E-cigarette regulations

Evidence Rating  
Expert Opinion
Evidence rating: Expert Opinion

Strategies with this rating are recommended by credible, impartial experts but have limited research documenting effects; further research, often with stronger designs, is needed to confirm effects.

Health Factors  
Decision Makers

Electronic cigarettes, or e-cigarettes, are a type of electronic nicotine delivery system (ENDS) which delivers nicotine via water vapor. E-cigarettes, also called e-cigs, e-mods, hookahs, or vape pens, are small with minimal odor or exhaled vapor and often resemble a USB flash drive or a pen1. They can be disposable or refillable; both can feature kid-oriented flavors such as cotton candy, chocomint, and blueberry lemonade2. E-cigarettes are regulated by the US Food and Drug Administration (FDA)3 and subject to the national minimum tobacco age of 21 years old, set by Tobacco 21 (T21)4, 5. State and local governments can further restrict access to e-cigarettes through efforts such as face-to-face sales mandates, limits on marketing and promotion (i.e., indoor and outdoor ad placement, ensuring ads and products are not at children’s eye level, special pricing, etc.), retailer licensing, implementing price policies, restricting available flavors, adding e-cigarettes to smoke-free indoor air policies, and developing educational initiatives aimed at youth and young adults1, 6. Some state laws preempt local efforts7. E-cigarettes are sometimes used by current smokers who want to reduce their tobacco use or quit8; in 2021, the FDA authorized the marketing and sale of three new tobacco-flavored ENDS containing fewer harmful chemicals for adult smokers looking to make the switch to e-cigarettes9.

Note: The term “tobacco” in this strategy refers to commercial tobacco, not ceremonial or traditional tobacco. County Health Rankings & Roadmaps recognizes the important role that ceremonial and traditional tobacco play for many Tribal Nations, and our tobacco-related work focuses on eliminating the harms and inequities associated with commercial tobacco.

Expected Beneficial Outcomes (Rated)

  • Reduced youth use of e-cigarettes

  • Reduced tobacco use

Other Potential Beneficial Outcomes

  • Increased tobacco cessation

Evidence of Effectiveness

Regulating e-cigarettes through efforts such as age restrictions, marketing regulations, and expanded smoke-free air policies is a suggested strategy to reduce tobacco use and decrease youth use of e-cigarettes1, 10, 11, 12, 13, 14. However, additional evidence is needed to confirm effects of e-cigarette regulations.

Available evidence indicates that the impact of regulations varies by intervention. One study suggests areas with strong tobacco retailer licensing requirements have lower rates of youth e-cigarette and tobacco use15. However, other research indicates that state level bans on e-cigarettes may increase traditional cigarette use among youth, while price increases to traditional cigarettes may prompt adult smokers to switch to e-cigarettes16. Before Tobacco 21 (T21) set the federal minimum purchase age for all tobacco products to 21, a national study of state laws restricting the minimum purchase age of tobacco appeared to decrease the initiation and continued use of e-cigarettes by youth and young adults11. A California-based study of the state’s T21 law found decreased use of e-cigarettes among middle and high school students, with possibly greater reductions for youth identifying as racial and ethnic minorities; however, use may not have decreased for youth who were already regular e-cigarette users10. In contrast, a study at an Ohio university found that implementing T21 may reduce use of traditional cigarettes and smokeless tobacco but have no impact on e-cigarette use. Experts suggest that minimum tobacco age laws may need to be paired with other control efforts to reduce e-cigarette use among youth17.

A national study suggests e-cigarette regulations at the state level, including retailer licenses, bans on self-service displays of e-cigarettes, and e-cigarette bans in workplaces, restaurants, and bars, may be associated with reduced e-cigarette use by adults and that higher taxes on e-cigarettes may reduce use by young adults6. Whether e-cigarettes and traditional cigarettes act as substitutes for each other is unclear. In some cases, high prices or taxes on one can result in increased sales of the other16, 18, but that is not always the case19. Adding e-cigarette restrictions to smoke-free air and smoke-free worksite laws does not appear to reduce e-cigarette use19, 20.

Nicotine and other potentially harmful chemicals have been found in e-cigarettes1, 21, 22 and e-cigarette flavorings1, 23, even in e-cigarettes labeled as containing no nicotine24. Pod-based e-cigarettes may contain the same amount of nicotine as 20 traditional cigarettes1. There is mixed evidence about the particulate matter produced by e-cigarettes. Some studies find that there are similar or slightly higher concentrations than traditional cigarettes16. However, others find that particulate matter16 and carcinogenic particles in e-cigarette vapor are lower than traditional cigarette smoke25, creating less of a health risk for bystanders26, 27, 28, 29; emissions are typically lower than regulatory standards for workplace air quality30, 31. E-cigarette, or vaping, product use-associated lung injury (EVALI) has become more common in recent years, particularly for younger users32. More research is needed regarding harm levels and long-term effects of e-cigarettes16.

