Electronic cigarettes, or e-cigarettes, are a type of electronic nicotine delivery system (ENDS) which deliver nicotine via water vapor. E-cigarettes are regulated by the US Food and Drug Administration (FDA) as of 2016 (US FDA-E-cigarette regulations) and can contain flavors such as chocolate, mint (CDC MMWR-Corey 2013), or gummy bear (Wilson 2013). State and local governments can restrict access to e-cigarettes through efforts such as bans on sales to minors, mandates for face-to-face sales, and limits on promotion (US DHHS SG-E-cigarette 2016, CDC Vital signs-E-cigarette). Some state laws preempt local efforts (Grassroots Change) and most smoke-free air policies do not include ENDS as ENDS release vapor (ChangeLab-E-cigarettes 2014, Gourdet 2014*). E-cigarettes are sometimes used by current smokers who want to decrease tobacco use or quit (Malas 2016*).
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
Evidence of Effectiveness
Regulating e-cigarettes through efforts such as age restrictions, marketing regulations, and expanded smoke-free policies is a suggested strategy to decrease youth use of e-cigarettes (US DHHS SG-E-cigarette 2016, CDC Vital signs-E-cigarette, CDC-MMWR-Marynak 2014). Early studies of age restrictions on e-cigarette sales indicate increases in use of traditional cigarettes among regular users under age 18 while use among peers in states without restrictions decreases, suggesting that youth substitute traditional cigarettes for e-cigarettes (Friedman 2015*, Pesko 2016*). However, additional evidence is needed to confirm effects of e-cigarettes.
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 ads (Villanti 2016*, Farrelly 2015*, Singh 2016*). Youth who have tried e-cigarettes may be more likely to use traditional cigarettes than peers who have not tried e-cigarettes (Leventhal 2015, Primack 2015), suggesting potential for e-cigarettes to act as a gateway product for other forms of tobacco (Primack 2015, CDC-MMWR-Marynak 2014, McMillen 2015*) and renormalize tobacco use (CDC-MMWR-Marynak 2014, HA HPB-E-cig).
Nicotine and other potentially harmful chemicals have been found in e-cigarettes (CDC MMWR-Corey 2013, Schober 2014*) and e-cigarette flavorings (Tierney 2016), even e-cigarettes labeled as containing no nicotine (Blank 2016). E-cigarette vapor contains fewer carcinogenic particles than traditional cigarette smoke (Oh 2014*), creating less of a health risk for bystanders than cigarette smoke (Vansickel 2010, Wagener 2012*, Flouris 2013*, Goniewicz 2014*); emissions are typically lower than regulatory standards for workplace air quality (Burstyn 2014, O’Connell 2015).
A Connecticut-based study suggests e-cigarette flavors, a desire to experiment, and peer influence may make e-cigarettes appealing to youth and young adults (Kong 2015*). E-cigarette users, regardless of age, often report selecting e-cigarettes over traditional cigarettes because they believe e-cigarettes are healthier (Pepper 2014*, Farrelly 2015*, Berg 2015*, Wills 2015).
Some studies suggest that e-cigarettes can help tobacco users decrease use or quit (Cochrane-Hartmann-Boyce 2016*, Malas 2016*, Waghel 2015*); others suggest that e-cigarettes do not affect quit rates or are less effective than quit aids such as nicotine replacement therapy (NRT) (Kalkhoran 2016, Waghel 2015*). Additional research is needed to determine effects on cessation (USPSTF-Tobacco cessation, Cochrane-Hartmann-Boyce 2016*).
Impact on Disparities
The Family Smoking Prevention and Tobacco Control Act was expanded in August 2016 to include e-cigarettes and other electronic nicotine delivery systems (ENDS), granting the FDA authority to regulate manufacturing, packaging, promotions, and sales of ENDS through mandatory ID checks at the point of sale, restrictions on marketing and sales locations, and other efforts (US FDA-E-cigarette regulations).
