making e-cigarettes more appealing to young
people,5 some of the chemicals used to make certain flavors may also have health risks.2 E-cigarettes can also be
used to deliver other drugs, including marijuana.2 In 2016, one-third of U.S. middle and high school students who
ever used e-cigarettes had used marijuana in e-cigarettes.6
For adults, e-cigarettes may have the potential to reduce risk for current smokers if they completely transition from
cigarettes to e-cigarettes; however, a majority of adults who use e-cigarettes also smoke cigarettes. 7 For youth,
the use of multiple tobacco products puts youth at even greater risk for addiction and tobacco-related harms.1-2
Moreover, a 2018 National Academy of Sciences, Engineering, and Medicine report concluded that there was
moderate evidence that e-cigarette use increases the frequency and intensity of cigarette smoking in the future.7
But any e-cigarette use among young people is unsafe, even if they do not progress to future cigarette smoking. 2
E-cigarettes Come in Many Shapes and Sizes
E-cigarettes are a rapidly changing product class, and are known by many different names, including "e-cigs," "e-
hookahs," "mods," and "vape pens."2 Recently, a new type of e-cigarette has become increasingly popular among
our nation's youth due to its minimal exhaled aerosol, reduced odor, and small size, making it easy to conceal.8
Many of these new e-cigarettes look like a USB flash drive, among other shapes. One of the most commonly sold
1
Item 11.a. - Page 23
USB flash drive shaped e-cigarettes is JUUL, which experienced a 600% surge in sales during 2016-2017, giving
it the greatest market share of any e-cigarette in the U.S. by the end of 2017.9 Other companies are now also
starting to sell e-cigarettes that look like USB flash drives.
All JUUL e-cigarettes have a high level of nicotine. A typical JUUL cartridge, or "pod," contains about as much
nicotine as a pack of 20 regular cigarettes.10 These products also use nicotine salts, which allow particularly high
levels of nicotine to be inhaled more easily and with less irritation than the free-base nicotine that has traditionally
been used in tobacco products, including e-cigarettes. This is of particular concern for young people, because it
could make it easier for them to initiate the use of nicotine through these products and also could make it easier to
progress to regular e-cigarette use and nicotine dependence. However, despite these risks, approximately two-
thirds of JUUL users aged 15-24 do not know that JUUL always contains nicotine.11
You Can Take Action
We must take aggressive steps to protect our children from these highly potent products that risk exposing a new
generation of young people to nicotine.2 •7 The bad news is that e-cigarette use has become an epidemic among
our nation's young people. However, the good news is that we know what works to effectively protect our kids
from all forms of tobacco product use, including e-cigarettes.1·2 ·12 We must now apply these strategies toe-
cigarettes, including USB flash drive shaped products such as JUUL. To achieve success, we must work
together, aligning and coordinating efforts across both old and new partners at the national, state, and local
levels. Everyone can play an important role in protecting our nation's young people from the risks of e-cigarettes.
Information for Parents
• You have an important role to play in addressing this public health epidemic.
• Learn about the different shapes and types of e-cigarettes and the risks of all forms of e-cigarette use for young
people at https://e-clgarettes .surqeonqeneral.qov/.
• Set a good example by being tobacco-free. If you use tobacco products, it's never too late to quit. Talk to a
healthcare professional about quitting all forms of tobacco product use. For free help, visit smokefree.qov or
call 1-800-QUIT-NOW.
• Adopt tobacco-free rules, including e-cigarettes, in your home and vehicle.
• Talk to your child or teen about why e-cigarettes are harmful for them. It's never too late.
• Get the Surgeon General's tip sheet for parents, Ta lk W ith Your Tee n About E-cigarettes , at https://e-
ciqarettes.surqeonqeneral.qov/. Start the conversation early with children about why e-cigarettes, including
JUUL, are harmful for them.
• Let your child know that you want them to stay away from all tobacco products, including e-cigarettes, because
they are not safe for them. Seek help and get involved.
o Set up an appointment with your child's health care provider so that they can hear from a medical
professional about the health risks of tobacco products, including e-cigarettes.
o Speak with your child's teacher and school administrator about enforcement of tobacco-free school
policies and tobacco prevention curriculum.
o Encourage your child to learn the facts and get tips for quitting tobacco products at
Teen .smokefre e.qov.
Information for Teachers
• You have an important role to play in addressing this public health epidemic.
• Learn about the different shapes and types of e-cigarettes and the risks of all forms of e-cigarette use,
including JUUL, for young people at httos://e-clqarettes.surqeonqeneral.gov/.