A Connecticut-based study suggests e-cigarette flavors, a desire to experiment, and peer influence may make e-cigarettes appealing to youth and young adults33. A survey-based study of young adults suggests that e-cigarette flavoring was the most important factor in selecting an e-cigarette34; flavor restrictions have shifted sales from non-menthol flavored e-cigarettes to menthol e-cigarettes35. A California-based study found that local laws can reduce in-person purchases of flavored e-cigarettes by youth36. E-cigarette health warnings are associated with lower intent to purchase e-cigarettes16; however, one study found that young adults vaping regularly viewed nicotine health warnings on e-cigarette packages as a positive because they want nicotine in their e-cigarettes34. E-cigarette users, regardless of age, often report selecting e-cigarettes over traditional cigarettes because they believe e-cigarettes are healthier37, 38, 39, 40.

Youth who are exposed to e-cigarette ads via TV commercials, print, or the internet appear more likely to use e-cigarettes than peers not exposed to such ads16, 38, 41, 42. Youth who have tried e-cigarettes may be more likely to use traditional cigarettes than peers who have not tried e-cigarettes43, 44, suggesting the potential for e-cigarettes to act as a gateway product for other forms of tobacco14, 44, 45 and to renormalize tobacco use14, 46.

To reduce e-cigarette use, experts recommend stronger state and federal restrictions to prevent youth from purchasing flavored e-cigarettes online or from social sources36, greater enforcement of T21, tighter regulations of in-person and online sales, higher e-cigarette taxes, bans on all types of flavored e-cigarettes, and additional awareness campaigns on the dangers of all forms of tobacco products, including e-cigarettes1, 47. A California-based study suggests that retailer violations relating to in-store e-cigarette samples and signs may be more frequent in vape shops located in neighborhoods with more minority residents; greater enforcement is needed to prevent youth from purchasing e-cigarettes48. Additional oversight of online e-cigarette retailers is also needed, as retailers frequently lack proper age verification methods16. Furthermore, the Surgeon General recommends coordinating efforts with partners at the federal, state, and local levels to reduce youth use of e-cigarettes and other tobacco products1.

Some studies suggest that e-cigarettes with nicotine can help tobacco users decrease use or quit for at least six months and can be more effective than quit aids such as nicotine replacement therapy (NRT) and nicotine-free e-cigarettes; e-cigarettes may also be more effective than no support or than behavioral support alone and may not be associated with serious adverse events49. Other studies suggest that e-cigarettes do not affect quit rates or are less effective than quit aids50, 51. Additional research is needed to determine effects on cessation49, 52.

Impact on Disparities

No impact on disparities likely

Implementation Examples

The US Food and Drug Administration (FDA) regulates manufacturing, packaging, promotions, and sales of electronic cigarettes (e-cigarettes), and mandates ID checks at the point of sale and restrictions on marketing and sales locations3. In 2020, e-cigarette manufacturers were required to submit applications to the FDA to continue manufacturing their devices. The FDA did not finish ruling on which companies can make e-cigarettes, both with and without flavoring, by the September 2021 deadline. As of April 2022, manufacturing and sales continue. Additionally, many e-cigarette companies are making flavored and unflavored e-cigarettes with synthetic nicotine, which is not considered a tobacco product and therefore not regulated by the FDA2.

As of December 2021, 33 states and Washington, DC require retail licenses for over-the-counter sales of e-cigarettes; 30 states and Washington, DC tax e-cigarettes; and 17 states and Washington, DC have smoke-free indoor air laws that prohibit smoking and the use of e-cigarettes in restaurants, bars, and private worksites53. Many states have also expanded smoke-free policies to prohibit use of e-cigarettes in schools, child care facilities, health care institutions, or state-owned buildings; Arkansas, Vermont, and Minnesota are three examples54.

Local governments can also include e-cigarettes in smoke-free policies7. Chicago and New York City, for example, included e-cigarettes in their respective smoke-free policies55, 56. State legislation preempts local government control of e-cigarette products in Arizona, Arkansas, Iowa, Montana, Nevada, Oklahoma, South Carolina, South Dakota, Utah, and Washington as of 20227.

The FDA features resources to prevent youth access and educate retailers about the need to protect youth from tobacco products, including e-cigarettes, and reduce youth-oriented tobacco marketing57.

