Regulatory controls applied to e-cigarettes vary widely across the world, with approaches ranging from complete sales bans, allowing vapes to be sold as consumer products, or—least commonly—regulating vapes as medicinal products (see Section 18.14). In Australia, laws that went into effect over the course of 2024 prohibit the importation of single-use vapes and the general retail sale of all e-cigarette products, regardless of nicotine content. Since 1 July 2024, e-cigarette products can only be sold in pharmacies, and since 1 October 2024 vapes containing less than 20mg nicotine per millilitre are available over-the-counter (without a prescription) to adults in pharmacies in most states and territories—see Section 18.13. Flavours are limited and manufacturers must notify the regulator that products comply with labelling, contamination and ingredient controls, and other safety requirements. The primary objective of these reforms was to close the regulatory loopholes that had allowed widespread illegal sales of e-cigarettes to young people, while still providing access to vapes for smoking cessation or management of nicotine addiction.
Regardless of a country’s regulatory model, concerns about rapidly increasing use among young people and the potential for health risks and addiction have led to calls for a variety of policies and programs that seek to minimise e-cigarette use among young people and non-smokers, including restrictions on advertising and promotion, prohibiting use in smokefree areas, banning flavours that could appeal to youth, raising taxes, implementing health warnings, and prohibiting sales to minors.1,2 Targeted research and data collection in the coming years that examines smoking and vaping transitions, harms among people who have never smoked, and industry circumvention is needed to effectively monitor and evaluate the impact of vaping regulations.3 As with tobacco control policies, the nicotine and tobacco industries have opposed and undermined e-cigarette and nicotine product regulations, highlighting the ongoing need to protect public health policies from industry interference—see InDepth 10A and Section 18.8.3.
Many jurisdictions, including most Australian states and territories, have extended smokefree legislation to include banning vaping wherever smoking is prohibited. Such legislation can protect others from involuntary exposure to vape aerosol as well as help to denormalise vaping, with research showing that exposure to e-cigarette use can promote uptake among young people (see Section 18.9). Several studies in the US have found that uptake and use of e-cigarettes among young people is lower in states that have comprehensive vaping bans; for example in workplaces, bars and restaurants.11-14 Such bans may also reduce cannabis vaping among young people.15 Among adults, research in the US has produced mixed findings, with some studies finding that vape-free policies were associated with a lower likelihood of vaping,16 and others finding no such relationship.17,18 Research in Canada found that bans on e-cigarette use in public places had no effect on vaping or smoking, though noted that violations may be common.19 A systematic review similarly concluded that vape-free laws did not appear to reduce vaping, perhaps due to lax enforcement, greater tolerance for vaping compared with smoking, and the relative ease of vaping discreetly.20 In Europe, many countries have included vaping in smokefree policies, though one review notes that the coverage of bans varies widely by setting and country.21 Smokefree policies in the home may also be protective against e-cigarette use.22,23
Many states in the US require retailers to obtain a license to sell e-cigarettes. License fees range from very small amounts (e.g. $5 in Montana) to more substantial fees (e.g. $800 in Connecticut), and penalties for noncompliance can include suspension or revocation of a license, fines, and criminal sanctions. Licencing schemes can facilitate communication between governments and retailers, support effective enforcement of laws (e.g. bans on sales to minors, advertising restrictions), reduce illicit trade, and may reduce supply, for example by capping the number of licences in a given jurisdiction or by discouraging retailers though high fees (see InDepth 11B). Despite their promise, a major study in the US concluded that the adoption or strength of licensing laws do not appear to have reduced access or use of vapes among young people, likely because most obtain their e-cigarettes from informal sources.26 Among adults, research has similarly shown no association between the strength of retailer licencing and vaping.27 Another study that examined e-cigarette delivery laws found that they varied widely in scope and coverage between US states, allowing much easier access to youth in states with less stringent age verification procedures.28 There is also very poor compliance in the US with laws that require packages that contain tobacco or vaping products to be clearly labelled as such, which can facilitate underage purchases and circumvention of flavour and product restrictions.29 In New Zealand, 2023 regulations mean that new specialist vape retailers are not allowed to open within 300 metres of schools and marae (meeting place for indigenous Māori). However, existing specialist retailers and general vape retailers, such as convenience stores and petrol stations, are unaffected by the changes, and vapes still appear to be easily and widely accessible to young people.30 One study notes the importance of comprehensive surveillance to improve compliance with retailer requirements.31