• Develop, implement, and enforce tobacco-free school policies and prevention programs that are free from
tobacco industry influence, and that address all types of tobacco products, including e-cigarettes.
2
Item 11.a. - Page 24
• Engage your students in discussions about the dangers of e-cigarette use. To help you, the Food and
Drug Administration (FDA), and Scholastic, developed free resources for teachers. These materials can
be found at www.scholastic.com/youthvaplngrisks.
Information for Health Professionals
• You have an important role to play in addressing this public health epidemic.
• Learn about the different shapes and types of e-cigarettes and the risks of all forms of e-cigarette use,
including JUUL, for young people at https://e-cigarettes.surgeongeneral.gov/.
• Ask about e-cigarettes, including small, discreet devices such as JUUL, when screening patients for the
use of any tobacco products.
• Educate patients about the risks of all forms of tobacco product use, including e-cigarettes, for young
people.
• Encourage patients to quit. For free help, patients can visit smokefree.gov or call 1-800-QUIT-NOW.
Information for States, Communities, Tribes, and Territories
• You have an important role to play in addressing this public health epidemic.
• Implement evidence-based population-level strategies to reduce e-cigarette use among young people,
such as including e-cigarettes in smoke-free indoor air policies, restricting young peoples' access to e-
cigarettes in retail settings, licensing retailers, implementing price policies, and developing educational
initiatives targeting young people.
• Implement strategies to curb e-cigarette advertising and marketing that are appealing to young people.
• Implement strategies to reduce access to flavored tobacco products by young people.
KNOW THE RISKS. TAKE ACTION. PROTECT OUR KIDS .
References
1. Office of the Surgeon General. The Health Consequences of Smoking-SO Years of Progress : A Report of the Surgeon
General. Atlanta, GA : US Department of Health and Human Services, Centers for Disease Control and Prevention (US),
National Center for Chronic Disease Prevention and Health Promotion, Office on Smoking and Health; 2014.
https ://www .s u rgeonge ne ra I .gov /I I brary/re po rts/50 -yea rs -of-progress/tu II-report. pdf.
2. Office of the Surgeon General. £-cigarette Use among Youth and Young Adults: A Report of the Surgeon General.
Washington, DC: U.S . Department of Health and Human Services, Centers for Disease Control and Prevention; 2016.
https :ljwww.cdc .gov/tobacco/data statistics/sgr/e -cigarettes/pdfs/2016 sgr entire report 508.pdf.
3. Wang TW, Gentzke A, Sharapova S, et al. Tobacco Use Among Middle and High School Students -United States, 2011-
2017 . MMWR Morbidity and Mortality Weekly Report. 2018;67(22):629-633.
4. Cullen KA , Ambrose BK, Gentzke AS , Apelberg BJ , Jamal A, King BA. Notes from the Field: Increase in use of electronic
cigarettes and any tobacco product among middle and high school students -United States, 2011-2018. MMWR
Morbidity & Mortality Weekly Report 2018; 67(45):1276-1277.
5. Ambrose BK, Day HR, Rostron B, et al. Flavored Tobacco Product Use Among US Youth Aged 12-17 Years, 2013-2014.
Jama. 2015;314( 17} :1871-1873.
6. Trivers KF, Phillips E, Gentzke AS, Tynan MA, Neff U. Prevalence of Cannabis Use in Electronic Cigarettes Among US
Youth. JAMA pediatrics. 2018;172(11):1097-1099.
7. National Academies of Sciences, Engineering, and Medicine . 2018. Public Health Consequences of E-Cigarettes.
Washington, DC: The National Academies Press . https ://doi.org/10.17226/24952.
8. Ramamurthi D, Chau C, Jackler RK . JUUL and other stealth vaporisers: hiding the habit from parents and teachers. Tob
Control. 2018 . Epub ahead of print. doi : 10 .1136/tobaccocontrol-2018-054455.
9. King BA, Gammon DG, Marynak KL, Rogers T. Electronic Cigarette Sales in the United States, 2013 -2017. Jama .
2018;320(13):1379-1380 .
3
Item 11.a. - Page 25
10. Willett JG, Bennett M, Hair EC, et al. Recognition, use and perceptions of JUUL among youth and young adults. Tob
Control. 2018 . Epub ahead of print. doi: 10.1136/tobaccocontrol-2018-054273.
11. Truth Initiative. JUUL e-cigarettes gain popularity among youth, but awareness of nicotine presence remains low.
https :ljtruthlnitiatlve .org/news/juul-e-clgarettes-galn-popularity-among-youth .