Implementation Resources

CDC-E-cigarettes - Centers for Disease Control and Prevention (CDC). Smoking & Tobacco Use: Electronic cigarettes.

ANRF-E-cigarettes - American Nonsmokers’ Rights Foundation (ANRF). Electronic cigarettes.

PHLC-E-cigarettes - Tobacco Control Legal Consortium (TCLC). E-Cigarettes. Saint Paul: Public Health Law Center (PHLC).

CTFK-E-cigarettes - Campaign for Tobacco Free Kids (CTFK). Electronic cigarettes: An overview of key issues. 2017.

US DHHS SG-E-cigarette risks - US Department of Health and Human Services (US DHHS), US Surgeon General, US Centers for Disease Control and Prevention, Office on Smoking and Health (CDC-OSH). Know the risks: E-cigarettes and young people.

CDC-E-cig dictionary - Centers for Disease Control and Prevention (CDC). E-cigarette, or vaping, products visual dictionary.

Footnotes

* Journal subscription may be required for access.

1 CDC SG-E-cigarette 2018 - Centers for Disease Control and Prevention (CDC). Smoking & Tobacco Use: Surgeon General’s Advisory on e-cigarette use among youth. 2018.

2 CTFK-Flavored e-cigarettes - Campaign for Tobacco Free Kids (CTFK). An e-cigarette market update flavored products remain widely available three months after court-ordered deadline for FDA to rule on marketing applications. Washington, DC: Campaign for Tobacco-Free Kids (CTFK); 2021.

3 US FDA-E-cigarette regulations - US Food and Drug Administration (US FDA). Center for Tobacco products. FDA's deeming regulations for e-cigarettes, cigars, and all other tobacco products. 2021.

4 CDC-Tobacco 21 - Centers for Disease Control and Prevention (CDC). Tobacco 21: Policy evaluation for comprehensive tobacco control programs. Atlanta, GA: Centers for Disease Control and Prevention, National Center for Chronic Disease Prevention and Health Promotion, Office on Smoking and Health; 2020.

5 Farber 2016 - Farber HJ, Pakhale S, Neptune ER. Tobacco 21: An important public policy to protect our youth. Annals of the American Thoracic Society. 2016;13(12):2115-2118.

6 Du 2020 - Du Y, Liu B, Xu G, et al. Association of electronic cigarette regulations with electronic cigarette use among adults in the United States. JAMA Network Open. 2020;3(1):e1920255.

7 Grassroots Change - Grassroots Change: Connecting for better health. Preemption Watch.

8 Malas 2016* - Malas M, van der Tempel J, Schwartz R, et al. Electronic cigarettes for smoking cessation: A systematic review. Nicotine & Tobacco Research. 2016;18(10):1926-1936.

9 US FDA-E-cigarette marketing 2021 - US Food and Drug Administration (US FDA). FDA News release: FDA permits marketing of e-cigarette products, marking first authorization of its kind by the agency. 2021.

10 Grube 2021* - Grube JW, Lipperman-Kreda S, García-Ramírez G, Paschall MJ, Abadi MH. California’s Tobacco 21 minimum sales age law and adolescents’ tobacco and nicotine use: Differential associations among racial and ethnic groups. Tobacco Control. 2021.

11 Jun 2021* - Jun J, Kim JK. Do state regulations on e-cigarettes have impacts on the e-cigarette prevalence? Tobacco Control. 2021;30(2):221-226.

12 US DHHS SG-E-cigarette 2016 - US Department of Health and Human Services (US DHHS). E-cigarette use among youth and young adults: A report of the Surgeon General. Atlanta, GA: Centers for Disease Control and Prevention (CDC), National Center for Chronic Disease Prevention and Health Promotion (NCCDPHP), Office on Smoking and Health; 2016.

13 CDC Vital signs-E-cigarette - CDC Vital Signs. E-cigarette ads and youth. Atlanta: Centers for Disease Control and Prevention (CDC). 2016.

14 CDC-MMWR-Marynak 2014 - Marynak K, Holmes CB, King BA, et al. State laws prohibiting sales to minors and indoor use of electronic nicotine delivery systems - United States, November 2014. Morbidity and Mortality Weekly Report (MMWR). 2014;63(RR-49):1145-1150.

15 Astor 2019* - Astor RL, Urman R, Barrington-Trimis JL, et al. Tobacco retail licensing and youth product use. Pediatrics. 2019;143(2).

16 Glasser 2017* - Glasser AM, Collins L, Pearson JL, et al. Overview of electronic nicotine delivery systems: A systematic review. American Journal of Preventive Medicine. 2017;52(2):e33-e66.