Australia’s unique pharmacy-only supply model introduced over the course of 2024 (see Section 18.13) aims to reduce use of vapes by young people and non-smokers while providing access to vapes and clinical support to people wishing to use vapes to quit smoking or manage nicotine dependence. A study that modelled the impact of pharmacy-only supply in New Zealand suggested that it would lead to modest reductions in vaping and net health gains, though noted significant uncertainty in these findings due to unknown long-term health risks and the complex relationship between vaping and smoking.32 Prior to Australia’s vaping reforms, although nicotine vapes could legally only be imported by people with a prescription under special access arrangements, most Australians who vaped nonetheless reported using products that contained nicotine that they had obtained without a prescription.33 Further, despite bans on sales to minors, young people reported finding it easy to access e-cigarettes.34 The widespread illegal sale of nicotine vapes was able to flourish as non-nicotine vapes could be sold by general retailers—making it difficult for authorities to identify if the vapes available on the market were legally imported and sold (i.e. were nicotine-free), as individually testing all products and shipments was unfeasible.25 Vaping products can now only be sold in pharmacies and must comply with product standards, facilitating easier enforcement of regulations and identification of illegal imports and sales. An online audit and in-person inspection of vape stores in Western Australia found that by September 2024, 99% had either closed or were no longer visibly selling vaping products. However, products remained readily available in convenience stores, suggesting enforcement gaps.35 Early Australian data suggest that supply to young people may have begun declining since the new laws came into effect and that the prevalence of vaping may have peaked. Results from a national survey of young people aged 14–17 showed that fewer young people reported buying their own vapes since implementation of the reforms. Among those that had purchased their own vape, tobacconists and vape stores were the main supplier, suggesting that these are important targets for enforcement efforts.36 Data from NSW similarly showed meaningful declines in the proportion of teenagers who had ever vaped between April 2024 and October 2025, though again noted access to vapes remained easy among young people.37 A report by the Illicit Tobacco and E-cigarette Commissioner (ITEC) estimated that in 2024–25, 95.7% of the e-cigarette market in Australia was illicit products, highlighting the importance of strengthened national and state efforts to enforce laws banning the sale of vapes outside of pharmacies.38
Several states have also gone further than the federal vaping reforms, with Tasmania and Western Australia maintaining prescription-only supply. The New Zealand modelling study suggested that this approach may lead to small additional benefits over pharmacy-only supply,32 and it has also been advocated by US researchers.39 Sale of all types of e-cigarettes is banned in 34 countries.40 In some countries, bans on sales cover nicotine e-cigarettes only, while in others, bans cover both nicotine and non-nicotine e-cigarettes.41 An examination of a total e-cigarette ban in Taiwan notes highlights the critical role of restricting online sales and preventing illicit trade in allowing effective implementation of the ban.42 A systematic review and meta-analysis that examined five Asian countries with vaping bans found considerable variation in prevalence between countries. It concluded that while the bans appeared to have reduced prevalence, vaping was still a significant and persistent issue, potentially due to poor compliance and enforcement, or alternative sources of e-cigarettes.43 In the US, where several states implemented short-term emergency bans on e-cigarettes following the EVALI outbreak (a serious acute lung injury associated with vaping), studies showed substantial reductions in sales and use during ban periods.20,44 Following its ban on vaping in 2018, in 2025 the Prime Minister of Singapore announced that vaping would be treated as a drug offence, with harsher penalties for possession, sale or use. Researchers have noted the importance of future research examining the effects of the criminalisation of vaping.45
Although it is one of the most common policies implemented in US jurisdictions, evidence for the effectiveness of minimum age laws on reducing e-cigarette use among young people is limited and mixed. Findings range from showing decreased vaping,13,46 to no effect, to increased vaping, with a similar range of impacts shown for the effects of e-cigarette age restrictions on smoking.47,48 Research in Vermont found that while increasing the purchase age to 21 years (alongside a wholesale tax on e-cigarettes and banning the mail delivery of tobacco products) was associated with decreased vaping among middle and high school students, there was a substantial increase in vaping among young adults aged 18–25. Underage respondents continued to report that it was easy to access vapes.49 Surveys also shown relatively low levels of awareness about e-cigarette minimum age laws among people in the US.50 Research in Canada found that implementation of a ban on e-cigarette sales to minors was associated with a significant reduction in the rate of increase in e-cigarette use; however use continued to increase in provinces with and without such policies.51 Another Canadian study concluded that e-cigarette minimum age laws were associated with reduced smoking uptake but also reduced smoking cessation among young people.52 Studies have shown that underage young people can often easily purchase e-cigarettes, particularly online,53-55 and that violations of laws banning sales to minors are common.20,56-61 Enforcement of comprehensive regulations are needed to reduce access and use of e-cigarettes among young people.59,62,63 Longitudinal research in the US suggests that minimum age laws may help to increase risk perceptions among young people, which may strengthen prevention efforts.64
