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
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.
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.
* Journal subscription may be required for access.
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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.
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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.
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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.
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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.
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