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, new laws introduced in 2024 prohibit 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. The primary objective of these reforms is to close the regulatory loopholes that have 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 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.10-12 Such bans may also reduce cannabis vaping among young people.13 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,14 and others finding no such relationship.15,16 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.17 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.18 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.19 Smokefree policies in the home may also be protective against e-cigarette use.20,21
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.23 Among adults, research has similarly shown no association between the strength of retailer licencing and vaping.24 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.25 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.26 One study notes the importance of comprehensive surveillance to improve compliance with retailer requirements.27
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. 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.28 Further, despite bans on sales to minors, young people reported finding it easy to access e-cigarettes.29 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.22 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. 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.30
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,12 to no effect, to increased vaping, with a similar range of impacts shown for the effects of e-cigarette age restrictions on smoking.35,36 Surveys also shown relatively low levels of awareness about e-cigarette minimum age laws among people in the US.37 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.38 Another Canadian study concluded that e-cigarette minimum age laws were associated with reduced smoking uptake but also reduced smoking cessation among young people.39 Studies have shown that underage young people can often easily purchase e-cigarettes, particularly online,40-42 and that violations of laws banning sales to minors are common.18,43-48 Enforcement of comprehensive regulations are needed to reduce access and use of e-cigarettes among young people.46,49
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.50 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.51
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.52 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.53
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, the only products authorised for sale to date are 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.55 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.56 These enforcement efforts likely promoted switching to products that were exempt or not being targeted rather than leading to reduced overall flavour use,57-61 highlighting the importance of comprehensive rather than selective flavour bans.62 Product and promotion strategies by the e-cigarette industry also encouraged switching to alternative products;63 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.64 Health experts have also expressed disappointment following the authorisation of several menthol products in 2024 due to their appeal to children.65
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 products66 as well as in current e-cigarette use and levels of cigarette use.67 Such bans may also help reduce susceptibility to uptake.68 One survey found that only a minority of adolescents and adults who vape reported travelling to border states to purchase products,69 and other study found that total product bans appeared to be more likely to lead to cross-border sales than flavour bans.70 Survey research in San Francisco following implementation of a comprehensive flavour ban also found a reduction in use of e-cigarettes among young adults.71 A study comparing states with and without flavour bans found that bans were associated with decreased vaping among young adults, though were also associated with increased smoking. However, the authors note that there was no evidence of increased smoking in Maryland, which exempted menthol and products more commonly used by older adults.72 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.73 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.74 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.75 However, one survey found that despite a decrease in prevalence, almost all young people who vaped still reported vaping flavoured products.76 California's flavour restrictions led to a significant decrease in the availability of products with explicit flavour names in retail stores, though hundreds of restricted products remained available.77 Studies have noted that violations of flavour bans are common, highlighting the importance of enforcement efforts and retailer education.78-84 A systematic review found that overall, the evidence suggests that flavour restrictions reduce vaping among young people.18
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.85 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.86
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.87
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.88 An experiment in New Zealand found that among people who smoke, an addiction warning led to the greatest decrease in appeal.89 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,90 though another found that including both types of messages may promote quitting among people who smoke.91 As with tobacco warning labels (see Section 12A.4), design elements92-94 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,95,96 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).97
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.98 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.99 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.100 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.101 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.102 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.103 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.104
Since 2018, the US FDA also mandates that e-cigarettes include a health warning: “WARNING: This product contains nicotine. Nicotine is an addictive chemical.”105 There is generally high levels of compliance with this requirement,106 though less so for synthetic nicotine products.107 Research suggests that this warning is believable and understandable, and effectively communicates health risks, compared with reduced risk warnings.108 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.96 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.109 Several studies have shown that higher exposure is associated with increased harm perceptions among US teens.103,109
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.110 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.111
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.112,113 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 sales114-116 and vice versa.117,118 However, others have noted that not adequately taxing e-cigarettes could result in higher use among young people.119 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.115,120 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.121
Studies examining price sensitivity (i.e., the extent to which people’s purchasing decisions are affected by the price of products) in the US117,121-123 and the EU115 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.124
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.125 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,126 while a systematic review found that reducing affordability via taxes appears to reduce vaping among adults.18 Among adolescents, some research has suggested no impact of taxes on vaping,10 while others find reductions in use in states that have implemented tax policies.127,128 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.129 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).130 Receipt of e-cigarette coupons appears to undermine the effectiveness of tax policies, highlighting the importance of limiting industry marketing strategies.131 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.132 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.133