17 Roberts 2022* - Roberts ME, Keller-Hamilton B, Teferra AA. Tobacco 21’s impact amid the e-cigarette surge. Public Health Reports. 2022.

18 Pesko 2020 - Pesko MF, Courtemanche CJ, Maclean JC. The effects of traditional cigarette and e-cigarette tax rates on adult tobacco product use. Journal of Risk and Uncertainty. 2020;60(3):229-258.

19 Cotti 2018* - Cotti C, Nesson E, Tefft N. The relationship between cigarettes and electronic cigarettes: Evidence from household panel data. Journal of Health Economics. 2018;61:205-219.

20 Friedman 2021* - Friedman AS, Oliver JF, Busch SH. Adding vaping restrictions to smoke-free air laws: Associations with conventional and electronic cigarette use. Addiction. 2021;116(8):2198-2206.

21 CDC MMWR-Corey 2013 - Corey C, Wang B, Johnson SE, et al. Notes from the field: Electronic cigarette use among middle and high school students - United States, 2011-2012. Morbidity and Mortality Weekly Report (MMWR). 2013;62(RR-35):729-30.

22 Schober 2014* - Schober W, Szendrei K, Matzen W, et al. Use of electronic cigarettes (e-cigarettes) impairs indoor air quality and increases FeNO levels of e-cigarette consumers. International Journal of Hygiene and Environmental Health. 2014;217(6):628-637.

23 Tierney 2016 - Tierney PA, Karpinski CD, Brown JE, Luo W, Pankow JF. Flavour chemicals in electronic cigarette fluids. Tobacco Control. 2016;25:e10-e15.

24 Blank 2016 - Blank MD, Breland AB, Cobb CO, et al. Clinical laboratory evaluation of electronic cigarettes/electronic nicotine delivery systems: Methodological challenges. Tobacco Regulatory Science. 2016;2(4):426‐439.

25 Oh 2014* - Oh AY, Kacker A. Do electronic cigarettes impart a lower potential disease burden than conventional tobacco cigarettes? Review on e-cigarette vapor versus tobacco smoke. The Laryngoscope. 2014;124(12):2702-2706.

26 Vansickel 2010 - Vansickel AR, Cobb CO, Weaver MF, Eissenberg TE. A clinical laboratory model for evaluating the acute effects of electronic “cigarettes:” Nicotine delivery profile and cardiovascular and subjective effects. Cancer Epidemiology, Biomarkers & Prevention. 2010;19(8):1945-1953.

27 Wagener 2012* - Wagener TL, Siegel M, Borrelli B. Electronic cigarettes: Achieving a balanced perspective. Addiction. 2012;107(9):1545-8.

28 Flouris 2013* - Flouris AD, Chorti MS, Poulianiti KP, et al. Acute impact of active and passive electronic cigarette smoking on serum cotinine and lung function. Inhalation Toxicology. 2013;25(2):91-101.

29 Goniewicz 2014* - Goniewicz ML, Knysak J, Gawron M, et al. Levels of selected carcinogens and toxicants in vapour from electronic cigarettes. Tobacco Control. 2014;23:133-139.

30 Burstyn 2014 - Burstyn I. Peering through the mist: Systematic review of what the chemistry of contaminants in electronic cigarettes tells us about health risks. BMC Public Health. 2014;14:18.

31 O’Connell 2015 - O’Connell G, Colard S, Cahours X, Pritchard JD. An assessment of indoor air quality before, during and after unrestricted use of e-cigarettes in a small room. International Journal of Environmental Research and Public Health. 2015;12(5):4889-4907.

32 CDC-Vaping injury - Centers for Disease Control and Prevention (CDC). Smoking & Tobacco Use: Outbreak of lung injury associated with the use of e-cigarette, or vaping, products.

33 Kong 2015* - Kong G, Morean ME, Cavallo DA, Camenga DR, Krishnan-Sarin S. Reasons for electronic cigarette experimentation and discontinuation among adolescents and young adults. Nicotine & Tobacco Research. 2015;17(7):847-854.

34 Baker 2021 - Baker AN, Wilson SJ, Hayes JE. Flavor and product messaging are the two most important drivers of electronic cigarette selection in a choice-based task. Scientific Reports. 2021;11:4689.

35 Diaz 2021* - Diaz MC, Donovan EM, Schillo BA, Vallone D. Menthol e-cigarette sales rise following 2020 FDA guidance. Tobacco Control. 2021;30(6):700-703.

36 Gaiha 2021* - Gaiha SM, Henriksen L, Halpern-Felsher B, et al. Sources of flavoured e-cigarettes among California youth and young adults: Associations with local flavoured tobacco sales restrictions. Tobacco Control. 2021.