In light of research showing that plain packaging can reduce the appeal of tobacco products, researchers have examined the role of packaging in promoting vaping. Experimental studies have shown that among young people, brand imagery on vapes increases interest in trying vaping and can be used to target interest among particular groups. As with cigarettes, plain packaging reduces interest in trying vaping among youth.65,66 For example, a recent study conducted with young people in Canada, England, and the US tested whether standardising the look of disposable vapes, by removing branding and using plain white colouring, influenced interest in trying them. Participants shown standardised vapes were more likely to report no interest in trying them compared to those shown branded versions of the same vapes. The reduction in interest in using standardised vapes was stronger among participants who had recently or formerly used tobacco and/or nicotine products.67
Packaging regulations also aim to reduce safety risks of products; for example, to prevent accidental poisonings among children. Several jurisdictions require childproof packaging, including the EU, the US, and Australia. It is yet to be seen whether legislation introduced in 2024 in Australia restricting the sale of vapes to pharmacies and to those that meet strengthened product standards will reduce the incidence of poisonings, which had increased over time.68 Products sold in Australia must also state the nicotine concentration on the label, however research suggests that this may not be well understood by young people. Experimental research suggests that colour-coded or thermometer-style labelling may be helpful for conveying nicotine strength.69
Given the role of flavours in increasing the appeal and use of e-cigarettes among young people (see Section 18.2.4.5), banning sweet and fruit flavours has been suggested as one approach to curbing youth uptake. In the US, e-cigarette manufacturers must apply for marketing authorisation from the FDA in order to legally market and sell their products. Although flavoured products are not strictly banned, until recently the only products authorised for sale were those with tobacco or menthol flavours. However, sales data shows that fruit and menthol flavours increasingly dominated the market in the years following the ban on unauthorised products, suggesting poor compliance and enforcement.72 In 2020, the US FDA announced that it would prioritise enforcement of unauthorised manufacture, distribution and sale of flavoured cartridge-based e-cigarettes, and products targeting young people. In order to avoid discouraging adults from using the products for quitting smoking, the policy targeted cartridge-based products, such as JUUL, and exempted disposable devices.73 These enforcement efforts likely promoted switching to products that were exempt or not being targeted rather than leading to reduced overall flavour use,74-78 highlighting the importance of comprehensive rather than selective flavour bans.79 Product and promotion strategies by the e-cigarette industry also encouraged switching to alternative products;80 for example, JUUL appears to have increased the menthol and nicotine concentrations in its pods in response to the FDA targeting flavoured pod-based e-cigarettes except tobacco and menthol.81 Health experts have also expressed disappointment following the authorisation of several menthol products in recent years, including a number of JUUL products, due to their appeal to children.82,83 In May 2026, the FDA authorised the first non-tobacco and non-menthol products, mango and blueberry pods (named ‘Gold’ and ‘Sapphire’).84 The FDA Commissioner reportedly opposed this authorisation which was advocated by the Trump administration, and has subsequently resigned.85
A number of jurisdictions in the US have gone beyond the federal Tobacco Control Act and have enacted stricter policies on flavoured tobacco products and e-cigarettes. In late 2019, Massachusetts became the first state to prohibit the sale of all flavoured tobacco products, including flavoured e-cigarettes, and evaluations have found that implementation of this policy was associated with reductions in sales of flavoured products86 as well as in current e-cigarette use and levels of cigarette use.87 Another study found that restrictions on the sale of flavoured e-cigarettes in Massachusetts, New York, Rhode Island, and Washington were associated with a reduction in total e-cigarette sales.88 Analyses of PATH data have shown that flavour bans in California, Massachusetts, New Jersey, New York, Rhode Island, and Utah were associated with lower odds of e-cigarette use among adolescents and young adults,14,89 though one found that these declines were not experienced among young people with social disadvantage90 and another concluded that impacts were limited among adults aged over 30.89 Following a flavour ban in New Jersey, sales data showed a rapid decrease in flavoured e-cigarettes alongside increased sales of unflavoured e-cigarettes. There was minimal impact on total e-cigarette, cigarette, or cigar sales, suggesting that the ban did not lead to an increase in combustible tobacco product use.91 Similarly in New York, sales data showed an association between the implementation of a flavour ban and reduced flavoured vaping product access and sales, with no change in cigarette sales.92 Such bans may also help reduce susceptibility to uptake.93 Despite concerns that flavour bans would substantially increase cross-border sales, this has not been borne out by research.94,95 For example, research in California concluded that its flavour ban reduced e-cigarette and cigarette sales without increasing sales in neighbouring states.96 Survey research in San Francisco following implementation of a comprehensive flavour ban also found a reduction in use of e-cigarettes among young adults,97 and another survey of US adults who smoke or vape found that flavour bans may help reduce vaping among those who dual use.98