As of December 2016, more than 40 states ban e-cigarette sales to youth under age 18. Four states (Alabama, Alaska, New Jersey, and Utah) ban sales to youth under 19 and two (California and Hawaii) restrict sales to youth under age 21 (PHLC-E-cigarettes review). Many states have also expanded smoke-free policies to prohibit use of e-cigarettes in schools, childcare facilities, health care institutions, or state-owned buildings; Arkansas, Vermont, and Minnesota are three examples (PHLC-E-cigarettes review).
Local governments can also include e-cigarettes in smoke-free policies or ban sales to youth (Grassroots Change). Chicago and New York City, for example, have banned sales to youth under age 21 and included e-cigarettes in their respective smoke-free policies(Chicago-Tobacco, NYC Health-Tobacco). State legislation preempts local government control of e-cigarette products in Arizona, Arkansas, Iowa, Nevada, Oklahoma, South Carolina, South Dakota, and Washington as of 2017 (Grassroots Change).
US FDA-Tobacco rule - US Food and Drug Administration (US FDA). The facts on the FDA's new tobacco rule. 2016.
ChangeLab-Regulate e-cigarettes - ChangeLab Solutions. How to Regulate E-Cigarettes and Other Electronic Smoking Devices: A model ordinance & flowchart.
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.
Citations - Evidence
* Journal subscription may be required for access.
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.
CDC Vital signs-E-cigarette - CDC Vital Signs. E-cigarette ads and youth. Atlanta: Centers for Disease Control and Prevention (CDC). 2016.
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.
Friedman 2015* - Friedman AS. How does electronic cigarette access affect adolescent smoking? Journal of Health Economics. 2015;44:300-308.
Pesko 2016* - Pesko MF, Hughes JM, Faisal FS. The influence of electronic cigarette age purchasing restrictions on adolescent tobacco and marijuana use. Preventive Medicine. 2016;87:207-212.
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.
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.
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.
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.
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.
McMillen 2015* - McMillen RC, Gottlieb MA, Shaefer RMW, Winickoff JP, Klein JD. Trends in electronic cigarette use among U.S. adults: Use is increasing in both smokers and nonsmokers. Nicotine & Tobacco Research. 2015;17(10):1195-1202.
HA HPB-E-cig - Health Affairs. Health Policy Briefs. E-cigarettes and federal regulation. 2014.
CDC MMWR-Corey 2013 - Corey C, Wang B, Johnson SE, Apelberg B, 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.
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.
Tierney 2016 - Tierney PA, Karpinski CD, Brown JE, Luo W, Pankow JF. Flavour chemicals in electronic cigarette fluids. Tobacco Control. 2016;25:e10-e15.
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.
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.
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):1945–53.
Wagener 2012* - Wagener TL, Siegel M, Borrelli B. Electronic cigarettes: Achieving a balanced perspective. Addiction. 2012;107(9):1545–8.
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.
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.
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.
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.
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.
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.
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.
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.
Cochrane-Hartmann-Boyce 2016* - Hartmann-Boyce J, McRobbie H, Bullen C, et al. Electronic cigarettes for smoking cessation (Review). Cochrane Database of Systematic Reviews. 2016;(9):CD010216.
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.
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.
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.
USPSTF-Tobacco cessation - US Preventive Services Task Force (USPSTF). Draft Recommendation Statement: Tobacco Smoking Cessation in Adults, Including Pregnant Women: Behavioral and Pharmacotherapy Interventions. 2015.
Citations - Implementation Examples
* Journal subscription may be required for access.
US FDA-E-cigarette regulations - US Food and Drug Administration (US FDA). Tobacco products: Rules, regulations, and guidance. FDA's new regulations for e-cigarettes, cigars, and all other tobacco products. 2016.
PHLC-E-cigarettes review - Public Health Law Center (PHLC). US e-cigarette regulations: 50 state review. 2017.
Grassroots Change - Grassroots Change: Connecting for better health. Preemption Watch.
Chicago-Tobacco - City of Chicago. Business affairs & consumer protection. Tobacco regulations. 2016.
NYC Health-Tobacco - NYC Health. Smoking and tobacco control laws. City of New York. 2016.
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