18B.14 Policies and programs to reduce e-cigarette use among young people and non-smokers

Last updated:  January 2022


Suggested citation: Greenhalgh, EM, & Scollo, MM. 18B.14 Policies and programs to reduce e-cigarette use among young people and non-smokers. In Greenhalgh, EM, Scollo, MM and Winstanley, MH [editors]. Tobacco in Australia: Facts and issues. Melbourne: Cancer Council Victoria; 2022. Available from: https://www.tobaccoinaustralia.org.au/chapter-18-harm-reduction/indepth-18b-e-cigarettes/18b14-policies-and-programs-to-reduce-e-cigarette-use-among-young-people-and-non-smokers

In Australia, there are no nicotine e-cigarettes currently approved on the Australian Register of Therapeutic Goods, meaning that that they can only be lawfully accessed via the relevant pathways available to ‘unapproved therapeutic goods’. From 1 st October 2021 nicotine contained in vaping products was rescheduled under the Australian Poisons Schedule so that these could be dispensed by Australian pharmacists to people with a prescription from a medical practitioner.1 In a supply model that is unique to Australia, nicotine vaping products can be prescribed to individuals using them as part of an attempt to quit smoking, but are otherwise not permitted to be sold in retail outlets, even when a customer has a prescription. A prescription is also now required to import nicotine e-cigarettes from overseas. The primary objective of rescheduling of nicotine vaping products in this manner was to prevent uptake of their use by non-smokers including teenagers.2

In countries where nicotine vaping products are available for general sale to adults, concerns about 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.3, 4 The usefulness of such policies in Australia would need to be assessed in light of the prescription model of legal supply to adults but also any continuing illegal supply of nicotine vaping products to teenagers following the change in scheduling.

Surveys in the US,5, 6 Canada,7 and Australia8  have found strong support for measures that aim to prevent e-cigarette use among teenagers. See Sections 18B.8 and 18B.9 for an overview of current Australian and international regulations.

18B.14.1 Smokefree policies

In the US, research has shown that higher levels of state tobacco control spending is associated with reduced e-cigarette use among young people.9 An analysis of state-based policies in the US found that smokefree legislation for combustible products was associated with increased e-cigarette use among adolescents,10 however a more recent study found that ever and current use of e-cigarettes among youth decreased in states that included e-cigarettes in their smokefree policies.11 Another study similarly found that adults living in US states that included vaping in smokefree policies were less likely to use e-cigarettes compared with those that did not.12 Conversely 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.13 Smokefree policies in the home may also be protective against e-cigarette use.14, 15

18B.14.2 Banning sales to minors

In US states with T21 policies (i.e., prohibiting sales of tobacco and e-cigarettes to people under 21), an analysis found that use of e-cigarettes remained steady, whilst increasing in states without such policies.11 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.16 Studies have shown that underage young people can often easily purchase e-cigarettes, particularly online,17-19 and that violations of laws banning sales to minors are common.20, 21 In 2018 it was reported that the US Food and Drug Administration (FDA) had conducted large-scale undercover checks of retailers, resulting in a significant number of warning letters for violations related to the illegal sales of JUUL products to youth.22

18B.14.3 Flavour bans

Given the role of flavours in increasing the appeal and use of e-cigarettes among young people (see Section 18B.2.4.5), banning sweet and fruit flavours has been suggested as one approach to curbing youth uptake. In April 2020, the US FDA issued an enforcement policy ceasing “the manufacture, distribution and sale of unauthorized flavoured cartridge-based e-cigarettes,” and requiring manufacturers to reduce youth access. 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.23 Disposable brands such as Puff Bar (which look almost identical to JUUL) dramatically increased in popularity among young people, and despite being temporarily removed from the market following instruction from the FDA,24 Puff Bar sales resumed in 2021. The company claims that since its e-liquids are not derived from tobacco, and its products are not intended as a treatment, it does not fall under FDA regulation.25 Researchers have noted that it is important to consider the inclusion of products made from synthetic nicotine in policies aiming to discourage use of e-cigarette products.25