Concerningly, several US studies have found that flavour bans were associated with decreased vaping and/or vape sales, but were also associated with increased smoking or sales of cigarettes.99-103 One paper notes that this appears to be primarily driven by substituting cigarettes for e-cigarettes (rather than uptake of e-cigarettes among nicotine-naïve people), highlighting the importance of cessation aids and support alongside the implementation of flavour bans.100 Experimental research has suggested that flavour bans may be associated with increased purchasing of nicotine replacement therapy.104 An evaluation in the Netherlands concluded that its e-cigarette flavour ban effectively reduced vaping among both young people and adults, without significant shifts to or increases in cigarette smoking. The authors highlight the importance of comprehensive and well-enforced flavour bans to minimise unintended consequences.105 For example, including menthol in flavour bans, which is often exempted, due to its appeal to young people and poly-tobacco users.106
Even in US states with flavour bans, restricted products and flavours still appear to be widely available.107,108 Similarly in Quebec, Canada, an evaluation of its flavour ban found no evidence that it reduced uptake or use among young people, noting ongoing widespread availability of restricted products.109 In New Zealand, an analysis of online retailers found frequent breaches of flavour name restrictions introduced in 2024,110 and in response to the laws some convenience store retailers created separate premises within or beside their existing stores (‘store within a store’ outlets) to obtain specialist vape retailer licences, enabling continued sale of the full range of vape flavours. An analysis found that the density of ‘store within a store’ outlets increased with neighbourhood socio-economic deprivation, and more than half (56%) of specialist vape retailers were located within 300 metres of at least one educational institute.111 Many studies have noted that circumvention or violations of flavour bans are common, highlighting the importance of enforcement efforts and retailer education.112-120 Nonetheless, a systematic review found that overall, the evidence suggests that flavour restrictions reduce vaping among young people.20
Despite concerns that flavour bans could dissuade people who smoke from using e-cigarettes to quit or stay quit, findings from Canada, England and the US showed that although largely opposed to such bans, many people who vape would be willing to use available flavours from a more restricted range.121 One study found that experiencing success in quitting smoking was unrelated to e-cigarette flavour restrictions. Responses among people who smoked who used e-cigarettes for quitting included switching to tobacco or menthol flavours or managing to obtain restricted flavours. Experiencing flavour bans or changing vaping behaviours in response to bans were unrelated to successful quit attempts.122
The EU, Canada, UK and several other jurisdictions limit the nicotine concentration in vaping products to a maximum of 20 mg/ml. In Australia in most states and territories, vapes containing less than 20mg/ml of nicotine may be sold over-the-counter (without a prescription), while a prescription is required to purchase products with a nicotine concentration of more than 20 mg/ml. Such limits aim to balance the use of vapes for nicotine withdrawal, while limiting health and addiction risks for nicotine-naïve users.123
A growing number of countries require that e-cigarettes bear warning labels. An experimental study found that text warning labels on e-liquids decreased young adults’ intention to use e-cigarettes, increased harm perception and decreased the appeal of the product, however there were no changes in perceived addictiveness and warnings often failed to grab users’ attention.124 An experiment in New Zealand found that among people who smoke, an addiction warning led to the greatest decrease in appeal.125 Findings from one study suggest that conflicting health warning information (i.e., the presence of both a modified risk and a health risk statement) may reduce the effectiveness of warnings,126 though another found that including both types of messages may promote quitting among people who smoke.127 As with tobacco warning labels (see Section 12A.4), design elements128-130 are an important consideration in developing prevention messages and e-cigarette warnings, in order to maximise attention and increase harm perceptions. Pictorial warnings may also be more effective than text warnings,131,132 and rotating and refreshing warning content may be important for reducing the tendency for warnings to become less effective over time (i.e. wear out effects).133
In the EU, the Tobacco Products Directive (TPD) requires that e-cigarette products must state either “This product contains nicotine which is a highly addictive substance” or “This product contains nicotine which is a highly addictive substance. It is not recommended for non-smokers”, with experimental research showing that these rate highly on measures of understandability, believability and convincingness.134 A survey of people who smoke in the EU concluded that the mandated warnings may reduce willingness to use and likelihood of purchasing e-cigarettes, but there were no differences in ratings between a hypothetical reduced risk warning (that is, a warning that compared vaping with smoking: “The Royal College of Physicians (2016) report concluded that e-cigarettes are 95% less harmful than cigarettes”) and no warning.135 Another study similarly found that the TPD warning increased, and a reduced risk warning decreased, perceptions of harm