E-cigarette regulations
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 pen (CDC SG-E-cigarette 2018). They can be disposable or refillable; both can feature kid-oriented flavors such as cotton candy, chocomint, and blueberry lemonade (CTFK-Flavored e-cigarettes). E-cigarettes are regulated by the U.S. Food and Drug Administration (FDA) (US FDA-E-cigarette regulations) and subject to the national minimum tobacco age of 21 years old, set by Tobacco 21 (T21) (CDC-Tobacco 21, Farber 2016). 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 adults (Du 2020, CDC SG-E-cigarette 2018). Some state laws preempt local efforts (Grassroots Change). E-cigarettes are sometimes used by current smokers who want to reduce their tobacco use or quit (Malas 2016); 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-cigarettes (US FDA-E-cigarette marketing 2021).
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.
What could this strategy improve?
Expected Benefits
Our evidence rating is based on the likelihood of achieving these outcomes:
- Reduced youth use of e-cigarettes
- Reduced tobacco use
Potential Benefits
Our evidence rating is not based on these outcomes, but these benefits may also be possible:
- Increased tobacco cessation
What does the research say about 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-cigarettes (Grube 2021, Jun 2021, CDC SG-E-cigarette 2018, US DHHS SG-E-cigarette 2016, CDC Vital signs-E-cigarette, CDC-MMWR-Marynak 2014). 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 use (Astor 2019). 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-cigarettes (Glasser 2017). 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 adults (Jun 2021). 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 users (Grube 2021). 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 youth (Roberts 2022).
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 adults (Du 2020). 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 other (Pesko 2020, Glasser 2017), but that is not always the case (Cotti 2018). Adding e-cigarette restrictions to smoke-free air and smoke-free worksite laws does not appear to reduce e-cigarette use (Cotti 2018, Friedman 2021).
Nicotine and other potentially harmful chemicals have been found in e-cigarettes (CDC SG-E-cigarette 2018, CDC MMWR-Corey 2013, Schober 2014) and e-cigarette flavorings (CDC SG-E-cigarette 2018, Tierney 2016), even in e-cigarettes labeled as containing no nicotine (Blank 2016). Pod-based e-cigarettes may contain the same amount of nicotine as 20 traditional cigarettes (CDC SG-E-cigarette 2018). 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 cigarettes (Glasser 2017). However, others find that particulate matter (Glasser 2017) and carcinogenic particles in e-cigarette vapor are lower than traditional cigarette smoke (Oh 2014), creating less of a health risk for bystanders (Vansickel 2010, Wagener 2012, Flouris 2013, Goniewicz 2014); emissions are typically lower than regulatory standards for workplace air quality (Burstyn 2014, O'Connell 2015). E-cigarette, or vaping, product use-associated lung injury (EVALI) has become more common in recent years, particularly for younger users (CDC-Vaping injury). More research is needed regarding harm levels and long-term effects of e-cigarettes (Glasser 2017).
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). A survey-based study of young adults suggests that e-cigarette flavoring was the most important factor in selecting an e-cigarette (Baker 2021); flavor restrictions have shifted sales from non-menthol flavored e-cigarettes to menthol e-cigarettes (Diaz 2021). A California-based study found that local laws can reduce in-person purchases of flavored e-cigarettes by youth (Gaiha 2021). E-cigarette health warnings are associated with lower intent to purchase e-cigarettes (Glasser 2017); 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-cigarettes (Baker 2021). 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).
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 (Glasser 2017, 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 the potential for e-cigarettes to act as a gateway product for other forms of tobacco (Primack 2015, CDC-MMWR-Marynak 2014, McMillen 2015) and to renormalize tobacco use (CDC-MMWR-Marynak 2014, HA HPB-E-cig).
To reduce e-cigarette use, experts recommend stronger state and federal restrictions to prevent youth from purchasing flavored e-cigarettes online or from social sources (Gaiha 2021), 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-cigarettes (Kim 2021b, CDC SG-E-cigarette 2018). 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-cigarettes (Huh 2021). Additional oversight of online e-cigarette retailers is also needed, as retailers frequently lack proper age verification methods (Glasser 2017). 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 products (CDC SG-E-cigarette 2018).
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 events (Cochrane-Hartmann-Boyce 2021). Other studies suggest that e-cigarettes do not affect quit rates or are less effective than quit aids (Kalkhoran 2016, Waghel 2015). Additional research is needed to determine effects on cessation (USPSTF-Tobacco cessation, Cochrane-Hartmann-Boyce 2021).
Implementation Examples -+
The U.S. 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 locations (US FDA-E-cigarette regulations). 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 FDA (CTFK-Flavored e-cigarettes).
As of December 2021, 33 states and Washington, D.C. require retail licenses for over-the-counter sales of e-cigarettes; 30 states and Washington, D.C. tax e-cigarettes; and 17 states and Washington, D.C. have smoke-free indoor air laws that prohibit smoking and the use of e-cigarettes in restaurants, bars, and private worksites (CDC-STATE E-cigarette fact sheet). 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 examples (PHLC-E-cigarettes review).
Local governments can also include e-cigarettes in smoke-free policies (Grassroots Change). Chicago and New York City, for example, 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, Montana, Nevada, Oklahoma, South Carolina, South Dakota, Utah, and Washington as of 2022 (Grassroots Change).
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 marketing (US FDA-Youth tobacco prevention).
Implementation Resources -+
ANRF-E-cigarettes - American Nonsmokers’ Rights Foundation (ANRF). Electronic cigarettes.
CDC-E-cig dictionary - Centers for Disease Control and Prevention (CDC). E-cigarette, or vaping, products visual dictionary.
CDC-E-cigarettes - Centers for Disease Control and Prevention (CDC). Smoking & Tobacco Use: Electronic cigarettes.
CTFK-E-cigarettes - Campaign for Tobacco Free Kids (CTFK). Electronic cigarettes: An overview of key issues. 2017.
PHLC-E-cigarettes - Tobacco Control Legal Consortium (TCLC). E-Cigarettes. Saint Paul: Public Health Law Center (PHLC).
US DHHS SG-E-cigarette risks - U.S. Department of Health and Human Services (U.S. DHHS), U.S. Surgeon General, U.S. Centers for Disease Control and Prevention, Office on Smoking and Health (CDC-OSH). Know the risks: E-cigarettes and young people.
Citations -+
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Astor 2019* - Astor RL, Urman R, Barrington-Trimis JL, et al. Tobacco retail licensing and youth product use. Pediatrics. 2019;143(2).
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CDC Vital signs-E-cigarette - CDC Vital Signs. E-cigarette ads and youth. Atlanta: Centers for Disease Control and Prevention (CDC). 2016.
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Grassroots Change - Grassroots Change: Connecting for better health. Preemption Watch.
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HA HPB-E-cig - Health Affairs. Health Policy Briefs. E-cigarettes and federal regulation. 2014.
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.
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US FDA-E-cigarette marketing 2021 - U.S. Food and Drug Administration (U.S. FDA). FDA News release: FDA permits marketing of e-cigarette products, marking first authorization of its kind by the agency. 2021.
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US FDA-Youth tobacco prevention - U.S. Food and Drug Administration (U.S. FDA). Center for Tobacco Products. FDA's youth tobacco prevention plan.
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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.
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