Despite concerns that flavour bans could dissuade smokers 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 vapers would be willing to use available flavours from a more restricted range.26 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 an evaluation found that implementation of this policy was associated with reductions in current e-cigarette use and levels of cigarette use.27 Survey research in San Francisco following implementation of a comprehensive flavour ban also found a reduction in use of e-cigarettes among young adults.28

18B.14.4 Health warnings

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.29 A recent experiment in New Zealand found that among smokers, an addiction warning led to the greatest decrease in appeal, and reduced risk messages such as “If you are a smoker, vaping reduces harms to your health” also decreased appeal among most smokers. Messages about the health risks of vaping reduced the appeal of e-cigarettes among non-smokers.30 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,31 though another found that including both types of messages may promote quitting among smokers.32 As with tobacco warning labels (see Section 12A.4), design elements33-35 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.36, 37

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.38 A survey of smokers 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.39 Another study similarly found that the TPD warning increased, and a reduced risk warning decreased, perceptions of harm and addictiveness among smokers and non-smokers.40 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 vapers or smokers. Although users from England reported noticing warnings more than Canada, the US, or Australia, noticing was generally low across all groups.41 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.42 Among teenagers, about one in eight reported noticing health warnings on e-cigarette products in England in 2018. Noticing was more common among vapers and/or smokers, and was associated with higher harm perceptions.43

The US FDA also mandates that e-cigarettes include a health warning: “WARNING: This product contains nicotine. Nicotine is an addictive chemical.” 44 Research suggests that this warning is believable and understandable, and effectively communicates health risks, compared with reduced risk warnings.45 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 smokers.37 In 2020, about one in five high school students in the US reported high levels of exposure to e-cigarettes warnings,46 and several studies have shown that higher exposure is associated with increased harm perceptions among US teens.43, 46

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.47

18B.14.5 Taxes

Several countries and jurisdictions have introduced special taxes on e-cigarettes. 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.48, 49 A number of studies have suggested that e-cigarettes and tobacco cigarettes are substitutes, with higher cigarette prices being associated with increased e-cigarette sales.50, 51 However, others have noted that not adequately taxing e-cigarettes could result in higher use among young people.52 Raising taxes on e-cigarettes to deter initiation by never smokers, alongside concomitant greater tax increases on cigarettes to encourage switching among smokers, has been suggested as one possible regulatory path in countries that allow general sale of both products.51

Studies examining price sensitivity (i.e., the extent to which people’s purchasing decisions are affected by the price of products) in the US53 and the EU51 have consistently found that e-cigarette demand is responsive to price, possibly even more so than tobacco cigarettes (see Section 13.1), 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.54 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,55 but not among adolescents.11 The authors suggest that state e-cigarette taxes may not be high enough to achieve reductions in use among young people.11

18B.14.6 Public education campaigns

A number of comprehensive reviews have concluded that, when included as part of a comprehensive tobacco control program, mass media campaigns can positively influence smoking behaviour56, 57 (see also Chapter 14). The most consistent evidence is for the effectiveness of mass media campaigns in reducing smoking among adults,56, 58 though studies also suggest that adult-targeted campaigns can reduce smoking behaviour among young people.57 There is also evidence that well-developed youth-targeted campaigns can reduce smoking among adolescents and young adults. 57, 59 In light of this evidence, researchers have begun to develop anti-e-cigarette public education campaigns with the aim of reducing use among youth.60 Experimental research has examined message elements that could maximise the effectiveness of campaigns; for example, loss-framed messages61, 62 or those that evoke fear,63 negative descriptions of e-cigarette users (inducing social identity threat), 64 images that show vapour, devices/e-liquids, and those from warning labels,65 and information about financial costs,66 links with the tobacco industry,66 harmful constituents66-68 and health risks.69-71 Consulting with young people themselves69, 72-74 and with traditionally hard-to-reach groups75 may also form an important part of message development.76

Given the difficulty in developing public health messages for e-cigarettes (as there is scarce research and a rapidly evolving market), researchers have suggested a number of steps in planning a campaign for novel health behaviours: (1) creating a comprehensive and complementary set of beliefs, (2) identifying overarching themes and nuances within themes and beliefs, (3) identifying appropriate and relevant language for the target population, and (4) prioritising beliefs for message testing.77 An examination of existing vaping prevention messages found that while there is wide variation in content, the most common themes are addiction, chemicals, health effects, and industry targeting, and most messages include images78 (see comprehensive database here). Qualitative research with young people and parents that assessed their reactions to existing prevention messages emphasised the importance of ads being relatable and believable, perhaps through the use of personal testimonials. Messages that highlight links between e-cigarettes and the tobacco industry, and target youth who are already addicted to e-cigarettes, may also be effective and worthwhile.79