37 Pepper 2014* - Pepper JK, Brewer NT. Electronic nicotine delivery system (electronic cigarette) awareness, use, reactions and beliefs: A systematic review. Tobacco Control. 2014;23(5):375-384.

38 Farrelly 2015* - Farrelly MC, Duke JC, Crankshaw EC, et al. A randomized trial of the effect of e-cigarette TV advertisements on intentions to use e-cigarettes. American Journal of Preventive Medicine. 2015;49(5):686-693.

39 Berg 2015* - Berg CJ, Haardoerfer R, Escoffery C, Zheng P, Kegler M. Cigarette users’ interest in using or switching to electronic nicotine delivery systems for smokeless tobacco for harm reduction, cessation, or novelty: A cross-sectional survey of US adults. Nicotine & Tobacco Research. 2015;17(2):245-255.

40 Wills 2015 - Wills TA, Knight R, Williams RJ, Pagano I, Sargent JD. Risk factors for exclusive e-cigarette use and dual e-cigarette use and tobacco use in adolescents. Pediatrics. 2015;135(1):e43-e51.

41 Villanti 2016* - Villanti AC, Rath JM, Williams VF, et al. Impact of exposure to electronic cigarette advertising on susceptibility and trial of electronic cigarettes and cigarettes in US young adults: A randomized controlled trial. Nicotine & Tobacco Research. 2016;18(5):1331-1339.

42 Singh 2016* - Singh T, Agaku IT, Arrazola RA, et al. Exposure to advertisements and electronic cigarette use among US middle and high school students. Pediatrics. 2016;137(5):e20154155.

43 Leventhal 2015 - Leventhal AM, Strong DR, Kirkpatrick MG, et al. Association of electronic cigarette use with initiation of combustible tobacco product smoking in early adolescence. JAMA. 2015;314(7):700-707.

44 Primack 2015 - Primack BA, Soneji S, Stoolmiller M, Fine MJ, Sargent JD. Progression to traditional cigarette smoking after electronic cigarette use among US adolescents and young adults. JAMA Pediatrics. 2015;169(11):1018-1023.

45 McMillen 2015* - McMillen RC, Gottlieb MA, Shaefer RMW, Winickoff JP, Klein JD. Trends in electronic cigarette use among US adults: Use is increasing in both smokers and nonsmokers. Nicotine & Tobacco Research. 2015;17(10):1195-1202.

46 HA HPB-E-cig - Health Affairs. Health Policy Briefs. E-cigarettes and federal regulation. 2014.

47 Kim 2021b* - Kim SCJ, Martinez JE, Liu Y, Friedman TC. US Tobacco 21 is paving the way for a tobacco endgame. Tobacco Use Insights. 2021;14.

48 Huh 2021* - Huh J, Meza LR, Galstyan E, et al. Association between federal and California state policy violation among vape shops and neighbourhood composition in Southern California. Tobacco Control. 2021;30(5):567-569.

49 Cochrane-Hartmann-Boyce 2021* - Hartmann-Boyce J, McRobbie H, Butler AR, et al. Electronic cigarettes for smoking cessation. Cochrane Database of Systematic Reviews. 2021;(9):CD010216.

50 Kalkhoran 2016 - Kalkhoran S, Glantz SA. E-cigarettes and smoking cessation in real-world and clinical settings: A systematic review and meta-analysis. The Lancet Respiratory Medicine. 2016;4(2):116-128.

51 Waghel 2015* - Waghel RC, Battise DM, Ducker ML. Effectiveness of electronic cigarettes as a tool for smoking cessation or reduction. Journal of Pharmacy Technology. 2015;31(1):8-12.

52 USPSTF-Tobacco cessation - US Preventive Services Task Force (USPSTF). Final recommendation statement: Tobacco smoking cessation in adults, including pregnant persons: Interventions. 2021.

53 CDC-STATE E-cigarette fact sheet - Centers for Disease Control and Prevention (CDC). State tobacco activities tracking and evaluation (STATE) system. STATE system e-cigarette fact sheet. 2021.

54 PHLC-E-cigarettes review - Public Health Law Center (PHLC). US e-cigarette regulations: 50 state review. 2017.

55 Chicago-Tobacco - City of Chicago. Business affairs & consumer protection. Tobacco regulations. 2016.

56 NYC Health-Tobacco - NYC Health. Smoking and tobacco control laws. City of New York. 2016.

57 US FDA-Youth tobacco prevention - US Food and Drug Administration (US FDA). Center for Tobacco Products. FDA's youth tobacco prevention plan.

Date Last Updated