E-cigarette manufacturers claim that advertising is necessary for providing information and supporting people who smoke to quit.134,135 However, research suggests that exposure to any sort of e-cigarette advertising likely increases young people’s intent to initiate e-cigarette use,136 and that all advertisements contained at least some features attractive to youth137 (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.138 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.139
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.140 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.141 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.142 In Mexico, where the sales and marketing of e-cigarettes is largely banned, half of middle school students were aware of the products in 2015.143 Violations of e-cigarette advertising restrictions can be common.144-146
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.147,148 The FDA requires warnings on e-cigarette advertisements, and studies show this should also apply to social media.149 However, the prevalence of FDA-mandated warning statements in e-cigarette related YouTube videos has been found to be low.150 The FDA also ruled that JUUL misrepresented its products by selling or distributing them as modified risk tobacco products without an appropriate FDA order.151 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.106
Surveys in the US suggest that the majority of adults support the prohibition of e-cigarette sales and marketing to youth,4,152 as well as banning flavours.3,4,153 Similarly, most Canadians support restrictions on e-cigarette advertising in order to reduce use among youth.5 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.154
Among a sample of parents in Melbourne, Australia the overwhelming majority (87%) supported banning marketing and advertising that targets teenagers.6 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.155 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.156
A number of major reviews have concluded that, when included as part of a comprehensive tobacco control program, mass media campaigns can positively influence smoking behaviour157,158 (see also Chapter 14). The most consistent evidence is for the effectiveness of mass media campaigns in reducing smoking among adults,157,159 though studies also suggest that adult-targeted campaigns can reduce smoking behaviour among young people.158 There is also evidence that well-developed youth-targeted campaigns can reduce smoking among adolescents and young adults.158,160 In light of this evidence, researchers have developed anti-e-cigarette public education campaigns with the aim of reducing use among youth.161 Experimental research has examined message elements that could maximise the effectiveness of campaigns;162 for example, loss-framed messages163-165 or those that evoke fear,166 negative descriptions of e-cigarette users,167 images that show vape aerosol, devices/e-liquids, and those from warning labels,168 and information about financial costs,169 links with the tobacco industry169 or vape industry practices,170 harmful constituents,169,171,172 and health and addiction risks.173-177 Consulting with young people themselves173,178-180 and with traditionally hard-to-reach groups181 may also form an important part of message development.182
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.183 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 images184 (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.185 Findings from a survey of young people in the US suggest that campaign themes that focus on flavours, comparative risk with cigarettes, and relaxation and mental health may be particularly effective for influencing attitudes and behaviours.186
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.187 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.188 Subsequent qualitative research also supported this finding.185 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.189 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.190,191 Evaluations of the campaign have shown that exposure to the ads was associated with increased beliefs about the harmfulness of vaping192,193 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 2024.194 One study also found that ‘Real Cost’ ads targeting smoking may have positive spillover effects on vaping outcomes.195
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”).196 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.197 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.198 The campaign has also been shown to successfully increase targeted attitudes, increase social disapproval of vaping, and reduced odds of vaping uptake and use.199-201 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.202
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,205 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.206,207 Experimental studies have found that exposure to anti-vaping messages is associated with increased knowledge about e-cigarette harms, addiction, and constituents208 and can increase intentions to quit.209 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.178 An Instagram-based campaign (‘Quit the Hit’) in South Carolina was associated with increased confidence in quitting and reductions in vaping.210 In Australia, a number of digital anti-vaping campaigns have been developed to raise awareness about the harms of vaping.211,212 Campaigns using ‘influencers’ have also been launched, with the aim of reaching and resonating with young people.213 Social media can also be used to assess reactions to e-cigarette regulations and public education campaigns,214-217 and to target particular groups with campaign messages.218 For example, messages have been developed to specifically targets First Nations Australians.219
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.220-224 For example, the ‘CATCH my Breath’ e-cigarette prevention program had been adopted in many US schools,225 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.220 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.226 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.227 Evaluation of a 30-minute e-cigarette educational session for middle and high school students in Alabama based on the Stanford Tobacco Prevention Toolkit222 found that it did increase knowledge and perceptions of harm and addiction, and reduce intent to vape.228 Research also suggests that peer leaders may increase the acceptability of programs229 and reduce e-cigarette acceptability and use.230,231 Programs that teach students media literacy and marketing tactics may also be helpful in reducing susceptibility to vaping.232,233
In Australia, several resources have been developed to help schools implement programs to prevent vaping and promote cessation among students.234-236 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.237 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.238
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.239 The World Health Organization has developed a resource that can support educational facilities to ban smoking and vaping on campus.240,241 There have been reports in Australia of schools installing ‘vape detectors’ in bathrooms in order to monitor and discourage use.242 Given the high rates of use among young adults in the US, colleges/universities may also play an important role in education and prevention.243
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.244 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.245 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.246
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.247 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.248 Evaluation of a virtual reality game showed that it improved adolescents’ knowledge about e-cigarettes and addiction.249
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