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.80 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.81 Subsequent qualitative research also supported this finding.79  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, however there were no differences in intention to vape (though this was low overall).82 Additional experimental research examining the effects of the campaign found that it did succeed in generating higher risk beliefs about the harms of vaping, creating more negative attitudes toward vaping, and reducing intentions to use e-cigarettes among US adolescents.83

Also in 2018, the Truth campaign aired a series of anti-e-cigarette media messages in the US targeting young people (aged 15–24), particularly focussing on the JUUL brand which had become extremely popular in that age group. 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”).84 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.85 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.86

In December 2018, Health Canada launched a youth vaping prevention campaign to reach youth (13 to 18 years of age), parents, trusted adults and educators. The campaign aimed to “prevent youth uptake of vaping by: educating youth about the harms and risks associated with using vaping products; providing parents, adults and educators with resources to support conversations with youth about vaping; and increasing awareness of where to get more information on vaping.” An evaluation of the advertising campaign found that 26% of teens who reported having seen the advertisements decided not to vape as a result of the advertisements.87   Health Canada has also launched a campaign aiming to assist parents and other significant adults to discourage vaping among young people.88 Given its near-ubiquitous use among young people, researchers have also explored the role of social media in educating teenagers about the risks of vaping, particularly as there has been a proliferation of e-cigarette promotion and discussion on social media in recent years (see Section 18B.2). A small pilot study found that teenagers were receptive to text messages about the harms and risks of e-cigarettes.89 Among a sample of adolescents, an experimental study exploring social media messages about e-cigarette risks found that exposure led to increased knowledge about e-cigarette harms, addiction, and constituents.90 The ‘Rethink Vape’ online campaign was developed based on extensive research and consultation with adolescents, and it communicated three main messages: what’s in the vapour, 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.72 Social media can also be used to assess reactions to e-cigarette regulations and public education campaigns,91-93 and to target particular groups with campaign messages.94

18B.14.7 School-based programs

Programs and policies have also been developed and implemented in some US high schools, aiming to prevent e-cigarette use among young people.95-97 For example, as at mid-2020 the ‘CATCH my Breath’ e-cigarette prevention program had been adopted in 4,000 US schools,98 and an evaluation of its pilot program found that ever e-cigarette use was lower among middle schools that implemented the program than among those that did not.95 Another evaluation, this time looking at its effects in a small middle school, found that while knowledge about e-cigarettes improved postintervention, there was no change in attitudes about vaping, and susceptibility toward vaping increased or remained the same.99 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.100 Evaluation of a 30-minute e-cigarette educational session for middle and high school students in Alabama based on the Stanford Tobacco Prevention Toolkit97 found that it did increase knowledge and perceptions of harm and addiction, and reduce intent to vape.101 Research also suggests that peer leaders may increase the acceptability of programs102 and reduce e-cigarette acceptability and use.103 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.104 There have been reports in Australia of schools installing ‘vape detectors’ in bathrooms in order to monitor and discourage use.105 Given the high rates of use among young adults in the US, colleges/universities may also play an important role in education and prevention.106

Despite some of these programs showing promise, a review in 2020 found that that there are few adolescent-focused e-cigarette prevention programs, and most have not been evaluated. There is wide variation among the different educational programs, and often insufficient information available about their development, theoretical foundations, and delivery.107

18B.14.8 Other approaches to preventing vaping

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 18B.13.2. Resources have also been developed to help parents have conversations with their teenagers about vaping.108 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.109 Evaluation of a virtual reality game showed that it improved adolescents’ knowledge about e-cigarettes and addiction.110

See Section 18B.13.2 for a discussion of interventions to help young people who use e-cigarettes to quit vaping.

 

Relevant news and research

For recent news items and research on this topic, click  here. ( Last updated August 2022)

 

References

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