12. US Department of Health and Human Services. Preventing tobacco use among youth and young adults. Atlanta, GA: US
Department of Health and Human Services, CDC;2012 .
https ://www .cdc .gov/tobacco/ data statistics/sgr /2012/i nd ex.htm .
..
4
ATTACHMENT 3
Item 11.a. - Page 26
~
SIERRA VISTA
REGIONAL MEDICAL CENTER
City of Arroyo Grande
Attn: Caren Ray Russom and City Council Members
300 E Branch Street
Arroyo Grande, CA 93420
September 26, 2019
RECEIVED
OCT l O 2019
CITY OF ARROYO GRANDE
Re: Letter of Support to ban/eliminate adolescent access to Vaping and E-Cigarettes
Attached: CDPH Health Advisory dated September 24, 2019
Dear Mayor Russom et al;
On behalf of the Governing Boards and Medical Staff of our two Tenet Health Central Coast
hospitals, which serve your community and along with two Urgent Care Centers, two Imaging
Centers, and several other Primary Care Practice sites, I am offering my strongest professional
recommendation to you to immediately and permanently ban all sales of electronic cigarettes and
vaporizers, designed for the vaporization of chemical oils, and collectively referred to as "vape
pens", to adolescents in the City of Arroyo Grande.
In an Advisory entitled "Va ping Related Lung Illness: A Summary of the Publrc Health Risk and
Recommendations for the Public" published September 24th, the California Department of Public
Health states that vaping is an imminent public health risk because it has recently been linked to
severer breathing problems, lung damage, and even death. Through the Advisory, CDPH makes the
following recommendation: " ... quit vaping altogether, no matter the substance or source."
At Tenet Health Central Coast, we see Vaping as a public health threat, especially to our youth, and
all steps should be taken to remove this threat by banning its sale in Arroyo Grande. I urge you to
give strong consideration to immediate and permanent action. Please contact me if you need
further information or have any questions .
Mark Lisa
. ·~
Chief Executive Officer
Tenet Health Central Coast
1010 Murray Avenue, San Luis Obispo, CA
1100 Las Tablas Road, Templeton, CA 93465
805-546-7600
805-434-3500
www.sierravistaregional.com
www.twincitieshospital.com
Item 11.a. - Page 27
~
~C~PH
SUSAN FANELLI
Acting Director
State of California-Health and Human Services Agency
California Department of Public Health
California Department of Public Health
Health Advisory -September 24, 2019
GAVIN NEWSOM
' Governor
Vaping Related Lung Illness: A Summary of the Public Health Risks
and Recommendations for the Public
. .
This health advisory seeks to inform the public about the imminent public health
risks posed by vaping any product, including the use of electronic cigarettes (e-
cigarettes), as vaping has recently been linked to severe breathing problems,
lung damage, and even death.
Va ping is inhaling aerosol from an e-cigarette or other vaping device
that heats a liquid that can contain nicotine, marijuana (THC),
cannabidiol (CBD) or other substances. The shapes and sizes of these
devices vary and include colorful vape pens, modified tank systems,
and new pod-based devices that can look like USB flash drives, cell
phones, credit card holders, and highlighters. These devices are
frequently referred to as e-cigarettes, e-cigs, vapes, vape pens,
ele~tronic vaporizers, pod mods, or pod systems.
The California Department of Public Health (CDPH) urges everyone to refrain
from vaping, no matter the substance or source, until current investigations are
complete. Since June 2019, CDPH has received reports that 90 people in
California who have a history of vaping were hospitalized for severe breathing
problems and lung damage, and two people have died. Across the U.S., there
are over 500 reports of lung damage associated with vaping across 38 states
and 1 U.S. territory, and more reports are coming in nearly every day.
CDPH, along with other states, the Centers. for Disease Control and Prevention
[CDC), the U.S. Food and Drug Administration (FDA), local health departments,
and healthcare providers are working hard to investigate what is in the vape
materials that is making people sick.
Although CDPH regulates manufacturers of cannabis vaping products to ensure
they are as safe as possible for those who choose to vape, CDPH warns that
individuals put themselves at risk any time they inhale a foreign substance into
their lungs. The risk of vaping now includes death. CDC continues to warn that
any tobacco product use, including e-cigarettes, is unsafe, especially for youth,
Item 11.a. - Page 28
pregnant, and breastfeeding women.
Sudden lung damage from vaping is a new health problem.