and addictiveness among both people who did and did not smoke.136 However, findings from the International Tobacco Control (ITC) study showed that TPD e-cigarette warnings were not associated with increased perceptions of nicotine harm or relative harm and addictiveness in England among people who vape or smoke. Although users from England reported noticing warnings more than Canada, the US, or Australia, noticing was generally low across all groups.137 Another study similarly found that there was no change in reported noticing and reading of e-cigarette warning labels across six European countries following implementation.138 Among teenagers, about one in eight reported noticing health warnings on e-cigarette products in England in 2018. Noticing was more common among those who vaped and/or smoked, and was associated with higher harm perceptions.139 Focus group research suggests that strengthening and rotating warnings, alongside making packaging less appealing, may be needed to more effectively reduce appeal and increase knowledge and harm perceptions.140
Since 2018, the US FDA also mandates that e-cigarettes include a health warning: “WARNING: This product contains nicotine. Nicotine is an addictive chemical.”141 There is generally high levels of compliance with this requirement,142 though less so for synthetic nicotine products.143 Research suggests that this warning is believable and understandable, and effectively communicates health risks, compared with reduced risk warnings.144 Another study supported the beneficial effects of these text-only warnings, but also found that pictorial warnings may further increase effectiveness. Such warnings also reduced interest in smoking among people who snoke.132 Between 2018 and 2019 the proportion of middle and high school students who saw an e-cigarette package and reported high exposure to warning labels increased, and in 2020, about one in five high school students in the US reported high levels of exposure to e-cigarettes warnings.145 Several studies have shown that higher exposure is associated with increased harm perceptions among US teens.139,145
A systematic review of the impact of e-cigarette warning labels found that nicotine addiction messages (such as those mandated in the US and the EU) resulted in greater perceptions of health and addiction risks, and reduced smokers’ intention to purchase, try or switch to e-cigarettes. Relative risk messages (that compared the risks of vaping to smoking) increased perceptions that e-cigarettes are less harmful, and increased smokers’ intention to purchase, try or switch to e-cigarettes. Trust in information from public health agencies was associated with lower odds of vaping and perceiving vaping as less harmful, while trust in information from e-cigarette companies was associated with perceptions of e-cigarettes as less harmful than cigarettes.146 More recently, a meta-analysis of experimental studies found that text-based warnings on e-cigarettes were associated with increased attention, emotional response, perceived message effectiveness, and beliefs about addiction and health risks, and decreased intention to vape and increased intentions to quit. Warnings about the health harms of vaping were more effective than addiction-focussed warnings in increasing attention, negative affect, perceived effectiveness, risk beliefs and intention to quit.147
Several jurisdictions allowing general sales of e-cigarettes have introduced special taxes on these products (NB taxes on e-cigarettes are not appropriate in jurisdictions which have banned their sales, or where access is facilitated for cessation purposes). Some have argued against high taxes on e-cigarettes, particularly if prices exceed those of combustible cigarettes, as it may encourage the use of cigarettes over e-cigarettes.148,149 A number of studies have suggested that e-cigarettes and tobacco cigarettes are substitutes, with higher cigarette prices being associated with increased e-cigarette use or sales150-152 and vice versa.153-156 However, others have noted that not adequately taxing e-cigarettes could result in higher use among young people.157 Raising taxes on e-cigarettes to deter initiation by never smokers, alongside concomitant greater tax increases on cigarettes to encourage switching among people who smoke, has been suggested as one possible regulatory path in countries that allow general sale of both products.151,158 A modelling study in the US found that while higher e-cigarette taxes would not appear to increase the prevalence of smoking, a combined tax on both products would likely be the most effective at reducing both smoking and vaping prevalence and therefore have the greatest public health benefits.159 Unintended consequences of e-cigarette taxes, such as shifting users to cigarettes or to informal sources of products, are important considerations in designing and enforcing effective policies.160
Studies examining price sensitivity (i.e., the extent to which people’s purchasing decisions are affected by the price of products) in Korea,156 the US153,160-162 and the EU151 have consistently found that e-cigarette demand is responsive to price, suggesting that increasing taxes on e-cigarettes could potentially reduce use. A study estimating the effect of price on JUUL use among adolescents found that teenagers become more price sensitive as the price of e-cigarettes increases, particularly for non-users. It estimated that a 10% increase in price could result in up to a 24% reduction in JUUL demand among adolescents using nicotine, and up to a 45% reduction among those not currently using nicotine.163
Research in the US comparing e-cigarette use in states with and without statewide vaping product excise tax policies has found significantly lower increases in e-cigarette use prevalence among young adults in states with such policies.164 Findings from the International Tobacco Control (ITC) study found no relationship between e-cigarette taxes and transitions in smoking or vaping behaviours among adults who smoke or vape,165 while a systematic review found that reducing affordability via taxes appears to reduce vaping among adults.20 Among adolescents, some research has suggested no impact of taxes on vaping,11 while others find reductions in use in states that have implemented tax policies.166,167 A systematic review and meta-analysis of studies in the US found that e-cigarette taxes generally reduce use among young people and adults, but noted variable impact depending on tax type, economic setting, and industry response.168 Taxes on e-cigarettes are generally lower than for cigarettes in the US, and in some states taxes vary depending on whether the product is an open (i.e. refillable) or closed system.169 One study found that e-cigarettes have become more affordable for young people in all states over time, though are comparatively less affordable in states with ad-valorem taxes (taxes based on the value the product).170 Receipt of e-cigarette coupons appears to undermine the effectiveness of tax policies, highlighting the importance of limiting industry marketing strategies.171 The UK has announced plans to introduce a new tax on e-cigarettes in 2026 with higher levels of duty applied to higher-strength nicotine e-liquids, with the differential tax rate aiming to reduce vaping progression and dependence among young people. Future work will examine the impact of the policy.172 It will also be important to monitor and limit the industry’s ability to undermine tax increases, with evidence from China showing how industry pricing strategies reduced the impact of excise increases.173
E-cigarette manufacturers claim that advertising is necessary for providing information and supporting people who smoke to quit.174,175 However, research suggests that exposure to any sort of e-cigarette advertising likely increases young people’s intent to initiate e-cigarette use,176 and that all advertisements contained at least some features attractive to youth177 (see Section 18.2).
In response to concerns regarding the effects of e-cigarette advertising, particularly on young people, several countries have introduced bans on advertising and promotion (see Section 18.14). Following the implementation of a ban on e-cigarette advertisements by retailers (apart from specialty shops) in Ontario, Canada, in 2020, there was a large reduction in the number of ads surrounding schools.178 A study examining data from 48 countries found an association between implementation of the WHO FCTC tobacco advertising, promotion and sponsorship (TAPS) bans on the internet and lower vaping prevalence among young people. Bans covering product placement as well as stronger additional TAPS measures were also associated with lower e-cigarette use.179 Strong bans on online e-cigarette advertising are also associated with fewer vaping-related internet searches, potentially indicating reduced interest in vaping in countries with such bans.180
Even in countries with bans, e-cigarette advertising can be difficult to monitor and regulate, particularly as much of it occurs online. One study in the EU found that in member states with more comprehensive advertising bans, exposure to e-cigarettes advertisements was similar to member states without such bans.181 Another study in the EU found that following the implementation of the Tobacco Products Directive, exposure to e-cigarette advertising tended to decline for some channels, particularly television and radio, but tended to increase in some unregulated channels, such as at points of sale.182 An evaluation of vaping prevalence in Great Britain found that it appeared to plateau among young people following implementation of the TPD, which the authors suggest may be due to marketing and product regulations limiting the rapid introduction of new, targeted products.183 In Mexico, where the sales and marketing of e-cigarettes is largely banned, half of middle school students were aware of the products in 2015.184 Violations of e-cigarette advertising restrictions can be common.185-187 For example, following more stringent advertising and marketing restrictions in New Zealand, an audit of vape retailers found violations—including product visibility from outside the store, in-store advertising, and discounting—were relatively common.71
Following warning letters, in 2018 the US FDA banned e-liquids made by 17 different manufacturers that came in packaging strongly resembling candies, cookies and other snacks.188,189 The FDA requires warnings on e-cigarette advertisements, and studies show this should also apply to social media.190 However, the prevalence of FDA-mandated warning statements in e-cigarette related YouTube videos has been found to be low.191 The FDA also ruled that JUUL misrepresented its products by selling or distributing them as modified risk tobacco products without an appropriate FDA order.192 Despite policy changes in the US aiming to reduce the appeal of products to young people, an analysis of advertisements found that many still included youth-appealing features and flavour cues.142
Surveys in the US suggest that the majority of adults support the prohibition of e-cigarette sales and marketing to youth,5,193 as well as banning flavours.4,5,194 Similarly, most Canadians support restrictions on e-cigarette advertising in order to reduce use among youth.6 Research in the EU found that in 2018, support for a ban on e-cigarette promotion ranged from 33% in Spain to 57% in Poland.195