We are learning from this investigation that lung damage can happen very
suddenly to people who vape, including people who have not been vaping for
a long time, and young, healthy people who do not have lung disease or other
health problems. This is different from most other health issues caused by vaping
and smoking, which happen over a long time and can be worse in people who
have other medical conditions. Additionally, most patients do not have a recent
history of smoking regular cigarettes, suggesting these lung issues are exclusively
related to vaping. Many types of vape products may be causing the lung
damage from vaping.
Almost all people with lung damage from vaping say that they vaped or
"dabbed" the cannabis products THC and CBD in cartridges, waxes, oils, and
other forms. Some people report vaping only nicotine. Many people report
vaping a combination of both nicotine and cannabis products. The
investigation is still in process, but the one thing that people with the lung illness
have in common is a history of vaping.
County health departments are contacting the people who had lung damage
from vaping to find out which products they used, where they purchased the
products, and to collect their vape products to test for harmful ingredients.
The government does not ensure the safety of vaping devices through
regulation. In California, licensed cannabis retailers are required to sell products
obtained from a licensed cannabis manufacturer that have been tested by a
licensed laboratory. Cannabis products sold by licensed sources are tested for a
variety of chemicals, pesticides, microbial impurities, and heavy metals. Illegal
cannabis dispensaries sell unregulated and untested cannabis products and
absolutely should not be used.
People are hospitalized with breathing problems and other symptoms.
People with lung damage from vaping typically have symptoms that start a few
days to a few weeks before they go see a doctor. All people hospitalized
developed some type of breathing problems, but many people also have other
symptoms. The symptoms reported by those who have gotten sick are:
• Breathing symptoms: trouble catching their breath, coughing, chest pain
• Gastrointestinal symptoms: nausea, vomiting, diarrhea, abdominal pain
• Non-specific symptoms: feeling tired, fever, weight loss
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Item 11.a. - Page 29
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These symptoms are' very similar to having a lung infection like pneumonia .or
bronchitis, so it can be hard to tell if the symptoms are from an infection or
vaping the first time someone sees the doctor. There is no test that a doctor can
do to know that breathing problems are from vaping right away. Laboratory
blood tests and an x-ray or CT scan of the lungs may be necessary.
People with vaping-related lung disease are usually admitted to the hospital
because of their breathing problems.
• Teenagers and young adults make up almost half of the people
hospitalized with breathing problems from vaping in California.
• 30% of people hospitalized in California had to be treated with a
mechanical ventilator, or "life support," in the intensive care unit {ICU).
Be Aware That Your Child's Respiratory Issues Could be Related to Vaping
Parents should be aware that numerous cases involve children under age 18.
Parents in particular should be aware that e-cigarettes and vaping devices are
available in more than 15,000 flavors that may be attractive to children, such as
mango, bubble gum, unicorn poop, mint. The secondhand aerosol typically
smells sweet so it can be hard to detect. Be aware of the symptoms in case your
middle or high school child develops symptoms, and seek medical attention.
No one knows yet why this lung damage is happening from vaping.
There are many different possible ingredients added to cannabis and nicotine
to make the cartridges, waxes, and oils used for vaping. Multiple people who
were diagnosed with lung damage from vaping say that they received the
cannabis products from unlicensed smoke shops or individuals. Vape products
sold by unlicensed retailers are not tested and can contain harmful ingredients.
We do not know yet if all of the people in the country with this illness use the
same vape products, or if the products were contaminated with the same
substance.
The long-term effects of vaping are still unknown, but these short-term effects
are alarming.
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Recommendations for the Public
1. CDPH urges everyone to quit vaping altogether, no matter the substance
or source. For those who continue, you are urged to avoid buying any
vaping products on the street and never modify a store-bought vape
product.
2. If you, or your child, have vaped at all in the past few months and are
having new problems with breathing or other symptoms, you should seek
medical care immediately and tell your healthcare provider about your
history of vaping.
3. If you decide to stop vaping, do not replace vaping with smoking
combustible cigarettes. Ask your doctor for FDA-approved quitting
treatments.
Resources
CDPH Tobacco Free California Website https://tobaccofreeca.com/
The California Smokers' Helpline offers vaping cessation services including
telephone counseling, text messaging, web chat, and an online app to help all
tobacco users quit. For more information and resources for youth, young adults
and parents, call 1-800-NO BUTTS or visit http://www.nobutts.org/vaping.
If you suspect your child is vaping, visit flavorshookkids.org for more information
on the health effects and actions you can take. You can download the parent's
guide for information on how to talk to your child about vaping.
For help on how to quit vaping marijuana, consult a doctor or contact the
Substance Abuse and Mental Health Services Administration helpline at 1-800-
662-4357.
For additional information, please review the CDC's recommendations about
the vaping-related lung injuries.
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