Among a sample of parents in Melbourne, Australia the overwhelming majority (87%) supported banning marketing and advertising that targets teenagers.7 A survey of Australian e-cigarette users found that just over one-third supported e-cigarettes being regulated in the same way as tobacco cigarettes, which would include a ban on advertising and promotion.196 A survey of pharmacy customers in Brisbane, Australia found that most non-smokers (87%) felt that nicotine-containing e-cigarettes should be regulated either as a medicinal product or completely banned. Twelve per cent thought they should be regulated in line with tobacco products. Among smokers, 62% thought nicotine e-cigarettes should be regulated as tobacco products.197
In 2018, the US FDA launched a public education campaign to educate teenagers about the risks of e-cigarettes, including health effects and addiction, as part of its ‘Real Cost’ campaign that initially focused on cigarette smoking.241 Research informing the development of this campaign found that messages focusing on addiction or flavours alone did not resonate with young people; rather, pairing these concepts with strong health effects messages showed the most promise for discouraging vaping.242 Subsequent qualitative research also supported this finding.236 One experimental study comparing the perceived effectiveness of the Real Cost ads with “news style” informational ads found that the Real Cost ads were rated higher. Perceived risks of vaping were also higher following exposure to the Real Cost ads.243 Additional experimental research examining the effects of the campaign found that it succeeded in generating higher risk beliefs about the harms of vaping, creating more negative attitudes toward vaping, and reducing susceptibility and intentions to vape among US adolescents.244-246 Evaluations of the campaign have shown that exposure to the ads was associated with increased beliefs about the harmfulness of vaping247,248 and lower odds of vaping uptake among young people, with one study estimating that the campaign prevented an estimated 444,252 US youth aged 11 to 18 from initiating e-cigarette use between 2023 and 2024.249 Additionally, the ads appear to have effectively driven traffic and engagement to intended cessation resources.250 One study also found that ‘Real Cost’ ads targeting smoking may have positive spillover effects on vaping outcomes.251
Also in 2018, the Truth campaign began airing anti-e-cigarette media messages in the US targeting young people (aged 15–24). Survey research using a national sample of young people underpinned the development of campaign messages, and identified five message themes for targeting e-cigarette use: social acceptability of vaping (i.e., “vaping is ok to do socially with friends”); anti-vape industry sentiment (i.e., “people should be angry at vape companies for promoting their products to young people”); independence from vaping (i.e., “I am more in control of my life when I don't vape”); and non-vaping identity (i.e., “I want to be part of a community that rejects vaping”).252 An early evaluation of the campaign found that young people who reported frequent exposure to the campaign ads demonstrated higher levels of knowledge about addiction and health effects, as well as more negative attitudes toward the products and the e-cigarette industry.253 Another evaluation found a dose–response relationship between exposure to the campaign and desired outcome, with more frequent exposure associated with greater intentions to quit and agreement with the targeted beliefs.254 The campaign has also been shown to successfully increase targeted attitudes, increase social disapproval of vaping, and reduced odds of vaping uptake and use,255-257 and an economic analysis concluded that it was highly cost-effective.258 Longitudinal research also found that higher brand equity (that is, positive perceptions of the ‘Truth’ brand) was significantly associated with greater anti-e-cigarette attitudes and lower odds of intention to use e-cigarettes over time.259 Evaluation of a state-based vaping prevention campaign in Vermont, the ‘UnHyped’ campaign, found that it increased risk perceptions and reduced susceptibility to vape among adolescents but was not associated with changes in vaping behaviours.260
Given its near-ubiquitous use among young people, researchers have also explored the promising role of social media in educating teenagers about the risks of vaping,263-266 particularly as there has been a proliferation of e-cigarette promotion and discussion on social media in recent years (see Section 18.2). Small studies have found that teenagers are receptive to text messages about the harms and risks of e-cigarettes.267,268 Experimental studies have found that exposure to anti-vaping messages is associated with increased knowledge about e-cigarette harms, addiction, and constituents269 and can reduce intentions to vape270 and increase intentions to quit.271 The ‘Rethink Vape’ online campaign in the US was developed based on extensive research and consultation with adolescents, and it communicated three main messages: what’s in the aerosol, health risks, and connections to the tobacco industry. Results of a pilot study showed that it increased vaping knowledge, perceptions of risk, and anti-vape intentions, and its launch in 2018 resulted in good reach to young people on social media.229 An Instagram-based campaign (‘Quit the Hit’) in South Carolina was associated with increased confidence in quitting and reductions in vaping.272
In Australia, a number of digital anti-vaping campaigns have been developed to raise awareness about the harms of vaping.273-275 Campaigns using ‘influencers’ have also been launched, with the aim of reaching and resonating with young people.276 Social media can also be used to assess reactions to e-cigarette regulations and public education campaigns,277-280 and to target particular groups with campaign messages.281 For example, messages have been developed with and by First Nations Australians.282,283 Table 18.10.1 lists public education campaigns that have run in Australia to date, with a review of their content concluding that they generally focused on health risks and nicotine addiction through loss-framed and fear-based messaging.284 An evaluation of the ‘Every Vape is a Hit to your Health’ campaign in NSW found that it was associated with increased awareness and risk perception of the harms of e-cigarettes and increased quit intentions and behaviours.285
A number of school-based programs and policies have been developed and implemented, aiming to prevent e-cigarette use and/or promote cessation among young people.286-292 For example, the ‘CATCH my Breath’ e-cigarette prevention program had been adopted in schools in the US and Canada293,294 and evaluations of the program have generally found increases in knowledge about vaping among participants, though findings on effects on e-cigarette susceptibility and use have been mixed.286,295-297 An evaluation of the first two years of the program across schools in West Virginia found that reported use remained stable over time, while knowledge and refusal-related beliefs improved.298 Evaluations of e-cigarette prevention programs based on the Stanford Tobacco Prevention Toolkit288 have also found that they increased knowledge about the risks of vaping,299-301 and several other vaping prevention curriculums delivered to US school students have shown positive impacts on perceptions and knowledge.302-304 Research in Canada examining school-based e-cigarette prevention and cessation programs found that such programs generally had no effect on e-cigarette uptake. Further, students at schools that implemented a prevention “theme week” had higher odds of e-cigarette initiation, with the authors concluding that more evidence-based guidelines and tools for schools are needed.305 Research also suggests that peer leaders may increase the acceptability of programs306 and reduce e-cigarette acceptability and use.307,308 Programs that teach students media literacy and marketing tactics may also be helpful in reducing susceptibility to vaping.309,310
In Australia, several resources have been developed to help schools implement programs to prevent vaping and promote cessation among students – see Table 18.10.2.311-313 For example, Quit Victoria has launched a suite of curriculum-aligned resources for schools (‘Seeing Through the Haze’) to educate young people about the harms of vaping.314 An inquiry report into smoking and vaping released by The Public Accounts and Estimates Committee recommended that the Department of Education commit to making tobacco and vaping education programs compulsory curriculum at the primary school level and supply schools with resources to implement them. It also recommended that the Departments of Education and Health consider if a dedicated counselling and support program for school children in relation to nicotine use and addiction needs to be set up and rolled out across Victoria.315 A randomised controlled trial evaluated the effect of a school-based vaping prevention intervention, OurFutures Vaping, among students in years 7 and 8 in participating schools in New South Wales, Western Australia, and Queensland. After one year, students who received the intervention had lower odds of reporting e-cigarette use in the past year compared with those receiving usual health education.316 Interviews with school professionals, parents and students in Western Australia identified that comprehensive prevention activities in schools incorporating clear policies, vaping curriculum, professional development, access to health information and support, and parent/community involvement are needed to reduce uptake.317
School policies may also be helpful, with research in Canada showing that a ban on the use of e-cigarettes on school property may have contributed to decreased use of e-cigarettes among students.318 However, a review of school policies in Canada found that many were weak and lacked important components and enforcement approaches.319 The World Health Organization has developed a resource that can support educational facilities to ban smoking and vaping on campus.320,321 There have been reports in Australia of schools installing ‘vape detectors’ in bathrooms in order to monitor and discourage use.322,323 Given the high rates of use among young adults in the US, colleges/universities may also play an important role in education and prevention.324
Despite some of these programs showing promise, a review in 2020 found that that there were few adolescent-focused e-cigarette prevention programs, and most had not been evaluated. There was wide variation among the different educational programs, and often insufficient information available about their development, theoretical foundations, and delivery.325 More recently, a review of school-based prevention programs found that such interventions were associated with improvements in knowledge, intentions, and attitudes. Findings suggested a benefit for preventing e-cigarette use; however, the authors note that more high-quality evidence is needed.326 Another study notes that while evidence-based e-cigarette prevention programs may be promising, there is a dearth of evidence for e-cigarette cessation programs that support users to quit.327
Outside of the school environment, there may be other opportunities to educate young people about the harms of vaping and reduce their risk of use. Doctors and other health professionals who have regular contact with young people and parents can offer education and brief interventions—see Section 18.11.2. Resources have also been developed to help parents have conversations with their teenagers about vaping.328 Given that many adolescents regularly play videogames, researchers in the US have begun to develop videogame interventions to educate about and prevent e-cigarette use.329 Evaluation of a virtual reality game showed that it improved adolescents’ knowledge about e-cigarettes and addiction.330
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